Radical Doula

I had the unique pleasure of interviewing midwife and birth activist Ina May Gaskin (via email) for my latest Colorlines feature.

Ina May graciously allowed me to post the full text of our interview since only a few snippets made it into the Colorlines piece. She had a lot of wisdom about this issue (not surprisingly!). It really is worth the read–Ina May displays a really comprehensive understanding of the issues facing women of color when it comes to out-of-hospital birth care.

Here’s Ina May:

RD: You mention briefly in Birth Matters that when obstetricians were trying to bring birth to the hospital (and learn how to care for birth), one doctor in Chicago paid immigrant women to give birth there. I’ve also understood that initially, particularly black women weren’t allowed access to hospital birth because of segregation/racism and class issues as well.

IM: That’s true. In general, low-income women in urban areas were initially brought into hospitals so that doctors in training could practice on them. That how they “paid” for their care.

RD: Can you tell me a little more about the history of particularly women of color in the US when it came to birthing in the hospital? Did they have a different experience than white women in terms of when they made the transition from home birth to hospital birth?

IM: Yes. For the most part, women of color who lived in the rural south didn’t go into the hospital until the 1970s and 80s. Alabama, Mississippi, Arkansas, Florida, and Georgia still had midwives who assisted women giving birth at home right through the 1970s. When doctors could count on Medicaid reimbursement for the first time, that situation quickly changed, and the midwives who were so needed before were forced to retire. Farther north, the pattern was somewhat different, because midwifery was outlawed in many states. Everyone was pushed into the hospital when this happened, regardless of the color of their skin. Women of color and poor white women were both used as teaching material in the teaching hospitals throughout the country. For this reason, the shift from home birth to hospital birth took place much earlier among urban women of color than it did for those in rural areas of the south.

RD: Tell me about what you know about the demographics of women currently giving birth out of hospital with midwives. Are women of color accessing these services? If not, why do you think this is?

IM: A growing number of women of color are accessing these services, and I believe that many more would, who currently lack access to home birth services. I am sure that we’ll see more people gain access if the House Bill put forward by Chellie Pingree early this year becomes law [Edits made to reflect factual corrections about legislation sponsors]. This bill will include Certified Professional Midwives (CPMs) as Medicaid providers. Currently, birth centers which are staffed by CPMs are not able to open their doors to women with Medicaid coverage. I do know quite a few people who have visions of opening birth centers in urban areas with large populations of women of color. If the CPM bill passes, I think that we will see a great change, because many young women of color would like to be able to enjoy birth choices that include having a midwife-assisted birth, laboring in water and that kind of thing.

Lack of choice in maternity care is a major burden for women of color. In Los Angeles, for instance, going through MediCal means that you can count on getting an obstetrician instead of a midwife, and you’ll get the bare minimum of services. The obstetricians themselves are reimbursed so little by Medi-Cal that the moms get the worst care available. Informed choice is not part of the program. Each woman is expected to take the one choice that’s on the menu without complaint.

Another burden comes under the heading of required testing. Low-income women getting their care via Medi-Cal, for instance, are often told that they’ll have to be x-rayed for tuberculosis while pregnant.

Another problem is that CNMs of color in many areas of the country have a lot of trouble finding work. I can’t count the number who have told me that they are unable to get jobs at hospitals or birth centers, and it can be just as hard to find a doctor who will provide backup for home births.

RD: There has been a focus on the issue of low-birth weight and fetal mortality among particularly black and Latina women (for example, Healthy Start). Those programs have focused mostly on home visiting and case management to ensure that women get access to prenatal care and get enrolled in insurance programs.

Do you see a relationship between these negative outcomes and the dominance of hospital birth?

IM: Absolutely. Amnesty International’s publication, Deadly Delivery, has documented how difficult it is for women of color in many areas of the country to get into prenatal care early during pregnancy. This means that pregnancy complications are often missed in early stages when they could be turned around or prevented in the first place. It is also very clear that the kind of prenatal care that focuses on empowerment and education about healthy choices to make during pregnancy is central to preventing premature births and low-birth weight babies. Obstetricians don’t have the time or the training to provide the kind of care that actually prevents prematurity and low-birthweight. Countries that make more use of midwives (the countries with the lowest rates of newborn and maternal mortality make sure that in about 70% of births, the dominant caregiver is a midwife. It is she who provides the prenatal care and it is she who attends the birth, not an obstetrician. These countries understand that prevention of problems makes more sense than continuing to perpetuate the myth that every pregnancy and birth is a disaster waiting to happen. Prevention of complications depends upon helping women in early pregnancy to get good nutrition and exercise, and it also has to do with helping women reduce the stress in their lives.

RD: Do you think expanding access to midwifery care via CPM coverage in Medicaid could have an impact on these rates for women of color?

IM: I do. If CPMs could be reimbursed by Medicaid, more women of color could get into prenatal care early during pregnancy. CPMs aren’t under institutional constraints to do 10- or 15-minute prenatal visits. It takes time to provide the kind of counseling about nutrition and exercise that can prevent complications such as prematurity and low-birthweight.

It’s not just complications during pregnancy and labor that need to be prevented. Postpartum care after hospital discharge is very scanty in the US, except for that offered by homebirth midwives. It used to be that women were kept in hospital for five days after giving birth because of the possibility of postpartum hemorrhage, pulmonary embolism, or postpartum infection. Since the early 1990s, women have been discharged early from hospital. Even women who have had cesareans are often discharged on the 4th day or so after birth. This can be a safe practice, as long as there is a system of postpartum home visits that are organized specifically to make sure that mothers who could be in danger are diagnosed and treated before a problem becomes life-threatening. Most western European countries make sure that women get postpartum home visits during the ten days or so following birth by specially trained nurses or midwives—the kind of care that is routinely provided by home birth midwives, whether they are CNMs, CPMs, or CMs. However, most hospital-based practices do not provide such home visits, and in many cases, a phone call is all that a new mother might get during the first week or so after discharge.

I know of at least two cases in which single mothers (they were both women of color) died at home of postpartum hemorrhage after hospital discharge. (Tameka McFarquhar and Virginia Njoroge’s stories can both be found by clicking on “Virtual Quilt” at the Safe Motherhood Quilt Project website www.rememberthemothers.org. At least one of these women had what was supposedly decent insurance coverage, but it still didn’t provide for a home visit after hospital discharge, even though it was known that she was single and had no family members available to help her.

It’s not unusual for some bits of placenta or membrane to be left inside a mother after the placenta is delivered (usually when it removed manually, or sooner than it wants to come out on its own), and these women are in danger of a late postpartum hemorrhage if this situation is not detected. Ideally, placentas are carefully inspected for completeness just after they come out, but often this important step is neglected in hospitals where the assembly line runs fast. Midwives and postpartum nurses can diagnose this problem by smell or by touch, but a phone call to a new mother is not sufficient.

Other problems that may emerge after hospital discharge are infection or pulmonary embolism (particularly in women who have had cesareans). Both can be fatal. If women aren’t told of the symptoms of these conditions (I’m told that the discharge information is more likely to focus on providing birth control information), they may ignore symptoms and assume that leg pain is nothing to worry about (when it is, because it is a symptom of deep vein thrombosis that can lead to a pulmonary embolism).

All this said, I worry that if we, with all good intentions, decided to provide routine postpartum home visits to all mothers (not just those who have home births), such care could degenerate into another way to putting pressure on women of color by threatening them with losing custody of their babies. We have to find a way to provide postpartum for women that is nurturing and get away from the mode that we see too often that expects them to be perfect without education and constantly threatens them with punishment without providing the least support.

RD: Do you think there are particular barriers to encouraging women of color to consider midwifery care out of hospital that might different than for white women?

IM: I know that a generation ago, there was a perception among many women of color that midwife care was somehow second best—that it was associated with poverty. For a while now, I have been noticing that many women of color have wised up about this. I’m meeting many who are doulas, childbirth educators, and lactation consultants, and they tell me there is a huge demand for their services. They tell me that the young women that come to their classes are aware that water birth is a possibility and aware that breastfeeding is better for their babies than formula feeding. They’ve seen “The Business of Being Born” and “Orgasmic Birth” and “Birth Day” and want that kind of midwifery care too. The trouble is that these choices are not part of the standard package that is available to low-income women of color.

Despite what I mentioned above about a growing awareness of the value of midwifery care and the choices that midwifery-led care includes among women of color, there is still a lack of understanding of what a midwife does, and there is just as much fear of giving birth without medication among women of color as there is among Caucasian women. This fear obviously keeps many women from choosing out-of-hospital birth.

RD: In my work with immigrant women, particularly from Latin America, I’ve noticed that they bring with them the idea the home birth is what women who can’t afford to go to a hospital do. Have you noticed this bias among immigrant women toward hospitals? If so, how do you think this could be addressed by midwives and advocates?

IM: There is quite a lot of pressure on immigrant women to fit in and do things the way that most US women appear to be doing them. Part of this is probably because so few US women actually do give birth at home that immigrant women are barely aware that such services are available. Hospitals are able to provide interpreters for women whose languages aren’t spoken by midwives who provide out-of-hospital services. On the other hand, I do know that Muslim women in Dearborn, Michigan, do access home birth services in many cases. The Morris Heights Birth Center in NYC is another example of an out-of-hospital maternity service that provides access to immigrant women.

All this could change at a faster rate if the CPM bill passes.

RD: There is a really compelling argument for out-hospital birth in terms of cost saving. Why do you think this argument hasn’t been very effective for changing policy or practice when it comes to birth in the US?

IM: Cost-saving actually means very little in the organization of US maternity care. What we do here is to narrow the choices that women have while providing a very expensive form of care—one that often creates problems that then must be addressed. US maternity care is more focused on generating income for hospitals than it is on achieving the best possible birth outcomes for mothers and babies. If we were more focused on safety, there would be some limits placed on what fertility specialists are allowed to do here, since the multiple gestational pregnancies that have become so popular create many more risks for these mothers and their babies. If we were focused on safety and not just the appearance of it, we would already have turned over the care of healthy women to midwives. The evidence has been there for years, but the obstetrical profession in this country built itself on eradicating midwifery and it’s hard to turn this kind of situation around. It’s possible, but it’s hard.

Profits are maximized when caring midwives are replaced by electronic fetal monitors. Profits are maximized even as cesarean and induction rates rise. I’d like to see us junk this profit-based system and replace it with one that prioritizes mothers’ and babies’ best interests. That’s the only way I see us turning around the obscenely high rates of c-section, inducted labors, and maternal deaths that we have in this country