Creating More Inclusive Midwifery Communities

Birth Workers Of Color Scholarship 1

I’ve been thinking a lot lately about inclusion in the midwifery profession. Of course, this is not the first time I’ve written about this. Those of you who know me know that I think about issues of inclusion and diversity all the time.

For me, midwifery has never been simply a matter of supporting individual choices in birth, although certainly that is one aspect of it. In fact, I often hesitate to blindly associate the concept of “choice” with birth, as it assumes that we all have equal access to knowledge, support and empowerment to advocate for our preferences. It doesn’t take long to realize that the illusion of choice in birth doesn’t extend very far when we’re still privileging some people as parents over others.

On a broader level, I see midwifery as a public health tool to address major disparities in birth outcomes and family health in our country. However, one big stumbling block is that the midwifery community currently does not reflect the broader community of those we seek to serve. While race is only one of many components of diversity, I do believe it is an important one. As an Asian-American woman, I rarely see myself reflected in either the general media covering empowered birth choices, or in my chosen profession. Some days I can be lulled into thinking that something as simple as seeing other Asian midwives is almost trivial, and yet, there is a substantial body of research on ways in which people of color, especially Asian-Americans, are made invisible in the Black-White racial paradigm of the United States.

In 2011, 6.6% of CNM’s who responded to ACNM’s triennial membership survey identified as people of color. Out of 2,230 total respondents (about a third of the membership that year), a whopping 4 midwives identified as Asian or Pacific Islander. Granted, a total 4% of midwives did not answer the question at all or had missing info. However, 91% (2,034 respondents) identified as white. Only 2.6% of CNM’s who responded identified as Hispanic. The last census placed the Hispanic population of the U.S. at 16.9%. The report notes that these numbers have not changed much between 2009 and 2011. Looking at the 2006-2008 report yields similar results.

So, what are some solutions?

As in any of the health care professions, addressing pipeline issues and lack of funding support are key.

How are we supporting the development of a strong, qualified applicant pool? What programs are being put in place to connect potential midwives with good mentors? How are midwifery organizations connecting with young students to introduce them to the option of midwifery as a career path? What financial supports are in place to support students who come from disadvantaged backgrounds?

This is why I’m so excited to see leaders within the CPM community take it upon themselves to make concrete changes that will support more midwifery students of color. Spearheaded by CPMs Vicki Penwell, Claudia Booker, and Jennie Joseph, they have created an opportunity for midwifery programs to commit to providing a full scholarship each year to a student of color.

And so, our Grand Challenge is this: What if every midwifery program in America, big or small, non-profit or for-profit, were to offer one FULL scholarship per year to a qualified candidate who was a woman of color?

If every school or program now in existence were to offer one full scholarship per year, the burden will not be too much on any one school’s budget. We will all share the responsibility and privilege of addressing a grave injustice in our own time and country. Within a few years we could see this imbalance shift and begin to see many women of color serving their own populations with quality midwifery model care.

It’s one step towards making our community more inclusive. What other ideas do you have? I’d love to hear them! Let’s keep this conversation flowing!

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The Next Generation

Minneapolis

Mill City, Minneapolis: site of the first annual NSfC Activist Summit!

No, this isn’t a post about Star Trek (although, I may have watched it from time to time with my dad).

It’s actually a post (finally) about my amazing weekend in Minneapolis for the first annual Nursing Students for Choice Activist Summit. It came at a great time–I really needed a reminder of why I’m subjecting myself to the stress that is otherwise known as an accelerated nursing program.

It’s so that I can become a full-spectrum nurse-midwife who provides comprehensive reproductive health care.

Right. Check.

There’s something so powerful in being in a room full of your people. Do you know what I mean? It’s that feeling of walking in, and recognizing yourself in the people that surround you: We are all here because we are dedicating our lives professionally and personally to ensure that everyone has access to quality health care, including abortion. We’re here because we believe that nurses are leaders in this work.

I’ve been at other conferences related to reproductive health and justice, but always as the younger, not-yet professional. At those conferences I see where I would like to be in ten years. I see the communities that can be built when we network across the country to collaborate together. But that’s not quite the space I’m in yet. I’m hungry to connect with others who share my experience, who are in that messy phase of becoming the kind of health care provider they want to be.

Papaya2

Practicing MVA during the “papaya workshop”

What made this weekend so rich was that it was geared specifically to where I am in my professional development as a nursing/nurse-midwifery student. The workshops spoke to the particular challenges that nursing students face in getting the education and clinical training opportunities they need to become competent providers. We learned strategies from each other about how to  advocate for more reproductive health material in both undergrad and grad nursing curriculum. We practiced our decision-assessment and counseling skills. I also really appreciated the chance get hands-on and practice both an MVA and an IUD insertion.

But beyond the specific skills and strategies is something even more valuable to me. What I carried home with me and continue to draw upon is the sense of community we cultivated. There is a new generation of nurses rising up. We’re eager for change. We see ourselves as leaders in the expansion of full-spectrum reproductive health care. It’s incredibly exciting to be a part of the culture change within the world of nursing that will lead to more nurses being involved in abortion care and family planning. Who says we need to wait until we’re RN’s, or CNM’s, or NP’s to start advocating for change? Not us! I look forward to staying connected with the new friends and colleagues I’ve met and continue to support each other in our work.

(Hats off the entire NSfC team that made this gathering happen–you folks are amazing and wonderful and made this first summit an awesome experience!)

 

 

[Friday Wrap Up]: 30

So many articles this week! Some of the highlights: exciting news for APC’s in California, one woman’s experience of a later-term abortion, new trends in prenatal screening, a call to action to end the shameful shackling of laboring patients in prisons, and an awesome, awesome story about transgender parenting from Canada. Read on!

California Expands Abortion Access!

Gov. Jerry Brown on Wednesday expanded access to abortion in California, signing a bill to allow nurse practitioners, midwives and physician assistants to perform a common type of the procedure, an aspiration abortion, during the first trimester.

Oregon, Montana, Vermont and New Hampshire allow nurse practitioners to perform such abortions, which use a tube and suction, while several other states, including California, permit nonphysicians to provide drugs to terminate pregnancy.

But the new California law goes further, allowing a wider range of nonphysician practitioners to perform surgical abortions. While other states have passed a tide of laws restricting abortion access, California has gone against the political tide.

It Happened to Me: My Late-Term Abortion Was a Nightmare, But It Didn’t Have to Be

Stories like this break my heart…and make me angry. As an aspiring abortion provider, I can’t fathom how anyone involved in abortion care would let personal judgment get in the way of providing compassionate care for their patients, especially in situations like this. I want to believe that all health care providers bring good intentions to their work…but experiences like this remind me that we have a long ways to go.

Was I expecting too much, some special treatment because I wanted my baby, because I felt like my situation was particularly emotionally fraught? Maybe I expected the clinic to feel sorry for me, and they treated me like any other woman having a “regular” abortion. Except no abortion is a “regular” abortion, and no woman having an abortion should be treated with suspicion and disrespect. Every woman having an abortion for any reason deserves a little kindness and warmth. It could make a world of difference.

Breakthroughs in Prenatal Screening

“Breakthroughs”…but with a lot of nearly impossible ethical dilemmas to ponder. I so admire the work of thoughtful genetic counselors–it’s not an easy job and the growing number of tests makes this one of the more dynamic professions in health care today. Unfortunately, this article doesn’t really delve into the ethical questions of what it means to have more testing available, however, it does touch on some of the financial aspects of testing–which really, is another ethical dilemma of its own.

In the nearly four decades since amniocentesis became widely accepted, new techniques have gradually improved the safety and accuracy of prenatal diagnosis. Prenatal tests for more than 800 genetic disorders have been developed. And the number of women who must undergo amniocentesis or C.V.S. has been greatly reduced.

We Need to Stop Shackling Women in Prison–Now

The headline says it all.

One of the first women who shared her story with Birthing Behind Bars was Linda Rosa. She learned that she was pregnant with twins after entering jail in 2008. Linda Rosa recalled being shackled each time she was taken to see the doctor: “They used to shackle my hands and my legs. I would have to walk with the shackles on my legs, which would leave cuts on the back of my ankles.” Linda had to undergo a C-section and was shackled while recovering in the hospital. She recalled having stitches and staples from her c-section and shackles on her wrists and ankles when she visited her newborn babies in the ICU. “Everywhere I had to go, I had to wear shackles,” she said.

Transgender Pregnancy: The last frontier in assisted reproductive technology

Loved. This. SO. Much. We need to hear more stories like this. It’s so important.

It took nine rounds of intrauterine insemination for Heller to become pregnant. The first four experiences at a Montreal fertility clinic had been quick and impersonal. But their fifth try was worse than usual. The doctor rushed in, never said hello or gave his name, never looked at the women. He asked “insemination?” and they said “yes.” He was quick and rough, Heller recalled, and she bled afterward, something she’d never experienced. He left the lamp on between her legs as he rushed out of the room, they say.

More Thoughts on Expanding Midwifery: Action Steps

On Sunday, I blogged about my thoughts on the ways in which National Midwifery Week is being publicized. Here’s the one sentence summary :

I love midwifery and I aspire to collaborate with other midwives to expand the midwifery model of care to be more inclusive and reflective of the communities in which I will serve. 

Since Sunday, I’ve been thinking about what I would like to see in the midwifery community. It’s been a good exercise for me to move beyond articulating the problem towards envisioning and enacting solutions.

Historically, I would argue that midwifery has been a women-centered profession. It’s in the name, for sure: “to be with woman.” It is still considered by many to be “women’s work” and often we talk about “women-centered care.” There’s the assumption that midwives are about “mamas and babies.” When we talk about the midwifery model of care, we’re generally talking about women’s reproductive health–by which we mean people who were born as females and fit into the gendered binary ideal of female. There’s also an assumption (at least here in the U.S.) that the people providing the care are also women. All of these assumptions add up to a partial truth. The whole truth is, ironically enough, is more simple than that: midwifery care is for everybody and can be provided by anybody, regardless of gender, race, sexuality, etc. Period.

As a woman of color, I think a lot about my positioning and the ways in which I am seen and not seen in the culture I live in. I am a college-educated woman with a lot of resources at my disposal…but I have to work hard to find myself reflected in the broader culture of this country. I also have to work really, really hard to find myself reflected in the world of nursing or midwifery. Because of the resources I have access to, this experience ranges from a mild inconvenience to sometimes an uncomfortable dissonance, and at times more intense frustration and anger. I don’t think I’ve ever experienced true disparity in my health care or education. Sadly, I can’t say the same is true for many of the marginalized communities in this country.

When I think about potential steps that major midwifery organizations can take to walk the talk of inclusion, I dream big, but also recognize that sometimes the small steps mean a lot. Here are a few of my ideas at this moment in time.

Show more images of diverse families.

I think many organizations are getting better about this, but images matter. They are the reflection of an organization’s values. When only certain types of families are portrayed, the underlying message says “We only serve this kind of cliente.”

Show more images of diverse midwives. 

It’s a bit of a chicken and egg question, to be sure…but the way to truly connect with a diverse clientele is to have care providers that reflect the diversity of those they seek to serve. As an Asian-American, I don’t see myself reflected anywhere in the midwifery community, as a potential parent or midwife. Likewise, where are the images of male midwives? What about queer midwives? They’re out there, doing great work! You can see it here, and here, and here. (And check out this article from Vanderbilt’s School of Nursing for more on the history of male midwives.) When we limit ourselves to the narrow mindset of midwifery = women, we’re only speaking to one community.

Make the shift in language to be more inclusive. 

My friend K wrote a short sweet post about language three years ago that I still love. Language, like images, is a powerful change agent that instantly can open or shut doors.

Speak up as an ally, loud and proud during Trans Awareness Week

At every opportunity, collaborate with ally organizations committed to anti-oppression work. There is definitely value in the quiet, behind-the-scenes work of culture change within institutions. But there is also incredible power that comes with using one’s voice, whether as an individual or as an organization, to speak up for justice.

Make real, concrete changes to the core competencies of midwifery training so that midwives graduate with the skills they need to be able to provide not just competent, but quality, skilled, compassionate care. 

This action step is especially near and dear to my heart. As a current student, I want to know that when I emerge from the cocoon that is midwifery school, I will be able to provide quality care to all my patients, no matter what their anatomy or gender identity may be. Right now, I am not convinced that midwives are getting these skills without having to pursue supplemental training outside the core curriculum.* This seems like a huge gap that needs to be narrowed before midwives can practice inclusive care.

[*Case in point: Varney’s Midwifery (fourth edition), considered by many to be the “Bible” of midwifery textbooks, includes one paragraph on transgender issues. It can be found towards the end of the 13-page chapter (of a 1,386 page text) titled “Health Issues of Lesbian and Bisexual Women.” The paragraph itself focuses on MTF transgender individuals who identify as lesbian. Two references are cited, dating back to 1996 and 1997. Obviously, not all trans people are gay or lesbian. And a lot has changed in LGBTQ health care since 1996.]

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I don’t think the process of making midwifery care will always be easy or simple. I imagine there will be some struggle and conflict and discomfort as patterns of thought shift. But the responsibility is ours and I am eager to connect with other healthcare professionals, especially midwives, who are ready to do this work together.

Midwives Make a Difference (for everyone, not just women)

It’s National Midwifery Week! As a future midwife, it’s exciting to have a designated week to celebrate all that is awesome about midwifery care.

I will say, I wish they included more about our midwifery colleagues who are Certified Professional Midwives. This is a pretty CNM-focused campaign, which I think in the end, is a disservice to potential midwifery clients everywhere. Everyone deserves to know all their options regarding midwifery care, and nurse-midwives are just one piece of that picture.

I’m also incredibly disappointed that the Our Moment of Truth website continues to feature predominantly white, heterosexual imagery and language. Yes, midwifery care is for women, but really, it’s for everyone, no matter how you express your gender identity.

Let me repeat that. Midwifery care is not just for women, despite the language and images you’ll see on the ACNM website.

ACNM released a position statement about trans-gender care earlier this year, so I was hopeful that I would start to see that language reflected in this year’s National Midwifery Week campaign. Sadly, it is still very women-focused. As an example, on the bottom of the front page, the reader is directed to

CLICK HERE to download a new document, designed especially for women, which clearly explains normal, healthy childbirth.

According to the Transgender/Transsexual/Gender Variant Health Care position statement, ACNM has adopted the following goals:

  • Work toward the incorporation of information about gender identity, expression, and development in all midwifery educational programs;
  • Make available educational materials that address the identities and health care needs of gender variant individuals in order to improve midwives’ cultural competence in providing care to this population;
  • Support legislation and policies that prohibit discrimination based on gender expression or identity;
  • Support measures to ensure full, equal, and unrestricted access to health insurance coverage for all care needed by gender variant individuals.

But really, the first step is to publicly acknowledge that transgender people exist.

You do this by making your websites inclusive in language and imagery. You speak directly to the people you aspire to serve. I don’t see this happening yet.

I’m not trans, but if I were, and I were looking at the ACNM website this week because a friend recommended I check out midwifery care, I would not see anything that reflected my experience and my health care needs. And as a future midwife, that’s a huge disappointment. Because midwives do make a difference and not just for women.

[Friday Wrap Up]: 27

Doula care in low-income communities, an awesome new children’s book on where babies come from, a pair of articles exploring infertility, a rocking birth story, thoughts from a 20-something who’s tired of being asked when she’ll start having kids, and a gorgeous photo essay of Muxas, or ‘third’ gender folks in Oaxaca. Another beautiful week of vacation reading that left me inspired, provoked, intrigued and more.

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The Amazing People Who are Changing How Low-Income Moms Give Birth

A great article exploring the rise of doulas in low-income communities and the ways in which doulas can improve birth outcomes in these communities.

You should really pair this with Miriam Perez’s great blog post earlier this spring about the future of the doula movement. I appreciate the hard questions she asks about the intersections of doula care, sustainability, finances, etc. The real question is…as we move more towards seeing Medicaid reimbursement for doula care, what does that mean for the way in which the doula role might shift?

What is the end goal of the doula movement? What are we working toward? Many doulas would likely say—and I would have been among them just a few years ago—that the end goal is to have a doula at every birth. But I no longer believe that’s the right goal.

I think doula work is valuable and important, and I also don’t believe the essence of doula work—non-judgmental and unconditional support for pregnant and parenting people—needs to be locked away in a system that says only a certain amount of training, certificates, or other paperwork bestows upon someone the right to provide this support. We run the risk of replicating the model we’re trying to revolutionize. And I don’t think that is where real social change happens.

What Makes a Baby

An awesome new book by Corey Silverberg. In his words:

What Makes a Baby is a children’s picture book about where babies come from that is written and illustrated to include all kinds of kids, adults, and families. 

Geared to readers from pre-school to about 8 years old, it teaches curious kids about conception, gestation, and birth in a way that works regardless of whether or not the kid in question was adopted, conceived using reproductive technologies at home or in a clinic, through surrogacy, or the old fashioned way (you know, with two people and some sexual intercourse), and regardless of how many people were involved, their orientation, gender and other identity, or family composition.

Just as important, the story doesn’t gender people or body parts, so most parents and families will find that it leaves room for them to educate their child without having to erase their own experience.

Fertility Diary (a new Motherlode blog feature by Amy Klein)

This I.V.F. stuff is hard. It is my first time in the trenches, but I already feel as if I need some sort of medical degree to do this — or at least a medical technician degree to give myself daily shots. Some women I know hire nurses to come to their homes to do it. Other women have to take two shots a day.

and related to this, an editorial called Selling the Fantasy of Fertility:

As former fertility patients who endured failed treatments, we understand how seductive that idea is. Americans love an uphill battle. “Don’t give up the fight” is our mantra. But the refusal to accept physical limitations, when applied to infertility, can have disturbing consequences.

It’s no wonder that, fueled by magical thinking, the glorification of parenthood and a cultural narrative that relentlessly endorses assisted reproductive technology, those of us going through treatments often turn into “fertility junkies.” Even among the patient-led infertility community, the prevailing belief is that those who walk away from treatments without a baby are simply not strong enough to run the gantlet of artificial conception. Those who quit are, in a word, weak.

I LOVED this birth story, from Mutha MagazineS. LYNN ALDERMAN’S Ugliest, Beautiful Moment (Or, Fuck Ina May): 

But inside my head, I could not believe what was happening. How painful it was. How terrifying. I felt helpless. And degraded and humiliated by there being witnesses. And at the same time, I felt so, so alone.  I remember at one point saying, completely out of my mind, “I don’t understand why no one is doing anything to help me! Please help me!” Della reminded me that what I was feeling was the baby coming. That I was doing just what I was supposed to, having the baby, right then.

26, Unmarried, and Childless

This post comes from a Christian-focused blog. I found the perspective quite intriguing. I grew up in a Catholic family, in which having children was seen as a way of manifesting God’s love and fulfilling our God-given role as men and women. Reading this article brought up a lot of memories of arguments with family members about this argument can lead to hurt feelings for those who experience infertility…or simply don’t want to have children or be parents.

Instead of relishing in the freedom, blessings and limitless possibilities that this stage of life offers me, I am left frozen, feeling like I’m not enough. Like what I’ve done doesn’t really matter or that I’ve accomplished nothing. I’m an outcast. I’m defective. I’m panicked. When you comment on my life stage as if there was something I could do to change it, it makes me feel inadequate. Most days I truly do love where I’m at right now, but when people question my marital status, I think I’m messing up my chances to do anything worthwhile with my life.

Striking Portraits of Muxes, Mexico’s ‘Third’ Gender

Before Spanish colonization blanketed Mexico with Catholicism, there were cross-dressing Aztec priests and hermaphrodite Mayan gods; gender flexibility was inherent in the culture. In much of the country now, machismo prevails and attitudes toward sex remain relatively narrow. But things are different in the southern state of Oaxaca where more pliant thinking remains. In the Zapotec communities around the town of Juchitán, men who consider themselves women—called “muxes”—are not only accepted, but celebrated as symbols of good luck.