Birth politics in a “majority minority” country

There has been a lot of news lately that keeps tying back to the thread I started a while back, about how midwifery can truly be accessible to communities of color.

First, last week we had a big media splash with new census data that shows the majority of babies being born in the US today are not white. This has been true for quite some time in certain parts of the country, like California, but now it’s a national fact. Demographers have been predicting for a long time that we’re heading in this direction, so it’s not a surprise. But it does make for good headlines, and stirs the pot of zenophobia and racist panic.

It also makes extremely clear how important it is that we focus on the needs of communities of color when it comes to maternal health. It’s no longer about an interest group! It’s no longer about the minority! Dealing with race-based health disparities in maternal health is actually about the majority of births. Wow.

Feels like a game-changer to me.

Unfortunately for midwives and birth activists, women of color are still a very small minority of those accessing out of hospital birth. A bigger slice is likely accessing in hospital midwifery care (anyone know those stats?) but we’ve got a long way to go.

Then, yesterday, the news that the Midwives of Color contingent of MANA, Midwives Alliance of North America, resigned in protest. Still waiting to see a statement from MOC about what prompted this move, but MANA already acknowledged it on their facebook page:

It is with heavy hearts that the Midwives Alliance today received the resignation of several key members of the MANA Midwives of Color (MOC) Section, including the Chair. MANA is fully aware of its history of privilege and the issues related to cultural and systemic hierarchies in decision-making. We are committed to working towards a structural change in the way our organization operates in light of the repeated failures to address the needs of our midwives of color. We recognize the disproportionate impact of perinatal disparities and poor outcomes for women, infants and communities of color. MANA has an ongoing responsibility to address these issues in order to fulfill our mission of providing a professional organization for all midwives.

I’m not involved in MANA, I’m not a midwife, I haven’t talked to anyone from the MOC. (I did attend a MANA conference back in 2005/2006 in Mexico City). I don’t know the specifics of what went down, what prompted this major move.

What I do know is this: We have to center the needs of communities of color in maternal health. The disparities alone should have been enough of a reason. Black women are FOUR times more likely to die during childbirth than white women. FOUR TIMES. But of course, that’s how racism works.It perpetuates systems of oppression by marginalizing the needs of those most in need.

But now we’re no longer the minority. Now, the health of the nation very literally depends on our ability to tackle race-based health disparities, particularly in maternal health.

I personally believe that the midwifery model of care is a big piece of the puzzle when it comes to answering the problem of race-based maternal health disparities. And a big piece of the puzzle of making midwifery care accessible in communities of color? Midwives of color.

So I sincerely hope that MANA, or whatever other governing bodies exist in the midwifery world, can get their priorities straight, and do what work needs to be done.

The numbers don’t lie–and they point in a clear direction. We need to be putting all of our attention on race-based maternal health disparities. All of it. It’s a concern of the majority now.

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Increase in home birth leaves women of color behind

Last week, the CDC released data proving what those of us in the birth activist community have noticed for years: home birth is on the rise. They evaluated home birth numbers from 1990-2009.

After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.

There are many reasons for this increase, from Ricki Lake and the Business of Being Born, to studies that show serious problems with our maternal and fetal mortality rate. Also midwifery is on the rise, and CPMs have been successfully pushing for recognition at the state level.

To those of us who support the midwifery model of care and believe that leaving the hospital setting is a good idea for many low-risk births, this is great news. It’s also still disappointing that the overall percentage is so low–less than 1% of all births! Although when you look at it on a state level, there are places (like Montana and Oregon) where the rates are double the national average.

CDC graph of home births broken down by race/ethnicity

But, as we’ve come to expect, when you examine these numbers based on race and ethnicity, the picture is very different:

For non-Hispanic white women, home births increased by 36%, from 0.80% in 2004 to 1.09% in 2009. About 1 in every 90 births for non-Hispanic white women is now a home birth. Home births are less common among women of other racial or ethnic groups.

About 90% of the total increase in home births from 2004 to 2009 was due to the increase among non-Hispanic white women.

The chart above shows just how dramatic the disparity is. I addressed some of my thoughts about what’s behind this gap in this post, which generated some good discussion in the comment thread.

I think we’ll see that racial gap diminish when midwifery advocates include people of color in their work. When more midwives and doulas of color are leading these initiatives, and also when public funding for out-of-hospital birth care is addressed.

The other disparity that the CDC study points out is a geographic one, which may also mirror the racial disparities:

Map of US with percentage home births by state

The percentage of home births was generally higher in the northwestern and lower in the southeastern United States.

This Northern/Southern disparity is true for many health outcomes, and can probably be attributed to demographic differences, as well as a political climate that more favors midwifery and out of hospital birth in the Northwest. It’s clear we need more strong midwifery advocates in the South–and that would also be a place where it would make sense for people of color to take the helm.

We know that a shift as radical as bringing maternity back out of the hospital is going to take decades. It was a decades-long,  well-funded campaign that brought birth into the purview of doctors and hospitals to begin with. The good news is we are moving in the right direction, but if we leave women of color behind, we’re not going to achieve the wide-spread culture shift we’re working towards.

How can midwifery truly be made accessible to communities of color?

Right as 2011 was wrapping up two articles were posted about home birth and midwifery revivals in communities of color. Having written about the question of race in the home birth movement back in 2009 for RH Reality Check in these two articles, I’m excited when new outlets pick up the story. There is much movement in this arena, and also much more than can be done to make sure US midwifery is accessible to people of color.

In New America Media, Valeria Fernandez writes about efforts to revive Mexican midwifery in Arizona:

Marinah Valenzuela Farrell is one of only a few licensed midwives in Arizona. Though it isn’t a profitable venture, helping mothers bring their newborn children into this world is for Farrell a calling deeply rooted in her native Mexican tradition.

“It is really hard to be a midwife,” said the 41-year-old. “You don’t sleep, and you don’t make money. People think you’re crazy because you’re doing homebirths.”

A majority of Farrell’s clients are middle class and white, though as a Latina she aims to make midwifery accessible to low-income women in dire need of prenatal services but too afraid to seek them out in a state virulently hostile to undocumented immigrants.

“I think they don’t know that we exist,” she said. “I think the more the community knows that there’s a midwife who will come and visit them at home and do a homebirth… [attitudes] will change and shift.”

I spoke to the author while she was working on the piece, and a quote of mine is included toward the end.

In The Grio, Chika Oduah writes about black women and home birth. The article includes a video, which is a good primer of the issues at hand with home birth. It also references my Colorlines article about the possible connection between maternal health in communities of color and access to midwifery care.

What is clear from the research about this issue is that women of color are less likely to receive midwifery care, and that disparity is larger than the population numbers would suggest. I think this dynamic is complicated by global sociopolitical historical factors. For example I experienced resistance from Latina immigrant women to midwifery care because of the stigma toward parteras (midwives) in their home countries. In many places in Latin America, midwives and home birth are seen as the option used by women who can’t afford to go to hospital for birth–basically an option only for those who have no other option.

That creates class and race stigma on home birth and midwifery care.

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Midwife Robin Lim honored with 2011 CNN Hero Award

Vodpod videos no longer available.

I hadn’t followed this competition, but was excited to learn that the winner of this award, which comes with $300,000 for her cause.

About Robin:

Robin Lim, an American woman who has helped thousands of poor Indonesian women have a healthy pregnancy and birth, was named the 2011 CNN Hero of the Year on Sunday night.

Through her Yayasan Bumi Sehat health clinics, “Mother Robin,” or “Ibu Robin” as she is called by the locals, offers free prenatal care, birthing services and medical aid in Indonesia, where many families cannot afford care.

After reading about Robin and her work, I realized that her clinic sounded familiar. They are listed on my Volunteer Doula Program page! A friend of the clinics posted in comments a few years ago about their work, suggesting I add them to my list.

So glad to see their impact is being honored, and on such a mainstream platform. It’s also lovely to see a birth activist and woman of color honored for her work.

Learn more about her clinic here. They even have a birth doula workshop for interested doulas in Indonesia!

Vermont mandates insurance coverage for licensed midwives

Great news from Vermont:

“One of the things that’s extremely important to our families is to be able to have a choice about the way we bring Vermonters into this world,” said Gov. Peter Shumlin, D-Vermont.

Shumlin signed a bill into law Wednesday requiring Vermont insurance companies to pay for the prenatal care, deliveries and aftercare that licensed midwives provide.

Insurance coverage for midwifery is a win-win situation. It saves insurers and the state money, and parents get the care they want.

Victory for midwives in Colorado

For the last few months I’ve been watching the situation in Colorado, where the bill allowing direct-entry midwives to practice was set to expire.

Indra Lusero and a group of consumer advocates were working hard to improve the new version of the law. They wanted to make sure that midwives were given the best opportunity to practice their trade, supported by the law.

This is a legislative situation we don’t hear much about. A lot of the news focuses on states trying to get these licensing laws established in the first place (there are currently 23 states without them on the books). But all of these laws do “sunset” at some point, and have to be renewed. It presents an opportunity to change things for the better, which is what these folks were able to do.

Indra and I spoke on the phone during the campaign. Indra became a midwifery advocate after her own home birth. This is what she had to say about why they began the campaign:

Midwives were frustrated with the current state of the law which was inacted in 1993 and hadn’t been improved in 17 years. Some of those initial compromises that had been made in that fraught time were really limiting. Some of the language was explicitly opposed to midwifery—”we’re going to regulate you but we don’t feel good about it.” Some of the scope of practice things: not being able to carry anti-hemorrhagics. Rogam, Vitamin K. And one of the bigs one that we’re fighting over this session is suturing—the ability to repair minor tears at home.

In political environments that are often very midwife unfriendly, these battles can be particularly challenging. Midwives are afraid if they push to hard, they might lose altogether and no longer be able to practice in the state. So often what results is compromise laws that can severely limit the midwives ability to practice as they are trained to do.

Indra’s group though, presented a different advocacy effort–that of consumers, not the midwives themselves. Their stake in the fight is different, and can be received by elected officials in new ways.

In the end it was a big success, and the new version of the bill has passed through the State Legislature with little opposition, to be signed into law by the Governor soon. They weren’t able to secure suturing privileges, but there is a possibility that could be allowed through other mechanisms.

Here are a few of the changes they were able to achieve:

  • Registered CPMs can now be simultaneously licensed as nurses (and vice versa). This was prohibited in the original law.
  • Registered CPMs can now obtain and use these drugs: Vitamin K, Rogam, antihemorrhagic drugs, and eye prohylaxis.
  • The language that spoke negatively of midwifery was removed.

Those are just a few highlights! You can read all the nitty gritty details here. A big congrats to the folks in Colorado who worked on this bill.

Interview with Ina May Gaskin about women of color and birth

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.

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