Analysis Maternity and Birthing

Maternity Care in a “Majority Minority” Country

Miriam Pérez

Race-based maternal health disparities are no longer a concern of the minority — they are a concern of the majority. And they should be a top priority. If Medicaid doesn’t make room for alternative, potentially life saving maternal health models, we risk endangering the health of generations to come.

Two weeks ago the news from the Census Bureau that non-white children make up the majority of those under the age of one year created a firestorm of media headlines across the nation. These demographic shifts have many implications for our nation, but my first thought was this: The majority of the babies being born in the US are now at serious risk for a whole host of maternal, fetal, and infant health problems.

Why? Because women of color have significantly higher rates of pre-term birth, low-infant birth weight, maternal, and fetal mortality.

Race-based maternal health disparities are no longer a concern of the minority — they are a concern of the majority. And they should be a top priority. According to Amnesty International’s 2010 report, African American women are four times more likely to die during childbirth than white women, a rate that has not improved in over 20 years. Data from 2008 showed that African American women also had an infant mortality rate that was twice that of white women. While only comprising 16 percent of births, African-American women experienced 30.4 percent of the infant deaths.

Similar statistics and disparities exist for Native American women, Asian Pacific Islanders and Latinas to varying degrees — but with few exceptions, the rates for all these groups are higher than for white women. The United States lags behind 49 other countries in our maternal mortality rates, and 40 other countries in our infant mortality rates, a fact that was reiterated in an article in Sunday’s New York Times Magazine. The piece was a profile of Ina May Gaskin, famous for her work promoting out of hospital birth as a midwife in rural Tennessee. What the article neglected to talk about, however, was maternal health disparities for women of color.

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The cause of race-based maternal health disparities is likely complex and intimately connected to issues of poverty, racism, and quality of health care. For many advocates like Gaskin, the midwifery model of maternity care is an often-touted way to address these disparities. I myself, as a doula and frequent writer about the connections between race and maternal health, have explored how the midwifery model, which emphasizes patient-centered care and utilizes fewer interventions, could successfully reduce these disparities. 

In order to truly address these long-term and seriously detrimental race-based maternal health disparities, we need to make room for innovation. Our current model is broken. It’s failing us. That model is one that is dominated by hospital birth (98 percent of all births in the United States happen in hospitals) and are attended by obstetricians likely using interventions. The place where that innovation is most desperately needed is Medicaid-funded maternity care. According to Amnesty International, “Medicaid pays for over 40 percent of births in the United States, and costs related to pregnancy and birth account for over one quarter of all hospital charges billed to Medicaid.”

There is evidence to back the claim that midwifery care could be the innovation we need to improve maternity care, especially for women of color. Jennie Joseph, a midwife in Orlando Florida who runs a birth center and maternal health clinic, says she’s almost eliminated the maternal health disparities typically seen in her low-income Black and Latina patients. Recent findings by the American College of Nurse-Midwives also showed improved outcomes with midwifery care.

But the problem is that midwifery in the United States just isn’t reaching women of color. Recent data from the CDC showed a 29 percent increase in the number of women having home births — but the vast majority of that increase was due to white women choosing home birth. Many have also pointed out that midwifery care won’t be accessible to women of color until midwives themselves are more representative of the communities they are trying to reach. It remains an overwhelmingly white profession, and for those midwives of color who have ventured into the field, challenges abound. Around the same time the census data was released, a group of midwives of color resigned from the leadership of the Midwives Alliance of North America, one of the main professional associations for midwives in the United States. Their resignation, explained in their letter to the MANA leadership, named instances of institutional racism and ongoing frustrations within the organization.

Claudia Booker, an African American midwife in Washington DC who was among those who resigned, talked with me about a bigger challenge — one that will affect any maternal health providers who want to work with low-income populations and communities of color: the business model. She explained that Medicaid and its reimbursement fees make it almost impossible for the midwives of color she knew to stay in business while serving primarily low-income women of color. Out-of-hospital midwives receive just $1200 for each Medicaid birth, which includes all pre-natal visits and the labor itself. That’s in contrast to the $4,000 that midwives charge individuals for similar services.

Other medical providers are able to cater to Medicaid patients, but the thing that keeps them in business is volume. If they can handle many patients in a day, than the lower reimbursement rates can be counteracted. The problem, Booker explained, is that having a high volume practice goes against the midwifery model.

“If we were able to give quality care to clients at 45 minutes each, and be able to handle enough clients to live well, then Medicaid would be the answer for us. But we can’t do that. You just can’t say your five minutes are up and you’re gone.”

It’s this patient-centered and time-intensive care that may be the key to eliminating disparities, but the Medicaid system leaves little room for this kind of practice. That means that a maternal health model of care that could eliminate disparities might never reach the population that most needs it.

I’m not the only one who believes we need innovation in maternal health. The Center for Medicaid and Medicare Innovation just announced 43 million in funding for new approaches to prenatal care that address the problem of premature births — something that leads to much higher mortality rates, and a host of other complications for newborns. But once again it looks like midwifery will be kept out of this discovery process — the only eligible providers are those who see at least 500 births per year — something that few midwifery practices or birth centers do. These requirements are based on the desire for statistically significant findings, but they might just exclude those who can actually produce the results they are seeking.

It’s hard to imagine that a medical provider who is forced to carry a high volume of clients will be able to provide the care necessary to eliminate race-based health disparities. If Medicaid doesn’t make room for alternative, potentially life-saving maternal health models, we risk endangering the health of generations to come. The challenges are clear, what we require are the innovative solutions. Our nation’s health depends upon it. 

Commentary Abortion

Why Is Obama Afraid to Embrace Reproductive Rights?

Erin Matson

On June 14, the White House will host the United State of Women Summit to "celebrate the progress we've made on behalf of women and girls and to talk about how we're taking action moving forward." Yet abortion is nowhere on the agenda.

On June 14, the White House will host the United State of Women Summit to, as its website explains, “celebrate the progress we’ve made on behalf of women and girls and to talk about how we’re taking action moving forward.” Yet reproductive rights are scarcely included.

Six themes are on the agenda: economic empowerment; educational opportunity; violence against women; entrepreneurship and innovation; leadership and civic engagement; and health and wellness—”looking at health coverage, preventative care, pregnancy and more.” Speakers will discuss a number of topics to “inspire all of us to take action on June 14th and well after.” The audience is to be made up of advocates and leaders hand-selected by the White House.

Prenatal care is highlighted in the programming descriptions. Contraceptive coverage is mentioned as part of the Affordable Care Act. Maternal mortality and HIV prevention is discussed as an issue of global health, although these issues remain urgent within the United States as well, with women of color experiencing unconscionable disparities in care. Yet the word “abortion” is nowhere to be found.

This, despite the fact that in the last five years, states put upwards of 288 new abortion restrictions on the books, which is more than a quarter of the total such laws adopted since Roe v. Wade. It’s not stopping. In the first three months of 2016, states introduced 411 new abortion restrictions. The “pro-life” dream is coming true: Clinics are closing, specific methods of abortion are being banned, and those women who take matters into their own hands are starting to trickle into jails under fetal homicide laws that backers swore wouldn’t be used to prosecute women.

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President Obama is well aware of these issues. He knows that Congress has established a select investigative panel for the purpose of harassing Planned Parenthood, even after the sting videos created by David Daleiden to bring the organization down were thoroughly debunked. He knows that the incendiary rhetoric used by the activists and politicians colluding with Daleiden sadly and predictably erupted into a terrorist act, leading to the murder of three people in a Colorado Springs Planned Parenthood health center late last year. He knows that five men and three women in Supreme Court robes are considering Whole Woman’s Health v. Hellerstedt, a challenge to Texas’ abortion clinic closure law and the biggest abortion access case in a generation.

In this environment, there is no acceptable excuse for leaving abortion out of a policy agenda for women. Abortion is an inextricable part of the struggle for women’s equality, and as I’ve covered for Rewire previously, you simply can’t do feminism—a commitment to the social and political equality of all people, especially women and girls—and set the controversy of abortion off to the side.

The strategy of trying to make things better for women by talking about everything but reproductive rights doesn’t work. Hushing up about abortion has not magically ended the domestic violence crisis, produced the votes for paycheck fairness, or mandated paid family leave. Leaving abortion to the side has certainly failed to help women parent their children in safe and healthy communities, free of state or systemic violence.

And yet the current plan for the United State of Women Summit is silence. As a time for women’s advocates to gather and outline strategies for moving forward, abortion should be included, period. Obama has nothing to lose politically by taking a more robust stand on reproductive rights during the sunset days of his administration. In fact, embracing abortion and sexual health for women would serve to strengthen his legacy toward women and girls.

Since that history-making day in 2009 when he took office, Obama has mistakenly treated reproductive rights as playing second fiddle to the women’s movement, and to his broader legacy toward dignity, equality, and justice for all. Yes, Cecile Richards has visited his White House 42 times and yes, public actions such as including the birth control benefit in the health-care law and refusing to allow shutdown-happy Republicans in Congress to defund Planned Parenthood show a level of access, commitment, and support.

But when this president convenes a big table, even a women’s summit, abortion is lucky to get a folding chair in the back. Women who have sex are placed in a silo on purpose.

If we’re honest about it, abortion is controversial because affirming a woman’s inherent right to dignity, power, and sexual pleasure is the controversy. This is about gender roles, sexuality, and control—especially over people born into bodies of color and families without wealth.

Either we believe that women are people and deserve dignity, or we don’t. There is no such thing as equality for women if the precondition of equality is that women shut their legs. Justice doesn’t come with behavioral preconditions targeting the very people experiencing injustice.

An advocate for reproductive health, rights, or justice could, on a level, sympathize with Obama for not wanting to have his presidency and even his legacy-minded women’s summit flanked by bloody fetus posters and buses full of Troy Newmans. But the threat of a sideshow shouldn’t stand in the way of justice. On other issues, this president and his administration have proven capable of growing and changing, as with Obama’s journey to embrace marriage equality. Or, more recently, consider the administration’s clear and firm stance for equality in the face of outrageous discrimination and lies peddled by the right wing, as when it filed suit against North Carolina’s bathroom discrimination law as Attorney General Loretta Lynch told the transgender community, “We see you.”

Not so with reproductive rights. Even the signature accomplishment of the Affordable Care Act—the birth control benefit—was tarnished by new restrictions on abortion funding, and contraceptive coverage exemptions that continue to grow and fail to placate the opposition. President Obama traded away Washington, D.C.’s right to local abortion funding in 2011. His administration attempted to overrule the Food and Drug Administration’s decision to make emergency contraception available over-the-counter without age restriction, an issue that had to be resolved by force of a court order. To date he has failed to take action to correct a ridiculous interpretation of the Helms Amendment, which bars funding in foreign assistance for abortion “as a method of family planning,” and surely was meant to include customary exceptions for rape, incest, and life endangerment. The president has the sole power to fix this—no congressional action required. An executive order on Helms that stands up for rape victims in war zones and women who can’t live through a pregnancy should be a no-brainer.

In any case, this issue can and should be corrected now. Abortion should not be censored out of Obama’s big party for feminism, nor from feminism in general. A webmaster can add reproductive rights to the United State of Women Summit website, and the programming can be updated. President Obama can, for that matter, sign a life-saving executive order on Helms. And his legacy toward women that he cares so much about will be vastly improved.

CORRECTION: This piece has been updated to reflect the correct number of themes on the agenda at the summit.

Culture & Conversation Family

Breastfeeding, Bias, and Men Who Give Birth: Q&A With Trans Activist Trevor MacDonald

Britni de la Cretaz

In his new parenting memoir, Trevor MacDonald talks about pregnancy and breastfeeding as a trans man—and why we must dislodge the idea that bearing children is only women's labor.

Pregnancy, birth, and breastfeeding are acts often associated with womanhood. We talk about pregnant women and nursing mothers, but this language—which depends on the male-female gender binary—seems inadequate as trans and nonbinary folks are increasingly visible in the parenting sphere.

With his first book, Where’s the Mother?: Stories From A Transgender Dad, Trevor MacDonald hopes to blow the conversation wide open. MacDonald is a Canadian author who has been blogging about his journey as a nursing man on his blog, Milk Junkies, since 2011. He also facilitates a Facebook group for trans folks who nurse, and he initiated and helped design a University of Ottawa study focusing on the experiences of transmasculine individuals with pregnancy, birth, and infant feeding.

MacDonald’s book explores his transition from living as female to living openly as a man, and how that transition ultimately led to his decision to carry and birth a child with his partner.

By sharing his experiences and documenting the many challenges he faced as a man who planned to give birth and nurse his baby, MacDonald asks readers to reconsider everything they think they know about what it means to be a gestational parent. By the end of the book, readers come away understanding that despite a person’s gender, pregnancy and nursing are universal experiences and valid regardless of how they happen. MacDonald’s voice is an important and necessary one in the birthing community, and there are surely many more people out there like him.

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Rewire: You talk a lot about struggling to find literature that you related to because pregnancy, birth, and breastfeeding are typically only associated with women—and motherhood. Can you tell me about the kind of language you’d like to see used to talk about these experiences and why it’s important?

Trevor MacDonald: I think I was a bit naive at first when I was reading those materials. I felt like, “If only the authors knew, I’m sure they would have used different language. They just didn’t know about people like me.” And that’s definitely been the case for some of those authors. Many are starting to change language and using words like “parents” or “pregnant people.” It’s a simple shift, really.

Where I was naive, though, is that there are some people who really don’t want to use inclusive language. Ina May Gaskin is one. I had read her book [Ina May’s Guide to Childbirth] during my first pregnancy and had been so inspired by her writing, and the birth stories are so valuable and needed. I was so hungry for information about what others had experienced. I love that book so dearly, and to realize she really was opposed to including gender-diverse people in her writing was really upsetting. [Gaskin signed this open letter by Woman-Centered Midwifery, a group of “gender-critical” midwives who believe that biological sex determines gender and were concerned about the Midwives Alliance of North America’s use of gender-neutral language to talk about pregnancy and birth.]

It’s also really important to me to point out that no one needs to throw out the words “mother” or “woman”; you just need to include more words. So you could say “women and men and gender-nonconforming people” or “parents.” It’s nice to have more than one word to mix things up a little bit.

Rewire: What was the decision to carry a baby like for you?

TM: It was something I’d never thought I would do until after I transitioned and after getting together with my partner. For me, transitioning in the medical way that I did [through hormone therapy and top surgery involving breast removal] made me comfortable enough with myself to contemplate carrying a baby. Before that, there was so much stress and constant background noise in my thoughts and in my life to do with gender, with bathrooms, and with all the ways I really wasn’t comfortable. When I transitioned and so much of that fell away, I started to consider things I never had before. It helped that I was able to present as male throughout my pregnancies because I had taken testosterone [before pregnancy]. Those things enabled me to express my gender and present myself during pregnancy in ways that were comfortable for me.

Rewire: Did you experience any gender dysphoriathe distress or discomfort that occurs when the gender someone is assigned does not align with their actual gender—during your pregnancy?

TM: For sure, but for me it was more around medical stuff than around everyday living. In my everyday life, I was still presenting as male. But with health-care providers, especially providers who specialize in prenatal care, they’re so used to everything being woman-centered, and it’s really important to some providers to use woman-centered language.

I didn’t have any providers who had worked with an openly trans client before, so people certainly had trouble with the language. One midwife offered a blanket apology that she was going to have trouble remembering to use the right words and that she didn’t mean to be offensive. For me, I think I would have preferred if she had made more of a commitment to trying to change her language—going beyond apologizing, but trying to do something to remember to use my pronouns. I think it must be hard when it’s your first client who has asked you to use new language. It’s a new skill that has to be practiced and learned, like any other.

Another place where I sometimes experienced challenges was when people at work who had previously been using the correct pronouns for me switched to using the word “mom” and female pronouns when they found out I was pregnant.

But for me personally, in my body, I didn’t feel like the experience of being pregnant triggered dysphoria. It was more the way society responded to me that did.

Rewire: Birthing at home was something important to you. Can you talk a bit about why that option felt safest?

TM: I think the difference for me was that care is different. In Canada, we have midwifery care that is part of the health-care system, and it is covered by insurance. We still have a shortage of midwives, so not everyone who wants one can get one. I was fortunate to get midwives for both my births. For me, the continuity of care that they provide and that you get with a home birth is important.

At a hospital birth, there is no way to meet all your providers before you go there and labor, and I felt like there might be a lot of explaining that I might have to do. I did go to a hospital during pregnancy and another time when I had a miscarriage. I had to come out to every provider there, starting with the first nurse and every subsequent person that I saw. Each person needed to hear the same story about how I, a man, was pregnant. One doctor even had a lot of questions about how I could no longer be taking testosterone and still have facial hair. I couldn’t imagine having to explain those things and educate during labor.

Even with midwives, though, it’s not a magical recipe for getting exactly the kind of care that you need. I still had midwives at my first birth that I hadn’t met before.

Rewire: How do you think care providers—whether they’re doctors or midwives, or lactation consultants—can best support families like yours, or people who are not women but may be giving birth or nursing their babies?

TM: I think considering the topic, doing reading and practicing using the language ahead of time, before they ever meet their first trans or gender-nonconforming client is really important. There are more and more resources available now and places to go to read about people’s experiences, and there are a number of different medical associations who have called on their members to do exactly that. This is so they are not asking their individual patients to educate them, particularly when that person needs care and is in a vulnerable position. That’s not the time to be asking questions that they could learn about in other places.

Rewire: Finding donor milk for your son Jacob seemed to be quite a challenge. You mention that you produce about a quarter of the milk your baby needed, and the rest had to come from donors. Can you talk about what some of the challenges to finding donor milk are? Do you think protocols that see milk sharing as “risky” keep babies from being breastfed who might otherwise benefit from receiving breast milk?

TM: I think some of the taboo against milk sharing is really starting to shift in our culture right now. Currently, a lot of regulatory bodies—for example, the Food and Drug Administration and Health Canada—have a position against peer-to-peer milk sharing—like through Facebook groups like Human Milk 4 Human Babies, where we found many of our milk donors.

But La Leche League (LLL) has actually changed their position on it. LLL’s leaders, who facilitate their local support groups, used to not be allowed to discuss peer-to-peer milk sharing in any way, but last year the organization released a statement with a new policy. Leaders are allowed now to share information and can say that these milk sharing websites exist. It would be a great shift if other groups start to take a position more like LLL, where they can provide information. It would be awesome if medical professionals started to tell patients that these networks exist. Karleen Gribble has written papers about the ethics of peer-to-peer milk sharing and the ethical implications of letting patients know about it and how care providers could discuss risks and benefits, not just of peer-to-peer milk sharing, but of using formula.

In pop culture, when people talk about being worried about milk sharing, the fear most often brought up has to do with diseases like HIV. But something we had to consider as well was the medications that people were taking and whether it could be passed through breast milk. Many people who donate milk through peer-to-peer sharing do so because formal milk banks have such strict requirements around who can donate to them. Formal milk banks are not necessarily in competition with peer-to-peer milk sharing, which is important to understand.

Rewire: You talk a lot in the book about milk donation and the community that sprung up around you to help your family achieve your breastfeeding goals. Can you speak about the support you received and how it affected your breastfeeding journey?

TM: We met people that we otherwise never would have met and never would have become friends with. Many of our milk donors are still our friends, and they were such a diverse bunch of people. From a Mormon donor to a military family to a Mennonite family, all these different kinds of families from different backgrounds came together to help us feed our baby. It was amazing to meet these different people and to realize that despite us being a different kind of family in this one particular way, what was most important to all these people was that a baby needed breast milk.

Rewire: It sounds like prior to having your son, you didn’t know any other trans people who had nursed their babies. Has that changed? Are their experiences similar to yours?

TM: Before Jacob, I only knew about the guy, Thomas Beatie, who went on Oprah. I didn’t know anyone in person. I knew a few trans people who had children prior to transition. Through writing my blog, that’s how I first started to connect to a lot of other trans parents and people who were carrying babies while being out as trans. People asked me questions through my blog about how I navigated the medical system and a lot of questions about breastfeeding.

I also got a lot of questions from cisgender women as well, who were grappling with all kinds of different breastfeeding challenges. Many people deal with low milk supply and try to use a supplementer, like I use to nurse my baby (since I only make about a quarter of the milk my baby needs, I use a supplementer to deliver the milk at my chest, which allows me to feed my baby at my chest). So many people can relate to these challenges. A lot of the time, it’s a private struggle that people have, and it’s intense but you don’t necessarily talk about it that much. All kinds of people reached out to me because they could relate to these issues.

Rewire: What do you wish you had known before giving birth to Jacob?

TM: I wish I had trusted my own instincts a little bit more, and given myself more space to just see what my body would want to do in labor. I felt like I was looking to my care providers and my doula for suggestions, and I’m sure a lot of people have that experience when they’re going through something they’ve never been through before.

Rewire: What do you hope people take away from your book?

TM: I really hope that it will open up conversations. I hope it will provide opportunities for people to talk more about gender diversity, not just generally, but in parenthood and related to pregnancy and breastfeeding. If this book contributed to a conversation that way and opened up discussion, that would be amazing. I would be really thrilled.

This interview was conducted by email and by phone. It has been lightly edited for length and clarity.