Birth Justice Tribunal Report Back

Released December 2024

“True resistance comes with people confronting pain…
and wanting to do something to change it.” - bell hooks

One in five pregnant people experiences discriminatory mistreatment during pregnancy and childbirth in the United States. Despite growing national attention on perinatal health inequities, too few options exist to seek- and find- accountability for these harms. Community-led strategies have emerged in response to this failure to account for this discrimination. This report amplifies these strategies, focusing in particular on those that emerged from the 2023 Birth Justice Tribunal. 

On October 6th and December 1st, 2023, twenty-six brave families came forward with their experiences of violence and discrimination during the perinatal period at the 2023 Birth Justice Tribunal events in New York and Memphis. Honoring and believing in the power of centering people who have been directly impacted, this report weaves together their individual stories, anchoring its discrimination analysis in the voices and vision of people who have experienced obstetric violence and obstetric racism first-hand. The report concludes with community-led calls to action that we trust and believe hold the power to disrupt harm, and radically expand accountability for these harms.

Doula Is a Verb

At Elephant Circle, we like to say “Doula Is a Verb.”

This simple sentence reflects a specific philosophy about our values and commitment to doula-work*.

Our philosophy includes 5 core principles:

1. Doula-work does not need to be professionalized in order to work or be valuable for the clients and communities doulas work alongside.

2. Doula-work in the U.S. today happens in the context of the broader perinatal health care system where inequity is built-in; doulas are only one strategy we have to equip people with tools and resources inside of these systems and spaces.

3. Doula-work is connected to a long history of care-work that has been systematically deprioritized and devalued inside of patriarchy and white supremacy.

4. Healthy communities have doulas.

5. Pregnant people are experts; they are best positioned to navigate their pregnancy, birth, and postpartum.

*Learn more about this term here: https://static1.squarespace.com/static/57126eff60b5e92c3a226a53/t/638f562c3ebfa36a53bf88de/1670338102604/FINAL+Advocating+for+Birthworkers+in+Colorado.pdf

1: Doula-work does not need to be professionalized in order to be effective

What do we mean by “professionalized”? Professionalization is a process that turns an activity into a distinct, standardized occupation (a “profession”). This process is often inspired by a desire to make more money from the activity. To make more money from the activity, people need to see it as an activity with a value that you can put a price tag on. To put a price on it, you have to be able to show exactly what it is, and distinguish it from what it is not. This usually requires distinguishing it from activities that aren’t in the market, like hobbies, religious callings, family duties, and relationship practices. You also have to put it into the market. Market rules can include fees, proof of credentials for the activity, and demonstration of standards.

People in your world probably have experiences with this. Maybe you have a family member who cuts hair but who couldn’t open a salon because they aren’t a licensed cosmetologist; or a friend who makes amazing food but runs into all kinds of roadblocks when they want to open a food truck. This process is not unique to doulas. As you think about it you can see how it is a process that involves a change in how people think about the activity, as well as a change in the economics of the activity, and the regulation of the activity. It deeply impacts who can do the activity and what the activity can be.

A stark example of professionalization in health care is midwifery. This process is still underway in the U.S. (and globally), and is well documented for those who want to learn more. Briefly, Midwifery is a human practice of support for pregnancy that has been happening across time and cultures. In the U.S. the effort to professionalize medicine, specifically obstetrics, included an effort to distinguish between the activities of obstetricians and the activities of midwives (even though many of the activities were the same). This process led to the criminalization and sidelining of midwifery, which reduced access to midwives, which then led to the professionalization of midwifery as a way to bring them back into the market and increase access. It’s a huge topic by itself, but if you’re talking or thinking about doula professionalization you should definitely study midwifery.

There are many lessons that can be learned from the history of midwifery professionalization and it’s clear that professionalization comes with pros and cons. Reasonable minds can come to different conclusions about those. But for us, one critical fact stands out: doula work does not need to be professionalized in order to work. The great outcomes policymakers tout, the intervention against inequities that doulas offer, and simply, the many benefits that flow from having a doula, exist because of the activities of doula-work. The benefits do not rely on (and may even be reduced by) doulas being a profession. In fact, the concept of “professionalism” has historically been weaponized against doulas, especially doulas of color – creating expectations that birthworkers adhere to standards of white supremacy culture masquerading as “professionalism”, and marginalizing those that do not assimilate. For people who care about getting more of these benefits to more people it is essential that you keep this fact in mind: doula-work is effective because “doula” is a verb.

2: Doula-work in the U.S. today happens in the context of the broader perinatal health care system where inequity is built-in

It turns out that the activities of doula-work, the action in the action-word, have been shown to improve outcomes. In studies, this activity has been defined as “one-to-one intrapartum support.” That having personal, individual, support helps people should be no surprise. The data bears out what we know logically and intuitively. Helping, helps! What may be less obvious is that one-to-one support is lacking in perinatal health care because it wasn’t built-in.

Why wasn’t it built-in and how do we know this? It wasn’t built in because the pregnant woman wasn’t the priority. The social and scientific significance of the pregnancy was more important and this significance varied by race and class. So, for example, certain obstetric procedures were developed on the bodies of enslaved Black women because those procedures could both support their value as property and increase the value of the obstetricians who could perform the procedures. But the support these women may need was not a consideration in the slightest. Even for privileged white women, the social and scientific significance of pregnancy was more important than their personal needs: the fact that they had a uterus dictated their purpose (pregnancy) and their position (secondary) and any support they may get was delivered through this lens.

Of course there are many perinatal health care providers today that see their pregnant clients as worthy of individual support. But they will have learned their trade from people who learned their trade from people who did not. They will practice in settings that were designed and built and bankrolled by people who did not see pregnant clients as worthy of individual support. This history is only 3 or 4 generations old. It is as present as your great-grandma’s recipes.

Doing the work of supporting a pregnant person one-on-one may help that person feel helped, and that may improve their lot. But doing the work of supporting a pregnant person one-on-one, even lots of them over and over, cannot change the shape of the system by itself. If support is an action that works, and we want more of it in the system, we’ve got to build it in. Doulas should not be the only people doing that action. Doula is a verb that everyone in the system could do - if it were built that way. 

It is worth noting that midwifery incorporates the value of the pregnant person more effectively than other models (as illustrated by various surveys and data) and part of the inequity built-in to the status-quo comes from the marginalization of midwives. Incorporating doulas into the system cannot resolve this inequity. A system that truly addresses perinatal inequities includes midwives.

3. Doula-work is connected to a long history of care-work that has been systematically deprioritized and devalued

Work is part of the human condition. Every culture across time has had a system for organizing work. One of the ways work has been organized is by separating the “domestic” work from “real” work. 

Work that drives markets has been prioritized in the U.S. and has relied on “domestic work” being available and undervalued. Work involving the care of children, elders, people with disabilities, pregnant and postpartum people, and homes, has been considered “domestic work” and associated with women and lower-classes. Today, the majority of “domestic work” as a profession, is done by women of color (over 90% of domestic workers are women and Black, Hispanic and Asian American/Pacific Islander women are vastly overrepresented as a proportion), and “unpaid family work” like care of dependents and households is still performed mostly by women.

At Elephant Circle we are aware that work is not neutral, that work is about power. So the issue of doula-work has to be considered in the context of the organization of work in society more broadly. We see doula-work, that action-verb of one-on-one care and support, as part of the broad umbrella of care-work. Ai-jen-Poo, Director of the National Domestic Workers Alliance, calls care-work, “the work that makes all other work possible.” We need to think about what work doula-work makes possible.

Care-work has been marginalized socially, culturally and through explicit policies. For example, when other workers got protections through the Fair Labor Standards Act one hundred years ago, those who performed care-work were explicitly left out. This had the effect of maintaining racialized and gendered inequality. The inequality was the point.  

Because inequality was built in, we need to think about what inequalities the organization of doula-work maintains, and how we can organize doula-work to dismantle inequities. 

4. Healthy communities have doulas. 

Along with the idea that doulas can address inequities in perinatal outcomes is the idea that doulas can bring culturally congruent care. In this vision, doulas reflect the communities they are in and are able to step in to care for the people in their community who need them, and that money isn’t a barrier to that care for the people who need it or the people giving. We love this vision! 

But we keep in mind that the process of culturally congruent care is one that happens spontaneously in communities. Culturally congruent care isn’t “out there.” People care for each other as part of social-mammalian systems. Social-mammalian systems are ordered for in-group care. We already know how to do this! It’s just that things get in the way. We are concerned that by focusing on doulas as the solution we lose sight of where the problem actually lies. It isn’t that we lack the capacity or awareness to care, it is that culturally congruent care has been disrupted.

Some of the things that disrupt our social-mammalian instincts to care for each other are 1) the marginalization of care-work (see above), 2) socially constructed timelines and calendars that work against the rhythm of the perinatal period, 3) extractive economic policies, 4) organizing health systems around disease instead of wellness, and 5) oppression that defines some people as unworthy of care.  

This is one reason why the image of the elephant circle is so important to us. It reminds us that we too are mammals. We already have a blueprint for this. We are part of the ecology. By looking to doulas as the solution we should be cautious not to take our eye off the problem. Setting up structures to support culturally competent doula care doesn’t guarantee that the structural problems are fixed. In fact, a surface solution could even distract from the problem in the short term. We want to see systems that are built for our mammalian circles, and protect against things that disrupt us. 

5. The pregnant person is best positioned to navigate their pregnancy, birth, and postpartum.

Along those lines, one of the inequities built-in to the system, as we have discussed, is how the pregnant person is not the priority. To the extent that “doula” is the verb, the pregnant person is the noun, the subject of the sentence. 

We don’t want to lose sight of the pregnant person. As the studies and our intuition show, doula-work can make a difference. But if the pregnant person’s life circumstances are dire, that support can only go so far. If the pregnant person is still not a priority in the system, that support can only go so far. Since doula-work is some of the only work in the current perinatal care system dedicated exclusively to the pregnant person, it is a powerful tool for reorienting the system. But it’s not the only tool and maybe not even the best one.

Doula-care can improve outcomes. But strong, healthy pregnant people who are respected, prioritized, and resourced, also improve outcomes. Keeping the focus on pregnant people themselves is key. 

In conclusion, Doula is a Verb is how we practice doulaing, how we organize doulas, and a political-orientation to the role of doulas in caring for and supporting people across the perinatal period. It’s a practice of principles that reorient the perinatal system so that care is a top function and priority. Care isn’t just an intention you hold in your heart, it’s a way of taking action that anyone and everyone can do. This practice is also a way of resisting and reversing built-in inequities, so that women, people of color, and gender nonconforming birthing people are healthy and free. 

Provider Discrimination in Medicaid Reimbursement is Unlawful

On July 20, 2023 we submitted this brief “Legal Bases for Medicaid Reimbursement for Direct Entry Midwives in Colorado” to HCPF and other allies and stakeholders to address HCPF’s failure to credential or reimburse Colorado Direct Entry Midwives.

This thread illustrates the denial and run-around of one particular midwife who sought to be enrolled as a Medicaid provider.

Federal Civil Rights Investigations - An Opportunity for Accountability

This article from the LA Times about a federal civil rights investigation into the pregnancy-related death of Kira Johnson illustrates the potential for the Office for Civil Rights (OCR) to bring much needed systemic accountability for birth inequities, obstetric racism and obstetric violence.

Elephant Circle has been working on developing this pathways for years, having first met with leaders at the OCR in 2021. We now have a process in place to help people file complaints with the office - learn more here and share widely!

We also wrote a comprehensive brief on the issue, Mobilizing the Office for Civil Rights’ Authority to Address Obstetric Violence and Obstetric Racism, which we delivered to the Office for Civil Rights in 2022. Follow-up conversations we have had with the office in 2023 confirms that this is a tractable pathway. We encourage anyone who has experienced obstetric racism, obstetric violence, or inequities during the perinatal period to file a report.

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Cedars-Sinai faces federal civil rights investigation over treatment of Black mothers

BY MARISSA EVANS STAFF WRITER

JULY 11, 2023 5 AM PT

Cedars-Sinai Medical Center is facing a federal civil rights investigation over how the Los Angeles hospital treats Black women who give birth there, an official with the U.S. Department of Health and Human Services confirmed.

The investigation comes after allegations of racism and discrimination emerged in the years after the death of Kira Dixon Johnson.

Johnson went to Cedars-Sinai in April 2016 to deliver her second son by cesarean section but died hours later after hemorrhaging blood. News of the incident spread over social media and led to her husband, Charles Johnson IV, filing lawsuits against the hospital over her death.

The Times obtained a copy of a letter the federal agency sent to Charles Johnson in March indicating that it was aware of the allegations involving the hospital’s level of care for Black women.

The Office of Civil Rights “has been made aware of concerns regarding the standard of care provided to Black women in the care of Cedars-Sinai Medical Center,” the letter said. “Specifically, OCR is aware of allegations that Black women are provided a standard of care below what is provided to other women who are not Black when receiving health care services related to labor and delivery.”

The letter noted that based on the allegations and the fact that Cedars-Sinai receives federal funding, the agency is reviewing whether the hospital is complying with federal civil rights laws.

Melanie Fontes Rainer, director of HHS’ Office of Civil Rights, confirmed the agency’s investigation in an emailed statement.

“Maternal health is a priority for the Biden-Harris Administration and one in which the HHS Office for Civil Rights is working on around the country to ensure equity and equality in health care,” Fontes Rainer said. “To protect the integrity of this ongoing investigation we have no further comment.”

Landscape Analysis

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In the past few years interest and awareness in birth justice has grown tremendously, as has philanthropic support and impact investing. There is no doubt that increased attention and investment is sorely needed. However, without an understanding of what the landscape includes, who is there, doing what, and why, that increased attention and investment could be ineffective or even harmful. This reminds us of the way a sudden downpour impacts the land in the dry west where Elephant Circle is based. Mapping and planning can help maximize the benefit of much needed water, while mitigating the harms. We are working to make sense of what’s happening in our landscape so that people can plan and strategize. To receive outreach and updates add your name here!

A view of state infrastructure destroyed by heavy rains, with some areas receiving as much as 18 inches in a 24-hour period in Boulder, Colo., Sept. 14, 2013. (U.S. Army photo by Staff Sgt. Wallace Bonner/Released)

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Plan for a Landscape Analysis for the Birth Justice Movement

In response to poor outcomes in maternal health, persistent experiences of structural racism and gender-based violence, poor quality and disrespectful care, local communities have generated a movement for “birth justice” to create perinatal health services, support systems, and policies that address and improve these conditions. Understanding the response mechanisms communities are using to address these problems, and the ecology, is key to understanding birth justice and how to maximize opportunities for change. 

The goal of the project is to provide a reproductive justice framework for understanding who is doing what, and why, for people in the perinatal period, in the U.S.

A deep understanding of community led strategies through a national birth justice landscape analysis will allow birthworkers, activists, researchers, donors, and policymakers to identify key strategies for collective impact, enable tangible improvements, and scale up. Elephant circle is uniquely positioned to conduct the landscape analysis with a team of researchers, activists and change makers who are deeply connected within the birth justice movement. Through a community led qualitative landscape analysis over six months we will:

1. Define the birth justice movement and why and how it is both part of, yet distinct from the reproductive justice movement.

2. Describe the networks and alliances within the birth justice movement. and map the services and strategies offered for people in the perinatal period, in order to create a picture of the existing change-infrastructure.

3. Describe the funding needs of the birth justice movement and how funding for various services and strategies may impact it. 

4. Caution against funding strategies that could be detrimental to the movement and its participants.

5. Recommend a strategic approach for the larger maternal public health/early childhood health landscape to work with the birth justice movement and participate in improving outcomes.

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The process will include pathways for individuals, invited organizations, and sponsors to engage and inform the report.

Individuals can participate in community meetings, interviews and surveys. Some individuals will also be invited to be reviewers.

Organizational partners host community meetings or invite their networks, recommended interviewees, participate in and share surveys, and provide reviews. Organizational partners are invited or nominated by other partners.

Sponsors make a financial commitment to support the work of the report. Funders that contribute at least $10,000 will be recognized. Organizations that sponsor at a rate that is commensurate with their budget will also be recognized. If you’re interested in being a sponsor contact Indra at indra@elephantcircle.org

To receive outreach about community meetings and interview opportunities, or updates about our progress, add your name here! Check our events page for more about the Community Meetings.

Thank you to Orchid Capital Collective for encouraging us to take this leap! And thank you to Perigee Fund and Ms. Foundation for their support of this effort.

Policy and Demographic Considerations for LGBTQIA Families and Midwives

Midwives who either are themselves lesbian, gay, bisexual, transgender, queer or questioning, intersex, two spirit or other aligned identities (LGBTQI2S+) or want to serve the LGBTQI2S+ community have to consider both the policy environment for the practice of midwifery and the policy environment for LGBTQI2S+people. This write-up provides an initial and novel analysis of data about midwifery integration and LGBTQI2S+ equality. There are some great tools available to address these issues. We hope to bring them all together for the first time here. 

The Birth Place Lab created an interactive map based on their paper “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.” The maps can be accessed at: https://www.birthplacelab.org/maps/ 

Using the “Integration” tab on the map, you can quickly get a sense of where midwifery is most integrated and where it is least integrated. There are four levels of integration on the map. You can also click on each state to get some more details or to see how integration relates to birth outcomes. For even more information they have created a “report card” for each state. The report cards include five components of midwifery integration for the CNM, CPM and CM credentials including whether that credential is licensed, covered by Medicaid, authorized to write prescriptions, has easy access to physician referral, and no restrictions on site of practice. 

Integration is “scored” on a scale of 1-100. Even the state with the best midwifery integration score (Washington) has room for improvement (they have a score of 61 out of 100). But even the lower scoring states (like North Carolina with 17 out of 100) are worth taking a closer look at to learn for example, that the percent of births attended by midwives there is higher than the national average (13.4% versus 10.3%) and higher than other states with more midwifery integration like Missouri which scores 39 out of 100 but where midwives attend only 4.4% of births. Seven states in the West and Northwest are in the highest category of integration, with five in the Northeast and one in the Midwest. But there are thirteen states in the second-highest range spread across the country. 

There is also a “Density” tab on the map, that illustrates where there are more and less midwives in the country which can be further distinguished by CNM/CM versus CPM. Right below that is the “Access to Place of Birth” tab that illustrates access based on the relative amount of community birth in each state, which can then be distinguished based on home or birth center, and CNM/CM and all other midwives. Together, the “Density” tab and the “Access to Place of Birth” tabs provide a view of where midwives are across the country.

There are twenty states that meet the two highest levels of midwife-density, but only four of those have the highest levels, Vermont, Oregon, Maine and Alaska. Of those, Vermont, Oregon and Maine have high rates of CPMs, while Alaska has higher CNM density. Of course, more midwives are needed everywhere. We don’t yet have demographic data about how many midwives are LGBTQI2S+ or how they are distributed throughout the country. There is also a tab that illustrates the percent of “Black Births” by state, but not the race of the midwives, and other racial categories are not mapped for percent of births of midwives. 

For information about the LGBTQI2S+ population State-by-State, the Williams Institute has done extensive demographic research and has a map which can be accessed at: https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT#density These are complex demographics to calculate, not to mention complex categories to define. Notably, the Williams Institute categorizes people demographically as “LGBT” whereas The Equality Maps uses “LGBTQ.”

Based on the Williams Institute data, 4.5% of the adult population in the United States is LGBT, 29% are raising children, and 25% have income of less than $24k per year (another myth the Williams Institute has tackled is that LGBT people are more affluent than their heterosexual counterparts: they are not). This data project includes the “LGBT People Rankings” where the percentage of LGBT people who are raising children are ranked for twenty states. The highest, is Idaho where 44% of LGBT people are raising children, followed by Utah, Oklahoma, Arkansas, Delaware and Mississippi. 

This information can be combined with the Equality Maps created by the Movement Advancement Project (MAP) which can be accessed at: http://www.lgbtmap.org/equality-maps 

Together, these three maps provide a view of how midwifery integration lines up with the policy climate for LGBTQ people and families. 

The Equality Maps indicate “policy tallies” of all the states. State scores are ranked in five gradations from “High” to “Negative.” The policy tally combines the Sexual Orientation Policy Tally and the Gender Identity Policy Tally. You can also look at the map based on the Sexual Orientation Policy Tally alone or on the Gender Identity Tally alone. Overall, 46% of LGBTQ people are living in states with “High” or “Medium” scores, and 45% of LGBTQ people are living in states with “Negative” or “Low” scores. 

The policy tallies come from MAP's tracking of dozens of LGBTQ-related laws. Those laws fall into seven categories: Relationship and Parental Recognition, Nondiscrimination, Religious Exemptions, LGBTQ Youth, Health Care, Criminal Justice, Identity Documents (it’s possible to look more deeply into each of these types of laws in their methodology information). The states aren’t ranked from highest to lowest like they are for the midwifery integration scores, but you can look at the data in a table instead of as a map. 

In the state profile you can see both tallies, plus the percentage of the state’s population that is LGBTQ and the percent of LGBTQ people in the state raising children. Population numbers are based on estimates created by demographic researchers so there is some interpretation involved (which explains why the percentages in this map vary a bit from the percentages in the Williams Institute maps referenced below). The numbers are not broken down by gender identity, sex,or race, and it’s not easy to determine how many of those raising children gave birth to those children.

By way of example, Washington is in the “medium” category overall (and “high” for Gender Identity) and 5.2% of the adult population is LGBTQ, with 29% of those folks raising children. North Carolina is in the “low” category overall (and “negative” for Gender Identity), and 4% of the adult population there is LGBTQ, with 26% of them raising children. Missouri is also in the “low” category overall, and have a lower percent of the adult population who identify as LGBTQ (3.8%), but even more of them are raising children (30%). 

One of the most interesting discoveries from the demographic data about LGBTQ people is how many LGBTQ families are in rural areas and areas with negative laws. For example, Kansas, which is near the bottom in terms of midwifery integration, and is also near the bottom in terms of equality tallies, nonetheless is a place where 40% of the LGBTQ population is raising children. This is something to consider for LGBTQ midwives or midwives especially interested in serving the LGBTQ population.

We analyzed midwifery integration scores, midwifery density, Equality Tallies, and LGBT population (both the percent of the overall population that is LGBT and the percent of the LGBT population raising children for the top 20 States). 

Three states stood out for their high scores (top twenty) in all five categories: Delaware, New Hampshire, and New Mexico. That means in these three states, midwifery integration is among the highest in the country, overall equality tallies are among the highest, the percentage of the population that is LGBT is among the highest, and the percentage of LGBT people raising children is among the highest.  

Five states were in the top twenty in four out of five of these categories: Hawaii, New York, Oregon, Vermont and Washington. In these states there are several things going for midwives and LGBT folks. Hawaii had a lower midwifery integration score that set it apart. The other four had a slightly smaller percentage of the LGBT population raising kids.

Seven states had three out of five scores in the top twenty: California, Colorado, Maine, Massachusetts, Rhode Island, Utah and Wisconsin. Utah and Wisconsin had lower Equality Tallies which set them apart in this group, but sizable proportions of the LGBT population raising kids and decent midwifery density. In contrast, Maine and Massachusetts didn’t make the top twenty in terms of percent of the LGBT population raising kids - but their rates were still high. Colorado wasn’t quite as strong in midwifery integration but had more midwifery density, while California lacked midwifery density but had a decent integration score (again, keeping in mind that 61 was a high score out of 100, so all top 20 states have room for improvement).

Seven states are worth looking twice at despite some problematic scores because they present an opportunity in some way: Arkansas, Idaho, Indiana, Maryland, Minnesota, Nebraska, Nevada. For example, Arkansas has a -.5 Equality Score, but 36% of the LGBT population there is raising kids, and the midwifery integration score is in the middle of the pack. Idaho, mentioned above, has the highest percent of the LGBT population raising kids, a high integration score, and a low equality tally, but one that is not “negative” (the lowest level).  

Six states have the unfortunate distinction of having high proportions of LGBT families, combined with “negative” Equality Tallies, and fair-to-good midwifery integration: Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, and Texas. These states might have something to offer midwives, but should also be scrutinized carefully for a realistic view of how dangerous the climate could be for LGBT people. 

As far as we know midwifery integration and LGBTQI2S+ equality have never been analyzed together, and there is room for more analysis across the board. From analyzing midwifery density by more detailed demographics (like the race and LGBTQI2S+ identity of midwives), to analyzing how the children who are being raised by LGBTQI2S+ folks were born, and the demographics of those families by race, and gender. Not to mention surveying the experiences of LGBTQI2S+ families during the perinatal period (check out Birth Includes Us).

Despite the relatively small numbers in the population of midwives and the populations of LGBTQI2S+ people, this is important work from an equity perspective. As efforts to increase the midwifery workforce continue, so do efforts to ensure that workforce is diverse and capable of meeting the needs of the community including people of color, LGBTQI2S+ people, and LGBTQI2S+ people of color.

This was originally written in February of 2020. Some data may have changed.

We Must Oppose Inhumane and Unjust Prosecutions of People in the Perinatal Period

This legislative session Elephant Circle, along with a coalition of organizations* worked to pass a law that would protect the perinatal period at all stages of the criminal legal process.

Here is a fact sheet about the bill, HB23-1187, and here it is on the Colorado Legislature website. Elephant Circle has been involved in advocating for incarcerated people who are pregnant or postpartum since 2010 when we helped pass a law to prohibit use of shackles on pregnant and laboring people. Since then we have had groups at Denver Women’s Correctional Facility for many years, and collected stories from people who experienced incarceration during the perinatal period (thanks to the storytellers and support from Colorado Equity Compass).

We have also tracked cases across the country of people being charged for crimes specifically related to the perinatal period and understand the unique vulnerability of people facing such circumstances, including an increased exposure to blame (see for example Blaming Mothers by Linda Fentiman, who testified in support of SB23-1187).

Unfortunately, the need for policy change and advocacy in this area has been confirmed by Arapahoe County, Colorado’s prosecution of two parents for the death of their one-day-old newborn. No, there is not any evidence to suggest they caused their newborn’s death, and we are calling on the District Attorney prosecuting this Colorado case to drop the charges.

When such a young baby dies an investigation is inevitable, and such investigations are ripe for all of the emotions, stigma, and bias surrounding pregnancy, birth, and early parenting. Someone will certainly be blamed; mothers and midwives are the most common. When this happens, often, normal and appropriate things that mothers and midwives do are recast as criminal.

For example, in one case we are familiar with a woman who had been using drugs and did not know she was pregnant, went to the hospital complaining of abdominal pain. Still not knowing she was pregnant, which had also not yet been diagnosed by hospital staff, she went to the bathroom (within the hospital) where she proceeded to give birth while sitting on the toilet.

The prosecution recast the fact that she was sitting on the toilet to birth the baby as evidence of this mother’s criminality, as if it suggested malice or indifference: it does not. In fact, birthing stools which have been used throughout history, look quite like toilets, because it is very supportive and appropriate shape to facilitate birth.

Compounding the problem of bias-prone investigation is the problem that people tend to think if someone is punished it must be for a reason, they must deserve it. This can further isolate and stigmatize the person who is being blamed, even when that blame is unearned. The criminal legal system should guard against such dynamics through due process, but in these highly charged cases the due process that exists is inadequate or set aside, overridden by emotion, bias and stigma that can lead prosecutors to cut corners and ignore or withhold exculpatory evidence.

Take for example this case from South Carolina, where a mother was charged with killing her newborn through breastmilk that contained high levels of morphine. Experts contend that it would be extremely unlikely, if not physiologically impossible to transmit enough morphine through breastmilk to harm a child (without an innate genetic condition that impacts metabolism).

But since the breastmilk was not tested for levels of morphine, and other modes of transmission of morphine were not investigated, critical information was simply unavailable. Similarly, in this recent Arapahoe County case, the formula was not tested, the prosecution delayed sharing the autopsy report which is supportive of the defense, and the prosecution is still withholding potentially exculpatory evidence (of the parents’ consistent negative drugs tests, among other things). This underscores the implicit bias at play; the assumption that someone is to blame shuts down inquiry and curiosity.

We need strong policies that guard against these weaknesses, and better protect due process and human rights. SB23-1187 aims to reinforce the value of protecting this unique timeframe for both the pregnant/postpartum person and the newborn. It aims to provide prosecutors, defense attorneys and judges with extra reason to consider and reconsider the facts in any criminal case involving someone who is pregnant or within one year of the end of a pregnancy, and be very reluctant to incarcerate during this time.

We are sad that the need for this policy was confirmed so soon after the law passed, but appreciate the motivation to push forward with this work and ensure that the law is enacted as intended.

• Supporting Organizations:

  Elephant Circle, Soul 2 Soul Sisters, ACLU of Colorado, Children’s Campaign, Colorado Center on Law and Policy, Colorado Consumer Health Initiative, Colorado Criminal Justice Reform Coalition, COLOR, Healthier Colorado, New Era Colorado, Office of Respondent Parents’ Counsel, Planned Parenthood of Rocky Mountain, ProgressNow, Reimagining Policing Taskforce, Together Colorado, Women’s Foundation of Colorado, Young Invincibles,

Payment and Equity for Birthworkers

Ricardo Levins Morales from an article in The Forge

It is widely understood that there is a crisis in perinatal care in the United States. (See Maternity Care in the United States: We Can - and Must - Do Better from Nat’l Partnership for Women and Families, for context).

It is not just that something isn’t working in the interactions between providers and patients (though that is part of the problem as indicated in measures like Giving Voice to Mothers study).

The structure of perinatal care is also part of the problem. For example, it is built in to the structure that most providers of perinatal care are physicians and most births in the U.S. occur in hospitals (see for example this video from Vox and ProPublica and this report from the Commonwealth Fund comparing the U.S. to ten comparable countries).

Fixing the problem requires changing the structure. One part of the structure is how the money flows. This is why it is so important whether, how, and how-much birthworkers are paid.

This is part of why the 2021 Birth Equity Bills included a requirement that both public and private insurance in Colorado reimburse providers in a manner that:

• promotes high-quality, cost-effective, and evidence-based care

• promotes high-value evidence-based payment models

• prevents risk in subsequent pregnancies

These requirements are now law in Colorado, see C.R.S § 10-16-104 and § 25.5-4-425, and are aimed at addressing both the lack of evidence-basis for much of what happens in perinatal care, and the existence of strong data supporting integration of midwives and doulas. See, for example, Maternity Care in the United States: We Can - and Must - Do Better from Nat’l Partnership for Women and Families and Expanding the Perinatal Workforce through Medicaid Coverage of Doula and Midwifery Services, from the National Academy for State Health Policy..

Despite these laws, inequities continue and more work needs to be done to realize these goals.

This report describes the context for nonclinical birthworkers, also known as doulas, in Colorado, focusing on nonclinical birthworkers of color.

These Fact Sheets are also useful for understanding what is happening in Colorado:

• Elephant Circle’s Statement on the Governor’s Budget Request for Reimbursement of Doulas

• Barriers to Reimbursement for CPMs and Freestanding Birth Centers in Colorado

But the problem isn’t just about the healthcare system, it is also about a system-wide failure to value, plan for, and invest in care-work (see this interview with the Culture Change Directors at Caring Across Generations and the National Domestic Workers Alliance, see also “Care Can’t Wait,” about creating a comprehensive care infrastructure).

We lack the infrastructure to support the care humans need, including in the perinatal period. Birthworkers are part of the solution because of how care is woven into the work. But if the system they work in doesn’t value care then their existence in the system won’t ensure care matters (and they may feel uncared-for as well).

We want to help transform the system to one that values care and invests in it like the infrastructure that it is.

---

For additional context:

Paying nonclinical birthworkers as part of the healthcare system isn’t simple since the way payments work in the system isn’t simple. To get a sense of the complexity of payment in the U.S. healthcare system, these two charts illustrate how the money flows. This is also how it flows in the perinatal care system.

From Economix Blogs at the New York Times

From the Commonwealth Fund

Part of the reason birthworkers, like doulas, are helpful is because this system is not good at ease, continuity, or flow for the patient - it’s organized around other interests as illustrated in these graphics - so having someone help navigate that chaos can be helpful to the patient.

Some other nonclinical providers that have been used in this way is Community Health Workers. (See this article to get a sense of how community health workers are utilized and considered in the system, and this article about sustainable financing for them). The following graphic from the article is illustrative.

From the article linked above.

Effectively Partnering with Communities in Research to Improve Maternal Health Outcomes

“Effectively Partnering with Communities in Research to Improve Maternal Health Outcomes and Reduce Disparities: Using Research to Create Community-Centered Policy” held on March 10, 2022. Hosted by Maternal Health Coordinating Committee (MHCC) of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

the 508-compliant webinar recording is now available for public viewing at https://www.youtube.com/watch?v=en47IZa_fOA

Child Abuse Prevention and Treatment Act Webinar

Elephant Circle participated in the creation and presentation of this webinar about the Child Abuse Prevention and Treatment Act and the Comprehensive Addiction Recovery Act for the New York State Department of Health. Much of the information presented is relevant for a wider audience, including anyone who is a "mandatory reporter" under state law. The presentation contextualizes the family regulation system and its impact on families including people who use drugs during pregnancy. Click on this link to register to access the recording.

Birth Equity Laws - Implementation!

As discussed in the Birth Equity Bill Package blog post, our ambitious set of legislation has been signed into law. And with it - lots of implementation work begins.

To facilitate that work we have been hosting various community meetings. Check out our Events Page for the latest meetings you can join! Consider reading the above blog post to get a sense of what the bill process was like and what was in the bills.

And we know this is just the beginning, if you have additional ideas for policy solutions, please share them here: bit.ly/birthequityideas

We also have recordings of these introductory meetings to help people get oriented to participation.

September 28, Support for Incarcerated Parents Work Group

September 30, Payment Work Group, access code: DoBE2021!

October 1, Implementation Steering Committee, access code: DoBE2021!

November 2, Civil Rights Work Group, access code DoBE2021!

November 4, Provider and Facility Work Group, access code DoBE2021!

You can also learn about some foundations of our work in this places:

• Introduction to Design Thinking

• Read our Policy Platform, which Includes a link to our Blueprint for Birth Justice

• And this interview with people involved in the bill process provides a glimpse of how we work.

Sex is Not Binary

We are so often faced with misinformation about sex, namely that it is binary, that we are posting here some of our favorite resources on that topic.

This is a RadioLab episode called Gonads: X&Y which is about how sex is more than chromosomes and much more complex that XX or XY.

This is a Scientific American articled called Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic, and the title certainly sums it up well. For a more technical approach consider this Nature article, Genetic Mechanisms of Sex Determination.

This video from Human Rights Watch and InterAct illustrates the conditions intersex people and the parents who advocate for them experience in terms of pressure to conform, even via surgery, to binary notions of sex.

Here is National Geographic’s Gender Revolution Issue - some of it is behind a paywall, but the Discussion guide is not.

We also recommend The Gender Wheel by Maya Gonzalez and her children’s book by that name.

All of these only scratch the surface, there are a lot of great materials out there for those willing to explore.

For those concerned that there is a “trans agenda” or that women are being erased and have to be defended by undermining transgender and intersex people, well… It is not clear that there is anything we could say. But - you might be interested in the connections between anti-trans feminism and the Christian right which is described in this article, A Room Of Their Own: How Anti-Trans Feminists Are Complicit in Christian Right Anti-Trans Advocacy.

Tactics for Transformation in Birth Justice

What is a tactic?

A tactic is “an action or strategy carefully planned to achieve a specific end.” (Websters) The most important thing to know about tactics is that there are many. People often have a go-to tactic that they always think of when confronting obstacles or trying to persuade targets. It’s fine to have favorite tactics, but it is unnecessarily limiting to only use one or two.

The whole point of being tactical is tailoring your approach to a specific goal. Not every situation calls for the same tactic. As you strive to increase your effectiveness you will want to increase your set of tactics. At Elephant Circle we value being multidisciplinary because it means we have more tactics to choose from which can help us choose more effective and efficient tactics. We often use tactics from the fields of education, art, science, the law, and community organizing.

A diversity of tactics is needed because each situation is different, and all tactics might not be available for or effective with each target. For example, many of the harms people experience during birth, from force or coercion to lack of access to midwives, are not easily remedied through traditional means of complaint/resolution or lawsuit/judgment so we have to get creative to effectively confront these things.

What is a target?

The book Politics the Wellstone Way: How to Elect Progressive Candidates and Win on Issues describes a primary target as “the individuals or groups that actually make a decision about your issue.” And secondary targets are “the individuals are groups that influence the primary targets.” Regardless of the issue at hand it is worth thinking in strategic terms about who is responsible for what, and who holds the levers of power. It doesn’t have to be a legislative or governmental issue to warrant strategy. For example, even racism, which is ubiquitous, can be strategically addressed. Tools like the the lens of systemic oppression provide a way of thinking strategically about problems like racism (and the tool works for other forms of oppression as well).

Once you know the targets you can map their relationships to identify opportunities for influence and change. The process called power-mapping can be a liberating and empowering way to identify and strategize around power dynamics. Check out this great little video on power mapping by former Colorado State Senator, Jessie Ulibarri.

Calling out and calling in

Calling out and calling in are tactics suited to different targets depending on the overall goal. Much has been written about calling out versus calling in. We strongly recommend diving into the great writing on that subject, it’s Googleable and a quick search pulls up several articles including this one by Birth Rights Bar Association Board Member Jenn Mahan. This feature explores Loretta Ross’ efforts to redirect calling out (which can be an overused tactic lacking in strategic value) to calling in (which has movement building and transformational utility).

We are also inspired by the work of survivors who have developed transformative justice strategies that respond to harm and violence without relying on policing, punishment, or incarceration. Policing, punishment and incarceration have negative effects that ripple through society and often negatively impact the same communities we are trying to protect. For more about this, we recommend the book Beyond Survival: Strategies and Stories from the Transformative Justice Movement. And we are delighted that one of Elephant Circle’s early collaborators, Elisabeth Long, has an essay published in it! We also recommend this series of videos:

·      What Does Justice Look Like for Survivors?

·      What is Transformative Justice?

·      How to Support Harm Doers in Being Accountable?

Collectively these resources illustrate a range of tactics beyond calling out that can be used in a range of scenarios and on a range of targets.

Tactics for Transformation in Birth Justice

Strategy and creativity are needed to bring about transformation and pave the way for birth justice. Birth justice can be overwhelming because there is not just one target, and since racism is everywhere it can seem like anyone and everyone is a potential threat/target at all times. Thinking through tactics and targets is an important step because there are people and organizations with more and less power, and those positions can be revealed and even mapped.

Being strategic about power dynamics is critical to transformation. If you remove a threat without transforming it, another threat will simply fill the void created by removal of the first, like whack-a-mole.

At Elephant Circle we envision a world where every pregnant person has a circle of support and protection during the entire perinatal period. Barriers to that vision are our foes. But – every foe is not an equal target. Someone’s abusive family member might be a big barrier to their circle of support, but as a matter of strategy, we do not aim to eliminate every abusive family member. Instead, we set our sights on people and organizations that have levers to power that influence many more pregnant people at once.

People often aim their firepower at lower-level targets with limited influence, often because those targets are more obvious or accessible (and because of how the human mind perceives threats). Sometimes people aim their firepower at targets who are even on their side. The graphic below illustrates this. The target in red is a target with little power, who leans toward supporting our goals. The target in green has more power and leans toward opposing our goals.

It is possible that both the red and the green target need to be addressed in some way – but probably not with the same tactic. For targets who are near our same level of power, or below, and who are in the supportive portion of the map, we prefer tactics like calling-in. Tactics that preserve and strengthen relationships and create pathways for increased understanding. The following graphic illustrates the range of targets suited to calling-in when you are at the yellow star level on the map.

Other targets on the map may warrant other tactics; tactics individualized for the target and the goal. For example, even the green target may not be suited to a tactic of elimination (punishment, removal), but might be more suited to persuasion that moves them over onto the support side of the map. As the transformative justice movement illustrates, even harm-doers can be called-in, instead of being punished, policed or incarcerated.

Another part of the analysis is to consider: what tactics are generally effective on this type of target? Are there available pathways of redress for this harm? For some harms, the are no effective pathways for redress. Civil disobedience is a good example of a tactic designed for a situation where there are no effective pathways for redress of harms. Often using such a tactic is a strategy in pursuit of more formal pathways of redress, like how the sit-ins eventually led to the Civil Rights Act.

In some scenarios, multiple different tactics are used on the same target successively in increasing intensity, or simultaneously by different strategists. For this approach it is important to think about the whole ecology, what other strategists are out there, and how can your actions compliment, amplify or support theirs. Also, how and with what intensity do your tactics need to be used for the best effect?

Again, when it comes to birth justice, creativity is often required because there are no good formal mechanisms for redress of harms. But not every situation is the same. One of the most common disputes among people, well-developed in our legal system, is the dispute over contracts and money: who paid what to whom and what number was agreed to? For this type of harm there are well-worn pathways that many people can use, even people without a lot of money or time. Consider using a well-worn pathway when it is available and generally effective, like small claims court instead of social-media shaming.

This graphic from the Birth Rights publication illustrates a range of tactics or ways to say that “what happened to me was not okay.” In the narrative of this section the pros and cons of each tactic is discussed. We recommend doing a pro-con analysis before implementing your tactics (and of course we recommend reading the Birth Rights resource available here in English and Spanish).

Because each situation is different, and each person or group will have different values and priorities, having a diversity of tactics to choose from is helpful. No matter how many tactics you know about or use, there are always new things to learn. To expand your thinking about practices that constitute tactics, we also recommend adreienne maree brown’s books Emergent Strategy and Pleasure Activism.

Like brown, we also think of it ecologically: what kind of environment do our tactics create for all the beings and ideas we want to protect and see thrive? A slash-and-burn tactic might be effective in the short term, but could have undesirable long term effects (as illustrated so many times throughout history). As a result we practice being thoughtful, considerate and strategic about both targets and tactics, in order to maximize the possibility for transformation and minimize the possibility of creating power vacuums that will be filled by more of the status quo.

Lack of Information is a Weapon of Oppression

If you are in a position to influence or block policy solutions and do not have the information you need, cede your power to someone who does. Unfortunately, this essay arises from our experience with professionals who have insisted that they cannot support a particular policy solution, or even need to block policy change, due to a lack of information. This is unacceptable. It is especially unacceptable when the policy solutions are being advanced by people who are directly impacted. There will always be someone whose life experience required them to find, understand, process and take a stand based on the available information, and those life experiences make them well-suited to policy change. Those life experiences are information that can and should be translated into policy solutions.

Lacking information is unacceptable since there is plenty of information freely and widely available.[i] From time to time a specific data point may be lacking. But in these situations it is not just possible, but responsible and necessary, to make sense of missing data. Missing data is information, and information about which policy decisions can be made.

When it comes to maternal health[ii] policy, “lack of information” is additionally unacceptable because the information is there and the time for action is now. Whole generations of professionals encountering this “lack of information” in maternal health have dedicated their lives to both gathering information and making sense of missing data. Those dedicated researchers took the “lack of information” claim as an earnest assessment, and not “delay and denial” on the part of policymakers willfully blocking needed change to the status quo. But it is worth examining “lack of information” as both earnest, and as a pattern of delay or denial that has dire maternal health consequences.

"When researchers have analyzed maternal deaths and near-deaths to understand what went wrong, one element they have noted time and again is what some experts have dubbed “delay and denial” — the failure of doctors and nurses to recognize a woman’s distress signals and other worrisome symptoms, both during childbirth and the often risky period that follows."[iii] Though more removed from the clinical setting, delay and denial happens in policymaking too, and the consequences are just as dire. Lacking information is part of a dangerous pattern in perinatal health care.

Providers fail to listen to their patients, people who have critical information, and this leads to poor care. This was put starkly by Susan Goodhue when she told USA Today, “The staff, by not knowing, and not listening and not taking precautions, almost killed us.”[iv] Indeed, not listening guarantees a lack of information. It is worse for Black, Indigenous and other women of color, as Pat Loftman aptly described to ProPublica, “If you are a poor black woman, you don’t have access to quality OBGYN care, and if you are a wealthy black wom[a]n, like Serena Williams, you get providers who don’t listen to you when you say you can’t breathe,”[v] referring to Serena Williams’ high profile experience with providers who initially ignored her when she told them she was having a pulmonary embolism after giving birth.

As midwife Demetra Seriki points out in this 9News Interview, "Being heard is a life-saving conversation that every Black person needs to have with their provider. And if they’re not getting it with this provider they need to get it somewhere else."[vi] The same is true when it comes to policymaking, we can no longer countenance providers who fail to listen and then stand in the way of necessary change. The stakes are too high.

Whether it be the voice of patients, or experts, researchers, and advocates too much critical information is being dismissed by people in a position to save lives. “Failure to listen to Black women” is such a common problem across industries that it is Googleable, and it is unconscionable every time. Lacking information about maternal health, in this day and age, means you have either failed to make gathering information a priority, or you have dismissed certain information as illegitimate. The egregious inequities in perinatal outcomes by race alone should give you pause and make you look closely at how and to what extent you are contributing to those inequities; how and to what extent you are missing distress signals, how and to what extent your lack of information is part of the problem.

Lack of information has been a persistent excuse for obstetric racism both at the individual and structural levels from the beginning; it was designed that way. Individual distress signals are deligitimized among providers, and expert, researcher, and advocate distress signals are deligitimized among policymakers. Many, many people had information about obstetric racism before the information was prioritized or legitimized.[vii] This antipathy to information in maternal health has costs and must be urgently addressed. 

The antidote is simple: make it a priority to gather information and listen more. Interrogate whether your lack of information is actually a failure to receive the available information; listening can be impeded by bias. It is part of the structure of white supremacy and other systems to categorize the voices of people of color, women, the queer, disabled, incarcerated etc, as illegitimate or not information. There is a long history of denying the information that Black and Indigenous people have (and need), denying the information that communities of color have (and need), denying the information that all kinds of marginalized people have (and need). “Lack of information” from people in power, when there is a cacophony of information being delegitimized, is a weapon of oppression.

Of course, it’s possible that when people say they lack information what they actually mean is that processing the information requires them to take a stand; perhaps a stand against white supremacy or some other powerful system. This too should give us pause. At whose expense and for whose benefit can you afford not to take a stand? At whose expense and for whose benefit can you afford not to listen? This is a good question in general and particularly acute when it comes to maternal health.

It is irresponsible to be in a policymaking position without the capacity to process information and the courage to take a stand. People who have been marginalized figure out how to process information and take the associated risks because they must as a matter of survival. Cede your power to them. Whether it is a lack of prioritization, a lack of legitimization, or a lack of willingness to take a stand, there is no excuse for showing up to influence policy without information. Come to the table ready or cede your power to those who are.

[i] Though there are other places to start, consider the 1925 White House Conference on Child Health and Protection that determined “untrained midwives approach, and trained midwives surpass, the record of physicians in normal deliveries.” See Judith Pence Rooks, Midwifery and Childbirth in America (Temple University Press 1997).

[ii] Using the term “maternal health” here, though the people who need health care for pregnancy and birth are not just moms, because there is a field of inquiry referred to in this way where there is a bounty of information.

[iii] Katherine Ellison and Nina Martin, "Severe Complications for Women During Childbirth Are Skyrocketing — and Could Often Be Prevented," ProPublica, December 22, 2017.

[iv] Alison Young and Alison Young, "Hospitals know how to protect mothers. They just aren’t doing it." USA Today, Jul. 26, 2018. See also this video: https://twitter.com/USATODAY/status/1022535120237080581  

[v] Annie Waldman, "New York City Launches Initiative to Eliminate Racial Disparities in Maternal Death," ProPublica, July 30, 2018. Available at: https://www.propublica.org/article/new-york-city-launches-initiative-to-eliminate-racial-disparities-in-maternal-death And speaking of not breathing, see also Rachel Hardeman, et. al., "Stolen Breaths," N. Engl. J. Med. July 16, 2020. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2021072

[vi] 9News.com, February 25, 2021. Available at: https://9news.com/embeds/video/73-33122767-fea2-44b7-a0aa-2ae9b40fd925/iframe?jwsource=cl

[vii] Not just in recent history, but for decades and decades and even hundreds of years. Every person whose reproduction has been politicized, through slavery or colonization just to name two broad examples, has information about inequities in health outcomes. The problem is not a lack of information but a characterization of some information as not information. There are so many citations for this, but to reinforce the point check out this Executive Summary from 2015.

Birth Equity Bill Package

We did it!! Our Birth Equity Bills passed!!

To protect human rights and address discrimination, mistreatment, harm, poor outcomes, and inequities in outcomes during the perinatal period -- Colorado passed three bills in the 2021 session.

1)    Protection of Pregnant People in the Perinatal Period, SB 193 established basic human rights standards in perinatal care for all people, including those who are incarcerated.

2)    Maternal Health Providers, SB 194 aligned perinatal care data and systems for equity.

3)    Sunset Direct Entry Midwives, SB 101 continued the Direct-Entry Midwifery program.

Here is the summary of the final version of the bills as signed into law on July 6, 2021.

Here are the bills on the Colorado Legislature’s website: SB21-193 and SB21-194.

Experienced mistreatment in the perinatal period? Fill out this form, one of the new requirements of SB 193.

Here is a 45 minute video of a panel including with Representative Leslie Herod, Indra Lusero, Kayla Frawley, Demetra Seriki and Briana Simmons talking about the process (and made by Promise Venture Studios). And here is a shorter version of the video (12 minutes).

These bills are a part of our birth equity policy platform, which also includes the Direct-Entry Midwifery Sunset bill (we are keeping this page updated with info on the DEM bill). This is a community-based effort. Learn more about what that means in our “What is Community-Based” fact sheet, below.

ENDORSE the Birth Equity Bill Package as an individual or organization here, YOU can identify if you want to advocate, testify, share our social media tool kit once the bill is introduced on this form here. Our collection of logos from endorsing organizations is below.

ENGAGE NOW: you can write your law makers and committee members to vote yes on the bill! Using this template.

Fact Sheets:

Bill Package Overview

Human Rights

Protección del periodo perinatal los derechos humanos son un resultado de la salud

Data, Systems and Equity

Cómo abordar las inequidades estructurales de la atención perinatal, Alineación de los datos y sistemas en favor de la equidad

Birth Equity Bills Content By Section

Birth Equity Bills Standards for Incarcerating Pregnant People

Answers to questions that came up in the Senate Hearing for SB21-194 on 4/14/2021

The Momnibus and Colorado’s Birth Equity Bill Package Side by Side

El Momnibus federal y la equidad de los nacimientos en Colorado

What is Community-Based?

¿Qué significa “basado en la comunidad”? 

Colorado as a part of National Efforts

This Colorado bill is part of a national effort to address inequity in maternal health through legislation like the Momnibus. And also aligns with this February 2021 publication, Diverse Colorado Voices: Community-Based Solutions for the Perinatal Period by Kayla Frawley, Holley Murphy, Lynn Vanderwielen. Sponsored by Clayton Early Learning, Families Forward Resource Center, and Raise Colorado, Caring for Colorado, Colorado Children’s Campaign, and Zero To Three.

Media about the Colorado Birth Equity Bill Package:

Colorado passes sweeping birth equity reform protecting the rights of pregnant people, Ms. Mayhem, August 27, 2021.

To end America's maternal mortality crisis, dismantle the racism that fuels it, CNN, July 14, 2021.

Elephants partly inspired these new Colorado laws, which aim to improve health care for pregnant people, Colorado Newsline, July 7, 2021.

Colorado Passes Landmark Birth Equity Bill Package, Harvard Law Bill of Health, June 22, 2021

Op-Ed: Meet the Leaders Behind Colorado’s Birth Equity Bill Package, Westword, June 12, 2021

Abortion Opponents Are Trying to Kill a Bill to Improve Maternal Health Care, Colorado Times Recorder, May 26, 2021

Colorado bill aims to protect incarcerated pregnant women’s rights, Denver Post, May 18, 2021

Colorado’s birth equity package aims to improve maternal mortality rates, Ms. Mayhem, May 7, 2021

Colorado bill aims to improve maternal health care, Associated Press, April 19th, 2021

Sen. Buckner: It’s time to pass legislation to improve maternal health outcomes in Colorado, April 18th, 2021

Colorado Birth Equity Bills Could Bring Better Maternity Care, Kayla Frawley, Westword, April 18th, 2021

Colorado bill aims to improve maternal health care, Associated Press & Durango Herald, April 14, 2021

New Bill Aims to Address Racial Inequities in Maternal and Infant Outcomes, Jordan Smith, Illuminate Blog, April 14th, 2021

Pregnant people of color face inequities, Dr. Jamila Perritt, Colorado Politics, April 12th, 2021

Approve Birth Equity Bills, Aubre Tompkins, CNM, Denver Post, April 11th, 2021

Outsources – Birth Justice with Indra Lusero: Learning histories and visioning for the future, Indra Lusero, March 29th, 2021

Why Colorado Needs to Pass the Birth Equity Bill Package, Kayla Frawley, Colorado Newsline, March 8th, 2021

Rep. Leslie Herod: Colorado to see maternal health legislation during the 2021 session, Colorado Sun, February 11th, 2021

Colorado Needs a Human Rights Approach to Maternity Care, Kayla Frawley in Colorado Newsline, February 11th, 2021

Other timely, related media:

Leading maternal health experts advocate for Medicaid extension to 12 months postpartum in Scientific American here.

The U.S. Maternity Care Consent Problem, Ms. Magazine, February 2021

Op-Ed about the death of Elijah McClain by Bill Sponsor Senator Janet Buckner and Senator Rhonda Fields, March 2021

9News feature of Colorado midwife Demetra Seriki, and this profile of her by the Colorado Trust

New York Times, March 11, 2021, Why Black Women Are Rejecting Hospitals in Search of Better Births

Slate, March 9, 2021, I’m an Obstetrician. Stop Stigmatizing Home Births.

Elephant Circle articulated some of the elements of the Birth Equity Bill along with other maternity care experts in a response to CMS Office of Minority Health request for information about improving rural maternal and infant health care here.

Why Is It So Risky to be a Black Mother, Colorado Trust

Related Events:

A recording can be found here of the first hearing for 194 on Wednesday, April 14th at 1:30pm Mountain (in the Senate Health Committee). SB 194 starts at 1:35:40

A recording can be found here for the first hearing for 193 on Thursday, April 22nd at 1:30pm Mountain (in the Senate Judiciary Committee). SB 193 starts at 2:11:30.

BIRTH Equity Lobby Day! Meet with your legislators and hear about how a bill becomes a law. March 31st, Register here.

Community Meeting February 27, 2021, recording and pdf of slides about the bills in detail, and pdf of slides about the criminal justice sections.

Check out our events page for more.

Direct Entry Midwives Sunset 2021

We will be posting updates and fact sheets here about SB21-101 so folks who are interested can access, advocate and be informed!

Here is our proposed amendment to change the legislative references from register to license.

Fact Sheets:

Licensed versus Registered

Professions Licensed in Colorado

DEMs in Colorado

2000 DORA report for DEM Sunset - just the pages about licensed v. registered

Certified Professional Midwife Education

Report to DORA - 2020:

Full Report to DORA from Elephant Circle, March 2020

Other:

EC letter in response to the CMA

Colorado Department of Regulatory Agencies, Report and Recommendations of the Direct-Entry Midwife Risk Management Working Group: Pursuant to §12-37-109(3)(b)(I), C.R.S., October 1, 2016. Plus our fact sheet on Colorado numbers and liability in general from 2016, and our fact sheet for the working group in 2016.

NACPM’s Support Letter

AABC’s letter of support

Letter of support from Families Forward Resource Center

Letter of support from a local midwife

Letter from Southern Cross Insurance

Support Letter from Dr. Seefeldt

Webinars:

Here are slides from the webinar with the Colorado Midwives Association on March 19, 2021: CMA slides on licensure, EC slides on Malpractice. And here is the recording.

History of Midwifery Laws in Colorado

The latest bill in Colorado’s midwifery history was introduced last week, and the dynamics were much as they have been for 100 years - since doctors began the campaign to eliminate midwifery. Here’s a great video on the “culture war between doctors and midwives,” though I think that is a generous way of putting it. I also recommend, Judith Pence Rooks, Midwifery and Childbirth in America, (Temple University Press 1997) and Judy Barrett Litoff, The American Midwife Debate: A Sourcebook on its Modern Origins, 5-7 Greenwood Press (1986).

Here is a short video I made about the history of midwifery laws in Colorado specifically. This blog post provides the details behind that video. In Colorado, the campaign to eliminate midwifery didn’t seem to culminate until 1941 when Senate Bill 640 proposed a revision to the Medical Practice Act that would end midwifery licenses with the goal of eliminating midwifery completely. Patricia G. Tjaden, “Midwifery in Colorado: A Case Study of the Politics of Professionalization,” 10 Qualitative Sociology, 33 (1987). The law was passed with a grandmothering provision that allowed already licensed midwives to practice but no new midwives to take their place.

In the 1940s most births were taking place at home, but by 1955 ninety-nine percent were in the hospital. Marian McDorman et. al., Trends and Characteristics of Home and Other Out-of-Hospital Births in the United States, 1990-2006, 58 National Vital Statistics Report 11 (2010).

In 1976 the Colorado legislature erased the history of midwifery from the Medical Practice Act, deleting the section on midwifery licensure and all references to it. H.B. 1032, 50th Gen. Assemb.. 2nd Sess. (Co. 1976). But midwifery had not disappeared in Colorado, it just moved underground, and along with it, homebirth.

My brother was born at home in Longmont, Colorado, 1977; his birth is one of my earliest memories and 1977 is the same year that Certified Nurse Midwives were licensed here. H.B. 1526, 51st Gen. Assemb, Reg. Sess. (Co 1977) . That law amended the Medical Practice Act and created a licensing scheme for advance practice nurses trained in midwifery, under the Board of Nursing.

In 1982, the same year my youngest sister was born at home in Boulder County, Karen Cheney a Boulder County midwife and founding member of the Colorado Midwives Association, was charged with the crime of practicing medicine without a license.

In response, House Bill 1528 “Concerning Midwifery,” carried by a state representative from Boulder was introduced in 1983. The bill proposed an Advisory Board under the Colorado Department of Health to regulate midwifery, defined midwifery as not the the practice of medicine, and included a provision stating that parents have the right to decide how they give birth. H.B. 1528, 57th Gen. Assemb, Reg. Sess. (Co 1983). The House Health, Environment, Welfare and Institutions Committee held a hearing on March 23, 1983 that 150 people attended. Medical professionals including nurses, doctors and nurse midwives spoke in opposition to the bill, as they do.

The next attempt in 1984 included a requirement of moral turpitude, to keep those "unsavory" midwives away. But as Patricia Tjaden reports, after a seven hour debate in the House State Affairs Committee on January 16, 1984 the bill failed, much to the shock of the representative who carried it and even failed to win the support of members of her own party on the committee. The bill in 1985 was different in that it proposed licensure and educational requirements under the Board of Nursing, but that bill was also defeated.

In 1990 two other midwives who were criminally charged. Jean Rosburg and Barbara Parker, appealed their cases to the Supreme Court. People v. Rosburg, 805 P.2d 432 (1991). It wasn't a particularly well reasoned decision, problematically conflating abortion and childbirth among other things, but it follows other poorly reasoned decisions of the day like the California case Bowland v. Municipal Court, 556 P.2d 1081 (1976).

In the two years following People v. Rosburg two bills were considered by the House one another licensure program and the other a “registry.” The Colorado Department of Regulatory Agencies released their first report on direct entry midwives following a request to be regulated by the Colorado Midwives Association. Colorado Department of Regulatory Agencies, "Sunrise Review of Direct Entry Midwives" June, 1992. The report defined midwifery, summarized contemporary perspectives on it and maternity care in general (with particular attention to rural maternity care), surveyed other state midwifery laws, provided a short history of previous requests for regulation, analyzed the proposed regulation and identified problems. The report recommended that the state “not sanction the practice of direct entry midwifery in Colorado.”

The 1992 bill “Concerning the Practice of Midwifery” was hotly contested but got further than any before. It passed the house but died in the Senate. The bill initially sought to exclude the “unlicensed” practice of midwifery from the medical practice act (decriminalizing what midwives had been prosecuted for) and requiring midwives to register (or face criminal penalties), and disclose their professional information and affiliations to consumers. H.B. 1010, 58th Gen Assemb., 2nd Sess. (Co. 1992).

In 1993 the bill that would finally legalize midwifery again in Colorado was introduced. House Bill 1051 was introduced in much the same form that it had after the House amended it in 1992 but with even more provisions that would isolate and minimize the practice of midwifery, while framing it within a medical risk model and attaching heightened punishments. H.B. 1051, 59th Gen. Assemb., Reg. Sess. (Co. 1993). The bill was amended extensively in the House and Senate but passed on May 12, 1993.

Looking at the language of the bill that finally passed, and comparing it to the 1992 version and other laws, it becomes clear that the struggle was over professional turf and liability more than the health and welfare of women and families. Just as the boundaries of maternity care over the last century has been about professional turf and liability more than the health and welfare of women and families. For example, the bill amended an article of the law regulating insurance in Colorado to state, “no medical malpractice insurer shall be required to provide liability coverage for unlicensed midwives who are registered and providing services. . . nor shall any medical malpractice insurer be required to include in any rate setting or classification both licensed physicians or certified nurse midwives and unlicensed midwives.”

An amendment to the Health Care Availability Act in H.B. 1051 made sure that the term “health care professional” excluded “a registrant conducting unlicensed midwifery.” This essentially meant that midwives, who make far less per birth than doctors, have a much lower annual salary, and no professional liability insurance, would be penalized. Where doctors could enjoy a million dollar cap on damages in the case of a baby born with brain damage for example, midwives could not.

The law goes on to say that “nothing in this article shall be construed to indicate or imply that a registrant. . . is a licensed health care provider for the purposes of reimbursement by any health insurer, third party payer, or governmental health care program.” So that not only would midwives be excluded from the professional liability framework, but consumers would be excluded from health insurance reimbursement. Colo. Rev. Stat. §12-37-109(2) (2010). Many of these egregious efforts to isolate and exclude midwifery have since been eliminated from the law thanks to community organizing efforts. But many other vestiges of this fraught history remain.

In the end, the midwives who had been organizing for over a decade won the basic protections they were seeking. In the process, not only did some of the ideals initially sought go by the wayside, but the social and political conflict that had been brewing for most of the century was written into the law. Susan Erikson, a medical anthropologist and Amy Colo, a Colorado midwife describe what happened with legalization: midwifery was “forced to appear to be something much less than it is in order to be palatable to the legislators.” Susan Erikson with Amy Colo, Risks, Costs, and Effects of Homebirth Midwifery Legislation in Colorado, Mainstreaming Midwives: The Politics of Change, 298 (Robbie Davis Floyd, Christine Barber Johnson Eds., Routledge 2006).

This has remained true throughout the history of the “Direct-Entry Midwifery Practice Act” and remains true today. Changing perspectives about midwifery in general and this law specifically are reflected in the Colorado Department of Regulatory Agencies Sunset Reviews from 1995, 2000, 2010, 2015 and 2020. They all underscore the fact that not much has changed and that we have a long way to go still to truly integrate midwifery and make the most of what midwifery has to offer the health and wellbeing of families.

Elephant Circle is part of Safer Childbirth Cities

Published by Black Women’s Blueprint on January 27, 2021 via newsletter:

In lock step with community, we are committed to the sovereignty, dignity, and safety of childbirth in Brooklyn.

Collectively, this moment not only calls each of us to radically reimagine our approaches, but to creatively strategize, to be wise, to move with our grandmother’s hands, to respond with intuition and care, and offer deep listening and observation – to advocate for all stakeholders to provide the respectful, culturally safe, and compassionate care that all laboring people need and deserve.

We are excited to announce receiving generous support through the Safer Childbirth Cities Initiative at Merck for Mothers. Over the next three years, with the collective knowledge and intelligence inherent to all communities, we plan to turn the tide on maternal mortality, morbidity, unsafe and disrespectful childbirth in Brooklyn through a “Designing for Equity” process led by community and facilitated by a multidisciplinary coalition between Black Women’s Blueprint, Ancient Song Doula Services, Elephant Circle, Cityblock Health, Primary Maternity Care, and New York University. This process will propose and pilot a new model of primary maternity service delivery specifically designed to advance equity and improve outcomes in Brooklyn, New York centering community.

Black, Indigenous, and People of Color (BIPOC) are most acutely impacted by maternal mortality and morbidity crisis - as they carry the unjust burden of racism, injustice and oppression. We believe that New York City needs to transform how we address these disparities - with an approach that is community-led, rooted in building an integrated and sustainable anti-violence, trauma-informed approach to maternity care. For the next three years to 300 years, for the next generation and beyond, we intend to both dream and give birth to a model that serves and uplifts all families, especially those least served by the dominant model.

Through coalition-building, this strategic design process prioritizes safety in pregnancy, birth, and the postpartum period; uplifting the rights of women and girls; ensuring bodily autonomy, and securing access to high-quality primary maternity care in communities most impacted by the overlapping maternal health crisis and COVID pandemic. In our continued and collaborative work, the organization, delivery and overall experience will center community values and voices, with Brooklyn families leading the way to reenvision what comprehensive, community generative care looks like for them.

We ground our work in principles of transparency, community, consensus and accountability. As our work begins and continues to evolve- we invite interested community members, providers, leaders, policy makers, parents, students, creators and imagineers to follow along, engage, and join us in building the world we want to give birth in. Connect with this initiative at info@blueprintny.org.

Safer Childbirth Cities was launched in 2018 by Merck for Mothers, Merck’s global initiative to help create a world where no woman has to die while giving life. The multi-year effort aims to foster community-led solutions that will help cities become safer, more equitable places to give birth. The second cohort is building on an inaugural cohort of ten community-based organizations working in coalition with unique collaborators to improve maternal health in their cities based on locally-identified needs and advance evidence-informed interventions to increase maternal health equity.

www.blackwomensblueprint.org

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. 

Blueprint for Birth Justice

We created this blueprint based on years of listening to community about needs, barriers, and opportunities.

You can access the pdf here.