A bill to criminalize Certified Professional Midwifery (CPM) in Mississippi was defeated today, according to reports, thanks to a groundswell of opposition led by the grassroots advocacy organization The Big Push for Midwives.
Had it been passed, HB 695 would have limited the practice of midwifery to Certified Nurse Midwives (CNMs), stating that “any person who is not a certified nurse midwife who engages in the practice of midwifery shall be subject to criminal penalties.” The bill also stipulated that the practice of midwifery would be overseen by the Board of Nursing, something Katie Prown, Campaign Manager of the Big Push for Midwives, saw as an “inherent conflict of interest.”
“This bill would have given the Board of Nursing power over the practice of midwifery when they are two distinct and different professions,” says Prown.
The bill also would have stripped women of an important option when it comes to prenatal, childbirth and postpartum care, leaving pregnant women in the state without the care they needed.
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“If CPMs were to become illegal in Mississippi and [had been forced to] stop practicing, then the families who have become reliant on out-of-hospital care [might] not get the care they need,” Prown noted. By criminalizing midwives who facilitate out-of-hospital and home births, Prown continued, “you’re not going to stamp out home birth. Getting rid of midwives who provide home care is only going to make things worse.”
Prown says that the bill, introduced in the House by Rep. D. Stephen Holland (District 16), was introduced with good intentions. According to Prown, the bill was a response to a 2008 case involving a Louisiana midwife who facilitated a home birth in Mississippi which resulted in the death of the newborn. Mississippi has one of the highest newborn mortality rates in the country, a rate which has risen in recent years.
Licensing and regulation of certified professional midwives is something which The Big Push for Midwives supports and for which it lobbies on the ground, but, says Prown, limiting state licensure to nurse-midwives would do nothing more than severely restrict women’s birth options, especially in a state like Mississippi where no nurse-midwives are providing home birth care.
“Rep. Holland had the right intention but he didn’t have the right information and didn’t understand that this bill criminalizes the midwives who practice out-of-hospital maternity care and outlaws out-of-hospital care entirely because there are currently no nurse-midwives in the state who provide out of hospital care.”
Certified professional midwives must be certified through the North American Registry of Midwives while certified nurse midwives receive an advanced nursing degree in addition to midwifery education and certification. Certified professional midwifery also involves education or apprenticeship. However, certified professional midwives are not universally regulated and licensed throughout the country. In one state, a CPM may be regulated and licensed through a Board of Midwifery, receive reimbursements through Medicaid and offer a range of prenatal, birth and postpartum care. In other states, as is the case in Mississippi, midwives are lawfully able to practice without regulation or licensure.
According to the North American Registry of Midwives (NARM), the organization by which all CPMs are certified, they are aware of only two CPMs in the state though there are likely many more practicing in Mississippi who live in surrounding states.
The Associated Press reports that “home births have been a long-standing tradition in the state, where 18 percent of the population is uninsured:”
Midwife deliveries have been solid options for some, particularly in the Delta, one of the poorest regions in the country. Advocates say a midwife delivery is usually about a third of the cost of one that occurs in a hospital because home births usually don’t involve anesthesia and other medical interventions.
Midwifery advocates were successful at stopping this bill by organizing quickly and efficiently and barraging Rep. Holland’s office with calls and emails. They also are encouraged by the headway they have made with Rep. Holland and the Mississippi state legislature. Prown says now that the “bad bill” is dead, they will push for an amendment but plan on coming back next year if that effort is unsuccessful. Says Prown, “And they’ve [advocates] definitely made an impression…Rep. Holland, told one of the callers to his office that in all his years at the state house, he had never heard “such a ruckus” over a bill before.”
Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”
Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”
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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.
All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.
Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”
For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.
“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”
“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”
Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.
Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.
“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”
Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”
The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.
In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.
Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.
“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”
Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.
LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
“Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”
In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.
“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”
Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.
“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.
While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.
“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”
The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.
Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.
Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.
“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”
Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.
“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”
A federal judge in Mississippi on Monday refused to block a law that challengers say will deny wedding services to LGBTQ couples, all in the name of protecting “religious liberties.”
The Mississippi legislature passed HB 1523, the “Protecting Freedom of Conscience from Government Discrimination Act,” this year; the law is set to take effect July 1. The law allows denial, “based upon a manner consistent with a sincerely held religious belief or moral conviction,” of services or goods for the “celebration or recognition of any marriage.” This could also include pre-ceremony, post-wedding, and anniversary celebrations. The law specifically provides protection for people who believe that marriage is a commitment only between a man and a woman, that sexual relations should only take place inside such a marriage, or that a person’s “immutable biological sex” is determined by anatomy and genetics at birth.
In May, attorneys from the American Civil Liberties Union (ACLU) and the ACLU of Mississippi sued to block the law, arguing it was unconstitutional. These attorneys say HB 1523 goes far beyond refusing wedding services by allowing county clerks to deny marriage licenses. They claim the law is likely to allow discrimination against same-sex couples who wish to adopt, and will encourage employee business practices that could include harmful bathroom policies.
But on Monday, Federal District Judge Carlton Reeves ruled that the plaintiffs, who include Nykolas Alford and Stephen Thomas, a gay couple engaged to be married, failed to show evidence that they faced a “substantial threat of irreparable harm” if the law was not blocked immediately.
“Here, none of the plaintiffs are at imminent risk of injury,” Reeves wrote. “Alford and Thomas’s injury, if one exists, would arise when they apply for a marriage license. But they declare that they will apply for their license sometime within the next three years,” Reeves continued. “That is not imminent. The ACLU has the same problem. If a member of the ACLU intends to enter into a same-sex marriage in 2017, any injury is at least six months away.”
In response to the ruling, the ACLU filed a motion requesting Reeves reconsider the denial of the injunction, which would block the implementation of the law as trial proceeds. Meanwhile, the judge has ordered both attorneys for the State of Mississippi and the ACLU to begin working up a scheduling order to move the case toward trial.