Jessica Mattingly, a doula from Blue Springs, MO, notes that midwifery-assisted home birth can foster the understanding that "birth is a normal, celebrated, empowering experience for a woman and her family." And, she adds, "This is not done at the sacrifice of safety for mother and baby, but at the enhancement of it. Midwives and mothers can be and are able to identify the rare cases when medical intervention is needed and can seek collaboration and assistance."
The Fight for Licensure
While dozens of professions drew their numbers together in widespread licensing systems in the last century, midwifery was not among them. While the reasons for this are unclear, it may coincide with the rise of obstetrics in the early 1900s, which seemed to be a competitor to midwifery. The profession pitched more sanitary and better-educated doctors, and that message resonated. By 1955, one percent of American births took place at home, the same rate that stands today.
The lack of licensure is a sticking point for a profession that seeks to provide high-quality, evidence-based care to women, because midwifery skeptics point to it as evidence that the practice is unsafe and unpredictable. Critics claim that its apparent lack of regulation indicates that midwifery unnecessarily endangers both the mother and the baby.
Today you need a license in the U.S. to practice psychotherapy and cosmetology, to drive trucks and to be a mortician -- but not to minister to laboring women in homes or in birthing centers. Or at least, not quite: Twenty-one states, including Wisconsin, Montana, and, very recently, Missouri and South Dakota, accept the certified professional midwife credential (CPM) for direct-entry midwife licensure. ("Direct-entry" means that standard midwifery training is recognized as sufficient to practice; the CPM isn't expected to secure an additional medical degree.) CPMs are backed by the North American Registry of Midwives "to provide out-of-hospital maternity care for healthy women experiencing normal pregnancies," according to Steff Hedenkamp of the advocacy organization, The Big Push for Midwives.
CPMs complete training that lasts three to five years and requires hours in birth observations, classrooms, and clinics. CPMs also pass a national board exam that includes a clinical assessment, out-of-hospital training, and continuing education and re-certification every three years. The CPM is recognized by the American Public Health Association as a basis for licensure.
But while CPMs are certified in their profession and practice across the country, they're not necessarily licensed. Licensure is up to boards that are set up on a state-to-state basis, and it is here that things get complicated. Certification by itself doesn't offer legal protection or permission to practice. When a state makes licensing available, it protects the midwife from criminal charges for practicing, even at the highest CPM standards. It's also likely to increase its number of active midwives, and those midwives will be more accessible to citizens via public awareness and, potentially, insurance reimbursement.
In more than half the U.S. states, midwives are vulnerable to prosecution for practicing medicine without a license. In 2006, an Indiana midwife who had overseen 1,500 births was prosecuted for just that when a baby she delivered didn't live. The law that could have put her in prison for eight years, and ultimately put her on probation, still stands. Midwives who practice in the District of Columbia, Georgia, Hawaii, and many other states face the same threat. Yet they're unable to receive licenses in states that don't recognize midwifery as a viable profession and, rather, see OB/GYN care in hospitals to be the appropriate route for laboring women.
Traditional Medical Organizations Oppose Home Birth
At its 2008 annual meeting in Chicago last month, the American Medical Association passed a resolution opposing home birth. While it didn't directly oppose direct-entry midwifery, it cited the "twenty-one states (that) currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay" midwives)..." as cause for its challenge to home birth.
The AMA resolution quoted the American College of Obstetricians and Gynecologists in saying that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."
For its part, ACOG reiterated its opposition to home births last February:
ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births... Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.
While the AMA and ACOG are more accepting of midwives who work within hospitals, or in birthing centers that partner with OB/GYNs, the opposition to home births and "individuals who provide home births" equates into an invalidation of midwifery as a whole. Midwifery is fine, the implication goes, so long as it is safely within the realm of traditional hospitals, OB/GYNs, and nurses.
Physician disapproval of direct-entry midwifery assisting in home births resonates with the experience of California mother Alexis Aherns.
"When I told my final doctor later in the pregnancy that I was planning a home birth, he told me he didn't recommend that, and added that he had seen plenty of women who made that choice show up with dead babies," Aherns said. "It was such a ridiculous statement that it actually didn't even faze me." Despite her doctor's predictions, Aherns delivered a healthy child at home with the assistance of a midwife.
ACOG's position on home birth is one that Mattingly challenges as "terribly hypocritical and a violation of the ACOG Code of Professional Ethics which has as an ethical foundation 'the respect for the right of individual patients to make their own choices about their health care."
The original AMA resolution last month cited the popularity of Ricki Lake's recent documentary, "The Business of Being Born," which features her own birth experience as a catalyst for its resolution. Due to popular outcry, however, the AMA soon voted to delete references to Lake and the documentary from its resolution, while maintaining its opposition to home birth.
Though AMA, ACOG, and others skeptical of midwifery and home birth declare their concern for the well-being of the laboring mother and her baby, numerous reports indicate that home births are safe and minimally intrusive.
The British Medical Journal surveyed the 5,400 North American women who had home births with a CPM in 2005. No mothers died and five babies died, or .09 %. In context, the U.S., where nearly all births take place in hospitals, ranks 37th in world infant mortality; there are 6.37 deaths for every 1,000 live births, a rate behind South Korea and Cuba, according to the CIA World Factbook. The U.S.'s infant morality rate is second-worst in the developed world.
The journal survey also found that twelve percent of the home births were transferred to a hospital. Caesarean sections among these women were one-fifth the level of comparable groups who had hospital births.
A recent article in Florida's St. Petersburg Times quotes the AMA's citation of a study that compares a 1.7 per 1,000 death rate for babies born in hospitals and a 3.5 per 1,000 rate for those born at home. Home birth advocates charge that women should have the ability to choose what risks they want to face; many see the high rate of c-sections, drugs and labor inductions in hospitals as equally risky. They also point to other research that describes home births as being at least as safe as hospital births.
Doctors and Midwives React to the AMA
Dr. Henry Dorn of High Point, NC, is one OB/GYN -- and former AMA member -- who questions the recent obstacles to widespread licensure for midwives. Dorn operates a gynecology practice that offers midwifery services.
"I feel that (the AMA's) statement may stem from a combination of ignorance or avoidance of the facts regarding out-of-hospital birth by skilled attendants, and perhaps a desire to protect the business interests of the physician community,"
Dorn said. "This is not to say that AMA members do not care for their patients' best interests, but only that given the current medical climate, it would not be surprising to see those outside pressures affect [their] conclusions."
Dorn expects the resolution to "discourage another generation of doctors from considering alternatives to highly medicalized birth, as most feel that any statements by the AMA should be viewed as gospel."
Mattingly wonders if the root issue is that many doctors fear what they don't know. "Very few doctors have seen a birth without any medical intervention," she said. That means, "Most have never ever seen a normal birth."
Despite its discouraging tone, Coral Slavin of Well-Rounded Maternity Center in Menomonee Falls, WI, thinks the resolution will have an unexpected effect.
"Ironically, I think that the AMA stand against out-of-hospital birth has only driven more people to view Ricki Lake's documentary and spurred more questions. I don't see how lawmakers morally could ban out-of-hospital birth without proof of the alleged dangers," Slavin said.
Dr. Elizabeth Allemann, a physician from Harrisburg, MO (she is not an AMA member) found another reason to be positive: "Honestly, there's a little bit of a relief in having them actually make the statement. Now we no longer have to try to convince legislators that organized medicine is opposed to home birth and midwives, and can't be a good-faith partner in designing legislation."
If Midwives and Physicians Could Collaborate
The stance the AMA and ACOG have taken against non-hospital births, alongside the de facto stance taken by states that don't allow for midwife licensure, diminishes a culture of collaboration among doctors, midwives, and expecting women. While the two professional organizations detach themselves from CPMS, many midwives and home birth advocates recognize the important role OB/GYNs play in their vision for a renewed culture of birth.
Comparatively, home births are actively encouraged by U.K. governments, and in Edinburgh in particular. Nicola Goodall is an Edinburgh doula who reports that OB/GYNs and midwifes are partnering in an effort to respond to more babies being born than there are hospital units to accommodate them; Goodall said the collective goal is to increase home births by 800%. It's an ambition that also translates into making midwifery an appealing and accessible profession.
"Midwives are registered here and they work alongside doctors and hospitals," Goodall said. "All women giving birth in the UK get midwifery care, but they may get it alongside doctors if they have a special need (such as) a medical problem like diabetes."
Stateside, many are working to diminish the unfriendly competition that dates back to the development of obstetrics one hundred years ago.
Steff Hedenkamp of The Big Push outlines the way the AMA and midwives could collaborate:
We welcome the AMA joining the Big Push as we work to bring together a national effort that is creating meaningful consumer protections and a new model for the U.S. maternity care system -- one into which midwives are fully integrated. We welcome the AMA applying its vast resources to helping create a maternity care system that supports people from all walks of life from all over the U.S.
For their part, midwives often see the benefits of working with allopathic providers.
"We know that this partnership is needed to create that optimal environment for all mothers and babies," said Dr. Allemann.
For more information:]]>
The Business of Being Born - Official Film Website
The Big Push for Midwives
American Medical Association Resolution 205: Home Deliveries
"A bundle of debate over giving birth at home" -St. Petersburg Times
Or, of course, you can hear directly from women who've had the operation. It's not difficult to find them; 600,000 women have a hysterectomy each year, says Dr. Jay Goldberg, director of the Jefferson Fibroid Center at Jefferson Medical College in Philadelphia.
Put another way: one in three women has a hysterectomy before her 60th birthday. Yet treatment for life-threatening illnesses -- uterine and ovarian cancers -- accounts for only 10% of the procedures.
The other reasons? About 40% of hysterectomies are performed due to fibroids. Endometriosis, a condition in which uterine tissue grows outside of the uterus, accounts for others. Heavy bleeding, a uterine prolapse (when the organ slips out of place), a caution against cancer, birth control, and, for trans men, sexual reassignment surgery, are all among other reasons for hysterectomies.
Many who have the operation are making their best choice, and have never felt better. But what are the real implications of removing a major reproductive organ from a woman's body -- even when she doesn't desire giving birth to children? "In truth," Natalie Angier writes in Woman: An Intimate Geography, "
...we know remarkably little about the purpose of the various opiates, chemicals, hormones, and hormone precursors that the uterus secretes with such vigor. We don't know how important the output is to our overall health and well-being beyond considerations of reproduction, nor do we know whether the various secretory skills continue past menopause. ... We should be humbled by the fact that scientists discovered the very dramatic concentrations of anandamide in the uterus as recently as the late 1990s. And that humbleness should in turn enhance our vigilance against removing the uterus in all but the most extreme circumstances.
Women who have a hysterectomy require six to twelve weeks of recovery time -- a testament to the procedure's gravity. And HERS chronicles a long list of adverse consequences of the operation that call its widespread acceptance into question. Among the after-affects reported by women who had hysterectomies include personality change (79%); profound fatigue (76.9%); diminished or absent sexual desire (75.2%); short term memory loss (66.9%); insomnia (60.5%); and pain in joints and bones (59.9%). In Woman, Angier reports that hysterectomies -- even surgeries that preserve the ovaries -- cause a woman a "heightened risk of high blood pressure and heart disease ... possibly because the extraction of the uterus eliminates one source of prostaglandins that help protect blood vessels."
Deborah McConnell, a nurse at Boston's Brigham and Women's Hospital, said that hysterectomies that remove the ovaries cause immediate menopause, because of sudden disappearance of hormones ovaries release. "The sudden drop [in hormones] can have affects on bone health, heart health and mood effects as well," McConnell says.
So it's surprising that for illnesses that can be treated less invasively, alternative treatments aren't offered more often. And there are many possible treatments for fibroids, endometriosis, and pain: mymoectomies or lapatotomies to remove fibroids; uterine fibroid embolization (blocks blood supply to fibroids for shrinkage); endometrial ablation (uses microwaves to destroy endometrial lining in a five-minute procedure); pain medications; hormonal agents; lifestyle changes; a progesterone IUD; medications; and HIFUS (High Intensity Frequency Ultrasound), which targets fibroids with an MRI-guided ultrasound system. And Goldberg reports that alternative treatments for conditions that lead many women to hysterectomies are among the best-funded research projects, so we can expect still more options soon.
If there are so many options for women, and so much about the uterus still a mystery, then how did we get here, with hysterectomies the second most common operation that American women undergo?
How Did We Get Here?
After conversations with people who had, and chose not to have, hysterectomies, and with people who perform the operation and who counsel for alternatives, some explanations stand out.
1) Habit. As Goldberg points out, many doctors -- especially older ones -- are accustomed to prescribing hysterectomies for women who don't intend to have more (or any) children and who suffer from reproductive system troubles. "There's an older, paternalistic attitude," Goldberg explains. "'If you're done having kids, let's take the uterus out.' [Other doctors] will bring up alternatives to hysterectomies, and older doctors will scoff at you a little bit, like, why would you suggest anything else?"
The habits of individual doctors aggregate into regional and demographic patterns. The Agency for Healthcare
Research and Quality reports that "women who live in the Southern and
Midwestern areas of the United States, African-American women, and women who
have male gynecologists are more likely to undergo hysterectomies."
2) Lack of information. The doctor may not be aware of alternatives that might allow a woman to avoid a hysterectomy while relieving her symptoms. Or the doctor might not know how to do a procedure. "In Philadelphia, the doctor gets paid about $1200 for a hysterectomy," Goldberg says. "There's an alternative treatment, an embolization, that needs to be performed by a radiologist. So it can come down to economics: if you refer the patient to a radiologist, you lose the financial reimbursement."
Women often lack the information themselves. Judy Norsigian, executive director of Our Bodies Ourselves, says there's "no question that women aren't always getting good information about the implications of a huge surgery."
To explore alternatives and their
consequences, however, takes time. Many women are not willing, or able, to give
that time -- especially when they feel the urgency of their symptoms.
3) Imbalance of authority between doctors and patients. Dr. Clarissa Pinkola Estés's experience illustrates an extreme case. She had a hysterectomy at age 33; she's now 62. "I remember asking, ‘Please, please, help me save my body, so I can have more children," Pinkola Estés says. "I remember as though it happened yesterday, the male doctor literally shouted: ‘You will not dictate to me on matters of medical importance.'"
In less dramatic ways, many of us defer
to medical professionals. Goldberg says "a lot of patients don't want to insult
the doctor with questions," but with information increasingly accessible
online, many people are able empower themselves.
4) It's self-referential. With hysterectomies so common, the operation gains a whiff of normalcy, or is even seen as a rite of passage. Most of us know many people who had a hysterectomy. This, then, comes to seem the sensible alternative if we find ourselves suffering from bleeding, pain, or other symptoms.
Questions about hysterectomies don't exist in a vacuum. There's no doubt that we are informed by an ancient history of valuing women for their ability to bear (male) children. That is, a woman's body, and particularly her reproductive organs, had utilitarian worth and little more. But as Angier reminds us, the uterus may offer countless health benefits to women beyond its essential role in bearing children.
It's foolish to believe that we've overthrown millennia-worth of such sexism in a couple decades. The living legacy of a utilitarian view of women's reproductive organs is apparent in the arguments those who oppose abortion and contraception, where primacy is given to zygotes over the woman they exist within.
We also cannot forget that our country has a chilling history of abuse of women's reproductive systems. Dorothy Roberts has detailed the history of coercive or forced sterilization, often including hysterectomy, of women of color, indigent, and "mentally deficient" women in Killing the Black Body. She writes,
During the 1970s sterilization became the most rapidly growing form of birth control in the United States, rising from 200,000 cases in 1970 to over 700,000 in 1980. It was a common belief among Blacks in the South that Black women were routinely sterilized without the informed consent and for no valid medical reason. Teaching hospitals performed unnecessary hysterectomies on poor Black women as practice for their medical residents. This sort of abuse was so widespread in the South that these operations came to be known as "Mississippi appendectomies."
The prevalence of unwanted hysterectomies led many Black women, in activist Frances Beal's words, to be "afraid to permit any kind of necessary surgery because they know from bitter experience that they are more likely than not to come out of the hospital without their insides."
Sterilization wasn't just used to control African-Americans, but also Native Americans.
"Even the word (‘hysterectomy') just scares me so much and brings up all of these memories," says KL Pereira, a 27-year-old Native woman living in Cambridge, MA, citing a history of doctors using forced sterilization on Native women after difficult births and abortions. Pereira's aunt went in for a D&C treatment for her endometriosis. She expected superfluous tissue to be scraped away; she came out of the operation with a hysterectomy that her doctor decided that she needed.
"Especially for a young girl who was really just learning about her body and the medicalization of it, I felt like I would never trust doctors or hospitals. And I honestly still don't," she says.
This is the context we're in today: a history of coerced and forced hysterectomies is one part of why -- it bears repeating -- hysterectomies have become the second most frequent operation performed on women.
Truly Free Medical Choices
There is no doubt that a good portion of those operations are performed on women who diligently researched, explored alternatives, and partnered with her doctor to come to a mutual decision that a hysterectomy was her best option. There is no doubt that hysterectomies save the lives of many women.
Steve Wilson of Long Beach, CA, considers herself one of them.
"I was totally comfortable having the complete hysterectomy, and haven't been sorry since I did it," Wilson said. "The pathology report came back as pre-cancerous -- was relieved."
Who could blame her? But while we may cheer Wilson for her choice, we must be quite aware that many other women aren't making free choices -- free, in that it is unadulterated by an imbalance of power in the doctor-patient relationship, that the patient has complete and clear information about all options and their consequences, that her doctors are in no way biased towards her because of her color, class, marital status, and interest in bearing children, and that ability to pay in no way limits her options.
Dr. Lori Warren, a gynecologic surgeon in Louisville, KY, is pushing for genuine medical choices for women with her website, BetterHysterectomy.com. Says Dr. Warren: "I truly believe that biggest changes will come through patient education and for women to be empowered to ask for a better, less invasive surgery."
Perhaps the frequency with which hysterectomies are performed is symptomatic of the constrained options women, and all individuals, have in our country's broken health care system. We must expect more from our medical providers. And we can act on those high expectations with persistent questioning, self-education, and a thorough exploration of all treatments.
There's really no other option. Our very bodies are at stake.
How do you tell an awful story to the world?
You can begin by saying it plainly: in the eastern Democratic Republic of Congo, where 5.4 million have been killed in the deadliest war since World War II, women and girls are targeted by a pandemic of sexual violence and rape on a scale never before seen on the planet.
"Often successful in its intent to destroy and exterminate, rape as a weapon of war is causing the near total destruction of women, their families, and their communities," said a recent report from The Enough Project titled Getting Serious About Ending Conflict and Sexual Violence in Congo.
A lot of people are working to alert the world to a gruesome reality that's simmered for more than a decade in silence. But in a global context where humanitarian crises are too common, and where the concerns of both African nations and women are hardly centered in media and government, how can the DRC's story be told to incite compassion in the massive proportions necessary for change?
"In Congo, because of the complexity of the conflict, to get Americans and other overseas people to see what's happening, you have to have a narrative, a hook," said Colin Thomas-Jenson, co-author of The Enough Project's report. "It sounds crude, but you need to draw people in."
The key is, Thomas-Jenson says, to tell the DRC's story so that it triggers "an existing constituency" that will challenge the normalization of sexual violence that targets Congolese women and girls. "With Darfur, the narrative is genocide. The word is so loaded, it tells a story itself. And it immediately activated a certain constituency. The Jewish community was very seized."
Policy and activist efforts, then, are currently focused on grassroots communications strategies -- that is, telling the story of the DRC via blogs, media coverage, film, and research -- with the belief that once people see themselves as part of the story, they will move emphatically towards change.
And in Congo, the initial communications attention is aimed for the constituencies built around women's empowerment. "The narrative that's most compelling here is the victim's perspective. And we see women as the principle victims in Congo," says Thomas-Jenson. With V-Day and Women for Women International championing the human rights of women in eastern Congo, conveying their stories to their partners and beyond, the hope is that a political and humanitarian response will be swift.
Because, Thomas-Jenson emphasizes, more than charity is needed.
Nita Evale, a Congolese woman who is vice chair of Congo Global Action, has chosen to become another one of the storytellers of Congo's crisis.
"Congo is my country and just watching it die slowly wasn't an option any longer," Evale said. "I was waiting for some hero to come and rescue my people but quickly realized that that hero didn't exist. I had to do something to that when a hero ever comes, he will at least find a country to save."
Through CGA, Evale mobilizes a coalition of activist organizations to build awareness and pressure a political response. CGA recently held a legislative advocacy day and workshop series in Washington, D.C. The event connected the rape pandemic with the "raping" of the DRC's land of natural resources, and on governance and post-conflict issues.
It's a storytelling tactic that, Evale said, works. "The conference went really well, even exceeded my expectations," she said.
What are the specific political interventions that might change the DRC's course?
The Enough Project puts forth a plan of peacemaking, protection, punishment, and prevention. It calls for, among many other things, maintaining and consolidating the DRC's ceasefire; increasing the presence of UN peacemakers; the U.S. Senate's passage of the International Violence Against Women Act (S. 2279); and, via funding, vetting, and training, international support for the DRC's security sector reform.
One of the most catalyzing narratives put forth comes via Lisa Jackson's new documentary, The Greatest Silence: Rape in Congo.
The film centers the raped women and girls in eastern DRC who tell the stories that have been largely ignored by the international community. Jackson shared her own story of being gang-raped in Washington D.C. with the Congolese women, and thus built an uncommon intimacy into her film. Jackson also touches on the political context that makes such massive sexual violence possible -- for example, the Rwandan genocide that led thousands of soldiers to cross the DRC's eastern border, and the plundering of diamonds, gold, coltan (a metal used in all cell phones and laptops) and other rich Congolese resources. As well, Jackson brings forth the voices of the rapists in disturbing interviews with young soldiers.
Aired on HBO, winner of a Sundance Festival jury prize, and shown on screens ranging from local documentary festivals to a European Union commission, Jackson's striking film is having an impact.
"Women, and sometimes men, can't get a question out (during the Q&A session) because they're crying so hard," Jackson said. "I can't wait to go back to the Congo. I'm taking pictures of the diverse audiences, and I want to show their reactions to the women in the film. I want to show them that their stories are being heard."
But Jackson says that one of the most common question she hears -- even from avid documentary audiences, who she cites as being particularly aware of world affairs -- is: Why haven't I heard of this before?
"They're shocked at the extent of the catastrophe," Jackson said. "Many of them didn't even know there was a war."
Many bloggers have been activated by Jackson's film. They're writing about eastern Congo's women, developing resource pages for action, and building online collaborations. April 13 was a coordinated day where bloggers of all stripes committed to collectively sharing Congo's story.
Some bloggers wrote in tribute to Jackson's film, others offered contact information for legislators and activist groups, and still others reflected on how the current crisis emerges from a long history of damage.
"If there is anything to take away from the (Jackson's) film, from knowing about this horrific and inexcusable outrage, it's that the women who told their stories survived," wrote the blogger Anxious Black Woman in her April 13 post. "Those women broke their silence. Like our ancestral mothers before them, they found a song or they have created 'a way out of no way.'"
Jackson believes we are only seeing the very beginning of Congo's deep stories reaching a global audience.
"There are other filmmakers who want to do pieces on Congo's conflict, there's blogs and online columns, and a whole new class of art emerging," she said. "I hope people take this up on a grassroots level, by taking money out of investments and, since its now on the congressional record, there are senators and representatives that can be addressed."
But the most important thing?
"Become more informed," Jackson said.
Which means not just being storytellers, but listeners.
Learn more about the story!
News
Blogs
The Greatest Silence Trailer
]]>Prevention
It's funny how the numbers align. Among the 42 million sexually active American women of reproductive age who don't want to become pregnant, 89% use contraception. It's intuitive, then, that plenty of people who oppose legal abortion aren't appalled by birth control.
Laura, a 25-year-old Catholic campus minister in West Virginia, opposes abortion, but her feelings about global warming lead her to part ways with the Church on birth control (while Laura asked that her real name not be used, names used in this article are real unless noted otherwise). The Church's catechism calls contraception "intrinsically evil." But "we, as a country, use so much of the world's resources," Laura says. "We've got to be responsible about how we bring people into this world and especially into this opulent culture." She supports reproductive health access as part of a full-scale reorientation of national priorities toward sustainability. Laura's lived in Jamaica, where she said radio ads promote condom use and musicians talk of HIV/AIDS in their songs. She's also lived in Maine, where emergency contraception is available without parental consent, her public high school offered off-site day care to young parents, and her college gave free condoms to anyone who wanted them. She applauds these efforts as responsible and realistic.
Laura's in good spiritual company: Seventy-eight percent of U.S. Catholics believe the pope should permit contraception. The majority may not be a new development. Catherine (not her real name), a 50-year-old Philadelphia woman who opposes legal abortion, remembers sex education in an all-girls Catholic school in the 1970s as fairly progressive. "To the credit of the teacher, she did explain the basics of sex and pregnancy prevention," Catherine says. "We thought it was rather amazing to be taught about birth control when we weren't supposed to be having sex." These days, Laura, as a modern-day Catholic, says, "the Church has made itself irrelevant on this issue. Its rigid position is not for the good of its people. And it makes it too easy to trivialize the Church on other matters."
Brittany Galisdorfer is a 24-year-old from Detroit who reconciles her support of contraception with her opposition to abortion by taking a scientific perspective. "A lot of people don't support contraception because they believe life starts at conception, which requires egg and sperm to meet," she says. "But you can put egg and sperm together all day without a baby coming together. It needs to attach itself to the uterus to make a baby. That's why contraception is okay. It simply denies the third element required for pregnancy."
The life-begins-at-conception belief fuels the mischaracterization of some methods of hormonal birth control as abortifacients. Anti-choicers often go after emergency contraception -- simply two regular birth control pills taken within 72 hours of intercourse -- in particular, but some organizations would like to ban all hormonal birth controls and IUDs, claiming they cause abortions.
Beth Bovair, a Catholic 24-year-old from Arlington who believes life begins at conception, sees no validity in the birth control platform of organizations that oppose abortion. While she opposes abortion, Beth says we need to build a supportive society before it is no longer an option.
"We have to provide for children and women, and create a society where there's no stigma of pregnancy for women and men," Beth said. And that society, according to Beth, includes access and use of contraception to support family planning.
It's a sentiment that Claire Keyes, co-founder of the Abortion Conversation Project, echoes. "What happens after the child is born?" Claire said. "All our energy and dollars seem to go for having more babies, not caring for them."
Knowledge
Iowa just became the seventeenth state to decline federal funds for abstinence-only education in public schools.
Why the trend?
"Research continues to show that abstinence-only education fails to delay sexual initiation, reduce numbers of sexual partners or prevent pregnancy in adolescents," said Iowa Gov. Chet Culver in Medical News Today.
It's hardly theoretical: While over a billion federal dollars fund abstinence-only education (and zero support comprehensive sex ed), people under 25 have become the fastest-growing category of new HIV infections. A CDC study recently announced that one in four teen girls has a sexually transmitted infection. Eight hundred thousand teens aged 15-19 become pregnant each year. A number of those pregnancies end in abortions.
Given these statistics, Beth Bovair would like to see nuance, not just abstinence, in the classroom. Plenty of students aren't sexually active, so they don't connect to the material, she noted. Brittany echoed the sentiment: "I wasn't planning on having sex until I was married, and most of my friends weren't having sex, so [sex education] didn't feel relevant," Brittany observed. So it's important, Beth said, to provide facts while acknowledging that any given classroom includes people who are sexually active and people who feel far from that experience.
Catherine, the Philadelphia woman struck by her Catholic school sex education, and her husband found their children's sex education in both public and private schools to be "totally inadequate." They became the primary teachers for their children's sexuality education.
These four women are hardly alone in their desire for better classroom experiences. A 2004 Kaiser Foundation nationwide poll found that 85% of parents would like teenagers to receive comprehensive age-appropriate sex education, in lieu of abstinence-only.
Who Represents Them?
Laura, Catherine, Brittany and Beth aren't members of any national anti-abortion organization. Those that are Catholics distinguish their perspectives from Church catechism. Beth is church-hopping in Washington, D.C., looking for a parish where her spiritual and political views have a home. While Laura attended the March for Life in January, she spent much of it with a local friend, indicating that she doesn't feel comfortable among "hardcore" anti-choicers.
Brittany, too, is distanced from the traditionally-portrayed anti-abortion community. "The people who I share (my opposition to abortion) with, I don't share much else," she said.
But the numbers reveal that the conclusions of these women aren't uncommon. Who, then, represents their voices in the public conversation? It's not the groups that challenge reproductive rights at every level. These women -- representing many in their movement -- are left to speak for themselves within a context that begs misunderstandings and mischaracterizations.
"I've never heard anyone say these things, period," Brittany said. "I'm disappointed in the media in particular. There's nothing to do but live my life the way I choose to and speak up when I feel it'll be productive."
]]>What if I said that I once believed abortion was murder, or that I suspected women used the procedure to bypass the consequences of sex?
If I told you, would I lose your respect? Would you be suspicious when I say that today I'm committed to the right to reproductive health, access, and choice?
If so, you wouldn't be the first.
I'm a person who changed her mind. And no, it didn't happen with cymbal-crashing drama -- no unexpected pregnancy of my own or anyone I'm close to (that I know of). It didn't happen with abrupt college-age fervor; though I entered the University of Michigan as a progressive, I held onto my belief that abortion was wrong (though I got quieter about it).
Here's what did happen:
Growing up in Michigan, I advocated social systems as a response to unwanted pregnancies. Sure, there were plenty of reasons why someone wouldn't have the ability or desire to parent. But don't punish the future child, I argued.
Adoption seemed an ideal compromise. With some systematic improvements, then, I thought, abortion is rendered moot and the world will be just.
Fast forward: In college, I was part of the Prison Creative Arts Project. PCAP planned an event on reproductive rights and incarcerated women. It wanted the campus pro-choice group to sponsor it.
I argued for having both the pro-choice and the anti-abortion groups sponsor the forum. A more diverse audience! We won't preach to that interminable choir! Besides, not all inmates are pro-choice. No, of course, we don't want this to be a debate. Let's have a nuanced conversation.
In this leftist group, alluding to anti-abortion views was no less startling and shameful than if I'd proceeded to urinate on another PCAPer. The others made meaningful eye contact to each other and moved on. The event was sponsored by the pro-choice group.
Stay with me for one more fast forward.
In my twenties, in Boston, I was part of a feminist book club when I still hedged around identifying as pro-choice. Such a claim felt akin to articulating God: putting spirituality into words seemed to inevitably misrepresent it.
To assert the label "pro-choice" felt like I was taking somebody else's language to describe a most personal feeling about my own body and, yes, about my spirituality. To call it my own felt phony, cheap, and careless.
In my heart, however, the change had happened. I supported the right to choose, but I balked at throwing myself into the cartoonish divisions of the public "conversation" about abortion. So I said nothing. Silence seemed the only alternative to submitting my beliefs to sloganeering.
What changed?
I don't remember the day. But that day didn't come until after I'd met people -- surprise! -- who'd chosen abortion. It came after my school friends became parents; after I began having sex and selecting birth control; after I experienced and witnessed sexual harassment.
In short, it happened after pro-choice rhetoric took a human shape. I saw those I loved. I saw myself.
Today, I have the passion of a convert for reproductive rights. I remain equally passionate in my resistance to the machine that bypasses all ambiguity about abortion.
I didn't "switch sides;" I'm against the notion of "sides" in the first place.
I spent years in ambivalence, despite an inward belief in reproductive rights. While acknowledging my cowardice, I would've allied myself with the cause sooner had choice advocates talked with me, rather than dismiss me as an anti-choicer not worth the breath. I would've spoken sooner had I not felt that I must forsake anti-choice family and friends to do so.
My story echoes others -- those of parents, students, clinic workers; religious and non-religious individuals; those who changed their minds, those who changed their reasons, and those who changed nothing. Not only are a great many people unable to split themselves between the enemy camps of "pro-life" and "pro-choice," but there is widespread revulsion at how abortion is talked about.
Depending on whose statistics you use, 37-43% of American women have an abortion. Why don't more people connect their private and public ethic?
"I hear: ‘Don't get me wrong, I'm pro-choice, I always have been, I just never thought I'd be here,'" said Claire Keyes, director of Pittsburgh's Allegheny Reproductive Health Center. "And others who come in, who have been anti-abortion their whole life, they say: ‘Now I don't know how I can live with myself; not because of having abortion, but because I feel like a hypocrite.'"
Dr. Megan Gilliam practices pediatric and adolescent gynecology at a University of Chicago hospital; among other responsibilities, she provides abortions. When asked about patients that identify as "pro-life," she said, "Oh, it happens all the time."
"People obtain services for their reason," Gilliam said. "We luckily don't have protesters, but they tell me about how they protest (a clinic) one day, come in the next, and are back out protesting a few days later."
This dissonance is also apparent in Raleigh, North Carolina, where Emily Batchelder once managed a clinic that provides abortions.
"I can't tell you how many times I checked in a patient who said, ‘Now I don't believe in this kind of thing, but...'" Batchelder said. "No one wants to have an abortion, but it's all those ‘ands' and ‘buts' that make abortion services a necessary part of the reproductive health dialogue."
This fluidity between pro- and anti-choice beliefs also affects doctors.
Medical students may cite ethical difference and opt-out of aspects of their rotations. Dr. Gilliam said that in any trainee group, one or two pick their way through family planning. They might refuse to assist an abortion, Gilliam said, but they will offer counsel.
Many, particularly younger residents, change their mind about abortion.
"Where does conversion happen?" Gilliam asks. "They encounter us in so many settings. You admire someone as a physician, and biases begin to chip away."
"Conversion happens with the human connections," she emphasized. "People are able to live with a lot of grey. It's people with no experience whatsoever who can live with black and white."
Is there enough acknowledgment of the grey in the pro-choice movement? I do not mean that we should dilute strong positions against mandatory delays, for example, but we certainly could use more nuance in our interactions with one another and with those with whom we currently disagree. While many will nod knowingly at Gilliam's pronouncement that "the dichotomy is a political tool," our movement feeds into it.
So many of us feel like we don't fit -- to the point that even some who exercise their right to an abortion don't consider the movement to be their own.
Why do we support choice, after all? We cite constitutional rights (at least a little while longer); but as Claire Keyes points out, patients don't talk in those terms. "They don't come in to exercise their constitutional rights," Keyes said. "They may feel grief, but they feel this is the right choice for them."
We valorize "choice;" but Dr. Gilliam says that such language doesn't resonate with those who see themselves in communities -- part of a church, school, neighborhood, or family. "They don't approach life on such individualistic terms," Gilliam said.
We speak of the right to control one's body. But ownership language causes some progressives to bristle. One of them, Harvard sophomore Jessica Ranucci, recalls the world's sordid history of people who take it upon themselves to define who is and isn't human. She wonders how she can use the same language to justify abortion. "How is that different from the slaveholder?" she asks. The politicizated language of abortion leads us to address each other as one thing, or another. This is symptomatic of the discomfort when, as in my case, divisions blur.
Which is unfortunate for the future of reproductive justice, because those human connections that Gilliam says are vital to conversion -- that were vital to my conversion -- simply do not exist when we fight "the other side."
Says Matthew Spektor, a 41-year-old in Los Angeles and lifelong pro-choicer: "I sometimes think my liberal education and cultural background drilled the pro-choice ethic into me so absolutely that it's been difficult even to understand that pro-lifers aren't all religious crazies," Spektor said.
Enemy caricatures mask the greatest strength of pro-choice philosophy: inclusiveness.
"If you asked me five years ago about abortion, I would have told you that I was 100 percent pro-life and there was no way around that," said Jeremy Shermak, a 28-year-old from Illinois. "But somehow during that moment and today, I realized that you can be pro-life while at the same time be pro-choice."
Pro-choice society, like democractic society, is predicated on space for those who disagree. When we play sides, we forget there are no enemies in the vision we pursue. Our inclusiveness of those who choose not to have abortions, and even those who judge abortion to be morally wrong, is our movement's power. When we approach anti-choicers as friends, not only do we act on the heart of our beliefs, but we create space for anti-choicers to become our allies.
I urge reproductive health advocates to remember the ones who will change their minds. We must build spaces where those of us who move slowly into the pro-choice movement are recognized as true partners, rather than tagalongs.
Our beliefs are not created by what -- or who -- we are against. They exist because of what we are for: comprehensive reproductive health for all, and the ability to decide for ourselves if we will or will not have an abortion.
As individuals and as a movement, we must act from that truth.
]]>Known for arresting truthfulness in nineteen young adult novels, Blume’s characters wrestle not only with the usual friendship and family heartaches, but also with puberty, masturbation, sex, and developing bodies—all with an accuracy that’s made Blume, in her own words, “one of the most banned writers in the Americas” for nearly 40 years.
In a society dragged down by an avalanche of abstinence-only funding that strong-arms sex education into banishing the mention of, say, contraception or self-pleasure, Blume’s affirmation that sex changes are part of the lives of teenagers is, amazingly, a radical act.
That she’s one of the few prominent voices admitting such a thing is not a responsibility Blume takes lightly. Two of Blume’s most popular novels—her 1970 breakout book, Are You There God? It’s Me, Margaret and 1975’s Forever—are published today with textual updates, promising young readers modern health information.
Margaret is remembered—and heavily censored—because of the 12-year-old protagonist’s anxiety about when she’ll get her period. By the end of the book, when Margaret indeed menstruates, she has no trouble hooking her sanitary napkin to a belt underneath her clothes, because she’s practiced for months.
Ah yes, the belt. Dated hygiene technology baffled young readers since at least the early 1980s, but things have changed: since 1998, Margaret no longer uses a menstruation belt. She’s got herself some adhesive disposable pads.
While making the text accessible to adolescents, the update wasn’t without controversy; some ardent fans decried the changes as tampering with a classic. Blume justified the change as a minimal loss with great benefit of better communicating with today’s readers.
“No one uses belts any more,” Blume told The Providence Phoenix in 1998 “Half the mothers haven't used them. [Contemporary readers] have to go to their grandmothers.”
Forever is another Blume novel touched with up-to-date health information—and its stakes are higher than simple clarity.
Aimed for an older audience than Margaret, Forever was written as Blume’s response to her daughter’s simple request: she wanted to see a story about teenagers who had sex without being punished by grisly abortions, miscarriages, or deaths.
“I wanted to present another kind of story—one in which two seniors in high school fall in love, decide together to have sex, and act responsibly,” Blume writes on her website.
Forever’s Katherine and Michael seriously talk about their decision before they have sex, and after a visit to a health clinic, Katherine receives a birth control prescription.
It’s that scene that Blume refers to in a one-page preface added to recent editions of the book.
She writes:
“The seventies were a time when sexual responsibility meant preventing unwanted pregnancy. Today, sexual responsibility also means preventing sexually transmitted diseases, including HIV/AIDS. In this book Katherine visits a clinic and is given a prescription for The Pill. Today, she would be told it is essential to use a condom along with any other method of birth control. If you’re going to become sexually active, then you have to take responsibility for your own actions. So get the facts first.”
The preface refers readers to the websites of Planned Parenthood and Sex, Etc., a by-teens-for-teens online magazine.
Thanks to the young couple that has loving sex with the responsible use of contraception, Forever was the eighth most banned book in the U.S. in the 1990s, according to the American Library Association.
Despite censorship since its publication, it still managed to sell 3.5 million copies worldwide in three decades, according to The Guardian.
In an interview with Teenwire, Blume reflects on what might be so alarming about the book.
“If there's anything groundbreaking about (Forever),” Blume said, “maybe it's that they're sexually responsible. Or maybe it's that Katherine enjoys her sexuality. There are still people who are bothered by that today.”
Efforts to silence Blume through censorship parallel the silencing of potentially life-saving information in abstinence-only sex education—and Blume’s readers are targeted by both, ostensibly for their own good. And the moment is being pushed to its crisis.
"The 70s was a much more open decade in America," Blume told The Guardian. "Forever was used in several school programs then, helping to spur discussions of sexual responsibility. This would never happen today. How are young people supposed to make thoughtful decisions if they don't have information and no one is willing to talk with them? Girls and boys have to learn to say 'no' or 'not without a condom' without fear.”
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