White Ladies Love Them Some Homebirths; Meanwhile, Midwives Win in Colorado
Sunday, May 22, 2011 at 9:43PM
By Emjaybee
These two articles came my way this week and I thought they were both interesting.
First, USA Today posted an article on the rise in homebirth that included this interesting turn of phrase:
Home births rose 20% over four years, government figures show, reflecting what experts say is a small subculture among white women toward natural birth.
The article has some good numbers overall and is worth a read, but that line gave me pause; why is race being called out so specifically? I would guess the AP writer was just looking for an interesting hook to hang his or her story on. But it comes across as though the reader were being reassured that hey, it’s just a small subculture of white women doing something weird, not any kind of big change to see here…don’t worry, America!
Meanwhile, in a post about the legislative victory in Colorado for direct-entry (CPM) midwives (who appear to serve all or mostly homebirth clients in Colorado) Radical Doula writes:
In political environments that are often very midwife unfriendly, these battles can be particularly challenging. Midwives are afraid if they push too 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 [Lusero]’s group [Delivering Natural Care for Families] 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…
…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, Rhogam, antihemorrhagic drugs, and eye prohylaxis.
- The language that spoke negatively of midwifery was removed.
She also linked to this piece on Ms. Lusero’s personal battles to have homebirth and aid midwives, which is fascinating and inspirational in its own right; my favorite part of it, though, was this capsule history of Colorado midwifery:
In 1917, under pressure from doctors, Colorado enacted a law requiring midwives to pass an exam and apply for a license in order to attend births. In addition, midwives were forbidden to use any instruments to deliver babies or administer any drugs. Despite this, many babies were still born at home. But in 1941, state lawmakers passed a law preventing any more midwives from obtaining licenses; already-licensed midwives could continue to practice, but no new ones could join the field. It was an attempt to make midwifery disappear, and though the number of babies born in hospitals skyrocketed in the 1950s, the law didn’t completely succeed. Midwifery just moved underground.
The profession experienced a national resurgence in the 1970s, fueled by feminism, the burgeoning health-rights movement, and government reports that anesthetizing women during childbirth could harm their babies. In Colorado, nurse-midwives — nurses who specialize in midwifery and deliver babies under the supervision of a doctor, often in a hospital — won legalization in 1977. A group of so-called lay midwives — midwives who deliver babies at home without medical intervention — wanted the same thing. They’d been practicing off the radar for decades, risking arrest and charges of practicing medicine without a license. In 1979, they formed the Colorado Midwives Association in Boulder.
For the next several years, they fought to legalize their profession. “We threw ourselves against the state legislature again and again,” says Jennifer Braun, a midwife who started practicing in Boulder in 1982 and now runs a nonprofit called International Midwife Assistance that offers birth services in Uganda. “It was a David and Goliath story.”
Bills to regulate lay midwifery failed in the legislature in 1983, 1984, 1985 and 1991. Each time, doctors, nurses and even nurse-midwives testified against them, arguing that delivering babies at home was unsafe. Meanwhile, supporters said that women were going to give birth at home regardless of whether it was legal. State regulation of midwifery would make it safer, they argued, not the other way around.
In 1993, after several midwives were arrested and one case reached as high as the Colorado Supreme Court, the legislature finally agreed. The resulting law decriminalized lay midwifery and set up a process by which “direct-entry midwives,” as they are now called, could register with the state Department of Regulatory Agencies, or DORA. The law directed DORA to set education standards and rules for when midwives could and could not provide care, as well as a disciplinary process for when they broke those rules. The law also protected doctors and nurses from liability for a midwife’s “mistakes.”
It was a victory, but an imperfect one. The resulting rules included several restrictions: Midwives could not care for pregnant women with diseases such as diabetes, sickle-cell anemia or hepatitis. Midwives could not suture. Midwives could not administer common pregnancy-related drugs. Midwives could not deliver breech babies or twins.
The legislature also set a date — July 1, 1996 — to review the law and decide whether it should continue, in accordance with Colorado’s sunset process. The 1995 sunset review report, written by DORA, illustrates that the attitude toward midwifery in Colorado was still hostile. Even so, DORA recommended that the profession continue to be legal.
Speaking of white women (we were, right?) Delivering Natural Care for Families was aided by COLOR, the Colorado Organization for Latina Opportunity and Reproductive Rights as a “lead coalition partner.” COLOR was also instrumental in getting a law passed banning the use of shackles on incarcerated women during birth. I thought it would be nice to call out COLOR and thank them for the good work they appear to be doing for all the women of Colorado, regardless of subculture size.
More reading:
Guest Post: We Need a Movement
New Study Identifies Need to Distinguish Planned from Unplanned Home Births
Stuff White People Like: Talking About Birth
Convincing White Women that Birth is Painless Will End ‘Race Suicide’
Reader Comments (39)
I also read that ABC article in which the phrase "a small subculture of white women" who are accessing home birth midwifery care was used. Although all kinds of women use midwives, it is an unfortunate fact that many states do not reimburse medicaid expenses for midwifery care, for either CNMs or CPMs. Also to note, that a disproportionate number of women of color rely of medicaid for their health care due to systemic racism that falls outside of just the medical practice. I think it is important to understand why that it is a majority of white, upper-middle class, educated women who are seeking out midwifery care. It is because many white women have the means to pay out of pocket for expenses not covered by their health insurance and it is important to mention. I wish the author of the article had explained why the stats are this way, but getting the mainstream media to talk about racism and white privilege is generally a long shot ;)
As a future (white) midwife, I believe it is imperative to continue to examine the privileges that many of us have in order to understand and begin to solve problems of racial gaps in accessing midwifery care and maternal and infant mortality.
I too was perplexed by the not-so-implicit characterization of home birth of something that white women in "the natural birth subculture" are doing more and more. Just using the term 'subculture' makes this seem more like a caricature than a legitimate characterization.
(I haven't done the work to find this out, but I wonder if home birth rates did, in fact, rise among non-white women too. And yes, I question the motivation of calling on race specifically without adding any analysis to the discussion. Hmph.)
It certainly gave credence in the eyes of some of my friends and associates (who themselves are black, like me) who said my choice to birth at home came from hanging out with too many rich or granola type white women. They pointed this article as back up and the implications by both them and the article really bother me.
For the record I personally know very few "granola type" women and hang out with even less than that. As for the rich part...that just makes me laugh.
I thought about that when I saw the USA today article also- I thought, the only reason that I did not birth at home (not rich white person here) is because I couldn't afford it, or thought that I couldn't. Probably it would have been about the same price in the end, but I think that the reason why more women don't consider home birth is because they don't have a choice. They are dependent on the system to pay for their health care, and that means a hospital.
Jill,
Yes, the legislation in Colorado is a victory for CPMs, but it is a loss for babies.
Colorado licensed midwives have been required to submit their statistics for each of the past 4 years and the results are nothing short of appalling. In each and every year since licensure began, the perinatal death rate for planned homebirth with a licensed midwife exceed the death rate for the ENTIRE state, including premature babies and high risk pregnancies. Even worse, the number has risen each and every year.
In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).
The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That's TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. On hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.
I honestly do not understand how someone like you, who seems to be nice person, can actively ignore the fact that Colorado midwives are letting babies die in large numbers. How can homebirth advocates consider that acceptable? Why isn't a midwifery organization investigating the extraordinary death rate? Do homebirth advocates care about babies, Jill, or do they only care about homebirth?
Kristen please do post here if you find out more about how much (if any) of a rise there was in homebirth among women of color. The article said "For all races combined, about 1 in 143 births were at home in 2008, up from 1 in 179 in 2004." which doesn't tell us enough.
Michelle, thanks for pointing out the economic component re: Medicaid (and insurance for that matter) not reimbursing for midwives. Though in the reporter's defense, he or she might not have had any information handy about whether cost was driving the racial imbalance and didn't want to speculate.
Emjaybee: I am on the phone right now, so cross-posting is cumbersome, but the article I linked to earlier today broke it down.
Amy: At least read enough to learn to whom you should properly address your comments/questions, please. Which, btw, is not to imply that Emjaybee is not a nice person.
Emjaybee is free to answer why she thinks it is acceptable that Colorado midwives have an appalling death rate and that no one in the world of homebirth advocacy is doing a thing about it.
ANA thank you for reminding me of the NYTimes piece; it has a better breakdown on race
Link here: http://www.nytimes.com/2011/05/24/health/research/24childbirth.html?_r=1&hpw
Relevant part here:
"The turnabout was driven by an increase of 28 percent in home births among non-Hispanic white women, for whom one in 100 births occurred at home in 2008. That rate was three to six times higher than for any other race or ethnic group.
Home births declined slightly among non-Hispanic black women, to 0.28 percent in 2008 from 0.30 percent in 2004, while home births for Hispanic and American Indian women were unchanged, at 0.20 percent and 0.38 percent, respectively. Home births among Asian and Pacific Island women increased slightly, to 0.27 percent from 0.24 percent of all births.?
the "race" issue is about a little more than money. sure ultimately, it may boil down to money and lots of black women on welfare and such BUT white women have had this history of deciding for women what is the "in" thing to do at the moment. white women wanted to be in the hospital because their white male counterpart told them it was good. they went along with it. to be in the hospital was good. to be home was looked down upon. black women wanted to be good and have good things and do good things, too. white is right, so they went into the hospital, too--not to mention the set up by obs and nurses and the gubment, whom i'm sure were white, to create public health departments and free health care, to help to convince black women to come into the hospital.
now, you have changed your minds. but you forgot to tell black women this. but i'm sure you're actively working on it, right?
can we ever know if those dead homebirth babies could have been spared a death and lived comatose, immobile, partially mobile or some other varied [dys]functional life? is that the better alternative? do we not have a right to accept death of an infant as a risk? well, not in this "pro-life" culture.
Reader,
You honestly think that 9/800 low-risk babies are coming home from the hospital "comatose, immobile, partially mobile or some other varied [dys]functional"?? This is really your argument- that surely these babies would have been grievously injured in the hospital, so it's really a GOOD thing that they died in homebirth? I feel sick.
I couldn't help but think of the Chicago Maternity Center Story-- the Center served vast majority women of color (80%? I can't recall exact number) who wanted homebirths. They were asked to pay whatever they were able. When the Center was closed, so did that option for most of them. I think money and other resources is a huge factor, as well as race. And the subculture comment is just ... odd.
Go, CO!
I actually don't think the subculture comment is "odd," but I'm not sure it's exactly accurate either. IDK, I have a lot of concern over the issue of white American/"Western" women basically denigrating (!) things that WOC do, being complicit in nearly criminalizing those things and/or making them inaccessible and then "rediscovering" those things (that were/are already common among WOC worldwide), commodifying them and selling them back at a much higher price-- YKWIM?
Step 1: Ew, you eat that stinky stuff? I can't believe you give it to your children! We <3 Wonderbread.
Step 2: Wonderbread Wonderbread Wonderbread.
Step 3: Government issues Wonderbread to all.
Step 4: "Stinky stuff" is new, exotic and "discovered*" to have wonderful properties. White people drive up price of "stinky stuff."
Step 5: Ew, you eat Wonderbread? I can't believe you give that to your children!
But anyway...
What I *do* think I see is what Another Rachel mentioned-- while fewer WOC may be having homebirths, there are community-based FSBC that I know of whose clientele is (vast) majority WOC, (and which can often take Medicaid, etc.) So while it doesn't surprise me that homebirths are rising more among white women, I don't think that's necessarily due to some sort of white woman cult of faux-earthmama-ness. Which... I would say does exist to some extent, but I think the larger picture is being missed-- that some growing percentage of all women are clamoring for more autonomy and respect and fewer interventions in birth, but that they may be taking slightly different routes (birth centers instead of homebirths). Or that the relatively small "cult" does not account for nearly all of the movement, and that some folks are just looking for a way to dismiss the rise in homebirths as some sort of "trendy" thing.
It does also bring up the idea that white women tend to pursue change in a more individualistic way (RELATIVELY) and that they-- by being privileged in at least one way (at least two if they're well-off)-- are more likely to pursue what may be a better-for-everyone option simply out of self-interest. I will say that when I see that opinion ("I chose HB because I'm smarter than all of those stupid sheep-like women, and I just want MY choice to be respected") it has seemed to come from white women. So there's that, and that "narcissistic rage," as bell hooks calls it, is almost by definition going to be more common in more privileged women. (Narcissistic rage being less anger at the fact that the injustice exists and more anger that it is being directed at *YOU*.)
So... Just some thoughts. I certainly don't believe that all or necessarily even most well-off white women who homebirth only care about their own personal birth experiences, but I do suspect that this attitude is at least more common among well-off white women than WOC/poorer women who are more community-dependent, etc.
And I also have to say, I have definitely seen lots of white women who are interested in homebirth/birth with midwives travel far, pay a fair bit of extra money or otherwise compromise their births in order to avoid an EXCELLENT FSBC around here that has a mostly of-color, mostly lower-income clientele but is located in a neighborhood that is not even bad, just black and working class, just not super-frilly. Of course, they don't visibly recoil at the very idea of giving birth there, it's more of the subconscious weaselly, "Yeah, I've heard good things, but..." ("...people like me don't give birth there.")
KWIM?
Just saying.
*Kind of like how Columbus "discovered" America.
serious overkill, alexis. even i feel sick now
Ok Reader, please help me interpret your statement. It looks pretty clear to me that you are excusing homebirth deaths by saying that that's better than a possible hospital injury. Show me where I misinterpreted.
Dreamy--see I wondered about that. I get the feeling that happens quite a bit and also that there does seem to be WOC-friendly birth centers out there that don't get talked about much (just like WOC's experiences don't get talked about much).
I would love to hear more about their side of the story, though.
Ok, is there going to be a response to Dr. Amy's assertion? I'm a home birth mom (have had 3 births at home) and those numbers are absolutely horrifying to me. That's more than 1 in 100 home birth moms in Colorado having her baby die. That is completely unacceptable to me. I hope to God that it is unacceptable to other members of the home birth/natural birth community if true, and those numbers should be very very easily verifiable. Even if you exclude deaths before the onset of labor, that's scary as hell.
Dr. Amy, where did you find the number of women under the care of a midwife at the start of labor? I found the report at http://www.dora.state.co.us/midwives/Newsletter2010.pdf
but I can't find the information for how many patients at the start of labor. I was looking at deliveries performed by midwives in that chart plus transfers in labor (because I assume that a postpartum or newborn transfer still counts as a delivery by the midwife) and those numbers would be even scarier.
Am I the only person who thinks that a 1% baby death rate in full term, singleton, vertex planned home birth is not ok? Correct me if I'm wrong someone, but the post does seem to indicate that breech and twin births are not permitted at home, and no one should be delivering preemies at home. How do you mess up singleton, vertex, term births badly enough to have a 1% death rate? What on earth is going on in Colorado? I apologize if this is coming across harshly, but those numbers are mindblowing.
@ Precipmom: I wouldn't worry too much about "Dr. Amy's" stats as they are rarely based on a reality you and I live in. She is violently opposed to homebirth and believes that any statistics supporting it are automatically suspect, so she makes up her own to try to counter those.
Precipmom: Generally, we ignore Amy's rants where at all possible. She regularly makes assertions which she is then unwilling to back up or answer any questions regarding. An example is her statement that "[i]n 2009 Colorado licensed midwives provided care for 799 women" which does not match up with the report that midwives provided at least some care for 936 women. Of those 639 women entirely under midwifery care, there were 3 infant deaths (one before labor, one after the start of labor but before birth, and one after birth), leading to a rate of 4.7/1000 (lower than her quote regarding state specifics). The other 6 deaths occurred in the hospital after transfer which does not mean that the deaths were unconnected entirely to midwifery care, but does add murkiness to the situation. Also, she includes deaths occurring after birth, but not transfers (of mothers or infants), which could also affect the data.