FAB Gab Episode 7: Susan Stark on the Intersection of Gender and Race

2:44AM Apr 11, 2021

Speakers:

Kathryn MacKay

Susan Stark

Keywords:

birth

paper

home

people

childbirth

important

birthing

policed

hospital

outcomes

argue

midwives

united states

maternal mortality

gender

identity

safety

medical establishment

pushback

susan

Hello, and welcome to FAB Gab. This is the podcast for the International Journal of Feminist Approaches to Bioethics, brought to you by FAB network. My name is Kathryn MacKay and today I'm joined by Susan Stark, from Bates College, Maine, to discuss Susan's paper, 'Home Birth and Maternity Outcomes Emergency: Attending to Race and Gender in Childbirth'. And this appears in Volume 14, number one of IJFAB. Hi, Susan.

Hi Kate.

How are you doing?

Thanks for having me.

Oh, thanks for joining me. It's great to have you. I really enjoyed reading this paper, I thought it was fascinating. I learned a lot. I was challenged to think a lot. So I'm excited to talk with you about it. And the first question, I think, is just to sort of ask you to give us a summary of the paper.

Yeah. So I do really want to say thank you so much for having me, I'm delighted to be here. So I feel like the first thing that's important to say is to acknowledge my identity. My paper talks a lot about the importance of race and gender in childbirth. And so it's important to me to send her into acknowledge my own identity. I'm a white, cis, straight, mostly able-bodied woman. And, you know, that certainly informs the paper. So I wanted to begin by saying that. I also wanted to begin by saying that though I speak of mothers giving birth in the paper, I'm going to speak about parents giving birth and gestational parents or birthing parents today, because I think that that might be a little bit more trans-inclusive. So the basic idea behind the paper is that there was an article that was published about 10 years ago, a research paper that found that infants born at home... it compared infants born at home to infants born in the hospital. And they found that infants born at home have a twice higher mortality rate than infants born in the hospital. And the absolute numbers were low. So the absolute risk was not a lot, but the relative risk was twice as great. And so a few years after that study came out, there was a proliferation of articles written, really saying that home birth was not appropriate, it was not appropriate for clinicians - that is physicians or midwives - to be involved with home birth, some of the articles said that it was unprofessional, and that people should not give birth at home. The phrase that was used in some articles was 'un-motherly', to given birth at home. And so I was really interested to think about whether or not home birth was being held to the same standard as other things in society, and... or whether it was being held to a higher standard. So I wanted to compare this view about safety, if we just granted the outcomes as they were, and think about what other things that might be related to safety, how they would compare to giving birth at home. So that's kind of what began my investigation.

Yeah, that's fascinating. And it seemed like, what I found very interesting in your paper was the discussion of a contrast between safety to infants and safety to a mother, or in this case, a birthing parent.

Yeah, exactly. So. So really, after I kind of did that initial investigation into safety, I started looking at the way home birth occurred in the United States or birth occurred in the United States. And that's where you really see this contrast that people who give birth in the hospital experience a lot of morbidities. And of course, when we start to think about race, people who give birth in the hospital who are black and brown, have really high... exorbitantly high rates of maternal morbidity and maternal mortality, the, you know, the United States, just to sort of centre of my own... my own country, the United States ranks in the 50s in the world in maternal mortality, when you consider all people who give birth in the United States, and when you only think about black and brown people who give birth in the United States, we currently ranked 80th in the world in maternal mortality. And this is for a country that spends an enormous amount of money on childbirth and has enormous access to technologies. And so there's this great discrepancy between the way people who give birth fare in the US and infants and so in the hospital, maternal outcomes or birthing parents outcomes are less good than they are for infants just exactly to your question. And one of the things that I did in the paper was to look at things like other things that might be considered risky, like playing football, or swimming, or driving. And what I found is that we are willing to tolerate much higher risks as a society - again in the United States - when... with things like playing football, or, or swimming, or driving. And if you look at the years in which the speed limit was raised from, say, 55, to 65, or 65 to 75, highway traffic deaths go up in those years. And so you can actually quantify precisely how many humans and then specifically how many children are dying as a result of those increases in speed limits. And it's, it's much more than the number of infants that are dying and being born at home. And so it seems to me that... or one of the things I suggested in the paper is that home birth is being policed to a greater extent, because the people who are giving birth - because of gender - because the people who are giving birth are non-males, many are women identified people. And as a society were much more comfortable putting restrictions on and policing activities that are done by non males, by women-identified people and others, then we are things like driving where it kind of all parents drive. And all parents, or some parents, irrespective of gender, allow their children to play football or swim in home swimming pools. And so we don't really think about those things as being unsafe, but they're much more dangerous than giving birth at home.

Mm hmm. Yeah, the gender element is so interesting and thorny. Here, it's like an effort to control something. I think you mentioned that in your paper. It's an it's an effort to control something that is otherwise not in the control of the medical establishment or...

Yeah, exactly. We're very comfortable allowing parents, at least some parents, I mean, there are racial discrepancies in the United States, again, in how parents are policed while driving, or even policed at home, for sure. So there are racial discrepancies there, but we still pay a lot less attention to to those issues of safety, like sports and swimming in swimming pools and driving than we do with birth giving. Yeah, and I think the medical establishment is also much more comfortable constraining the actions of birth-givers than, you know others in other contexts. And so I thought it was important to highlight those kind of gender-neutral examples of football, driving and swimming, because it shows we don't really think that much about safety when it comes to those things. And we think about it a lot more with giving birth.

This is very random. But have you ever watched Monty Python's 'The Meaning of Life'?

I've seen them. Yeah.

(Laughs) Reminds me of the birthing scene. Yeah. Like, 'what do I do? Nothing dear. You're not qualified.'

Exactly. Yeah. In fact, that clip was also appeared in... Ricki Lake made a documentary about giving birth. And that clip was in there.

Oh, wow.

Yeah. It was called 'The Business of Being Born' it's a great film.

I haven't watched it. I'll have to watch it

Right, from the from the mid like, around 2015-2014. Somewhere around there.

Cool. I missed that, somehow. I'll have to find that. I wanted to ask you a question. Before we kind of get in, I want to ask you other questions about the sort of content details, but I think maybe it would be useful to the listeners first to ask you, if you could give us maybe an overview just of the main points of argument in the paper, because what now we've kind of talked about little bits and pieces of it.

Sure. So the first thing I argue is that homebirth is safe, that against this kind of movement in the medical establishment, spurred on by that initial study to thinkomebirth is unsafe. I argue that it's safe, it's well within the bounds of other activities that we don't even think about with regard to safety. We're just happy to raise the speed limit or happy to allow people to have swimming pools without fences, or play football, when you know many people, many children and teenagers, college students, high school students, die playing football every year. So that's the first thing I argue and then the then the kind of positive account in the paper is to look at the reasons why someone might choose home birth. And to argue that home birth is empowering that many people choose it because it it is a kind of positive, centering, powerful experience. And that that's an important argument in favour of it. I argue that it's in part a, it's a component or can be a component of birthing justice. Julius Opara argues that it's really important to change the culture of childbirth, to be anti-racist, and to uncover and address the issues of systemic racism in birth giving. And so Opara argues that giving birth at home with an attentive midwife can be also part of - a small part, but a part of - a movement for an anti-racist birth. And then I also argue that it's really important to respect the autonomous choices of birth givers of all humans, but in this context of birth-givers, and that undermining the autonomy... so this kind of connects to my first point that homebirth is safe. So the fact that it's safe means it's rational to choose it. And if it's rational to choose, it doesn't mean everyone needs to choose it. But if it's rational, it does someone a great wrong to undermine their autonomously chosen goals and ends. And so when homebirth is policed, or made unavailable or made more difficult, we are undermining the autonomous choices of a growing population of people. Home-birth went from, you know, being a very small fraction of births to being, you know, a much larger fraction of births in recent years, and indeed, the population among whom it's growing the fastest are black and brown birth-givers. So I also argue that against this backdrop of the real, you know, terrible disparities in birth outcomes, both within the US between white birth givers and black and brown birth givers. And then also the very low rate, the very poor outcomes compared to other countries, that there's a failure of the social contract, and that people who give birth should get to choose where they want to give birth, and that we shouldn't be undermining autonomous choices, especially in this context of a failure of a social contract.

Yeah, absolutely. It seems like it's extremely risky for a black or brown mother to go into a hospital.

Exactly. Yeah. I have lots of examples in the paper of women... Serena Williams in the US is one example. A woman named Chaumont Irving is another example, who is an epidemiologist who died in childbirth, in part because doctors and nurses did not take her seriously. And I also cite research that suggests that physicians don't listen well to black and brown women, and especially when giving birth. And so I think the experience that some birth-givers have in the hospital is a really traumatising experience. And so against that backdrop, I think it's important to give people the freedom to choose where to give birth.

Yeah, absolutely. And I had a question about that, about the context, I guess, in the United States. Because I was wondering about, you mentioned health insurance and how health insurance covers or maybe doesn't cover home births. And I was curious about how that plays into this story of birth, I think maybe in general in the United States. I guess, because I was wondering if there is sort of institutional pushback against it from physicians or from hospitals, because perhaps they don't get paid if people aren't coming in as their patients. And you also mentioned in the paper, how in Canada, and in some places in Europe, the midwives actually have hospital rights, so they have hospital access, which means that it's a very smooth thing. If you have to go from a home birth and in - suddenly you need to be into a hospital. Whereas that might not be the case in the US...

Yeah, there's several things there that I think are really important. One is that yes, you're right. Homebirth is not always - I mean sometimes it is but not always covered by insurance. And even though it is much less expensive to give birth at home than it is to give birth in the hospital, if someone's insurance plan doesn't cover home-birth, or if they don't have insurance, if they show up at the hospital, the hospital will take care of them. If they're, if they don't have insurance, or their insurance doesn't cover it, you know, it's many 1000s of dollars to give birth at home. And so that puts it out of reach for a substantial portion of humans. And that's really important. And then yeah, you're right there. I don't write about this. But there is... some people argue that there's a kind of turf war. And certainly that documentary I mentioned earlier, 'The Business of Being Born', argues that childbirth is a business. And that, you know, everyone is trying to kind of protect their piece of the business. And I should say, I don't think anyone is ill-willed or ill-intentioned, it's just sort of the way the system is structured. And so I think it can be very hard if midwives have not historically had that, at least in the last 100 years, certainly, most births were attended by midwives in the US, before the advent of hospitals and giving birth in hospitals. But if midwives have not had their piece of the business, and there isn't this really well-coordinated effort between physicians and midwives, when someone is giving birth at home and needs to transfer to the hospital, which does happen some percentage of the time, if there isn't that collaborative relationship there, the person giving birth just has to show up at the emergency room without their care provider and just sort of say, you know, I'm in labour and things are not going well, please help me. And of course, it's, it's hard for the medical folks in the emergency department. You know, I'm sure they try to be unbiased and non-judgmental, but everyone has their own beliefs. And that can present problems too, for the person giving birth if they appear to just show up without having a continuity of care with a care provider in the past. So it does make it really hard that there's this kind of uncoordinated effort with home-birth. I think would be much safer if it were integrated into medical practice. And if patients could, you know, either decide I don't want to give birth at home, it's, you know, month nine, and I prefer the hospital or they have some complication that arises during childbirth, and there's a smooth handoff. And I think in Canada, and in many countries in Europe, that's the way it operates. And, and those countries have far better outcomes than we do in the United States.

Yeah. And that would be so terrifying to have to just show up to an emergency department.Wow. Yeah.

Yeah. It's awful. I mean, and that that introduces another layer of psychological trauma for those first few person those families.

I have a question for you that's a little bit of a sort of change of direction. But I'm wondering about whether you had any particular challenges in writing the paper, and I wonder if perhaps some of it might connect to your positionality, as you mentioned at the outset?

Yeah. Yeah, that's a great question. Um, one of the things that was really, something I worked hard to do was to de-centre myself in the paper, and to think about people giving birth who don't look like me. And so really, the journey in writing the paper began with an interest in home-birth and this sort of stuff about safety. And then the longer I worked on that, the more I saw that I was really centering people who look like me, and that that's not... most people who are giving birth, and it's also to simply centre people who want to give birth at home to look like me really ignores the most pressing and urgent problem facing childbirth in the US right now, which is the exorbitant rate of maternal mortality, especially for black and brown women. I mean, I call it a crisis when you think about all women, and when you think about black and brown women alone, it is an emergency, it is it is just a terrifying thing for some to to give birth in the hospital because of the way the outcomes are right now. And I think that's so that was really an important trajectory, an important journey for me. And obviously as an epistemological matter, it's really hard to write about things that you don't experience and that aren't part of, of what you know, through your own embodied experience. So it, it took a lot of, you know, work and thoughtfulness and listening to others, and reading the excellent works that are out there, Opara is one great example, but others as well, but also trying to kind of overcome my own epistemic limitations as a result of the identities that I have.

Yeah, absolutely. That's fascinating. And it's a, it's really valuable, and also very difficult to go through that systemic work, as you say. Yeah.

Yeah. And, you know, and one wants to do the work oneself, because, you know, to ask others to share their experiences, or to tell you how things seem to them, especially folks who have marginalised and minoritised identities, that puts a burden on those individuals, that's really unfair. At the same time, you know, my own identity limits what I can see and know. And so it's a delicate matter, to be humble about what I can see and know, given my identity, but also to not burden others by you know, asking them to share their experiences, but to read and listen to podcasts and to go to talks and hear other's stories and truths and realities, and really de-centre, my own experiences.

Yeah, thank you. So I guess we're kind of coming to the end of our time here. So I just wanted to ask you, what sort of primary takeaway message you hope people will glean from the paper? And also, maybe if you've got an idea for what the next stage is?

Yeah, well, and so. So I'll say one thing before I answer those two questions, which is that, you know, I really see this paper as a contribution to a dialogue. And especially in this thought about decentering, my own identity. There may be ways in which I've made mistakes in the paper. And I really welcome feedback and, you know, pushback and comments from other people who know things through their own lived reality that doesn't fit with what I've described in the paper. And I think that's really, really important. Because a lot of times what happens is, someone put something out there, and then they get pushed back, and then they get defensive. And it's, of course, natural to want to defend your own ideas and beliefs. But... but I really put this out there as a, an opening or a contribution to a conversation. And I welcome pushback, and I welcome the opportunity to expand what I think based on what other people... how they share their experiences. So in terms of the most important takeaway, I think, I think if if folks don't take away anything other than that there is an emergency in the United States about childbirth, and the maternity outcomes, especially for black and brown birthing people. You know, I really want to shine a light on that. And I want people to appreciate that and be motivated to change it. I also think it's really important to think about gender and the way we police as a society, people who give birth and women-identified people more than we police others. And so I think that that would be a sort of secondary takeaway from the paper. I think that is very important. And in terms of what's next, I'm in the midst of a project on reparations. I'm working on a bunch of articles and a special issue of a journal that's concerned with making reparations for historic injustices. And here again, in the US, I'm focused primarily on institutionalised slavery, Jim Crow segregation, and also on the genocide of native and indigenous people in the US. And I am working on really thinking about what it means to make reparations, what it means to repair these historical wrongs that cause intergenerational harm and cause trauma in the present, and how we can really take very seriously the extraordinary task of attempting to repair these generations long wrongs and harms that have been occurring in the United States for before it was the United States for you know, 400 or 500 years. And so that's what I'm working on right now. I'm really excited about that project. I feel like it's it's way past time.

Yeah.

To take that's seriously. So...

Yeah, that'll be super interesting for Australian and Canadian readers slash listeners as well. Important, important work to be done there.

Yeah, absolutely.

Well, thanks so much for talking with me, Susan. That was a really great conversation, and we'll provide the paper in the link to the notes. So thank you for joining me.

Thanks, Kate. It's been really great conversation and pleasure to be here. Thank you so much.

Great. Thank you. And thanks so much for listening to this episode of FAB Gab, everyone. You can find Susan's paper linked in this episode's notes, along with a full transcript of our discussion. FAB Gab is hosted by me Kathryn MacKay and produced by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor, or wherever else you get your podcasts of quality. Thanks again for listening. Bye.