Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


Unregulate me?

This post was conceived with the help of The Big Push for Midwives, which also helped out with its delivery.

 Click the images to open a larger version in a new window.
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Private Membership Associations

Earlier this year, news articles reported on criminal actions against community (out-of-hospital) midwives in Indiana and Nebraska following infant deaths. More recently, the work of one midwife in Minnesota was highlighted; she was not under state investigation, nor were any bad birth outcomes mentioned. 

What do these three midwives have in common? They all have formed Private Membership Associations (PMAs), legal instruments that claim to exempt their members from state regulation. Clients of these midwives become members of PMAs, which supposedly allow them to essentially contract out of state governance of their midwives. 

However, in reality it doesn’t work that way. States with licensing regimes, like Indiana, allow their state midwifery boards to issue complaints against negligent midwives, whether the midwives have obtained licenses or not. Because the unlicensed practice of a profession is a criminal offense, these complaints are often conveyed to the state attorney general’s office, after which charges may be filed against the midwife. In states that do not offer licensing of community midwives, like Nebraska, the route to criminal charges is much more direct: reports of a bad outcome may land immediately on the county prosecutor’s desk.

The cartoon above is our take on why PMAs are a bad idea, and why midwife licensing is a good idea. Many people these days mistrust government – and who can blame them? But remember: the answer to bad law isn’t no law; the answer to bad law is good law.

An aside about PMAs, birth outcomes, and midwife arrests

When midwives are arrested after a newborn or maternal demise, as in the news articles linked above, some readers find it tempting to channel their lock-em-up-and-throw-away-the-key rage right at them. Allow us to take this opportunity to remark that physicians rarely face arrest when their patients die. Furthermore, this post is in no way a comment about the outcomes in any of the births in the news articles or on the level of skill and training possessed by the midwives who attended those births. Midwives are often blamed for bad birth outcomes no matter what their license status, training, skill, or education. The shamefully high infant and maternal mortality rates associated with conventional hospital-based care, on the other hand, is just starting to be questioned.

Image credits

All images are shared under a Creative Commons license, unless otherwise noted. Where required by license, changes to the image are noted.

Panel 1: 

Panel 2: 

  • The Fortress Midwifery building is really part of the
    Golubac Fortress in the Đerdap national park in Serbia.
    The image is from Max Pixel and is in the public domain.
  • The Viking longboat is by Midnightblueowl. We added the torch by Kiernax.
  • The bomber is by U.S. Air Force. The image is in the public domain.
  • The helicopter is by Capt. Richard Barker. The image is in the public domain.
  • The sailing ship is a photograph of Cannon Fired by Willem van de Velde the Younger, 1707. The photo is by the Rijksmuseum, Amsterdam and is in the public domain.
  • The Virginia-class attack submarine is by Owly K. The photo is in the public domain.
  • The cannon is from a photo of the Saint Kitts – Brimstone Hill Fortress, taken by Martin Falbisoner.

Panel 3

  • The background is a photo of the Ballroom at Rideau Hall, Ottawa, by Dennis Jarvis. We cropped the image, edited out some chairs along the back wall, and swapped the portrait of Her Majesty Queen Elizabeth II with one of Martha Ballard, midwife. 
  • The lectern is from “WikiData Presentation 2018,” by Michelle Nitto
  • The pink house in the poster is of Zemīte Manor, by J. Sedols.
  • The projector screen is from Max Pixel.
  • The midwife/breastfeeding mother is by Renoir. She is wearing an oxytocin necklace. Her bag is from Needpix.com. It is filled with a water bottle by wraithrune, a yoga mat by MikesPhotos, and a sweet little stuffed cow by OpenClipart-Vectors.
  • The Big Push for Midwives logo is from The Big Push for Midwives! You should check them out!
  • Finally, the speaker at the lectern is Cynthia Jackson, CPM, LM, of Michigan: midwife extraordinaire and unparalleled portrait subject. The photo is used with permission. Ms. Jackson runs Sacred Rose Birthing Service and is a founder of the Mosaic Midwifery Collective, both in Detroit. 


Don’t buy it!

 

Myth! Myth!

One myth that refuses to die is that patients who refuse a test or procedure Against Medical Advice (AMA) will be billed for all care up to that point, which their insurance company will not cover as a result of the refusal. Since shouting NOT TRUE! NOT TRUE! NOT TRUE! isn’t – or shouldn’t be – as persuasive as evidence, we incorporate a reference to published research in the cartoon itself, and provide this complete citation to the free full-text article:

G.R. Schaefer, et al., Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend? J Gen Intern Med. 2012 Jul; 27(7): 825–830. https://doi.org/10.1007/s11606-012-1984-x

Should I sign the form?

Hospitals and health systems usually require patients to sign a form acknowledging that they are taking an action AMA, such as discharging themselves from care. This documentation protects the provider from liability in the event that some harm befalls the patient as a result of the refusal. However, a patient’s right to refuse treatment is not conditioned on their signature. In other words, there is no requirement under state or federal law that patients sign such a form.

Why the big deal?

Misconceptions are one thing. But willfully using falsehoods in order to override patient informed consent is quite another. If a health care provider has to resort to effectively threatening a patient with bankruptcy in order for the patient to consent to a course of treatment, then that provider is clearly not thinking of the patient’s best interests or rights. It is not very different from ensuring “compliance” by raising the specter of Child Protective Services intervention or playing the Dead Baby Card.

Takeaways

  1. It’s a myth! Patient refusal of a treatment or procedure will not cause a health insurance carrier to refuse coverage or payment.
  2. Providers who use this myth to attempt to coerce their patients are acting unethically and in violation of the laws of informed consent.

Image Credits

Frame 2.
  • Photo of pregnant person and physician is by Bokskapet.
Frame 3.


Not you too?

190409 me too too.jpg

Image Credits

 

Updated April 9, 2019, to add copyright designation.


Cry havoc

This cartoon was created in memory of Palestinian medic Razan al-Najjar, killed in Gaza.

Images and credits


Catching up cartoons

The following cartoons were published on Facebook before they were posted here. Without further ado …

Subject-consent-object (SCO order!)

 

The usage “consent the patient” is one that horrified us when it first came to our attention. If any verb should be an active one, “consent” is the one.

Image credits

“Doctor Visit” is by mohamed mohamed mahmoud hassan, shared under a Creative Commons license. We added the facial features, which were chosen from assortments provided here and here. The framed picture is courtesy a collection of fantasy landscape cartoons.

 

Medicaid work requirement

The Michigan Legislature has decided to prioritize removing health care from expanded Medicaid recipients who are not working sufficient hours. They were able to do so because the federal government urged states to apply for waivers in order to allow exactly this kind of proposal.

Medicaid was not established in order to force people in need to abandon their families and work sub-subsistence-level service jobs; rather, its purpose is to provide health care for those who cannot afford to purchase it, even with the subsidies that the Affordable Care Act provides (so far!). When one of the Senators behind this bill claimed that “work improves health,” we were moved to create this cartoon.

For those who require a translation for the ironwork behind the Senator: Arbeit macht Gesundheit.

Michigan Governor Snyder has not yet signed the bill, which was enacted on June 7, 2018. We encourage him to veto this measure and instead throw his support behind federal proposals to institute Medicare for All.

Image credits

The Senator and his podium are from an image entitled “Presentation,” by Mani Amini.  The audience is from a FEMA photo, in the public domain.

 

Non-Apology

So many non-apologies arrive in the passive tense, don’t they? Another cartoon in the Bureau of Apologies series.

This image only suggests the offensive words issued by the doctor representing the American Birth Doctors Association (ABDO). The real-life context in which a major professional organization suggested that women control rising maternal mortality rates by using condoms (!) is described here.

Image credits

The doctor and his podium are both from PlusPNG.com.


Separation and selection

What kind of country ….?

immigrant selection

We’ve seen this before.

Images and credits

  • The Statue of Liberty photo is by Andrew Weber. The blue sky background has been replaced. The photo is in the public domain.
  • The Border Patrol guard photo is by Josh Denmark, posted on Wikimedia Commons. It is in the public domain.
  • The image of the Border Patrol logo is from Wikimedia Commons. It is in the public domain.
  • The American flag is from cliparting.com, shared under a Creative Commons license.


Abandon reality

When the current political reality is so unsatisfactory, it seems only reasonable to try something else.

 

Images and credits

  • We borrowed the gent in the cape from Rebels Market, an online “Counterculture Megastore.” While goth and steampunk aren’t exactly our style, we were quite taken with this black brocade coat.
  • The nondescript building of Frame 2 is really a Navy Department Office in 1918 or 1919.
  • The photo of the Oval Office is from the Clinton Administration.
  • The staffer in the black suit is from pixabay.com, shared under a Creative Commons license.
  • The photo of Mr. Trump is from the U.S. embassy in Uruguay.
  • The forest trees wallpaper behind Mr. Trump’s photo is by elias_noessing, shared under a Creative Commons license.
  • The hand holding Donny & Ahmed is from clker.com, shared under a Creative Commons license.

Finally, inspiration for this cartoon’s concept came from the work of Ben Katchor. Seek out his comic-strips – you won’t be disappointed!