Yesterday in New York City, [12] Julie Finefrock appeared before the health fund subcommittee of the Service Employees International Union (SEIU) as part of her appeal of their denial of her homebirth coverage. Ms. Finefrock, who is six months pregnant, is married to an SEIU employee. Their insurance plan excludes homebirth coverage, despite New York State regulations that require that private insurance cover out-of-hospital birth with a licensed practitioner. Ms. Finefrock's situation is just one example of a larger fight to increase access to homebirth nationally, and it's a fight that has ramped up due to new media attention to the issue.
One
mother laboring with her midwife on the roof of her Cobble Hill penthouse,
gorgeous Manhattan skyline in the background. Another holding her newborn
on her living room couch, exposed brick and high ceilings behind her.
These are just two of the scenes from the November New York Times article and slideshow [13] about the growing interest among New York
City women in birthing at home. These images paint a very specific picture
of homebirth--all the women were pictured in spacious, nicely decorated
apartments and, with the exception of one African-American woman, all
were white. Watch the popular Ricki Lake documentary The Business of
Being Born [14], released
last year, and you get a similar story: Lake and her interviewees
were all financially well off and could afford to choose to birth at
home. Neither the Times article nor Lake's film touched on one
thing that all these women seemed to have in common--money.
Despite The Business of Being
Born's [14] relative
popularity, the film only reaches and speaks to a limited audience.
"The Business of Being Born is fabulous, but low-income women
are not seeing it," says JayVon Muhammad, an African American Certified
Professional Midwife (CPM) in Sacramento "The midwives that
are promoting it don't typically have low-income women in their client
base...[Even when low income women see the film, they] don't see women
that look like them, economically and ethnically, they can't see themselves.
They think that only ‘those' women do that."
Upwardly-mobile
moms in New York City may finally be catching on to the benefits of midwifery
and homebirth, but low-income women are still firmly planted in the
hospital most often with medicalized births overseen by doctors. Current
efforts to transform birth - offering women more options and preserving
their decision-making - are not reaching low-income women. Birth activism
draws attention to the ubiquitous media portrayal of highly interventionist
births, the normalization of c-sections, and the lack of choice afforded to women by their doctors, whose hands, in turn, are tied by hospital
policy and malpractice fears. The criticisms made by birth activists
are accurate yet incomplete. Missing from these conversations is how
low-income women - who suffer the worst outcomes for their babies,
including lower
birth weights and higher infant mortality rates [15]
- are making decisions about where and how to give birth.
The maternity reform movement's frame of consumer choice (exemplified by the name of one of the primary advocacy organizations, Choices in Childbirth [12]) may be at least partially to blame. This frame neglects the reality that many women can't make a choice at all. "I work in a (very) low-income Medicaid clinic in Sacramento, and the women all have Medicaid or Family Pact as insurance," Muhammad explains. "Medicaid doesn't cover homebirth, so even if women choose to have homebirth, they are not covered, leaving no choice at all. As a result, when women show an interest, and very few do, they don't have a choice. They are forced (due to lack of money, and insurance) to deliver in the hospital."
There are a number of barriers to low-income women giving birth out of hospital. As Muhammad highlighted, Medicaid is the first. Medicaid and other state health insurance programs generally do not cover out-of-hospital births. According to Steff Hedenkamp, Communications Coordinator at The Big Push for Midwives [16], only in nine states can CPMs (who account for the majority of homebirth practitioners) register as Medicaid providers. Even in those states, very few CPMs go through the process because of bureaucratic red tape. Yet even if a woman has private insurance, she often faces similar barriers when trying to choose out-of-hospital birth. The estimated $4000 that a homebirth costs without insurance coverage might not be an impossible hurdle to cross for a middle class family, but is a near impossibility for low-income women.
Medicaid
policy may be the most significant logistical barrier, but it isn't
the only one standing in the way of low-income women delivering outside
the hospital. Doulas and midwives who work in low-income communities
of color see the barriers as being social in addition to financial. Muhammad explains: "In low-income black communities, which I am a product
of, we don't learn about natural birth, or birthing choices."
Claudia Booker, an African American doula in Washington, DC, agrees. She explains that women in low-income communities of color stopped giving birth outside of hospitals at least three generations ago. There is also a sense, she noted, that giving birth at home is "what poor people do and [that homebirth] was something we did because we had no option." This history reflects a larger transition among US women giving birth at home to hospital birth, which happened in the 1920s. Low-income communities, and particularly African American ones, took longer to make this transition because of poverty, racism and lack of access to hospitals. Now the paradigm has shifted and hospitals are where low-income people get most of their health care.
Another barrier to home birth for low-income women is concern over birth certificates for their babies. In recent years, particularly since 9/11, obtaining passports and other citizenship documentation has become increasingly difficult. The crackdown has focused on people born to midwives at home. Immigration authorities have begun questioning the validity of documents [17] from these midwives and holding those individuals to a much higher burden of proof. This has had a disproportionate impact on Latinos [18] and other immigrants, requiring them to go to great lengths to obtain passports and other documentation. Claudia Booker thinks this fear of citizenship being questioned may keep low-income people from leaving the hospital to give birth.
The media depictions of home birth moms are not far off from the demographics of those at the helm of the maternity reform movement. This small collection of organizations and individuals, primarily made up of midwives, doulas and mothers, is predominantly white and middle class. Steff Hedenkamp from the Big Push for Midwives [16] readily admits these shortcomings. "You could say we're not doing enough to reach out and engage with lower income women, and it's probably true. We're not doing enough on every level." It's difficult to say whether it's merely a demographic issue, or reflective of something larger, but it's clear that the demands of the maternity reform movement are not promoting the needs of low-income women. Even if the Medicaid barrier were to be eliminated, the education provided by films like The Business of Being Born need to be geared specifically toward low-income women or they aren't going to leave the hospitals anytime soon. "My clients don't know a thing about homebirth, nor do they understand why they would even consider such a thing," explains Muhammad. "They are not educated about the benefits of birthing out of the hospital or birthing without interventions. Many of them think the elective c-sections are okay, and can't wait to schedule theirs, as they have friends that have."
One thing that all these advocates can agree on is that the current health care crisis may provide an opportunity for real maternity reform. During such shaky economic times for the health care industry, cost cutting is a definite priority. Steff thinks birth might be the perfect target for savings, as midwives cost less than obstetricians, and vaginal birth less than a c-section. "If anyone is doing real healthcare reform, they have to look at the cost of maternity care. A thirty-percent c-section rate and rising? It's not sustainable. No way." These reforms may have a chance of reaching low-income women, particularly if lower cost birth options, like midwives, homebirth and birthing centers become part of a universal health care package.
Muhammad put it plainly: "If Medicaid doesn't start covering homebirth, any positive changes toward homebirth will not benefit poor women. They will have to choose between homebirth and food, and food will win every time."