Commentary Maternity and Birthing

The Way We Talk About Midwifery Care Matters

Avital Norman Nathman

Even as it championed midwives in a recent piece, the New York Times editorial board unwittingly slipped into language that suggests midwifery care is a second-tier option—language that reflects broader public attitudes throughout the United States.

The editorial board of the New York Times recently published a piece in praise of midwives, spurred by new guidelines out of the United Kingdom advising that low-risk pregnancies actually fare better out of hospital settings and under midwifery care. This editorial gives weight and visibility to an argument many in the birthing community have been making for some time: that midwives should be the standard of care for low-risk, healthy pregnancies, as well as key players in more complicated pregnancies. However, even as it championed midwives, the Times editorial board unwittingly slipped into language that suggests midwifery care is a second-tier option—language that reflects broader public attitudes throughout the United States.

The Times acknowledged that despite the difference in the British and U.S. health-care systems, “There is no good reason that midwives should not play a more important role in childbirth here.” Toward the end of the editorial, however, the board examined ways some organizations are trying to integrate midwives into their practices (emphasis ours):

Some medical centers are trying to have the best of both worlds by allowing midwives greater autonomy within the hospital. The Mayo Clinic, often a pacesetter, lets midwives handle low-risk pregnancies independently and hand off to doctors any cases that become complicated.

Words like “allowing” and “lets” imply a submissive relationship within the U.S. health-care system, in which permission may or may not be granted to midwives in order to practice what they have been trained, licensed, and certified to do. The above section also reinforces the idea that midwives drop care once a pregnancy gets complicated. In reality, however, midwives and doctors often work as a team for the benefit of a patient, rather than the midwife simply transferring care. While this was likely not intentional at all on the part of the New York Times, it’s clear that this way of thinking—that midwives are somehow seen as the lesser choice when it comes to birth providers—has become ingrained in how our society thinks and speaks about midwifery.

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Instead of using this value-laden language, the Times could have worded its assessment in a more egalitarian manner, such as: “At the Mayo Clinic, often a pacesetter, midwives practice independently and collaborate with physician when needed.”

Reframing the topic in this way also avoids playing into the idea of a “longstanding turf war between obstetricians and midwives,” as the Times put it elsewhere in their editorial. The situation is much more complicated than simply a “turf war” between two professions. While some individual providers might find themselves at odds, the false “turf war” narrative is more of a manufactured concept than it is representative of reality. Instead of fueling the false binary of doctors versus midwives, a shift in language in this way would uphold midwives and physicians as colleagues working together toward a shared goal of providing care that meets the needs of each individual patient.

Unfortunately, when it comes to midwives actually practicing, this type of language has set the stage, so to speak. In the United States, midwives—who are overwhelmingly female, which is a factor that cannot be overlooked in this discussion—are “allowed” to do their jobs, and only then with many constraints that often restrict them from practicing to the fullest extent of their licensure. Regulatory restrictions vary from state to state and affect the type of care midwives can provide, including where they can practice, what types of patients they are “allowed” to care for, and, oftentimes, how much they will be reimbursed for their services.

For example, although the Affordable Care Act stipulates that midwives should be reimbursed under Medicare 100 percent of the amount that physicians bill for identical service, the same can’t be said for Medicaid. The federal health-care program for low-income individuals’ reimbursement rate varies from state to state: A midwife may be reimbursed only 75 or 85 percent of the set fee for prenatal and delivery services, while a physician will receive 100 percent for the same work. This is vital to note, as Medicaid is often states’ largest single payer of Certified Nurse Midwife services, indicating the importance of midwives in marginalized communities.

Indeed, while some midwives are like those profiled in trend pieces in the New York Times, who care for white, upper-middle-class women, many others offer crucial services in underserved communities, taking on patients in low-income rural or urban areas where there may be provider and resource shortages.

And despite all of this, midwives remain unnecessarily regulated, both in language and in practice: set at odds with doctors rather than treated by legislators, the media, and the public as commensurate to them.

At the end of the day, it’s not about who provides the care that needs to change; rather, it’s our model of care that needs fixing. There is plenty of space and a great need for a range of providers—including physicians and midwives—when it comes to maternity care. Instead, however, we currently face a system that divides providers at the cost of the patient.

Health care in this country thrives in a for-profit world. And if you follow the money, you’ll see that this goes beyond midwives and doctors, into the insurance industry and corporate offices. Woven within this profit-centric system is the fact that the current approach in place driving maternity care in the United States is a biomedical model. This model—which focuses on pathology, physiology, and biochemistry of a disease, but does not bother to look at social, environmental, or psychological factors—procures the most revenue and is less patient-centric.

In these instances, it pays to follow the money trail and ask what type of care makes the most profit and for whom? Does the fact that providers are being paid more for interventions and the use of certain products influence their care? Are obstetric providers rewarded for the number of patients they see or for the slower-paced individualized care they can provide? Do hospitals receive more revenue for filling, or emptying, NICU beds? These are all questions we—both providers and patients—should be asking of our health care system.

As a whole, both the larger for-profit system and the biomedical model promote quantity over quality. Providers are rewarded for seeing more patients, because that brings in more revenue. This combination is at odds with the midwifery model of care—a model that has been shown to benefit both mother and infant. The American College of Nurse-Midwives carefully breaks down this model of care on its website, emphasizing the strong patient-provider relationship, patient agency, and individuality in care. It’s about long-term outcome improvements and quality over immediate revenue and quantity. Because of this, the midwifery model of care is disruptive to the for-profit/biomedical model. And disruption is exactly what is needed to fix this broken system.

When it comes to maternity care in the United States, the model of care needs to change to one where both physicians and midwives can flourish equally, as has been the case in the United Kingdom and other European countries. At present, we also need to be aware of how we discuss and frame the work of those providing care. Our for-profit system is set up to reward those billing more hours, patients, and procedures—due to the model of care they provide, that isn’t usually midwives. That has since translated into society viewing midwives as “less than” providers, despite evidence that they should be leading the way in all aspects of maternity care.

So, yes. Kudos to the New York Times for recognizing the immense benefit of midwifery care, but let’s go even further in our championing of the profession by respecting midwives in our action and our language. Hopefully the guidelines coming out of the UK will push this much-needed conversation into the mainstream and promote midwifery care in the United States. And, in the meantime, let’s do our best to talk about these providers of care in a way that is commensurate with their skill and evidence-based accomplishments.

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”

News Politics

David Daleiden Brags About Discredited Smear Campaign at GOP Convention

Amy Littlefield

Daleiden’s claims about the videos’ impact on Planned Parenthood contrast with a recent poll showing that support for Planned Parenthood has increased in the aftermath of the Center for Medical Progress' anti-choice smear videos.

David Daleiden, a year after he began releasing secretly recorded and deceptively edited videos claiming to show Planned Parenthood officials were illegally profiting from fetal tissue donation, appeared to boast about the videos’ purported impact at a luncheon during the Republican National Convention (RNC).

“I think it’s very clear that one year later, Planned Parenthood is on the brink, they’re on the precipice,” Daleiden said at the event, co-hosted by the Family Research Council Action and the Susan B. Anthony List. “Their client numbers are down by at least 10 percent, their abortion numbers are down, their revenues are down and their clinics are closing.”

The luncheon took place at the Hyde Park Prime Steakhouse, near the Quicken Loans Arena in Cleveland, Ohio, where the Republican National Convention is underway. Also in attendance at Wednesday’s luncheon were a slate of Republican anti-choice politicians, including Mississippi Gov. Phil Bryant, Kansas Gov. Sam Brownback, former Texas Gov. Rick Perry, Nebraska Sen. Deb Fischer, and North Carolina Rep. Virginia Foxx.

Daleiden—who is under felony indictment in Texas and the subject of lawsuits in California for his actions in filming the undercover videos—touted efforts to defund Planned Parenthood by state Republican legislators and governors, who used the Center for Medical Progress (CMP) smear videos as a basis for investigations. Those defunding attempts have been blocked by federal court order in several cases.

He celebrated Planned Parenthood’s announcement that it would close two and consolidate four health centers in Indiana, an effort Planned Parenthood of Indiana and Kentucky said would “allow patients to receive affordable, quality health care with extended hours at the newly consolidated locations.” Daleiden made no mention of last month’s Supreme Court decision overturning abortion restrictions in Texas, which dealt the anti-choice movement its worst legal defeat in decades.

“One year ago now, from the release of those videos, I think it’s actually safe to say that Planned Parenthood has never been more on the defensive in their entire 100 years of history, and the pro-life movement has never been stronger,” Daleiden said.

While his tone was victorious, Daleiden appeared to avoid directly claiming credit for the supposed harm done to Planned Parenthood. In a federal racketeering lawsuit brought against Daleiden and his co-defendants, Planned Parenthood has argued that Daleiden should compensate the organization for the harm that his smear campaign caused.

Republican congressional lawmakers have held at least five hearings and as many defunding votes against Planned Parenthood in the year since the videos’ release. Not a single state or federal investigation has produced evidence of wrongdoing.

Daleiden’s claims about the videos’ impact on Planned Parenthood contrast with a recent NBC/Wall Street Journal poll showing that support for Planned Parenthood has increased in the aftermath of the CMP smear videos.