Log onto Squarespace
Archives

Entries in race and midwifery (2)

Thursday
Sep272007

Continuation Still on Race & Midwifery

Jumping from the complete post here from Minority Midwifery Student:

I appreciate Minority Midwifery Student (whose words are italicized below) taking so much time to question and answer this issue. By the lack of comments, I wonder if it doesn’t interest people as much as other, more “fun” topics like birth stories… but I want to let those that read regularly know – these types of topics are infinitely important. Please continue reading, digesting, formulating your own ideas, opinions and then DO-ing what you feel is right in your own world. (I was traveling and birthing for a couple of days, so didn't see that there were comments, but still not as many as I'd hoped. The comments are phenomenal. Read them if you haven't!)

I am not saying that it is problematic that (new) midwives practice in communities other than their own. But ask yourself, why do they do this? Are there not any patients in their communities that need care?

Some of what I wasn’t able to say is that I know many women in the (wide) middle class swath are included in this “clinic” culture, finding themselves in that place of not having enough money for insurance, but qualifying for government programs that ensure prenatal care for most (who seek it).

Are there crowds of white women sitting in waiting rooms needing prenatal care? Absolutely, and the midwives take care of these women just as I am speaking about being a provider for women of color… these might just be the women of different culture (socio-economic… are we considering that a different culture? I didn’t distinguish that initially… perhaps I could/should have?).

Is that people in their community would rather be cared for by someone with experience?

Doesn’t everyone prefer to be cared for by someone with experience? (Antagonistically) Perhaps some cultures are more able to demand what they want than others – and get it. Perhaps generations of servitude has brow-beaten women into accepting what is given instead of believing they deserve more… or imagining a possibility were more might be theirs. Perhaps entire cultures of women are standing naked in hospital gowns with their asses bared to the room as choice after choice slips through their fingers and all they are left with is a vaginal birth to call “normal.”

It’s part of what I was trying to say about how maybe we aren’t the worst. Maybe we can elevate our own status by proving how wonderful we are as students. Let me move on….

Is that they feel drawn to help communities other than their own because they see that a need exists and they have the skills to fill the need?

You and I both know that answer varies. Ideally, yes. Realistically, not always.

Are they coming to this community to stay, or to get their numbers?

Or are they coming because they are assigned there by their school, preceptor or their state licensing that requires them to obtain a certain level of skill.

I don’t just see that as “numbers,” but as experience. I think when midwives speak about “getting numbers,” it is incredibly offensive and I move we all stop saying it now. I’m just as guilty as others of using the term, but it is highly offensive to the women who graciously allow us to work with them during their pregnancy and postpartum period.

So, is it a horrible offense to have to go somewhere where there are a great deal of women in need and be there to help out for a limited amount of time in trade for gaining a great deal of experience that will go on to make you a better midwife so you can move forward and help many, many more women along the way? I don’t see it as such. Maybe that is my own justification, but it is my view and my experience with working in a different culture than my own.

Why is there such a need in the first place? Why is that there aren't any providers/leaders from this particular community available to fill the need?

I don’t know the answer to these questions. Where are the leaders? I don’t know. Where are the leaders in the midwifery world? Who would we turn to as a bonafide leader if we had to pick one? Suzanne Arms? Ina May Gaskin? Ricki Lake? Each of them has their moments, but if we were going to think “Leader,” it might not even be easy for us and damn, don’t we want to get some things changed, too?

I'm a midwifery student; if it's helpful to get practice in communities other than your own...how come aint nobody ever sent me to the ritziest part of town to practice for clinical?

Well, that would have to be out-of-my-element, too, then! I’ve had a few clients make more than 5 figures, but I’ve had far more make less than those 5 figures. My own “class” range (I believe) falls squarely in the middle. (I’m probably delusional, though. I always thought my dad’s income was upper middle class and then I learned we were actually lower middle class. Isn’t “class” such an amazing concept? A topic all its own.)

NM asked: "If we didn’t move outside our own communities, isn’t that forcing women to travel outside their own neighborhoods to obtain care?" Can I say something radical? Withdraw your care. Maybe if you did, our community would find another way. I mean, we wouldn't have a choice, would we? When doctors and nurses would not care for us in the past, we cared for our damn selves. (we built the institutions to train and provide care) When we could not go to "your" schools, we educated ourselves (again, we built the schools and educated our children), and contrary to popular belief, we did a better job at it.

So, you never want me to serve a black woman again? (And I am not being a smart ass, I am trying to clarify.) You are asking midwives to not see the women sitting in the waiting rooms at clinics so they will figure out what to do on their own? Will there be a mad dash of the black midwives to “their” communities, the Latinas to “theirs” and the whites to “theirs” so women can immediately begin their apprenticeships and the pregnant women don’t lose continuity of care?

What if I consider the Mexican community “my” community? Did I have to be born in it to qualify? Who makes the rules? What if the Mexican women consider me “theirs?” Do I qualify then?

This gets sticky now, doesn’t it.

But I'm not convinced that what we have right now is any better, especially if you're already thinking that if you don't do it, no one will. (forcing women to travel out of their communities for care...maybe instead of coming to find you, I would support my local 18 year old who wants to apprentice, or my soon-to-graduate-college neighbor for a CNM program)

THEN DO IT! Don’t wait for some hypothetical day when whites aren’t in your neighborhood. Support her now! I don’t believe if I don’t do it, no one will… I believe there is an army of others behind me who will. They just might not be the color you want them to be. Why, I don’t know.

NM asked: "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?

My answer: NOPE. What I want is a way to give this "fabulous" care to my damn self. I want midwifery/medicine to stop being this barely attainable career path for people like me. I don't want to have to wait until you feel inclined to give me care. After I have managed to make this possible for people in my community, then YES, certainly, come join me. Let me learn from you, and you learn from me. You're more than welcome to set up shop, but it shouldn't be because the system that leads to this possibility is rigged in your favor. When most of the providers are from one background and most of patients are from another...the learning exchange doesn't feel quite equal...

Okay, so I (we) are to just sit on our asses and see a need and wait for someone to start something before we go in to help? Isn’t this a little… um… unrealistic?

If a community of women need maternity care and the community can’t find the resources to take care of them, why in the hell should outsiders just sit idly by waiting for someone to make some move towards doing something? What if those leaders mentioned above don’t give a whit about midwives? What if they think all the women should be shipped over to Cesarean Central Hospital and be happy about it? Have you not seen or heard about these examples in your midwifery school yet? I think it’s quite idealistic of you to think people should wait out self-help, but sometimes – many times – sharing resources is a gift and not seen as a negative. (And I don't mean that us white people's "gifts" should be accepted without question. I don't mean that. I really do mean a sharing of resources from both communities. That sharing is a gift we both offer each other.) It’s sad that you already see so much negativity in the joining of resources and experiences – I hope you can find a more gentle vision of what I meant in my post.

NM, do you know how very few of us there are? I mean really.

Yes, I do. I know there is one black face in my own community. I know the black midwifery community is so small they have their own conference. I cannot fathom what it would feel like to be the only black person in my entire midwifery community.

I can tell you with absolute honesty that when I was a child, seeing someone of color in a particular profession absolutely made that profession seem more feasible for me.

I am thrilled, then, that you and other blacks, Hispanics, Asians, Filipinas, etc. are joining the ranks – so you can inspire those that sit in front of you. It must make you beam with pride to know how much you are affecting change! How wonderful is that?

NM would "like to believe that [we] can leap over the color/race/culture hurdle all on [our] own without someone leading [us] by the hand."

It's not a hurdle. It's my existence. There's no getting over it NM. I might be able to work something out by going around it, but that's about it. And I'll tell you, it damn sure ain't no ways easy to get around it without some help. Someone did lead me (through this racial identity process) by the hand, and I intend to lead as many as I can by the hand, too.

Reading this, I selfishly thought of my own hurdles. We all have them, don’t we. I wore my fat (wear my fat) and it straddles me tightly to this day, affecting everything I do. I tried to make it come off, but yet, it remains. I think about being lesbian, Jewish, when I was disabled, sick… none of it even compares to the issues a black woman has to endure in this society. (Tack on lesbian or Jewish or or or… and it gets even more complicated!)

I really do appreciate this dialogue. It’s been one I’ve had for years about a variety of topics. (Once you get to be nearly 50, the topics just rotate around and around, I think.) It’s a great one that bears on-going discussion.

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.