Intersex Awareness

Healthcare in the US, Intersex, Midwifery, Midwifery students, Reflections on racism and oppression in midwifery, Social Justice

 

how many
Written by Kelsey Chieko Babb for AROMidwifery Blog

As we approach Intersex Awareness Day observed on October 26th, I felt compelled to contribute a post highlighting some of the excellent education out there that aims to increase visibility of intersex folks, as well as speak to the campaign to End Intersex Surgeries. Intersex people are those born with a range of biological sex characteristics that may not correspond to being distinctively male or distinctively female (4Intersex, 2018). The Association of Ontario Midwives (2018) reports, “people with intersex traits are a diverse group that face discrimination and often experience trauma when engaging with health care providers, beginning in infancy.”

Historically, cosmetic genital surgeries were performed before 18 months of age for the perceived benefits of early gender assignment (Intersex Society of North America, n.d.). Intersex children were generally not made aware of their condition and their medical histories were withheld from them by their doctors. Intersex treatments and surgeries in this manner are not only an inappropriate and unethical medical practice, it is an infringement on the child’s right to bodily autonomy. According to the United Nations, carrying out these procedures without consent violates human rights.

The United Nations states medically unnecessary genital surgeries should not be performed in light of the many serious, negative impacts they pose on children. The lasting and irreversible nature of repeated surgeries and treatment to intersex children can cause permanent infertility and lifelong pain, scarring, incontinence, loss of sexual sensation, and psychological trauma (United Nations, 2018). Conformation to the gender binary is not a basis for subjecting invasive procedures on otherwise healthy intersex children.

Many medical associations, such as The American Academy of Family Physicians (AAFP) have taken a firm stance against unnecessary intersex surgeries. Their policy reads, “scientific evidence does not support the notion that variant genitalia confer a greater risk of psychosocial problems” (AAFP, 2018). Unfortunately, even the most research based recommendations don’t always make it into current medical practices right away.

Where should midwives stand on these important issues regarding respect for bodily diversity? I believe that just as midwives safeguard and advocate for the rights of birthing people, midwives must also position themselves to advocate for intersex child autonomy. Midwives, as the baby’s primary health care provider, perform the newborn exam and care for the first six weeks of life. Midwives have a role in the identification of a visibly intersex newborn in their care. Therefore, they can hold a great deal of influence by simply addressing the misconceptions with parents, holding space for emotional processes, and further discussing the recommendations for care. Midwifery providers are well poised to help families navigate informed decision making, participate in medical consults, and make necessary referrals for the care of an intersex baby.

“Intersex babies are beautiful just the way they are”
-United Nations

Please consider showing your support by signing a petition to End Intersex Surgery at Lurie Children’s Hospital in Chicago!

twitter_EIS.png

 

Learn More Here! Resources for Intersex Education
InterACT Advocates for Intersex Youth
Intersex Justice Project
#4Intersex
Human Rights Watch and interACT Intersex Feature Video
United Nations Free & Equal

 

Resources for Article:
American Academy of Family Physicians. (2018). Genital surgeries in intersex children. Retrieved from https://www.aafp.org/about/policies/all/genital-surgeries-intersexchildren.

Association of Ontario Midwives. (2018). AOM position statement on intersex child autonomy. Retrieved from https://www.ontariomidwives.ca/aom-position-statement-intersex-child-autonomy

Intersex Society of North America. (n.d.) What’s wrong with the way intersex has traditionally been treated? Retrieved from http://www.isna.org/faq/concealment

United Nations Free & Equal. (2018). United nations for intersex awareness. Retrieved from https://www.unfe.org/intersex-awareness/

4Intersex. (2018). Intersex 101: Everything you need to know. Retrieved from http://4intersex.org/wp-content/uploads/2018/07/4intersex-101.pdf

Understanding Barriers to Healthcare Among Resettled Refugees

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

The life of a refugee is inarguably more difficult than most healthcare workers probably imagine. It is easy to forget about the challenges refugees face because many of our own communities are made up of homogeneous, native-born citizens. Citizens are more likely to understand and exercise their access to healthcare through private or community clinics, or, as a last resort, the emergency department. In contrast, a refugee has to overcome additional obstacles before accessing healthcare, and then might only have access to racist and xenophobic providers.  

The people displaced because of civil war, political oppression, and economic instability face many challenges and traumas in their attempt to seek liberty and safety. Once these people have made it to a new location, usually illegally, they face hurdle after hurdle trying to establish a life. Refugees are subject to sweeping employment discrimination because they cannot speak the native language (or are easily recognized because of an accent), are undocumented and therefore cannot demand better working conditions or livable salaries, and cannot setup informal businesses without attracting law enforcement (Langa, 2011).

Langa (2011) reports that “by and large refugee women live in fear, and feel dislocated, and displaced” (p. 2). As a provider it’s important to recognize how a refugee’s health status is tied directly to their plight as a refugee. Understandably, refugees are probably not the most reliable patients because they have to spend such an inordinate amount of time finding or creating livable income to support themselves and their families.

What some health care providers might describe as uncooperative or difficult patient behavior was clearly visible in The Spirit Catches You and You Fall Down (Fadiman, 1997). Lia’s parents are continually seen as disagreeable because their Hmong customs and ideas conflict with American ideals of personal responsibility and hierarchical submission to their doctors’ orders. The Lee family relied on state assistance and thus did not have the freedom of movement, time, and resources that the doctors expected from their patients. Foua’s culturally-motivated rapt attention to Lia and her determination to carry her, clothe her, feed her, and love her regardless of her physical health status created a strange tension between her doctors who were also trying to care for Lia in their own American, individual way (Fadiman, 1997). Unfortunately the doctors who treated Lia were somehow immune to the family’s plight as refugees and saw their battle for economic security as a hindrance to their care instead of informing how to best care for the Lee family.

Refugees are often among the hardest working people in any country because they have to be. Finding a new home, creating economic stability, and rebuilding a community are monumental tasks to undertake even with good health. Unfortunately, needing and seeking healthcare as a refugee might be as costly and dangerous as remaining ill.

References:

Fadiman, Anne. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York, NY: The Noonday Press.

Langa, M. (2011). Women empowerment: A case study of a refugee women’s group at the Centre for the Study of Violence and Reconciliation. Retrieved from http://www.csvr.org.za/images/docs/Other/women_empowerment_a%20case_study_of_a_refugee_women_s_group_appendix_e.pdf

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

Health care in the US’ biggest colony

Healthcare in the US, Midwifery students, Reflections on racism and oppression in midwifery

By Tamara Trinidad-Gonzalez, Student Midwife

First, I must confess that making this post has taken longer in time and energy than I had anticipated. Writing about this subject and all its layers is a huge trigger of all the frustrations that living in a colony entails.  Pointing out one preexisting factor of why the care system in Puerto Rico has been so inefficient is not that easy as there is no such thing as one factor. This is more a cascade of effects, in fact, a very complex one than an isolated situation. I will try my best to explain it.

All this inefficiency goes back to the origins of our colonial politic situation (starting in 1898), which opens the biggest gate for Puerto Rico to not being treated equal as the other US territories and jurisdictions. In addition to this, the predominant political corruption for decades, have been a fertile ground to make this a major disaster. You may have heard already through the media that there is a huge, and unfair $73 billion debt that Puerto Ricans are being blamed for. Economists keep studying this socio-economic issue and it is evident that the colonial control over the economy of Puerto Rico has contributed to create this crisis. This crisis is affecting the daily quality of lives of Puerto Rican’s especially when it comes to educations and health. Alvarez and Goodnough (2015) emphasize that the disparity of federal fund is responsible for $25 billion of the total debt because the government of Puerto Rico was forced to borrow money to be able to keep the Medicaid program running. They also explain in this article that the misery of Puerto Rico’s health care began in the late 60’s with the initiation of the Managed Care health system and the Medicaid Cap placed by the U.S. Congress for all of its territories. The managed care health system in Puerto Rico has proven to be very ineffective for decades. This type of health care plan only works in favor of the insurance companies and not to benefit the people nor the health care providers.

There is a huge disparity of federal funding available for Puerto Rico in comparison to what is available to the rest of the US jurisdictions and territories.  The federal funding and commonwealth funding need to be equally paired, but the Commonwealth pocket does not have the capacity to pair sufficient amounts so, substantially less amounts of funding are given to Puerto Rico. The problem is that in Puerto Rico, more than 60% of its residents (which used to be 3.5 million people before Hurricane Maria), receive Medicare or Medicaid. Thus, the funding allocated is just not enough to properly care for the health of people. Alvarez and Goodnoug (2015) make a comparison of how much funding is given to two other states equal in population, but wealthier than Puerto Rico, and I created this table to see it better.


State/ Jurisdiction Population Medicaid funding/year
Puerto Rico 3.5 million $373 million
Oklahoma 3.49 million $3 billion
Mississippi 3 million $3.6 billion



Because of this situation, we (Puerto Ricans) grow accustomed to hearing of doctors leaving the island motivated for better income and work conditions. There are great physicians in Puerto Rico (PR), so they are being offered an income that is 3 or 4 times what they are earning, with moving expenses covered, health insurance, vacations and even with their liability insurance paid. To have a clearer idea of the magnitude of this problem, an article from 2016, a year before hurricane Maria, was already revealing the dangerous migration of Puerto Rican physicians to the mainland. From 2006 to 2016, around 5,000 physicians had stopped working in PR. By the summer of 2016, there were only 9,000 physicians with active licenses. And with a population of 3.5 million people, this meant having like 5 doctors for every 2,000 people. The chaos that this causes in the daily lives of Puerto Ricans is very present and evident.  Some examples of this is when patients must wait many months to have an appointment with a specialist, or when someone that is sick, does not get treated for something simple, and then dies; or when there is an urge for a treatment and people opt to travel to the US to get the needed treatment.

If this already sounded like a shortage and terrible health conditions, after hurricane Maria, a massive amount doctors left the island, abandoned their practices and their patients and many hospitals closed. This includes OBs which left many women without adequate prenatal care. Although the midwives stepped in to help as they could, they lack the resources to help everyone as they would like and deserve.

In conclusion, although we pay the same Medicare and Social Security taxes as the rest of the US, we are not treated equally. All this produces an unbalanced health system that is not fair for the people nor for the health providers that are compromising their humanity and their Hippocratic Oath.

References:

Alvarez, L. & Goodnough, A. (2015). Puerto Ricans Brace for Crisis in Health Care. Accessed online at https://www.nytimes.com/2015/08/03/us/health-providers-brace-for-more-cuts-to-medicare-in-puerto-rico.html?_r=0

Bodenheimer, T. & Grumbach, K. (2012). Understanding Health Policy: A Clinical Approach, 6th Edition. McGraw-Hill, New York, NY.

GFR Media (2016). Peligrosa fuga de miles de médicos. Retrieved from https://www.elnuevodia.com/noticias/locales/nota/peligrosafugademilesdemedicos-2225024/

Written by Tamara Trinidad-Gonzalez, Student Midwife at Bastyr University originally for a class in the Professional Issues series: Health Care Systems and Health Policy

Owning the Shadow: White Patriarchal Culture in the Preceptor and Student Relationship

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

by Anonymous

I wish I were writing a happy fluffy blog about how great my apprenticeship was and how wonderfully supportive my preceptors were on my journey to becoming a midwife. Instead, I am writing this heavier piece. Hopefully it can shed some light on a problem and therefore help the movement along so that more people of color can more easily become midwives, and in turn serve populations who are currently not widely served by midwives of color, or the midwifery model of care. If we want to eliminate racial disparities in birth outcomes, we need more midwives of color, and culturally competent midwives in general.

I am a Chicana apprentice midwife. I recently worked at a birth center run by two white midwives, serving mostly white pregnant people. I am fairly accustomed to working in majority white spaces, and attending majority white institutions. I am comfortable in my skin and able to navigate many spaces, including majority white spaces. This navigation includes exiting those spaces when need be. I am grateful for the opportunity to attend births and apprentice with seasoned midwives. I mostly had great experiences and learned so much in my time there. And, with these preceptors, I also experienced a series of hierarchical and racialized interactions, which I call everyday racism. It is most often unconscious, rife with micro-aggressions, and subtle and overt displays of power-over. However unconscious, the role of everyday racism is to maintain the racial status quo. It eventually cost me the apprenticeship, and it cost me the opportunity. There will be other opportunities, but I point this out because this is something that people of color (POC) have to face again and again when we enter majority white spaces, with white supervisors, professors, and employers. What we face is to swallow the racist injustice and stay, or leave the opportunity, or to take-on the racism directly — all of which come with a cost to us personally and professionally.

I am writing this as an alternative to silence. While I chose not to address this on a personal level with my former preceptors, I write this to address a systemic problem that I see as pervasive in many institutions, of which midwifery institutions and birth centers are not immune. Upon reflecting on the problematic interactions with my preceptors, I decided it was going to be best for me to resign from my apprenticeship. Leaving was better than to stay working in the stress of those conditions. Leaving was definitely better than to stay and to take-on the massive unpacking of the everyday racism in their communications and behavior. It would have been a nasty job to unpack, and it could potentially have long lasting and far reaching negative impacts for me in the small community where we live. Unpacking racism with white women, especially ‘progressive’ midwives, is a massive job. It is painful, unrecognized, and unpaid work, and it’s a job that I will not volunteer myself to do this with these women. It is sad, but true. I reserve the right to not put myself through this kind detrimental action, because let’s be honest, however gentle you may be in your communication, how many people are actually thankful when you point out their participation in white supremacy and patriarchal culture? These people are rare. And if the person is your instructor, employer, or any person in a position with power to compromise your grades, employment, or apprenticeship, then the stakes are high.

Everyday racism is an issue which must be addressed in the wider community of midwives. I have witnessed everyday racism before and know it well. Most people of color know it well and have experienced it. We have experienced everyday racism in schools, university, at our places of employment, in hospitals, on the street, in our interactions with police, in our government, in businesses in which we are patrons, and in birth centers with midwives. As people of color in these situations where our livelihood or our very lives are at stake, our confidence becomes viewed as arrogance, disrespect, or worse, is viewed as a threat. Most of us have learned when we may need to dampen that confidence for appearances, to be “humble,” speak in whitewashed tones, keep our heads still, our faces without too much expression, and apologize when we have nothing for which to apologize. Most of us have played the game at some point or another. But where has that gotten us? It may temporarily save a grade, a job, but what life is that? I suppose it depends on what is at stake.

I know that my experience is not an isolated event in midwifery culture because of the mostly white landscape of midwives, and the smaller percentage of midwives of color in the U.S. I know from speaking to other students and midwives of color that they have had similar experiences. Until we commit ourselves to unlearn the lifetime of learning racism, then we are doomed to repeat and reproduce it. Unless these uncomfortable conversations are being had, and the inquiry, study, and practice to unlearn racism is in place, then we can be assured that the structures of patriarchy and white supremacy are being replicated. We all have implicit bias, and it is past time we get to know these unconscious biases really well. This is our work. It is your work. It is my work. It is our work together.

I am glad to see that this years 2017 MANA-CAM conference, “Collaborate,” is addressing some of these issues. Among other very important workshops, there are break out sessions entitled: “Whiteness and Racism in Birth in the US,” and “How to Use a Racial Equity Toolkit for Decision making in a Predominantly White Organization.” There are sessions centering women of color: “Indigenous Gathering: Ancestral Knowledge Keepers,” “We are the Gardeners, Leadership Training,” “Black Women Birthing Justice,” “Reclaiming Indigenous Midwifery: Stories of Honoring Ancestral Knowledge, Resisting Medical Colonization and Returning Birth to Native American Communities,” “The Giving Voice to Mothers Study: Communities of Color Speak of Disrespect and Inequity in Access to Birth Options,” “Centering Collaboration to Improve Equitable Birth Outcomes,” and “Birth Justice 101.” This is a wonderful line up of workshops and it makes me hopeful of real change.

The topic of racial equity in midwifery is vitally important, especially as it pertains to women of color working unpaid apprenticeships for white preceptors. This dynamic is fertile ground for historical trauma, and current racial patterns to be repeated and reproduced. That being said, it could also be a great opportunity for ever growing awareness, education, creating and sustaining equitable structures and relationships. Midwives need to be having trainings and making policy to address racial equity in midwifery culture and midwifery institutions. However, until this culture changes, for my following apprenticeships, I will be seeking out midwives of color for preceptors, and consider white preceptors only when they have truly made racial equity explicit in the student/preceptor relationship, and in their midwifery practices.

The following demographics matter because they illustrate the landscape of the midwifery field in which apprentices of color are entering. While the statistics I found do not wholly represent the midwifery workforce, they do offer a general picture of the racial make up of midwives in the United States. The department of Education released demographics in Race & Ethnicity by Degrees Awarded in Nurse Midwife for 2015. Here is the breakdown: White 250 (76.7%); Black 21 (6.4%); Unknown 19 (5.8%); Hispanic 18 (5.5%); Multiracial 8 (2.5%); Asian 7 (2.1%); Hawaiian 2 (0.6%); Native 1 (0.3%). While this is the racial demographics of Nurse Midwives for 2015, it offers a general picture of the racial make up of midwives in the U.S. We also have demographics from NARM. While it is not comprehensive, because only 33% of the CPM’s sampled, (that is 706 of 2,106 CPMs) completed the survey, it is still informative. From the 2016 NARM Job Analysis Survey Comprehensive Report:

Question #26: What is your ethnic background:

614 of the 706 respondents (approximately 87%) identified themselves as white or Caucasian. Of the remaining 13%, 31 respondents identified themselves as multi- ethnic, 18 respondents identified themselves as Hispanic and/or Latino, 9 respondents identified themselves as Black/African American, and 5 respondents identified as American Indian, Alaskan Native, or Hawaiian. This was an optional question, so 18 respondents declined to identify their ethnicity.

I bring the issue of everyday racism in midwifery forward because it needs to be brought into the light, understood, and dismantled. Everyday racism is not as easy for white people to see as compared to the more obscene racism, which many consider to be ‘real racism,’ or the real threat. Racism is often seen as ‘out there,’ not right here in our very own unconscious thoughts and actions. Everyday racism is often more subtle. There must be dialogue, but even more importantly, there must be a commitment by white midwives to reflect upon implicit biases and educate themselves, otherwise these dynamics will continue to unconsciously persist. If we are to have more midwives of color, if we care to serve pregnant people of color with cultural competence, and ultimately to effectively address the problems of racial disparities in birth outcomes, then the dynamics of everyday racism of preceptor to apprentice in midwifery culture must cease to exist.

Following are some examples of the how these dynamics have seeped into and are embedded in midwifery culture of today. The dynamic is present in the hierarchical culture between preceptors and students of any color. It is present in the bullying that is pervasive. It is present in micro-aggressions towards student of color. Often there are unspoken expectations of apprentices, which can change on the whim of preceptors. It is present in the replication of the racial status quo and historical tropes which are repeated. It is present in the centering, and directing of the narrative that some white midwives do when there is disagreement or conflict with a student of color. It is present in the white centering, or derailing of conversations about race. It is present when problematic behavior is called out in writing or in conversation and is met with claims of being “attacked.” (For example, this essay could be construed as an “attack” on white midwives.) It is present in the displays of power that preceptors hold over students if they should want to keep their apprenticeships. It is present in the implicit bias that is not acknowledged, and actively denied. It is present in the projection that racism is a problem of people of color, and not a problem of white people. That’s a radical idea: racism is a problem of white people.

There have been research papers and discussion of bullying in midwifery culture, (See the work of Marivette Torres and Marina Valenzuela Farrell). I understand that white student midwives also experience patriarchal hierarchies with their preceptors. To make a distinction, what makes these interactions racialized is the white history and current day of whites oppressing people of color. While white students and students of color both face the bullying and hierarchal structures of patriarchy, students of color are also confronted with the racial hierarchic structures of white supremacy. White people can no more easily extricate themselves than people of color can from the history and current day structures of patriarchy and racism. Just because one does not see their participation in actively reproducing these structures, it doesn’t mean they are not participating, or responsible. Without the tools and implementation of oppression, there is no oppression.

I’m exhausted by the conversation always being about how POC are wronged. We know. And if you’ve been paying attention, you know too. As Erna Stubble puts it, “Even when the history of POC is told, white violence is erased, and the consequences of historical injustices is minimized. White people do not connect themselves to [the present, or] history.” I’m ready to move on to the next phase of the conversation which centers and addresses the wrong doing, the wrong doers, and the silence — let us address the deafening silence. Part of this silence is because, as I mention above, many white people do not see oppression as their problem, and so they are not invested to learn how they contribute. While white supremacy is prevalent, it is pushed so deeply into the collective shadow. It is disgusting, and yet, as Robin DiAngelo says, we are ALL swimming in its waters. While some are burdened by it, others unconsciously benefit from it, and so they are not as inclined to do anything to change it, nor do they see their silence and inaction as collusion. If we do not take responsibility and actively practice racial equity, then we most assuredly are replicating unequal structures. Let that sink in. Midwives do not consciously choose this, so let’s not unconsciously choose it.

Maternal mortality rates in the United States have been on the rise. Do we blame the mothers? Not unless they are Black or brown, (see Ina May Gaskin). When we have the dire situation where Black mothers are dying from pregnancy related causes in rates of up to 4 times more, (and in some places 12 times more), than that of their white counterparts, and regardless of income or education, the problem is not because of Black women and Black people. When Black babies die at rate of 2-4 times higher than that of white babies, the problem is not because of Black people. So where does this devastating problem arise from? There are so many layers of this crisis, and they all have roots in the devastating effects of white supremacy.

NARM and some midwifery schools acknowledge the problematic dynamics when Westerners, and more specifically when white students go to Black and brown countries to study midwifery. In the same way, so must we acknowledge the problematic dynamics that can, and do arise when Black and brown American students work apprenticeships for white midwives. Even though we are all Americans, the legacy of colonialism, and the inherent hierarchies are residual and present in these relationships today. Let us make this dynamic explicit so that we may address the problems with honesty, transparency, and policy. The midwifery schools and organizations that oversee students and preceptors can make policy to address this issue, advocate for students, and ensure racial equity and access to midwifery education, and apprenticeship.

Midwifery is about women being with women, it’s about midwives helping pregnant people and their families. If there is any group of people that has the capability to actively address this issue, I hope it would be Midwives. To eliminate racial disparities in birth outcomes, we need more midwives of color, and we need culturally competent midwives in general. We need the path to becoming midwives to be accessible for all women, and without racial obstacles. Importantly, white midwives need to become conscious of their positions in white supremacy, to commit to not participating unconsciously, and to consciously take this on as their individual and collective work. We have to fully own all of the layers of this problem to get out of this dire crisis.

An Open Letter to the MEAC Board of Directors

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

The National College of Midwifery is encouraging preceptors and alumni to write letters to the MEAC board of directors using the following language:I am writing to voice my strong opposition to your proposed ban on all out of country clinicals for MEAC students.” Their suggested letter template is not only inaccurate in calling this a proposed “ban,” but this act by NCM is also divisive and fails to acknowledge the careful process that has led to MEAC’s proposed moratorium.

The suggested statement is divisive in that it forces an unneeded dichotomy of extremes. One “camp” decries all out-of-country service learning activities as unethical and the other “camp” assumes that these activities are mutually beneficial for students and the communities they serve.

We are arguing for a third “camp”, one in which MEAC, MEAC schools and other stakeholders including potential host countries/ sites, approach this complex issue with open minds and hearts, and agree to thoroughly explore the concept of culturally competent and ethical care in the context of service learning, whether here in the US, abroad, or both.

We commend MEAC for recognizing the complexity and multi-layered nature of the problem:

“It is clear from the evidence presented by the workgroup that, due to language and cultural barriers, disparities of power, wealth, and privilege, and the difficulties of obtaining informed consent when students are practicing upon a vulnerable or disadvantaged population, many out-of-country clinical placements for student midwives have caused significant harm to the mothers and babies being cared for, to host communities, and to the students themselves. The MEAC Board is deeply concerned about the possibility of students from our member schools perpetuating or being involved in ethical violations, abuses, and exploitation in pursuit of their clinical education.”

We look forward to a creative and collaborative exploration of these complex issues while ensuring that we are not currently engaging in potentially harmful activities. The moratorium proposed by MEAC affords our profession this opportunity. We applaud the MEAC leadership for this bold and appropriate action.

  1. Kathryn Haines, LM, CPM
  2. The Rev. Patricia Ross, OSL, CPM
  3. Marijke van Roojen, LM, CPM
  4. Makeda Kamara, CNM, MPH, M.Ed
  5. Erin Ryan, LM, CPM
  6. Claudia Booker, LM, CPM-PEP process
  7. Wendy Gordon, LM, CPM, MPH
  8. Krystel Viehmann, LM, CPM
  9. Jaqxun Darlin, student midwife
  10. Laura Marina Perez, CPM, LM
  11. Shauntée Henry
  12. Silke Akerson, CPM, LDM
  13. Audrey Levine, LM, CPM
  14. Anne Hirsch, LM, CPM
  15. Kelly Milligan, CPM
  16. Amy Rae Zimmerman
  17. Maria Teresa Noth
  18. Dionne Corcoran, CPM, LM
  19. Annie Moffat
  20. Meg Novak, CPM
  21. Brooke Casey, LM, CPM, IBCLC
  22. Jennie Joseph, LM
  23. Rachel Zazlow
  24. Brenda Burke, CPM, MSW, RN
  25. Grace Hannon, CPM, LM
  26. AnnMarie RianWanzeck, LM/CPM
  27. Kayla Quinlan Frawley, LM, CPM
  28. Cheryl Clearwater, LM
  29. Tiffany Shank, student midwife
  30. Angelique Chelton
  31. Connie Wakaluk, student midwife
  32. Lorrie Leigh, RN
  33. Joelle Ceremy, LM
  34. Nicole Morales, LM CPM
  35. Neva Gerke
  36. Rachael Cook
  37. Helena Wu
  38. Racha Tahani Lawler, LM
  39. Janine Stiles, CPM
  40. Angelita Nixon, APRN, CNM
  41. Jeanette McCulloch, IBCLC
  42. Susan Smartt Cook, CPM
  43. Holly Arends Murphy, CPM
  44. Mary Helen Ayres, CPM
  45. Donna Mitchell, CPM, CLC
  46. Angela Miller, LM
  47. Amy Jo Rist, CPM, LDM, LM
  48. Treesa McLean, LM
  49. Katherine Bramhall, CPM
  50. Michele James-Parham, Traditional Midwife
  51. Kristin Kali, LM, CPM

Letter to Midwifery Today: Real talk about midwifery and racial oppression

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery, Social Justice
This letter was collaboratively drafted in response to an article posted in Midwifery Today’s E-News on February 13, 2013, comparing the current-day US obstetrical care with chattel slavery and the midwifery movement with the 19th century US abolition movement. Although the piece was removed and the author apologized in a thread on Midwifery Today’s Facebook site, this letter hopes to use this incident to initiate a deep discussion about US midwifery and our history of racial oppression, which is very much alive in the present. The letter has been sent, but we welcome additional signatures here; we will update the list from the comments section at the end of each day. We also welcome criticism and dissenting views from readers interested in deepening the discussion. The original text of the article, as well as the author’s apology, are appended here below the signatures.
 
 

February 21, 2013

Dear Jan & the team at Midwifery Today:

We would like to start by expressing our appreciation for your efforts to educate midwives over the last 26+ years through your books, magazine and conferences.  Midwifery Today provides an important service to midwives all over the world, and your reach is broad.  It is for this reason that we are writing regarding the February 13, 2013 “Jan’s Corner” piece in your online E-News, formerly entitled “Childbirth Abolitionists” then retitled “Childbirth Freedom Fighters,” which drew a comparison between the contemporary midwifery movement and the movement for the abolition of slavery in the United States.

After many comments from readers on the Midwifery Today Facebook page, this article was at first slightly edited, and has now been removed. Jan, you also apologized in a thread on Facebook. We applaud the removal of the article and appreciate your apology. But we are asking you to do more. You write that you regret your words, and we can all relate to that; we have all said and done things that we wish we could take back. And the intent of this letter is not to make you feel ashamed. Rather, it is to use this incident as an opportunity to open what we hope will be a deep and ongoing discussion about a very serious problem.

The publication of this article highlighted the failure of the US midwifery profession’s leadership to integrate its advocacy for humanized birth with concern for the crisis in maternal and infant health in communities of color, especially African American communities, and to understand this crisis as the legacy of enslavement and racial oppression and violence. While the article is gone from the Midwifery Today site, the discussion it has engendered is too important to disappear without a trace. It is important to us that your readers understand why the comparison between the anti-slavery struggle and the midwifery movement is wrong and profoundly hurtful. Even more than this, however, we hope to show that the struggle to provide a full range of birthing options must address our history of racial oppression if we really want to change birth in this country.

We can all agree that in many areas across the United States, there is an egregious abuse of power in hospitals; laboring women (and women in general) are oppressed; there is a lack of informed choice for the interventions that are being used; and midwives are putting themselves at risk of hostility, large fines, and even criminal prosecution and jail time for making sure that mothers and families have evidence-based, safe, holistic and informed choices about how they bring their babies into the world.  The devotion and personal sacrifice of midwives has changed the lives of many women and families.

The work we do as midwives and birth workers needs no comparison to other struggles to be validated. But it should never be compared to the abolition of the horrors of enslavement.  There can be no comparison between the meanings of “freedom” and “choices” between these two contexts.  People from Africa were forcibly kidnapped, removed from their homes and families, transported across the ocean in the bottom of cargo ships where many of them died, then sold as property to white landowners who beat and whipped them to maintain control over them. Enslaved women were beaten and raped as part of everyday life; some were subjected to experimental surgeries on their reproductive organs with unsterilized instruments and no anesthesia. If they did manage to make it to the end of their pregnancies, their babies were often taken from them and sold to someone else. This short catalog of horrors does not even begin to scratch the surface, but it should help to illustrate why current birth care practices do not compare in their scale, violence, or power differentials to the atrocities of slavery or to the legacies left behind by such brutality.

When we talk about slavery, we cannot avoid bringing along the whole history of racial oppression, violence, and exploitation that came with it, whether we intend to or not.  The impact of slavery runs very, very deep in the families of those who were enslaved.  It is a massive wound that was inflicted over hundreds of years and several generations that continues to impact the health and well-being of African Americans today, even though the practice of what is referred to as the chattel enslavement of African people within the United States has ended. This enslavement was an atrocity carried out by white families over black families.  That is simply a historical fact.  It does not mean that any of us were personally complicit in what our ancestors may have done.  But it does mean that when we talk about slavery, we must realize the gravity of what we are about to say and how it may land with those who carry those deep generational wounds.

The same must be considered when we make references to the colonization of the U.S. and the brutal taking of lands from the Native Americans, Mexicans and First Nations peoples; the Holocaust; the Japanese internment camps; and so many other historical abuses of power by people of European ancestry.  To make analogies between these events of extreme violence and the very different modern-day struggle over birth choices honors neither.  Rather, it co-opts an ongoing intergenerational experience of trauma and oppression that does not allow people to heal.

Midwives have always been part of the fabric of communities. Native American peoples had midwives.  The European colonists brought their midwives.  African midwives were forcibly brought here along with other people who were enslaved.  Every population that voluntarily or involuntarily immigrated to this new “melting pot” had their midwives.  And the midwives provided excellent care to the women and families all of their communities, often extending far beyond the childbearing year.  They were our healers.

When the medical establishment took birth into the hospital in the first few decades of the 20th century, an emerging public health profession simultaneously sought to end the rich legacy of midwifery knowledge and expertise through the gradual elimination of these community midwives across the country.  The medical establishment succeeded in substantially reducing the number of community midwives in practice; those who remained continued to serve all women but were absorbed deeper into the fabric of their respective communities.  As your readers are well aware, some of us still remain underground to this very day.

As the 20th century continued and the occupation of medical obstetrics grew, those populations who had access to hospital care (middle- and upper-class white women, and later, women of various ethnic groups) began to embrace the move toward the “scientific” management of labor in hospitals and the promise of pain-free childbirth.  They were not shackled and dragged into the hospitals.

Today, we must be clear that the vast majority of women in the U.S. choose to birth in the hospital setting.  We are still in the early stages of our midwifery resurgence and many Midwifery Today readers are working tirelessly to improve access to midwifery and safe homebirth as we restore these options to our communities.  And to some extent, it’s working!  The rates of homebirth and midwifery care are increasing — but only for white women. This is meaningful and concerning, especially because there are decades of research that continue to show that women of color are being harmed and dying from maternity-related causes in far greater numbers than white women, and babies of color are sick and dying in far greater numbers than white babies.  Many of us share the belief that the midwifery model of care might make a difference in these gross disparities.  However, reducing disparities requires in part that all of us work to understand the full history of how this came to be and why it persists today.

In order to effectively do this, it is imperative for the midwives in leadership positions to be at the forefront of this education, as well as leading action to ensure that all mothers, all babies and all families have access to safe, family-centered, culturally-relevant care.  Our leaders are charged with inspiring midwives to keep fighting the good fight, but not at the expense of reopening the painful wounds of midwives and peoples of color.  Our leaders must actively and continuously examine their areas of privilege in this society — whether they be privileges of skin color, sexual orientation, citizenship, wealth/ class, religion, education, ability, age or gender identity — and it is vitally important that they do their work with a consciousness of the power that these privileges bestow.

It is incumbent upon our leaders to be aware of and to fully support those midwives of color who today are creating highly effective models of care that build upon their legacies of community-based midwifery and are essentially eliminating disparate rates of preterm birth and low birth weight.  In fact, this work represents what is perhaps the only valid comparison that might be made between the anti-slavery movement and the struggles of birth workers today: the resilience and creativity of people of color in fighting for the survival of their own communities.  Midwives and families of color have had to proceed on their own while the major midwifery organizations struggle to understand what is needed.

Midwives are putting themselves on the line in many areas of our country to address an egregious lack of access to safe care and choices for women and babies. But when we isolate the legal struggles of midwives from broader health injustices — such as outrageously disproportionate rates of unjustified interventions, increased surgical and infection rates, and deaths of women and babies of color, as well as growing lack of access to decent basic health care for working people of all colors — we drive a wedge into our own community that hurts us all.  There is an increasingly urgent need for a deep conversation about how midwifery is currently failing women of color.  Babies are dying, and mothers are being harmed.  At the same time, midwives of all colors are being persecuted.  We cannot afford to create further divides amongst ourselves or leave groups behind in any of this work.

Jan, you have a wide audience, which comes with large responsibilities. Many midwives and birth workers look to you and Midwifery Today as an important voice in this profession.  Because of that, we ask that you take the lead on furthering this crucial discussion. The removal of the article and the apology on Facebook were important first steps. We ask that you publish this letter in the pages of Midwifery Today’s print edition. We also ask that you publish your apology on the E-News site where the article was posted. We further ask that Midwifery Today devote an entire issue to the theme of racial disparities in birth outcomes, highlighting the highly effective ways that midwives of color are using midwifery models of care to heal their communities’ mothers and babies. Most importantly, we ask that this issue not stand alone, but initiate an ongoing effort to make the ways that social justice issues intersect with pregnancy and birth–such as racial disparities in health, disability, poverty, incarceration,  LGBTQ oppression and concerns, immigration, and homelessness–central themes of Midwifery Today publications and conferences.

For Midwifery Today to redress this incident publicly would show great courage, and would serve as a sorely-needed example for our professional organizations. This is a crucial opportunity for Midwifery Today to foster a substantial discussion in our profession about racism and other forms of oppression. And given the urgency of these issues, Midwifery Today’s willingness to be a venue for this difficult but necessary conversation could not be more timely.

We also invite you and your readership to join with us in our efforts to learn and to work together to end all forms of oppression in midwifery and the childbirth professions, by first reading the resources we have compiled on the AROM blog (aromidwifery.wordpress.com) and then joining us in our Facebook group:  Anti-Racism and Anti-Oppression in Midwifery.

Sincerely,

  1. Wendy Gordon, CPM, LM, MPH
  2. Annie Menzel, CPM MA PhC
  3. Jeanette McCulloch, IBCLC, RLC
  4. Jessica M. Roach
  5. Claudia Booker, Midwife, CPM
  6. Jennie Joseph
  7. Nechama Greenwood, CPM
  8. Lena Soo Hee Wood, MEd, CD, nursing/nurse-midwifery student
  9. Thérèse Greenhow Robinson, CMT, LST, CEIM, CD, BPC, BPCA LLI
  10. Neva Gerke
  11. Annie Kennedy, Director, Simkin Center for Allied Birth Vocations at Bastyr University
  12. Marijke van Roojen, LM, CPM
  13. Danelle Aurilio
  14. Elias Kass, ND, LM, CPM
  15. Monica Basile, PhD, CPM, CD(DONA), CCE(BWI)
  16. Audra Phillips, CPM
  17. Brooke Casey, LM, CPM, IBCLC
  18. Gretchen Spicer, CPM, LM
  19. Chloe Raum, CPM
  20. Meg Novak, midwifery student
  21. Amanda Heffernan RN IBCLC SNM
  22. Jennifer Linstad
  23. Dionne Corcoran CPM LM
  24. Racha Tahani Lawler, CPM, LM
  25. Emme Corbeil CPM, LM, CD(DONA)
  26. Kristin Kali, LM CPM
  27. Annie Moffat
  28. Megan Hill, CPM
  29. Beth Ebers , RM, MH, Squamish, British Columbia, Canada
  30. Rachel Zaslow on behalf of Mother Health International
  31. Olivia Kimball of Mother Health International
  32. Audrey Miles Cherney
  33. Grace Hannon LM CPM
  34. Danny Scar, The Prison Doula Project
  35. Aly Folin, CPM, LM
  36. Brynne Potter, CPM
  37. Autumn Vergo, CPM, NHCM, RN
  38. Janelle Lucido-Conate, Future Midwives Alliance
  39. Tracy Hydeman, SMW, Canada
  40. Muneera Fontaine, CD
  41. Michelle H. Kinne IBCLC RLC ICCE CD(DONA)
  42. Anne Hirsch, CPM, LM
  43. Kathryn Haines, CPM
  44. Joelle Ceremy LM
  45. Sarah Davis, LM, CPM, IBCLC
  46. Judith Goldberger RN
  47. Devorah Herman, CPM, sWHNP
  48. Makeda Kamara DEM, CNM, MPH, M. ED
  49. Marnie Cockrill, student midwife
  50. Marie Carnesciali
  51. Toni Hill, CD, CBE, student midwife
  52. Nikki Plaskett, CD, LLLIBPC, RYT, CNA
  53. Aimee Fairman, CPM
  54. Jaqxun Darlin, student midwife
  55. Nicole Morales, LM, CPM
  56. Tehmina Islam, CPM, LM
  57. Kristin Effland, LM, CPM
  58. Krystel Viehmann
  59. Eve German
  60. Erin Tenney
  61. Dana Churness
  62. Suzy Myers, LM, CPM, MPH
  63. Savita Jones
  64. Brenda Burke
  65. Emi Yamasaki McLaughlin
  66. Kirsten Pickard, RN-C, BSN
  67. Susan Smartt Cook, CPM
  68. Jess Kreuger
  69. Sharon Muza BS, CD(DONA), LCCE, FACCE
  70. Lora Hart, Student Midwife
  71. Melanie Parsons, LM
  72. Susan Hodges
  73. Rebeca Four, IBCLC, CD(DONA), LCCE
  74. Asteir Bey
  75. Lora Clem
  76. Sherry Payne SNM
  77. Ananda Phoenix, apprenticing with birth
  78. Alisha Wilkes RN, BSN, Student Midwife
  79. Elizabeth S.K. Reiner, CPM
  80. Gretchen Ryerson LMT, Doula, Student Midwife
  81. Stephanie Lynn Tanner, CHW
  82. Brenda Francis, LPN, SM, CCE
  83. Traci Palagi, LM CPM
  84. Laura Whitley
  85. Heather Chorley, LM
  86. Margy Porter, CPM, LDM
  87. Dr. LaVonne Moore, DNP, CNM
  88. Annique Sampson, CPM, LM, NHCM
  89. Lorie Seruntine, student midwife
  90. Audrey Levine, LM, CPM
  91. Lashaan Everett, RN, BSN, SNM
  92. Mary Lawlor
  93. Geradine Simkins, CNM, MSN
  94. Elia R. Cole, BA, MPH(c)
  95. Elezya Lane, Doula, Student Midwife
  96. Michelle Maisonville, CD(CBI)
  97. Arya Pretlow
  98. Nicole Deggins, CNM, MSN, MPH
  99. Laura Perez, Student Midwife

_____________________________________________________________________

Original article in Midwifery Today E-News February 13, 2013; Vol 15, Issue 4
Jan’s Corner

Childbirth Freedom Fighters
Did those of you who live in the U.S. see the PBS three-part series on the abolitionists? I hope you did or that you can get hold of it. As I watched, I realized how this anti-slavery movement parallels our movement to free women in pregnancy and birth from the jaws of the medical establishment. This plays out all around the world with some countries being worse than others. The treatment of motherbaby is often abusive—horrendously so. Perhaps nothing is as horrible as slavery and I don’t mean to downplay it in any way by this comparison, but the effects of pregnancy, birth and the first year of life affect both mother and child for their entire lives.
The abolitionists spent 40+ years working to free the slaves. First they appealed to the slaveholder’s reason—just like we are trying to do now with medical practitioners. For the past 37 years, ever since I first became a midwife, we have fought this fight. I first thought, “Okay, once they see how wonderful birth can be from the evidence coming out, they will change.” But this change hasn’t happened—things have only gotten worse. This was the same for the slaves. For us, when I first started midwifery, they hadn’t even invaded the uterus and the prenatal period. Prenatal care was simple and very good with no routine ultrasound(s).
The anti-slavery fight was magnificent, consistent, strong and dangerous—our fight is, too. More and more midwives are getting thrown in jail, persecuted and prosecuted, especially in the United States. We have so many voices and we are unrelenting in this activism. The slavery abolitionists had battles within their movement—we have these, too. Some of us want to be law-abiding and see the bottom-line as mom’s right to choose. It is, after all is said and done, her birth and her baby.
Then the Emancipation Proclamation by President Lincoln freed the slaves. The movie “Lincoln” is about his fight to make emancipation a constitutional amendment. He knew it wouldn’t hold if Congress didn’t change the Constitution. Even after 150 years, the battle for black equality is still going on. Martin Luther King took the freedom fight to another level, but peacefully. Were it not for these milestones in history, imagine where we would be.
We who work in birth are not even at the point of an Emancipation Proclamation, but we are in the abolitionist phase. We are Childbirth Freedom Fighters. Shall we take up this new terminology? It is powerful and has a huge successful movement behind it.
— Jan Tritten, mother of Midwifery Today


Apology in thread on MT Facebook page (2/18/13  1:42pm PST):
I was so passionate in writing about birth freedom and mothers being abused – an issue close to my heart – that I got carried away and didn’t use words and images as carefully as I should have. It was unwise on my part to make this comparison. My sincere apologies to all I have offended. I ask you to please forgive me. The article has been taken down and we at Midwifery Today have again been reminded to be more careful with the content we publish. -Jan Tritten

The article has now been removed from the E-News.