Midwife Connection: Should Pregnant Women Take the H1N1 Vaccine?

Eileen Ehudin Beard

During National midwifery week, a midwife recommends the swine flu vaccine for pregnant women in the United States and offers up more resources and information.

October 4-10 is National Midwifery Week! Each year during National Midwifery Week, midwives across the US raise
awareness of the midwifery profession and the services provided to women. Rewire will be publishing a series of posts this week from the American College of Nurse-Midwives blog, Midwife Connection, to recognize this week – and the care midwives, Certified Nurse-Midwives and Certified Professional Midwives, provide. Need a quick Midwife 101? Read more.  

This week, the first doses of H1N1 (swine flu) vaccine will begin
arriving at midwifery practices around the country. Although government
agencies and health care providers are urging pregnant women to get the
seasonal flu vaccine as well as the H1N1 flu vaccine, some women remain
hesitant. Pregnancy is a time to avoid caffeine, alcohol, and
unnecessary medications. So, why make an exception for a new vaccine?

As a certified nurse-midwife
and mom of five (plus five step daughters!), I am typically cautious
about new products. When it comes to H1N1 flu, however, I am absolutely
convinced that vaccination is a must.

Because of the normal
changes of pregnancy (for example, decreased ability to fight off
infections), pregnant women are especially susceptible to the harmful
effects of H1N1 flu. Research consistently shows that pregnant women
are at increased risk for serious illness and even death from H1N1
infection and are four times more likely to be hospitalized.

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If
you’re still on the fence about vaccination, consider this: for the
first time ever, a national coalition of eight organizations (including
ACNM, March of Dimes, ACOG, and AWHONN) has come together to develop a clear statement about the seriousness of H1N1 flu
and the importance of receiving the vaccination. This sends a pretty
clear message in favor of heading to your midwife to receive that
vaccine.

If one of your worries is thimerosal, a controversial
component of vaccines, about half the doses of H1N1 flu vaccine to be
released this fall are thimerosal-free and will be prioritized for
children and pregnant women. Ultimately, only you can decide what is
best for you and your family. I encourage you to give this issue
serious consideration and make a decision as an informed health care
consumer.

Need more information to make your decision? Check out these helpful resources:

Analysis Maternity and Birthing

Pregnant Women Are Being Shackled in Massachusetts—Even Though It’s Been Illegal for Years

Victoria Law

According to a new report, not a single jail or prison facility in the state has written policies that are fully compliant with the law against restraining pregnant women behind bars.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Lawco-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

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Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”

Commentary Science

Robert De Niro’s Move on Anti-Vaccine Propaganda Film Is a Win for the Science Side

Martha Kempner

The events surrounding the Tribeca Film Festival and a documentary called Vaxxed: From Cover-Up to Catastrophe may provide a glimmer of hope that facts and science can still win.

Recently, some political pundits have begun to suggest that we are living in a post-truth world. It doesn’t matter, they say, that candidates spread blatant falsehoods, or contradict themselves within moments, because the American public no longer cares about what is true; they only care about what they believe to be true. This is a terrifying thought, one perhaps unrealistically heightened by the drama of the current campaign cycle. Regardless, the events of this weekend surrounding the Tribeca Film Festival and a documentary called Vaxxed: From Cover-Up to Catastrophe may provide a glimmer of hope that facts and science can still win.

The festival, co-founded by legendary actor Robert De Niro, came under fire when it revealed last week that it would be screening Vaxxed in April. The documentary, directed by discredited ex-medical researcher Andrew Wakefield, claims to be a whistle-blowing piece; it accuses the Centers for Disease Control and Prevention (CDC) of knowing about a link between autism and the measles, mumps, and rubella (MMR) vaccine, and engaging in a conspiracy to cover it up. Though De Niro initially stood behind the choice to show the film as a way to encourage “further conversation” around autism, just one day later, the festival’s organizers announced the film would no longer be on the schedule. Scientists, filmmakers, researchers, and members of the public breathed a sigh of relief.

I think we can look at De Niro’s ultimate decision as a victory for facts—because when it comes to vaccines and autism, the history is complicated, but the science is very, very clear.

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The Study That Changed the World for the Worse

In 1998, a British researcher named Andrew Wakefield published a study in which he claimed to have followed 12 children who had developed normally until being exposed to the MMR vaccine. The study, which was published in the esteemed medical journal the Lancet, argued that the vaccine had led to intestinal problems, which had, in turn, led to autism. Though the study acknowledged that “we did not prove a connection between the measles, mumps, and rubella vaccine and the syndrome described,” this is how it was interpreted and reported by many.

In many ways, the study and the way it was reported gave birth to the anti-vaccine movement popular today. Celebrities like Holly Robinson Peete and Jenny McCarthy have claimed that vaccines caused autism in their children, and recommended that other parents reject medical advice and avoid vaccinating their own. And lawmakers around the country have sponsored legislation to let parents opt out of mandatory vaccinations of school-aged children for “personal reasons.”

Not surprisingly, as fear increased, vaccination rates dropped, both in Britain and the United States. Even less surprisingly, as vaccination rates dropped, incidences of diseases thought to be under control, like whooping cough and measles, increased.

Vaccination works not just because it protects an individual from a communicable disease, but because it provides the community with something called herd immunity. Public health experts believe that 90 percent of a given population must be vaccinated to protect the unvaccinated members—such as infants and people with compromised immune systems—from getting sick as well.

So parents who choose not to vaccinate their children are making a decision that affects other people as well. Yet in seven states and the District of Columbia, less than 90 percent of entering kindergarteners have been vaccinated for measles. There are many public health experts, myself included, who believe this is a direct result of Wakefield’s study and puts us all at risk.

Wakefield’s Study, Debunked

Almost immediately after Wakefield’s study was published, other researchers set out to recreate his results and examine the possible connection between vaccines and autism. None of them ever found it. Wakefield himself could not reproduce his results. In 2004, the Institute of Medicine reviewed all of the available research and concluded that no link existed between the MMR vaccine and autism. A 2014 review of all of the studies since Wakefield’s found that researchers have now looked at over 1.2 million children and have not found any link between autism and vaccines.

As others failed to find similar results, scientists began to question Wakefield’s credibility as well. In 2004, it emerged that Wakefield had been paid the equivalent of $674,000 by a law firm intending to sue the manufacturers of vaccines, and he had not revealed this obvious conflict of interest. Upon learning this, his co-authors asked for their names to be removed from the 1998 study. In 2010, the Lancet retracted the study and Britain stripped Wakefield of his medical license. Finally, in 2011, an investigation by the British Medical Journal (BMJ) concluded that Wakefield was guilty of “falsifying medical histories of children and essentially concocting a picture, which was the picture he was contracted to find by lawyers hoping to sue vaccine manufacturers and to create a vaccine scare.”

But Wakefield did not walk away quietly with his tail between his legs. Instead, he portrayed himself as the victim of a medical establishment that had a vested interest in keeping the “truth” a secret. In 2011, when the BMJ investigation was published, he told CNN’s Anderson Cooper that his work was “grossly distorted” and that he was the target of “a ruthless, pragmatic attempt to crush any attempt to investigate valid vaccine safety concerns.” Last month, he was one of the speakers on Conspira-Sea—a cruise for conspiracy theorists. And now, he has released Vaxxed.

According to the New York Times, Vaxxed claims to introduce a CDC insider who says the agency knew about the link between vaccines and autism and deliberately withheld information from the public. The Times also reports that in the promotional material included on the Tribeca Film Festival’s website last week, but has since been taken down, Wakefield’s bio said he authored the Lancet study that “would catapult Wakefield into becoming one of the most controversial figures in the history of medicine.” The bio did not mention that the article had been retracted, or that Wakefield’s medical license had been revoked.

The Film Festival Controversy

The inclusion of the movie on the Tribeca Film Festival’s roster prompted instant criticism from people across many fields who believed it was dangerous to give Wakefield any opportunity to spread his misinformation, let alone a platform as prestigious at this one. A group of scientists, physicians, and autism experts—many organized by the Immunization Action Coalition (IAC)—mobilized almost immediately. Alison Singer, president of the Autism Science Foundation and a member of the IAC listserv, told the Guardian:

Four or five years ago we weren’t as well organized and people didn’t realize the importance of responding quickly and strongly … Today, we know that we have to respond to every incident however large or small, because if you leave any of these discredited theories unchallenged, it allows people to think that there’s something still to be discussed.

Others in the scientific and medical communities weighed in. The science blog Respectful Insolence, which is written by an oncologist, argued that by putting Vaxxed on the schedule, “the organizers of the Tribeca Film Festival have screwed up big time and given antivaccine a big, fat piece of propaganda to scare parents into not vaccinating.”

Dr. William Schaffner, a preventive medicine specialist at Vanderbilt University, told the New York Times that the festival’s reputation lent credence to the film that it does not deserve:

All of us are out talking about it reassuring parents, children, anyone who wants to pay attention to this issue that vaccines are safe and effective, and they certainly don’t cause autism, and that Dr. Wakefield was a fraud and had his license removed over this very event.

Similarly, Dr. Mary Anne Jackson, a professor of pediatrics at the University of Missouri-Kansas City, said in an interview with the Times on Friday, “Unless the Tribeca Film Festival plans to definitively unmask Dr. Wakefield, it will be yet another disheartening chapter where a scientific fraud continues to occupy a spotlight.”

Journalists also sounded off. In a piece the LA Times published the day the film festival schedule was released, Michael Specter, a New Yorker writer who has written extensively about vaccines, said of Wakefield, “This is a criminal who is responsible for people dying. This isn’t someone who has a ‘point-of-view.’ It’s comparable to Leni Riefenstahl making a movie about the Third Reich, or Mike Tyson making a movie about violence toward women.”

Michael Hiltzik, a columnist at the LA Times, concluded, “Careless actions such as those of the Tribeca Film Festival don’t contribute to ‘dialogue and discussion,’ as the festival’s PR would have it; they just spread misinformation and pseudoscience and undermine public health.”

And the filmmaking community chimed in as well. In an open letter to the festival’s organizers published on Thursday in Filmmaker Magazine, documentarian Penny Lane wrote:

This film is not some sort of disinterested investigation into the “vaccines cause autism” hoax; this film is directed by the person who perpetuated the hoax.

And this hoax isn’t cute, or fun, or thought-provoking. Very possibly, some people will walk away from your festival having been convinced, in part because of your good name and the excellence and integrity of your documentary programming, not to vaccinate their children. And very possibly people will die as a result.

Still, the initial reaction from the festival’s organizers was to defend their decision. Robert De Niro himself spoke out to support the film on Friday. In a statement he explained that he had asked for the film to be included because he and his wife have an autistic child and felt this conversation was important. He wrote:

We believe it is critical that all of the issues surrounding the causes of autism be openly discussed and examined. In the 15 years since the Tribeca Film Festival was founded, I have never asked for a film to be screened or gotten involved in the programming. However this is very personal to me and my family and I want there to be a discussion, which is why we will be screening VAXXED.

Not surprisingly, this did nothing to assuage others’ outrage. As I have argued in the past, this is not an issue in which there are two sides who have equal credibility and equal right to discuss their opinions. This is settled science, in which research and facts are up against allegations proven to be false. And people said as much to Robert De Niro. More stories were written on Friday, and the comments section on the movie’s page on the festival’s now-defunct website exploded in a debate over vaccine efficacy.

The actor appears to have listened, if not directly to these voices, then to others who expressed similar opinions. In a second statement released Saturday, he wrote, “My intent in screening this film was to provide an opportunity for conversation around an issue that is deeply personal to me and my family. But after reviewing it over the past few days with the Tribeca Film Festival team and others from the scientific community, we do not believe it contributes to or furthers the discussion I had hoped for.”

This Is Not an Entirely Post-Truth World

Hopefully, the positive outcome of the controversy will help us reject the concept of a post-truth world. Granted, this was not a lawmaker being held to the fire for inaccuracies in their debate performance or admitting to inconsistencies in their messages, which they seem reluctant to do thus far on this issue; De Niro’s views on the issue, based on his statements, seem to be less motivated by deeply held beliefs or political strategy and grounded instead, however misguidedly, in “starting a conversation.”

It can also be argued that the free media dedicated to this short-lived controversy was exactly what Wakefield wanted—especially since the outcome gives him even more fodder for his conspiracy theory.

But I choose to look at it as a positive development. Believers in science organized quickly, stood up swiftly, spoke out loudly, and relied heavily on the facts. And those are clear: Vaccines don’t cause autism. Moreover, not vaccinating children leaves our communities open to outbreaks of diseases like measles that we know how to prevent. It took years to recover from Wakefield’s fraud, but it looks like rationality and science may be prevailing on this front—which gives me hope for other topics where the facts are firmly on our side.

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