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.