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Race and the Rights of Childbearing Women

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When analyzing maternity care reform in the U.S. and beyond from a social justice perspective, one of the first steps in looking at whom the system serves best and whom it harms is to peel away layers of ideological crust to find what lies beneath. Scraping off the tasty layer of buzzwords like Autonomy! and Choice!, then peeling back socioeconomic, racial and cultural barriers reveals of hot convoluted mess of insurance woes, patient coercion based on fears of litigation, an unprecedented number of unnecessary surgeries, internal battles between care providers and hospital risk management departments, unrealistic expectations and discrimination. 

Míriam Pérez’ article from March, 2009, The Cost of Being Born at Home, covered socioeconomic and racial disparities in maternity care. Around the same time, Dr. Michael Lu of UCLA presented his research on the effects of racism on birth outcomes at the Coalition for Improving Maternity Services Mother-Friendly Childbirth Forum and blew the (almost entirely white, female) audience away.

In December, a discussion began on the post Stuff White People Like: Talking About Birth, a comment-turned-post in which I tried to put my finger on that sick feeling in my stomach about the obvious dominance of white women in birth advocacy. In the months following that post, the obvious schisms in advocacy became too obvious to sweep under the rug. Coincidentally and with no prior discussion, two of the site’s new co-bloggers wrote posts that basically threw the rug out the window.

If you’re looking at maternity care reform as a health movement that relies upon procuring supplies and services outside of what public clinics, Medicaid or typical insurance plans cover, you’ve already alienated hundreds of thousands of families.

Furthermore, the overlapping birth advocacy communities, even with their widely differing views, appear to be a microcosm of U.S. society. There is a capitalistic system in place for handling maternity care (or anything else, really) in the United States. Privilege gets you a seat at the table in deciding policy and few actually get to pull up a chair as an advocate or activist. Ultimately, the faces at the top are white, middle and upper class, heterosexual, able-bodied with an advanced degree. The macrocosm gives insight to the microcosm.

This is a phenomenon that is more apparent in public education, which has a standardized curriculum. Textbooks set the white man as the norm, white people get crabby and feel like their good ol’ American history is being imposed upon by throwing a few sidebars in about Black History, and people of color are used to enrich and expand the cultural and linguistic horizons of white kids while administrators argue that they have a great multicultural education program because the Ballet Folklórico came up from the other side of town AND they served latkes in December.

Neither of these concepts—privilege in the health care “movement” or how members of the dominant culture get a larger voice— really socked me in the gut. I feel like I notice this everywhere.

What really shocked the hell out of me was how irrelevant the push for patient autonomy, right to informed consent and informed refusal, shared decision making and access to accurate information can be. What I was trying to say in the Stuff White People Like post was that I fit the profile of Competent, Reasonable Person and Good Parent in American Society. Just as I’m not as likely as a woman of color in the U.S. to get followed around Neiman Marcus or one of those fancy stores, I’m not as likely to get followed around by a social worker. I had the “dead baby card” pulled on me repeatedly in my dealings with doctors four years ago, but the odds of me having what we can probably call the “Child Protective Services card” pulled on me were slim.

Me and institutions? We’re usually okay. People of color and institutions… not so much.

According to Amnesty International, black women are eight times more likely than white women to be imprisoned, making up nearly half of the nation’s female prison population, with most serving sentences for nonviolent drug or property related offenses. Latina women are incarcerated four times as often as white women.

The foster care system targets black families at astounding rates. The California Black Women’s Health Project states on their web site that “[o]f the more than 513,000 children in foster care in the United States, nearly 75,000 live in California and an overwhelming 27% of California’s foster children are Black.” The site also says that by their seventh birthday, almost 40% of Black children have been referred to child welfare services and nearly 10% placed in foster care and, in California, 81% of all children entering the foster care system were removed from their homes for neglect-related reasons.

Racial disparities in health care reported on the AHRQ site show that about 30 percent of Latinos and 20 percent of African Americans lack a usual source of health care compared with less than 16 percent of whites. Latino children are nearly three times as likely as non-Latino white children to have no usual source of health care.

The American Congress of Obstetricians and Gynecologists cites an article in its 2005 Committee Opinion No. 321 regarding likelihood that obstetric judgment was incorrect in cases of coercive and punitive measures in forcing treatment on a woman.  In the same article from 1987, a survey showed that eighty-one percent of the women involved in court-ordered cesarean, forced hospital detention and forced intrauterine transfusion cases were black, Asian, or Latina, 44 percent were unmarried, and 24 percent did not speak English as their primary language. All the women were treated in a teaching-hospital clinic or were receiving public assistance.

The list could go on and on to include attitudes toward bodies of color, the outright abuse and experimentation on people of color in medicine, the view that black children are a different species, etc.

Patient autonomy, right to choose, right to personal agency, rights of laboring women, right to refuse care… all of these concepts are particularly sticky in society in which racism in institutions runs rampant. Of course, there are plenty of exceptions and women of color often receive excellent care without a hitch and middle-class, white women sometimes have CPS called on them for planning a home birth.

Courtroom Mama wondered about the possibility of a cohesive movement for the rights of childbearing women, and I have my doubts. I can’t speak for anyone else and I don’t represent anything more than myself and this blog, but knowing that the right to refuse medical intervention and exercise autonomy without the looming threat of CPS is more of a right for some women than it is for others makes me wonder who else is tiptoeing around this elephant in the room.



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Reader Comments (27)

First and foremost Jill, thank you for this post. I've been debating on tackling some issues I've had regarding race on my blog. For those who haven't seen me around facebook, or who aren't following my blog or a fan of my fanpage on facebook, I am a black woman who has birth in our (America's) Maternity health care system three times. I am also a childbirth educator, student doula, aspiring midwife and normal birth advocate. I'm 34 years old and have held many jobs where I was the only black woman in the office (sometimes the whole office building) and yet I've never felt so marginalized by my race (and gender) as I have felt in the few years I've been a childbirth educator and normal birth advocate.

It really hit home for me when a fellow colleague gave me what she considered positive and good feedback regarding my website. I'd just built it and wanted to make sure that it flowed well, have very few spelling and grammar errors (my two week points), and overall look good. She told me, and I quote: "It would be best if you used different pictures. The pictures you have don't represent your overall target audience and you need to reach everyone." Now I invite you ladies to take a look at my website www.birthyourway.org, however if you don't want to, I'll save you some time and describe the pictures. There is one of me, pregnant, with my third child. There is one of my son (who is of mixed race, I am black of course, and his father, my fiance, is white) and there is one of my niece, who is also of mixed race (my sister's husband is Italian) and then there is the international breastfeeding symbol picture. I asked her, point blank, if she meant I should have more white women or children on the site and she said, without flinching, Yes. Then she reiterated I needed to reach my target audience.
The conversation brought me back to a time when I needed to go on a job interview, but I was scrambling to get my hair redone. I'd had it in cornrolls (braids) and new that to be considered a viable candidate I needed to change my looks. I needed to conform. It angered me greatly because I'd seen her website and there was not one brown person represented. Did that mean that she didn't consider black, hispanic, asian, native american, or any other women besides white women her target audience? Did she assume that about me? Or did she mean that in order to be taken seriously by white women, I have to conform somehow? I decided to view many other websites, and while there were some with the occasional "brown" woman, or couple, there were by far more without. What does this mean? Does it mean anything? I'd never even really considered it until my conversation with her about my website.
Once I became more aware of my "blackness" in this field, so to speak. I became more aware of how I so many times I'm the only one. I'm the only one in some of my meetings, I'm the only one commenting on websites sometimes. I'm the only one in my circle of black friends (the only one advocating for normal birth that is). And I noticed how different my experiences are from other women, and that sometime because of this, their level of empathy isn't that great. For instance, there is a strong belief by some women that if you want a home birth, there are no real obstacles but the ones you allow to stop you. So what if medical doesn't pay for it. Pay for it yourself. And while there are so many women blessed with the ability to do this, some aren't. And I feel many women, the majority of them white, simply can't understand this. The lack the ability to really walk in someone else's shoes, but let me be the first to say, some don't want to. The don't want to identify with the women who have true obstacles in this maternity health care system. I don't know what the reasons are, I can speculate that some feel these women are playing the victim card and don't want to identify with women who portray weakness in this crusade for Autonomy in health care, and control over our bodies. Maybe those women are feminist, not just white. Maybe those women are "liberated" black women. I don't know who they all are. I do know the ones I've talked to, argued with, pleaded with were not just white women, but white women of greater financial means and education. Perhaps those are the targeted audience my colleague referred too. I know that even when I told them of my situation, how because I was jobless, and my boyfriend had just been fired, I found myself pregnant with no insurance. I tried in my last trimester to have a home birth after educating myself, but could find not one midwife who would take me and my dreaded medical. I still get the if you really wanted it, you would have found the money, comments and let me tell you they hurt. They cut like a knife. I was in a situation where we had very little money (in fact we were 2 payments behind on our 2k dollar mortgage), and very little resources, desperate not to birth my baby with a doctor who called me silly for wanting a water birth, and my fellow advocates basically told me I was lazy. They couldn't empathized at all.
Let me just say this, and I'll stop what I fear has become a rambled mess of my thoughts. I do know, from many personal experiences that We (birth advocates and professionals) are not all on the same page sometimes as basic women, wanting basic human rights and control over our bodies and birthing experiences. It makes me sad, it makes me anxious, because I feel division sometimes. A division I don't quite understand or think is necessary.

February 24, 2010 | Unregistered CommenterPatrice

Dear Jill,

Thank you for being such a great white person.

(I kid, I kid!)

This obviously is something that brings up a lot of issues for me. One of the predicate issues, like they say, is recognizing that you have a problem. In my travels, I have encountered a shocking number of people who genuinely, earnestly believe that there are not racial and socioeconomic barriers to what is commonly referred to as “natural” or “normal” birth (scare quotes because I know those terms are somewhat loaded). How anyone can say this when some states prohibit Medicaid reimbursement of midwives and birth centers is beyond me. (Looking at that typed out, it looks like indignation, but it’s really not. You can’t fault people for not being familiar with circumstances outside of their experience – but you can fault them for a failure to heed wakeup calls… ) In any event, Medicaid is just the first step. “Access” isn’t really access if you have to hold freaking Congressional hearings to actually get your birth covered, or if you can’t find a provider that speaks your language, or who respects your culture. I’ve heard people suggest that insurance shouldn’t cover epidurals for a vaginal birth, which is cute and cheeky from a vantage of privilege, but a huge WTF from the perspective of poor women (you “get to” experience the “joy” of unmedicated birth thanks to Birthing Rights Activists™! Cheers!) The same discussion has come up around elective cesarean surgery. I think that a great many of us have come around to the realization that—at the very least—there are some situations in which we think elective cesarean is justified. If this is the case, do we really want to make it something only the privileged can access? Another component that I think sometimes gets lost in the shuffle is that access to “natural/normal” birth is just a part of it, it’s also about dignity in birth and informed consent for women who DON’T make all the “right” birth choices. Our goal, as I see it, is not to “educate” and “reach out” to everyone so that they can make all the choices I would make. This, I feel, is where the birthing rights movement sometimes fails women of color, who are particularly vulnerable to degrading and even coercive treatment in pregnancy and birth.

One thing that is important to remember as we have these conversations was pointed out in the original post: it’s not that women of color aren’t talking about birthing rights, it’s that white birthing rights activists aren’t always listening. They might know that, say, the ICTC (www.blackmidwives.org) exists, but it’s worth pausing to ask whether they’re helping to amplify their work to the extent that they are other groups? Are they truly connecting with birth workers of color, or just paying lip service to diversity?

I get a definite sense of frustration from your post, and I share in that frustration. It is important to remember, however, that optimally birthing activism is just a part of social justice activism and not an end unto itself. Like Miriam, I worry about the viability of any movement that hangs its star on “choice” and consumer advocacy since the most marginalized women are not thought of as “consumers” by any stretch of the imagination (rather “recipients,” which carries with it an ugly “beggars can’t be choosers” connotation). One of the lessons that the reproductive rights movement learned, at great political cost in my opinion, is that choice is meaningless without social and economic justice. Nevertheless, this doesn’t mean that [what I perceive to be] the key issues of bodily autonomy and informed consent don’t have resonance for women of color -- if anything it's even MORE important because there is a long, ugly history of the state or even private entities having literal control over our bodies, our babies, and our reproduction. The promise of autonomy over one’s own body without threat from the state is something that we should continue to fight for for all women; not because “it could happen to you,” but because it is happening to “them.” The flip side of the “starving children in Africa, eat your peas” coin is that we can’t let ourselves totally lose focus on the legitimate crisis of maternity care at hand when there are other looming crises like a lack of access to healthcare period, lack of support for families, and out-of-control child welfare policies. Elsewhere on the internets, Miriam rightly points out that privileging home birth as the pinnacle of the childbearing experience is pretty exclusive because not everybody has a home that’s safe for birth. But, as Shafia Monroe points out, instead of excluding those women or writing home birth as something that is just for the privileged, “change home”: connect birth advocacy to larger-scale social and economic justice. And really, she has done just that, making helping birth healthy Black babies a centerpiece to trying to heal the effects of hundreds of years of institutionalized racism on Black communities. I promise you that we’re not just polishing the silver on the Titanic… as long as we can make damned good and sure that the contributions and demands of birthing activists of color are celebrated and heeded just as much as those of white women.

Sometimes, we’re going to be focused on different things, or even working at cross-purposes. An example of this from reproductive justice is sterilization; a lot of white activists get very angry (rightly, sure) that they can’t get sterilization services on demand. They may see lengthy informed consent procedures as oppressive obstacles to self-determination, whereas women of color may see these procedures as sometimes the only thing between them and the “Mississippi Appendectomy.” Still, I do believe that it is possible to have a cohesive birthing rights movement. Even if, like my mother, some women think that only the poor women with the dirt floors use midwives and the babies die and why in the WORLD would you do that when you have free access to the world’s best medical care… if we can look past any personal agendas or bugaboos and say no matter who you are, where you deliver, whether that’s by choice or circumstance, or whether society feels you’re fit to parent, you deserve to birth in peace with support, without lies or coercion, and without intervention from the state, we’ve done our job. Cohesive doesn’t necessarily mean that we agree about every single thing, but if we can come up with a few distilled points that we can agree upon as a starting place, who knows how far we can go…


February 24, 2010 | Unregistered CommenterCourtroom Mama

Bringing this away from race... don't forget about us military mamas and families. Often we can not afford out of pocket expenses that TRICARE does not cover. We often qualify for foodstamps and WIC yet our husbands, and some of us, are defending our country. A lot of us can't afford "normal births" to birth away from hospitals so we are stuck with OB/GYNS and in my area give substandard care and black or white, if you go against their "medical advice", they don't bat an eyelash at calling child services on ya. I have a lot to say about the race issue, some I agree with, some I disagree but there is another group of women that are often forgotten as well and with military it doesn't matter what race you are. You are just set up for no choice in care.

God Bless,

A Mamas Nirvana Birth Services

I welcome comments.. nmjennette@tds.net Amamasnirvana on facebook as well

February 25, 2010 | Unregistered CommenterNirvana (Harley)

I have a longer post I am writing/rewriting-
many AMOs Allied Midwifery Organizations and "Birth" advocacies- don't do shit for any mother. Trust me on that one- an entire book could be written- the past "subjugation" posts a few weeks back began to adress the tip of that iceberg.

February 25, 2010 | Unregistered CommenterBarbra-Jean

Harley, military families would make a good post in and of itself. Want to write it?

February 25, 2010 | Registered CommenterJill

I would disagree with one thing -- calling our American system of birth "capitalistic." It's not really. What we have is more rightly called "crony capitalism," with boards of doctors deciding that insurance companies can't cover home birth when it's across the board cheaper and in so many other ways better, which keeps women with insurance unable to afford to have the birth of their choosing.

February 25, 2010 | Unregistered CommenterKathy

Jill, I would be honoured. Will you please email me. Got a couple of questions for you as to the specifications that you want.

God Bless,

A Mamas Nirvana Childbirth Services (on facebook)
~A woman meets herself in childbirth.~ Callaigh

February 25, 2010 | Unregistered CommenterNirvana (Harley)

Unfortunately I think that no matter what background or race you come from you are going to confront obstacles. I myself have run into problems with certain Dr's because of my status as a single parent. I dont apologize for the fact that I made my own choices in life, and because of those choices now I will be raising my daughter on my own. It seems that because I am not a part of a nuclear family judgement is passed that I could not possibly be as good a parent as others who have a husband (or at least a boyfriend) to lean on. Once again this irks my feminine ideals, makes me want to scream at these people. I'm not saying this is what I would have chosen for myself or my family, single parenthood is difficult in the best of circumstances, but I am facing these obstacles with my head held high. There have been days (especially before I switched OB practices) where I felt bullied by my Dr and I know that if there had been a male there to defend me he never would have said certain things or been so condescending. No man should feel he has the right to assert power over me when I am already so vulnerable.

No matter what our differences of race, religion, origins or beliefs, I think that we can all agree that our rights as WOMEN to be respected and to have a say in our care is what we are all talking about. I would gladly stand next to any woman (or even man) who is trying to further the goals of autonomy and informed consent/refusal, no matter what our other differences may be. I would hope that these people would feel the same way, lets bind ourselves with these ideals, and throw the rest out the window (at least for the time being). If we can do that then we will be less likely to be weakened by dissention when we need eachother's support.

February 25, 2010 | Unregistered CommenterLilRedMommy

OK, I am having technical difficulties with both my computer and the back end of the site. The comments manager in Squarespace is all messed up and I'm working on what feels like a Commodore 64.

Quick reply for now:

Patrice-- Thank you for your insight both here and on the Facebook page. I think that's pretty telling that you were told to whiten up your site to appeal to a perceived audience. Disgusting and sounds like an intentional effort to alienate women of color from finding birth workers that share their experience and skin color.

And, yeah, I’ve noticed on FB that you are the only women of color on most threads.

Courtroom Mama—Thanks for making me spit coffee with your first line. That was hilarious.

You said: “Our goal, as I see it, is not to “educate” and “reach out” to everyone so that they can make all the choices I would make. This, I feel, is where the birthing rights movement sometimes fails women of color, who are particularly vulnerable to degrading and even coercive treatment in pregnancy and birth.”

That wraps up a lot of my reluctance to dive in to the discussion as a white person and was really the point of this post. The issue of racial disparities in health care/ maternity care goes *so* far beyond lip service/ Band-aid approaches that I’ve seen. Mai’a left an awesome comment on flipfloppingjoy about how it’s better to just put it out there rather than sit in overwhelm. But I’m pretty overwhelmed. Inclusion is not really the issue... systemic change is. But I guess we just start somewhere.

There are a lot of aspects that left out for the sake of brevity and I hoped would come out in the discussion—if not on this post, then another.

February 25, 2010 | Registered CommenterJill

Quote: "If you’re looking at maternity care reform as a health movement that relies upon procuring supplies and services outside of what public clinics, Medicaid or typical insurance plans cover, you’ve already alienated hundreds of thousands of families."

This also effectively alienates poor to low-income white families, also. I am very lucky we did not have to use any of our tax refund for the purpose of moving or buying a new vehicle (our refund is huge not just because we get the full earned-income tax credit, but because my husband takes zero deductions from his biweekly pay, so we overpay into taxes to an extreme degree - no, it doesn't gather interest the way a savings account or CDs would, but neither does it jeopardize our childrens' SSI the way traditional rainy day savings would). Our tax refund was how we were able to exercise our right to consumer choice and pay a midwife out of pocket - the full amount, since our state does not allow nonmedical professionals to assist at birth, does not reimburse ANY homebirthing midwives via Medicaid (not even CNMs), and the HMO we were in until recently did not have ANY midwives in it, or even the baby-friendly hospital and homebirth-supportive obstetrician we hope to use as a backup if something goes wrong against all odds.

If we had no money to pay the midwife for our expected fourth baby this August, what would we do? Make her wait another year or two for a refund that hadn't been used for a household emergency, the way we did for our third baby, who was a healthy 9 lb 3 oz HBAC? Hardly fair to her. No, probably we'd freebirth, and hope for the best. And call an ambulance to take me to a hospital if an emergency happened, I guess (and pay for the bill how?)

Quote: "The American Congress of Obstetricians and Gynecologists cites an article in its 2005 Committee Opinion No. 321 regarding likelihood that obstetric judgment was incorrect in cases of coercive and punitive measures in forcing treatment on a woman. In the same article from 1987, a survey showed that eighty-one percent of the women involved in court-ordered cesarean, forced hospital detention and forced intrauterine transfusion cases were black, Asian, or Latina, 44 percent were unmarried, and 24 percent did not speak English as their primary language. All the women were treated in a teaching-hospital clinic or were receiving public assistance."

Read between the lines. It is NOT uncommon for a woman who is on Medicaid (especially if she receives other welfare services, such as food stamps or TANF) to be bullied into obstetric interventions "for her own good," (and most poor people generally are made to feel like they'd better be damn grateful for whatever health care they get on charity, no matter how they are treated in clinics; I speak from experience) and to be told that she will be referred to child protective services for neglect if she refuses an intervention such as an induction or a c-section or, for that matter, if she asks questions about the care her baby receives in the NICU (which happened to me after our second daughter was born in a hospital, grudgingly VBAC'd. By the way, I was never allowed to hold her after giving birth. I was told I was dirty and a danger to her. And when I informed the hospital staff that I did not smoke, drink, or do drugs, they refused to believe me. It was MY fault the baby was eight weeks premature, at least in their eyes if not mine). This is a class issue, but because more black people (and Native American and Hispanic people) are on Medicaid than white people, for whatever reason, it is also a race issue. My husband and I are white, but we can easily imagine that what we went through while on Medicaid is all too common for mothers who are of racial and ethnic minority status.

February 25, 2010 | Unregistered CommenterSarah Dorrance-Minch
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