Why are natural childbirth advocates vilifying a black obstetrician who wants to reduce racial disparities in maternal mortality?

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Privilege can be very ugly.

Witness the specter of a black obstetrician being upbraided primarily by white people for a speech about reducing racial disparities in maternal mortality.

Vilifying Dr. Brown for stating an incontrovertible medical fact — contraception saves women’s lives — reflects the privilege of well off, white women who have easy access to birth control and the money to pay for it.

Dr. Brown made an incontrovertible claim: the single most effective way to prevent maternal mortality is birth control and now he’s being pilloried for it.

Comments, predominantly from white women, make three main accusations;

  • Claiming that Dr. Brown wants women at risk of maternal death to stop reproducing.
  • Implying that maternal death is due to an overuse of technology.
  • Insisting that midwives could reduce the maternal death rate.

These commenters are blinded by pregnancy privilege.

As I wrote in a recent post, pregnancy privilege is a set of assets a woman can count in on cashing in, and to which she is by and large oblivious. By far and away the most important asset in pregnancy privilege is this: The pregnancy is planned and wanted.

That’s not the case for many women. While it is difficult to imagine anything more tragic than a woman dying to give birth to a baby she wanted, dying as a result of an unintended pregnancy is possibly worse. Since 45% of US pregnancies are unintended — and possibly an even higher percentage of pregnancies of women of low socio-economic status — that means that easy access to birth control, including insurance that covers the cost, is a simple, effective, relatively inexpensive way to prevent maternal deaths.

That was Dr. Brown’s point and it is hardly a trivial point in the current political atmosphere where reproductive rights are under sustained assault and “pro-life” means pro-fetus, not pro-mother. If all women had access to the means to control their fertility, maternal deaths would likely fall precipitously.

But apparently privileged women can’t grasp this basic point and are accusing Dr. Brown of blaming the victim. That’s the last thing he has in mind. Reproductive rights — specifically the right to avoid unplanned pregnancy — is the sine qua non of women’s health, both physical and economic.That disparities in access to contraception exacerbate disparities in maternal mortality is a preventable tragedy.

Pregnancy privilege blinds women to other realities about maternal death. The leading causes of maternal death are cardiac disease, chronic pre-existing health conditions and complications of pregnancy like pre-eclampsia. Many women die of these problems because they lack access to the high tech care that saves privileged women. They aren’t healthy to begin with; they don’t have health insurance; they receive care from clinics; they must deliver at hospitals with poor safety records.

Invoking the rhetoric of natural childbirth: that obstetricians don’t follow scientific evidence (false), that unmedicated vaginal birth is safest (false), that interventions cause more health problems than they prevent (false) is worse than useless. In nature, childbirth is inherently dangerous with a “natural” maternal mortality rate of 1000 per 100,000. That nearly 50X HIGHER than our current maternal mortality rate, which is unacceptably high. It is ludicrous to imagine that a return to nature — a beloved affectation of privileged white women — is going to save the lives of chronically ill black women when nature itself is deadly.

The same thing applies to calls for more midwifery care. How is a midwife going to save a woman dying during pregnancy or postpartum of cardiomyopathy or congenital heart disease or kidney disease or eclamptic seizures? She isn’t, but the privileged women who recommend midwifery care are thinking of themselves and what they want instead of poor women of color and what they need.

The ugly truth is that vilifying Dr. Brown for stating an incontrovertible medical fact — contraception saves women’s lives — is a reflection of the privilege of women who have easy access to birth control and the money to pay for it. Recommending natural childbirth and midwifery care to reduce racial disparities in maternal mortality is the obstetric equivalent of “let them eat cake”: repugnant, clueless and entirely ignorant of the reality of life for anyone other than the privileged.

  • Peter Harris

    “Privilege can be very ugly.”

    Confected outrage, just to support a racial stereotype that just so happens to agree with your twisted view of nursing and motherhood, is even uglier

  • Alison Fowler

    Thank you! We don’t always agree, but when we do, it’s like you took the words right out of my mouth. I am an antepartum/postpartum/newborn RN in an urban hospital. I used to be one with the natural birth commuity…until I became a nurse. Now that I work with the patient population you describe above, I see the privilege rampant in the natural birth community. Until the natural birthers work with women of color, with chronic comorbidities, in low-resource urban settings, they will never understand. My patients do have access to midwifery care, in the same clinic as our high-risk OB’s practice. If care needs to be escalated, the OB’s are always there, and they work as a team.

    It’s so easy for women of privilege to demand we reduce CS rates. But what about the woman with chtn and pre-e who is on Medicaid and unable to go to all her prenatal visits because she has 3 other kids and has to take the bus to daycare and work every day? Why do they try to make her feel like a cs at 34 weeks, to prevent worsening of pre-e or fetal demise, is somehow a choice forced upon her by the medical community? What I really want to know is, what are women of privilege doing to actually improve the lives of urban women or to prevent chronic conditions in women of color? I could never work as an RN in a low-risk setting with women of privilege.

  • Charybdis

    Sorta OT: Why is the man standing in front of a happy cartoon condom?

    • Chi

      I’m assuming it’s a photo from Dr Brown’s presentation. Condoms are birth control, and he was talking about how access to affordable birth control can save lives, so I’m guessing it was part of his powerpoint.

      • Charybdis

        I figured it would be something like that, but it looks like it could be a part of the happy, dancing conga line of movie snacks singing “Let’s all go to the lobby and get ourselves a snack!” in old ads.

        • sdsures

          Hahahahaha!

  • BeatriceC

    Completely off topic but extremely exciting (at least if you’re me): I had my appointment with the insurance approved UroGYN and my surgery to fix my incontinence issues is approved and scheduled! She books really far out, so it’s not until the end of July, but it’s really going to happen. I am unbelievably excited.

    Of note, she was clearly unhappy at how I’ve been treated in the past regarding this issue. She jokingly asked for the names of all the doctors I’ve had who have blown me off telling me this is normal in women who have had children, and all the doctors who have blown me off because of my weight, so she can lecture them about how very horrible that is. Also, her immediate response when I said I was worried she’d blame everything on my weight was “well how are you supposed to exercise if you’re leaking every time you take a step?” I am so pleased with her. I’m still not happy my insurance company made me jump through so many hoops, but I’m glad I wound up in this particular doctor’s office.

    • Who?

      I hope it goes well, and the time between now and then passes quickly.

    • Empress of the Iguana People

      I like her! Good luck!

  • Anna

    Absolutely BANG ON! Midwives save lives only when there is really no other care. In wealthy, western countries maternity TEAMS save lives, and that only works when the midwives stay in their lanes. Its really terrible that NCB advocates would jump on this but to them, all OBs, except Neel Shah are the devil and any argument they make will be construed as anti-woman. If a midwifery leader was saying the same thing they’d all be fawning over her.

    • Amazed

      And even in not so wealthy, not so western coutries it’s a team work. Here, midwives’ functions partly overlap with those of neonatal nurses. You can bet that my friend with the 30 weeker is very pleased with the midwives who take care of her baby. Last occasion: baby had recently taken to waking up when feeding times approach and in expectation, pulls her feeding tube off before feeding and after she’s done. (Someone was saying thay bottle-fed babies are cursed to suck mindlessly long after they’re full because there’s a bottle in there? Hello?) A few days ago, a midwife saw her again pulling the entire tube out and sighed, “Oh baby, why are you doing this to me again?” while fixing it.

      How anyone can think it’s not a worthy occupation in itself is beyond me. Not everyone should be a doctor, you know. No need to “save” the world from evil obstetricians. Just do your own job which people do see as rewarding.

      I’ve often wondered about the complex these women and their followers have from doctors. They say doctors kind of envy them but it’s the other way round.

      I wonder what these women would offer to my friend who has been recently warned that another pregnancy is too risky for her. Pray that she doesn’t get pregnant? Because, you know, abortion is another devil.

    • Daleth

      Midwives save lives only when there is really no other care.

      I salute you. I’ve never seen it said so clearly and succinctly. THAT IS EXACTLY IT. You speak truth, my friend!

      In wealthy, western countries maternity TEAMS save lives, and that only works when the midwives stay in their lanes.

      YES! Again.

  • PeggySue

    I just want to scream at anyone who suggests that midwives, or even better DOULAS, are the answer to racial disparities in maternal mortality. To me, anyone who suggests this is, consciously or no, a racist. Access to highly competent, culturally sensitive care is what’s wanted. Sadly, I’ve seen women of color on Twitter boasting of spending their scarce resources to train as doulas… and by the time they’ve made that commitment I, as an old white women, can’t say a word.

    • fiftyfifty1

      Well, to be fair, if the doulas are available the entire pregnancy, I do think it could help. It’s like another social support–somebody you can text at any time with questions, somebody to drive you to appointments, to nag you to stop smoking, to notice that you have a headache and your ankles are swelling and make you call the OB office NOW and no not just wait until your appointment on Friday.

      Of course for that to work the doula has to be non-woo, and her agenda has to be about an actually healthy mother and baby however that happens. Right now, unfortunately, too many doulas measure “success” by whether they successfully pressured you into refusing induction, epidural, antibiotics etc.

      • guest

        This is the kind of doula I would like to be. Pre-pregnancy, I just floated through life and trusted any odd things happening in my body would sort themselves out or would get bad enough that I would realize I needed medical help. When I was pregnant, I had to really fight that urge and actually pay attention to my body. When the baby stopped moving at around 23 weeks, I waited a long time before going in to have it checked because I thought I was over-reacting (everything was fine, luckily). I could have really used someone that could talk some sense into me when I needed it.
        And I would have loved someone to help me get my epidural fixed when it wasn’t working and I was in too much pain to make the nurse listen to me and advocate for myself.

      • swbarnes2

        Or, we need doulas during and after delivery who will make lots of noise if their clients need more medical attention.

        Personally, I can see the appeal of a person who was experienced at what was normal and not normal at childbirth, who could stay with a woman throughout the whole process while the staff has shift changes, and help manage information hand-offs, help to remember what’s been going on when the patient can’t, explain things to the patient, especially for a patient with no family there with her…I’m not sure that most doulas now do that.

        • mabelcruet

          If we had care givers who listened to women when they were concerned about something, instead of brushing it off as a ‘variant of normal’, or whose immediate response is ‘you just need to try harder (at breast feeding)’ or downplaying symptoms because they think the woman is exaggerating, playing up or acting out,then we wouldn’t need doulas to act as their advocate. I still struggle to get my head round how they brushed off Serena Williams symptoms and concerns about her clot. I had surgery a few years ago, and was asked post recovery if I was in pain and did I need something. Yes I was, and the response was ‘I’ll come back in an hour and see how you are.’ There’s a lot of data that clinicians don’t take female chest pain as seriously as male chest pain and write it off as indigestion or something else minor. Having a doula shouldn’t be needed to do all the speaking up and being heard (although I accept that they be useful as emotional and practical support).

          • PeggySue

            Yes, this story of Serena Williams is staggering. She and her baby could have died while the medical staff waited around.

          • Charybdis

            If the medical people don’t/won’t listen to those ACTUALLY EXPERIENCING THE PAIN AND REQUESTING ADEQUATE RELIEF OF SAID PAIN, why in the world would they listen to an “outsider”?

            Oh, oh, oh!!!! I know!!!!!! We need MALE DOULAS, because men get listened to in medical situations. (I’m only sort of joking about that).

        • PeggySue

          Sounds like… a CNM!

          • swbarnes2

            Well, CNMs are nurses, they are trained to actually treat people. I’m thinking more a role for someone who isn’t trained like that, just trained in what to look out for, and someone who, unlike the CNMs, stays with one woman from start to finish;the expertise of the medical staff being a little too valuable to be spent sitting around with one patient a day, and who, because their work is more tiring, need to be working sane shifts, which necessitates care hand-offs.

          • fiftyfifty1

            Doesn’t sound like the CNMs I delivered my first with.

      • PeggySue

        You make a good point, and I may have spoken too quickly, but I don’t think the typical “doula” training would equip a graduate to function in this way. BTW if you really want to shriek, look up “death doula.”

        • fiftyfifty1

          Oh I 100% agree that a typical doula is just more likely to make things worse. My vision of what they could ideally be is influenced by a small successful program run by my hospital when I was training. It was created for a certain immigrant group from East Africa, with doc input, nursing input and of course lots of input from the immigrant community. It actually ended up being pretty useful. It addressed the concerns of the community (the doulas kept all men away except in serious emergencies), and helped bridge the culture gap. But it was for a community that despite lots of differences in culture and minimal experiences with hospitals was VERY open to giving birth in a hospital and having medical interventions (they knew very well what birth was like without access to medical care.)

          As for death doulas, we have those where I live too. I haven’t seen one in action, but I have read about them. I certainly would never want one at the side of my deathbed, but unlike regular doulas, at least they won’t be killing anyone (who wasn’t going to die anyway.)

  • Mel

    I don’t suppose any of the critics wondered if high-risk women themselves prefer having access to reliable forms of birth control. Not everyone is looking to have a baby right now.

    I’ve been extremely grateful for access to birth control pills since Spawn was born since a generous spacing between him and another pregnancy reduces the risk of uterine rupture from the classic CS scar I now have.

    I imagine that feeling of relief is shared by women with chronic health conditions who are not looking to conceive right now (or ever.)

    • J.B.

      Michelle Wolf had a section about that in her HBO special. It’s the segment you can watch for free on You Tube. If you’re not afraid of opinionated women 😉

      • Roadstergal

        Ooh, I will have to look that up!

  • CanDoc

    ARGH. I can’t bang my head against the wall hard enough after seeing all those ignorant comments. The “#midwivessavelives” hashtag completely, utterly, atrociously misses the maternal mortality Dr. Brown is addressing. Disgusting.

  • lawyer jane

    Is that Dr. Haywood Brown? Isn’t he actually president of ACOG, a man who has literally devoted his entire career to eliminating racial disparities in obstetrics, as far as I can tell? https://www.acog.org/About-ACOG/News-Room/News-Releases/2017/Haywood-L-Brown-MD-Becomes-68th-President-of-The-American-College-of-Obstetricians-and-Gynecologists

    I haven’t actually watched his talk, but the term “primary prevention” just means eliminating a medical problem before it ever occurs, in public health parlance. So “primary prevention of maternal mortality” pretty specifically refers to preventing pregnancy, and does not exclude any other measures to reduce maternal mortality.

    • fiftyfifty1

      Dr. Hayward Brown has been an advocate for the Levels of Maternal Care classification system. It’s the push to formally classify L&D units similar to how NICUs and Trauma Centers are already classified/stratified. So low risk women can continue to deliver at more basic hospitals, but women with high risk health conditions will be recognized and can receive care through specialists and deliver at hospitals that can provide advanced care. And the hospitals with the highest risk classification can then specialize further, for instance training their ICU docs, cardiologists, psychiatrists, renal specialists, diabetes specialists etc in all the extra knowledge needed for pregnant/postpartum patients. Sounds like nothing but good to me!

      • Empress of the Iguana People

        My insurance had something like that that going for a while. Low risk women gave birth in the smaller suburban hospital but if complications set in, the woman was sent to the larger urban hospital. The way it was explained sounded precarious, as I understand it, I wasn’t automatically risked out despite being 39, obese, and with a history of pre-e.

        • fiftyfifty1

          As this plan matures, I will be interested to see what the guidelines/cutoffs for the different levels of care turn out to be. Of course, no matter what they are the NCB crowd will criticize them, “pregnancy isn’t a disease.”

          Yeah, well trauma isn’t a disease either and yet we have different level trauma centers and nobody tries to advocate against them. And being a preemie isn’t a disease either, but nobody argues against Level 4 NICUs. It’s all so political that maternity care is the one area where we are supposed to pretend that everyone has the same level of risk, that that risk is low, and that different levels of specialty care won’t make a difference.

      • PeggySue

        Excepting for the problems of access to the higher levels of care–poor women often face barriers in terms of location and transportation as it is, and those need to be addressed. I am hoping that’s part of the plan. That’s an increasing problem, I believe, as smaller rural hospitals stop providing OB services. NO ONE is ten minutes from the hospital any more!

        • fiftyfifty1

          Yes, it’s part of the plan!

      • Lisa Hayes

        Great, but… my rural community is at least 40 minutes from a decent hospital. No bus. No taxi. What then? [I’m not aiming this at you personally, but at the initiative]. It seems to be a “given” that such moms are inner-city. Rural poor have exactly the same problems as the inner city–of multi-generational poverty, substance addiction, poor access to decent food, no culture of trusting authority, reliance on poorly educated elders for information, chaotic families, low-wage jobs if employed, kids with different fathers but same Mom, all kinds of things that put mom and baby at risk.

        • fiftyfifty1

          Totally true. What works for an urban area won’t work for a rural area. For a rural area it may include a high-risk OB specialist that can co-manage a pregnant woman remotely with the local Family Physician. Then, perhaps, a planned induction or CS if indicated at an appropriate hospital (which might not be the nearest hospital.) Might also include a plan to get into an ambulance at the first sign of labor and have it take the woman where she needs to go. Also the keeping of excellent records that have a well documented plan for each of her risks, “If this, then this…” etc.