Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


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

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<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.


Separation anxiety

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You wouldn’t cut the rope of someone rappelling down a mountain, would you? The umbilical cord fulfills a similar lifeline function for a newborn: it delivers oxygenated blood to the baby until Junior’s lungs expand and begin to function. With her usual wisdom, Nature has provided this backup because she knows that newborns do not always breathe immediately. So why the widespread and persistent belief that the cord must be cut, or at least clamped, immediately after birth?

The medical record

A 2012 article1 describes the origin of early cord cutting:

The first records of cutting before placental delivery hail from the 17th century. It has been suggested that changes in third stage management accompanied the emergence of male midwives; it became normal practice to deliver women in bed, thereby decreasing the likelihood of spontaneous delivery of the placenta …

In other words, the prone position demanded by new-fangled male birth attendants caused a slower or problematic delivery of the placenta, which then dispensed with the need to wait for the placenta to cut the cord. It makes as much sense as anything else. Providers also believed there to be little benefit in preserving the umbilical cord because the blood flow was so brief:

The contribution of the umbilical arteries was considered to be minimal as it was thought that arterial flow stopped within 25–45 s[econds]. However, no explanation for this cessation of flow was provided …2

One reason that practitioners might have believed blood flow to stop within 45 seconds after birth is that by clamping and cutting the cord immediately after delivery of the newborn, they caused it to stop! Other scientific rationales for early cord cutting included:
  • The desire to prevent analgesic or anesthetic medications administered to the mother from reaching the infant. Of course, these medications would already have crossed the placenta to the prenate* in utero, but it’s hard to argue with a harm reduction approach.
  • As early as 1938, placental and umbilical cord blood began to be used in transfusions.1 The value of this particular blood was recognized again in the 1990s after the function of stem cells became better known. Costly services offering “cord blood banking” cropped up; they persuaded anxious new parents to collect this blood and store it against the possibility of their newborn developing diseases years in the future for which stem cells might be the cure.
  • Newborn resuscitation in contemporary medicine is facilitated by very specialized tools. The baby is typically removed to a surface on or near a crash cart; an intact umbilicus is a hindrance to this removal. 
  • The outdated belief that blood from an uncut cord will flow backwards, out of the newborn, continues to find traction among medical professionals.
  • One also cannot discount the effect of institutional inertia, the perceived need to preserve hospital routines that promote speed and consistency (which then frees up expensive and in-demand physician time), and an inclination on the part of some medical professionals to invest the results of their early medical education with a carved-in-stone quality.
Whatever the rationale, premature clamping and cutting of the cord causes one very distinctive harm: It deprives the newborn of approximately one-third of its total blood volume. This puts the infant at risk for iron deficiency, which in turn may have neurological consequences.3 With many young children in the United States already at risk for iron deficiency from other causes, such as premature birth or lead poisoning, the need to transfuse as much blood as possible into the newborn seems particularly important. That’s the roundup on premature cord cutting from the medical community. But really …

We blame Hollywood

Fictional representation of birth on the silver screen and TV always features:
  • labor beginning with water breaking (8% in reality!) and sudden, immense pain
  • birthing person screaming in pain
  • the phrase (directed at male partner) “You did this to me”
  • whether in or out of hospital, birthing person lying on her back
  • someone telling birthing person to PUSH (or occasionally “don’t push!”)
  • and, of course, immediate clamping and cutting of the umbilical cord following birth of baby
The photo below, that shows an elevator birth in a 2004 episode of Joan of Arcadia, is typical of precipitous birth depicted onscreen. For whatever reason, people seem to fixate on the shoelace. Even Embezzler Home Birth Dad, who surely should know better, feels the need for one. With such depictions so ubiquitous, it’s hardly surprising that parents, first responders, and even medical providers believe that immediate clamping and cutting of the cord is an urgent necessity. Fortunately, care of the cord following a precipitous birth is remarkably simple: Do nothing.  Want to know more? The 2016 article How to Deliver a Baby (If You Absolutely Have To) provides an excellent set of instructions for supporting a birthing person through a birth in an unplanned location at an unplanned time. We take issue with the headline “You birthed a baby!” since it seems to attribute that accomplishment to the person assisting, rather than to the one who has just produced a new person, but in the face of so much otherwise sound information, we’ll forgive the article’s editors that small oversight.
*Prenate. We use this term, coined by Rebecca Todd Peters4 as a neutral descriptor of the being in utero.

Bibliography

  1. Candice L Downey and Susan Bewley, “Historical Perspectives on Umbilical Cord Clamping and Neonatal Transition,” Journal of the Royal Society of Medicine 105, no. 8 (August 2012): 325–29, https://doi.org/10.1258/jrsm.2012.110316.
  2. I Boere et al., “Umbilical Blood Flow Patterns Directly after Birth before Delayed Cord Clamping,” Archives of Disease in Childhood – Fetal and Neonatal Edition 100, no. 2 (March 2015): F121–25, https://doi.org/10.1136/archdischild-2014-307144.
  3. Judith S. Mercer et al., “Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial,” The Journal of Pediatrics 203 (December 2018): 266-272.e2, https://doi.org/10.1016/j.jpeds.2018.06.006.
  4. Rebecca Todd Peters, Trust Women : A Progressive Christian Argument for Reproductive Justice (Boston, Massachusetts: Beacon Press, 2018).
  5. Judith S. Mercer and Debra A. Erickson-Owens, “Rethinking Placental Transfusion and Cord Clamping Issues:,” The Journal of Perinatal & Neonatal Nursing 26, no. 3 (2012): 202–17, https://doi.org/10.1097/JPN.0b013e31825d2d9a.

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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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


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 U. Balt. L. Rev. 247-94 (2018).

Image credits

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


Drugs are bad

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Just one of those inconsistencies

Condemnation is a typical response to mothers who ingest opioids while pregnant. But these women are at risk of receiving much more than a scolding: they may lose their state benefits, their children, and their liberty. Mandatory reporting laws in many states turn health care providers into informants who connect the dots between health care, child welfare authorities, and law enforcement. Reporting of drug-using pregnant people is heavily racialized.

These same health care providers and institutions, however, are content to fix up their laboring patients with epidurals that contain opioids. Epidurals certainly make patients quieter, as the provider in Frame 2 suggests; they are also increasingly demanded by patients who are not permitted to move around during labor, whose contractions have been artificially strengthened with Pitocin, or who are experiencing long labors as a result of physiologic responses to the hospital environment.

Note: No one is suggesting that women in labor should not receive epidurals, only that patients should not be tricked or coerced into epidurals for providers’ benefit, and that patients should have true informed consent with explanations of both benefits AND risks.

Emerging evidence suggests that people exposed to opioids in utero are more likely to develop opioid addictions later in life. We hope that this recognition does not trigger greater retaliation against opioid users who face the sanctions shown in Frame 1, but instead explores all the factors that shape a system that leads to opioid use of any kind by any birthing person.

Further reading

  • Michelle Alexander, The New Jim Crow: Mass Incarceration in the Age of Colorblindness, 2011.
  • Lynn M. Paltrow, “Roe v Wade and the New Jane Crow: Reproductive Rights in the Age of Mass Incarceration,” American Journal of Public Health 103, no. 1 (2013): 17–21.
  • Khiara M. Bridges, The Poverty of Privacy Rights, 1 edition (Stanford, California: Stanford Law Books, 2017).
  • Kajsa Brimdyr and Karin Cadwell, “A Plausible Causal Relationship between the Increased Use of Fentanyl as an Obstetric Analgesic and the Current Opioid Epidemic in the US,” Medical Hypotheses 119 (October 1, 2018): 54–57, https://doi.org/10.1016/j.mehy.2018.07.027.

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 pregnant woman is by creativeitchalways. She was originally holding an orange drink; it was replaced by an orange water bottle created by alistairjtp. This image is in the public domain. The doctor’s office background is by annekarakash. The pointing hand is by Tumisu; the white sleeve was added later. The police officer’s hand is by Andrew Griffith; it is isolated from a much larger image of a police officer standing with his arms crossed. The handcuffs are from Needpix.com.
  • Frame 2: The laboring woman is from Max Pixel. The doctor’s office background is by Omar Bárcena; the image shown is a much smaller piece of the original photo. The downplaying hand is by truthseeker08; the white sleeve was added later. 


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 in style, they serve to 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 people of color, 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?

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