The Other Cost of Crises Pregnancy Centers

This week’s ruling by California’s Supreme Court that crises pregnancy centers can omit information from their counseling of pregnant women has many well documented outcomes. The primary goals of these centers are to deter women from accessing abortion care and to restrict their rights to autonomous reproductive healthcare decisions. In cities like the one I am living in there are enormous billboards, bus signs, and benches covered in ads for these centers. They read, “Don’t harm your baby! We can help!”, “Free Ultrasounds!”, and “Free Prenatal counseling, we will help you with your decision.” Women are lured to these centers through promises of seemingly unbiased guidance and support. These centers have been found guilty of, and defend their right to omit information about the availability of birth control and access to abortion care (including Plan B medication). They have proudly affirmed that they often tell women they are further along in pregnancy than they are. This helps convince women that they are not eligible for an abortion. It also causes them to imagine a fetus that is more like a baby than a few cells to make it emotionally harder to decide to terminate.

What no one talks about is what happens next if a woman decides to keep her baby. As a midwife in the South I have received these women into care many weeks after their first visit to one of these clinics. Most of them receive regular prenatal care from the clinics. However:

  • If they miss any appointments, they are kicked out of care and left to fend for themselves.
  • Sometimes they do not want to relinquish their baby for adoption through the clinic agency and they are harassed and pursued by agency representatives who prey on their vulnerability and try to shame them into submission.
  • Sometimes women come to a place where they embrace the idea of motherhood and want to do all they can to prepare and learn about birth and parenting. Their newfound power is threatening to the relationship with the crises center and they are pushed away from resources.
  • Sometimes they are violently ill from the pregnancy and ignored completely as long they remain pregnant. Their health really does not matter as long as the vessel of their body continues to carry the pregnancy.

I’m sure somebody out there has documented all of the pathways these pregnancies and women can take—they are varied and many, with complexities and layers we dissect and maneuver through with individuals who wind up in our care. I have sat in stunned silence on my own after these visits many times because the level of depravity and lack of compassion that rises up from these centers and the staff and providers who work in them is frankly unfathomable. It is a lifetime movie gone horribly terribly wrong but it’s no movie—these are very real lives with very real consequences.

What I never heard about, and I wager very few have considered, is this scenario: A woman goes to a clinic for a free ultrasound and prenatal assessment. She may or may not have ever considered abortion. She may be happy about the pregnancy or ambivalent or miserable. She arrives at the crises clinic not knowing the date of her last menstrual period. They do an ultrasound, give her a due date and print out an image for her to take home. They put the little black and white photo into a small white envelope with illustrations of a real baby, looking happy and fat and healthy, surrounded by blue and pink ribbons.

These are the questions we must ask:

  • Is the due date they gave her accurate or is it based on dating that will ensure she will not receive access to abortion care in her area?
  • Is the image they give her of her own baby or one who is more developed than the one she carries?
  • Do they explain how she can access Medicaid, social services, housing, job training, or food for herself and her baby or do they only share resources that exist in their clinic and lead to adoption by a family that pays hefty fees to that same agency?
  • What do we need to unwind to discover her true wishes? She comes to us over-exposed to the subtle and brutal art of shame, devaluing, and tinkered religious ideology all driven straight into her most vulnerable fears and emotions.

I know no one has ever come into our office from this care knowing what resources they have the right to access. Most don’t know they can easily sign up for Medicaid which will guarantee them perinatal healthcare at a variety of locations. I don’t know which clinics give the right dates and which give falsified dates.

But here’s what I want to share in this post: When the only ultrasound a woman has gives her a certain due date, and she does not know when her last period was, that is the only and best information we have to work with. Keep in mind that when a woman comes in late to care with no known date of her last menstrual period and no early ultrasound, we do an ultrasound and measurement of fundal height immediately and work off of that information. A baby who measures 33 weeks by ultrasound and fundal height will be approached as a 33 week old baby. A baby who measures 33 weeks when the early crises clinic ultrasound says it should measure 37 will not. For that baby, with a prior early ultrasound who measures small for that date, here is what we wonder:

  • Why is this baby so small?
  • Why isn’t this baby growing as it should be?
  • How long can we afford to keep this baby inside to try to prove interval growth before we are compromising it?
  • Can we prevent harm from intrauterine growth retardation or another syndrome, disorder, or anomaly by causing an early delivery?
  • Will we cause harm by causing an early delivery of a normal healthy 33 or 34-week-old fetus who would have done perfectly had it been allowed to stay inside and finish growing for a few more weeks?

There is no easy answer to these questions. We use technology to try to measure and assess the actual size of the baby, the flow of blood from the placenta to the baby, anything that is measurable, is measured. But all of our measurements are relative to the first and best known date of any pregnancy. Normal and abnormal interval growth can vary by just enough to give no good answers. We do the best we can. We use all of the power in the maternal-fetal medicine world to try to make the right decision. Sometimes we will get it right, and sometimes we will get it all wrong.

From the March of Dimes:

  • The average cost of a NICU stay for each baby born too early is $55,000. The average cost of a hospital stay for a normal birth is just over $4,000.
  • Babies born too early are at high risk for disabilities and developmental delays including physical, thinking, communicating, social and self-help skills.
  • Day-to-day life for the parent(s) and family is completely disrupted during and after the NICU stay as they navigate interventions and attend appointments and therapies.
  • Parent(s) spend hours in the NICU, and then at therapies, away from their other children and often lose their jobs.
  • The NICU stay can last for months, and often the facility is located miles from home.
  • There is tremendous emotional, physical, and financial stress with premature birth

Families deserve access to healthcare information, research, and guidance that leads to shared-decision making with their provider. The presentation of options that utilize provider skills and local resources to best serve a patient’s needs for their life is a fundamental right.

The cost of lying to patients is high in all directions—for negligent prenatal care, for the delivery of shame as a tool of coercion, for leading a woman to believe that there is help and then abandoning her if she asks questions or changes her mind, for the mother who is induced for a too-small baby who was really just fine but now faces a life of developmental challenges. Frankly the cost of stress to the multitude of providers who gather around a woman and her unborn baby struggling to make the right decisions with bad information is high, too. Yet these clinics are never held to account for those costs. And now the government has decided that they should be encouraged to carry on and pursue their right to lie which supersedes the rights of the mother and the baby to the truth and of society to the health of its most vulnerable people. Money and power are on the side of these clinics, but justice is not. It is one more unjust and unnecessary barrier for those most at risk for adverse outcomes.

A question just crossed my mind and I will close with it: What would happen to our maternal child outcomes if all of the resources being poured into these clinics, all of the concern, time of staff and providers, and faith-based communities was instead poured into the delivery of services designed to promote the good health of these women regardless of what their decision might be about their pregnancy and future?

Community-Based Midwives and Hospital Systems: A Case for Partnership (The Notes)

These notes are extracted from This Article

  • A set of good vitals and an uncomplicated medical history are not remedies for social inequities or lifelong lack of access to healthcare education and navigation, or accessible, timely, effective, and therapeutic interventions.
  • When a patient presents with a medical complication, a midwife can identify it and ensure access to appropriate care if she has access to those who would provide it.
  • The midwifery model of care recognizes that technical improvements in healthcare delivery are irrelevant without addressing the places where unjust and deeply impactful social determinants of health drive the patient’s life experiences.
  • This work [of midwifery care] results in trusting connections between patient and midwife. Indeed, at the time that hospital staff or a physician meets the patient, she may be experiencing a very real grief over the potential change in relationship with her provider and hopes for a unique and well-planned birth experience.
  • No one anticipates that the nurse or physician standing before them will do harm, but how likely is it that they will see you as an ally in their care when you take a stance of juxtaposition and even mockery of the one provider who has ever truly listened to, heard, and understood them?
  • Ignoring or belittling the midwife or any community-based provider for accessing those resources will make them hesitant to enter into the system in the future.  It is this behavior that pushes midwives to move patients further away from safe and timely interventions.
  • However, the ideals of community-based hospitals, so richly developed in many places, is to open the doors and welcome what the community brings, and to share the fullness of knowledge and technology from a place that recognizes the humanity of each patient and the irreducible needs of each person with whom it interacts.
  • …at all points of intersection [of the preventative and therapeutic pathways of care] patient health improves when they can easily step from one to the other as is appropriate for their needs.
  • We know that the impact of technical interventions is effective and wonderful but it is reliant on hospital policies that make these interventions accessible to the community.
  • If we can look together beyond the responsibility of the hospital to the community and financial interest in receiving midwifery patients, here are some ideas that lead to beneficence [see article suggestions]
  • Joining efforts to achieve the common goals of good health and easy, timely access to healthcare resources can only lead to improved outcomes and the development of a model that can truly serve the consumers and the providers in our community.

Community-Based Midwives and Hospital Systems: A Case for Partnership

Click Here to read just the notes from this article

Community-based midwives are held to particular and sometimes unjustifiable standards by the healthcare community.  They are under tremendous pressure to have perfect outcomes while serving the same communities who face the disparities that lead to premature birth, infant mortality, and maternal morbidities experienced so often in the hospital system.  Wanting or needing access to technology and resources is often seen as a failure of the midwife or as a nuisance to the system, even when those same resources which can prevent the same outcomes are distributed in medical care in an effective and timely manner.

The methods and standards by which Midwives determine that a patient is “safe for midwifery care” are not protective against these needs or outcomes.  A set of good vitals and an uncomplicated medical history are not remedies for social inequities or lifelong lack of access to healthcare education and navigation, or accessible, timely, and effective therapeutic interventions.  When well-networked, midwives can be a leverage point for patients to receive guided access to the larger healthcare system.  There they can receive the interventions and medical support necessary to achieve positive outcomes.  In other words, when a patient presents with a medical complication, a midwife can identify it and ensure access to appropriate care if she has access to those who would provide it.

Failure of a patient to stay healthy enough to remain under the sole care of her midwife, or to qualify for an out-of-hospital birth is often seen as both a shame on the patient who could not achieve optimal health or reach her birth goals, and shameful of the midwife.  Midwifery consumers work hard to address their health concerns, and there are times when all of the lifestyle interventions, guidance and education cannot overcome lifelong health disparities. We work hard to prepare for labor and birth and the most common reason we transfer during labor is for a patient who is just tired and needs an epidural, a nap, and will wake up and push her baby out just fine.  This is normal and reasonable and there is no shame in it—either for the patient, who is equally deserving of pain relief and rest as a patient who planned a hospital birth nor for the midwife who supported the efforts and goals of a family.

In community-based midwifery care we use the continuity of carer model, with hour long prenatal visits.  Three-quarters of this time is used to address healthcare prevention, education, and social support.  The midwifery model of care recognizes that technical improvements in healthcare delivery are irrelevant without addressing the places where unjust and deeply impactful emotional and social determinants drive the experience of a patient’s life.  These are the soil in which the patient is growing from and nurturing both herself and her pregnancy in.  These are the hardships, griefs, and burdens of absorbing the responsibilities of her family and community.  These are the anxieties over how to achieve perfection or avoid failure at every turn.  And these are the sheer terror for many due to the likelihood of their pregnancy resulting in their death or the death of their child simply because of the color of their skin.  This is intensive work, achieved on a platform of preventative healthcare that views each mother as vested in her own health and capable of change. It recognizes that she needs access to resources too long withheld and hidden from her until this point and it provides those freely.  This work results in trusting connections between patient and midwife.  Indeed, at the time that hospital staff or a physician meets the patient, she may be experiencing a very real grief over the potential change in this relationship with her provider and hopes for a unique and well-planned birth experience.

When a risk factor develops that requires entry into the hospital system, the patient has an acute sense that they must relinquish emotional and physical safety in healthcare.  This may very well be a contradiction from the midwife’s perspective because we are in the hospital due to a physical safety issue at the direction of the midwife because of her clinical judgment.  However, statistically speaking, every parent this patient knows who has lost a baby was in the hospital when that baby died or had a hospital birth.  Every mother they know who died or was harmed during childbirth was in a hospital when that event occurred.  While these events have been normalized in a broad sense, it is impossible to mitigate the very real fears that arise from personal exposure.  Every social message about the safety, especially of being a black pregnant patient, has taught them that their odds are not very good.  Every cell in their body and that most powerful function of our minds, the implicit memory, brings on a full red-alert for them in that space.  No one anticipates that the nurse or physician standing before them will do harm, but how likely is it that they will see you as an ally in their care when you take a stance of juxtaposition and even mockery of the one provider who has ever truly listened to, heard, and understood them?

We know that once the sympathetic system is activated in this way, people become hyper-alert to whatever is in their realm of focus.  This tunnel-vision is most often directed towards hospital staff—the nurses and doctors who she interacts with in triage before she regains access to a state in which she is ready to learn, engage, and process information.  These are basic principles applicable across many fields of medicine, and even more so when there is a sense of needing to protect one’s baby.

In the instant that you are introduced to the patient, she will see your response to her decision to use midwifery care, she will note how you greet or ignore her midwife, and she will read a thousand cues from your actions and responses.  How you treat the patient for her choices and the midwife for asking for an evaluation or intervention matters.  Her body will decide very quickly:  Fight, Flight, or Rest.  Can you ensure that she is never alone and has her partner or midwife with her at all points during care—especially those first few moments when she is most susceptible to panic?  These first interactions set the table for the rest of the patient stay and experience.

Midwives have extensive training and evaluate ongoing data sets from blood work, ultrasounds, clinic visits, and interactions over many weeks or months of care. She is in your hospital because she wants to be—because you are a resource and have access to resources her patient needs.  Like any community-based or rural provider, she relies on you, on hospital staff, systems, and technology to be there when her patients need it.  Ignoring or belittling the midwife or any community-based provider for accessing those resources will make them hesitant to enter into the system in the future.  It is this behavior that pushes midwives to move patients further away from safe and timely interventions.

The burden of community-based hospitals is to receive what the community brings and to provide basic medical care.  However, the ideals of community-based hospitals, so richly developed in many places, is to open the doors and welcome what the community brings, and to share the fullness of knowledge and technology from a place that recognizes the humanity of each patient and the irreducible needs of each person with whom it interacts.

The work of community-based midwives exists on the preventative pathway of maternal child healthcare.  The work of hospitals and obstetrics is on the therapeutic pathway of maternal child healthcare.  There are many opportunities for these pathways to cross, and at all points of intersection patient health improves when they can easily step from one to the other as is appropriate for their needs.

Midwives and the families and communities we serve are your families and your communities.  We share the work of seeking health and access to healthcare for all people.  We know that the impact of technical interventions is effective and wonderful but it is reliant on hospital policies that make these interventions accessible to the community.

We understand that relationships between community-based healthcare providers like midwives can be seen through a transactional lens—and if so, then view the midwives as great business.  They rarely bring a patient who does not require interactions and interventions that are highly billable and great for the bottom line.  We must address the scarcity mindset—that somehow allowing midwives to access resources will play a role in the diminishing of patient numbers for the hospital.  The number of patients that midwives see is negligible to larger healthcare institutions.  As stated, the patients midwives do bring in for care will typically increase the hospital census and income.  While this is a very low-level view of the potential relationship between the hospital and community-based midwives, it is very real and just fine to rely on.

If we can look together beyond the responsibility of the hospital to the community and financial interest in receiving midwifery patients, here are some ideas that lead to beneficence:

  • You receive patients every day who arrive in labor, screaming and incoherent, possibly drug-addicted. You have no history, no labs, no ultrasounds and no idea who that patient is.  You follow your guidelines and do the best you can for them.  Midwifery patients arrive with loads of documentation.  They come in with labs, ultrasounds, a known history, and notes about how this patient learns best and the stressors and norms of their lives.  That is a lot to work from! Use your guidelines and do the best you can for them, too.
  • Greet patients warmly regardless of where they arrive from. Use simple statements that have been shown to be effective in other teaching hospitals, “I’m so glad you are here today.  I see you were receiving your care from a midwife so this might all be new to you.  I want to assure you we are going to do our best for you today” or “I see you were in the middle of a planned homebirth.  I’m sorry that didn’t go as you wanted it to.  We are going to do the best we can for you here today”.
  • Greet the midwife with kindness—she will expect you to take the lead. She has decided based on clinical information or a concern that this patient is safer with access to you and the resources that you have. Talking to her about your thoughts and plans (when it is not an emergency) or being inclusive will help foster good will with the patient and out in the community
  • Adapt policies to allow consulting, referring, partnership and education for community-based physicians to include midwifery-led clinics. Seek community rotations in midwifery clinics for your residents.  Learning from and with each other allows providers to get to know each other and deconstruct ideas of “other” so common from both sides to this relationship.
  • Provide credentialing for Nurse Midwives who operate in community-based clinics so that they can follow patients and manage care for those that want to plan or are in need of a hospital birth

Joining efforts to achieve the common goals of good health and easy, timely access to healthcare resources can only lead to improved outcomes and the development of a model that can truly serve the consumers and the providers in our community. To learn more about midwives in your area, and to find out how your institution can ensure easy access to resources for the community, contact your local midwifery-led clinic or midwives association.