Text of a paper I originally submitted November 19, 2013 for SOSC 150 at Midwives College of Utah
I am haunted by a birth where I was doula to a primapara Blackfoot teen mother. She was determined to avoid a cesarean section. When she reached her 38th week, her health care providers inexplicably began pressuring her to be induced. In her 39th week, she learned what everyone else had already known: her doctor had left for three weeks vacation. She carried the baby to term, delivering with a stranger. This Ob-Gyn scared her into oxytocin augmentation after only one hour in the hospital, when she was just 3 cm dilated. The predictable cascade of interventions then followed, resulting in cesarean delivery. I chose the identity category Native American with the focus markers cesarean and oxytocin augmentation to investigate a suspicion that cesareans are higher among Native Americans, especially if they are eligible for Medicaid.
However, the 2003 study by Leeman and Leeman illuminates what really may have been at play around this client’s birth: practitioner attitudes may be the ultimate determinant of outcomes. Even from its title, the study modestly feigns ignorance as to the cause of the “anomaly” of a very low 7% cesarean delivery rate in a Native American community over the course of four years. The Leemans tried to point to other causal factors such as ethnic homogenity, aboriginal social support or cultural views and even geographical elevation. The suggestion that the medical team was made up of family physicians and a nurse-midwife instead of obstetricians may possibly be what got this study published. (It appeared in the first issue of a new scholarly journal for family physicians, but only after one of the authors had already safely earned his obstetrics degree). However well the passive voice was used to disguise it, the action verbs that appeared throughout the study – words like permitted, concur and allow – clearly indicate the determinant role played by health care providers in producing positive birth outcomes.
The health disparities faced by the Zuni-Navajo study population should have been similar to those faced by other Native Americans in New Mexico and across the country, including the Montana Blackfeet. Antenatal care should have been more difficult to obtain due to interrelated barriers (Downe, Finlayson, Walsh & Lavender, 2009). The Zuni-Navajo access to midwifery care was also atypical (Midwives College of Utah, n.d.). As Crenshaw elaborated (1991), the intersectionality of poverty, race and geography should have predicted this Native American population would be less valued and placed at the bottom of the medical hierarchy of services offered in New Mexico. Yet their cesarean rates were actually lower than the rest of the state and the country. Poverty has been associated with increased perinatal risk (Callister & Birkhead, 2002). Indeed, the Leeman’s study population had more women with pre-eclampsia, chronic hypertension, and diabetes (p.39). According to the racism theory proposed by Camara P. Jones of the CDC, such a positive outcome should not even exist in today’s America. Institutionalized racism in the hospital and personally mediated racism at the hands of care providers should have irretrievably doomed this population to worse outcomes (2000). In fact, this Native American population did have differential access to goods, services and opportunities, including the iatrogenic interference readily available to most of their peers. However, cesareans were not an option at this hospital, and protocols prohibited intervention without the unanimous consent of two physicians. Were these policies institutional or personally mediated by the Leemans and why were they enacted? Are they still occurring? Nothing in the study indicates that policies and procedures were the result of consumer demand.
Other studies of aboriginal populations have shown the damaging effects of the lack of social support connected to institutionalized racism upon birth practices and satisfaction (Kornelsen, Kotaska, Waterfall, Willie & Wilson, 2010). Does the Leeman study demonstrate institutionalized race support or the significant, perhaps overriding decision-making power of physicians within the community structure or both? Notably, the key factor of social support discussed by Keating-Lefler and Wilson (2004) neglected to outline the role played by health care providers, especially when, in the minds of many women, they are included as part of their trusted support group (Kornelson et al, 2010). If resilience is the ability to experience stress and deal with it effectively, perhaps the low numbers achieved during the Leemans’ tenure were a harvest of the effects of resilience experienced by their patients.
As Callister and Birkhead proved in their study of another epidemiological paradox, sociocultural rather than genetic variables are the primary factors associated with perinatal outcomes (2002, p.23). Indeed, Esposito demonstrated that during birth, women are expected to submit to doctors, the authority figures in the mainstream health care system (1999). Therefore, why does this study pay more attention to race rather than to provider?
Perhaps race does not matter in this study at all (Garcia, 2004), and to suggest that race played a part was, in itself, racist (Vasas, 2005, p.199, 201). It appears that the participants were treated only minimally as collaborators, nor was their race discussed as a living, changing process. Essentially, they were viewed as the Other by Insiders, the Leemans (Jackson, Phillips, Rowland Hogue, Curry-Owens, 2001). Can one deny they have power at the same time they wield it? Apparently. Did the Leemans use and abuse their white privilege in the publication of this study (McIntosh, 1989)? A Google search reveals that the couple did not remain in the service of their study population. They lived there only six years, then moved to Albuquerque to further advance their careers and raise their family on a property worth over $268,000. Did they stay just long enough to pay off their college debts by working for I.H.S? Was the study really self-serving subjectivity posing as objectivity? If the readings in this course have taught me anything, you see what you look for. I am disturbed that this success story may not really be one at all: Though the stories differ, the dominant and oppressed populations just remain the same.
Callister, L. & Birkhead, A. (2002). Acculturation and perinatal outcomes in Mexican immigrant childbearing women: An integrative review. Journal of Perinatal and Neonatal Nursing, 16(3), 22-38.
Centers for Disease Control and Prevention. (2000). A discussion with Camara P. Jones, MD, MPH, Ph.D. Retrieved from http://www.citymatch.org/special- reports/gardeners-tale-dr-camara-jones
Crenshaw, K. (1991). Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Review. 43 (6) 1241-1299.
Downe, S., Finlayson, K., Walsh, D., & Lavender, T. (2009). Weighup and balancing out: A meta-synthesis of barriers to antenatal care for marginalized women in high-incomes. BJOG, 116, 518-529.
Esposito, N. (1999). Marginalized women’s comparisons of their hospital and freestanding birth center experiences: A contrast of inner-city birthing systems. Health Care for Women International, 20 (2), 111-126.
Garcia, R. (2004). The misuse of race in medical diagnosis. Pediatrics, 113, 1395-5.
Jackson, F., Phillips, M., Rowland Hogue, C., Curry-Owens, T. (2001). Examining the burdens of gendered racism: Implications for pregnancy outcomes among college-educated African-American women. Maternal and Child Health Journal, 5(2), 95-107.
Keating-Lefler, R. & Wilson, M. (2004). The experience of becoming a mother for single, unpartnered, Medicaid-eligible, first-time mothers. Journal of Nursing Scholarship, 36(1), 23—29.
Kornelsen, J., Kotaska, A., Waterfall, P., Willie, L., & Wilson, D. (2010). The geography of belonging: The experience of birthing at home for First Nations women. Health & Place, 16(4), 638-645.
Leeman, L., & Leeman, R. (2003). A Native American community with a 7% cesarean delivery rate: Does case mix, ethnicity or labor management explain the low rate? Annals of Family Medicine, 1,1, 36-43.
McIntosh, P. (1989). White privilege: Unpacking the invisible knapsack. Peace and Freedom, July/August, 1-4.
Midwives College of Utah. (n.d.). Cultural diversity position statement. Salt Lake City, UT: Midwives College of Utah. Retrieved from http://www.midwifery.edu/cultural-diversity- position-statement/
Vasas, E. (2005). Examining the margins: A concept analysis of marginalization. Advances in Nursing Science, 28(3), 194-202.
Results from the non-academic Google Search about the Leemans, authors of the featured study:
Author’s Note: This is probably the paper I am most proud of because it cleverly met the progressive-marxist rubric of my instructor while simultaneously defeating its intended agenda. 🙂