Midwives of the Revolution

Explorations, analysis, and reflections on reproductive health, birth, and midwifery from a feminist, marxist lens

Healing to the test?

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In this day of Common Core and mandatory ACTs for high school graduation, it should not be surprising that patients are obsessed about getting all the lab tests they can to make sure “everything is alright.” Luckily, unlike my teacher friends being measured by their students’ test results, my patients’ performance on tests or other health measures does not directly impact my pay or job standing. But this preoccupation with testing does impact  how I work.

What tests matter?

Don’t get me wrong. The miracles of modern medicine include such wonderful innovations as cultures and blood tests for herpes, liquid based pap and HPV tests, vaginitis cultures, gonorrhea and chlamydia DNA tests, and sophisticated tests for syphilis and HIV. You don’t have to just rely on the patient’s history and the exam findings to make a diagnosis when such tests are available. I am ever so grateful to have these tests, as I like to compare my clinical diagnosis to the test findings to learn more about what I’m seeing, especially as a new provider. And duh, there are many infections and diseases you can’t diagnose from an exam alone, like HIV.

Someone that has high risk sexual practices, like multiple sex partners or a non-monogamous partner, or who doesn’t practice safer sex with new partners needs to be screened. Luckily, our scientist friends over at CDC have figured out based on evidence that such folks should be screened for common STIs even if they don’t have symptoms, based on such risk factors. In a healthy clinic environment, we can educate patients about what health practices put them at risk and for which screening is indicated. We can point to evidence based guidelines to shape our practices, and we can counsel patients about what we recommend they get screened for. We can also educate patients on reducing risk and promote prevention.

It’s also usually indicated to offer HIV testing to all patients at least annually and three months following a positive test for other sexually transmitted infections like gonorrhea, chlamydia, trichomoniasis, or herpes.

Why isn’t it all about the test though?

I know why we’re all obsessed about getting tested for everything. It’s widely promoted as the be all and end all of healthcare. And it probably has a lot to do with the fact that lab testing companies make money every time providers order tests. They have put a lot of work into convincing the healthcare world that tests are better than anything for most diagnoses. This contributes to the the move away from physical examination as an essential skill in health provision. How many times have you been to see a physician for care and they have not laid hands on you at all? Not listened to your heart, lungs, and bowel sounds, not measured your abdominal girth, not palpated your tummy, not inspected your legs or feet? I hear frequently from friends that their doctors don’t even touch them.

We have been trained to think that the test says everything. And when it comes to women’s health, our bodies are so often the site of something wrong, something that could be wrong, and we want that test that says “everything is alright.” But we are not test subjects, we are human bodies. I hate that my patients think they need to hold themselves up to be examined like that: alright or not alright based on a test. Even if a physical exam appears to be normal or not normal, there are also other elements of the clinic visit to be taken into consideration — the patient’s history or symptomatology, for instance. Technology cannot replace the wise hands or critical thinking skills of an experienced practitioner.

Then what is it all about?

Heart disease is the number one killer of women in the United States. It drives me crazy that I have many patients who are not at risk for gonorrhea and chlamydia, who don’t even get bacterial vaginosis, but demand to be tested for these infections as though the results to those tests will be the major determinant of whether or not “everything is alright” for them. The far bigger impact on their health is not something that may or may not be wrong specifically with their vaginas but that they have sedentary lives, eat no fruits and vegetables, and eat a ton of fast food and junk food. Somewhere down the line, when they begin to develop diabetes or high blood pressure, there will be tests they can demand, and those tests may reveal whether or not everything is alright. Maybe everything is “alright” until the tests say otherwise. Maybe these test-hungry patients are trying to buy time until there will be a simple solution like a blood pressure pill or diabetes medicine to take, something far less complicated than trying to change a lifestyle when there’s nothing “wrong” except for…well, their whole lifestyle. And who can blame them? Pretty much nothing about how this society is organized facilitates healthy lifestyles for any but the few, and that’s why we are mostly an unhealthy society. If it were easy to be healthy, most of us would be.

What is it all about? Making the clinic a welcoming environment in which the normal and healthy are celebrated and explained, and the provider and patient can be partners in moving toward healthier habits and reducing risks. Demystifying the office visit and the technology we sometimes use to aid our assessments. Patiently explaining. And hopefully winning patients’ trust to lean on the exam and not just the tests.

Author: queermarxistmidwife

I am a nurse-midwife practicing in full-scope (reproductive health and birth care) in a community birth setting in the Midwest. My clinical practice is an extension of my longtime commitment to social reproduction (a close cousin and friend to intersectional -- perhaps synonymous to, depending on who you talk to!) marxist feminism and reproductive justice activism. I write anonymously to protect my job security and make clear that these are my personal opinions, and to make clear that I am also a professional whose personal opinions can also be separate from the care I provide. (While I personally believe in abolition of the prison industrial complex, I still have clients that are cops/married to cops [etc.] and maintain respectful, compassionate clinical relationships with them.) I was called to midwifery circuitously, through my love for reproductive rights and an interest in providing abortion care. Then I met midwives and learned about the intertwined legacy of midwifery and abortion, and I fell in love with birth. In my practice, I have worked as a primary care midwife in a Federally Qualified Health Center and campaigned fiercely for true midwifery in a hospital setting rife with obstetrical violence (and lost that fight!). I have learned how to bring midwifery care from the belly of the beast in a large teaching hospital that functions in many ways as an assembly line of medicalized birth. I have also had my heart broken by my own midwife when I realized that my dream job in home birth was actually a nightmare in many ways. I have found healing through communities of midwives that work to support each other through the traumas of toxic healthcare workplaces. I am constantly learning, working on my personal and professional growth, and striving for accountability, particularly as an anti-racist that benefits from white privilege. Midwives of the Revolution is meant as a nod to Marx and Engles's writing on the process of social revolution, as well as an aspiration to be among the midwives fighting to transform the perinatal health system in the context of the struggles for reproductive justice. The social revolution it will take to win reproductive justice will have to involve birth workers, other health workers (unionized, and not; professionals and not), educators, abolitionists, environmentalists, and of course childbearing people and families. I love the way that Marx's collaborator Engles (a brilliant philosopher and activist in his own right) describes the dialectical process of childbirth, which, for me, also undergirds my commitment to bodily autonomy and reproductive justice. To paraphrase, some of the events that midwives are called to may be "violent" or forceful, like childbirth -- not unlike revolution and social struggle: The fetus is negated by the neonate, who can only be brought about by the force of childbirth. The midwife facilitates that transition, as force (or social struggle) facilitates the transition from one form of social relations to another. Scolding the philosopher Duhring, Frederick Engles defends the social force required to fundamentally transform society: "Force, plays yet another role in history, a revolutionary role; that, in the words of Marx, it is the midwife of every old society pregnant with a new one, that it is the instrument with the aid of which social movement forces its way through and shatters the dead, fossilised political forms." (Anti-Duhring, found here: http://www.marxists.org/archive/marx/works/1877/anti-duhring/ch16.htm#087)

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