Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


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Trans-Affirming Midwifery, Always

Dear readers,

If you are an ACNM (American College of Nurse Midwifery) member, please access and sign the open letter supporting the provision of trans health as a core competency for nurse midwives by clicking the link below.

The letter captures so many sentiments I share about why trans healthcare should be absolutely integrated into nurse midwifery from the beginning. Let’s stop ghettoizing any reproductive healthcare (including miscarriage management, elective abortions, basic assisted reproductive therapies for LGBT clients) — and in this moment, especially trans affirming care — and respond to the fact that queer and trans midwives and clients are demanding an expansion of core care that is appropriate and respectful. And let’s please root out the gender essentialism and transphobia in the midwifery community and the current ACNM leadership! Thank you to all the wonderful folks who put together this letter and who have been working so hard to advance an intersectional feminist leadership in midwifery. Our side will prevail.

-A proud signer to this letter and member of The Queer and Transgender Midwives Association (QTMA)

*********************

As ACNM members, we submit this letter to raise our concerns about the ACNM Board of Directors’ (BOD) recent actions in making decisions about access to care for transgender and gender non-conforming (TGNC) people in closed session and without any mechanism for transparency or accountability. We submit this letter on Transgender Day of Remembrance in the spirit of honoring the lives of those we have lost to transphobia, and fighting for the rights of those who continue to survive. We are publishing this letter publicly so that midwives and midwifery students can sign on in solidarity.

We are alarmed to learn that at their October 2018 Board meeting, the newly-elected BOD 1) failed to approve proposed revisions to the ACNM Position Statement on care of TGNC people, and 2) failed to uphold the March 2018 decision of the previous BOD, which had confirmed that the midwifery core competencies as they currently stand already include gender affirming hormone therapy for TGNC people. Instead, the BOD rejected the Position Statement, stating that “neither hormone therapy or care of natal men [sic] is a core competency.”

These actions were motivated by concerns regarding midwifery care of transgender women and non-binary people assigned male at birth (referenced by the BOD as “natal men”), and are in direct opposition to the recommendations of the Gender Equity Task Force (GETF) Chair and the Core Competencies Committee Chair. No midwives who identify as TGNC or who provide care to TGNC communities participated in the closed discussions related to these motions.

Frustratingly, the BOD is able to withhold the detailed minutes of their discussion per protocol that only open session minutes are released publicly. The BOD included only very vague information on this discussion in the open session minutes. This is particularly concerning given that these BOD decisions have significant implications for work currently underway by the GETF and a number of ACNM committees. In reviewing the available open session notes, it is notable that the only topics from open session that were moved to closed session were related to midwifery care of TGNC people.

With this letter, we intend to alert the BOD and ACNM’s membership of:

  1. The presence of the many current and future midwives who stand in support of transgender, non-binary, gender-diverse and intersex people;
  2. The importance of midwifery care for these communities;
  3. The ethical implications of the BOD’s lack of transparency; and
  4. The practice implications of these decisions on us all.

The BOD’s actions are very concerning in that they create an impression that gender affirming hormone therapy – widely recognized as straightforward and lifesaving care – is not appropriate for new-to-practice midwives. This creates a barrier to increasing the number of providers equipped to provide this care, a development that is very problematic given the significant and well-documented health disparities experienced by TGNC communities. It is important to remember that midwives – including new midwives – are well versed in many forms of hormone therapy (such as for contraception and for management of menopausal symptoms), and that these other therapies are uncontested in their inclusion in the core competencies. Therefore, the BOD’s exclusion of  only gender affirming hormone therapy specifically and unethically targets TGNC people.

While we cannot presume to know the exact intent of BOD members participating in these decisions, the impact is clear. These decisions are transphobic; they send a message that the current BOD does not view transgender women as “real women” simply because some transgender women have a penis; otherwise they would be deemed inherently appropriate for midwifery care under the ACNM vision of “a midwife for every woman.” Importantly, midwives are able to care for people with penises when it comes to circumcision, as part of expanded midwifery practice. Thus, these motions are clearly not an issue of scope, but of what ACNM leadership finds uncomfortable politically or personally.

The BOD did not specifically state concerns regarding midwifery care of transgender men and non-binary people assigned female at birth. In more neutral circumstances this could be perceived as reassuring or benign. However, in the context of the BOD’s actions it raises concern that the BOD perceives transgender men as “women” regardless of their gender identity, simply because some of these individuals may have breasts, ovaries, a uterus, and a vagina. This negates the true selves and humanity of these individuals, and tarnishes the value of midwifery care by filtering care provision through a lens of transphobia.

Biological determinism, the act of reducing a person’s identity to their body parts, is inhumane, abhorrent, and unconscionable. This is the first time the BOD has attempted to make any distinctions between TGNC individuals based on anatomy. Previous BODs have intentionally described TGNC care inclusively, recognizing that gender is a spectrum and that anatomical distinctions reinforce biological determinism. Our peers in allied professions which have historically defined their scope of practice as “care of women” (Obstetricians/Gynecologists and Women’s Health Nurse Practitioners) have long affirmed that care of all TGNC people – including transgender women – is important and within their scope. Our own prior BOD did the same in March of this year. Yet the current BOD has decided to change course entirely, in a move that favors biological determinism and is particularly foreboding given the current political climate.

Within the past month, the Department of Health and Human Services released a memo stating that it is planning to require that gender be identified as a biological condition determined by genitalia at birth. Immediately, over 2,600 experts in the field, including both scientists and care providers, published a response, stating that to define someone by genitalia is “not only fundamentally inconsistent with science, but also with ethical practices, human rights, and basic dignity.” Why are we, as a profession, reversing our prior well-thought-out decisions and joining in a widespread assault on the rights, bodies, and health of transgender and non-binary people? Why have we sided with anti-science and transphobic positions by defining who midwives can take care of based on their genitals alone?

This position places midwives in the inappropriate position of acting as “gender police” tasked with determining who is “woman enough” to receive midwifery care, and leaves the many midwives already providing sexual and reproductive healthcare to gender diverse patients in professional and licensure limbo. Given research that indicates people of color are more likely to identify as TGNC than their white counterparts, limiting access to care for TGNC people also serves to further the already significant health disparities experienced by communities of color.

The truth is that midwives take care of people, not body parts, and that body parts are not inherently gendered. As midwives we pride ourselves on treating the whole person. We care holistically, we believe what people tell us, and we meet patients where they are. These BOD decisions are ethically in conflict with core midwifery values. Instead of providing guidance for clinicians, they require that we choose between practicing midwifery, and participating in a political decision by our professional organization that privileges bigotry and ignorance over the people harmed by that bigotry. They violate midwifery’s ethical obligations as care providers and reinforce the systemic oppressions already experienced by TGNC and intersex people. They use midwifery as a tool to amplify harm rather than increase equity. That is not acceptable.

We will not stand by as this BOD makes decisions that dehumanize the patient populations we are honored to serve. We will not stand by as this BOD makes decisions that dehumanize our own midwife colleagues who are TGNC or intersex.

We ask the BOD to do the following:

  1. Commit to holding all future discussion of this issue in open session;
  2. Reinstate the March 2018 decision that care of TGNC individuals and provision of gender affirming hormone affirmation therapy falls within entry midwifery care as outlined in the Core Competency document Section V.C.
  3. Approve the revised Position Statement and revised Core Competencies documents as submitted by the GETF to the BOD for the October 2018 meeting, without the addition of restrictions on the care of transgender women or the provision of gender affirming hormone therapy
  4. Charge the GETF and other relevant ACNM Volunteer Committees to work collaboratively to review and update the Midwifery Scope of Practice document to include care for TGNC individuals.
  5. Publicly acknowledge the damage that has been done by the BOD’s recent actions, and outline a plan for accountability in the future, including BOD and DOME additional training in gender diversity and impact on health disparities.
  6. Use respectful and inclusive language when referring to TGNC individuals and communities in all communications and public documents; guided by ACNM’s Issue Brief on “Use of Culturally-Appropriate Terminology for Gender-Diverse Populations
  7. Charge the Ethics Committee to review public documents that have potentially political implications.

We, as individuals deeply committed to increasing healthcare access to TGNC populations, hope that you will join us as we continue to strive towards a more inclusive path for midwifery. These signatures below affirm and signify the gravity of the harm we feel these decisions have brought forth by excluding vulnerable individuals from midwifery care.

We invite you to consider taking the following steps:

  1. Signing this letter in support of inclusion of midwifery care for all bodies;
  2. Sharing this letter with peers, friends, colleagues, and students;
  3. Educating people about affirming language and engaging in conversations in a way that supports all people;
  4. Sending a personalized letter to a regional representative or the BOD;
  5. Running for office, and/or intentionally supporting the leadership of TGNC midwives in regional and national leadership roles, so that we have a Volunteer structure that understands TGNC issues;
  6. Sending a letter to your current midwifery Director or the Director at your Alma Mater, with copies to DOME, to advocate for the inclusion of this education in midwifery programs.

For midwives and midwifery students who are TGNC and LGBQ identified: The Queer and Transgender Midwives Association (QTMA) is dedicated to supporting and representing LGBTQIA2S+ midwives and student midwives as they train and grow as providers and people. QTMA provides educational opportunities, advocacy, community and tools for their members, all grounded in an intersectional ideology and framework. It envisions a world where all LGBTQIA2S+ midwives and student midwives have the resources and representation they need to thrive in practice and in their community. QTMA is fiscally sponsored by the birth justice organization, Elephant Circle. Interested folks can connect with QTMA on their Facebook page or by emailing QTmidwives@gmail.com.

Sincerely,

Stephanie Tillman (she/her), CNM, University of Illinois, Region IV – Chair, ACNM Gender Equity Task Force

Simon Adriane Ellis (they/them, he/him), CNM, Kaiser Permanente Washington, Region VII – Member, ACNM Gender Equity Task Force

Noelene K. Jeffers, (she/her), CNM, Region II, Member, ACNM Gender Equity Task Force

Margaret Haviland (she/her), CNM, WHNP-BC, Kernodle Clinic, Region III, Member – ACNM Gender Equity Task Force

Signey Olson (she/her), CNM, WHNP-BC, Columbia Fertility Associates, Region II – Member, ACNM Gender Equity Task Force

Lily Dalke (she/her), CM, LM, Planned Parenthood NYC, Region I – Member, ACNM Gender Equity Task Force; Member, ACNM Core Competencies Committee

Nikole Gettings (she/her), CNM, Region III- Member, ACNM Gender Equity Task Force

Anne Gibeau (she/her/hers), CNM, PhD, Director of Midwifery – Midwifery Practice, Jacobi Medical Center, Region 1, New York State Association of Licensed Midwives – Downstate Region Representative; Member – ACNM Gender Equity Task Force

Máiri Breen Rothman (she/her), CNM, MSN, FACNM, Director, M.A.M.A.S., Inc., Region II; Member – ACNM Gender Equity Task Force

Meghan Eagen-Torkko (she/her), PhD, CNM, ARNP, University of Washington Bothell and Public Health Seattle-King County, Region VII — Member, ACNM Ethics Committee

Lee Roosevelt (she/her), PhD, MPH, CNM, University of Michigan, Region IV

Jenny Nelson, (she/her), CNM, Region I

Jennifer M. Demma (she/her) MSN, APRN-CNM, Family Tree Clinic, Region V

Rob Reed (they/them), CNM, ARNP, IBCLC, Swedish Medical Center, ACNM Region VII – WA ACNM Affiliate Vice President

https://docs.google.com/document/d/1jS9Mxdkh45ROZR38H0yXYVI2Bxh05v6aZhCy0u0m57A/edit?usp=sharing


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A year in the life of a queer midwife

Over the last year, this CNM has found myself in the midst of needing to make, and then executing, some major personal life changes. While I welcomed 2018 with a fire in my belly around gender and sexual liberation from a political angle, and while countless issues impassioned me throughout the dumpster fire of this year in politics (though, most notably, the global and national war on immigrants and refugees), I learned that my ability to focus on, read about, and articulate my response to these was severely diminished by a need to take care of myself and my child above all.

I am making peace with this, and I don’t feel as though I’ve missed out on, say, a major social movement, or that some action I could have personally done would have changed some feature of the year in a fundamental way, outside of myself. But I will say participating in some kind of way in the so-called resistance (proudly proclaimed on car bumper-stickers but otherwise apparently a bit anemic these days) is usually quite therapeutic and makes me feel more connected. I also just want to be that guy that speaks up, that has something to say, a way to make sense of things, a way to connect people to social justice activism, to revolutionary politics, to communities that are organizing. I had hoped that this forum I created, however modest, could serve as a way to work through what it means to be a Marxist midwife throughout my own clinical experiences, and applying that lens to local and world events. (To be fair, I did make a few significant contributions at a national level on some things I quite care about; they just didn’t make it to this space.)

Instead, I’m apparently sometimes just an annual blogger! Living my life and more quietly and modestly thinking through things, reflecting on them to a smaller audience in my real life and adjusting to a new professional identity in the home birth world. It’s been a long year, and certainly not the one I quite anticipated, though it was likely somewhat inevitable that my commitment to and recent deeper explorations of the politics of queer and trans/gender liberation would eventually lead me back to wrestle with my own queer desires and identity. So, while this process started with identifying and attempting to address a series of political questions about the connections between queer and trans liberation and the feminist movement (a la The Women’s March), abortion rights, and birth justice, it seemed to culminate in finding my way back to my own, and yet somewhat newfound, queerness.

Molly Costello’s work kind of says it all. http://www.mollycostello.com

And so here I am, over 20 years since coming out as bi, reconciling my truth with the discomforts of coming out *again* to my Evangelical family who has had the ability to ignore my sexuality as long as I was partnered with a straight cis man. While it’s not easy to navigate divorce– let alone parenting throughout it– I feel somehow so much lighter and clearer in my heart and mind than I have for years, soberly deciding to end a relationship that did not work, and navigating a new, queer love in my freedom.

While this midwife closes the year looking forward to lots of loveliness for myself, my kiddo, the families I’m privileged to call my clients, and my gorgeous community in 2019 — I also dream big, for open borders, and queer and trans liberation, and a free Palestine, and an end to militarism and imperialism, and for reproductive justice, and climate justice, and housing justice, and loads of love, grace, and joy.

P.S. These changes could not have gone nearly as well as they have without the love and support and graciousness and political collaboration of a lovely bunch of humans in my life, especially my kiddo, my dearest comrades, my ex, the Blossom group, my forever friends, my Mama, and my sweetheart.


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Transition

It has been so long since I have put anything in this space. So much has happened over the last year for reproductive rights, workers, immigrants, healthcare access, the political mood and movements, and my personal and professional life has not let me keep up with it here. Though I have had my best work-life balance of my professional life so far over this last year, I’ve had a hard time squeezing in time for writing about my experience or my thoughts about what’s happening in the world.

A lot of what is hard is that my dear mother has really been on my case about protecting my professional identity, and about being ever so careful about how I present myself on the Internet, in spite of my attempts to remain as anonymous as possible here. It’s incredibly hard, as someone who has so many damn opinions and for whom my profession is a major passion of my life, to figure out how much I can say about what I think about things, while preserving myself professionally. Are there enough disclaimers in the world to cover me and protect me from losing my job, or offending my clients, or not getting some job in the future? Probably not. So I hold a lot of ideas in my mind and wrestle with what is appropriate enough for me to put into print.

Hopefully this is.

Well, I’m doing it. I’m transitioning. A very welcome, but also a terrifying change, from intrapartum care only in the hospital to not only full scope (GYN and OB) care but to homebirth. I have been working over almost the entire last year mainly in a very large private academic medical center that I previously thought of only as my city’s “baby factory” because so, so many people deliver there. I have also been moonlighting in a similar role in a small Catholic community hospital in my neighborhood that primarily serves Black and Latinx patients. These were both very welcome changes from the major challenges I encountered at my previous position, and my life over the last year has allowed me to settle into a fairly reasonable routine that works well with my family and activist lives.

But now my dream job has started, and my world is being uprooted, but for the better.  in the most delightful ways. champagne

Why am I making this change? I’m giving up a 36 hour workweek with hardly any stress about my job, for being on call 20 days a month for a position that I care about deeply and find spiritually satisfying. I’m giving up about 100 miles a week in bike commuting (often schlepping my daughter on the bike trailer) for having to always be close to my car and driving all over a large metro area to I can get to labors and births in a timely manner. I’m giving up a position that allowed me to make a midwifery stamp and positively impact my patients during their labor, as I provide physician extender service as part of a resident team, for one in which I will partner with a team of midwives to develop relationships with our clients, who have invited us into our homes for the most intimate moments of childbearing. I’m giving up watching how the medicalization of childbirth, while “evidence-based” and in highly skilled and talented hands, so often leads to much higher rates of complications than one should see in otherwise healthy people, for a birth setting in which emergencies can still happen, and the operating room or assisted delivery or complicated resuscitation is still a 9-1-1 call away.

Sure, I’m giving up some personal comforts (and admittedly, proximity to emergency help), but I am leaping into what I am hoping will be a tremendous adventure that will train me to be so much more skilled in what I care about: normal birth with healthy people. It’s a tremendous honor to be seen for my skills and potential, and to have been chosen for this practice. There’s only one way to know if this is my perfect fit, and it’s to try! So, here’s to doing my best at trying!


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Getting ready!

image

Spending this beautiful Sunday afternoon practicing surgical knots and perineal suturing. Took me a minute to remember how it works, but then it all came back to me. Next, rehearsing OB emergencies and mechanisms of delivery.

This week, I start attending deliveries! Looking forward to being there for my mamas inpatient, finally.


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Updates Galore!

I have made it past the 3 month mark…it’s hard to believe it’s only been three months. Almost four now, but still…

Here are some highlights and lowlights from my world these days…

1. Looking forward to the Socialism Conference.

It’s this weekend — an extended conference this year, it started today. But I can’t take any days off work until my six month work anniversary, so I’ll only be attending Saturday and Sunday. Here are some talks and featured events this year that I’m looking forward to:

Special Education & Disability Rights

Marxism and indigenous feminism

Women, race, and class: A history of Black feminism

Who needs gender? A Marxist analysis

Capital’s missing book: Social reproduction theory and the global working class today

Who cares: Work, gender, and the repro­duction of labor power

From criminalization to “rape culture”: Re­thinking the politics of sexual violence

From restrictions to criminalization: The fight for reproductive rights today

Capitalism, socialism, and mental illness

What should socialists say about privilege checking?

Microbes and Marxism: Capitalism and public health

“Obamacare” as neoliberal health care reform

…OMG there is so much! Obviously won’t be able to make it to all of those sessions, but those are some of the ones I thought might be of particular interest to readers, and which speak to some topics I’ve been thinking about/excited about lately.

2. I’m sick of the judging.

I feel like everyone I work with is burnt out and cynical. I’m sick of victim blaming, slut shaming, poverty-ignoring, moralizing attitudes coming from people I work with. Especially the OB I work with. It’s poisonous, and trying to figure out how to respond with fierce compassion. Patients and staff deserve to feel human. 

3. Getting into the hospital…

This will of course bring new challenges. Now, I kinda have it good. Getting used to being in clinic full time, getting to know my patients, learning what basic and expanded skills I need to have for clinic. But it will be nice, come September (fingers crossed!), to have hospital privileges so I can actually start to be present with my patients in the hospital. I still have to have a bunch of deliveries supervised by the aforementioned physician, and hopefully by some midwives I’ll be working with, but it’s good to know it’s on the horizon. 

4. Got a rad shout-out by the fabulous Feminist Midwife!

My friend, mentor, and trail-blazing hero over at Feminist Midwife gave me and a fellow red midwife a lovely mention in her recent post here, honoring the work of sharing the journey via the blogosphere. Thanks, FM!

5. Feeling appreciated

Though every day is emotionally and clinically challenging, it is also rewarding. I am feeling every day that I make a difference when I provide good care, and I can see it in my patients’ faces and in their continuing to come in for care and opening up to me. Another perk is outside of clinic — being known among friends, fellow activists, and family, as someone who knows some things about reproductive health — and who can be trusted to ask about it. Maybe it’ll get old one day, but I doubt it. I love those calls/texts/FB messages about family planning, pregnancy, and sexual health. So, thank you to those folks who have come to me with those questions, and I hope I have been helpful. 


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Why You Should Choose a Nurse-Midwife for Your Pregnancy/Primary/Well Person Care

When I started on this path, I was in my mid-twenties. None of my close friends had ever continued pregnancies or chosen to parent. This is partly why midwifery had never occurred to me as a career at that stage in my life — none of us were in that place in their lives. But now that we are approaching “AMA” or “advanced” maternal age, or the ripe old age of 35 (haha), many of my friends are now starting families (or trying to). Lucky for them, they now have a midwife friend! 

So, this is an open letter to all my baby-making (and aspiring baby making) friends and family. 

My basic advice/message is:

Choose a nurse midwife for your pregnancy care!*

Here are 5 reasons why many pregnant people should consider using a certified nurse midwife (CNM) as their prenatal care provider and birth attendant.

1. Client education and counseling

Nurse-midwives aim to spend time with our patients and get to know you. We want to know what is important to you and meet you there. If you want a provider to listen to you and to openly and without judgment respond to your concerns about pregnancy and birth, you have a pretty good chance of finding this in a nurse-midwife.

2. Supporting physiologic processes

This is a hallmark of midwifery care. Take initiation of labor, for instance. A midwife will take a holistic approach — to ensuring your due date is correct, to providing physiologic means of helping you go into labor on time, and choosing not to admit you to the labor and delivery unit until you are really in labor. All of these are part of an approach that supports the pregnant person’s ability to have a baby when it’s time. It may also mean helping you push your baby out to minimize trauma and tearing of the perineal muscles, and certainly avoiding cutting your muscle to make room for baby’s head or shoulders (episiotomy). 

3. Evidence-based practice (EBP)

From my first semester in nursing school, EPB was drilled into my brain. I can’t tell you how many papers I wrote about EPB…but I’m glad I did, because it instilled in me a drive to provide care that is based on rigorous review of current evidence and is patient-centered. What does this mean? A good provider (social worker/doctor/physical therapist, etc.) draws upon current research and literature reviews to determine how they practice. I am very proud that this is a centerpiece of nurse midwifery education and culture. Not that seeing a CNM is any guarantee of this, but it certainly something that most CNMs should be familiar with. The CNM professional organization put together this fabulous resource compiling data about how we use EBP – Midwifery: Evidence-Based Practice. Our practice is not (or at least should not be!) based on expert opinion, tradition, convenience, fear of malpractice lawsuits, or other provider-centered philosophies — but rooted in solid evidence and a patient-centered approach. 

 

4. Labor support!

The best midwives will support you while you’re in labor — not just leave you to labor on your own and then show up at the end to do the delivery. In some busy practices, that may not be possible, so I always encourage pregnant people to find out what their provider does. Midwives are trained in labor support, meaning they can help keep you active and can provide comfort measures that can help you out throughout the process. Unfortunately, many physicians do not (but should!) receive training in normal birth, and often do not know what to do to promote your comfort during labor other than offer drugs. Midwives understand that labor is hard work and can support moms through it. 

5. Greater chance of normal birth

According to a recent survey of research on midwifery, you are more likely to experience the following when getting care with a certified nurse midwife: 

• Lower rates of cesarean birth,
• Lower rates of labor induction and augmentation,
• Significant reduction in the incidence of third and fourth degree perineal tears,
• Lower use of regional anesthesia, and
• Higher rates of breastfeeding. (Newhouse, Stanik-Hutt, White, et al, 2011)

These are not reasons you should not use a nurse midwife

1. I want an epidural

If you choose to have your baby in a hospital, your nurse midwife can still order you an epidural, if that is the anesthesia/analgesia option of your choosing. 

2. I want to have my baby in hospital

No problem – the vast majority of midwife-attended births are in hospitals. You may not even realize it, but there may be midwives at your local hospital. 

3. Midwives don’t know enough stuff

So you may have heard that terrible slam Bill O’Reilly made about advanced practice clinicians (APCs, formerly known as mid-level providers, yech!) — worried that the increase in care by folks in these professions aren’t qualified be good healthcare providers. (Yeah, I know, my readers are big O’Reilly fans.) “Lenny from community college” couldn’t possibly be my provider, he said of physician assistants! (See the response from the American Academy of Nurse Practitioners here.) Even so! Many people don’t know what training we receive. O’Reilly’s ridiculous comments (among thousands he’s made over the years) aside, becoming a CNM is no joke. I’m proud to say that I have attended many community colleges throughout my education, but I also will report that CNMs are required to have a bachelor’s degree, be a registered nurse, hold a master’s degree, pass a rigorous certification exam, and become licensed through the state they live in as both a registered nurse and an advanced practice nurse. We are very well prepared to take care of people when it is within our scope of practice.

4. I want someone I can see always, not just when I’m pregnant

No problem! Loads of midwives work in settings where they can provide well woman, gynecologic, family planning, and even primary care. It depends on how the midwife’s practice setting works, but in many cases, you may be able to see your CNM across the reproductive lifespan. 

5. Doctors know best

Haha, I know no one reading this blog would think that. But I really ran out of reasons why you should not see a midwife. 

***

So…if you are low risk (not diabetic, chronically have high blood pressure, etc.) you may be a great candidate for working with a midwife! Get out there and FIND A MIDWIFE!!! And if there isn’t one in your area…well, shoot. Maybe you should get on the path to become a midwife, or tell someone you know who would make a great CNM to get on that path. We need more great women’s health providers. If you are feeling the call…better answer!

 

Reference:

Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nursing outcomes 1990-
2008: a systematic review. Nurs Econ. 2011;29(5):1-22

*Or your well person/family planning/gyne/primary care. More on “women” later…


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Abortion should be available on demand, without restrictions, for everyone who needs it. I believe that while society still places limits on what a woman may or may not do with her own body, while women’s sexuality and reproduction are still in effect controlled by the state, any discussion of equality or empowerment is a joke. – Laurie Penny

Sums it up.

http://towardfreedom.com/51-global-news-and-analysis/global-news-and-analysis/3542-abortion-should-be-free-safe-and-legal-for-everyone 


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Happy Mother’s Day!

Happiest of Mother’s Day to all you mamas out there. When judging mothers is something of an American pass-time, I hope you can enjoy this day and be celebrated!

***

Throughout the history of the women’s movement, there are been elements that have used an appeal to womanhood, to motherhood, to build movements for peace and justice. I’m not one to celebrate essentialist notions of gender, or to presume there is anything innate to women that should make us more peace-loving than other genders. But my political stance on that withstanding, I do want to take a minute to share some history from that side of the feminist movement — the radical anti-war mamas who started the tradition that is now known as Mother’s Day. 

Here’s a poem that serves as a rallying cry to mothers to oppose the Franco-Prussian war:

A Mother’s Day Proclamation
Julia Ward Howe, 1870

Arise then…women of this day!
Arise, all women who have hearts!
Whether your baptism be of water or of tears!
Say firmly:
“We will not have questions answ
ered by irrelevant agencies,
Our husbands will not come to us, reeking with carnage,
For caresses and applause.
Our sons shall not be taken from us to unlearn
All that we have been able to teach them of charity, mercy and patience.
We, the women of one country,
Will be too tender of those of another country
To allow our sons to be trained to injure theirs.”

From the voice of a devastated Earth a voice goes up with
Our own. It says: “Disarm! Disarm!
The sword of murder is not the balance of justice.”
Blood does not wipe our dishonor,
Nor violence indicate possession.
As men have often forsaken the plough and the anvil
At the summons of war,
Let women now leave all that may be left of home
For a great and earnest day of counsel.
Let them meet first, as women, to bewail and commemorate the dead.
Let them solemnly take counsel with each other as to the means
Whereby the great human family can live in peace…
Each bearing after his own time the sacred impress, not of Caesar,
But of God –
In the name of womanhood and humanity, I earnestly ask
That a general congress of women without limit of nationality,
May be appointed and held at so
meplace deemed most convenient
And the earliest period consistent with its objects,
To promote the alliance of the different nationalities,
The amicable settlement of international questions,
The great and general interests of peace.

Here’s a great post outlining the story: http://www.thedailybeast.com/articles/2014/05/11/the-radical-history-of-mother-s-day.html 

***

And on a lighter note, I’m looking forward to spending today with my Mother, who is ever my hero and my inspiration. I hope you, dear reader, have a restorative and beautiful day. 


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“Cool, you’re a midwife! So does that mean that you, like go to people’s houses?” Or: What Is a Nurse-Midwife Anyway?

The number one most frequently asked question of midwives in casual conversation or upon doing the whole “what do you do for a living” thing has to be about home birth. This piece is to set the record straight for the less informed readers and friends out there who may have some interesting ideas about what modern midwifery is about. 

International Day of the Midwife is around the corner (May 5), so in preparation, I invite you to learn about midwifery so come the 5th, you can show off your knowledge and love for women and midwives!

1. The vast majority of midwives who attend birth do so in hospital or out of hospital birth centers.

According to the American College of Nurse Midwives, a 2012 survey showed that only 2.5% of all certified midwife or certified nurse-midwives (CNMs) attended births in the home. Home births comprise a tiny minority of all deliveries — according to the CDC, only 1.36% of all births were not in a hospital setting, and that includes birth centers. 

Now…if you ask me, there are probably loads of people who would do well in out of hospital or even home birth. And I would *love* to attend home births one day when I’m more experienced. But nurse midwives would be in real trouble if we only attended home births, since these are such a small number of the births overall. Now, we capture 10% of the deliveries, which is great and probably will only increase. 

Anyway! Most of us are employed by hospitals or physician practices, and you are likely to find us as an option for prenatal care or delivery if you look. We are often listed as “under” a physician — for instance, if you were to look under your medical insurance for a provider, you might not find us independently listed, but we might be in the office as well. 

Imagemidwifery today is not like this.

 

 

2. Home birth…

Studies have shown that for low-risk healthy women, home birth is as safe as hospital birth. We are not nearly as healthy as a society as we should be, so many women risk out of home birth. But as a feminist, I believe that women’s bodies are capable of normal birth (that’s how we survived as a species) and support the appropriate use of technologies that can help lower risk (like fetal monitoring or c-section when medically indicated). 

But for now, most women have their babies in the hospital, and that has its own risks in this country. But that is where you will find most of us midwives.

3. Labor

Unlike nurses working as RNs, most nurse midwives are not in a good position for collective bargaining. Once you get to the “professional” or health care provider level, you are likely to be in a position to negotiate personally for your working conditions, wages, and benefits. Many midwives do work for themselves in private practice in a physician office or doing home birth, but the question most people ask when they find out I’m a midwife is if I have to drum up my own clientele and run my own business. And the answer is no, that’s why I work for a clinic and not as a homebirth midwife. And even though I’m not in a position for collective bargaining, at least I have coworkers, someone to do billing for me, malpractice insurance, and an office I don’t pay rent on. 

4. One Day

I want to have hundreds of births under my belt before I venture out to be a homebirth midwife. There is so much to see, so many different experiences, good and bad, that I feel I need to be prepared to attend births in patients’ homes. Unfortunately, in this country, we’re not set up to get experience this way unless we want to have our own practice/small business. 

Image

 

I love this piece. Can someone please buy this for my office?

5. In the Meantime

What do midwives do? Of course, we attend births. We take care of (usually healthy, low risk) pregnant, postpartum, and lactating mamas. But what most people don’t realize is that we take care of women across the lifespan. Yes, most of us focus on gyne issues — family planning, sexually transmitted infections, menstrual or other reproductive system issues, menopause management, cervical and breast cancer screening and prevention. Others may train to do more advanced stuff like primary care management of chronic health conditions or do more complicated procedures like colposcopy or dilation and curettage or even surgical assistance for c-section surgeries. Much like other advanced practice nurses like our nurse practitioner or physician assistant colleagues, nurse midwives manage many of the same patients our physician colleagues may also attend to. We may consult or co-manage care with physicians for more high risk stuff (diabetes or high blood pressure in pregnancy, or preterm labor), or refer to physicians for surgical care like tubal ligation, fibroid removal, or cesarean section. 

6. Science and Stuff: Or, How We Practice

For historical reasons, “midwife” does conjure up the lay healer, and that experience or association is often degraded, even among midwives. Traditionally, the lay midwife’s science was her knowledge of her own experience and that of her mentors. She learned about the wisdom of the body from attending to women’s reproductive needs from contraception to abortion to birth and postpartum care. The advent of modern medicine and the revolution in obstetric care has in many ways contributed to loss of critical knowledge about normal lifecycle events. Though midwifery wanted during that revolution, it is back and stronger than it has been in decades.

Midwife means: “with woman.” We are present with the woman (or female bodied or female identified person) for everything. Midwifery means respecting the body and helping the body and mind be healthy. Midwifery draws on traditional knowledge of women’s bodies, and modern nurse midwifery is demands evidence based practice to wed experience with science.

Midwives, like providers in any care field, practice with a wide variety of styles. Wherever we practice, whatever our style, being a midwife is not about where we deliver care to women or their babies — the hospital, public health clinic, private practice, home — but about bringing our knowledge about and respect for women’s experiences and choices. Wherever we are, whatever our job title, we should be found working with women to achieve general, reproductive, and sexual wellness goals.

No, I don’t do homebirth (yet). Most of my day is not that glamorous…I’m usually in the office assessing women’s health needs and trying to help them manage issues like unplanned pregnancy, menstrual disorders, STIs, sad vaginas (see earlier post), alcoholism and smoking too much weed, parenting while father of the baby or boyfriend is incarcerated, depression, overweight and obesity, family planning goals, and pregnancy. Promoting breastfeeding, teaching about the menstrual cycle, and most of all, trying to get women to understand and love their own vaginas–and yes, the smell that comes with it!

And sex. Mostly, my day is spent talking about sex. That’s why midwifery is awesome. 

 


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Sad Vaginas

Vaginal infection is a major reason that women visit the gynecology office (Brown, Hess, Brown, Murphy, Waldman, & Hezareh 2013; Overman 1993). I knew that going into midwifery. But my god, I never thought I would see so many sad vaginas every clinic day. My patients have a lot of vaginal infections. I spend a lot of time with patients talking about why for optimum vaginal health, less is more. Many have heard before that they “shouldn’t” douche, from other healthcare providers — but even among those patients for whom this is not a new idea, they continue intravaginal practices and don’t necessarily know why they shouldn’t.

This raises two issues for me as a nurse midwife and a feminist — the social roots of intravaginal hygiene practices (IVHP) and how providers educate –or don’t- — their patients about their own health.

Why do women douche? 

Many women tell me they feel they need to get clean after menses. They don’t like the residual menses they feel might be hanging around when the bleeding stops, and in particular they worry about the smell. They also think it will help them prevent infections. Commonly, my patients douche because their mothers, sisters, and grandmothers had and taught them these practices. But as one patient asked me this week, “why would they sell all that stuff if it’s so bad for you?” Good question.

And since Summers Eve re-vamped and expanded their product line beyond simple douche products to an impressive array of “yoni” personal products, these commodities are hipper and more attractive to consumers than they have been in a long time. Image

In a small (141 participants) prospective cohort study of sexually active women 18-65 years old in Los Angeles, researchers found that 66% reported IVHP, 49% of whom admitted using an intravaginal product (other than tampons) and 45% of whom reported intravaginal washing (Brown et. al 2013). This washing could include vinegar, water, soap and water, or commercially available products (Brown et. al 2013). One 2004 pharmacy journal reports that the reasons for these IVHP vary according to geography, racial background, age group, and rates of sexual activity (Pray & Pray 2004). According to Pray and Pray, African American women inherit IVHP from their mothers, while white women learn these habits more from advertising.

There is nothing wrong with your vagina

Wherever women get the specific idea that they need to use special products and habits to keep the vagina clean, smelling like roses (or lilies or citrus or island splash!), no one who lives in a wretchedly sexist society should be surprised that any woman would get the general idea that there is something wrong with how her normal healthy vagina smells, tastes, etc. But if women in modern capitalism can’t be trusted to decide if, when, and under what circumstances she gets pregnant, labors/births babies, and parents — wherein, for instance abortion is expensive, unavailable, often provided under non-compassionate conditions, and women are shamed for considering or choosing abortion (and even using birth control, these days!) — why could they be trusted to take care of their own vagina they way nature made it?

As a matter of fact, the vagina has its own beautiful environment that does all the work you think a douche might do for you — keeping your vagina clean — all on its own, when you are healthy. The vagina likes to be nice and acidic, which is made possible by a wide variety of anaerobic and aerobic gena and species (Overman 1993). Acid-producing bacteria like Lactobacillus keep in check the more basic bacteria that cause the common infection bacterial vaginosis (Overman 1993).

When you douche, you are likely to wipe or wash away the “good” bacteria, leaving lots of room for the “bad” bacteria to take over, causing you bacterial vaginosis (BV). Studies have not shown a direct correlation between douching and BV — for instance, infrequent douching may not directly cause BV (Brown et. al 2013). Overall, however, douching may increase a woman’s risk of contracting a sexually transmitted infection, or HIV if she is exposed to those pathogens, developing pelvic inflammatory disease, or be associated with preterm labor and birth when performed during the second and third trimester of pregnancy (Brown et. al 2013; Pray & Pray 2004).

Then there are all the products designed to make the vagina smell like something it’s not. All the deodorants, sprays, wipes, external washes, creams, and powders designed for vulvar application may place you at risk for yeast infections or irritation, but even if they don’t, their very existence and success on the market contributes to the cultural perception that there is something wrong with your vagina in its natural state. And it makes individual women feel bad about their bodies in a very particular way. As this wonderful columnist for Essence wrote: “There is nothing wrong with the totally natural, completely unaltered smell of your va-jay-jay in its normal state. (Our “down under” isn’t supposed to smell like summer linen, fruits, or fresh mint)” (Lucas, D. L. 2011).

Well, society doesn’t really value anything “natural” about women except for our bodies’ ability to 1. sexually excite men and 2. bear and mother children. So, we are meant to buy cosmetics, sexy clothes, enjoy pole dancing for exercise, be ok with making less money than our male counterparts, do more housework, assume primary responsibility for childcare, etc.

So if we do everything else to bend to society’s desires for who we are as women, why shouldn’t our vaginas be part of that package? As the “EVEangelist” over at Summer’s Eve reminds us, ”It’s time for a shower inventory. If you’ve got a cleanser for everything but your vaginal area, it’s time to make room for our pH-balanced Cleansing Wash.” Products for everything! You are not good enough as you are!

(As an aside, a simple, non-scented soap to cleanse the vulva should do the trick! Avoid body washes and avoid washing in the vagina itself.)

Don’t get me started about the pseudoscience and fake pro-vagina crap over at that website…Barf.

…Until there is

Not all vaginas are going to be happy all the time. And vaginal health isn’t just about products you do or don’t put in them or any sexual pleasure/stimulation a vagina might be party to. Vaginas are part of the female body, which may have lots of experiences that can enhance or hurt vaginal healthy: like diet, exercise, sexual consent, history of abuse or assault, body size, and emotional stress.

But none of those things can be rapidly fixed with an over-the-counter product that makes claims that it will fix up your vagina, unless it is medicine designed to treat a real infection, like intravaginal treatment for yeast infections. And I am all for trying things yourself, DIY, and taking care of yourself using health knowledge grounded in non-commercially biased information like that which is found in, say, Our Bodies, Ourselves and Guide to Getting It On. But douching and using these so-called yoni products that are making some CEOs rich over at Hate Your Vagina, Inc. isn’t gonna help.

Where the provider comes in

I’m glad when patients come into the clinic for evaluation of vaginal discharge because it allows for patient education. I like talking to patients about the difference between healthy and abnormal vaginal discharge, and what a healthy vagina might look/smell like, versus what could put it at risk for infection.

And that’s why I’m glad I’m a midwife (do I say that in every post?). Midwifery is about meeting women where they’re at, and working with them to achieve desired health outcome. Women really are the best expert in their own body/experience, and I am just there to facilitate her reaching her optimum health. When women tell me anything about their health habits that I may think is unhealthy or possibly harmful, my first question is “tell me more about that.” If you want to help a patient/client change a health habit, you need to know what motivates her to either continue or change. This is what we do for smoking cessation, nutrition or exercise promotion, and especially for sexual health risk reduction.

This gets back to my initial observation that many patients know they “shouldn’t” douche (or do lots of other health behaviors deemed unsafe/unhealthy, but I digress), but most don’t know why. When I explain to a woman how wonderful her vagina is and how douching disturbs that beautiful environment, she is more likely to understand her own anatomy and how to promote her own health. My hope is that instilling pro-vagina sentiment can also clear the way for greater acceptance of vaginal delivery of medication and contraception and to an increased motivation to use condoms/protect the goods from more dangerous infections and disease. We shall see.

Really sad vaginas

 

A much riskier health habit than douching, though douching may compound the risk, is practicing unprotected sex with someone whose infection status you don’t know, or having multiple sexual partners, having a partner who has multiple partners, anonymous sex or sex when high or drunk. (You can look forward to my forthcoming Condoms, Part II post for more on that.)

Actually sad vaginas have infections like trichomonas, chlamydia, gonorrhea, herpes, warts, and syphilis. Many of these have no symptoms or barely noticeable symptoms, but none of those can be treated with douching, and all of them require diagnosis and treatment in clinic. And someone who gets one of those infections is at higher risk for sexual transmission of HIV and hepatitis.

I guess a part of me understands that when my patients who are at risk for STIs douche, they may be trying to cleanse themselves of STI risk. (Fortunately, the old myth that douching can prevent pregnancy is much less prevalent these days.) And even here, I can find a good instinct. Douching may not get the desired results (a healthier, happier vagina), but it is a health habit, and I think providers need to recognize that patients do want to be healthy.

Toward a world with happier vaginas

I don’t blame individual women for buying into the crap that the vaginal hygiene industry sells them, any more than I blame women for using makeup, enjoying fashion, partaking in gossip and petty shit among women, or being in abusive relationships, for instance. These are all symptoms of a sexist society, and individual women who make these “choices” are operating in a false set of choices we are allowed to make in capitalism. Sexual liberation (or for the sake of this post, happier vaginas belonging to happier female bodied people) is about a lot more than lack of vaginal infection/STIs, but I do think that would be a good start.

Health care providers–not just midwives–can play a role in that by promoting and practicing in line with Dr. George Tiller’s call to trust women. We need to stop blaming women when they make “poor” choices about their health in a society full of so much sexism, racism, and class inequality. And we can take part in every social movement that confronts sexism, misogyny, and inequality, because health isn’t just about what happens in the exam room — it is determined by the world we live in, and we have to fight for a world that values women and allows for people to make the best possible real choices about our lives and our health.

References:

Brown, J. M., Hess, K. L., Brown, S., Murphy, C., Waldman, A. L. & Hezareh, M. (April 2013). Intravaginal practices & risk of bacterial vaginosis & candidiasis infection among of cohort of women in the United States. Obstetrics & Gynecology 121(4), 773-780. doi: 10.1097/AOG.0b013e31828786f8

Lucas, D. L. (July 21, 2011). Real talk: feminine care 101. Essence. Retrieved 04/14/2014 http://www.essence.com/2011/07/20/real-talk-feminine-care-101/

Overman, B. A. (May-June 1993). The vaginal as an ecologic system. Journal of Midwifery & Women’s Health 38(3), 146-151. doi : 10.1016/0091-2182(93)90038-I

Pray, W. S., & Pray, J. J. (2004). Douching: perceived benefits but real hazards. US Pharmacist 29(1). http://www.medscape.com/viewarticle/490338