Defensive Medicine Series at The Unnecesarean

In case you haven’t heard, The Unnecesarean recently ran a series of guest posts on the topic of Defensive Medicine. It is well worth a trip over to check out the posts. Start here at the beginning with Jill’s post Defending Ourselves Against Defensive Medicine and work your way through.

However, if you have time to read only one article of the series, might I suggest reading the brilliant Barbara Katz Rothman’s Who is defending whom from what? Katz Rothman links defensive medicine to socioeconomic class and access (or lack thereof) to money and healthcare. All of this, of course, is tied up together with our current medical culture that privileges some decisions and outcomes and medical heroism and others as, well, sue-able offenses. Add to that the complicated lens of risk, and we’re in a fine pickle now.

Just a taste:

In the United States especially —where each child is born into great and unending poverty unless lucky enough to be born to a parent willing and able to pull it out, where basic needs go unmet, where medical care for children with disabilities can wipe a family out financially, where medical bills are the leading cause of bankruptcy — a needy child inevitably necessitates a search for deep pockets.  If I had a child who used a wheelchair, I’d want the best possible chair, and probably a sports-use chair besides; the best household adaptations money could buy; every imaginable object and service that would make that kid’s life better.  And if I had to sue my mother to get it, why sue I would.


In a better kind of insurance system, people would be insured for need – if you have a very expensive kid, one who needs wheelchairs and ramps, expensive surgeries, long-term nursing care, or all of those, then those needs would be met.  That is how universal health care coverage works in most of the world.  But we have not got that kind of system, so instead, individuals have to sue.  Private companies insure practitioners, and patients with unmet needs can sue practitioners who in some way failed them.

Crisis in the Crib – Black Infant Mortality in the US

This post was inspired by Courtroom Mama’s mini blog carnival about the documentary Crisis in the Crib by Tonya Lewis Lee. If you haven’t seen the documentary, please go and watch it. You will need Windows Media Player (which turned into a bit of a challenge for this Mac user, but I did it!) and is a little longer than 30 minutes. Courtroom Mama is right that we should all be talking about this. Get ready, because here’s your call to action.

Here’s the deal, plain and simple. Infant mortality rates in the US are embarrassingly high and almost nobody is talking about it. Furthermore, this does not play out equally amongst all babies. Black babies are dying at twice the rate of other babies. In some counties, you have numbers that look like this:

So I’ve seen the numbers and I’ve read articles and blog posts about the infant mortality rate in the US. Let me tell you about the part of Crisis in the Crib that really hit it home for me. The film starts with a scene in a cemetery or memorial with markers for every baby that died in the past year in that particular county. As I watch, I note that the audience and speakers are almost all Black. I remember the mothers I have served as a doula and a midwifery student and start to think concretely about what it would be like for me, the other birth attendants, and for these new mothers and their families if any of them experienced an infant death within the first year of life. So far, they have all been healthy pregnancies and births, but it could happen. It would be absolutely devastating, right? Something like that affects you for your entire life. So I keep pondering this while they move to the next scene.

We are now in an auditorium and Tonya Lewis Lee is talking to high schoolers about the importance of being healthy before becoming pregnant. She asks the audience if they or anyone they know has experienced infant mortality in their families. Students raise their hands and get up to speak. They talk about losing siblings. One student’s sibling was killed by an angry babysitter. Another student’s sibling was born so prematurely it would have been nearly impossible for her sister to live. Later in the film parents talk about losing their children. One father relates that his baby lived only 17 minutes.

Right, folks. This is when it really hit home for me. I realize that this is not my reality. It simply isn’t. I grew up in a relatively privileged household in a majority White area. I wrack my brain and I realize that I cannot recall a single person that I know personally who lost a baby before the age of one. No one in my family, none of my friends, none of my clients (of which there admittedly haven’t been that many). I could raise my hand and share a story about breast cancer, heart disease, diabetes, environmental disaster, 9/11, etc. etc. etc. But infant mortality, until recently, has not even been in my purview. It was something that happened in other places, far far away, with health care systems that were far worse than ours. And now you’re telling me that this is an everyday recognized reality for whole groups of Americans just like cancer is an everyday reality for some of my loved ones? Ok, you’ve got my attention.

For me, learning about the dramatically different infant mortality rates for Americans from different racial backgrounds has been a process. When I first learned about it, I was almost embarrassed to talk about it with people because I figured if it was something this big, I certainly should have heard about this before I signed up for midwifery school, right? Shouldn’t I have learned about this back in high school or earlier? I realized that part of the reason I had never heard of this before, wasn’t taught it in school, didn’t hear it spoken of with outrage on the media, and don’t hear it widely discussed in midwifery circles is due in large part to the systemic racism we all live with on a daily basis.

Right, so I got over my personal embarrassment and decided to learn as much as I could about this. I was quickly overwhelmed – what could I as a future midwife do that would have any dent on the racial disparities in infant mortality? Well, it’s a multi-faceted problem with more pieces to the puzzle than solutions, but I realized that there ARE some things I can do even if I can’t solve the whole puzzle:

  1. Continue to educate myself about racism and privilege. Learn the ways racism affect the body physically and birth outcomes negatively. Continue to oppose and undermine racism, educate others, and in general be a radical anti-racist. Learn as much as I can about Camara Phyllis Jones and her work linking health disparities to racism. This is not necessarily going to help women on an individual level, but every act towards dismantling this oppressive hegemony is important for the whole.
  2. Nutrition and Vitamin D. Vitamin D is an important part of nutrition and can have profound effect on birth outcomes. It is also a race-based problem because here in North America (especially in the cold frozen north like Maine) it can be difficult for anyone to get enough Vitamin D from the sunlight and this gets harder the darker your skin is. Infant mortality rates are high amongst Black women regardless of socioeconomic status or educational level, and it has been suggested that Vitamin D plays a starring role in this truth. I certainly don’t think that Vitamin D is the magic bullet for infant mortality, but I do think it is important to test your clients’ Vitamin D levels and treat accordingly. You can’t undo a lifetime of Vitamin D deficiency in 9 months, but you can start to make a dent and help this birth be a healthier one.
  3. Reduce the number preterm labor and births. Prematurity is a major cause of infant mortality. I’ve talked about this before, but the midwifery world as a whole could learn a lot by paying more attention to the work that Jennie Joseph is doing down in Florida and putting the lessons she’s teaching into action in their own practices. She’s an incredibly important heroine of mine.
  4. Serve women of color as a midwife. Do so sensitively and with humility. Continue to remember that I have (will always have) a lot to learn. Keep learning. Ask questions. Continue to find ways to serve populations of women who are not or have not had access to the care of a homebirth midwife. Work to make myself truly accessible – not just say I am. Show that I have an inclusive practice through my actions, not just my words.

I know that this is just the tippy top of the iceberg here. What other ideas do you have on concrete ways we can help fix this enormous and devastating problem?