Summit Day 1 (cont.)

How Might You Be Prosecuted: Let Me Count the Ways: Punishing Pregnant Women Based on Claims of Fetal Rights and the War on Drugs

• Whitner v. South Carolina (NAPW fact sheet here) expanded the state's child abuse and neglect laws to include pregnant women. Initially aimed at presecuting women who use drugs while pregnant, it has also been used to force a woman to have a c-section
• once a fetus is elevated to personhood a woman's identity is inevitably devalued and her rights are subordinated to a third party (the state)
• (sorry I don't have a good reference for this one) a woman pregnant with triplets wanted to have a vaginal birth, and expressed this desire to her doctor who then, unbeknownst to her, passed the information on to the police, who filed child endangerment charges, the court granted custody of the fetuses to the hospital. No one ever told the woman any of this until she was in active labor and being prepped for a c-section, which she had, against her will.

An overriding theme of this conference has been that we are all, to some extent, the same. That the media tries to portray women who have children as different from women who have abortions as different from women who choose not to have children, when the reality often is, these are all the same woman at different stages of her life. Likewise, some of us may find it difficult to sympathize with women who consume drugs or alcohol during pregnancy, and yet the same laws that are used to prosecute them may one day be used against us (or someone we care about) concerning an unwanted c-section or an at-home birth or the use of a midwife. We have to find our common ground and work together because laws and court decisions and medical decisions that are detrimental to the health of one woman affect all of us.

Tayshea Aiwohi, the first woman in Hawaii to be charged and initially convicted of manslaughter due to the death of her child, was brave enough to share her story with us. There were many tears and at the end, a much-deserved standing ovation. Tayshea has gotten (and stayed) sober, regained custody of her other children, and opened a recovery house, in her son's memory, for other substance-abusing pregnant women.

Mary Barr stepped forward to say that she was here in spite of the system, not because of it. She says she has recovered from many things more damaging than addiction - poverty, low self-esteem, and lack of social services. She reminded us that lack of education and lack of options keeps people addicted longer and that the majority of politicians these days are legislating from a place of emotion rather than common sense. Barr was sent to prison while she was pregnant, and told that prison may save her life because at least she wasn't on the street doing drugs. Meanwhile, in prison she was raped by a guard and she and her fellow inmates were infested with lice so badly that you could see the eggs on their eyelashes. Not once was she offered any prenatal care.

Pregnancy, Birth, and Distortion of Risk
This panel featured four women (Margaret Olivia Little, Elizabeth M. Armstrong, Lisa Harris, and Anne Drapkin Lyerly) who are all part of the same research team, trying to get a handle on how to improve healthcare for pregnant women and new moms. Their main theme was that prior to birth, interventions (of any kind) are frequently avoided due to concern for the fetus, and then during birth interventions are often used, again due to concern for the fetus. Often in both cases to the detriment of the woman. Armstrong told a story about a pregnant woman whose appendix burst, because doctors were too concerned about possible radiation poisoning to conduct a CT scan to confirm appendicitis. "We notice the risks of intervening to the exclusion of the risks of not intervening." As another example, women 35 and over are recommended to have amniocentesis to screen for the possibility of down syndrome. This age was chosen because it is the age at which risk of downs equals risk of loss of pregnancy from the procedure. But most women do not equate those two risks. Women should be empowered to make an informed decision about whether or not to have amnio. But women under 35 who want amnio, say, because of a strong family history of down syndrome, must have some sort of other diagnosis, like pregnancy-related anxiety, to get her insurance to cover the test. Lastly, many hospitals refuse to perform VBACS (vaginal birth after c-section) and yet the risk of the baby dying during vaginal birth for first time moms is equivalent to the risk of the baby dying during VBAC (different causes, same risk; fortunately in both cases, extremely small). The group is working on making the move from a single standard of care to a 'range of reasonable options,' but worry about how this will work from a legal/insurance standpoint. And lastly, a reminder from Harris, "Pregnancy means what a pregnant woman tells you it means."

After this session I had the pleasure of being invited to have a drink with Little and the rest of her research group and a few other friends (after kissing up a bit by telling Little that over the past few days I'd read everything by her I could get my hands on and loved every bit of it). Unfortunately, my drugs were starting to wear off, so I had to make it an early night. But not before hearing a wonderful woman named Kitty tell stories about choosing to become a midwife, witnessing her first home birth, babies in saddle bags, and singing midwife songs!

Sick Blogging

So once again I have been felled by the little germ monsters that are little children. But I'm supposed to be blogging the NAPW summit, so I've been a very irresponsible public healther and ventured out into the masses. To anyone I may have infected, I'm sorry! And now I sit, curled up in bed, with the sweats and the chills, and attempt to piece together my notes from the past two days. Apologies if they're less than coherent.

Day One
The first day of the summit was an optional "Pre-Summit Coalition Training" led by Be Present, Inc. I could only stay for the first half (I wasn't yet fully sick, but the MLK Community Service Awards beckoned) but from what I saw, what a way to kick off a conference! Lynn Paltrow (NAPW founder) believed that the way to contextualize everyone's work and presentations at this conference was to start by telling our own personal stories. So we went around the room and did introductions and told deeply personal, often upsetting stories. There were many tears and much applause and hugging and encouraging each other to pause, take a few deep breaths, and start again. Many women (and a few men) were here because they've spent decades in the trenches of reproductive health work, some were doulas and midwives, others were OBs in shiny hospitals, and others were new moms who had just experienced a traumatic birth and opened their eyes to personal activism.

Day Two
Yesterday I indulged in 12 hours of drug-induced sleep, so I didn't hit the conference until partway through the lunch time plenary. There I heard Leslie Reagan lay down the history of midwives and OBs and abortions and power. You see, by the mid-19th C midwives were deliverying 50% of all babies. But midwives were immigrants and other minorities, and they were creeping in on the domain of white, educated doctors. So even though doctors and midwives (at this time) were performing approximately the same number of abortions, doctors used mixed feelings regarding abortion to start to limit and control midwife activities. By 1896 Chicago passed the first law controlling midwives and subordinating them to OBs. By the mid-1900s midwife's records had no medical confidentiality and they could be asked to turn their records over to the board of health for any reason, or no reason. Reagan finished with this important message, and I'm paraphrasing here: When abortion is decontextualized from why women need abortion we are not serving women's reproductive rights and healthcare needs.

Erica Lyon (whose new book, The Big Book of Birth will be available next month; original title, If you're pregnant, you've been fucked! rejected by publishers) started her story with her mother's story, "You came out mooning the world!" (Lyon was a breech birth). She said that conventional wisdom says pregnant women don't need birthing education classes. This made me pause, and wonder, where are all the other mothers? Not just your mother, because certainly mother/daughter relationships can be all kinds of screwed up, but are that many pregnant women and mothers really not communicating with each other? Because pretty much from the time I knew about sex, my mom told me that if I had kids, even if I planned to be fully medicated, I must take a birthing class. Because she saw lots of other women in the delivery ward with her who were either sent home (because they came to the hospital at the 'wrong' time in their labor) or who were really frightened because they didn't understand what was happening and what their body was going through. Both my parents have always emphasized the importance of birthing classes, if for no other reason than to decrease the anxiety around the feeling of, holy crap what's happening to my body!? Is there really that little communication these days among parents and soon-to-be parents?

Lyon also focused on informed consent, and that from the very beginning of pregnancy women's self-confidence is undermined - she is taught not to trust her own body and instead to hand power over to an external authority (typically, a doctor). The phrase "the goal is to have a healthy baby" is used over and over again to shut women down and disregard her requests. Given that we have system that currently is not serving women, we need to change the to "the goal is healthy mothers." Pregnant women are making decisions thinking about the long term health of their child ("a woman has an abortion because she is thinking abou the long term health of that child") and to imply otherwise is insulting.

Lastly, apparently, women in NY have been told that because they are having twins they are required to have an epidural.

Two more panel sessions from yesterday - How Might you Be Prosecuted and Pregnancy, Birth, and the Distortion of Risk (during which I get to meet one of my new favorite people, Maggie Little!). But I need a break.

For other perspectives on the summit go here, here, here, here, here, here, here, here, here, or here.

Pro-What?

Let me start by saying that I know in my gut that abortion should be safe, available, and legal. I know that I will write letters and make phone calls and donate money and march on streets and sidewalks and whatever else it takes to protect a woman's access to trained medical professionals who perform abortions.

However, if you really pin me down, I don't have a good, moral, reason for why I believe this. Truthfully, I don't know when life begins. I don't. I don't know if or at what point abortion becomes killing a person. Yet it makes sense to me, if abortion is killing a person, that it should be illegal. And that people will feel compelled to try to stop abortions from happening.

And yet this train of thought is unsatisfying, because it feels incomplete. It feels incomplete because it fails to take the pregnant woman into account. This provides a good rhetorical road, for a while, until you get past medical complications. What's the moral defense of abortion in cases where the health of the woman is not at risk? I can provide lots of arguments, but they all leave me a little uncomfortable, they all feel slightly inadequate.

Fortunately, as part of my prep work for the upcoming summit, I have been introduced to the writings of Margaret Olivia Little. Regardless of your stance on abortion, if you're truly interested in some thought-provoking reading on the subject, I'm not sure you can do much better. She fills, in my opinion, an often overlooked gap in the rhetoric surrounding abortion. She includes the pregnant woman in her moral reasoning, but in a very specific way - by acknowledging and addressing that the relationship between a pregnant woman and an embryo/fetus is unlike any other relationship. Therefore, every analogy is inadequate, every argument faulty, specifically because we don't have the ethical and rhetorical tools to tackle this problem. As she states in "Procreative Liberty, Biological Connections, and Motherhood":

Let me put it more bluntly. The central figures in the abortion drama - fetus, gestating woman, and their relationship - are left out of the conceptual paradigm. When we reason about them, we appeal to analogies that are at best awkward, at worst dangerous, but always distorting, because we are trying to analogize to classifications that have at their root the denial of the situation we confront.

In "Abortion, Intimacy, and the Duty to Gestate" she gets into some really interesting thinking about this specific relationship:

...a fetus's right to life circumscribes a woman's rights to bodily autonomy; but it could go just the other direction: we could conclude that a person's right to life is circumscribed at the point at which that life involves occupying and using another's body. We could conclude that a woman's right to bodily autonomy ends when her decisions reach the body of the fetus; alternatively, we could say that the fetus's right to life ends when it relies inextricably on hers. In wondering whether abortion is murder, then, the issue is not just a matter of deciding whether or when the fetus is a person: it is a matter of determining the contours of the right to life in the rather distinctive circumstances of being gestated.
...
The really interesting questions about abortion, I think, are questions about whether or when one has a duty to continue gestating when one finds oneself pregnant.

In the same piece, I think she really hits the nail on the head with regard to the state's interference in this relationship and decision (albeit through the use of language that is a bit insensitive to the fetus):

The fetus, of course, is innocent of malintent, indeed, of any intent; but the complaint here is not with the fetus, it is with the state. The complaint is with the idea of forcing a woman to be in a state of physical intimacy with and occupation by this unwitting entity. For, unwitting or not, it still intertwines and intrudes on her body; and whatever the state's beneficent motives for protecting the interests of the fetus, it matterse that the method used for that protection involves forcing others to have another entity live inside them.
...
With pregnancy, of course, matters are especially loaded, because it taps into expectations of motherhood: women are supposed to want this sort of enmeshment. But this is just to point out the ideal (if it is one); whatever she is supposed to want, the point remains: it's what she actually wants and agrees to that determines the status of the enmeshment.

She also has a chapter in "Contemporary Debates in Applied Ethics" (the whole book is fascinating and challenging) in which she defends the moral basis for abortion. In the previously mentioned piece Little says, "What we need in thinking about abortion is a moral approach that does justice to the ethics of intimacy; what we have is a moral approach that rarely uses the word." In this chapter she runs with this idea, part of which involves distinguishing between one's moral obligations in deciding whether or not to enter into a relationship and one's moral obligations once one is involved in a relationship.

Then there is the aftermath of the nine months: for gestation doesn't just turn cells into a person; it turns the woman into a mother. One of the most common reasons women give for wanting to abort is that they do not want to become a mother - now, ever, again, with this partner, or no reliable partner, with these few resources, or these many that are now, after so many years of mothering slated finally to another cause. Not because motherhood would bring with it such burdens - though it can - but because motherhood would so thoroughly change what we might call one's fundamental practical identity.
...
To argue that women may permissibly decline this need not trade on a view that grants no value to early life; it is, in essence, to argue about the right way to value pregnancy and parenthood. It is to recognize a level of moral perogative based not just on the concretely understood burdens of the activity in question, but also on its deep connection to authoring a life.

Little goes on to point out that for many women, abortion is viewed as 'preferable' to adoption because they realize that they will not be able to care for a child at this point, and yet also know that after living with that gestating child for nine months, will be incapable of giving it up.


Lastly, returning to the first piece mentioned above, Little does an excellent job of pointing out the double standards that currently exist regarding mothers and fathers:

Legan 'duties to assist' for instance, are far more extensive for pregnant women than for fathers of children already born. Courts have ordered women to undergo cesarean sections without their consent in order to increase incrementally fetuses' chances of survival, while courts routinely deny attempts to force fathers to undergo procedures such as kidney transplants or even blood tranfusion in order to save their existing children.
...
For instance, concerns about the dangers that alcohol poses to a fetus focus almost exclusively on women's dangerous proclivities...even though fetuses also face significant harm from drunk men battering their pregnant partners. Or again, public health campaigns concerned with fetal damage from tobacco smoke almost never target expectant fathers' responsibilities not to smoke around their pregnant partners.

And yes, I realize this double standard works both ways, and men are still getting the shaft when it comes to 'positive' rights too. I think work toward equality has to focus on both awarding the positive things and punishing/restricting the negatives.

The conference starts tomorrow, I'm sure I'll be back with another mouthful.

Holy Shit! Today was a good day for mail, e- and snail! First (and in increasing order of excitement!) my registration materials for the upcoming stroke conference in San Francisco arrived. Second, my abstract on health disparities was accepted as a poster at an upcoming conference. Third, another abstract was accepted as an oral presentation* at an upcoming conference! And fourth, via snail mail I received my complimentary copies of the journal featuring the article on which I am second author!!!! Huzzah! AND the package, from the Harvard School of Public Health, is addressed to Dr. Megan!!!! That makes three pieces of mail (two e-, one snail) addressed (erroneously) to Dr. It gives me chills. I'm such a dork, I literally cut the address label off the package. I may frame it. Hot damn!


*so I had better get over the previously mentioned performance anxiety ASAP!