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Is Reproductive Healthcare Access a "Consumer Rights" Issue? Christa Craven Movements to enhance reproductive rights have played an important role in reforming healthcare policy in the US. From grassroots efforts to pass the Sheppard-Towner Maternal and Infant Protection Act in 1921—the nation’s first social welfare policy, which directed public funds to prenatal programs—to more recent struggles to legalize abortion and gain access to new reproductive technologies, the women’s movement has been at the forefront of efforts to expand publicly-funded healthcare access. Oftentimes, however, the resultant “reforms” passed into law by federal, state and local legislatures have not been as broad-ranging and inclusive as activists had intended. Despite the best efforts of activists, reproductive healthcare “reforms” have not succeeded in ameliorating uneven access to reproductive technologies and services. While these policy shifts have often enhanced reproductive options for white, middle-class and affluent women, they have not been as successful for women of color and poor women, many of whom still lack access to prenatal care and many other reproductive healthcare services. Recent anthropological research on the US healthcare system has explored the further stratification of access to healthcare through the commodification of public resources under neoliberalism. My research focuses on the effects of neoliberal policy “reform” on grassroots efforts to secure access to midwives in the US. Even as midwifery advocates challenge dominant biomedical and corporate models of childbirth many are also increasingly employing market-based terminology to identify their struggle for access to midwives. Challenging
Ideals This situation has added yet another layer of complexity to an already complexly stratified system. As Gertrude Fraser has shown, for example, after being denied access to biomedical care for many years, many contemporary African-American women see using midwives as going “backwards” and choose to give birth in hospitals with physicians in attendance. Although some African-American women and other women of color remain vocal proponents of midwives, their numbers remain small.
Efforts to organize midwifery supporters are often complicated by uneven state laws regulating midwifery practice and limited (or non-existent) access to midwives within many localities. That there are two different classifications of midwives in the US also challenges organizers, as well as lawmakers. Certified Nurse-Midwives (CNMs) are legal in all 50 states and practice primarily in hospitals. Although all CNMs train as nurses and then receive an advanced degree in midwifery, regulations regarding relationships with physicians, hospitals and insurance companies vary widely throughout the US. Of particular concern to midwifery advocates is the growing trend towards eliminating nurse-midwifery practices associated with US hospitals (as has happened in Austin, Chicago, the District of Columbia, New York and Philadelphia). Hospital officials cite financial pressures as the motivation for their decision, despite the success of many services at drawing in clients from a range of class backgrounds who seek personalized birthcare. This apparent contradiction raises questions about the relationship between corporate and biomedical institutions among the growing numbers of women left without access to midwifery care in hospitals and birthcenters. Direct-Entry Midwives (DEMs), who train directly as midwives and specialize in out-of-hospital birth, face different challenges. They are currently legal (with varying levels of regulation) in about a third of the states in the US; they are illegal in a third, and undefined (effectively illegal, and subject to charges of “practicing medicine without a license”) in the remaining third of the US—including Virginia, where I conducted ethnographic fieldwork. Concerns about the safety of homebirth have become the focus of biomedical opposition to DEMs in many states, and homebirth mothers in particular were consistently identified by medical officials in Virginia as “pathological”—often linked with drug users and child abusers. The state has responded in Virginia by continuing to deny homebirthers legal access to the reproductive care that they believe is the safest and, for many, the most affordable option. “Consumer
Rights” Rhetoric Although this consumer model offers some midwifery advocates a useful metaphor to describe themselves as political actors, it does not always speak to the experiences of women who have restricted financial options for birthcare. In fact, most middle-class, affluent participants in my study felt strongly that it was their right to have choices in their childbirth experience, while most low-income participants indicated an interest in choices for their birthcare, but also a dependence upon midwives as a low-cost childbirth option. Low-income homebirthers also highlighted the challenges of cross-class organizing when “choosing” a midwife; often their financial reasons for choosing midwifes put them at odds with other advocates. One homebirth mother explained, “Every time [I said] I homebirthed because I was poor . . . this one woman [would say], ‘But that’s not the only reason,’ because they don’t want to hear that within the movement. I am told not to say it’s because I was poor [that I had a homebirth] because that makes you look dumb.” As an active member of national and Virginia-based efforts to improve access to midwives, I began to bring up what I saw as the limitations of “consumer rights” arguments with fellow organizers, sharing examples from my interviews with low-income homebirthers who consistently apologized for not being politically active because they didn’t feel “like the normal midwife consumers.” My well-intentioned suggestions prompted some organizers to rethink a focus on consumer rights and favor language that evoked the rights of citizens, but many organizers highlighted the limitations of discussing citizen’s rights with lawmakers. Consumer rights rhetoric, they argued, has become the most persuasive argument in support of alternatives to the dominant biomedical model of childbirth—especially in the age of legal battles over caps on malpractice lawsuits and in the wake of privatizing social and healthcare services. Ultimately, it remains to be seen how this strategy will affect laws and regulations around midwifery in Virginia; after five years with several close votes in the legislature, no laws have been passed to offer any women access to legal DEMs for homebirth. This “consumer rights” rhetoric is a direct response to the shifting understandings of citizenship under neoliberal governance. In effect, the meaning of a “right” has changed for all citizens and the state’s support of “consumer rights”—instead of the protection of all citizens’ rights—forces citizens-as-consumers to rely upon the fluctuations of other consumers’ desires within the market to compete for their social, political and economic rights. As reproductive rights are increasingly subject to the whims of a globalizing capitalist economy, anthropologists must critically examine how and whether consumers’ rights can intersect with the rights of all citizens as they seek access to quality healthcare. The increasing commodification of healthcare services throughout the world will continue to force us—along with other reproductive rights advocates—to interrogate both the possibilities and limitations of market-based activist strategies. Christa Craven teaches in the department of sociology and anthropology at the University of Mary Washington. She is active in efforts to promote midwifery care. |
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