If you’re not a birth worker, and you’ve ever watched any narrative on television/in a movie that involves birth, you know the drill. You know it’s coming — your birth worker friend is about to give the laundry list of every lie about birth that depiction has unleashed through its powerful platform!
Ugh! It’s never like that! No one’s labor progresses like that!
Can you believe it? That midwife didn’t even call in an assistant!*
For real? Her water broke, and the baby was born 5 minutes later?
Why is the OB the star of the birth?!?!
Anyway, I’m used to being that bitch that ruins movies for my boo/child/friend with such comments. I mean! I’m sure oncologists can’t stand most cancer diagnosis/treatment segments, and cardiology and other acute care nurses probably cringe over all the inaccuracies of heart attack scene…but this is birth!
The portrayal of birth in popular media has pernicious effects on how people understand this major event. Of course, people who have had babies can recognize the lie, and many people can just see birth scenes as the plot device they actually are. Birth scenes in mass media contribute to weaving the fabric of fear around birth and pathologizes labor pain — often justifying the medicalization of birth.
But for those of us that are invested in the power of birth and horrified by the perinatal health crisis in the US, particularly for BIPOC birthing people, unrealistic birth scenes usually represent so much more than just a way to move along a story, and we want to have a say in the cultural narrative around birth.
…Which is why I was blown away by the unexpected turn toward home birth and how well it was treated in one of my favorite shows, The Chi. Seriously, if you’re not watching it already, catch tf up on it!
Look — it’s not everything. I can still give loads of critiques about how The Chi tells the story of Kiesha’s pregnancy and eventual home birth, so I’ll get that negativity out of the way! Like with most birth scenes you get on TV (etc.), Kiesha’s contractions appear to never give her any breaks — adds to the drama of the scene, but in reality she would have breaks to catch her breath, doze, take a sip of water, cry, whatever. It’s also not clear how she went from being pretty unengaged with her health and prenatal care during the pregnancy (made sense, given her character and the circumstances of her pregnancy) to being prepared to roar her baby into the world at home.
But that’s exactly what happens, where she is surrounded by loving women, including a badass midwife (and apparent midwife assistant, who is not really introduced). It’s beautiful!
I don’t know who the show used as a midwife (or other really smart) consultant on the episode (none is cited on the episode’s IMDB page), but clearly the writers knew some key elements of physiologic birth — and about Black birth in particular as a family event. The calm, confident, and loving midwife centers Kiesha in a way that recognize that the birth is not a medical emergency, and that the work Kiesha is doing is part of a legacy of millennia of childbearing people (“women” in the show). This is a powerful intervention to reclaim the power of a Black birthing woman, who an episode earlier nearly consented to a what turned out to be an unnecessary medical induction of labor with a white obstetrician resident.
We are never privy to the negotiations around the adoption plan other than Kiesha’s choice to name Octavia as the adoptive mother (and apparently work on birth intentions with her and invite her to the birth). When the birth assistant whisks off the baby to Octavia after the birth — without clear consent from Kiesha as the birthing parent — the shift to silence in the birth space felt as eerie to me as that immediately following a stillbirth. Both the baby and Kiesha would have benefited from immediate skin-to-skin time together in the tub, and in real life, the birth team would have been involved in making a plan around these details. The omission of this step forecloses a step in Kiesha’s grieving of the motherhood she seems to wrestle with losing — something I of course wish the midwife had played a role in.
Black Birth Matters
There’s such a myth of home birth as a bourgie choice for white people and hippies** — a myth that erases a powerful history of BIPOC midwifery, while naturalizing the disparity in access to culturally concordant home birth care (stay tuned for more from me about this). I love that this episode highlights a Black family (headed by strong queer women, at that) choosing a birth provider and setting that makes them feel safe, out of the hospital.
This show is continuously responding to various aspects of the movement for Black lives***, and by demonstrating the power of Black midwifery, they also seem to be uplifting the voices of BIPOC birth workers around the urgency of increasing access to culturally concordant care for birthing people. Research points to the life-saving ability of concordant care, in contrast to the harms of racism and implicit bias in perinatal health care. The perinatal health crisis will be solved in part by increasing the numbers of BIPOC birth workers, so that birthing people like Kiesha can access quality, concordant care — with a critical impact on the health of the next generation as well.
The work of reproductive justice also means addressing so many of the social issues that this show engages (in sometimes cheesy ways, but usually pretty thoughtfully) — education access, food justice, housing justice, community safety, sex workers’ rights, and of course, policing and the prison system. The writers’ choice to showcase an empowered birth — and for a young woman whose pregnancy is a result of rape and who plans an adoption — feels in line with their commitment to portraying and building Black resiliency.
Kiesha’s home birth not only does not involve any of the emergencies (including the emergency of racism) that too often cause severe morbidity and trauma for, not to mention take the lives of, a disproportionate number of BIPOC birthing people. It also helps her be fully part of the process in a way that she wants to be.
And for all that, this birth snob is delighted to have a labor and birth scene to celebrate for its contribution to shifting the narrative around birth. Let’s keep making Black birth matter.
-QMM
*Actual and incredibly upsetting account of home birth in Netflix’s atrocious midwife-fuck-up film, Pieces of a Woman. (Critiqued well with input from health professionals here, but without any engagement of the midwife’s utter unpreparedness, which would be highly unlikely for a professional midwife.)
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:
The presence of the many current and future midwives who stand in support of transgender, non-binary, gender-diverse and intersex people;
The importance of midwifery care for these communities;
The ethical implications of the BOD’s lack of transparency; and
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:
Commit to holding all future discussion of this issue in open session;
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.
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
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.
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.
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
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:
Signing this letter in support of inclusion of midwifery care for all bodies;
Sharing this letter with peers, friends, colleagues, and students;
Educating people about affirming language and engaging in conversations in a way that supports all people;
Sending a personalized letter to a regional representative or the BOD;
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;
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
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.
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.
On Thursday, I was pregnant. Seven weeks and six days of gestation. This was a very carefully timed, meticulously planned, and surprisingly quickly achieved pregnancy. On Thursday, I was happy. I had attended a meeting after work, hearing a report back from a protester that had been in the streets of Ferguson, Missouri, and analysis of police violence and the new phase in the struggle against American racism and police terrorism.
And then, I was bleeding.
I didn’t know, I couldn’t know, at first, if I would be the one in two women with first trimester bleeding, or the one in ten pregnant women overall, that would have a miscarriage, or spontaneous abortion. But I knew enough to identify that sign of bright red bleeding that doesn’t stop, when I had no risk factors for other causes of first trimester bleeding, meant I was losing this pregnancy.
And so, by Friday, I wasn’t pregnant any more.
And, since I’m not allowed to take any days off work until I’ve been at my job a complete six months (and I’m just three weeks shy of that), I went to work caring for women on Friday, while my uterus emptied. I felt myself bleeding while listening to a young mom’s baby’s heartbeat for the first time, celebrating with her and her beautiful partner. I patiently explained the speculum exam to a terrified young woman, and did a six-week postpartum checkup and got to coo over her gorgeous baby. I counseled an older woman on the risks and benefits of sterilization versus long-acting reversible contraception. I tried to have a normal day, when I wanted to be home, mourning.
It’s only Saturday, and I’m still pretty devastated. I was supposed to attend my city’s SlutWalk protest, where a year ago, I had given a rousing speech tearing apart sexism. I wanted to be standing with my sisters and comrades in the streets. But more so, I need to heal.
***
I have been musing quietly about the loneliness of the first trimester since I peed on the stick weeks back and had the delightful moment of reading “pregnant” on the digital screen. The feeling was so different from the myriad other times in my life when I had taken the test in anguish — especially the one other time when I had a positive result, in midwifery school, and knew I was going to have an abortion. I was, this time, elated.
But there is convention in our society to stay quiet about that positive pregnancy test until the second trimester, regardless of which choice we plan to make about the pregnancy. We know that people won’t really understand the complexity of our feelings about the pregnancy, and that we don’t want to tell everybody the bad news, if we end up needing or wanting an abortion, or if the pregnancy ends in a miscarriage. And so we tend to suffer through many discomforts of the first trimester, in silence.
I remember telling some of my comrades and friends what was going on, when I had the unplanned pregnancy years back. Because I am part of a community that embraces reproductive rights, I was fortunate that it was fairly easy for me to tell people at the time that I was planning an abortion, or that I was still dealing with some of the medical issues related to my abortion the few months after it started. I have since publicly spoken out about my abortion many times, working to de-stigmatize the experience that three in ten women will experience before the age of 45.
Telling abortion or miscarriage stories can be a powerful way to break the silence. But it will take more than telling stories to break the stigma. Art by Favianna Rodrigeuz, Just Seeds Cooperative
At that time, however, I didn’t talk openly about what was going on outside my activist network. But I did have a fellow midwife student classmate and friend who turned out to have an unplanned pregnancy at the exact same time as me. We turned to each other one day after class with our secrets: “I’m pregnant.” Neither of us felt good about it. We were both in the first of our two year program, and planned to go full time. There was no time for pregnancy, birth, and parenting, and both of us had partners that were full time graduate or professional school students. It was terrible timing. We each made different decisions, however. I ended my pregnancy, while she continued hers and is parenting this beautiful child, who is almost three now.
The other difference between us was that none of our classmates knew that I was pregnant or had an abortion, while they eventually found out about hers, when she started showing and eventually had the baby during the program. We both knew that even in a midwifery program, people weren’t emotionally intelligent enough to deal with a sister midwife’s pregnancy to respond appropriately to our news. So we both kept quiet, attending class while coping with our own pregnancy challenges.
I have wondered sometimes if we would have felt that way if we were attending school in a more politicized or radical time, say at the height of second or third wave feminism. Interestingly, I was able to talk about it with my faculty and preceptors, who all had trained as midwives in more political times and were very accepting of my decision.
If a group of midwife students can’t be mature enough to be present with each other during pregnancy, who can be?
***
This time around, I spent much of the initial weeks of pregnancy being silently excited. I talked about it with few people: my mother, my partner, my nurse-midwife team, and one friend, whom I had asked to be my birth doula. It was strange not revealing the news when talking to friends and family about this big thing that was going on in my life. Many times, I wanted to tell more people. It was humbling to now be experiencing life as a “pregnant patient,” much as I had appreciated the experience of being the “abortion patient,” knowing that this would make me a more compassionate nurse-midwife.
And I continued with my life — bicycling, gardening, going to protests, working long hours, cleaning my house — while thinking about the little life growing inside me. Fantasizing about the home birth I expected to have in early April with the fabulous team of midwives I had chosen to care for me. Talking with my partner about changing the guest room into the baby room over the winter. Getting excited about the cousins our baby was going to have, given that my sister in law is pregnant with her second, and my brother and his wife might be trying to conceive soon. Planning with my partner how we were going to cleverly announce my pregnancy on Facebook and to friends in person. Looking forward to the excitement and congratulations we could expect from family, comrades, and friends. And trying to imagine what it would be like to meet that tiny creature my partner and I had created.
***
I was starting in some ways to relish the privacy of the last couple of months. It has meant more time for introspection, self-care, and focus. I have needed that inner space to deal with some significant changes to my body and my changing life priorities.
Like sobriety. I chose to stop drinking around the time that I believed I was ovulating, in the first cycle we tried to (and did) conceive. I genuinely enjoy beer, wine, and the occasional cocktail, but since beginning my new job for the last few months at my job, I had also relied on that delicious glass of wine after work to help me unwind. Being sober means having to actually face all the trauma I see at work, and process it in some other way. And this is a pretty drug- and alcohol- heavy society we live in, so not drinking or partaking in any drugs can be pretty challenging, socially and personally. I have loads of patients that aren’t able to cope with life without substances, and continue drinking and using (marijuana, mostly) during pregnancy. Like many women facing the prospect of complete sobriety for 40 weeks, I worried that I would be tempted to drink and felt guilty for even thinking it might be hard to stop.
Fortunately, I have felt pretty good about not drinking and have enjoyed the challenge of sobriety. But I also dreaded social situations in which I would normally be drinking, worried someone would ask why I am not having my customary glass (or three) of wine. What would I say if someone suggested I was not drinking because I was pregnant? Would I choose to tell them? Would I lie? Would I tell them I didn’t want to talk about it? Fortunately it never came up. (For the record, peeps: Don’t ever ask someone if they are pregnant! They will tell you if they want you to know!)
Another major chemical change occurred in my body as I prepared my body for pregnancy by weaning myself off the anti-depressant I had been taking the last few years. That drug had really helped me through some major difficulties the last few years, from completing my midwifery program, to facing my midwifery board certification, to an extended job search, to the major transition of this new and difficult job I eventually landed and accepted. I am fortunate that my depression is well enough managed, and I am stable enough to face stress without the help of this wonderful pharmaceutical product or alcohol. Mostly I owe that to years of therapy and yoga practice that have enabled me to access pretty decent coping skills, along with an extremely supportive partner. Nonetheless, it felt very difficult to stop drinking and to stop taking this antidepressant at the same time. In hindsight, I may have done it a little differently, but it worked out OK.
Mainly, the changes in my body with the new pregnancy made me feel extremely vulnerable. I knew I had little control over if this pregnancy would continue successfully or not — knowing what I do about rates and causes of miscarriage. For the first few weeks, I could hardly believe I was really pregnant! Every trip to the bathroom, I feared seeing blood on the tissue paper. Every little tiny cramp or feeling in my pelvic area felt like it could be something wrong with the pregnancy. And since I only experienced momentary twinges of nausea, I looked forward to them, as proof that I was in fact pregnant. I caught myself looking at my breasts in the mirror and sometimes touching them to make sure they were really growing, and tender enough. Loads of women face extreme nausea and vomiting in the first trimester and are completely miserable, whether or not the pregnancy is desired or if she plans to continue it. I’m fortunate I was at least feeling well.
And when the proof was there, out of nowhere — sustained bright red vaginal bleeding, cramping, and passing tissue — it was clear that it was all over, in a flash. One day, a pregnant patient, the next, a “miscarriage patient.” And I had to believe there was nothing I could have done differently. It wasn’t my fault. It just wan’t going to work out this time.
***
These are some of the things we don’t talk about when we talk about pregnancy, planned or unplanned; desired, undesired, or ambivalent; spontaneously aborted, continued successfully, or electively aborted. These are some of the things we don’t talk about because we have internalized the messages of the war on women. This war psychically imposes a social and cultural expectation that all women naturally 1. want to become a mother and should embrace every chance at motherhood, no matter the circumstances; and 2. adjust and cope in a healthy way to the emotional and physical challenges of pregnancy. And if they don’t, there is something wrong, or even criminal in her thoughts or actions. Yes, lawmakers have proposed criminalizing miscarriage. Yes, every year, dozens of laws in every state of the United States are proposed and pass regulating women’s bodies and restricting abortion. Yes, laws primarily aimed at Black women criminalize drug and alcohol use in pregnancy (see Dorothy Roberts’s Killing the Black Body).
Yes, this impacts popular opinion, and shapes how people–even and maybe especially women themselves–understand and talk about pregnancy, abortion, miscarriage, and motherhood. And mostly creates the circumstances for not understanding what it is to be pregnant, or how to empathize with a woman who is pregnant, or wants, does not want, or who cannot achieve pregnancy or parenting.
*** I was grateful I was pregnant on Thursday, and still sad that I’m saying goodbye to that little embryo that I hoped would become a fetus and eventually the baby I would get to parent. I am nervous about what happens next. Will I be able to get pregnant again right away? What kind of loneliness and fear will I face the second time around? Will I make it past the eight week mark next time? Will my readers and friends respond compassionately to this post?
I feel like I’m in a good enough place emotionally to be able to share my miscarriage story, alongside my abortion story. And like coming out about being queer, or about having had an abortion, I hope that by telling my story, I can contribute to de-stigmatizing something that our deeply misogynistic society doesn’t understand.
But it takes more than being able to tell the story, for those of us for whom it is safe to do so, to change cultural values around pregnancy and sexuality. We have to end the war on women if we want to shift people’s consciousness and foster solidarity with the challenges people face during pregnancy and parenting. How could we do that? It means opposing every state/federal/local law and institutional policy that aims to decrease women’s bodily autonomy and impose control over women’s sexuality. It means being in solidarity against every form of sexual violence and coercion. It means fighting to end the New Jim Crow. It means demanding comprehensive sexual education for all children. It means standing up for a living wage, the right to union representation, and dignity on the job. It means building a movement for immigrant rights and to tear down the borders. It means calling for free quality childcare and the valuing of care work.
Some of these things might seem far-fetched and maybe even only tangentially related to my story. Maybe you think I am coming out of left field?
But there used to be a saying in the women’s movement that really meant something, though it has ceased to bear any resemblance to its original meaning: “The personal is political.” In its best sense, it meant that our personal struggles as women or as women of color, weren’t ours alone, but a reflection, or a symptom, of the broader racism and sexism in society. In the era of neoliberalism, we are meant to see our problems as isolated from each other’s, and mostly as a reflection of our own personal weaknesses and inner failings.
More and more, however, I am seeing my personal struggles as intimately related to the structures of social oppression, and I’m tired of bearing them alone. When I fight against the war on women, or against the war on the poor, or the war on people of color, it’s personal. It’s deeply political, as well, but when I think about the circumstances of my reproduction, it’s also deeply personal.
***
The last women’s movement, like the civil rights and Black Power movements, changed culture dramatically — but throughout my entire lifetime, the right wing has undertaken a sustained attack on the progress those movements made possible. It is my hope that we can build new social struggles from the ground up, that take up some of the demands I mentioned above, and more. Yet most of all, my hope and my argument is that the voices and demands of ordinary people as we struggle with our “personal” issues must be at the forefront of these movements — rather than the tepid Democratic Party politicians and NGO leaders who have been too afraid about upsetting the right wing that they have done nothing but compromise while our rights are under attack.
After all, it was- not well-meaning liberal politicians that made Roe v. Wade possible, but the fact that women took to the streets to tell their own stories about illegal abortion and forced sterilization. Those movements put women first — not the careers of politicians or career “activists.” Change happened, then, and it happens now, from the bottom, up. Or, as the late, great historian Howard Zinn put it, “What matters most is not who is sitting in the White House, but ‘who is sitting in’ — and who is marching outside the White House, pushing for change.”
I don’t think the first trimester, or any part of pregnancy or parenting, has to be lonely. I know that people can develop deep empathy and solidarity with each other’s struggles — and we see a glimmer of that in every mass movement, from the revolution in Egypt to the capitol occupation in Wisconsin, to Occupy Wall Street, and even how people looked after each other in the immediate aftermath of Hurricane Katrina. We have to foster that in our communities as much as we can, but more so, we have to organize movements for reproductive justice that put the demands, voices, and strategies of ordinary women and other people who can get pregnant at the forefront.
Being part of those social movement traditions is what makes me feel a little less lonely as I grieve my lost pregnancy and look forward to the future.
The fact that a dad was surprised that he got someone pregnant, for one.
The fact that this suggests a cute baby is all women need to convince them that they should accept and embrace any surprise pregnancy, for two.
That the fact a potential baby has a heartbeat is supposed to sway an actual human that she shouldn’t have an abortion, for another.
But really, the fact that this has been up and prominent on my commute route home for at least two months and it hasn’t been defaced, is what really bums me out. I’m not saying that y’all should go out and mess it up. But if there was a movement to turn the tide against this kind of anti-woman garbage, that might have happened.
We have a lot of work to do to de-stigmatize abortion. These kinds of billboards show us our work is cut out for us. We desperately need a movement in the streets that proclaims that whatever the reason a person wants to terminate a pregnancy is ok.
Only a pregnant person can know if it’s right to continue a pregnancy, whether it was a surprise (for her or the sperm donor) or not. I look forward to the day such messages of reproductive freedom are found publicly and beautifully in public spaces, paid and not.
I wouldn’t be a very good Marxist or feminist midwife if I didn’t have some things to say about what’s going on in the world. But once my first three months of the new job were over, I finally had energy to do more political work, and therefore have had less time for blogging.
I am trying to carve out more time to write on this forum about the ongoing war on women, and what people of all genders and political persuasions can and are doing to fight it. I wanted to share just a few things here about what I’ve been thinking about, and that I hope to explore more in later, more in depth posts.
The Hobby Lobby decision prompted immediate protest at the grassroots
First, the Hobby Lobby Supreme Court decision of last month irked me more than I can say. It was an insult to science and to “freedom” and to women’s bodily autonomy. And so everything I wanted to say about it was published over at SocialistWorker.org, in this piece: “The ‘Freedom’ to Deny Women Healthcare.” I have more to say on the resistance to that decision, especially how defensive everyone is about contraception, but that will hopefully be developed in another upcoming article in that publication.
Also, I follow with great interest the ongoing legal battles over forced surgical birth, and their connection to abortion and other reproductive rights in this country. I really liked this piece, and laud Jennifer Goodall for her courageous stance for normal birth after c-section: “Pregnant Women Warned: Consent to Surgical Birth or Else.” Women losing the right to how they give birth is intimately connected to the right to contraception and abortion — another topic I look forward to exploring more in this space and others.
You must see this film. #ObviousChild
On a lighter note, I LOVED seeing Obvious Child in the theaters on its brief stint in my city. What a *fabulous* and hilarious comedy about abortion, of all wonderful things. There is nothing so wonderful as a bunch of sex-positive, abortion-positive, pro-woman people dealing with an unplanned pregnancy in a very real way on the big screen. I have heard people say that if Knocked Up or Juno were about abortion, there wouldn’t have been a story. But guess what — you can have a story when an unplanned pregnancy results in abortion (like half of all unplanned pregnancies do in this country) — that story just happens to then focus on the woman herself. Revolutionary.
Finally, I am sick to death of the divisive commentary that passes for analysis about why the LGBT movement has made strides, while the war on women continues. This disturbing piece from the Daily Beast, “Ten Reasons Women Are Losing While Gays Keep Winning” has its response from yours truly coming up quickly. Suffice it to say that biological determinism has no role in progressive analysis, and apology about abortion is what got us further entrenched in the war on women, and will not provide our way out.
* * * * *
Too many teasers? Sorry. Let’s say this is my way of holding myself accountable to myself and my readers. It shall be written!
As of July 1 this year, my state has adopted an HMO model for its Medicaid plans. All Medicaid members have been assigned a primary care provider in the network. Many members were bumped from the regular Medicaid onto one of the handful of private insurance companies this state’s Medicaid has contracted with. This will be a disaster for patients in loads of ways: private insurance is part of the problem with peoples’ access to healthcare in the United States. Those insurance companies and the underfunded state programs are really the only ones for whom this can be seen in any way as part of a solution. What a boon for Blue Cross Blue Shield, Humana, and a host of other for profit corporations that they now have millions more customers handed to them from state governments.
As with all of the reforms packaged with the Affordable Care Act, I am waiting to see how it will all shake out. So far, however, I have noticed that a huge problem for patients is how difficult it is to navigate these plans. And from a provider standpoint, it is much more confusing. Where do we send our OB patients for ultrasound or to see a Maternal-Fetal Medicine specialist when their pregnancy is complicated? Well, it depends on their insurance. Whereas many area hospitals still accept regular Medicaid, many have decided not to contract with some of these new private Medicaid plans. So depending on the managed care plan you were assigned, you may have to travel farther to get care than previously.
One plan in particular has been on my shit list for years. My clinic actually does have a contract with this company, so this is the first time I’ve seen up close how it operates — everywhere else I’ve worked or had a student rotation at didn’t take it. They used to do this direct marketing thing — set up a booth at the shopping mall or in the neighborhood and offer women diapers, coupons, and other incentives to get them to switch to their plan. The woman would sign up only to find that she now cannot go to the clinic where she already had established care. Luckily, this practice is no longer allowed, so in theory patients are signing up for more above-board reasons.
Their prescription drug coverage remains a reason for me to campaign against them. Regular Medicaid in my state is not perfect — but the drugs they cover actually make medical sense (though there are loads of gaps). Now, when prescribing, we have to look up the formulary for myriad private Medicaid plans. (And don’t get me started on the limitations of contraceptive coverage on regular or these private plans, even with the contraceptive mandate.) Insurance, not public health, is determining many of my medical treatments. This is not a rational healthcare delivery system.
The absolute tip of the iceberg for me, though, with privatized Medicaid, is the requirement for the provider or pharmacy to submit a prior authorization request when prescribing treatment for two conditions that I see pretty frequently: gonorrhea (which includes injection of a drug called ceftriaxone) and Pelvic Inflammatory Disease (PID) (which requires both ceftriaxone and 14 days of oral doxycycline).
What is prior authorization? Basically, a road-block to getting my patient the necessary treatment immediately at the time of diagnosis. It means that either the pharmacy or I have to submit an form to the insurance company explaining my medical rationale for scripting this drug. We fax the request and then wait 24-48 hours for it to be approved.
The request is invariably granted. They pay it. Then we have to get the patient back into the clinic pharmacy to pick up the medication, and in the case of ceftriaxone, to get an injection from clinical staff (it cannot be injected in the pharmacy). Some clinics get around this by stocking the medication themselves, but that is not an expense my clinic is able to take on.
These antibiotics are expensive, and should not be. But it is not as though we are throwing either around unnecessarily. Believe me, it is very important to not over-prescribe antibiotics. But is cost the only factor to consider in treatment? Don’t patients deserve to get appropriate treatment for infections that can have some pretty horrific consequences if not treated correctly?
To that end, I wanted to share with you a letter that I sent to that private Medicaid contractor that requires prior authorization. I was fed up. And two weeks after sending it, I received a call from one of their representatives asking for more background on why I sent the letter. I’m not convinced this is the end of it, but I am happy to say that the representative reported to me that she would pass my concerns on to people [who I deduce are the company pharmacists] that make formulary decisions.
If you are a healthcare provider dealing with this issue in your patient population, I heartily encourage you to pick up the phone and add your voice to the dissent. Or copy and paste elements of my letter and forward on to the insurance company that corresponds in your instance.
We are many. They need to hear from us.
***
Hello,
I am writing today because I am very concerned about the prior authorization requirement for medication ceftriaxone (Rocephin) and doxycycline. According to the Centers for Disease Control, a one-time injection of 250mg of ceftriaxone is the most appropriate treatment for gonorrhea (to be prescribed with azithromycin or equivalent). It is also the best treatment for pelvic inflammatory disease, along with 100mg oral doxycycline for 14 days.
As a women’s health provider, many patients present to my office with one or both of these conditions, requiring immediate treatment. Due to your organization’s prior authorization requirement for these medications, my [private corporation contracted] Medicaid patients face an unnecessary and potentially unsafe barrier when seeking treatment for these conditions. The prior authorization requirement means that complete treatment is delayed for these patients. I work in a setting for which transportation to the health clinic can be a significant issue – patients often report they delay seeking care due to economic and transportation barriers. It may not be easy for the patient to present to the clinic on a different day to pick up the prescription from the pharmacy and then receive the injection from our staff.
In addition to facing the stigma and emotional stress of having a sexually transmitted infection or PID, which can threaten a patient’s future fertility, this added barrier of delaying ceftriaxone treatment not only increases the emotional toll of such an infection – it also increases the threat of antibiotic resistance. If patients are not able to complete the full dose of the last remaining medication we have to treat gonorrhea, we could see an increase in resistance. Injection treatment for gonorrhea is supposed to help decrease antibiotic resistance. The prior authorization requirement runs the risk of making this an infection that can become even more threatening in not only the community I serve, but on a larger scale as well.
I am extremely concerned about the barrier that prior authorization requirement for these two medications creates for my patients, who deserve nothing less than safe and compassionate quality healthcare. I hope you will add ceftriaxone and 100mg doxycycline to the preferred drug list immediately, so we can enhance our patients’ access to care and improve public health.
Thank you for your attention to this matter. I look forward to hearing from you
Now that I’m here, I’ve jumped through the hurdles of getting my degree, passing boards, getting licensed, and becoming employed, I thought it would be nice to reflect on how I got here. It’s easy to take for granted sometimes, now that I just wake up and go to work every day. But I’m doing what I set out to do! I’m midwifing! So…how did that happen?
Back in the day…
My background is in languages and literature. I studied English and Spanish in undergrad. Like many undergrads, I had no idea what I would do when I grew up…Like many women, I thought I was “bad” at science and hadn’t really taken myself seriously in that regard. When the nursing shortage blew up in the mid-2000s, my mom suggested I look into nursing. I didn’t really think it was for me. I had the old-school pre-feminist movement (and very middle class) idea about nurses as doctor’s handmaidens and couldn’t see myself doing it. But then I started looking into it, and taking my prerequisites for nursing school (adventures to tell of another day), and more and more found it seemed like the right next step for me. Hands + heart + science + possible unionism + healthcare activism…that I could get into.
I originally planned to be a WHNP. When I started nursing school, I had never attended a birth, and I really didn’t know much about midwifery. I liked the idea of working with women, but I didn’t want to try to get into a program/field that I wasn’t as passionate about. I knew folks who were planning to be midwives, and they were excited about Ina Mae Gaskin and doulas and home birth. But I was in my mid-twenties, and no one I was close with had had a baby yet, and these topics were remote from my experience. The abortion world was more my bag, and I knew that as a WHNP, I could possibly train to provide early aspiration abortion or at least do lots of cool family planning work.
Then, I fell in love with birth and also realized that, as I later saw expressed beautifully in the documentary After Tiller, trusting women and being pro-woman/pro-abortion was midwifery. The issues of birth and family planning and abortion are inextricably linked. And, from a practical standpoint, I realized that it made sense for me to provide pregnancy and birth care as well as the other family planning and gyne care I would do as a WHNP. Why hand off patients to another provider to attend the birth, when I could actually be the one to be there for the whole lifespan? So, during nursing school I asked the women’s health department if I could switch to midwifery. They OK’d me.
An Alternative Route
For a variety of reasons, my path to practicing midwifery has not been traditional, at least how it’s done “typically” by CNMs. According to tradition, an RN works in labor and delivery, then goes to midwifery school, then works as a CNM. When I finished my nursing program, nursing jobs in labor and delivery were hard to come by. I got one interview on a hospital unit but did not get the position. I applied to dozens of others. I also had put out my feelers for work in abortion care and managed to get a position through a student colleague connection, at the abortion service in the county hospital.
My first nursing position was a nightmare, but it paid the bills for my first semester of midwifery school and gave me valuable insight into the lives of women seeking abortion in fairly desperate situations. I then got a scholarship so I didn’t have to continue working as a nurse during my program, but it required me to complete it in two years. I babysat for a wonderful family and watched their family grow throughout my graduate studies. Then, as I was completing my final semester of my masters program, I landed another position in abortion care, which eventually turned into a broader family planning nursing role. That is the last job I held until beginning this current job.
After I passed my boards (got certified by the American Midwifery Certification Board), I again looked for jobs around my city. This time around, I had more interviews and got a lot more interest, but still, employers and even my mentors questioned if I could work as a full-scope (meaning: catching babies, not just working in the office) CNM without having worked as a nurse in labor and delivery. Some suggested that I should swallow my pride and try to get such a position and then try again in a year or two for a full scope job. It was a full six months between my initial interview and my start date for the position I landed, and there were times that I considered this option. Luckily, this position came through, and I got to do things the way I originally thought I could (more or less).
Acceptance
What is midwifery? Is it only possible to be a midwife if you’ve been a nurse during hundreds of births, many of which were probably complicated or high risk? I don’t think so.
It’s hard being one of the handful of people who graduated from programs like mine, that allow you to graduate without having to work labor and delivery, having to prove that you belong and that you can hang with the more experienced nurses. But I am not alone, and I’m grateful for others who blazed the trail before me — whether they intended to or not.
Midwifery is a whole lot of things.* True, the only births I’ve attended are the ones where I was doing the baby-catching (or doing labor support in a few instances). I haven’t seen a ton yet. My career is young. I am humbled by all I have to learn. But I have also worked in women’s health for over six years, and have learned compassion and to not judge women’s lives and choices. Midwifery is trusting women, it’s listening to women, and it’s being present with women. You can’t learn that from a textbook or demonstrate that on a board exam, but you can show it in the type of care you give. I am confident that, as one quarter of women in the United States will have an abortion before the age of 40, my background in abortion provides a ton of useful clinical and emotional skills to be a good midwife. Good midwifery care has to include all phases of the reproductive lifespan, including abortion. (And hopefully one day CNMs will be legally allowed to provide spontaneous and elective abortion care in all states!)
Now
Tomorrow will mark three months as a practicing CNM, but I think I’ve been practicing the midwifery model of care for more than that. I respect that other midwives took other paths — and they may have done so out of their own necessities. I hope that as I enter the birth setting again in a few months, when I get my hospital privileges, I can continue to safely develop my labor and birth skills and humbly continue my journey with new mentors and teachers.
*There are, of course, other paths to midwifery outside of nursing. I respect direct-entry or certified midwives, but I don’t claim to know much about their paths. I can only speak as someone that went the CNM route, and know that non-nurse midwives have their own contributions to women’s healthcare that may differ from where CNMs might be coming from (e.g. Ina Mae Gaskin).
I’m really looking forward to attending this year’s Socialism Conference, which I have been attending annually since 1997. I always learn a ton of history, theory, and current events, and get re-energized for another year of struggle. Unlike many conferences out there, it’s truly participatory and accessible. …
The entrance for the whole weekend is very affordable, and worth every penny. This conference can change your life — or at least give you new perspectives on the challenges of the movements, insight to history from a working class lens, and lots of positive vibes from being around so many bad-ass and brilliant anti-racist, anti-imperialist, anti-capitalist, and anti-sexist folks for the weekend.
Hope to see you there, fellow feminists, activists, marxists, and curious folks who want to change the world.
This is a common refrain from my collaborating physician, a woman who has worked in this community for decades and whose spirit betrays her lack of ability to maintain empathy. I’m not sure what she had to begin with, but now it is worn pretty bare.
It was hard to imagine those first few weeks. It can’t be that bad, I thought. Most people probably have some level of interest in taking care of our health, have some buy-in. Especially pregnant patients, right?
***
Every week, there are patients who show up toward the end of pregnancy, realizing it’s time to have the baby, having not been in prenatal care for months, maybe at all. They know they need to get the baby out. But they didn’t come in for their second trimester anemia follow-up, the anatomy scan ultrasound, the diabetes screen. They didn’t necessarily take their prenatal vitamins and likely haven’t been eating healthy. Maybe they were smoking weed or drinking or having high risk sex. They don’t know if the baby is going appropriately or if the baby is “okay,” but they come in…they come in.
Everyone I work with, even those who have been working in this community for years, still seems surprised that our patients don’t reverence prenatal care the way they did, or the way they think everyone should. “I went for every one of my prenatal appointments, I took my vitamins, I showed up, why can’t these people?”
“These people.”
And it’s true. In the narrowest sense, all pregnant patients in my state can get prenatal care. For undocumented mamas, it can be more difficult. No public health clinic is going to turn you away, that I know of. And for our patients, getting insured, getting Medicaid, is possible. Not saying the state doesn’t make you jump through hoops that may at times be humiliating and exhausting, but in theory pregnant women at least can get insured. But at least there is some assurance that the state will cover the cost of your care. It’s free!
And then there is coming in.
There is, of course, a wide variety of reasons patients don’t come in until midway through the second, or even until late in the third, trimester to establish care or to pick up where they left off after the initial dating ultrasound. I can’t pretend to understand all that goes on outside the clinic, in my patients’ lives, but I can say that moralizing about patients not showing up doesn’t actually help get them in the door or make them feel welcomed when they do show up.
No, this isn’t a rural community in subsaharan Africa, where there isn’t modern medicine. Oh, here, we have it all! We are in the heart of a wealthy American city!
***
…A wealthy city in which fifty public elementary schools were just closed, almost all in black and brown neighborhoods; in which the majority of my patients only ever see white faces in their health clinics, maybe their kids’ schools, and in blue uniforms; in which there are few grocery stores and terrible transportation systems in the neighborhoods that are majority people of color; where in some areas youth are tracked into the criminal injustice system and in others, they are offered the world.
When the City doesn’t really give a shit about you, doesn’t value your basic human needs, let alone your higher aspirations…why would you necessarily adhere to the proscribed regimen of care for the baby you are carrying?
And even in these terrible circumstances, most of our patients are active participants in their care — they show up, get excited each time they hear the baby’s heartbeat, they worry when anything isn’t normal, they ask great questions about their bodies and the life growing inside of them.
But just as you can’t compare yourself, who did everything “right” when you were pregnant, to the few patients that don’t show up for care, you also cannot compare these “delinquent” patients to those mamas in the (other) third world who would be so grateful to have access to the kind of care that our patients take for granted.
And what if your managed care Medicaid company has you tied to your primary care provider at a clinic where every time you meet with the doctor, you feel like she doesn’t have time for you, doesn’t explain where your cervix is, doesn’t follow up on your look of bewilderment with a simple question about how she can help you understand?
I might not keep showing up either.
***
It is frustrating and scary as hell to be a prenatal care provider in those situations. When you accept a pregnant patient into your care so late, you just don’t know what you’re going to get. Intrauterine growth restriction? Fetal alcohol syndrome? Uncontrolled gestational diabetes? Preterm labor? You feel like you’re scrambling to catch up, to find out what is going on physiologically, with the pregnancy, and what motivates the woman carrying the pregnancy. You worry she might expect everything to go perfectly, while it appears she hasn’t done her part to reduce risk, since you haven’t seen her for so much of her pregnancy. You might become the type of provider you swore you’d never become. You might not even recognize yourself after years of seeing the same social problems reflected in the faces of your beautiful young patients.
Until we fight for and win from the system quality affordable housing, excellent free public education, decriminalization of our youth and of blackness, safe and affordable food and water, expansive mass transit, and a single payer health care system, the circumstances under which we utilize any and all of these basic human needs will be less than ideal. And so will our provision of such care and services.
I look forward to working in healthcare in which women’s and children’s lives will be truly valued, and in which we will collectively trust, not scrutinize–but also, enhance–women’s decisions and lives.
For now, I am grateful for having a worldview that helps me find empathy alongside righteous rage against the system. I’m grateful for education that gave me the tools to provide evidence based care, so I can continue working to do my best for patients as they show up in my clinic, whenever they’re at in the lifecycle. I’m grateful for lunchtime office yoga or forest preserve walks that preserve my sanity. And I’m grateful for intersectional (anti-racist, anti-sexist, environmental justice approach) social and economic movements in the city, country, and world, that can make things better inside and outside the clinic walls. Because good lord, things need to get better, soon.
The absolute tip of the iceberg for me, though, with privatized Medicaid, is the requirement for the provider or pharmacy to submit a prior authorization request when prescribing treatment for two conditions that I see pretty frequently: gonorrhea (which includes injection of a drug called ceftriaxone) and Pelvic Inflammatory Disease (PID) (which requires both ceftriaxone and 14 days of oral doxycycline). 
Midwives of the Revolution 