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Saturday
Sep222007

Race & Birth Issues (PiggyBack from SageFemme)

(post used with permission)

Midwife: Sage Femme, Hebamme, Comadrona, Partera challenged me (and others) with this powerful post about race and birth issues.

SageFemme says:

I'd like to hear from all of you but specifically Minority Midwifery Student and LaborPayne in regards to this:

In my midwifery school, it was VERY rare to see a woman of color. In my experiences in the birth activism/lactivism world, again, not only is it nearly all white women but the class issue plays a big piece, too.A woman of color once said to me, "Midwifery is a rich, white girl's hobby". Hobby in terms of the fact that so many women shell out thousands to attend midwifery school, only to never be a midwife. They usually move on to other things/jobs, which is fine, but many young women right out of high school or college have some sweet funding by their parents for midwifery school.

(I know, of course that this is not the majority, but there is a huge gap in funding for midwifery school since most schools do NOT have grants or student loans that pay for the entire education like a CNM program - I know that there are women caught in the middle of all the financial issues. But seriously, if an education costs you $30-40,000 and only part of that could be funded through student loans or grants, how does this serve women from less privileged homes, white or of color?)

I guess what hits me most is that if black women make up for some of the worst outcomes in birth, is the inaccessibility to midwifery schools (especially homebirth) to blame? Or is there a lack of awareness re: options in birth? Are we, as white women, keeping the role of midwife in our own privileged community and not taking it further (and I honestly believe that communities are best served by people that come from that community, though it's not always the case if there's no other options*). I admit that I'm coming from a place of white privilege and ignorance about what the issues are. That's why I'm inquiring. I'd like to have a dialogue about this and to be taught about what I see or perceive.I know that Shafia Monroe, a midwife in my state is working on alot of these issues.

* - I have negative feelings about white people going into other countries and cultures, telling them that how they live and heal is wrong and then try to teach them the "white way" of doing things (when we are messing up so much stuff in our own culture)..I guess I feel the same about missionaries converting indigenous people from their native spiritual beliefs.

This male midwife is from the US. He drives two hours down to Mexico to serve poor Latina women. However, his attitude is misogynistic at best and since he's married to a Mexican woman, there's this assumption that he can get away with racist judgments about these women's lives. Why is it necessary to have a male midwife (whose own practices are sometimes questionable, but not included in his website) go to those women to help them? There are midwives there, but "not enough" he has said. Are we to believe that none of these women would want to be a midwife, to apprentice under one of the other midwives? Do the women in this Mexican community find him more skilled than their own parteras because he is a white man coming from the US?

And the pictures of him with the women - the paternalistic poses seem odd to me, but that's a whole 'nother subject. So are the graphic birth photos taken of these women, many under age and likely few realize what the 'internet' is or how widespread these pictures will get.

Then there are places where mostly white women go to get their "numbers" for midwifery school...and they train on minority women. How do other people feel about this? I mean really feel about it, not just "well, I went there to train and it was really helpful!".

Am I off my rocker here? Please, help me understand this because I cannot talk about it at all with most white, progressive women.

[End Sagefemme's post]

So far, there are 12 comments. Mine, a few spots down, says:

I’ve often wondered how many midwives there are amongst us doing our toenails, cleaning our houses or selling us fruit at the corner store. Just because the woman can’t speak our language doesn’t mean she isn’t a midwife. What is she unable to teach us? What women, even in her own community, are (un)able to benefit from her knowledge simply because she is unable to take the state exam in her native language?

Yet, I know from talking to the women at the nail salons that those particular women and those in their particular communities would never dream of going to a midwife and having homebirths. They want American hospital births with American doctors and all the “status” that comes with those words. Even in their own community, the midwives are shunned.

I am one of the women who went to El Paso to “get numbers” and work with the migrant Mexican women that came in droves through the doors at Casa de Nacimiento. First, the women who come there know the providers are students and are informed of that at their first appointment. They understand that they might get a couple of exams sometimes in case something is amiss or if a midwife needs to check after a student. They agree to it. Do they totally understand what they are agreeing to? Probably not, but do any of us signing a contract understand 100% what we are agreeing to until after the fact? And, at any time, the women can refuse any procedure (and do) and that is totally respected.

Secondly, I found it difficult when the students who came made zero effort to learn Spanish. When I went the first time, I spoke some OB Spanish… pretty bad conversational, but my OB Spanish was okay. But when people know they are coming for 4 months or whatever and take no initiative to learn, that bugged the crap out of me. By the time I went the second time (7 years later), I was fluent in Spanish and the whole gig was a delight and I had a blast with the women and their families. There was no issue with cultural divisiveness (my Spanish is Mexican Spanish and my knowledge is Mexican knowledge) and when there were moments of my American goofiness, I always made it my “duh” moment and they were very gracious and forgiving of my ignorance.

Thirdly, I never saw what I did as “practicing on” anyone. I think if I had done that, I would have, right there, been guilty of some horrid Anglocentrism. Instead, I was a care provider… a midwife… and I gave the women phenomenal care. Better care than many (most) might have gotten in Mexico. There weren’t any parteras that we knew about in Ciudad Juarez… we looked for them. I love the Mexican women. Loved the women I served in El Paso. Many of whom I can still remember by name and face. I have wanted to move to El Paso for years, but my Sarah won’t have any part of it; that makes me sad. I know I might be in the minority… the “not practicing on the women” type, but let me tell you, when I spent the year plus there, I was crazed with overseeing that nobody treated the women disrespectfully. I know Linda (the owner) works hard to do the same.

It’s easy to pass judgment on somewhere you’ve never been, but I’ve been there and I wouldn’t have stayed two seconds if the women weren’t seen as beloved human beings. Great topic

DoctorJen adds:

It's always interesting to me to think about issues of race and class as it pertains to healthcare. I know the discussion is about midwifery, but I think allopathic medicine is right there with it. I did my residency training in the inner city, and definitely experienced that element of "practincing on" folks from less advantaged backgrounds.

Like a couple of posters above, I feel that I was always kind and compassionate, truly tried to learn about cultural differences, and really cared what happened to my clients. I'm still in touch with one client, especially, who I became close too in the 3 years that I was her doc, starting with the first week I had that "MD" after my name.

Also interesting to me to read those of us from the advantaged backgrounds talking about how it wasn't like that, we weren't practicing on poor folks, we really care, blah, blah, and then see the perspective of someone from that background saying their truth - that we aren't trusted, that clients of color and poverty who go to the teaching establishments know that we are only there to get training and then move on. Maybe we provide good care - likely better care than anything else that's available, but the clients know why we do it.

I think it is absolutely vital to hear these opinions as truth. It doesn't matter what my white, middle class self feels about my training in the inner city. It doesn't matter that I had only the best intentions. What matters is how the people I served feel about it. I think many of us who come from a place of privilege just do not see subtle racism and classism and tend to discount it when we do see it. We don't understand the additive effect of living with it year after year after.

I am forever grateful for my training, for the few years peek into a different culture, a different world. I'm grateful for the opportunity to learn, but also feel sort of eternally guilty for having learned with clients who mostly had no choice. Please don't misunderstand me - I'm a lovely person, really, and in many (maybe even most)cases I'm sure I was the best provider available to my clients during my training, but how shameful is it that the best they had available was a small-town white girl just out of med school?I'm not sure what the answer is - how do communities become empowered to provide their own midwives, their own healthcare providers, their own wise women? Would taking training programs out of these communities help, or make it worse? Is there anything we, as outsiders, can do to encourage leaders to rise up within a community?

Good questions you raise, sagefemme, and I hope to see more folks joining in this discussion.

[end DoctorJen's comment]

So, I have been thinking about this for days and days now and have been jotting down notes when I stop at lights and in traffic and when I am in the store and such and I’m going to try and put the notes and thoughts into some sort of cogent piece of writing.

DoctorJen raises some interesting questions and points.

First off, it’s important to know, for those that don’t, that most schools of any kind – midwifery and medical – put their students and residents into an under-served community to learn/practice. “Teaching Hospitals” are what they are usually called and I know loads of CNMs that went to Teaching Hospitals as they wended their way towards CNM-dom. If they didn’t go through the hospital route, they would go the birth center route and there, too, they found the under-served… the Medicaid women… more often than not. In fact, from my experience, CNMs, by far, serve women on Medicaid more than women who have other forms of insurance. This could be because of where I have been (Florida, Texas, California), but it seems a common theme that CNMs take an unbalanced role in Medicaid births compared to physicians.

I say this about CNMs because in my limited world, LMs are not permitted to take Medi-Cal (the California equivalent of Medicaid). I would love Love LOVE to take Medi-Cal, but the force holding us back is that we have to have a supervising physician and none of us does. The state is aware of this and we are making great attempts at removing the stipulation requiring supervision (changing it instead to collaboration), but until some glacial change is made, we are immobilized on the Medi-Cal issue. Some states do, however, allow LMs/CPMs to accept Medicaid – lucky ducks!

But, this begs the question.

If the Medicaid women are shoved “down” to LMs/CPMs/CNMs because the OBs don’t want them – they don’t get enough money from Medicaid to make it worth their while – does that mean that the women are getting inferior care?

Of course not!

The women, in many respects are getting SUperior care, right? The midwives are going to take more time, “see” the women as individuals, talk to them more respectfully, give them more attention and allow them more autonomy during their births as much as they can, right? (In general… these are serious generalizations, I know.)

Does race and culture come into any of this? I don’t believe it does. I believe that respect and the love for the WOMEN and the disgust that the women are tossed aside by the OBs and the culture in general elevates the women, together, in a common goal and they can see each other in a way they might not have otherwise. Is it equal? Absolutely not. Is it perfect? Of course not.

Some believe that students are the worst and they never want anyone practicing on them. I know women who put in their birth plans, “No students or residents” so they don’t have to contend with anyone else looking at them, much less touching them. I am one who encourages any and all students and residents to come and learn on me. I want them to find perfection in their learning… if they don’t practice on me, how will they be skilled when they put their hands on my daughter in 10 years? I want them to learn to look at my saggy, baggy body and not be grossed out, not laugh so they can become de-sensitized and look at all those other bodies and “see” the person’s illness and not their skin.

At births, midwives sometimes come up against walls; I call mine “blind spots.” A situation presents itself and the solution is baffling. When I was in New Orleans, for example, my wonderful VBAC client was pushing for hours and I couldn’t figure out what to do anymore. I was so tired and overwhelmed with what to do. I knew we should go to the hospital, but was so terrified of giving in and worried about her having another cesarean, I couldn’t even go there. I called a woman I use as an assistant… a student midwife… and she talked me through all the steps I’d tried already and the mental and emotional process I needed to be able to talk to my client about going to the hospital. It was an incredibly intense discussion, 2000 miles away over the phone, but one I will never forget – she so strong and sure – and me, a crumbling mess of not wanting to fail my client. She helped me stand up again and be the strength my client needed to get her into the hospital where, it turns out; she pushed for even longer and had her hard, HARD-worked-for VBAC.

The students are IN the fire. They are in the midst of the books and the information. They are the most meticulous with making sure their thumbs aren’t on the woman’s clitoris during a vaginal exam. They are very gentle with a woman’s body. They are clear with instructions. They are great with charting. Students can be so wonderful to bounce ideas and concerns off of because they have so much information right there in the front of their brains.

Sending a student in to take care of a client, I believe, can be giving the women some of the best care available. Many (Most) students don’t take unnecessary risks and will ask for help if they don’t know something. Preceptors should be going over the charts and should be catching things that seem out of sorts and questioning the students anyway. When given express limitations, I believe students will follow them.

So, when midwives are sent out to train, wouldn’t it be the anomaly if she were to train in her own community? Is it maybe the norm for midwives to leave their own neighborhood/community/culture to learn how to be midwives?

Perhaps leaving our own culture is part of what we need to do in order see/hear/understand the women clearly as new midwives.

Is it always racist/classist that we are sent to under-served communities? Or can it be seen as a positive and the racist thought possibly be that we should sit tight in our own communities while becoming health care providers (just thinking aloud, DoctorJen).

So, if we are supposed to sit tight in our own communities, what about the women around the world who don’t have midwives in their communities yet? What if we’ve been invited in? Does that make a difference?

I wholeheartedly agree with Sagefemme about converting the “natives” and foisting our beliefs and ways on those who are unsuspecting and innocently open to our “kindnesses.” But, how do we balance if we might really have something to offer… a skill to help with shoulder dystocia, for example. What if we know they have something to teach us? If things are reciprocal, does that make it okay? How do we know if the reciprocity is immediate or might take a decade? (This could go ‘round and ‘round, you see?)

If we didn’t move outside our own communities, isn’t that forcing women to travel outside their own neighborhoods to obtain care? Wouldn’t it be a much kinder and more respectful move to get off our asses and set up shop in their areas of town, acclimate to their culture and offer them the fabulous care they deserve? We most certainly shouldn’t abandon them because we aren’t their race, color or because their language isn’t our first.

Sagefemme speaks about midwifery being a rich woman’s hobby (and I agree). I own at least $10,000 worth of equipment. To start a decent kit, it takes about $2000-$4000 if you include meds, sutures, oxygen, tanks, setting up accounts… and that doesn’t include the vehicle, gas and insurance to carry all that equipment around in. Most of us don’t start with an entire trunk-full, but gradually add pieces as our apprenticeship advances towards independence. Still, a good pair of needle holders costs $110. I’ve written about the “costs” of apprenticeships, so won’t elaborate on all of them here, but they are expensive and include not being paid, sometimes for years on end, paying for schooling at the same time, paying for childcare, food out, gas to and from births, prenatals, postpartum visits, cell phones, and more. If a woman is trying to survive day to day and feed her children, where does the luxury of an apprenticeship come in? It doesn’t.

When I was a single mom on welfare, I had the opportunity to be an apprentice, but had to turn it down because my car wasn’t reliable and childcare was non-existent. The midwife was kind and gentle in telling me how qualified I was and that she wouldn’t hesitate to take me on if I were married and had support, but I had to think of my children first, didn’t I? It’s what a midwife does, doesn’t she? How was I going to argue with that? How could I have worked around the obstacles? In our un-supportive, non-tribal community, how was I ever going to be a midwife with young children unless I had a partner who supported my expensive hobby?

As it turned out, I couldn’t. For the years Sarah and I were not together, I left my children alone while I worked as a midwife’s assistant or a paid doula. I made choices that sucked, but that forwarded my career AND fed my children at the same time. That one choice that eventually landed me in jail – working and accepting welfare – was another painful time of “is this the best I can do for my kids?” It seemed, at the time, it was.

When I was again back with Sarah and she was the money-maker of the family, I was finally able to fly, headfirst, into midwifery, despite having so, so many years of experience (and one license already) behind me. Before that time, I couldn’t afford any equipment to practice independently, but as soon as I was able, I bought the equipment, went to El Paso, and finalized my plans to become a Licensed Midwife. Which was bloody expensive, too. All of it.

So, when we cross all the hurdles and we become midwives and we are in these other communities – and we have a young pregnant woman of another culture sitting in front of us, who says she might not be influenced by us to become a midwife? Did all the African-American, Asian, Anglo or Hispanic midwives only consider becoming midwives by seeing African-American, Asian, Anglo or Hispanic midwives? I like to believe the thought might have crossed their minds even without a race/culture card being super-imposed over the midwife’s face. I like to believe that they can leap over the color/race/culture hurdle all on their own without someone leading them by the hand. And even if the midwife does lead them by the hand, as many of us do when we find a potential midwife in our midst, it’s okay if we aren’t her same race, don’t you think? I think it would be wonderful to be a role model to someone… even if we weren’t the same race or color.

I want to be a woman who is with woman. Not an Anglicized Cuban-Swede woman with an illegal Mexican woman.

A midwife.

Let’s be midwives.

Reader Comments (9)

Hi there, I had to do some serious reflection on my attitude to race and paternalism when I moved from a very white, middle class area in the UK to Gisborne in New Zealand, which has a high Maori population. I learnt many things about myself and how to be with women during that time, not least to be honest and true to myself and the women I serve. Best wishes Sarah

September 22, 2007 | Unregistered CommenterSarah Stewart

I think that I agree with you here on many issues, but let's face it: we're white women with at least a middle class living. I think it's so hard to speak on this topic coming from this vantage point - there is only our version of it and so much that is unsaid because our white world cannot allow the other voices to be heard. you know?

But, yes, I agree to a large extent. I just don't know how blind to race we can be when we're the majority and have privilege...I feel like it's a big issue even talking about these things with other white women because it always ends up being, "well, I have a friend who is black!" type of talks.

*sigh*

But, yes, I appreciated your views and your words. I am open to being a midwife for all women - but many of those women don't have the ability to reach me or even the remotest satisfactory care...be they white, latina, black, asian, etc.

Still, the idea of who IS becoming a midwife and the whiteness of that is one that is mind boggling. Then there's the birth activists, the conference speakers, the lactivists, etc. Are we as white women pushing minorities out? Or were they never there in large numbers to start with?

I think it's because birth "choices", breastfeeding "choices" and SAHM "choices" are issues that affect women who have privilege to make these "choices".

September 22, 2007 | Unregistered CommenterSage Femme

I think you have a really great point about my not having the "eye" to even be able to see the issue clearly. I accept that and will openly listen as others of color share their thoughts.

Thanks for reminding me... again.

September 23, 2007 | Unregistered CommenterNavelgazing Midwife

Going through that male midwife's site, I do have to say that it was nice to see "A VERY Tiny women's home birth"

how "tiny" she was and how "big" her baby was. should use those pictures just to show women, our bodies and our babies bodies adapt.

September 23, 2007 | Unregistered Commentermommymichael

"I think it's because birth "choices", breastfeeding "choices" and SAHM "choices" are issues that affect women who have privilege to make these "choices"."

I agree with that. I always wondered who made the art, the music, the theatre... it's not refugees in Africa- you have to get above "survival" before you can get to "actualization" (to borrow a term from Maslow).

September 23, 2007 | Unregistered CommenterAnonymous

“(post used with permission)”
(except my part )
But I’m glad to keep this conversation going – I have been looking at sagefemme’s blog daily since I left my comment waiting for more conversation and thought everyone just didn’t care about it.
My point is not really that one shouldn’t leave one’s community and comfort level and be exposed to other cultures, races, values, histories. I truly believe I am a much better doctor and person because of the time I spent training. I also gave great care to my clients during training, for many of the reasons you pointed out – I was reading and learning constantly, I was super careful how I did things, and I wanted to do well. Especially as a student, before residency, I had in abundance the one important thing that more experience and busy clinician did not – Time. I had time to listen to a dying cancer patient tell me about their life, or a frightened first time pregnant woman share her fears about birth. These skills and background experiences help me every day give better care to the clients I serve today. I practice in a rural area, and have some middle class type clients, but continue to take care of a lot of poor, young, disadvantaged women, although mostly white in my area and I do a great job of it. My training experiences were vital to making me see how I can better support all women I care for, not just those who look like me, who live like me, and who think like me.
I know that the care I gave my clients in training– like the care many midwifery training programs give – was better that the care they could get in a standard OB’s office. I had higher breastfeeding rates, higher numbers of prenatal visits, better follow up for babies after birth, lower pregnancy rates among my teen clients – any method you might use to quantify care, than the so-called private OBs in the same area, whose clients rotated among whomever was working in the office that day and got whoever was on call for their birth, with a couple residents and students thrown in during labor. The births I attended as a resident meant that those women I attended had the chance to not be shouted at to push, were able to birth without being cut, were able to at least touch and kiss their babies. I still think about some of the beautiful, peaceful births I attended in the middle of a crazy, loud, uncaring teaching hospital environment and know that it was better because I was there.
But the question remains: Why do we train among less advantaged clients? On the one side we can say that many of us who choose a profession like medicine or midwifery have a genuine desire to help people. I think there are many altruistic motives out there, and many individuals who are driven mostly by those motives. We see a need, and we want to meet it, want to do better than what is otherwise available.
The flip side to this is that realistically adequate training is not necessarily available among advantaged populations, because those women have the right and privilege to say “no.” They don’t always, and some people seek care at training institutions because of the perceived better level of care, but in truth, a 35 yr old upper middle class white woman can look at a student and say “Uh-uh, I only want my own doctor (midwife)” and that is respected. It is much harder for a 15 yr old poor black woman to say “No one but my own doctor (midwife),” especially because in order to get care in a teaching institution she’s already had to accept having trainees provide care along the way, and maybe doesn’t even have her own doctor or midwife to point to.
I don’t think it would be better to stay isolated in our own worlds and never reach out. I don’t think we can’t provide excellent care outside of our own social, racial, or economic class. I just think it’s a mistake to think that social, racial, or economic factors don’t come in to play. It’s a mistake to think that because I only have good intentions, that my clients only enjoy good experiences. You ask “Does race and culture come into any of this?” and answer “I don’t believe it does.” I’m not willing to say that race and culture don’t play a part speaking solely from my place of privilege. (And I know you haven’t exactly lived the perfectly easy, well supported life – I’ve read you long enough to know that you’ve climbed a lot of mountains to get where you are. Without going into a lot of detail, suffice it to say that my back ground has its own mountains.) I’m not going to quit caring for my clients of other races, I’ll never stop accepting Medicaid clients, or clients who can’t pay me, and I’ll continue to provide excellent, compassionate, heart of a servant care to all my clients. But I’ll also continue to question why there aren’t more choices for so many women, why there aren’t more midwives and other care providers of color, and believe that there are factors of racism and classism at play.

September 23, 2007 | Unregistered Commenterdoctorjen

Thanks for continuing the discussion NM.

CNMs absolutely participate in the "practicing" aspect of serving in low-income areas. I would hope that if a CNM (or a future CNM) makes a comment about anything similar to this (ie; Casa), she isn't ignorant of this fact. I certainly am not. However, I would argue/have argued that this practice (of teaching hospitals being disproportionately located in low-income areas - *IF* THIS IS THE CASE...I haven't found the numbers to support this- anyone else?) is just as ethically questionable as any other form of practicing on patients. It is not the act of "learning" that I am speaking of - it's so much more than that. This has to be my next post, I won't highjack your thread with it...

I think you're talking about two different things when you talk about 1) low-income women who come into midwifery by accident because of OBs not wanting to deal with low-paying medicaid, and 2) women who are stuck with whatever provider happens to be in medical school at the moment doing their rotation at the clinic. Yes, in our arrogance, we would love to assume that midwives are only providing the best of care to these women...even if we allow ourselves that...we are talking about a limited number of women in the grand scheme of things. There were only a few midwives in my city, so most women were NOT receiving this "SUperior" care from midwives of which you speak. By far, most women receive care from docs (who can also provide SUperior care). I agree with you that being "forced" into care by certain providers does not automatically mean that you will receive lesser care, after all, the provider you are referred to could have 20 years experience.

But, I disagree with your opinion that race and culture don't have anything to do with the way we determine who receives what care and from whom. One could make an arguement that it is more socioeconomic than it is racial/cultural, but even then, the two are so inextricably linked that you wouldn't be able to deny the role of race and culture. One only has to know a little about the history of midwifery in the south to know that race and culture historically have determined who we see for care and why. Some might argue that that was "then" and this is "now" but I challenge us to see how that very same structure plays out in today's society. If you meant that midwives who provide care for these patients who don't have very many options don't care what race or culture their patients are, only that they are women...human beings...worthy of good care, I understand. However, the cynic in me would add that even if one doesn't want to be biased, bias probably still exists because it is nearly impossible to grow, live, and learn in this country without internalizing at least a fraction of the crap that is taught to us. Even when we want to ignore things like skin color, socioeconomic status, and sexual preference (if this is the right term...it seems very "narrow" to me...I'm ignorant about this), we fail to do so.

I agree that students are "in the fire" and hyper-aware of everything they know to be aware of. And I can dig it that you love to be practiced on, and relish the teaching moments. Is that a choice that you're making? Do you think everyone has this choice? If they have it do they know that they have it? Are they equipped to stand up for themselves?

My comments are getting long...I'll continue them over at my place...

thanks for continuing the thread...

September 23, 2007 | Unregistered CommenterLoving Pecola

I apologize, DoctorJen... I should have asked your permission, too.

Please accept my apologies.

September 27, 2007 | Unregistered CommenterNavelgazing Midwife

That was a kind of snarky thing to say, sorry. I don't really think you need to ask permission to use publicly made comments. I would have liked to know my words were being debated, though, so I could get over here and debate back!

September 27, 2007 | Unregistered Commenterdoctorjen

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