Midwifery Care: a Good Choice in Childbirth

Tracy Cooper

As a Licensed Midwife, Tracy Cooper discusses the benefits of and challenges to midwifery care, which is part of a larger conversation about reproductive rights, health care rights, and basic human rights.

It's a weekday night and I am headed to bed soon because I might be woken in the night to go to a birth. The birth, when it happens, will be with a young woman who—although she and her partner moved last month to another part of Washington State that has no local midwife—chose to come back to Seattle to stay with an aunt in order to have access to midwifery care. She wants the kind of birth where her chosen care providers and support people will be with her; where she will have privacy and intimacy; where she will be allowed to eat and drink to sustain her energy during the labor; she will be encouraged to be in whatever position feels comfortable to her, including finding comfort in a warm pool of water; and where she and her baby will be carefully monitored to make sure they are well and the labor is progressing normally.

She will be "allowed" to labor at her own pace without intervention, unless she asks for it—whether that takes just a few hours or many. She will be given information at each decision-making point; allowing her the ability to make her own educated choices about her care and her baby's. She and her partner will be supported to make this journey of labor together and she will come out the other side empowered and amazed at what her body can do. She'll know after that intense experience "if I can do that … I can do anything!"

The state of Washington is picking up the tab for her care since she qualifies for Medicaid coverage. DSHS (Department of Health and Human Services) recognized early on, in a study about the "safety of home birth" in Washington, the benefits of Licensed Midwifery care. They halted the pilot program and started providing access to the services of Licensed Midwives as part of the Medicaid plan. What are some of the benefits? Quality care at low cost. Childbirth at home or at a birth center. Lowered rates of intervention, medication, and cesarean section. A higher rate of vaginal deliveries with no increase in adverse events for mothers and infants. There are no differences in birth outcomes, except, as some studies have noted, an increase in maternal satisfaction with the birth, and the care.

Unfortunately many women who are covered by Medicaid don't know it's an option to have a Licensed Midwife attend their birth at home or at a birth center. Even women for whom it may be more culturally appropriate to have a midwife may not know about their rights and options for childbirth; Washington is home to many low income, minority, immigrant and refugee women who might benefit from midwifery care. Fortunately for my client, a very young but educated white woman, she does have the skills and privilege to explore her options and make informed choices.

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As much as I love my work—I am honored to be a part of one of the most intimate, challenging, moving moments in a woman's life—it's amazing to me that my midwifery partner and I are still in practice. Indeed, at only seven years in practice together, we are the second longest running midwifery partnership in Seattle. Although we are contracted with insurance companies and receive payment for our services, the costs of having a practice are high and the (financial) payoffs are low. I am still awaiting the decision of legislators in Washington to see if our annual licensing fee, currently the highest of any licensed professional in the entire state, will be stabilized at $500, or rise to the projected $3,000 or more next year. Every year we pay increasingly more for malpractice coverage. And insurance companies reimburse us at a similar rate as MDs. However, although an MD might attend the end stages of a labor or be on call so the labor nurse can consult with them about the management of the birth, a midwife will be at a woman's side for hours on end (without nursing staff or shift changes) in order to give continuous one-on-one labor support.

A San Francisco hospital executive recently described midwifery care as "boutique" care: too expensive and labor intensive to be provided in a hospital setting that serves mostly low-income patients. Is it a luxury to have a provider you trust who will be with you, encourage you in your most difficult moments, help keep your birth safe, give you information and choices about your care, regard you as the expert of your own body, and strive to honor and protect your experience? Rather than having this type of care as a right, women are often forced to sacrifice the right to safety, information and the fulfillment of their goals for birth in order to help the hospital run more smoothly and make the medical doctors less prone to liability. Perhaps normal birth is just not a money-making operation.

As hospital administrators urge their staff to step up production and minimize the risks of lawsuits, caesarean section rates are rising. A hospital in my community is approaching 40 percent. The hospital's Chief of Obstetrics told me "…now that we know c-sections are safer and cheaper, if you discount the personal satisfaction of a vaginal delivery, why have a vaginal birth?" Perhaps he meant it as a tongue-in-cheek statement about how medicine views a normal physiologic process as an accident (or a lawsuit) waiting to happen.

But it's more than just a normal physiologic process; it's a vulnerable, hard, beautiful transition in a woman's life. Doesn't she deserve to be supported, encouraged, and kept safe? Doesn't she deserve information about her body and this experience that will allow her to be an active participant in her care? No matter her culture, race, or income level? So why are midwifery practices closing around the United States at a time when many states are experiencing a shortage of obstetrical services? Why don't public policy makers, MD's, hospital administrators, midwives, and public health educators all agree to provide a team approach to meeting individual women's needs? I worry about the sustainability of my practice if I can't survive financially, or politically. I worry about the lack of access to safe, respectful maternity care for all women, especially if midwives and OB's are not supported to continue to provide quality, individualized care.

These issues are too much for one tired midwife to grapple with alone. I'd like this to be part of every woman's conversation with her friends, partners, health care providers, and above all, her legislators. It's part of a larger conversation about reproductive rights, health care rights, and basic human rights. All women should have their choice of care provider—in the setting of their choice, as appropriate to that individual person.

Analysis Law and Policy

Federal Court Says Trans Worker Can Be Fired Based on Owner’s Religious Beliefs

Jessica Mason Pieklo

“Plain and simple, this is just discrimination against a person because of who she is,” said John Knight, the director of the LGBT and HIV Project of the American Civil Liberties Union of Illinois, in an interview with Rewire.

When the U.S. Supreme Court ruled in 2014 in Burwell v. Hobby Lobby that the owners of secular for-profit businesses could challenge laws they believed infringed on their religious liberties, civil rights advocates warned that the decision was just the start of a new wave of litigation. On Thursday, those predictions came true: A federal district judge in Michigan ruled that a funeral home owner could fire a transgender worker simply for being transgender.

The language of the opinion is sweeping, even if the immediate effect of the decision is limited to the worker, Aimee Stephens, and her boss. And that has some court-watchers concerned.

“Plain and simple, this is just discrimination against a person because of who she is,” said John Knight, the director of the LGBT and HIV Project of the American Civil Liberties Union of Illinois, in an interview with Rewire.

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According to court documents, Stephens, an employee at Detroit’s R.G. & G.R. Funeral Homes, gave her boss—the business’ owner—a letter in 2013 explaining she was undergoing a gender transition. As part of her transition, she told her employer that she would soon start to present as a woman, including dressing in appropriate business attire at work that was consistent both with her identity and the company’s sex-segregated dress code policy.

Two weeks later, Stephens was fired after being told by her boss that what she was “proposing to do” was unacceptable and offensive to his religious beliefs.

In September 2014, the Equal Employment Opportunity Commission (EEOC) filed a lawsuit on behalf of Stephens, arguing the funeral home had violated Title VII of the federal Civil Rights Act, which prohibits employment discrimination. According to the EEOC, Stephens was unlawfully fired in violation of Title VII “because she is transgender, because she was transitioning from male to female, and/or because she did not conform to the employer’s gender-based expectations, preferences, or stereotypes.”

Title VII of the Civil Rights Act allows those employees who have been discriminated against in the workplace to collect money, known as civil damages. Those damages usually come in the form of lost wages, back pay, and funds to make up for—to some degree—the abuse the employee faced on the job. They are also designed to make employers more vigilant about their workplace culture. Losing an employment discrimination case for an employer can be expensive.

But attorneys representing Stephens’ employer argued that the Religious Freedom Restoration Act (RFRA) protected their client from legal liability for firing Stephens. On Thursday, a federal court agreed. It said that paying such damages for unlawfully discriminating against an employee could amount to a substantial burden on an employer’s religious beliefs. 

According to the court, despite the fact that Stephens’ boss admitted he fired her for transitioning, and despite the fact that the court found this admission to be direct evidence of employment discrimination, RFRA can be a defense against that direct discrimination. To use that defense, the court concluded, all the funeral home owner had to do was assert that his religious beliefs embraced LGBTQ discrimination. The funeral home had “met its initial burden of showing that enforcement of Title VII, and the body of sex-stereotyping case law that has developed under it, would impose a substantial burden on its ability to conduct business in accordance with its sincerely-held religious beliefs,” the court wrote.

In other words, Hobby Lobby provides employers a defense to discriminating against LGBTQ people on the basis of religious beliefs.

“The RFRA analysis is extremely troubling, and the implications of it [are] as well,” said Knight. “I believe this is the first case applying RFRA to a Title VII claim with respect to nonministerial employees.”

If the scope of the opinion were broader, Knight continued, “this would allow [employers in general] to evade and refuse to comply with uniform nondiscrimination law because of their religious views.”

This, Knight said, is what advocates were afraid of in the wake of Hobby Lobby: “It is the concern raised by all of the liberal justices in the dissent in Hobby Lobby, and it is what the majority in Hobby Lobby said the decision did not mean. [That majority] said it did not mean the end of enforcement of nondiscrimination laws.”

And yet that is exactly what we are seeing in this decision, Knight said.

According to court documents, Stephens’ boss has been a Christian for more than 65 years and testified that he believes “the Bible teaches that God creates people male or female,” that “the Bible teaches that a person’s sex is an immutable God-given gift, and that people should not deny or attempt to change their sex.” For Stephens’ former boss, Stephens’ transition to a woman was “denying” her sex. Stephens had to be fired, her boss testified, so that he would not be directly complicit in supporting the idea that “sex is a changeable social construct rather than an immutable God-given gift.”

If the “complicit in denying God’s will” sounds familiar, it should. It has been the exact argument used by businesses challenging the birth control benefit of the Affordable Care Act. Those business owners believe contraception is contrary to God’s will and that complying with federal law, which says birth control should be treated in insurance policies as any other preventive service, makes them complicit in sin. Thursday’s decision cites Hobby Lobby directly to support the court’s conclusion that complying with federal nondiscrimination law can be avoided by asserting a religious objection.

Think of the implications, should other courts follow this lead. Conservatives have, in the past, launched religious objections to child labor laws, the minimum wage, interracial marriage, and renting housing to single parents—to name a few. Those early legal challenges were unsuccessful, in part because they were based on constitutional claims. Hobby Lobby changed all that, opening the door for religious conservatives to launch all kinds of protests against laws they disagree with.

And though the complaint may be framed as religious objections to birth control, to LGBTQ people generally, and whatever other social issue that rankles conservatives, these cases are so much more than that. They are about corporate interests trying to evade regulations that both advance social equity and punish financially those businesses that refuse to follow the law. Thursday’s opinion represents the next, troubling evolution of that litigation.

CORRECTION: This article has been updated to clarify John Knight’s position with the American Civil Liberties Union of Illinois.

News Health Systems

The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

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