Elephant Circle resources and efforts during COVID-19

Hello Elephant Circle fans!

Like many of you, we have been busy responding and adapting to the world of COVID-19. 

We wanted to share our recent efforts and resources!

International efforts:

• Elephant Circle was invited to be part of the Global Perinatal Task Force on Birth Setting – an effort by birthworkers and advocates around the world in response to the pandemic, convened by the Birth Place Lab.  Stay tuned for more information on this effort!

National/Colorado efforts:

• We created an early guide to integration of community birth into the pandemic response in Colorado.  Read that guide here. 

• This guide inspired collaboration on a national document, and the FAM Statement on Pandemic Planning was born.  It was adapted for a MomsRising blog post and can be found here. All contributors are credited at the end.

• We have consulted with New York state birthworkers and advocates about how to plan for birth in the face of the surge that is happening there (see reporting below for examples).

• We developed a guide to help consumers thinking about community birth during this time.  This document was designed to help consumers and to help community midwives – who are currently fielding these questions daily as their inquiries increase exponentially.  Find our Consumer Guide to Community Birth during the Coronovirus here.

• We have been instrumental in the development of this resource on defending human rights during birth.

• We surveyed Community Birthworkers here in Colorado about their capacity to serve more families during COVID-19.  Read our summary here.

• We collaborated with the Colorado Organization for Latina Opportunity and Reproductive Rights (COLOR) to send this letter to Governor Polis about the role of community birth in a pandemic. This letter was based on our work with the Birth Rights Bar Association addressing the challenges pregnant and birthing people are facing.

• One of our recommendations was to include Certified Professional Midwives (CPMs) as clinical staff at Colorado birth centers.  Read our fact sheet about why we think this is a good idea here.

• We know that crises like pandemics increase the rates of human rights violations.  Childbirth is no exception.  Elephant Circle is serving as a international resource to track human rights violations during childbirth during the pandemic.  Find our reporting form here.

• We hosted informational webinars for pregnant and birthing folks here in Colorado in both Spanish and English.  Those will be out during the week of April 13.  Stay tuned!

Elephant Circle in the news talking about the coronavirus.

'They Separated Me from My Baby' Hospitals are keeping newborns from their parents over the coronavirus fears. By Irin Carmon, April 7, 2020, The Cut

This article tells the story of LaToya Jordan who gave birth in New York on March 30th and was separated from her newborn due to COVIC-19 concerns.

If a parent refuses to be separated from a baby at birth and the hospital insists, she would face an unsympathetic legal landscape, said Indra Lusero, a staff attorney at the National Advocates for Pregnant Women.

Lusero said similar conflicts have arisen when, say, a hospital tries to separate a newborn from a mother who tests positive for substance use. “In my work, I already see how hospitals make policies that don’t always take into account families’ needs, people’s psychological well-being, or even the specific needs of newborns with regards to bonding and attachment,” they said. “The way perinatal health care is organized in hospitals prioritizes the baby to the detriment of the pregnant, laboring, postpartum person.” 

COVID-19, Surrogacy, and Birthing Alone: Coronavirus or no coronavirus, the babies just keep coming.  By Ellen Trachman, April 1, 2020, Above the Law.

This article analyzes the law and legal history around hospital policies and support people at birth.

Lusero explained that with little ability to challenge the crisis-driven hospital policies, some are turning to birth centers and home-birth options. Others are steeling themselves for an isolated and separated hospital birth.

But Lusero also points out that it was public pressure and changing norms that led to fathers being commonly included in the delivery room, and public pressure led to New York’s executive order requiring hospitals to adjust their no-accompaniment policies. Advocates can continue to press for pandemic-appropriate accommodations for this “crucial psychological milestone.”

Covid-19 Restrictions on Birth Breastfeeding Disproportionately Harming Black and Native Women.  By Kimberly Seals Allers, April 3, 2020, We*News.

This article articulates the many challenges facing pregnant and birthing people and the impact on Black and Native Women.

“What we have right now are a set of bad options, including no legal basis for having someone with you at childbirth and a hospital system that has historically prioritized protecting itself (and avoiding liability) over the needs of women and birthing people,” explains Indra Lusero, a reproductive justice attorney at National Advocates for Pregnant Women (NAPW).  

“During this time, we recommend individuals look for local childbirth educators, doulas, lactation support providers, midwives and doctors offering digital support, information and resources that can reassure, connect, inform and support people,” adds Lusero, who is also founder of the Birth Rights Bar Association.  

Birth Justice Briefing on the National Academy's Birth Settings Report February 2020

A bi-partisan Congressional committee commissioned “an evidence-based analysis of the complex findings in the research on birth settings, focusing particularly on health outcomes experienced by sub-populations of women.” The report, Birth Settings in America: Outcomes, Quality, Access and Choice was released on 2/6/20 by the National Academies of Science, Engineering, and Medicine.

The National Academies (initially established by an act of Congress by President Lincoln) exists to provide nonpartisan, objective guidance for decision makers (including members of Congress) on pressing national issues. This report has the potential to move the needle on issues of access to high-quality birth care in all settings for people of color.

Two of the committee members, Melissa Cheyney, PhD, LDM, and Wendy Gordon DM, MPH, CPM, LM, reached out to Elephant Circle to offer a briefing to the Birth Justice community, with the goal of answering questions you may have about the findings. Elephant Circle hosted the National Academies Birth Settings Briefing for Birth Justice Leaders on Sunday, February 9, at 2:00 EDT (11:00 am Pacific; 12:00 pm Mountain; 1:00 Central). Here is an audio recording (there were no slides). Here is a video of the Zoom call.

For more information on the National Academies report, here is their press release about it.

The report was officially released in a webinar on Thursday, February 6, at 1 pm EDT hosted by the National Academies: Assessing Health Outcomes by Birth Settings. The webinar recording and slides are both now available here.

The free download of the report is available here.

Biosketches of the committee members can be found here.

In the Birth Justice briefing representation in the workforce came up. Folks might be interested in checking out this JMWH publication that will soon be available as open access for one year.

Also, in case you haven't seen it yet, VOX/ProPublica reporters Nina Martin and Julia Belluz are circulating a survey intended for parents who opted to birth at home.

The impact of HB19-1174 on Direct Entry Midwives in Colorado - Consumer Protection for "surprise billing."

What is HB19-1174?

HB19-1174 is designed to protect consumers from “surprise billing,” as a result of healthcare encounters, especially with out-of-network providers.  You can find HB19-1174 here, and a good explanation of the bill here.  This legislation goes into effect January 1, 2020, and applies to all providers regulated by DORA, including Direct Entry Midwives (DEMs). 

What does DORA have to do with this legislation?

The legislation empowers the Department of Regulatory Agencies (DORA) to create rules and the disclosure documentation required of all out-of-network providers and facilities.  Elephant Circle attended DORA’s stakeholder meeting and the emergency rule-making hearing about the rules that pertain to DEMs.  You can view a copy of the rules that passed the emergency hearing here.  Final rules will be implemented 120 days after Jan 1 2020.

How does this affect Colorado DEMs?

The bottom line is that this legislation applies to providers who take insurance regulated by the Department of Insurance, so it rarely applies to DEMs.  I talked with the Deputy Director running the rulemaking hearing and she agreed this legislation will not affect DEMs much (if at all).  Her advice for best practice was twofold:

1. If you have an office, hanging the documentation provided by the rulemaking process in a visible location would suffice generally.

2. If you are ever an out-of-network provider, provide the documentation directly to the client.

As always, reach out with questions, comments, or concerns!

Birth Justice, Like Reproductive Justice: Reclaiming Our Time

This essay is published in Funding Equity: Birth Justice and Human Rights in Maternal and Infant Health

by Indra Lusero

Birth Justice is a concept that has grown alongside Reproductive Justice. However, since childbirth and the perinatal period have continued to be ignored or inadequately addressed it is helpful to articulate Birth Justice on its own. Like Reproductive Justice, Birth Justice is a call for intersectional change rooted in communities of color and queer and transgender communities.

Following Forward Together[i], it can be helpful to understand the need for a Birth Justice framework by looking at three ways of addressing the problems in birth and the perinatal period: Perinatal[ii] Health Care, Perinatal Rights, and Birth Justice. Each of these three avenues have distinct theories of change, which I outline below.

Perinatal Health Care

Looking at the issue from a Perinatal Health Care perspective approaches the problem as one of service delivery. The idea is that if the service delivery system were improved it would lead to better birth outcomes. This approach is based on research and direct-service models that follow research findings. The focus of this approach is on reducing medical interventions, increasing evidence-based services that support physiologic birth, and increasing access to the midwifery model of care. The root of the problem is seen as inadequate or absent information about optimum care on the part of practitioners and consumers alike. Thus, if everyone was better informed, practitioners would provide optimum care and consumers would choose that care.[iii]

Perinatal Rights

The central theme of perinatal care as a legal and advocacy issue is that pregnant people and those who provide care to them should have certain rights, and that the protection of those rights is essential to inidivduals’ health during the perinatal period and to the wellbeing of society at large. These rights are secured through legal and legislative advocacy. Therefore, the focus is on liberty as expressed through informed consent/refusal, bodily autonomy, the right to privacy, the rights of parents to make healthcare decisions for their children, and the right to choose among health care approaches, procedures, and providers. From this perspective, the problem is seen as a lack of protection for basic rights during the perinatal period. The idea is that if these rights were better protected, people could assert their rights against threatening providers, facilities, regulators, and legislators. At the very least, individuals would have a legal recourse when their rights are violated[iv] and this would improve the system overall.

Birth Justice

Birth justice sees the issue as one of structural inequality. Ideas about pregnant bodies, infancy, motherhood, family, reproduction, and life reinforce historical power dynamics that are based on bias and economic inequality. The perinatal health care system creates ideas and effectively stratifies using laws and policies that were built to advance the racial identity, gender position, and economic position of white men. The problem is therefore seen as existing in both social institutions and individual consciousness.

Perinatal health care is a space where these inequities are reinforced or broken down, especially because it is a natural point of transformation. As a result, the strategy for change is multidimensional; it involves ensuring access to service delivery, and guaranteeing rights, but it also involves developing leadership and building social, political, and economic power. In order to break down inequities, the focus is on bringing those who have been historically marginalized to the center. When childbirth is more just, we will also give birth to more justice, and more justice will promote the health and wellbeing of people through the perinatal period.[v]

The Need for All Three

There is incredible need for all of the work being done in Perinatal Health Care, Perinatal Rights and Birth Justice, and there is need for more of all three approaches. So far, the majority of the funded work in this area has focused on Perinatal Health Care, which is important. But very little funding has supported work related to Perinatal Rights or Birth Justice.

Birth Justice asserts that without a multidimensional strategy for change that focuses on expanding access to power and leadership beyond the current actors, and dismantling oppressive structures within the system, gains in service delivery and legal rights will be inadequate or may even reinforce existing inequities. This is why the Birth Justice approach should be the at the center. Perinatal Health Care and/or Perinatal Rights work can be optimized by implementing it in collaboration with a multidimensional Birth Justice strategy.

Birth Justice at Work: The How and the What

At Elephant Circle we prioritize the Birth Justice approach. When we think about Birth Justice we picture the HOW and the WHAT. How we achieve birth justice is just as important as what we achieve. How do we get there? By tackling power and oppression through strategies for change and resilience. What do we need to get there? Expertise in the health care system, the legal system, and the sociobiology of the perinatal period.

How: Tackling Power and Oppression

Tackling power and oppression as part of a Birth Justice approach means that at every level, in every project, every decision is geared both toward advancing the stated goal and toward dismantling oppressive systems. So, for example, at Elephant Circle when we run legislative or regulatory campaigns we are trying to persuade policymakers of our platform, but we are also trying to disrupt white supremacy. It’s a squirmy thing, white supremacy. It wears many guises. Sometimes it’s saying “that’s too queer” and other times it’s saying “she’s just too aggressive,” it takes a full-time commitment and ongoing practice to tackle.

One of the biggest symptoms of white supremacy that we deal with when it comes to perinatal and newborn health is the absences of birthworkers of color where one hundred years ago there were black midwives in the South, indigenous midwives of all tribes, Latino midwives of every hue, and every immigrant community had midwives who spoke their language and knew their culture. White supremacy shows up in our field when we accept the status quo as some sort of natural state of affairs or just the way things are. To achieve Birth Justice we must actively work against acceptance of the status quo as a natural state of affairs.

How: Strategies for Change and Resilience

Tackling power and oppression alone is interminable and ultimately insufficient because Birth Justice requires not just the disruption or elimination of oppression, but the ability to envision and create something new. This is why we also need strategies for change and resilience. Having strategies for change and resilience means that we support our humanity as we do the work. We honor seasons of growth, cultivate joy and wonder, and listen deeply. We draw from art, psychology, spirituality, leadership development, meditation, trauma-informed care, and innovation. This work is key to how we advance Birth Justice.

What: Expertise in the Health Care System, Legal System, and the Sociobiology of the Perinatal Period

Our current perinatal health care system is rife with inequties, subpar outcomes, expensive and ineffective interventions, human rights violations, and preventable deaths and complications. For this reason, the WHAT of Birth Justice requires expertise in Perinatal Health Care systems—their clinical, organizational, and legal aspects—and in Perinatal Rights.

In both policy and clinical work, risk is a common thread. Racial, and other biases, are implicit in notions about risk. Risk is a subject that illustrates the importance of a Birth Justice approach. It is important to understand risk from a clinical, health care system, legal, and sociobiological perspetive and to be able to identify bias in the way risk is defined or managed or mitigated.

Centering Birth Justice

The Birth Justice approach helps us not only understand and address risk but to dismantle oppressive systems and protect our humanity while doing so. Perinatal Health Care and/or Perinatal Rights work can be optimized in collaboration with a multidimensional Birth Justice strategy.

More resources are needed across the board to tackle these interconnected challenges. Birth Justice organizations, like Reproductive Justice organizations, need to be centered and scaled up to ensure that as resources in this field expand, they are used to truly transform the conditions that led here, and to point the way to more just and humane solutions.

[i] A New Vision for Advancing Our Movement for Reproductive Health, Reproductive Rights, and Reproductive Justice, Asian Communities for Reproductive Justice, (2005). Available at:  https://forwardtogether.org/tools/a-new-vision/

[ii] I use the term perinatal health in place of maternal health in order to better identify care related to the time before and after childbirth, and as a more gender neutral term for that care.

[iii] This publication is a good example of the Perinatal Health Care approach: Peter B. Angood, et. al. The Transforming Maternity Care Symposium Steering Committee, Blueprint for Action: Steps Toward a High Quality, High-Value Maternity Care System, Womens Health Issues 2010 Jan-Feb;20(1 Suppl):S18-49. doi: 10.1016/j.whi.2009.11.007

[iv] The Birth Rights Bar Association was founded to address these issues. This document is a good example of the Perinatal Rights approach: Birth Rights Bar Association, “Know Your Rights,” available at: https://birthrightsbar.org/resources/Documents/brba-know-your-rights.pdf

[v] The work of Black Mamas Matter Alliance is a good example of this multidimensional understanding of the problem and similarly multidimensional approach to the solution, see https://blackmamasmatter.org/

Black Student Midwife- a financial Dilemma

Another day.

Another young, ambitious Black woman appearing on my timeline collecting coins—hustling her way into or through midwifery school.

For many Black student midwives, the cost of a midwifery education creates financial barriers that are difficult to climb over or get around in an attempt to reach their goals. This leads some students to social media in search of financial support.  

One donation at a time.  

Their pitches vary and so do the depths of financial need. The requests are undoubtedly sincere with a familiar one of urgency and passion.

They usually flow something like this:

Hello.

I’m an amazing young woman from some place suffering from an overwhelming need for more Black midwives to meet the needs of underserved  Black mamas. (Drops stats of Black maternal mortality).

I was recently accepted into a midwifery school or an apprenticeship someplace outside of my state.  I’m reaching out to ask for support from my folks to help me pursue my lifelong dream of becoming a midwife.  (Drops more stats on current number of Black midwives in their state and adds a few lines on the history of Black midwives in United States)

I hate asking for support, and actually, I’m a bit embarrassed. But at this point, I need family and friends to hold me up. (Drops even more stats but this time highlighting the cost of midwifery student life which includes books, travel, lodging and, of course, childcare)

You can donate through my CashApp, Venmo, GoFundMe,  PayPal, Zelle, and cash. Checks can be sent to the following address.

Thank-you. (Drops headshot and 27 hashtags)

Beautiful pitch. But Sis, when did crowdsourcing become financial aid?  

Yes. That’s a bit critical, but a valid question. And here’s another.  Where is your personal financial accountability? After all, this is your education.  

I can feel the collective eye rolls. The ancestors are not pleased with my sass.

But wait—here me out.

Before we go forward, let me acknowledge a few facts for sake of total transparency.  One, I am not a Black student midwife; and two, there is always more to the narrative. Nobody is better at telling the story of a Black student midwife than an actual Black student midwife.Specifically a student who was banking on public charity of strangers.

After a few minutes of scrolling through my timeline, I found the student I was searching for. Paige Jackson. Paige is raw, vulnerable and honest. These are posts directly from her page.  

“Your donations show me that you believe in me and in the purpose I’ve been called to. Because of your donations, because of your prayers...I can breathe without being anxious or stressed. I can live--focusing on my studies and not just the struggle to survive. I’m encouraged. I’m so very encouraged.”

And another:

“This is the part that makes this midwifery journey so difficult--the financial struggles. I miss my family too. But being in Idaho struggling, not wanting everyone to worry and not knowing how to fully convey everything that I’m going through is rough. It’s draining. I keep smiling and saying everything is ok even when I’m not sure that it is.”

Last one:

“My room, board, and food are covered by my scholarship but all of my other expenses I must rely on donations to cover.” But the truth is, I really didn’t have a solid answer for him because even I’m amazed by how God has kept me from losing my mind by now.”

I thought, “This is my girl!” and immediately shot her a brief request for an informal phone interview. It was now my turn to reach out and ask for support across social media from a stranger--just as she had.

When the time arrived, we jumped right in and Paige Jackson did not disappoint.

I asked, “What did it take for you to publicly ask for support on social media?” Paige pauses, takes a breath, and replies in a thick Arkansas accent, “hitting rock bottom.” She continues, “I had to be vulnerable or quit [midwifery school].” I’m impressed with her honesty, but Paige isn’t done. She says, “I had to decide to put my pride aside and I had to humble myself in ways that I didn't know were possible. Either I reach out and ask for help or quit and get a regular job.”

Paige is clear that she was called to midwifery and shares, after she was tagged on a Facebook post from Mercy in Action College of Midwifery in 2017, that she prayed, applied, and was accepted into the Mercy in Action program all within a week’s time. She was also awarded the merit-based Grand Challenge Scholarship from Mercy in Action to cover the full cost of her tuition. But this scholarship wasn’t enough to cover all the living expenses for Paige.   

“It’s stressful day to day and I feel bad.”  Paige shares that she has support for housing and that her community have gifted her the e-textbook she needed. But struggling to pay her car note, car insurance (which has lapsed a few times), and cell phone bills leaves her feeling financially crippled.

I know what you’re thinking—she should just “get a job” or maybe a side hustle.

But Paige says, “I can’t work. My schedule just can’t handle it. I have to be there for all the pieces of birth—continuity of care, labor checks, birth, third-stage management and postpartum visits.  People don’t understand the responsibility of a senior primary student midwife.” And she’s right. Paige admits that even her own parents didn’t understand why she would leave her full-time job with benefits to live in a racially isolated city as a poor college student in her thirties. Thankfully, they’ve come around.

But there’s more.

Paige tells me that many Black student midwives struggle with more than just car payments, insurance coverage, and cell phone bills. Several students she’s known have left programs because of lack of childcare and family support. “Single moms are forgotten about. These programs are not set up for them,” says Paige. And she’s telling the truth. Many preceptors face challenges supporting students with children, as securing childcare can be a massive barrier and ultimately can impede the safety of clients and entire birth team.

I asked Paige how she is able to focus on providing care to her families and herself when she literally has precious lives in her hands and the financial world on her shoulder. She admits sometimes she can’t keep up. All the stress impacts her mental health and keeps her up at night. Paige told me about a time her car payment was late—really late. She feared it would be repossessed and all she could do was pull the parking brake to prevent the tow truck from rolling away with her car in the middle of the night.

This is no way to live. But Paige, like many other young women, is dedicated to her pursuit of midwifery. For her, there is no greater calling.

She has found her life’s purpose.

So what are we missing? How are Black student midwives expected to get through school when they can neither financially meet their personal needs nor maintain a modest lifestyle? Quite literally, some can’t afford to eat, but the expectation is that they show up ready and grateful.  The decision should never come down to eating or education.

There are groups like Elephant Circle which offer small grants ranging from $250-$600 through the Birth Worker of Color Scholarship, but the need is so much greater.

I am clear.

We have failed Black student midwives, and unless we overhaul the educational institutions and preceptorships contracts which hold them financially hostage, we will continue to fail Black mothers and babies. Period.

Paige Jackson set me and me critical attitude straight. In the future when I see a post from a Black student midwife seeking financial support, I’ll pause to consider how humble and passionate they are to put their hands out and ask for help. Paige represents the many student who did not “give up and go get a job.” Who decided to persevere by any means necessary, even if that means pulling parking breaks and pitching dreams.

But let us not forget those with dreams deferred by the financial expectations set too high, with support out of reach.

Yes, it’s their education, but it’s our future- the future Black maternal health.

----

Paige Jackson is a second-year student at Mercy in Action College of Midwifery, and is the recipient of the Grand Challenge Scholarship.  She lives and precepts in Boise, ID. If you would like to donate to Paige, find her on Cash App at @pjackson87.

----

To contribute to the Elephant Circle Birthworker of Color Scholarship visit elephantcircle.org

China Tolliver is the founder of the eCommerce community RiseUpMidwife.com,  an apparel line designed for impact. Partial proceeds from their signature “Birth Rights” shirt are contributed to the Elephant Circle Birth Worker of Color Scholarship.

China is from Detroit, and still believes in fire hydrant is the original water park for Black folks.

Chat: hello@riseupmidwife

Follow: @riseupmidwife

Shop: riseupmidwife.com

Tag: #riseupmidwife

Midwifery Matters Special Edition: Anti-Racism and Equity in Midwifery

The perspectives of Black people and other people of color in midwifery are seldom acknowledged. Midwifery Matters will publish a special summer edition from the perspective of an editorial and design team comprised of people of color to focus on the contributions from within communities of color. This issue seeks not only to highlight creative solutions to the systemic racism we know exists within the practice of midwifery as well as policies, education, and workforce but will also explore the impact these models have on both providers and communities of color.

Read the call for author proposals for journalistic paid articles here.

Read the call for abstracts for academic paid articles here.

Thank you!

THANK YOU ELEPHANT CIRCLE COMMUNITY!

We asked and you gave so generously.

We set our sights on raising $5000 and, thanks to your generous support, WE DID IT!

We raised more than $5K and funded 10 Birthworkers of Color all over the United States.  Three applicants received $600, four applicants received $300 and - in the spirit of meeting immediate needs - we gave $400 to a birthworker who went to extraordinary lengths to support a family and found themselves stuck, without the funds to travel back to their own family. 

Folks donated from $5 to $500, with 5 individuals giving more than $400 and two organizations, The Colorado Breastfeeding Coalition and the Queer and Transgender Midwives Association, supporting birthworkers generously at $1200 and $500 apiece.

Thank you! 

We plan to move from a rolling application process to two-three rounds of funding per year.  Please keep an eye out this spring for information about the next round of applications!  Open to all who identify as a person of color and a birthworker.  Awards generally range from $200-$500 each.

 ——————————————————————————————————————————————————————

History of Elephant Circle’s Birthworkers of Color Fund

Since 2009, Elephant Circle has funded Birthworkers of Color on their journey to serve parents and families.  Until recently, applying for these funds had been primarily word of mouth and we funded about 6-12 people a year.  Though exact amounts have varied across the years, we have consistently met our organizational priority that the money we spend supporting Birthworkers of Color is the second biggest line item in our budget (the first is paying the folks who work directly for Elephant Circle).  This practice both represents and feeds what this priority means to us in the work we do as a birth justice organization - this fund is one of our ongoing, long-term, grassroots contributions to equity in birth in the US.

In the fall of 2018, a single Facebook post about our scholarship generated nearly 200 requests for applications in 36 hours.  The need was real and urgent!  We received nearly 100 completed applications.  We funded 10 birthworkers this time and we plan to open applications a few times a year to fund as many folx as possible.  Stay tuned for the next round!

An Open Letter regarding the Division of Access and Equity at MANA

The Division of Access and Equity was convened to address systemic issues impacting midwifery and those seeking midwifery care. The hope was that the Division, by being people of color led and autonomous, could help shift the organization away from its foundation in white supremacy and toward a more equitable culture. Our strategy was that we could make this shift from the inside and that such a shift would make MANA’s mission of uniting all midwives more possible.

And certainly it has been a time of disorientation and discomfort for everyone involved. The kind of discomfort that hearkens back to Bernice Johnson Reagon's speech "Coalition Politics: Turning the Century" presented in 1981 when she said, "There is no where you can go and only be with people who are like you. It's over. Give it up."1

We had hoped that the Division, as both part of MANA and yet made by and for the outsiders MANA had not yet institutionally welcomed, could turn that disorientation into transformation.

This effort was undertaken at a time when people were finally starting to listen to black and indigenous people about disparities in infant and maternal health, and when the role of racism in creating those disparities was finally taking center stage. Not to mention other issues that surfaced at this time including: the importance of transgender inclusivity (see MANA’s updates to their Core Competencies), and acknowledgment of the intersectional issues that impact reproductive health, including abortion.

For us, turning disorientation into transformation is the essential next step, the key priority. And it requires not just words, but action. It requires clear and deliberate action that demonstrates both that white supremacy is no longer acceptable and that another world is possible. As the Division this is what we tried not only to say, but to be. We are fueled by a commitment to equity in midwifery and to centering the work of people in midwifery who have been historically and structurally at the margins because this is essential to all of us thriving, this is essential to uniting all midwives.

During the “Midwife Debate” one hundred years ago, when midwives were maligned by doctors using such blatantly bigoted language as, “poor, black, immigrants, dirty, illiterate, untrained, ignorant, immoral, drunken, unprincipled, overconfident, superstitious, callous, rough, ‘relics of barbarism,’ and in some cases criminal abortionists,” (Pence Rooks) the consequences were not equally shared by all midwives. Midwives who were categorized as “poor,” “black,” “immigrant,” ‘barbarous’ (aka uncivilized) were impacted differently than those who weren’t, for what we hope are obvious reasons. We live with the resulting inequities today.

And so we wonder, like adrienne maree brown in Emergent Strategy, “How do we shift from individual, interpersonal, and inter-organizational anger toward viable, generative, sustainable systemic change?” This has been a guiding question: how? Our experimental answer has been to act with clear and deliberate action like our Mama’s Day campaign celebrating midwives of color in 2017, interrupting white supremacy in public forums in 2017 and 2018, coaching board members in leadership decisions since 2014, and convening groups of leaders of color at MANA in 2016, 2017 and most recently in 2018 with funding from the Birth Equity Leadership Academy. We have tried to answer this by showing up as the outsiders within.

We are still at the beginning of trying to figure this all out as a movement and as a society. Despite the many who have come before us and tried, manifestation of the world we envision is still on the horizon. MANA has not shifted its power dynamics, as evidenced by the most recent conference where confrontations around race surfaced in multiple forums. Our number one priority as a Division was to take clear and deliberate action demonstrating both that white supremacy is no longer acceptable and that another world is possible. Following the 2018 conference, based on action and lack of action, we believe that this is not a priority shared by the Board.

As a result, our efforts within MANA do not feel viable, generative or sustainable. We have determined that the best place for our work to continue is not as a Division of MANA, but through our own projects and organizations. And while such a departure is certainly not new (recall the Midwives of Color Section at MANA who disbanded in 2012), each generation adds something to the generations who come before, and so we offer our footsteps and fingerprints and these words to those who come next.

While we don’t yet know what the next iteration of this work will look like, we will make sure that many projects already underway will continue, like supporting the leadership of midwives and student midwives of color, convening national stakeholder groups around equity, conducting trainings and workshops, and generating educational materials.

We each remain, as individuals and members of the various groups and organizations we represent, part of this ecology, in coalition and in relationship. And we will keep trying to figure out how to “intentionally change in ways that grow our capacity to embody the just and liberated worlds we long for.”

Signed:

Indra Lusero

Demetra Seriki

Nicole White

Maya Johnson

Delmar Bauta

Jamarah Amani

Jaqxun Darlin

Marinah Valenzuela Farrell

Farah Diaz Tello

1.Bernice Johnson Reagon, “Coalition Politics: Turning the Century,” Home Girls: A Black Feminist Anthology, Kitchen Table Women of Color Press (1983). (Available here).

2.Judith Pence Rooks, Midwifery and Childbirth in America, Temple University Press 1997.

3.If it is not obvious consider reading, Dorothy Roberts, Killing the Black Body, Vintage Books 1997.

4.Adrienne Maree Brown, Emergent Strategy, AK Press 2017.

5.See Keisha La’Nesha Goode, Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism, p. 182 (October 2014) (PhD dissertation, City University of New York) (Available here)

6.Brown, supra note 3.

My take on the most recent paper on cannabis and human milk, "Marijuana Use by Breastfeeding Mothers and Cannabinoid Concentrations in Breastmilk."

2018 has been relatively prolific for research on cannabis and human milk. The InfantRisk Center published a paper in April 2018 examining THC pharmacokinetics in human milk in 8 subjects from Colorado. I reviewed the data presented in Baker paper (and lecture) in a condensed version here and a longer version here.

This most recent paper on cannabis use and human milk in the August issue of Pediatrics comes from California and adds a fair bit of detailed information to the body of information.  You can find the full paper here.

 I begin this post with my summary of the paper and what I think are the most important take-away messages. At the end of the post, I integrate what we learn from this paper with the rest of the literature. You can find a downloadable Elephant Circle fact-sheet with a similar integration here.

---

Join me as we dive into

“Marijuana Use by Breastfeeding Mothers and Cannabinoid Concentrations in Breastmilk”

by K. Bertrand et al. in the journal Pediatrics, August 2018

 The samples:

The milk samples came from the Mommy’s Milk Human Milk Research Biorepository.  This repository “strives to understand the numerous benefits human milk offers at a molecular level, and use these findings to improve the health and development of all children.”

The biorepository folks go on to say, “This [biorepository] demonstrates our place at the forefront of human milk and lactation discoveries. We are making it easier for scientists to perform research with standardized, sterile and indexed human breast milk samples. We are the organizing entity, but we need inquisitive researchers and the open-handedness of lactating moms. With your help, we can all demonstrate our commitment to the future improvements in children’s health and development.”

From https://mommysmilkresearch.org/about/

Funding:

This particular research was grant funded by NIH and Gerber.

Participants:

1. A subset of samples from the repository were used in this study

2. The samples selected for inclusion in this paper were samples from folks who reported cannabis use in the last 14 days

3. 88% reported at least daily use (This is important to remember!)

4. 64% used inhalation as their primary consumption method

A few important technical notes:

1. The limit of detection for the quantitative analysis: > 1ng/mL (as compared to > 5ng/mL in Baker, 2018).

2. This study examined single milk samples from individuals.  Unlike Baker 2018, there was no dosing with cannabis to determine THC levels.  The time since last consumption was self-reported and these data were used to evaluate (and demonstrate) a relationship between time of last consumption and THC levels.

3. This research was looking to describe concentrations of the psychoactive cannabis molecules in addition to two other well-known cannabinoids found commonly in cannabis products. It is important to distinguish this from the scenario in which parents or infants are tested for exposure to cannabis. IN this detection situation, THC is not the molecule being measured.  Instead, COOH-THC is the molecule used in the detection of the exposure to cannabis.  This research did not look for COOH-THC.  For more information on the molecules involved in the metabolism and detection of cannabis in humans, please check out our Molecules 101 fact sheet.

Results:

1. 20/54 samples did not show any detectable THC

2. When THC was detected (n = 34), the median milk THC concentration = 9.47 ng/mL (range = 1.01 – 323)

3. 11-OH-THC was detected in 5 samples

4. CBD was detected in 5 samples 

5. CBN was not detected in any samples

6. In 76.5% of the samples with detectable THC, exclusive inhalation was the method of consumption (vs 36.8% in the no THC samples)

7. Calculated a ½ life of ~ 27 hours

8. The longest duration between last use and THC detection was 6 days. This was seen in only one sample.

9. Only one sample had all three molecules: THC, 11-OH-THC and CBD

10. This sample also had the highest level of THC detected in this study = 323 ng/mL

11. The sample with the highest CBD had no detectable THC (11-OH-THC was detected)

12. The cohort with no detectable THC had fewer daily users and a longer average time since the last use (53h vs 24h).  This suggests that daily use increases THC levels in human milk and that time allows for the metabolism and subsequent decrease of THC levels.

13. See Figure 1 below for a visual of the relationship between time and THC levels.  As time since last consumption increases, THC levels decrease. (Note: This paper used log concentrations for their analysis because the absolute amounts of THC were very low. This mathematical transformation allowed for numbers that were easier to analyze statistically.)

Incorporating 2018 data with the pre-existing literature. What can we say we know?

1. Nursing infants are exposed to an Relative Infant Dose of 2.5 (Baker, 2018), or, as stated in Bertrand 2018, “the estimated infant dose ingested would be 1000 times lower than the adult dose.”  Remember, a baby is exposed to THC orally. The bioavailability of THC when consumed by mouth is between 1-5%.

2. There appears to be a curve for THC metabolism in human milk

   1. The shape of the metabolic curve is quite consistent between individuals

   2. The THC concentration at the peak of this curve varies dramatically between individuals

   3. Peak THC levels may occur between 60 and 120 minutes after use

3. The half-life of THC in human milk is ~ 1d in daily users

4. THC detection and metabolism in human milk appears to vary dramatically between daily and more occasional users

5. Clinical advice should distinguish between these two types of users in both perspective and advice

---

So there you have it! My thoughts on the state of the science on cannabis and human milk.

I believe that 2018 provided us with some compelling data that can be used in personalized, clinical, conversations about cannabis and lactation. Whether we stand in the role of parent, practitioner or both, holding space for careful consideration of what we know, what we don’t know, and what we believe is essential. Centering these ideas help keep the conversation curious and empathetic - creating space for a non-judgemental risk/benefit analysis of cannabis use during breastfeeding In my view, that is the ideal conversation for this tricky topic.

Hello Circle Blog Readers!

Hello Readers! My name is Cynthia and I will be writing for the Elephant Circle Blog each month. I just want to introduce myself and give a little bit of background as to how I became connected with Elephant Circle and where I am headed in my own birth work and birth justice journey.

I live in Southern California and began working with Indra and Heather in August 2017 as an intern. At the time I was in the process of completing my master’s degree in American Studies at a California State University and wanted experience in working with a non-profit organization that focused on child birth, diversity, and equity. I sought out my own internship and gladly connected with Indra. Since the completion of my internship in December 2017, I requested to remain involved with Elephant Circle, I feel their intentions and mission of diversity and inclusion align with my own personal values and professional goals. In addition to my work with Elephant Circle I am also on the board for the California Association of Midwives Foundation (CAM) and a member of a local collective, which we call the Inland Empire Birth Workers of Color Collective.

I strongly believe in Elephant Circle as an organization and the people who keep it going on a daily basis. I enjoy being part of this team and look forward to writing for The Circle Blog as well as finding additional writers to contribute to our blog.

Please look for our next post in November/December. Starting in January we will be publishing at least one blog a month and will strive for two. If you are interested in being a contributing writer to our blog let us know in the comments and I will reach out.

Thank you for reading!

Cynthia

The expanded re-cap of the lecture by Drs. Teresa Baker and Thomas Hale on their recent publication, “Transfer of Inhaled Cannabis into Human Breast Milk.”

Introduction to the lecture

Dr. Teresa Baker and Dr. Thomas Hale traveled from the Texas Tech Health Sciences Center in Amarillo, Texas to Denver, Colorado to present their paper, “Transfer of Inhaled Cannabis Into Human Breast Milk.”  The lecture was co-hosted by the Colorado Breastfeeding Coalition and Elephant Circle, with a big shout out and thanks to Katie Halverstadt of COBFC and Laurel Wilson of Mother Journey.  They were both essential to the planning and facilitation of the event.

I was honored to have the chance to introduce Drs. Baker and Hale and I took the opportunity to thank them for the thoughtful ways in which they conducted their research. 

I said something along these lines,

When the InfantRisk Center decided to pursue doing research in CO, they reached out to lactation groups as well as cannabis groups, to include the perspective of the potential subjects as early as the study planning and theorizing stage.  Constituent-led research is rare, and it was an honor to collaborate with all the groups involved.

It turned out to be a good idea to have involved local organizations with previously cultivated relationships with parents who use cannabis, as they ended up recruiting nearly all the subjects who participated.  We quickly learned that there were some significant barriers to health care and lactation professionals recruiting subjects.  Those folks who were board-certified, registered or licensed expressed two main obstacles: 1) the fear that by recruiting subjects they would look like cannabis advocates and that would damage their relationships with colleagues and clients, and 2) the fear of the tension created by recruiting subjects while being a mandatory reporter.  As a result, subject recruitment became a grassroots effort and was slower going than was originally hoped - 9 subjects participated over the course of 10 months of active subject recruitment. 

There is a saying that was popularized in this country by the disability justice movement -

“Nothing about us without us.”

Drs. Baker and Hale showed what it looked like to put that saying into action, and we at Elephant Circle were grateful to be part of such a collaboration.  Thank you to all the organizations involved: CannaMama Clinic, Badass Breastfeeders of Denver, COBFC, the Colorado Lactation Consultant Association, and Mother Journey as well as those individual practitioners who also helped recruit subjects.  Thank you!

The lecture itself, starting with background from Dr. Thomas Hale:

Dr. Hale presented the first half of the lecture with an overview of pharmacokinetics, the endocannabinoid system, what we know about the pharmacokinetics of cannabis in human milk, and the reason for doing this research in the first place.

Before he started, he wanted to be very clear about his and Dr. Baker’s stance on cannabis use during lactation:  THEY DO NOT SUPPORT IT.  Let me say that one more time - Neither Dr. Hale or Dr. Baker support or advocate for the use of cannabis during breastfeeding.  They do not believe it to be “safe.”

They do not support the use of cannabis during breastfeeding in part because we are ignorant about it.  The perspective of the InfantRisk Center is to provide information on the pharamacokinetics of any drug that may be used by nursing parents.  In this way, individual consumers, along with their practitioners, can make data-driven decisions about the risk of a particular drug in their particular situation.

(A quick note about safety and risk.  They inform each other but are not interchangeable concepts.  Describing the risk of something as low does not mean you believe it to be safe.  Safety is the lack of harm, but harm is a subjective idea.  What looks like harm to me may not look like that to you.  Risk - sometimes talked about as risk factors - can be low or accumulate to high levels, but risk is not an absolute concept either.  Something that might be low risk for one family, might present more risk in another family, based on their circumstances.  Safety is the evaluation of the known risks with the known benefits in the context of an individual’s life to decide if it is something to pursue during breastfeeding.  Now, sometimes, the risk is so high that it is never advisable for anyone - it cannot be used safely under any circumstances - but that is a rare phenomenon in the metabolism of drugs in breastmilk.  In describing the risks associated with drugs that nursing parents use, the InfantRisk Center is providing information to be used in the evaluation of the use of those drugs, not commenting on their inherent safety.)

Dr. Hale reminded us that he produces information for folks to use in their individual lives.  He wants to meet them where they are and help them make good decisions for them.  He reminded us that we can never know the journey of another person, and it is important not to judge them for the decisions they make.

He also reflected that when we are in the “ignorant phase” of a drug’s use (like we are currently with cannabis), there can be hysteria about its use.  He recalled that despite the deep fears about the effects of in utero exposure to LSD and crack cocaine, the reality showed that the childhood environment and access to early education were the most impactful factors for childhood development, much more than drug exposure. He assured us that solid data collection would move us out of ignorance and would allow us to “work through the hysteria.”  Good reminders!

Pharmacokinetics

This refers to the way that pharmacologic agents (drugs or medications) are metabolized by the body.  Pharmacokinetics involve parameters that describe how quickly a drug enters the bloodstream after consumption, what the accumulation of that drug looks like, how quickly the drug is broken down and then removed from the blood stream and where that drug goes after it leaves the bloodstream.  Pharmacokinetics is also concerned with the bioavailability of the drug, both to the nursing mother and the baby.  In other words, how much of the dose is experienced by the person exposed to the dose?  In the case of this study, how much THC is available to reach the mother’s brain after smoking or reach the infant’s brain via the oral intake of breastmilk?

The Endocannabinoid System

This system is part of the human body - we are all born with it -  and it consists of molecules called cannabinoids that affect the human body through their interaction with cannabinoid receptors (the two most well-researched receptors are CB1 and CB2). We have only known about this system for the past 15 years or so.  The term “endo” means internal and the fact that humans have an endocannabinoid system is the reason that cannabis exerts any effect on the human body (cannabis is a plant full of cannabinoids - called phytocannabinoids). It is not known what happens to the endocannabinoid system when exposed to an exocannabinoid (external cannabinoid) like THC.

Dr. Hale went on to tell us that 2-AG (2-Arachidonoylglycerol, an endocannabinoid) is found in human milk.  Animal studies suggest the endocannabinoid system is essential for the suckling reflex at birth (pups will die without their endocannabinoid system), but we do not know the role of 2-AG in human milk.  This is one of Dr. Hale’s next research projects.

He also summarized the important details to know about the molecules involved in cannabis consumption, metabolism and detection - if you need a refresher, please check out our Molecules 101 fact sheet.  And, if you would like a review or a prep for what you need to know in background to understand the paper, please check out our 10 concepts to understand when reading or thinking about cannabis and breastfeeding.

What we know about the pharmacokinetics of Cannabis

This summarizes what you need to know to understand their paper:

1. The bioavailability (availability to the body) of THC when smoked is 5-50%.  This wide range is due to individual variation in smoking efficiency and personal metabolism.
2. THC is not absorbed well orally.  90-95% of the THC taken orally is broken down by the liver, so only 1-5% is bioavailable when consumed orally (through human milk).
3. THC enters the human system and is quickly redistributed - broken down and re-routed to other tissues.
4. Brain is not one of the primary tissues for THC to reside long-term.  Adrenals, adipose and the thymus are the sites for long-term detection of THC.
5. In plasma, smoking results in a peak THC of 150-250 ng/mL.
6. Consuming cannabis orally results in a peak at 1.0 ng/mL, more than 100 times lower than smoking.
7. In animal models (chimps) fetal blood shows 1/6 of the maternal blood concentration of THC.  The placenta is a good filter for THC exposure.
8. Regular users (daily or near daily) tend to have plasma levels of THC that remain between 1-5 ng/mL for at least 30 days.  Occasional users do not show this static baseline.

Why study this in Colorado?

The InfantRisk Center studies the pharmacokinetics of drugs used by nursing parents.  They receive hundreds of calls a month about cannabis, so they decided to do a study that would improve upon what was in the literature.  The only other investigation to describe the movement of THC into breastmilk was published in 1982, had only two subjects and did not control for the dose or the timing of the consumed cannabis.  Good pharmacokinetic studies must control for the dose and timing of the drug being studied, so there was definitely room for improvement.

Drs. Baker and Hale decided to come to CO because it was already legal for breastfeeding parents to use cannabis.  It was important that the study design not appear to promote cannabis use, so subject recruitment focused on folks who were already using cannabis.

An important - and unique - element of their study design was that participants could give consent for participation just by participation.  This allowed subjects to participate anonymously and confidentially and protect them from legal retribution.  The Institutional Review Board (the IRB) in Texas reflected the way research was done in the early days of HIV - it could be risky for a person to sign their name admitting they had HIV (or were gay), so consent was given via participation, not through the traditional signature route.  Women who participated in Colorado were protected by this nuanced approach by the IRB of Texas Tech.  Another example of ethical research approach executed by Drs. Baker and Hale.

The second half of the lecture, details about the paper itself, was presented by Dr. Teresa Baker.

Dr. Teresa Baker, primary author of the paper, gave the second half of the lecture and delivered pure, delightful science!  I have broken the information down into sections for ease of reading.

The Study Design

Goal - Evaluate the transfer of delta-9-THC, 11-OH-THC and COOH-THC in human milk

Dose - 0.1g of Prezidential Kush cannabis flower (23.18 g THC)

Consumption - Smoked in an unused glass pipe

Timing of milk collection - Evaluate milk prior to cannabis consumption and at 20 minutes, 1, 2 and 4 hours after consumption

Subjects - Term baby, exclusively breastfed, 1-6 months old, abstain from all cannabis for 24 hours prior to participation, already cannabis users, able to pump and not nurse baby for 6 hours while participating, 4 reported they used cannabis infrequently (not all participants quantified their use) and one reported using cannabis 7-10 times in the past week.

A total of 9 subjects met the criteria and sent their milk to Texas for analysis.

Data from eight of those subjects are reported in the paper.

Technical note: It should be noted that instrumentation used by the Texas Tech team is the best available and their expertise is important to this project.  Extracting THC and its metabolites from human milk can be a tricky task.  1.9 ng/mL THC was determined to be the lower detection limit.

The Results

The paper reports:

1. “An exclusively breastfeeding infant ingests an estimated 2.5% of the maternal dose (range 0.4-8.7%).”
2. “Our findings demonstrate breast milk concentrations of delta-9-tetrahydrocannabinol peaked at 1 hours with a peak of 94 ng/mL (range = 12.2-420.3), and receded slowly over the subsequent 4 hours.”
3. “The results at zero hour were exceedingly low in 6/8 participants, suggesting that most participants were able to abstain from using cannabis for 24 hours before the collection of the samples.  A relatively low but measureable concentration of delta-9-tetrahydrocannabinol was found at zero time in two of the participants, which suggests some residual accumulations of delta-9-tetrahydrocannabinol either from prior heavy use or use close to the start of breast milk collection.”
4. Neither of the metabolites (11-OH-delta-9-tetrahydrocannabinol nor 11-nor-9-carboxy- delta-9-tetrahydrocannabinol) were detected in milk (their detection limit was even lower than for delta-9-tetrahydrocannabinol at 0.097 ng/mL).

Note:  The paper refers to the full scientific names of the molecules studied and refers to delta-9-tetrahydrocannabinol, which I have called “THC” throughout this document.  The paper calls the metabolites 11-OH-delta-9-tetrahydrocannabinol and 11-nor-9-carboxy- delta-9-tetrahydrocannabinol.

What are the takeaways from these results, point by point?

1. The data collected allowed the authors to calculate a relative infant dose (RID) of 2.5%.  This means that these infants were exposed to 2.5% of their mother’s dose.  Of that 2.5%, only 1-5% is biologically available to the baby orally (see above for more about the bioavailability of various methods of consumption).

The RID is a way to talk about how much would an infant receive over the course of the day if exposed to a known maternal dose.  It is based on this calculation:

infant dose mg/kg/day  /  maternal dose mg/kg/day

This resulting ratio is then multiplied by 100 to express RID as a percent. 

In the case of this paper,

Infant dose = 53.5 ng/mL x *150 mL/kg/day = 0.008 mg/kg/day

Maternal dose = 23.18 mg/*72kg/day = 0.32 mg/kg/day

0.008/0.32 = 0.025 x 100 = 2.5

the terms with an * are generalized assumptions that babies consume 150 mL/kg/day and the average maternal weight is 72kg

So, in this study, infant exposure would have been 2.5% of 0.32 mg/kg/day, or .008 mg/kg/day.  But because oral bioavailability of THC is so low, 1-5%, the amount available would have been 1-5% of that amount, or 0.00008 to 0.00004 mg/kg/day.

2. Time zero - the milk collection prior to cannabis consumption - represents the baseline THC concentration for each subject.  Subjects were asked to abstain from any cannabis for 24 hours prior to participation.  For all but two of the subjects, there was no THC detected in their milk prior to their consumption in this study. 

The detection of THC in two of the subjects could be the result of not abstaining for 24 hours, having a slower metabolism of THC than other subjects or may be indicative of consistent use.  Interestingly, the subject who reported the highest use (7-10 times in the past week) did not have any detectable THC at baseline.

3. THC levels measured at their peak one hour after smoking in all subjects, though absolute peak levels varied among subjects. 

Note that this is just the measured peak - there were no measurements taken between 20 minutes and 60 minutes (because human milk would be hard to pump at 20, 40 and 60 minutes) - so the peak could have been somewhere between 20 and 60 minutes.  These peak levels declined over the next 3 hours and were approaching the levels seen prior to smoking by 4 hours after consumption.

4. Neither metabolite was detected in the milk at any time during the study.  (For a refresher on the molecules involved in cannabis consumption and detection, check out our Molecules 101 fact sheet.) 

This may be because 1) these two molecules are more water soluble and more polar than the parent molecule THC, restricting their entry into the breastmilk compartment or 2) the relatively short timecourse of the study did not allow for the detection of these metabolites.

Next Steps for the InfantRisk Center:

Drs. Baker and Hale’s rich research program has lots of plans for the future of this topic.  They shared two main topics for immediate future research:

1. They want to study regular users.  Several observations from this pilot study suggested the pharmacokinetics may differ between occasional and regular users.  The InfantRisk Center would like to look at this variable.
2. Endocannabinoids in human milk!  Why are they there? What do they do??

Please find a full, free copy of the paper here if you have not yet downloaded it.

Questions?  Please contact Heather at 720-504-8206 or heather@ElephantCircle.org.

My take on the recent paper, "Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use."

This is part of a series of posts commenting on a recent paper on cannabis and parenting. In these analyses, I offer my years of experience reading and writing scientific papers along with a perspective centered in mammalian physiology and harm reduction.  This often results in an view that is different from the headlines that report the publishing of these papers.

This post is about the recent publication in Obstetrics and Gynecology (a leading ObGyn journal in the US), "Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. 1 "

You can read the paper here and I have also included my summary of the paper itself at the end of this blog post.   

There is a lot I could say about this paper - but today I will discuss several of the thoughts this paper brought to the forefront for me.

 

My initial thought.

I understand that doctors, health care providers and public health officials want folks to know that using cannabis during pregnancy is a largely unknown science and the risks and benefits are still unclear.  But to assert that dispensaries are offering personal opinion rather than medical evidence - and that is somehow different from the medical-legal-public health establishment - is a false claim.  The medical establishment has a long way to go in their ability to offer unbiased, non-punitive, evidence-based care, most especially in maternity care.  I would love to believe that this paper highlights the need for education on all sides, and I worry that it will simply end up being another assertion from the dominant paradigm that the marginalized narrative simply needs to “get in line.” (an assertion we see already, see this Westword article.) 

Despite the fact that the liberalization of cannabis in Colorado has moved it from the margins to the center of attention, the idea of cannabis as an “illicit” substance still exists.  More importantly, the reality of cannabis being scheduled as a controlled substance still impacts the dominant conversation dramatically in ways that prevent a harm reduction, nuanced approach.  I would love to start talking about how to really bridge this gap between parents who use cannabis and their health care providers, but I am concerned that the opposite is true in Colorado right now.  From where I stand, it often looks like the process of figuring out cannabis liberalization is widening the distance between pregnant/breastfeeding cannabis consumers and their health care providers, creating a climate of fear and retribution that will inhibit future conversations.   This paper provides many examples of the way the gap is being forged, not bridged, by the research/medical/legal communities in Colorado.

1. The medical community is not seen as the best place to talk about medicinal cannabis use when you are pregnant.  Though the paper places blame on the willingness of budtenders to give personal opinion, the truth is that the majority of health care providers are unwilling or unable to have a risk/benefit conversation about prenatal cannabis use.

As the authors noted early in the paper, women of reproductive age often feel uncomfortable talking with their health care providers about their cannabis use during pregnancy and parenting.  This certainly reflects my experiences talking to pregnant and parenting cannabis users in Colorado over the past five years.  In my experience (which, in this case, is also is backed by the scientific literature on this topic), almost no one starts using cannabis during pregnancy.  And of the folks who continue using cannabis during pregnancy, many make a specific, explicit decision to do so based on their own best risk/benefit analysis.  Much of the time these folks would be happy to consult a medical professional, but make the conscious decision to not talk about cannabis use with their health care providers.  This decision not to talk to medical professionals about cannabis use is generally rooted in one of a few concerns, 1) an abstinence-only approach being the only available conversation, 2) fear of judgement, 3) fear of retribution of some kind. 

Rarely do I hear a pregnant person feel like they have an MD who will work with them if they decide cannabis is the best medicinal choice, as ACOG recommends an abstinence-only approach with little information beyond a risk-centered analysis.  And it isn’t because OBs are not able to have nuanced conversations - because they do find ways to have risk/benefit analyses about other medications.  For example, SSRIs, a class of medication to treat depression, can result in respiratory challenges in the newborn at birth.  Even with that risk, there are times when the risk of a woman who is both pregnant and depressed is greater than the risk of newborn respiratory challenges.  And so OBs have an individualized conversation about the risk/benefit analysis with an eye for the wellbeing of the fetus and the gestating parent.  This is not the kind of conversation the medical community is generally willing to have about cannabis. 

The other problem I see with an abstinence-only conversation is the bias it must hold against someone who is, in fact, using cannabis during pregnancy.  The fear of judgement by health care providers is real and drives pregnant folks to talk to someone other than their doctors about cannabis for morning sickness (like a dispensary).  The fear of retribution is mentioned by the authors and is also a very real fear.  Medical professionals are mandatory reporters - meaning they must report child abuse and neglect.  In the state of Colorado, a positive test for exposure to cannabis in utero is defined as child abuse and neglect.  I have spoken with many OBs, nurses and pediatricians who feel the tension of caring for a patient and being a mandatory reporter.  These providers tell me that they feel that reporting prenatal substance use to the Department of Human Services is the most cautious approach to mandatory reporting and is, therefore, how they approach that element of their work.  Unfortunately, this has the long-term effect of reinforcing the worry about personal and legal retribution from their health care providers, and it discourages pregnant and parenting folks from talking about their cannabis use.

This paper highlights how cannabis users do not feel there is an accessible, non-judgmental, non-punitive conversation to be had with their medical care providers.  In fact, health care providers receive little support in promoting harm reduction, and public health agencies and professional organizations continue to center the potential risk of cannabis to a fetus being the reason for an abstinence-only approach.  While the authors contend that budtenders are often not giving advice “informed by medical evidence,” I contend that the medical establishment is not either.

2. I wish we were talking about what we learned from the “crack baby epidemic.”

(Or, what happens when we focus only on the risk and harm of the particular substance being discussed or researched.)

Our scientific inquiry into the topic of prenatal cannabis exposure, both historically and currently, has been largely funded by organizations invested in demonstrating harm or risk associated with substance exposure in utero (ie. National Institutes of Drug Abuse, March of Dimes).  There is great risk in this approach because of the bias that exists in such a situation - risk that has been documented since the “crack baby epidemic.” 

The quest to show the harm of prenatal crack exposure to babies resulted in 30 years of funded research that primarily demonstrated the harm of poverty on the development of babies and children.  The crack baby epidemic also allowed us to quantify the harm of the “null-hypothesis,” the idea that only papers that show differences between groups are selected for publication and/or presentation.  If a study shows no differences between exposed and unexposed fetus’, infants or children, it rarely becomes a part of the scientific literature.  Combined, these two elements can create a body of medical evidence that is centered only in harm/risk and is without a broader discussion of a risk/benefit analysis.  In the case of cannabis, the literature is murky enough that most medical professionals are having an abstinence-only conversation based on the potential for risk.  This is in stark contrast to conversations about alcohol, cigarettes and caffeine, all with known, demonstrated risk to the fetus.  In the case of these substances, abstinence-only might be the starting point for the conversation, but the conversation often proceeds to a more nuanced, individualized risk/benefit analysis.

3. I am just plain tired of the language that characterizes pregnant women as either ignorant of the risks of certain substances or harming their babies on purpose - and both states require management from a medical professional.

I often wonder “What outcome do the authors or the public health campaign writers expect as a result of a scare tactic approach?”  It seems they believe that if we just appropriately scare the pregnant folks with a clear explanation of the risks involved in prenatal substance use, we will educate the ones simply making a bad decision with bad information, and they will then make a good decision (to not expose their fetus to these risks).  Problem solved.  And the ones that keep using prenatal substances even with all of the properly scary information?  Their bad, selfish decision-making will be revealed, making it clear they are the parents we should worry most about.  This approach has not been successful with cigarettes or alcohol, yet his perspective drives much of the language I hear from the medical-legal discussion on prenatal substance use, and I think it is problematic.

I object to the phrase, “Future studies should focus on the effects of maternal cannabis use on maternal and neonatal outcomes in hopes of being able to provide guidelines to care for pregnant women.”  (emphasis mine).  If we are talking about the risk of cannabis exposure on the fetus, let’s not rephrase it as the risk of maternal cannabis use.  It reduces pregnant women to incompetent incubators - instead of caring parents making a choice they believe is in the best interest of their entire family and all its members.  It prioritizes the wellbeing of the fetus over that of the mother and sets up a dynamic where the medical-legal system takes the view that it is in the best interest of the baby to protect it from its mother.   As a result, separation of mothers and babies at birth is common even though this is a practice known to cause harm to both parents and babies.

The other issue I have with this phrase is that it centers the conversation only on the risk to the fetus and not on the potential risk or harm of maternal substance use on the mother herself.  What if we were concerned about BOTH the risks to the fetus AND the risks to the mother?  Moreover, what if there were potential benefits of prenatal substance use for babies or mothers? Though it may sound counterintuitive that there could be benefits, that is only because our conversation is so centered on (potential) risks.  Remember our SSRI example?  Exposure to SSRIs have the benefit of not being gestated by a depressed mother.  It turns out depression is more harmful than the medication.

The current abstinence-based conversation does not provide the nuance to hold concern for both the baby and the mother.  And truth be told, neither does the research.  The vast majority of the research on the “effects of maternal cannabis use” look only at fetal, newborn and child outcomes.  I have not seen any papers from the longitudinal studies that examine and report the wellbeing of the parents or family. 

I also object to the second part of this phrase, that future research should be done “in hopes of being able to provide guidelines to care for pregnant women.”  This language reinforces the idea that the best use of our research dollars is to provide guidelines for the people caring for pregnant women.  Be very clear, we are not looking to produce guidelines for the women to use themselves - so that they can make good decisions in consultation with their care providers.  Instead, the research is designed by the care providers for the care providers and overlooks pregnant and parenting women as valid stakeholders altogether. The narrative of the power being in the hands of the “well-informed expert” who will manage the clinical situation over the person actually experiencing the pregnancy is endemic in the maternal-pediatric health system in the U.S.  This narrative, and this power dynamic, displace the pregnant person as an expert in their own experience and ultimately strips pregnant and parenting folks of the authority and autonomy to make good decisions for their families. 

This language - these particular phrases - are pervasive in medical-legal conversations about pregnancy substance use (which, by the way is generally considered synonymous with substance abuse), and I think there is harm in talking about this issue this way.  We all know I am passionate about language and how it is a powerful tool.  That is also true here.

4. We need to remember that we don’t evaluate the safety of most of the substances used and prescribed during pregnancy.

Near the end of the paper, the authors say, “expanding legalization may increase use among pregnant women and may be accompanied by increased perception of safety without data to assure safety.”  Let me be very, very clear here.  In the United States, we almost never collect prospective data on the safety of any drugs prescribed during pregnancy.  That is not how scientific research works.  We do not believe in experimenting on pregnant folks, so we do not collect data (aside from anecdotal data) to evaluate the safety of much of anything prescribed during pregnancy.  The vast majority of drugs used in pregnancy - Zofran included, the most commonly prescribed drug for morning sickness despite never having been approved in the US or anywhere for use in pregnancy - have not been evaluated for their safety.  In clinical trials, pharmaceutical drugs are generally tested for safety on white males, the results are extrapolated to the rest of us, and these drugs are then used by collective agreement (based on data that say that more than 60% of practices by ObGyns are based on community consensus2).  The bar for “illicit,” whole plant medicines is much, much higher.  Which is part of why the cannabis research is even more limited than pharmaceuticals prescribed in pregnancy.

5.  If we are going to talk about risks and harms, let’s be thorough.  The risks and harms involved in cannabis use during pregnancy or parenting involve not only medical risks and harms, but legal ones as well. 

I know that doctors are not lawyers, but the myopic view that health risks should be the primary concern of pregnant families is just that, myopic and missing the bigger picture.  In this country, we have decided to regulate and legislate actions of pregnant individuals with the idea that it protects children.  In my view, what is missing in that perspective is that the vast majority of the time, when we resource parents with information and support, we resource kids as well. 

There are real, harmful, legal risks to using cannabis when you are pregnant in Colorado.  To talk about the potential health risks without also highlighting that one of the definitions of child abuse and neglect in Colorado law is a positive test for fetal exposure to cannabis at birth is irresponsible.  I believe it is the responsibility of the doctors counseling and researching prenatal cannabis use to understand the legal implications as well. 

And I don’t think this is too much to ask.  Doctors and nurses already participate in the legal part of the medical-legal system.  As mandatory reporters, they are already drawn into the medical-legal ways we manage pregnant people, though (in my experience) they are sometimes unsure how to navigate that intersection.  They want to care for the health care of pregnant, laboring and parenting folks.  But Colorado law requires they also be a site of investigation.  This tension is felt by providers and consumers alike.  Continuing to publish papers that ignore this tension serves no one. 

6. The final statement of this paper is this: “Public health initiatives should consider collaborating with dispensary owners and other valuable stakeholders in conversations about standards for advice provided to pregnant women.” 

I agree wholeheartedly!  And I wish I felt this paper was a step in that direction.  And I hope that this statement includes parents as stakeholders as well, not just agencies or organizations or retail operations. 

But unfortunately, once again, this statement feels like the medical establishment asserting their superiority in the cannabis conversation.  Positioning themselves as the experts over pregnant folks and dispensaries, both of whom might already be having more nuanced, harm reduction conversations based in evidence.  Despite what the results of this study may indicate.

It makes me wonder sometimes, “What do doctors and agencies think will happen as a result of their abstinence-only position?”  And in the case of this paper, “What does the medical-legal-public health establishment think parents who use cannabis will say when they invite them to a discussion that only includes the potential risks of perinatal cannabis use?”  Do they believe they are bridging informational and emotional distance between practitioner and patient?  Both consumers and dispensaries battle bias and discrimination from health professionals and agencies, making a non-punitive conversation between equal stakeholders out of reach.  This research does not feel like a step towards including consumers or dispensaries in the conversation, rather a reminder that they don’t hold the “correct” information and are not to be considered equal stakeholders in a conversation about perinatal cannabis use.

For me, both the study design and presentation of the results of this paper feel like the medical establishment attempting to shame dispensaries and pregnant folks into talking to their doctors.  This is unfortunate.  In my experience, shaming techniques rarely work during prenatal care.  The doctors who provide care for folks who use substances during pregnancy with a non-punitive, open and transparent relationship generally see the best results in improving the wellbeing of both the infant and their parent(s).   

To close.

I am going to come full circle here and simply repeat what I said in the beginning.  From where I stand, it often looks like the process of figuring out cannabis liberalization is widening the distance between pregnant/breastfeeding cannabis consumers and their health care providers, creating a climate of fear and retribution that will inhibit future conversations.  This paper provides many examples of the way the gap is being forged, not bridged, by the research/medical/legal communities in Colorado.

References:  

1. Dickson, B. et al. Obstet. Gynecol. 131, 1031–1038 (2018), 2. Wright, J. D. et al. Obstet. Gynecol. 118, 505–12 (2011).

---------------------------------------------------------------------------------------------------------------------

The gist of the paper:

Two folks from Denver Health (the major public hospital in Denver, CO) called 400 dispensaries (medical, recreational and both), posing as a pregnant person, 8 weeks along, looking for relief from morning sickness.  The majority (69%) recommended a cannabis product primarily (65%) based on personal opinion.  The paper states that 82% of the budtenders suggested the “pregnant” caller talk with a medical professional, but many but only 32% mentioned a health care provider without being asked about it by the caller.

Introduction and primary objective:

The authors open the paper with the expected reference to the stance of the American College of Obstetricians and Gynecologists (ACOG), “obstetrician– gynecologists should be discouraged from prescribing or suggesting the use of marijuana for medicinal purposes during preconception, pregnancy, and lactation.”  The authors follow with their concern that “expanding legalization may increase use among pregnant women and may be accompanied by increased perception of safety without data to assure safety.”

They acknowledge that “Pregnant women who are interested in using marijuana may refrain from seeking safety information from health care providers as a result of fear of legal repercussions and instead seek advice from cannabis retailers.”  This concern leads to the study’s primary objective, “to estimate the proportion of cannabis dispensaries that recommended cannabis products to a caller posing as pregnant and experiencing nausea in the first trimester of pregnancy.”

What did they find? 

The primary question of the paper asked how many dispensaries would recommend cannabis to a pregnant person for first-trimester nausea.  Of the 69% dispensaries that recommended a cannabis product, 65% of the budtenders revealed that their recommendation was based on personal opinion.  Medical dispensaries were most likely to base their recommendation on personal opinion (85%).

The secondary finding most highlighted by the paper and the subsequent press coverage was whether budtenders suggested the mystery caller talk to their health care provider.  The study reports that, by the end of the call (which lasted about 2.5 minutes), 82% of the budtenders suggested the “pregnant” caller talk with a medical professional.  The paper noted on several occasions that only 32% mentioned a health care provider without prompting; retail dispensaries were the least likely to mention a health care provider without prompting.

A few other statistically significant secondary findings were interesting.  Nearly all (99%) dispensaries recommended a specific type of cannabis combination of THC and CBD with 26% recommending CBD-only products, 17% recommending THC only products and the remaining 56% recommending combination THC/CBD products.  The finding that only 15% of budtenders warned the consumer of possible legal implications (medical dispensaries offered this warning more than other dispensaries) is not surprising, but is important.  The legal implications of a newborn who tests positive for exposure to cannabis are a critical part of this public health conversation.

What did they conclude from these findings? 

Pretty much what you would expect.  They reiterated the professional organizational stance from the American College of Obstetricians and Gynecologists (ACOG): “given the concern for potential adverse effects on the fetus with maternal cannabis use, ACOG recommends against the use of cannabis products in women who are pregnant.”  The authors went on to discuss the warning required by law on all cannabis products that says there “may be health risks associated with the consumption of this product for women who are pregnant, breastfeeding, or planning to become pregnant.” Still, the authors expressed concern this warning did not go far enough, saying, “Despite this warning, Colorado and other states that have legalized marijuana have refrained from prohibiting marijuana use during pregnancy….” and “there are currently no regulations about recommendations or advice that cannabis dispensaries can provide to customers in Colorado.”

The final paragraph reads, “This study prompts many questions about laws and regulations pertaining to cannabis dispensaries. As cannabis legalization becomes more common, women should be cautioned that advice from dispensary employees might not necessarily be informed by medical evidence. Future studies should focus on the effects of maternal cannabis use on maternal and neonatal outcomes in hopes of being able to provide guidelines to care for pregnant women. Public health initiatives should consider collaborating with dispensary owners and other valuable stakeholders in conversations about standards for advice provided to pregnant women.”

About me

I am a scientist, with a Masters in Biochemistry and a PhD in Molecular and Cellular Biology.  I have worked in various aspects of Maternal/Child health for over 20 years, including clinical, human research, in-home postpartum care, and serving as the Director of Research at a midwife-led, freestanding birth center.  My beliefs about birth and parenting are rooted in physiology, specifically mammalian physiology, and I believe birth is a biologic moment with lots of potential for long-term imprinting, both good and bad.  The concept of harm reduction drives my work to promote evidence-based conversations that reduce the stigma of parental cannabis use to improve the wellbeing of parents and children.  I advocate for less biased, less punitive conversations about parents who use cannabis but I do not consider myself a cannabis advocate.

Publication of Colorado data! "Transfer of Inhaled Cannabis Into Human Breast Milk" by T. Baker, P. Datta, K. Rewers-Felkins, H. Thompson, R. Kallem and T. Hale.

 

Obstetrics and Gynecology, April 2018

Elephant Circle’s involvement

As many of you know, Colorado has a law that says that an infant who tests positive for exposure to a Schedule I or Schedule II substance is an automatic finding of child abuse and neglect.  When we heard about Dr. Teresa Baker and Dr. Thomas Hale’s research, we worried that participation in their study could land participants in hot water with Child Protective Services.  So we offered to think through that issue with them with great success! Their home institution, Texas Tech, helped them navigate the human subjects’ approval process with lessons learned from the early days of HIV research.  The result was an anonymous consent process, which allowed participation without worry of state involvement.  Hurrah!

Our involvement continued through data collection and we were specifically involved in subject recruitment in two ways.  First, our work supporting perinatal families who use cannabis provided us access to a unique population and previously established relationships that allowed us to encourage and support participation.  Further, many lactation and health care professionals worried that recruiting subjects could jeopardize them professionally because of their license and/or board certification.  One of the advantages of Elephant Circle being a small, independent organization is that we could lean into this risk more fully.  As a result, we found ourselves creating opportunities for folks to participate in order to boost the numbers.  It was hard work!

In case you don't have access to the paper itself, we wanted to make sure you could access the highlights!  Here is our summary of the paper and its findings.

The goal of the study 

To accurately determine the transfer of Delta-9-Tetrahydrocannabinol (D9-THC, the primary psychoactive molecule) and its metabolites (11-OH delta-9-THC and 9-carboxy delta-9-THC) into human milk at 20 minutes, 1 h, 2 h, 4 hours after smoking 0.1 g of cannabis containing 23.3% THCA.  A baseline sample was also collected 2 hours prior to cannabis consumption. (For a review of the molecules involved in cannabis metabolism, please refer to this guide.)

The subjects 

Eight lactating women participated in this study.  All participants were 2-5 months postpartum and were not supplementing with artificial milk substitutes or solids.  Half of the participants reported they smoked cannabis infrequently and one smoked cannabis 7-10 times during the prior week (3 participants did not answer these questions).  Participants were not taking any other medications.

Baseline D9-THC levels in human milk

Prior to cannabis consumption, D9-THC levels were exceedingly low in 6 of 8 subjects (< 2 ng/mL), suggesting that most subjects were able to abstain from using marijuana for 24 hours before the collection of the samples. The other two subjects had low but measurable levels of D9-THC (5.8 and 15.8 ng/mL) possibly due to residual accumulations of D9-THC from prior heavy use or use close to the start of milk collection.

THC levels after smoking 0.1 g cannabis

D9-THC levels were detected in the human milk as early as 20 mins after smoking and peaked at 1 hour (94 ng/mL, range 12.2 - 420.3 ng/mL) in the milk samples.  These data suggest that an exclusively breastfeeding infant ingests 2.5% of the maternal dose (range 0.4-8.7%) and demonstrate that D9-THC levels decline quickly in the breastmilk compartment.  By 4 hours after smoking, D9-THC levels were much lower (25.62 ± 6.8 SEM).

Conclusions

These pilot data demonstrate that, after smoking 0.1g of cannabis, the psychoactive molecule D9-THC enters the breastmilk compartment rapidly, peaks at 1 hour and is returning to baseline by 4 hours after consumption.  Moreover, despite differences in absolute levels of D9-THC in their milk, THC peaked and declined in a similar timeframe across all participants.  Finally, given the very low levels of D9-THC at baseline and the rapid decline after smoking, these data do not support the idea that D9-THC lingers in breastmilk because of its high fat content.

For the nerds out there

Several pharmacokinetic parameters for D9-THC were calculated using the data collected for this paper (n=8).  Specifically, the median area under the curve (AUC) was 110.5 ng/h/mL (range: 33.9-744.4), the median average drug concentration across the dose interval (Cavg) was 27.6 ng/mL (8.4-186.1), the median maximum drug concentration across the dose interval (Cmax) was 44.7 ng/mL (12.2-420.3), the median time at which the max occurred (Tmax) was 1 hour (1-2), the median infant dose was 4.1 micrograms/kg/d (1.3-27.9) and the median relative infant dose (RID) was 1.3 (0.4-8.7).  Enjoy!

Clinical application?

Certainly, further research is needed for a complete understanding of the pharmacokinetics of D9-THC in breastmilk in addition to the clinical implications on cannabis use on parenting and infant neurodevelopment.  However, these pilot data suggest that, like alcohol, there may be a day where it is possible to talk to lactating parents about the peak and fall of D9-THC exposure via human milk after smoking cannabis.  We certainly aren't there yet, but this paper is a good place to start an evidence-based conversation with well-collected data.

Read the full paper here.

Circling Back to Midwifery

I vividly remember the day I fell in love with midwifery. Of course, it was the day that my baby was born. In addition to the awesome experience of giving birth, I got a front row seat to midwives in action that day. I can still feel the quiet energy of the student midwife in apprentice-mode, watching and learning with so much love and awe and respect it felt like a heat-lamp on a cold day. I felt that kind of awe and respect for my midwives after the birth, when they were huddled together, reverently discussing each stitch of the repair they were making where I tore. Their care for me and my family is forever etched in my memory.

I don’t think that story threatens women, even though it doesn’t contain a gendered pronoun or the word “woman.” If you don’t know me and read that paragraph, you probably pictured a woman, and probably not a woman who is sometimes called “he.” That’s why I tell my story, so that we have more stories, not less.  The beautiful thing is that our stories can co-exist.

*          *          *

The Midwives Alliance of North America (MANA) recently hosted a gathering for queer and transgender birth workers as a pre-conference offering at their convening in Long Beach, CA. I co-facilitated this event. And while we gathered to talk about midwifery, the struggles of clients and families, and how midwives can maintain their stamina while supporting women and birthing people, people on social media questioned the legitimacy of our presence. They questioned the premise of the gathering, and whether it should be happening at all.

Then they began to question MANA’s decision to include gender inclusive language in their core competencies and conference materials. They questioned MANA’s commitment to women, their leadership and decision-making processes, and they questioned the conference before it even began. As the conference ensued, questions festered and swirled about race and power, history and respect, voice and violation. Questions were raised about my involvement with MANA, and many derogatory insinuations were made.

While it was not my idea to bring gender-inclusivity to MANA, the women who thought of it rightly wanted to consult with a transgender or genderqueer person, so here I am. I’m not spearheading MANA’s gender-inclusivity work, but something separates me from others who are: my gender expression. This is no coincidence. I am a target because we are not equally vulnerable to suspicion. It is always easier to demonize the “other”. It is always easier to assume the worst about someone when they are different from you.

*          *          *

I envision a time when a diverse body of midwives can work together strategically and in collaboration with supporters to make it easier to become a midwife, remain a midwife, and access a midwife. I envision a future where there are simply more midwives-- of all kinds and for all communities.

I have made it my life’s work to help make this happen.

Some of the things I’ve done are very tangible, simple even. For example, certain practice restrictions in Colorado were creating barriers to remaining a “direct-entry” midwife, so I helped remove those barriers in 2011 and 2016. Midwives couldn’t suture, midwives couldn’t carry or use anti-hemorrhagic drugs, midwives couldn’t carry or use oxygen. So, I helped fix those things.

Midwives often need legal representation, but when they try to find it they can’t find a lawyer who understands the profession, which can lead to bad representation. So, I started the Birth Rights Bar Association to try and develop more knowledgeable lawyers who could provide more high-quality representation for midwives.

Some of the barriers to midwives are universally recognized, like the cost of hiring one, or the cost of becoming one. But some of the trickiest barriers to midwives and midwifery care are the ones some people think of as untouchable. Things like assuming that you can get somewhere (like through midwifery school) if you just work hard enough. Or assuming that it is easy enough to find a preceptor and train as a midwife close to home, because you easily found one who is just like you (or enough like you) in your own community.

These things aren’t historically true for midwives of color, because they have told us so over and over again. My great-grandmother wasn’t disadvantaged in the same way that white, English-speaking, community healers were, even though any woman healer was disadvantaged in the 1920s. As a Spanish-speaking Hispanic woman she had different barriers. We have to remove those kinds of barriers. To do that, we all have to consider if things we hold dear (even our own assumptions) are blocking someone’s way.

Midwives of color experience barriers in mostly-white organizations and spaces, so I try to help tackle those barriers too. Like by coaching white folks to recognize and help remove those barriers, interrupting the dynamics that play out in mostly-white spaces, and building community power with folks of color who are already leading the way.

*          *          *

Where there are barriers to having and becoming a midwife, I strive to be part of the circle that helps to remove them. When there are more midwives, it’s easier to have one or be one. When midwives can practice to their full scope, it’s easier to have one or be one. When they aren’t criminalized, it’s easier to have one or be one. And removing the barriers of racism to make it easier to have a midwife of color - those benefits of that are vast, including directly improving atrocious birth disparities.

I have a bias toward action. If things start to feel sticky or stuck, I figure things out by trying things out. I don’t just think or say, I do.

It may seem odd, but sometimes this means I wait a lot. It’s a deliberate and active kind of stillness. If you’re ever done improvisational theatre (or watched it), you might know the feeling of the actors listening and waiting until the right moment to jump in. It’s like that. I’ve heard midwives say that the very art of midwifery is not doing anything at all, and then knowing exactly when to step in. Maybe it's like that, too.

I keep trying to do better in my work. I mess up, and I don’t turn away from failure or let shame take over. I just try to look at it, learn from it, adjust, and try again. Having my privilege checked is an essential part of this. To have skin-color privilege while working in and for circles of people without that privilege requires me to be aware of and responsible for that unearned power.

Whenever I am involved in this work, I try to make each circle better: create action where things are stuck, wait a lot, and learn from my mistakes. I constantly practice these things.

And I am in a body that has experienced all of this, and all the pronouns, and birth. I am a person who adores and admires midwives, and is here to support and champion your work. I see many ways forward for all of us, together. I hope that I’ll see you along the way.

Update on the Colorado Birth Center Rulemaking Process

This post is an update to an earlier post about the Colorado birth center rulemaking process. The Colorado Department of Public Health and Environment facilitated a stakeholder process to revise the rules that govern Birth Centers in Colorado for the first time in over 30 years. [Update: the final version of the rules as adopted are here.]

The rulemaking hearing will be July 19, 2017 at 10am at Sabin-Cleere Conference Room, Colorado Department of Public Health and Environment, Bldg. A, 4300 Cherry Creek Drive South, Denver, CO. 80246. The public is invited and we encourage you to attend. The new rules are excellent and the Board is expected to approve them, so your presence alone sends a loud message from birth center consumers that the Board is doing the right thing in protecting and expanding this model of care.  

The process and the proposed rules have been a great success so Elephant Circle and the Colorado Birth Center Coalition will have a reception following the hearing across the street from CDPHE at Creekside Park to celebrate! Please join us immediately following the hearing or as early as 11:30am! Bring your lunch (there are many places nearby where you can pick up food), we will have some cool drinks and treats, plus materials to help spread the word about birth centers.

Information about the proposed rules is available in this document (scroll down or use the "find" function to search for "birth centers"). Written comment must be received by 5pm on July 13, 2017.

We encourage comments that state your support for the proposed rules and describe your experiences with Colorado birth centers. You can send your comments to Lorraine Dixon-Jones at CDPHE, lorraine.dixon@state.co.us or Jamie L. Thornton, at CDPHE, cdphe.bohrequests@state.co.us - or mail them ATTN: Jamie L. Thornton, 4300 Cherry Creek Drive South, EDO-AS, Denver, Colorado 80246-1530.

An example of written comments is, "My name is XXX YYYY, and I am a Colorado resident. My child was born in a Colorado birth center in 2016. A birth center was the right facility for me and my family because it allowed us to have an intimate and intervention-free birth that supported the physiologic process of both me and my baby." Your comments do not need to be long. If you have specific issues you want to address feel free to add details like for instance, "Under the previous birth center rules I was not able to choose a birth center for my birth but instead gave birth at home. I am glad to see that the new rules no longer exclude moms like me who had a previous cesarean from giving birth in a birth center."  

Elephant Circle and other stakeholders worked hard to expand the Clinical Staff in Colorado birth centers to include Certified Professional Midwives (CPMs). Draft language was reviewed including and defining them, and the department staff and other stakeholders were open to these changes.

However, the Department of Regulatory Affairs that oversees CPMs indicated that the definition of a CPM in Colorado would have to be legislatively changed before they could be added as Clinical Staff. This, despite our formal petition to DORA requesting a rulemaking that could address this instead of legislation. We will continue to work on this, but still encourage consumers to express their support for CPM Clinical Staff during this open comment period. 

Elephant Circle supplied the Department of Public Health and Environment with many studies and papers on various issues related to the birth center regulations, and also created and submitted the following fact sheets which may be of interest when developing written comments: 

• Context and History of Birth Centers and Midwives as Clinical Staff in Colorado
• Key Characteristics of a Birth Center and Facility Requirements
• Certified Professional Midwives as Clinical Staff in Colorado Birth Centers
• VBAC and Birth Centers in Colorado
• Mitigation of Risk in Birth Center Care
• Managing Birth Center Admissions for Varying Clinical Staff
• CNM and CPM Scope of Practice Comparison in Colorado
• CPM Practice Settings 

The changes to the rules were comprehensive. The agency described the changes well in their Statement of Basis and Purpose (which you can find here by searching birth centers), here is an excerpt:

The entire regulatory chapter for birth centers has been revised to enhance the safety and well-being of clients. While most of the revisions clarify and enhance existing requirements, some amendments delete obsolete provisions and others establish new requirements. Examples of changes are shown below. Examples of Deleted Provisions - The requirement that certified nurse midwives (CNMs) have “a backup agreement with a physician who will accept calls and referrals” has been deleted. This provision became obsolete when the Nurse Practice Act was changed to allow CNMs to practice independently. - Currently, the regulations specify high risk factors that preclude eligibility to birth center care, such as certain levels of hypertension. Since these specifications can become outdated when medical standards change, they are being deleted and replaced with provisions that require facilities to establish risk factors based on national standards of birth center care. This allows facility practices to evolve with changes in professional practices... In addition, the entire chapter has been reformatted to more closely align with the regulatory chapters of other facility types, such as ambulatory surgical centers.  

If you value having the option of a birth center birth in Colorado, we hope you will participate in this important public process in some way. Whether it be by submitting comment, attending the hearing, attending the celebration, or all three!  If you have any questions, don't hesitate to contact Elephant Circle at 720-504-8206 or emailing Indra or Heather: indra@elephantcircle.org or heather@elephantcircle.org

Circling back to Ina May and the conference in Texas

Edited to add:

After publishing this, I learned another terrific lesson on critical importance of language and saying what we really mean.  Dr. Monica McLemore appropriately reminded me that phrases like “racial disparities in birth outcomes,” or “race is an independent risk factor in birth outcomes” imply there could be something inherent about black (or indigenous) skin that affects parents and babies at birth.  And, to Dr. McLemore’s point, in the past few weeks I have seen a number of birthworkers trying to work out the biologic relationship between melanin and birth.  (There is none).  So I want to be very clear about what we know:  it is the exposure to racism that negatively affects the health and wellbeing of Black and Indigenous birthing families.  Indeed, the exposure to racism has biologic implications (such as increases in the stress hormone system), that affect health and birth.  But it is the experience of racism that changes birth outcomes.  The experience of racism is intergenerational and daily – navigating systemic racism in every part of life changes a person’s biology.  These data are very clear - there is no doubt in this scientific conclusion.  So, in fact, it is more appropriate to say that the exposure to racism is an independent risk factor for birth outcomes.  This post has been edited to reflect this new understanding.

It has been a few weeks since the conference in Texas where Ina May Gaskin’s answer to a question initiated a conversation that exploded on social media.  It created an intense flurry with the usual divisiveness and defensiveness.  The entire situation caused harm to many.

And yet, I believe Ina May has handed us a terrific opportunity to examine a number of specific examples of systemic racism and white supremacy at work.  Further, given that Ina May is a white woman and hero to (mostly) white women in the US, a critical interrogation of the interchange and the resulting response may bring us – us white women - one step closer to understanding our own participation in white supremacy.  Which, I hope, will bring us one step closer to how to disrupt systemic racism more effectively.

Before I begin, I want to be clear about who I am and what I hope to offer.  I am a birthworker and a white woman attempting to navigate what it looks like to disrupt white culture in practice– and I think Ina May provided a moment to learn from.  I offer these thoughts outside of the traditional judgement, guilt and shame that keep us from being bold – but with an attitude of curiosity, empathy and compassion.  I want us all to move with intention beyond an intellectual analysis into a place of action.

Her age

I want to get this one right out there.  I understand that Ina May is 80-something years old.  That has no bearing on how I feel about this or evaluate the situation.  If she is competent to continue to use a stage as a platform, I feel I must hold her accountable for all the things she says if she is 15, 45 or 80.

She didn’t know better  

From what I understand, Ina May absolutely knew better as there have been concerted efforts to make sure she understands the impact of the exposure to racism on birth outcomes and reports that she has previously spoken to racial disparities in birth outcomes.  Regardless of her personal history with this information, it is not new news: we have known that exposure to racism is an independent risk factor for maternal and neonatal mortality for 10-15 years.  It has been in the public eye for a decade now (see PBS’s 2008 video here).  As a birth advocate, Ina May should have known. In my view, every birthworker in the US should understand the current reality and historic context of Black and Indigenous families. I feel very strongly about this. 

When I shared this history/perspective with several white women – they replied that they hadn’t known that Ina May had been told before and, knowing that she had previous access to the information increased Ina May’s responsibility.  White women!!  We must stop this!  We must stop excusing our elders for centering whiteness once again.  We must expect, from our leaders and ourselves, that disrupting white supremacy will take all of us stepping up every single time we can.

The apology

I don’t want to spend much time on this, because the apology was not to, for or about me.  I suppose publishing an apology was better than silence, though in my view the apology sounded canned and inauthentic.  It is unclear to me if the apology itself caused harm, but it may have.  I also believe that apologies are best when they take place in the same venue as the harm, so I would have preferred to see a video apology.  Enough said.

The “shero” element

I am quite sensitive to public shaming.  I have witnessed it and lived it.  My goal in this conversation is not to knock a hero off her pedestal.   However, I am also extraordinarily sensitive to the ways in which we are not talking about the role of racism in maternal and family health in this country right now.  Particularly in midwifery. 

I feel frustrated and angry that this particular hero is credited with being the matriarch of “modern out of hospital midwifery” in the US.  She deserves lots of credit for highlighting a wealth of knowledge of midwifery and her persistent courage in speaking about her experiences at the Farm.

But midwifery in the US has a much longer history than that.  We rarely if ever talk about the countless black women, the grand midwives, who attended out of hospital births for much less glamorous reasons.  They attended births when no hospital was available to communities of color, keeping traditions of midwifery alive when white folks were benefiting from the gynecologic/obstetric advances perfected on the bodies of black female slaves without their consent and with inhumane treatment (thank you Anarcha, Betsy and Lucy).  Why didn’t I see pictures of grand midwives repeatedly during Women’s History Month in my FB feed?  I saw Ina May as the matriarch of midwifery over and over.  I worry part of the reason for this is that white birthworkers do not know the history of the Grand Midwives. If that describes you - please educate yourself now.

Part of what I have heard from women of color is that Ina May was never their matriarch precisely because she has never been speaking to their reality.  White women must understand this.  One of the problems with the idea that Ina May is a Hero is that Ina May was actually a hero for white women.  Some of what I heard from black women is that their speaking out did not knock Ina May off her hero status because she was never a hero for their communities.  In my view, part of the reckoning with this situation is that we need to understand that white heroes for white people may not be heroes for all people.  We must stop making that assumption. 

I also want to speak to the impact of white supremacy on our white heroes.  They grow into leaders, in part, because of their ability to navigate white culture.  In that navigation, they swim ever more deeply in white culture and it gets harder and harder to remind themselves what is outside white culture.  As a result, unlike leaders of color who must navigate race every day, my experience with white leaders is that they are not as prepared to speak to race and racism as their colleagues of color because that ability has not been honed by their every life experience.  In fact, white leaders succeeding at white culture are invested in not seeing their complicity in white supremacy, which keeps them from seeing, which makes them more complicit - and the cycle continues. Our white heroes are bound to disappoint us when they demonstrate white supremacy. And we need to understand the system was built and maintained that way.

How we deflect talking about race specifically (and why this a benefit of being white).

The issue of whether Ina May said “racist” things or not doesn’t feel like the central issue to me.  Rather, it is the way Ina May dealt (or did not deal) with a very direct question about race and mortality that is problematic for me.  And in my opinion, it is a lesson all of us white women in birth should examine closely.  It is a pattern that I experience us repeating over and over and I want us to learn something from Ina May’s response.  I want to make different choices myself if presented with a stage and a question like that. 

What I saw in the video reflected something I see over and over in the birth world.  Ina May refuses to talk directly to the role of racism on birth outcomes for African Americans and Indigenous communities.  Tasha Portley, the person asking the initial question asks it once – relating it to her own experience in her own community – and Ina May replied with statements about nutrition and poverty and overcoming these risk factors.  Tasha Portley asks the question more directly the second time – uses the word race in fact – and still Ina May refuses to use the moment to highlight what we all need to know: EXPOSURE TO RACISM changes birth outcomes for parents and babies.  I am not going to break this down in this post (for more information look here) – but we know for certain that the stress of racism is passed down through generations and affects pregnancy and birth dramatically.  These stressors transcend class and education and are not related directly to poverty.  They are directly related to white supremacy increasing the stress of black and brown bodies their entire lives, including in the womb. 

Instead of using her platform to talk about something we white birthworkers all need to be talking more about, Ina May talked about poverty and the Amish and that more prayer might go a long way towards improving birth outcomes.  I agree that community and centered spirituality is a terrific way to improve outcomes and experiences, but it completely missed the mark of the question.  Even worse, it redirected the conversation away from the essential topic: RACISM.  Increasingly I try to stand in a perspective that if I am not actively disrupting white supremacy and white culture, I am complicit with it and upholding structural inequities.  Ina May’s silence was a failure to disrupt.  In that moment, she upheld white supremacy rather than actively dismantle it.

I am not judging Ina May except that I am disappointed she missed an opportunity to talk about all the data we have on the topic of racism and birth outcomes.  I always hope my heroes use their platform to raise awareness about the topics that scare us.

What next?

White folks, we can go our whole lives and not talk about our race.  This is one of the benefits of whiteness.  So when a situation like the one in Texas gets as much coverage as it does – we need to be very careful to recognize that just because we are new to the conversation does not mean it is a new conversation.  I encourage us to move quickly past our discomfort with the conversation and all its implications, aware that it is our white privilege to expect comfort at any given time.  We are used to being racially comfortable nearly all the time - another benefit of whiteness - and this can make us quite resistant to the hearing about the pain racism causes to other communities. I hope that we can stand back and listen to and acknowledge the hurt.  We should not need evidence of the harm, instead, let’s listen to and learn from the experiences of those who have been harmed by our failure to talk about whiteness and racism.  

I challenge us all to raise our voices and talk loudly and regularly about the effects of racism (yes racism, not race itself) on birth outcomes.  There is plenty to talk about – intergenerational stress, healthcare inequities, bias at every step of the way – so we need to start talking.  And we need to start acting to disrupt these systems that perpetuate these outcomes.  As white women in birthwork, we need to be actively working to change these outcomes by supporting leaders in communities of color who have the knowledge and skills to drive real change.  For me, to learn from Ina May’s silence is to commit to speaking out about racism and birth outcomes every chance I get with everyone I know.  And to donate my time and resources raising voices of folks of color whose work aligns with the change I hope to see.

Will you join me?

Working Ecologically

I recently read this great piece in Colorlines about the Ella Baker tradition of leader-full movement building.

Ella Baker was a civil rights activist who worked to help “everyday people channel and congeal their collective power to resist oppression and fight for sustainable, transformative change.” She’s described as working in many concentric circles, strengthening each group she was part of, forging sustainable ways forward. She worked in a way that helped the whole ecology improve.   

This is something I aspire to, to improve each group I am a part of. It is an ongoing challenge to balance my own ego and blind spots with the competing demands of other individuals and organizations. And that is why I believe in and am inspired by “group-centered leadership,” because the challenges are the antidote to broken systems that systematically oppress certain people. The concentric-circle approach has built in feedback-loops and pressure points just like healthy ecological systems. Healthy ecological systems are in balance, no one has all the power all the time.  

The dynamic tension of working ecologically helps us hold each other accountable, helps ensure that many different people have access to power, and helps prevent one person or group from growing too big. This is why Elephant Circle prioritizes working collaboratively with so many groups: we want to be held accountable by what is healthy for the whole. 

In this graphic Elephant Circle is at the center only because that's where we are standing, not because the ecological system begins or ends here. Each point on the circle is a circle of it’s own, connecting with many other circles. The background forest is meant to indicate the depth and complexity of the whole. Elephant Circle is but one tree.

To be accountable to the Denver Health Doula Program, or COLOR, or New Legacy Charter School, or birth workers of color in general, the centrality of Elephant Circle, or myself, has to be checked. Having privilege checked is essential to dismantling systems where people are given unearned power. To have skin-color privilege while working in and for circles of people without that privilege requires me to be aware of and responsible for that unearned power. The same is true of all kinds of privilege, of course. 
 
By being involved in many circles, and being oriented to lifting up each group I am part of, I am constrained by the needs and demands of each of those circles. I believe that working ecologically means forging sustainable ways forward from that constraint. Because my growth is bound up with yours, my freedom is tied to your freedom. 

My Gender Inclusive Language Experiment

As I have mentioned before, words and language are important to me.  I have deep respect for the power of words in our understanding of ourselves and each other.  I appreciate that language is fluid – that it is not meant to be static but evolving, reflecting shifts in culture and new understandings.

A few years ago, the birth community had a moment of deep divide around language.  When the Midwives Alliance of North America (MANA) revised their Core Competency document to reflect a growing desire for less gendered language in our culture in general, including birth, there were strong and varied responses.  There were rumors that that the words “woman” and “mother” were erased completely from the document.  In fact, the language was revised to be more balanced with woman or mother being used about half the time and a more gender neutral term (like pregnant person or parent) was used when possible.  As I understand it, the motivation and intention was to expand the language to achieve more balance.

But to some, it felt more like erasure than balance.  I participated in many discussions where folks worried that using gender neutral language would erase the feminine from birth.  That by not saying woman, we were going to change the experiences of the women we serve.  I heard a number of birthworkers say that if there was ever a place where gendered language was appropriate – perhaps even essential – it was birth.

This last point was especially tricky for me, as I personally found the binary gendered language and experience of being pregnant, mothering and breastfeeding very difficult.  I have struggled with both my sense of my own gender and my gender presentation for as long as I can remember.  I found it hard when my breasts blossomed and I didn’t look like the flat-chested human I pictured (and desired myself to be) in my head.  I had femme moments too, mostly when I was not expected to be.  I found I was attracted to people of all sexes and genders and enjoyed thinking of gender as a spectrum more than a binary.

And then I got pregnant just a few months after moving to a new town.  I didn’t have that many friends and the ones I had were not parents yet.  As my belly grew, I found myself increasingly uncomfortable with the gendered maternity clothes and the way I was supposed to be reveling in my womanhood.  I birthed at home with a midwife (in part to help me navigate the gendering of corporate healthcare) and my care was fantastic and empowering.  And very, very gendered.

To be quite honest, being pregnant really freaked me out.  It thrust me into a gendered world I had avoided for a long time.

Breastfeeding and mom’s groups weren’t much better. Especially since once the baby was earthside, everyone wanted to gender me AND my baby.  It is only in hindsight (and moving back into more genderfluid communities) that I have been able to reckon with the anxiety these issues produced in me during that period of my life.

So I was very curious about how birthing families might feel when they attend a presentation that uses a lot of gender inclusive language. For the past 7 years, I have been working to use increasingly gender inclusive pronouns in my work with birthing families, so it comes easily and naturally to me.   When working one-on-one, I always ask families what sorts of names and words and terms they use for themselves.  I try to make no assumptions in that context.  But in the context of group education, I didn’t know how folks felt about my language.  And I thought it was important to know given the strong reaction to MANA’s language change.

So of course, being a scientist, I decided to conduct an experiment.

The Experiment:  

Subject pool

I have been collecting data since October of 2015.  I have talked to 242 individual folks (N=242).

I had easy access to a population, as I work as an educator in a community birth center.  The data are divided about equally between people who took a class with me at 28-32 weeks of pregnancy and people coming to a birth center orientation to see if our model of care was a good fit for them.  The demographic is primarily white, 80% private health insurance and most folks have a high school education. 

The questions

I asked five questions with very little variation and I always consented folks before asking.  I assured them their data would be de-identified and requested their honesty. 

The questions were as follows:

·      Did you notice that I used a fair bit of gender neutral language? (Edited to add: I wish I had asked this question with the term gender inclusive language.  It is what I would say now, but I did not have that awareness at the time of this experiment.)

·      Did it bother or distract you?

·      Did it change the way you feel about your own journey?

·      Did it detract from your experience?

·      I ended by asking if they had any other comments to share.

I also collected data on their apparent gender presentation (where I assigned male or female) and whether they were the partner or the pregnant person.  Anyone who was not the pregnant person went into the partner category; there were a few family members or other support people.  

It is very important that I note that these data are significantly limited by the fact that I decided not to ask people to identify their gender.  I made that difficult decision in an effort to center the questions above and keep conversations short.  I do understand and feel concerned about the inherent problems with this.  Especially that it has the potential to erase gender non-binary folks.   I hope to improve on this in future research.

Results

There were 129 apparent females and 103 apparent males.  I know of 5 self-identified lesbian couples.  The other females may have been partners or support community; I did not gather those data.

Of the 113 folks who noticed my gender neutral language, 72% (n=81) of them were apparent males.  Of the 32 apparent females who noticed, 10 were females in known lesbian relationships.

Interestingly, as the numbers indicate, it was not uncommon for apparent male partners of pregnant folks to notice the gender neutral language even when their partner did not.  A number of pregnant folks were in shock that their partner noticed and they did not.  One woman asked her husband, “Really?  Are you sure?  How did you notice something like that and I didn’t?”  She was not the only one who expressed this sentiment.

The apparent males who noticed my language shared a consistent experience of listening to me.  They were relieved by the shift from female-centered birth preparation into parent-centered preparation.  They reported that they felt more included in the pregnancy, birth and postpartum period. 

For example, I often talk about the non-breastfeeding parent and received feedback that it helped them feel more included and relieve the liability they felt about not having the breasts that everyone talked about so much.  One partner put it well when he said, “I have been wondering what role I would play with the baby since we talk so much about how much time the baby will spend breastfeeding.  Calling myself the non-breastfeeding parent helps me feel like I have a role.  That breastfeeding is probably going to be a big tool, but it is only a tool.  I just need to find the tools that are unique to me.”

My use of gender inclusive language bothered 4 people.  Three of them were pregnant and the other was an apparent male partner.  The only person who felt it detracted from their experience was the male partner.  He expressed dismay that I undermined the essentialism of gender when talking about birth.  He asked me a number of questions about why I used such language and we chatted for a few minutes.  At the end he said he was particularly bothered by the term “pregnant person.”  He exclaimed, “I mean, if woman isn’t woman when it comes to birth – how do we ever know what woman is?”  I was not sure how I would reply, but it turned out I didn’t have to.  His pregnant partner said, “Come on, I’ll explain to you in the car.”

Some of the results of this small experiment surprised me.  The results do support the idea that the dominant culture (in this case, enjoying the femaleness of birth preparation) hears themselves in lots of language.  Because they don't hear themselves being represented (and therefore being seen) marginalized folks feel appreciative of language that intentionally includes them.

What surprised me most is that so many apparent male partners noticed and appreciated the language.  Even when their pregnant partner did not notice.  It suggests that male partners might feel more marginalized by the very gendered language of birth that I realized.  I can only speak to the midwifery model of care, but the language can be quite female- and woman- centered.  I think these data indicate that we need to query our male partners more often about what language suits them.

I’ll be honest here, I was also quite relieved that the vast majority of the apparent females who noticed the language shift were not bothered by it.  And none of them thought it detracted from their own journey and experience.  Phew!

Takeaways

I learned two elements from this experiment that I will use in my future practice.  One, gender inclusive language allows some folks to feel seen in the birth preparation process, particularly male partners.  I had generally experienced this to be true one-on-one, but was delighted to find that this was true in group presentation-style education as well.  Two, the use of gender inclusive language in group education did not negatively affect pregnant clients’ sense of their own journey.  These data allow me to continue to use gender inclusive language with the sense that I am being more inclusive than offensive.  For me, that was great news!

Who is a Parent Under Colorado Law?

There are two sections of Colorado law that address parentage: Title 19 which is called “The Children’s Code” and Title 14 which covers “Domestic Matters.” These statutes provide the structure for how to be a parent under the law in Colorado.

In addition, Colorado courts have had the opportunity to interpret these statutes in various kinds of cases. Those cases add clarification and nuance to the statutes, further defining the law.

Together, the statutes and the court decisions are what we have to go on in trying to figure out how different facts work under the law. But there are facts that the Court hasn’t addressed directly, and so there are questions that are unsettled in the law.  That is why it is hard to get a black and white answer.  

Title 19: The Children’s Code

The goal of this law is essentially to “To secure for each child…such care and guidance, preferably in his own home, as will best serve his welfare and the interests of society.”

It includes provisions about juvenile law, dependency and neglect, adoption, foster care, and parentage.

Article 4: Uniform Parentage Act

Article 4 of the Children’s Code describes ways to be recognized as a parent under the law. This law is specific to Colorado, but it is based on a model that many other states use too. There are many parts to Article 14 including how a parent-child relationship is established and how to establish parentage using assisted reproduction. Neither of these sections account for all the ways people create family.

The sections that determine how a parent-child relationship is established provides for a range of ways to “prove” that a parent-child relationship has been established not limited to gender, biology, or marriage.  Adoption is one kind of proof and assisted reproduction is another kind of proof. Surrogacy was recently added. Genetics is another kind of proof, but it is not exclusive; holding yourself out as a parent is yet another kind of proof. The law provides for several ways to prove that a parent-child relationship has been formed. This process results in an order establishing parentage or a parent-child relationship. The order establishing parentage in this way has the same legal effect as an order for adoption.The law recognizes “natural” parents (which can include parents with no genetic connection to the child) and “adoptive parents,”

The most common scenario where you have to prove that you are a parent is when someone else claims to be a parent as well and there is disagreement about who is the “real” parent.[1] Another common scenario where proving parentage comes into play is when the State needs to determine parentage either for benefits (a child needs resources) or when a child is being adjudicated “dependent and neglected.” The law is really built to figure out who the parent is when there is a conflict about parentage. It isn’t built to establish who the parent is when there are multiple people who could qualify but who are all in agreement about parentage. That is one reason why it doesn’t fit alternative family formation as well.  The assisted reproduction, surrogacy and adoption provisions address this to some extent, but none fit every imaginable situation. Furthermore the act is written in a heteronormative, gendered way. Although Colorado law is required to be read as gender neutral, many statutes are gendered.

Assisted Reproduction: 19-4-106

This provision of the law is written primarily for a heterosexual infertility context: it assumes that a medical provider is doing the insemination, and it assumes that the insemination is happening in a heterosexual marriage. It does acknowledge the possibility of other egg and sperm donation contexts, but doesn’t go into depth about those scenarios. Essentially – the law leaves many questions unresolved with regard to how egg sperm get combined, gestated, and cared for.

Surrogacy: 19-4.5-101-114

In 2021, the Colorado legislature passed the Colorado Surrogacy Agreement Act which makes surrogacy legal in Colorado. The Act defines a genetic surrogate, a gestational surrogate and intended parents and describes the basic requirements for a surrogacy agreement. The Act also explains that the intended parents can petition a court prior to the birth of a child for determination of the parent-child relationship. It also distinguishes this process from adoption.

Article 5: Adoption

Article 5 of the Children’s Code describes ways to be adopted and ways to adopt. It recognizes varieties of adoption: including “step-parent” adoption (where one person is married to a parent and wants to become a legal parent to their child, and the other parent agrees to the adoption or is deceased), and “second-parent” adoption, where the child only has one legally recognized parent before the adoption. When the one legal parent wishes to have another person become a parent they have to undergo a home-study, similar to the home study a family undergoes when they want to adopt a child from an agency or from another country.

Adoption recognizes that a person can have parents who will no longer be recognized legally as parents after the adoption; it also provides for processes to deal with those former parents. It does allow for a person to have two parents of the same sex.[2]

Another way a child can become available for adoption is if their parents have their legal parenting status terminated, or has to have abandoned the child for a year or more.

Title 14: Domestic Matters

The other piece of the parenting puzzle is the law that helps people figure out how parenting roles and parameters after a divorce, or when a non-parent is involved in taking care of a child.  This is handled by a section of law that is separate from the Children’s Code.

This part of the law allows the court to allocate “parental responsibilities” – so it is not the same as being a legal parent, but it does allow a court to give a non-parent the right to care for a child and make decisions for a child. The law provides ways for people to ask the court to assign parental responsibilities and the court uses the “Best Interest of the Child” standard to do so.

Before same-sex parents were legally recognized people would use this part of the law to argue that the same-sex partner should have “parental responsibilities” because it would be in the best interest of the child. They would argue that since the child had bonded with them, and the child relied on them “like a parent” that the court should honor that child’s need to have them remain in a parenting role.[3]

The best interest of the child standard is important because when a case has been before the court with open questions – the court has used that standard to figure out what to do.[4] It also factors in to the process the court uses to make a determination of parentage under the Uniform Parentage Act.

Conclusion

There are several ways to create a family under the existing law, given that the existing law does not directly address all circumstances none of these options may be perfect.  Each of the options comes with different pros and cons.  

-------------------

[1] There isn’t a law that requires anyone who is acting as a parent to prove that they are a parent, which means it is possible to just act as a parent and never have to prove it.

[2] The law is silent with regard to transgender people, but given the way the law allows parentage to be blind to gender, it certainly doesn’t prohibit a transgender person being recognized as a legal parent.

[3] Of course, people would also argue that the same-sex partner should not have parenting responsibilities because their moral flaws as gay people would not be in the best interest of the child.

[4] One Colorado case was called In the Interest of S.N.V., 2011WL6425562 (Colo. App. 12/22/11), in it were competing maternal claims. Birth mother versus the wife of biological father.  Birth mother had consented to the father and his wife raising the child although the birth mother claimed that the birth of the child was as a result of an intimate relationship between she and the father whereas the father and his wife maintained that the birth mother was simply a surrogate by arrangement.  The court found for the “intended parents” – not the biological mother. Another case called In the Interest of K.L.W. and J.L.W, No. 20CA1387 (Colo. App. 4/22/21) used the best interest standard as a factor in determining parentage under the Uniform Parentage Act when one parent claimed a genetic connection and the other claimed they had held themselves out as the parent. The case arose from a dependency and neglect action. One potential parent claimed that there could be more than two legal parents and that would be in the best interest of the children, but the court disagreed, and affirmed the lower court’s determination that the parent with the genetic connection was the legal parent.

Birth Center Consumers past, present and future: We need you!

UPDATE: The rulemaking hearing will be July 19, 2017 at 10am at Sabin-Cleere Conference Room, Colorado Department of Public Health and Environment, Bldg. A, 4300 Cherry Creek Drive South, Denver, CO. 80246. The public is invited. And Elephant Circle will have a reception following at a location nearby. Information about the proposed rules is available in this document. Written comment can be sent to Lorraine Dixon-Jones at CDPHE, lorraine.dixon@state.co.us. We encourage comments that state your support for the proposed rules. 

Hello Birth Center Consumers!  We are so glad you are interested in speaking up for Colorado Birth Centers.  Here is the scoop -

The rules that regulate birth centers in the state of Colorado were written in the early 1980s and have not been revised since that time.  In late 2015, the Colorado Birth Center Coalition, comprised of Bloomin' Babies Birth Center in Grand Junction, the Birth Center of Boulder, Denver Center for Birth and Wellness, and Mountain Midwifery Center, pushed hard on the Colorado Department of Public Health and Environment (CDPHE) to open and update the Birth Center regulations.  The journey has included many challenges including trying to impart the understanding that the birth center and midwifery model of care are quite different from the obstetric and hospital model of care.  One of the midwives involved in the process has chronicled her journey here if you would like more details.

Elephant Circle participated in this process in two ways:  1) We facilitated consumers to advocate for the kind of community maternity care they wanted for their families and 2) Elephant Circle was thrilled to be hired to coordinate the CBCCs preparation and execution of this revision process.

Monthly meetings began last September and have involved reading and revising (if necessary) every single line of the regulations.  Elephant Circle has advocated for birth centers to be allowed to provide care for clients they can’t see now (such as those having their 6th baby or those with a previous cesarean birth) and for both Certified Professional Midwives (CPMs) and Certified Nurse Midwives (CNMs) to be allowed to practice at Colorado birth centers.

Though we are nearing the end of the process – WE STILL NEED YOUR HELP!  The critical time for consumers to tell regulators about their birth center experiences will be from May 17 to July 19.  As the end of May approaches, we will post and disseminate names and addresses where you can direct your comments.  As for July 19, put it on your calendar!  We may need the public to show up in support – we will let you know!

So at this point, you have two choices:

1)    Put your name on our list found HERE and we will contact you with specific asks and details at the appropriate time

or

2)    Put May 17 and July 19 on your calendar and stop back here at our website or here on our FB page for more information.