Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


Weed whacking

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The last few years have seen an increase in states working to decriminalize recreational marijuana use by adults. Apparently, the U.S. Surgeon General believes that only illegal status was preventing pregnant people from puffing their nine months away, because this year he issued a strong warning against marijuana use during pregnancy.

This cartoon addresses criminalization of marijuana use rather than a generalized warning, but the fact is that laws that criminalize drug use during pregnancy and issue special penalties for it already exist and women are being charged under them. Furthermore, even in decriminalized states, mothers still face consequences for marijuana by way of the child welfare system; sanctions can include one that many mothers would rate even worse than the loss of their liberty: the loss of their child. These repercussions seem vastly disproportionate to the drug-using behavior, considering the following facts:

  • The effects of marijuana use during pregnancy are often overstated in the absence of concrete data.
  • The effects of marijuana use during pregnancy are often confounded with other substance use – including alcohol and tobacco, which are far more dangerous to the baby than any illicit drug.
  • The effects of marijuana use during pregnancy are often confounded with socio-economic status and with disparate effects by race, including uneven enforcement, uneven consequences, and uneven expectation of privacy. Indeed, the effects of intervention itself in the form of child welfare agencies cannot be classified as benign; certainly, separating babies from their mothers in the first hours of life isn’t good for either party.

Sanctions, whether threatened or real, scare pregnant people away from prenatal care. When so many things in our lives are bad for babies (job loss, environmental pollution, violence against women), this fixation with a substance whose harm hasn’t even been fully established looks like just another way to criminalize pregnancy. In addition, when marijuana use is legal, punishing users might serve as the bridge to criminalizing tobacco and alcohol use. Or consumption of runny cheese! Or hot tub use. … Or living in a neighborhood where the water has been turned off, homes have been foreclosed upon, and the factory next door belches a queasy-making smoke that the municipality assures residents is Perfectly Safe. 

If we want pregnancy to result in healthy babies and healthy mothers, perhaps we might concentrate on known dangers and support parents in ways that don’t involve a) a jail cell, or b) the threat of separation on the single most important day in a brand-new person’s life.

Suggested 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.

  • Frame 1: “Reefer Madness” poster (“drug-crazed abandon!”) is from Wikimedia Commons. The image is in the public domain.
  • Frame 2: Policymaker and scientist/doctor are by Mohamed Mahmoud. RJ Truthteller is borrowed from another cartoon that states the image source.
  • Frame 4: Pregnant woman is by Thiago Borges. Health Department is by Michael Rivera; the image was cropped.
  • Frame 5: The photo is by Patricia Deal, and is in the public domain. Because this photo portrays a real person, we wish to emphasize that the pregnant woman pictured did not speak the words we put in her mouth. In no way do we wish to suggest that the circumstances suggested by those words apply to her.


Unregulate me?

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

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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. 


Just say … what?

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Bibliography

  • Catharine A MacKinnon, Feminism Unmodified: Discourses on Life and Law (Cambridge, Mass; London: Harvard University Press, 1994).
  • Elizabeth Kukura, “Birth Conflicts: Leveraging State Power to Coerce Health Care Decision-Making” 47 (2018 2017): 48.

Image credits

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


How bad can it be?

How bad can it be?

Very.

Some women1 are pregnant. Some women are fat.2 Some women are fat and pregnant. Almost all of these women need jobs, the same as anyone else. Employment discrimination in hiring is sadly not unknown to many would-be employees, but the fat-and/or-pregnant job-seeker encounters specific additional challenges.

Pregnant?

The Pregnancy Discrimination Act of 1978 forbids employment discrimination on the basis of pregnancy, considering it a form of sex discrimination. The strongest protections apply to the hiring process, but are difficult to access unless an employer documents their decision to discriminate. Employers are not allowed to ask applicants if they have children, plan to have children, or are currently pregnant. Of course, at a certain point a pregnancy becomes visible – unless it is mistaken for fatness.

Fat?

Discrimination faced by fat people is widespread. Fat people are seen not only as failures at controlling their body size, but also as generally untrustworthy, incompetent, and unhealthy. Most U.S. jurisdictions offer no legal protection against weight-based discrimination in employment or any other context. Even if legal protection were available, remedies might remain elusive should traditional code words for overlooking fat applicants be used: “unprofessional appearance” or “incompatible with company image.” Now for the double whammy …

Fat AND pregnant?

Yes, Virginia, fat people get pregnant and have babies! It is in these circumstances that employers fall prey to the particularly injurious prejudices about fat people, who are so often characterized as being “one cheeseburger away from a fatal heart attack.” Imagine if a fat person is also pregnant! It’s practically a death sentence! This rate of fatality would be highly inconvenient to employers – not to mention the fat person herself – if it were true.

There are higher risks of some complications of pregnancy associated with higher body weights, but that is true of other (visible) conditions as well: very low body weight, twin or multiple pregnancy, and pregnancy for African-American women, whose maternal mortality is tragically 3-4 times that of white women. The scientific evidence is finally beginning to concede that higher mortality for the African-American population is not the result of race, but of racism. The role of bias and stigma may also be behind the associations of certain types of risk with bad outcomes for fat pregnant women. Regardless of the science, the popular perception is as stated in Frame 4: hiring a pregnant fat woman will bankrupt your business through high health care costs3 when her pregnancy inevitably goes south.

Why do these beliefs persist?

The cultural understanding of women’s participation in the workplace remains far from settled, at least when women take valued positions previously held exclusively by men. Even women who are not pregnant or incapable of becoming pregnant can suffer from employer suspicion that members of the sex that “naturally” acts as family caretakers are likely to be called to do just that, to the detriment of their jobs. Applicants who are pregnant are felt to be freeloading: if other new employees are not permitted to take leave until they have put in the required amount of time, why can babymakers? They should have kept their legs closed!

As for fat pregnant women, well, should they really be permitted to reproduce? Not only will they almost certainly harm their babies and themselves in the process, draining company and public health dollars at an alarming rate, but they might produce more little fat people. A job would just encourage them! 

While these last paragraphs are increasingly sardonic, they illustrate the result of combining over a century of anti-fat bias, medical eagerness to believe that fat is the cause of all ills, pressure on businesses to reduce health care spending, an economic framework that blames the need of the human race to reproduce on the people doing the reproducing, and a general lack of understanding that we are all in this together. And this moral mess hasn’t even begun to address the additional and intersectional issues encountered by LGBTQ people, people with disabilities, or immigrants.

“I want to do the right thing – what is it?”

You don’t really need us to tell you, do you? Stop discriminating! 

Admittedly, it’s not that simple. However, like charity, abuse begins at home – and that’s a good place to stop abusing your fat friends and family members. Even if you’re doing it because you’re “concerned for their health.” Especially then.

Then take up the standard in your workplace. Make sure that both pregnant and fat people are accepted as full members of the workforce. If you are responsible for hiring, then you are especially positioned to make change. Finally, when the common beliefs about fat and/or pregnant people begin to budge, work with policymakers to forbid this kind of discrimination. 

1We usually use the phrase “pregnant people” or “birthing people.” However, because the topic of this cartoon is extremely gendered, we will refer to “women,” with the understanding that pregnant people who do not identify as women face additional problems beyond the scope of this post.
2The accepted medical term these days seems to be people who “have obesity.” We use “fat” as the term preferred by the fat acceptance movement.
3Obviously, the structure of the U.S. health care payor system is a key culprit in employers’ general fears about health care costs. This post is not trying to solve that problem. One thing at a time, okay?

Bibliography

 

Image credits

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


Pushed and Consented

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Photo by chuttersnap on Unsplash

Product announcement!

We are very pleased to announce that our 20-page booklet, Pushed and Consented: Rights in Childbirth?, is available for purchase on the Birth Rights Bar Association website. Click the cover image to go straight there!

Cartoons with explanatory text address the question mark in the title and lay out the current legal landscape. Buy your copy today!

maternal barrier

If you would rather view the booklet online, it is available at this link. BRBA suggests making a donation if you choose view the booklet online.


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.


The HHS Office for Civil Rights

Personal beliefs and denial of care

Earlier this month, it emerged that tennis star Serena Williams came close to experiencing life-threatening blood clots after giving birth last fall, in part because medical staff delayed taking action after she requested treatment.

More recently, President Trump announced the establishment of a Conscience and Religious Freedom Division in the HHS Office for Civil Rights. Its purpose is to expand the ability of health care providers to exercise conscience clauses. ACOG, the chief U.S. professional organization for obstetricians and gynecologists, promptly issued a press release objecting to the move, stating, “Abortion, contraception and sterilization are a part of comprehensive reproductive health care and are essential to the health of patients. Professional medical organizations have clear guidance on the issue of refusal, noting that refusals of care must not compromise patient health.”

Well. All these announcements in such close proximity generated some questions in Ye Olde Cartoon Shoppe. Who is refusing care? To whom? What is their religious justification? Is it religion, or merely culture? What about having children, as opposed to not having them – are there any civil rights in play there?

Sometimes you look around, and no one is behaving the way you think they should. Except, of course, Ms. Williams, who acted intelligently and forcefully under challenging circumstances. And Baby Olympia, who does not need to do anything except be herself – which she so clearly does, perfectly and adorably. Congratulations on both counts, Serena Williams!  For all the other participants in these various dramas, there’s this:

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Images and permissions

  • The white-coated doctor is from Pixabay, shared under a Creative Commons license.
  • The plant is from pluspng.com. The site does not state any terms of use, but seems to make images freely available.
  • The photo of Serena Williams and Beautiful Baby Olympia is taken from an online video. Ms. Williams did not to our knowledge speak the exact words attributed to her in this cartoon, but we believe we have correctly represented her intentions.
  • The distinguished fellow with the stethoscope comes from Michelangelo’s The Creation of Adam, where he appeared with more background and without the stethoscope. The work is in the Public Domain.