Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


Securing ourselves out of a vote, #4

This is the fourth and final installment in a series of cartoons warning voters not to sign the Secure MI Vote petition.

The so-called “Secure MI Vote” petition currently being circulated puts barriers in the way of Michigan voters, particularly voters already vulnerable to disenfranchisement.

If you have ever locked yourself out of your house or your car, consider that this is exactly the kind of “security” this petition stands for.

Do not sign the petition!

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Click image to open larger version in new window.

 


Further reading

Image credits

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

  • The “Stop the Steal” protestor is from a photo by Elvert Barnes. The figure was isolated from other protestors and background images.
  • The photo of parent and child is from pxfuel.com.


Securing ourselves out of a vote, #3

This is the third in a series of cartoons warning voters not to sign the Secure MI Vote petition.

The so-called “Secure MI Vote” petition currently being circulated puts barriers in the way of Michigan voters, particularly voters already vulnerable to disenfranchisement.

If you have ever locked yourself out of your house or your car, consider that this is exactly the kind of “security” this petition stands for.

Do not sign the petition!

C

Click image to open larger version in new window.

 


Further reading

Image credits

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


Securing ourselves out of a vote, #2

This is second in a series of cartoons warning voters not to sign the Secure MI Vote petition.

The so-called “Secure MI Vote” petition currently being circulated puts barriers in the way of Michigan voters, particularly voters already vulnerable to disenfranchisement.

If you have ever locked yourself out of your house or your car, consider that this is exactly the kind of “security” this petition stands for.

Do not sign the petition!

C

Click image to open larger version in new window.

 


Further reading

Image credits

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


Securing ourselves out of a vote, #1

This is first in a series of cartoons warning voters not to sign the Secure MI Vote petition.

The so-called “Secure MI Vote” petition currently being circulated puts barriers in the way of Michigan voters, particularly voters already vulnerable to disenfranchisement.

If you have ever locked yourself out of your house or your car, consider that this is exactly the kind of “security” this petition stands for.

Do not sign the petition!

CClick image to open larger version in new window.


Further reading

Image credits

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


All the controversies at once!

What this cartoon is not about

  • Abortion, and whether it’s good or bad to have one.
  • Vaccines, and whether it’s good or bad to have one.

People will and do differ on these questions. This cartoon assumes that you want to do the good thing, whatever that is, and that a bad thing is mistreatment or exploitation of people of Color based on racism, whether intentional or not. Are we clear?

What this cartoon is about

C"Click image to open larger version in new window.

<a href="https://mamasgotaplan.files.wordpress.com/2021/06/210609-one-moral-concern.jpg&quot; alt="C" width="1018" ><img="" class="wp-image-2081 size-full aligncenter" style="margin-bottom: 0;" title="CLICK TO ENLARGE!"

<a href="https://mamasgotaplan.files.wordpress.com/2021/06/210609-one-moral-concern.jpg&quot; alt="C" width="1018" ><img="" class="wp-image-2081 size-full aligncenter" style="margin-bottom: 0;" title="CLICK TO ENLARGE!" Some people with concerns about the safety or efficacy of vaccines object to the presence of “aborted fetal cells” in vaccines. However easy (and gruesome!) it is to picture a dismembered hand pushing up through a syringe’s liquid, that is not the reality. As the blue-jacketed person in Frame 3 tries to point out, what is in question are cell lines. How are cell lines formed? Scientists use cells taken from an organism, e.g. kidney cells taken from a dead human embryo, and create a replicating cell line. The original kidney cells eventually die off, just as cells in the body do, and are replaced by genetically identical cells created by standard biological cell division. These cells are then combined with viruses and used to create a vaccine. (For fascinating photos of human embryonic stem cells, see here.)

Given this significant distance in both time and nature between embryo and vaccine, what are the moral and practical grounds for boycotting the vaccine because of this association? Those who wish to discourage abortion will not do so by refusing vaccines; the abortions that created the cell lines involved took place decades ago. Should a scientist decide to create a new cell line from embryonic material, current U.S. ethical rules1 forbid the solicitation of pregnant people to terminate pregnancies for the purpose of supplying material for scientific research. People will no doubt continue to terminate pregnancies and the products of conception might subsequently be donated to science, but disrupting that relationship will not prevent abortions. 

Do boycotts ever work?

1979 divestment protest, University of Michigan

Boycotts have been effective in other circumstances. Starting in the 1970s, a divestment movement demanded that global institutions isolate South Africa from external trade and investment as a way of pressuring the regime to break down its racial Apartheid system. It worked! South African carried out reforms, a civil war was averted, a Truth and Reconciliation commission took place, and eventually Nelson Mandela became president. By the mid-1990s, Apartheid was no more. In South Africa’s case, the objectionable behavior – the subjugation of a majority of the citizenry – was ongoing. The intense financial pressure applied in the boycott served as an incentive for the government to change its behavior.

Harm that can be redressed – but how?

Other wrongs, however, remain to be righted: consider the case of Henrietta Lacks. The HeLa cell line was developed from cells taken from the cervical tumor that killed Lacks in 1951. The line has been successfully used for far-reaching discoveries in cancer drugs, space research, and immunology, including in the study of COVID-19 in search for a vaccine. The moral issue arises from the fact that while great good came of the establishment of the line, none of that good was directed specifically toward the Lacks family.

The cell line was created from cells taken from Henrietta Lacks, all without the knowledge or permission of the the Lacks family. This practice was and is perfectly legal, as validated by a 1990 California case: the court found that patients do not own any blood or tissue samples taken from their bodies, nor do they possess a right to share in profits from research activities that made use of those samples. However, in HeLa’s case it is difficult for us to ignore the vast gulf between the sums generated by the cell line and the reality of the lives of the Lacks family, who were African-American tobacco farmers in Virginia at a time of blatant racial discrimination. Because such inequalities continue and magnify down through the generations, this injury can be considered an ongoing one.

Should we refuse COVID vaccines because of what was done to the family of Henrietta Lacks? The last panel of the cartoon shows the absurdity of such a proposal: even if it were possible to discard the findings of the space program (!), how would such an action help the Lacks family? 

Restorative justice

Let’s try that again.

The concept and practice of Restorative Justice provides a way to compensate victims of injustice, while simultaneously working to prevent future similar injustices. Once used primarily as an alternative within the criminal justice system to address individual instances of property crime, Restorative Justice is now beginning to be deployed more broadly to tackle systemic injustice and inequity.2 The Restorative Justice framework would dictate compensation for the Lacks family and a strategy to reform medical research so that research subjects, particularly those whose bodies were historically used for others’ profit, would be assured of enjoying the benefits of the research. 

Following the publication of Rebecca Skloot’s 2010 book on Henrietta Lacks, her descendants established a foundation to “preserve her legacy by educating future generations on the impact of her phenomenal HeLa cells while promoting health equity and social justice.” In fact, August 1, 2020 marked the beginning of a year’s “Cellebration” of the 100th anniversary of Henriette Lacks’s birth. Today, February 14, 2021, the day of this blog post, the foundation suggests a donation of $14 as a “V-Day gift.” It is also worth noting that the foundation actually advocates for receiving the COVID-19 vaccine as a way to honor the legacy of Henrietta Lacks.

Similarly, those who wish to decrease the number of abortions might also consider a Restorative Justice approach. All birthing people, but especially people of Color, who are disproportionately represented among people terminating pregnancies, should be guaranteed sufficient health care access and financial support so that those who wish to do so can carry their prenates to term and parent all their children in safety and with dignity. Data from the Guttmacher Institute, as reported by CBS News, suggest that the inability to afford a baby is a reason for 73% of women who obtain abortions. Obviously, the fate of prenates who were not carried to term cannot be changed. But the fate of birthing people can. It would make sense for everyone, whatever their position on abortion, to support organizations that fight to improve circumstances for birthing people and their children, like Mothering Justice, Black Mamas Matter Alliance, and others

One moral concern?

Finally, regardless of the utility of boycotts and the application of a restorative justice lens to problems of fairness and equality, is there ever a world in which one moral concern can override all others? You might believe, for example, that your cause in life is to save elephant species from extinction. They are beautiful, intelligent animals, and you are sure they have souls. You might feel moved to decline a vaccine because it was created using, say, cells from elephant ivory,3 which poachers obtain by killing the animals. But to ignore all other issues – climate change, political unrest, or a world pandemic, perhaps? – not only means  that an opportunity to save the elephants might elude you, but also suggests a lack of connectedness to the larger world. Friends, the world needs many things. We our connected to our natural world and to one another. Please, let us consider multiple viewpoints and multiple approaches for our mutual aid.

Updated June 9, 2021: graphic replaced and small stylistic changes made

1The Common Rule (45 CFR part 46), the Federal Policy for the Protection of Human Subjects, was established in 1991. It is enforced by research institutions through Institutional Research Boards. Note that the Common Rule applies only to medical research, not medical practice.

2“Restorative justice began as an effort to deal with burglary and other property crimes that are usually viewed (often incorrectly) as relatively minor offenses. Today, however, restorative approaches are available in some communities for the most severe forms of criminal violence: death from drunken driving, assault, rape, even murder. Building upon the experience of the Truth and Reconciliation Commission in South Africa, efforts are also being made to apply a restorative justice framework to situations of mass violence. These approaches and practices are also spreading beyond the criminal justice system to schools, to the workplace and religious institutions. Some advocate the use of restorative approaches such as circles as a way to work through, resolve and transform conflicts in general.” Zehr, Howard. The Little Book of Restorative Justice: Revised and Updated. New York: Skyhorse Publishing Company, Incorporated, 2015. See also “Restorative Justice as a Social Movement,” in Mark Umbreit and Marilyn Peterson Armour, Restorative Justice Dialogue: An Essential Guide for Research and Practice, 2010.

3Completely fabricated, in order to make a point.

Further reading

Image credits

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


Viral flight


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Click the image to open a larger version in a new window.

An Epidemic of Home Birth?

As if the U.S. maternity care system didn’t have enough challenges to deal with – a spot of obstetric violence here, a 4-fold racial disparity in maternal mortality there – now there’s that dang Coronavirus! It should come as no surprise that both hospitals and pregnant people might now find themselves with qualms about the practice of giving birth in hospitals.

One potential objection is that healthy people about to give birth might be wary of doing so in a place filled with sick people with a highly contagious disease. The other concern, from the hospital’s point of view, is that facilities and providers might well be strained to the maximum by the exigencies of caring for pandemic patients.

As a result, even parents-to-be who would not have chosen home birth before might find themselves considering it now. It’s not a bad idea! A majority of pregnant people are healthy and are good candidates for home birth. (For comparable safety data on place of birth, see our post here for starters. For more recent data, see the just-released Birth Settings in America report or this summary.) We won’t pretend that hospital-based experts recommend home birth, but others have weighed in on the benefits of separating out healthy mothers and babies from COVID-19 sufferers. None of this is news: in past epidemics, some pregnant hospital patients have switched their planned place of birth.

In order to make out-of-hospital birth possible for many families, however, appropriate providers must be found to attend those births. The good news is that midwives, particularly Certified Professional Midwives, are currently practicing in almost every state. How those states facilitate access to that care is another matter. CPM practice is legally authorized in 35 states, but each state has different views on CPM scope of practice, Medicaid coverage, and many other issues. In the remaining states, CPM practice exists on a spectrum from unregulated to illegal status. 

If ever there were grounds for support of these maternity care providers who specialize in out-of-hospital care, the COVID-19 pandemic provides it. States must use the emergency police powers available to them to facilitate access to CPMs, and hospital-based medical providers must turn to the important work that only they can do and stop opposing what pregnant people want: the option to give birth in the place of their choosing, attended by a provider of their choice.

Image credits 

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

  • Frame 1: The cityscape image is by Ricinator.
  • Frame 2: The car racing to the hospital is from a photo on  ph.
  • Frame 3: The ultrasound scene is by artistraman. The busy hospital exterior is a cropped version of a photo by PAspecialNHCL
  • Frame 4: The messy dining room is by Hans. The pregnant woman is by readingruffolos. The child with fingers in his nose is by ranjatm
  • Frame 5: The bedroom is from pxfuel. The doctor is by OpenClipart; the image is in the public domain. The hand reaching for the button is selected from an image from pxfuel. Helper midwife is cropped from a photo from AllGo. The red carrying cases at her feet are by Dids. The wall portrait is by pxfuel, as is the children’s drawing. At the head of the bed, the map of licensed states is from The Big Push for Midwives; a larger copy is included in the blog text above. The primary midwife is by Tosha Noakes.

We Can Work it Out

Click images to view full-size.

Ah, America the Beautiful. Where good, honest hard work leads – by means of bootstraps – to the bountiful life. That’s a value we can all get behind, yes? Maybe. There are just too many unanswered questions about the nature of work, what constitutes work, and who deserves the rewards of (someone’s) hard work. Give it some thought, and consider whether we don’t all deserve a reasonable measure of security, financial or otherwise, regardless of what occupies our time.

 

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: The hayfield is by jplenio. The candidate at the lectern is by Ricinator. The journalists are by al-grishin. The purple mountains are from Needpix.com. The flag bunting is from PinClipart.com. The spacious sky photo is by MemoryCatcher. The “not lovin’ poverty wages” protestors are from a photo by Fibonacci Blue. The “on strike” sign was inserted from a photo by Martin Lopez. The little girl with arms folded is by ivanovaassol. The reaching hand with pink slip is from Piqsels. The elderly people knitting are from a photo from pxfuel.
  • Panel 2: The up-close-and-personal view of the cornfield is from peakpx.com. The bicycling child and her caregiver are by Ben_Kerckx. The mother serving salad is by skeeze. The photo of the crossing guard is by Airman Ashley J. Woolridge; it is in the public domain. The inmate firefighter (in orange) and another firefighter in yellow were isolated from a photo by the California National Guard. The photo of the leased convict with a shovel is from Our Common Ground. The chain gang overseer is in reality 1912 Chicago White Sox umpire William Dineen. The woman in labor is in reality a photo by popo.uw23 of a contestant in a jalapeno eating contest.
  • Panel 3: The underlying photo of the shining sea is from Pikrepo. The son shown inheriting the castle is actually the painting Washington on his Deathbed, by Junius Brutus Stearns (1810-1885); the reproduction is in the public domain.
    The two executives celebrating their good fortune are from a photo from pxfuel. They have been placed in a boardroom photographed by Phil Manker. The television image in that photo was added, built on a public domain image by Shealah Craighead.
    The “ukrainair” plane was created from a photo from ph. Hunter Biden’s image was isolated from a photo by Ben Stanfield
  • Panel 4: The lilies of the field are from ph.

This gallery contains 4 photos


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.