Making the Midwife Possible
/Closing Remarks for the American Association of Birth Centers 2020 Conference
by Indra Wood Lusero
Presented on October 4, 2020, you can find a pdf of the powerpoint slides here.
I was a queer polyamorous twenty-something in the late 90s and my college girlfriend and I had decided to make babies with our gay college roommate. He’d be a dad not just a donor. We figured you can’t have too many parents. We’d both get pregnant. She’d go first because her parents were more likely to reject the plan: the thinking being that a grandbaby might soften them to the queerness of it all. It worked!
After going to college in the northwest I was excited to move back to Colorado where I felt so rooted to the land my ancestors had inhabited for generations. Ancestors on my dad’s side come from northern New Mexico/southern Colorado which had been the land of many tribes, a Spanish colony, part of Mexico and part of the United States. I was acutely aware of being from a small lineage of people who, over hundreds of years in this region, had been both colonizer and colonized, and I think that perspective primed me to recognize how midwifery became “impossible even of mention.”
There was just over a year between when my first son was born and when I got pregnant. During that time I started reading a collection of writings by Subcomandante Marcos, a spokesperson of the Zapatistas. The Zapatista uprising involved a community of mainly indigenous people in the Mexican state of Chiapas who took up arms and mobilized the imagination against powerful corporate landowners backed by multinational corporations and the Government. It is an inspiring example of the underdog’s innate resourcefulness and drive for equity.
Skipping perhaps the best part of the story, after I gave birth at home with a beautiful team of midwives, I was captivated by the treasure trove of power and energy that felt available because of that experience. I marveled at how little technology my labor required. I marveled at how it mobilized my imagination. It felt revolutionary. It felt like a Zapatista uprising: small, but mighty, powerful enough to ignite the world and fundamentally redistribute resources more equitably. This is what Making the Midwife Possible means.
It’s not too much to ask, and it’s not too expensive to implement, but it does require a reordering of power and priorities.
And that’s the tricky part.
Before we can truly make the midwife possible we have to grapple with what has made the midwife impossible to begin with. It was not just Joseph DeLee or the campaign to eliminate midwives but a confluence of forces. Forces quite similar to those experienced by the Zapatistas.
When I think about the power of those forces I think of my Grandma Ella. My paternal grandparents had four sons right when the medicalization of birth in the U.S. was solidified. And my Grandma Ella was a modern woman. She worked at Douglass Aircraft as a “skinner,” drilling the holes where the riveters would put their rivets. She was ready and willing to view parturition with modern eyes, and assumed technology and industrialization would liberate her from it. I often wonder what her mother-in-law, my great grandmother Rosa, thought of her. Rosa, who had given birth a dozen times, never in a hospital! From what I understand, some called her a curandera.
Of course this is interesting to me as a matter of family history - but I also think it’s important more generally to think about the relationship between individual lives and massive systems (like the Military Industrial Complex, or white supremacy) that are both much bigger than individual lives but also comprised of them.
If there is one thing we have learned in my generation, it is the limits of technology, and the pitfalls of industrialization. Certainly, the same is true of the limits of the obstetric model.
The question, then, is what individuals can do, given these massive forces, to make the midwife possible. First we have to grapple with what it means to come from people who sought liberation, and along the way also limited themselves, and helped undermine the liberation of others. How we too are vulnerable to limiting ourselves in pursuit of freedom, and apt to trample on others as we go.
We have to do some uncomfortable reckoning with the DNA of the system we’ve inherited, the code that undergirds this system:
the way it has contributed to racism and homophobia in a way that violated innumerable people’s human rights and bodily integrity
the relationship between healthcare and eugenics
and the insidious collaboration between healthcare and policing, including policing in the guise of “child welfare”
These are just a few examples from history - but we can see how they continue to manifest today.
You’re all well aware of the contemporary consequences of DeLee’s insistence that childbirth was so pathological that only a surgeon could manage it. This proposition impacts everything about the work you do from the staff, to the building, to the financing, and malpractice insurance. But you may not realize the way this proposition impacts some individual women differently than others. Women I’ve had the honor of helping to defend from criminal prosecution related to the combination of their substance use during pregnancy and the circumstances of their birth.
For example, this incredibly courageous woman, who after enduring the loss of her newborn just a day after his birth also had to endure criminal prosecution and is serving 20 years in prison.
When asked at trial about whether she got prenatal care she said this, No… I’m just – I have experience. This is my fourth pregnancy. If I had been going to a doctor… I know what they would have done medically for me.
And she acknowledged that fear of persecution and losing her kids also drove her away from medical care.
So she decides she will just stay home and handle it herself. She makes a plan, and invites a friend who is a nurse to be with her just in case something goes wrong. And then she labors.
And gives birth.
And she’s reassured by his being alive. And feeling proud of herself for giving birth under her own power. She messages a friend about how strong she feels. But she’s worried too. She knows he may have withdrawals because she was using drugs during pregnancy. And she wasn’t ever sure about her dates but realizes he’s small, maybe it’s early…
When his color changed she woke her uncle, summoned her mom who called 911, they started mouth to mouth, CPR. He didn’t survive. Instead of getting to grieve she was handcuffed.
This is a hard story. I’m sorry to have to tell it. But I tell it because this is how deep we have to go to make the midwife possible. This story is one acute glimpse at all that has to be recovered.
If you have questions or feel discomfort, I’m sorry. I am. But. I don’t want, even you all, you wonderful advocates for the Midwifery Model, to think that this will be easy. We’ve gotta dig deep.
The criminalization of pregnant people has largely been supported by what “junk science.” Of course this stems from the many strands of explicitly racist policies that seamlessly work together to give us this result: the Drug War, eugenics, child separation, medical experimentation on people of color - to name a few.
And I think you all will be familiar with the power of this kind of allegiance between biased ideas and medical technology.
Notably, sometimes those coordinating for the few use words that suggest the public good, despite having motivations that are not entirely grounded in the public good. This is absolutely true of the Drug War and one of the lessons I have learned from the history of midwifery and childbirth in America. Indeed, the American anti-midwife campaign of the 20th century purported to be about health and safety, as did the experimentation of Dr. Marion Simms on enslaved women without anesthesia. Many “maternal health” efforts throughout history have failed to be grounded in the health and safety of all though they’ve been sold that way.
Justice Brandeis said in his dissent in the case Olmstead v. United States, “Experience should teach us to be most on our guard to protect liberty when the government's purposes are beneficent.... The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well meaning but without understanding.” I emphasize that it was a dissent because of the important role of dissent throughout history, and as we are on the threshold of an even more idealistically imbalanced judiciary, dissent will be paramount. Of course the majority and the dissent are equally likely to be well meaning but without understanding.
In 1961, Dwight D Eisenhower warned of a military industrial complex: a confluence of technology, power, magnitude and money that has important utility but also “grave implications;” he warned about creating something enormous that lacks balanced judgment. This complex too, grew out of words suggesting the public good, but also wrapped up in motivations not entirely grounded in the public good of all. In the United States, in so many ways, including our health care “system,” that’s where we are at. Beneficence and greed all tangled up.
One of the ways this manifests is the lack of integration of midwives - which of course is not a flaw in the system it is working the way it was built! This lack of inclusion of midwives is the solution to the “Midwife Problem” of 100 years ago.
To measure this and the effects of this, Birth Place Lab researchers created the Midwifery Integration State Scoring (MISS) system. Each state is given a score out of a maximum of 100, they range from lowest at 17 (North Carolina) to highest at 61 (Washington). 61 is not a great score - on a grading scale of 100, that would be a D-. So - even our best isn’t great.
Integration scores had to do with Regulation & Medicaid, Autonomous Practice & Risk Assessment, Scope of Practice, Medication - Authority, Midwifery Board Composition & Regulatory Agency, VBAC, Reporting and data collection, Options for birth site, and number of midwives. I think if access to private insurance networks, and access to liability insurance were included the integration scores would be even lower. Of course, a lower integration score is correlated with worse perinatal care outcomes.
It would be nice, if we could just course correct - based on this data - just - turn the ship around!
But this is where Eisenhower’s warning about the risks of an industrial complex comes in - there is so much industry, so much money keeping the status quo in place. Turning the ship around is not an easy proposition!
Hospital charges related to birth amount to over 79 billion and far exceed charges for any other condition. But not only that - the industry is self perpetuating with some parts of it more strongly invested in the status quo than others - and they are expending resources to protect their interests. The money that certain entities spend on lobbying also illustrate the scope of the lack of midwifery integration.
And here I use an image from Humprey Yang’s great videos illustrating Jeff Bezos’s wealth with grains of rice.
Last I checked annual report data(the details aren’t as important here as the broad strokes, just for example): The American Cancer Society has 1.3 billion in net assets - huge compared to the American Diabetes Association has 84 million.
Perinatal care doesn't even have a society like the American Cancer Society of American Diabetes Association, but the closest comparison is probably Childbirth Connection which started around the same time as the American Cancer Society, over 100 years ago. They had around $500 thousand in net assets before merging.
It is interesting that an 80 billion dollar industry doesn't have a more robust advocacy organization. Childbirth Connection merged with National Partnership for Women + Families, which has more like 24 Million to work with, but of course, a small portion of this goes to their work related to childbirth.
Filling the advocacy gap related to childbirth are professional associations, including ACOG with assets in the range of 44 million. Compared to ACNM which has assets of about 3 million. The CPM professional association isn't even in the millions. AABC and CABC have a few grains of rice.
And of course this is all part of how our health care system operates in general, many of these issues are not unique to perinatal health care. There are lots of entities we could look at in this way to evaluate their power and investment in the status quo. The insurance industry is a Trillion dollar industry.
The reproductive justice framework, developed by women of color, and taken up by many other organizations provides helpful insight relevant to making the midwife possible. There are some who see this as a health access or information access issue, one that can be addressed by more accurate data. Others see this as a lack of legal protection for midwives or lack of laws protecting the right of individuals to choose midwives. But the reproductive justice way of seeing this is to recognize that any midwife or individual seeking a midwife will be necessarily constrained by power inequities across multiple systems. This is part of what the previous slide illustrated. Information access and individual rights can only do so much when there are vast resources going into making the midwife impossible.
I’ve given us some stories of individuals to consider as we grapple with this, because I think my grandparents, and the woman who was incarcerated after giving birth each illustrate in different ways how they are indeed individuals making choices, but they are also very much shaped by forces bigger than themselves. My great-grandma probably had a partera - and then lived to see them and her community-based expertise as a curandera marginalized. My grandma wanted to be free of the limitations of her mother’s generation and believed medicine had the cure: but it’s hard to see how the new highway systems and hospital buildings could have led her anywhere else. And for the woman who used drugs during pregnancy, she probably couldn’t even imagine getting access to the Midwives Model of Care, she literally had no safe provider. But she didn’t believe that childbirth had imposing pathologic dignity, and was punished for it.
Quoting from the book Radical Reproductive Justice edited by some of the founders of the movement, Loretta Ross, Erika Derkas, Whitney Peoples, Lynn Roberts, Pamela Bridgewater: “liberal ideology misused the concepts of rights and justice to situate responsibility for health and wellness in individual choices”
This graphic shows how the individual, interpersonal, institutional and structural all interact.
At Elephant Circle we think of this as the How and the What of birth justice. And you can read more about this in this publication, Funding Equity. How we achieve birth justice is just as important as what we achieve. If we just write white supremacy and racism into new code, we will not have birth justice. We have to go about birth justice by casting aside systems of power and oppression. That’s the HOW of birth justice.
But of course we also need Expertise in the health care system, the legal system and the sociobiology of the perinatal period. That’s the WHAT of birth justice. One of the key insights of birth justice, which grows out of reproductive justice, is that individual rights is a losing strategy. Of course the individual and the systemic are interconnected, but to make real progress we have to focus on systems.
So if there is one thing you can practice, it is to zoom out - to consider the bigger picture. If you find yourself focusing on an individual: think twice. There is no harm that any individual can cause and no benefit they can bring, that is anywhere near what an industrial complex can do.
We have to get away from the frame of individual choices: it is a false one, it’s a losing one, and it is used against us.
This framing is used in legislative conversations about midwifery and community birth today. In fact, I think this insidious distraction is actually at the root of those conversations about training and differences in credentials that can be so contentious. These conversations where we have to defend or clarify a provider’s “real role” or “legitimate training” puts the focus back on the individual and takes the focus away from the systemic, the institutional. It’s like focusing on one grain of rice instead of focusing on the huge pile of rice.
So going back to the rice, if each grain represents $100,000, Jeff Bezos, the richest person in the world has about 80 pounds of rice. And the insurance industry has hundreds of times that amount. This image represents what Bezos had in February but since the pandemic he has made an additional 50 Billion, bringing the total to over 100 pounds of rice. And remember in this model one grain is more money than most of the humans on earth will have in their lifetimes. I point this out because income inequality is certainly tied to making the midwife impossible. But I really want to emphasize what you miss when you focus on one grain of rice. To make the midwife possible we need a bigger view.
And I get it - this can be completely overwhelming to the point incapacity. The last thing I want is for you to feel frozen, stuck, unable to move forward. But imagine the 3,000 Zapatistas in 1994, up against 10 to 20 times that many members of the Mexican military. And regardless of the political details or whose side you are on, I ask you to appreciate the imbalance in power and imagine the guts it took for the Zapatistas to show up to armed battle! But more than guts, and this is what really inspired me back in the 90s, it took vision. The Zapatistas began as a spark of an idea that generated its own current of energy that rippled across networks no one could have imagined - especially before the World Wide Web.
Like Adrienne Maree Brown writes in her book, Emergent Strategy: “The crisis is everywhere, massive, massive, massive. And we are small. But emergence notices the way small actions and connections create complex systems, patterns that become ecosystems and societies. Emergence is our inheritance as a part of this universe; it is how we change. Emergent strategy is how we intentionally change in ways that grow our capacity to embody the just and liberated worlds we long for.”
All the underdogs throughout history accomplish this with humanity’s best tools: through art and storytelling and symbols. These are ways of speaking across time and culture. This is the kind of energy I had access to after giving birth. Imagine countless humans with this energy unleashed. There is a lot of power in Vision.
The Zapasistas also accomplished this by not leaving anyone out. Imagine my surprise when I found that the Zapatistas - included me, this guera queer from up north, arguably part of the problem. In the 1990s the Zapatistas said to the movement for gay liberation, our admiration for your courage and audacity to make yourselves seen and heard, for your proud, dignified and legitimate ‘Ya basta!’ Our best wishes to your organised existence. Long life to your fighting spirit and a different tomorrow, one that is more just and human for all those who are different.”
The generosity of that astounds me to this day.
They had an explicitly large tent, an explicitly pluralistic view. They believed in, quote, “A world where many worlds fit.” And they were fighting for that world even though they were a tiny part of it so that, quote, “[h]umanity, recognizing itself to be plural, different, inclusive, tolerant of itself, full of hope, continues.”
So that humanity continues.
I think, to Make the Midwife Possible we need a comparably large view. I truly believe that if every birthing person had access to fully supportive, culturally congruent midwifery care, in the Midwives Model of Care it would change the world.
Imagine if every birthing person was told their “physical, psychological, and social well-being” matters. Imagine if everyone got the education, counseling and support they needed. This could make the world a more equitable and just place.
How can we be so generous as to include everyone, even though Making the Midwife possible is a matter of concern to only a tiny fraction of us? We need to see how our work is connected to the income inequality folks, and the police accountability folks, and the abolish the Drug War folks, to the climate change folks. We need to have humility, and recognize how we are connected to the Black Lives Matter folks, or to the Water Defenders, and we need to realize that sometimes we are connected because we are the guera from the north who is arguably part of the problem.
When I chose to birth at home as a queer Latinx person in the Rocky Mountain west, I didn’t know much of this. But I did know that dominant society didn’t always have me in mind, so I would have to take what was useful and leave what was harmful in order to thrive. And that’s what I did, as many of us do.
But instead of learning to cope with being the “other” in a society not made for us, instead of creating a society made for the privileged few, it is time that we create a society that could actually work well for all of us, “a world where the whole world fits.” This is equity, the organization of things so that they work well for all.
I don’t want to end poetically but without giving you something tangible to do. So with that in mind I’ve created this table of some next steps for the HOW and the WHAT of birth justice that you can do.
So, first, Trust Black Women. Seriously. I know some of you, and I know that you cannot yet do this. And no, I do not mean “trust a black woman.” It’s gotta be plural. And this is a great place to notice that individualizing thing. Figure out how to take yourself from “trust a black woman” to “Trust Black Women.”
Read Emergent Strategy. The great thing about this book is you can pick it up and flip to the page that speaks to you, it does not have to be linear. Get this book and develop a relationship with it.
Practice humility. This can be tricky, especially in the context of a profession that has been viewed as impossible even of mention, a profession comprised of women trained to enact humility in various sometimes problematic ways. This is not about accepting some lesser-than positionality. That’s not it. But I do think there is a way that we can be in harmony with our strength while also being humble. This has to do with having a generosity of spirit while also asking the question “where are my blind spots?” And I just know this, because I don’t just trust Black women, I learn from them. So always remember to circle back to #1.
In terms of the WHAT. Here are some key ideas:
Support policy positions that counteract monopolies. Think about Making the Midwife Possible in terms of markets. Identify who has the power in the market. Because we are dealing with an industrial complex there are lots of interconnecting markets. Remember that monopolies drive discrimination and bias and contribute to inequity. Root out monopolies. Challenge entities that have a stangle-hold on the market. Expose the industrial complex behind the veneer of beneficence.
Which leads to the next one - Fight corruption. Anything can be corrupt, including midwifery. So don’t get too precious, but do keep an eye on distortions, junk science, lack of transparency, lack of accountability, inadequate transfers of power. And advocate for policy solutions that require public disclosure of information, including information about how and where the money flows, that include oversight and accountability, and that have checks and balances. Whether it be the Maternal Mortality Review Committee, the Insurance Commission or the Governing Body, no one person better be able to run away with the thing - that’s corrupt.
Decolonize. This could just as well have fit in the “how” category since decolonizing is a practice of the mind as much as a legal policy. But as a matter of policy decolonizing is a process of retracting from spaces that are illegitimately occupied. As an explicit example there are too many legal barriers to sovereign Indigenous birth, and these need to be eliminated. Surveillance of communities that intersect with childbirth, like drug testing of newborns, especially without consent, CPS investigations triggered by health care provider reports - need to be eliminated. Retract from these spaces.
So, again, Making the Midwife Possible is something we can achieve even though we are small and the crises are “massive, massive, massive.” But it does require a reordering of power and priorities - so that humanity continues.
