Working part-time as a pregnancy options counselor at a busy abortion clinic and also as an apprentice midwife in an out-of-hospital birth practice, I see firsthand the obvious parallels between birth and abortion every day. Given that clear connection, I am continually disappointed by the lack of attention the mainstream reproductive rights agenda has shown to birth options.

For those of us who work in abortion care or are advocates for reproductive freedom for all, we know that sex and pregnancy are more than just biological events. They are social and political events as well and can carry very different meanings among individuals. The ability to access abortion services, as well as birth control and comprehensive sex education, are dependent on cultural and geographical factors. It has been widely acknowledged that the mainstream reproductive rights movement has historically fallen short because of its compulsory and singular focus on access to safe and legal abortion specifically for economically privileged white women. What many of us have missed in our critique of these shortcomings is that the same oppressive cultural mechanisms that restrict women's abilities to make fully informed decisions about when to have children also affect their decisions regarding where, how, and with whom to birth those children. It is clear that the current reproductive rights agenda has overlooked the broader reproductive experiences of women and families, including those who choose out-of-hospital births attended by midwives. This absence is to the detriment of pregnant women, children, and families.

Birth Options

Part of our responsibility as advocates for women's health and reproductive freedom is to educate ourselves on the full range of birth options in order to help facilitate well-informed birth options and also to support and protect the practitioners who provide out-of-hospital birth, prenatal and postpartum services. Midwives in the U.S. have attended births at home for hundreds of years and have a strong history of offering professionally trained, highly skilled, woman-centered care during the childbearing year and beyond. Current research reflects what many consumers of midwifery care have known for years – that planned home births for low risk women attended by Certified Professional Midwives are safer and ultimately involve much less intervention than births attended by doctors in hospitals. Of course, giving birth at home or in a birth center is not appropriate for high-risk pregnancies or women with severe health problems, as well as those women who do not desire to birth out of the hospital. But for women and families who do desire out-of-hospital birth, it is a valuable and necessary option that must be protected.

There are many reasons that women choose to give birth out-of-hospital, and this includes the fact that hospital birth can be an unpleasant, and even traumatic, experience for some people. The current state of mainstream obstetrics in the U.S. reflects steeply rising cesarean rates and increasingly "actively managed" births using technological and medical interventions to alter the course of labor, birth and the postpartum. Currently in the U.S., more than 1 million cesarean sections are performed each year, amounting to more that 29 percent of all births. However, the World Health Organization has calculated that the optimal c-section rate is between 10 and 15 percent. Despite the increased documented risks of undergoing cesarean section rather than giving birth vaginally, the numbers continue to rise. While access to cesarean in the case of true obstetrical emergency is essential to the health of women and babies, it does bring up many ethical questions when it becomes an overused and even non-medically indicated option. Some pregnant women have found that the best way to avoid these risks altogether is to choose the care of midwives. As more women and their partners question the practices and protocols of obstetricians, midwifery care has become a common alternative.

Midwifery and Medicine: An Uneasy Alliance

The relationship between midwifery and medicine is complex on many levels and the two models have struggled in conflict with one another since childbirth started to become medicalized during industrialization. The medical opposition to midwives and the transition of childbirth away from the home and into the hospital has been well documented by historians. This history of intense scrutiny that midwives have undergone in the U.S. is directly related to the current marginalization, and even criminalization, of contemporary midwives.

Many aspects of reproductive freedom are affected by the conflict of theory and practice between midwives and doctors, and it is an issue that the reproductive justice movement must take on. The fact that abortion care is so enmeshed within the medical model presents trouble on many levels for a potentially inclusive movement. It is particularly problematic that the mainstream reproductive rights agenda has historically focused almost exclusively on abortion rights, especially for economically privileged white women, in that it inherently bonds the movement solely to the medical model, and thus prevents true alliance with the midwifery model at times when it is appropriate. In simpler terms, birth and abortion are separated within our culture as entirely different events, having nothing to do with one another, while in fact both are defining elements of the reproductive experiences and choices of women. While it may seem subtle, this separative dynamic serves to block coalition building and mutual support among a full scope of health care providers.

Abortion Remains Elusive in Midwifery Community

Doctors are not the only ones responsible for this ideological division. Within the midwifery community, abortion remains a somewhat elusive topic. Regardless of its relevance and importance to women's reproductive health, abortion is missing from much of the midwifery literature, education curriculum, and community conversations. In her article Mi Companera, Rewire contributor Miriam Perez writes about this controversial issue as it relates to the new phenomenon of abortion doulas. Clearly, abortion is an issue that midwives are likely to come across in their careers. According to the Alan Guttmacher Institute, over 60% of abortions are among women who have had one or more children. It seems logical then, not only from a clinical perspective, but also emotionally and culturally, that abortion would be a valid and important matter of discussion among midwives.

Despite this, the topic remains distinctly unspoken. The only midwifery organization to speak out about reproductive choices is the American College of Nurse Midwives, although they don't at any point in their literature specifically use the word "abortion." For many pro-choice midwives, doulas, and other birth professionals, this avoidance of the topic of abortion can be alienating and often seems unfounded. Some members of the community maintain that birth activism and pro-choice activism go hand in hand. On a personal level many of these midwives, doulas and birth advocates are communicating with each other about the place of birth options in the reproductive justice movement, and also the role of abortion within midwifery. To these birth advocates, it is apparent that strong bridges must be built between the midwifery model of care and the reproductive justice movement and that coalition building among us is essential.

But abortion is clearly a divisive issue. Some midwives do not consider abortion to be a valid reproductive option and do not want to align themselves with any pro-choice movement. And conversely, many pro-choice medical providers do not want to align themselves with direct entry midwives or out-of-hospital birth communities. This dynamic is at the crux of our cultural struggles for control over reproduction and the female body.

Personal and political action is needed to help us to achieve the ultimate goal of providing a full range of birth options to all women and families. This includes fully integrating midwifery care into the health care system of each state, including pushing our state medical programs and private insurance companies to cover midwifery care. Currently, many families who choose to give birth out of hospital with the help of licensed midwives are forced to pay out of pocket, even if they are insured.

Birth options advocates in several states are hard at work fighting for insurance coverage, and in New Hampshire this month the House voted to require insurance coverage of home births. Nationally, activists have launched "The Big Push for Midwives" campaign, advocating for regulation and licensure of midwives in every state. The media too, not just politics, has begun addressing these important issues. The new documentary from Ricki Lake and Abby Epstein, "The Business of Being Born," examines and questions childbirth in the U.S. and advocates for wider acceptance of midwifery care.

And in addition, we need to fight cohesively and effectively to legalize the practice of midwifery nationwide and to ensure the availability of state licensure.

Pregnancy, reproduction and birth practices are significant social and cultural issues that greatly effect women and their families. For midwives and reproductive rights activists alike, the inclusion of birth options into the conversation will offer an essential connection within this movement. Comprehensive birth options have an appropriate, and even necessary, role within this movement. We can help further this role by demanding a new framework for understanding "choice," as well as creating a more comprehensive philosophy that includes and honors the varied reproductive experiences of all women. I encourage those of us who are involved in any way with reproductive health and the movement for reproductive justice to expand our conversation past merely protecting the decision of when to give birth, but also advocating for a full range of options of how, where, and with whom to give birth.

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• Miriam Perez, Mi Compañera