I explain my reason why I do doula and midwifery work as a response to systemic oppression.
Videographer: Greisy Genao
I explain my reason why I do doula and midwifery work as a response to systemic oppression.
Videographer: Greisy Genao
I am not the typical Beyonce fan. I became a fan much later in her career, specifically with the release of her first audio-visual album in 2013. It wasn’t simply her boldness and artistry that captured me, but moreso the knowledge that her growth had come out of her own trials and tribulations. I connected to her from the perspective of a Black midwife witnessing another Black woman step into her power after the birth of her daughter. It wasn’t until her second pregnancy and the recent albums released by both her and her husband that I was moved to cathartic tears. She has been blessed with not just one but two rainbow babies; for many of us who have had miscarriages, the birth of a rainbow baby can come with a lot of emotions ranging from fear to gratitude to triumph. Watching the healing and glory that exudes from her music and photographs is deeply inspiring to someone like me, waiting for their own rainbow baby.
I became curious about Beyonce’s reproductive journey when I heard the song “Heaven”, a haunting song describing the loss of a loved one. Though I am not sure it was about miscarriage, when I did research for the first article I wrote about her, I came across her documentary in which she spoke about her pregnancy loss. I could hear the pain in her voice and in her eyes. It was a familiar pain I have witnessed in my mother and many other women who have confided in me when they had a loss. I vividly remember my mother once going to a church service for the child that never had the chance to be my older sibling and her sadness was palpable. There is no amount of time that can erase experiencing a miscarriage with a fellow midwife when I was studying at the birth center in Texas. Losing a pregnancy, even when there are rational biological reasons for it, is so difficult. So difficult that I’ve avoided writing this essay for about a week. So difficult that I cannot write this without being choked up with tears.
Grace was conceived the last full week of February. I felt it almost as soon as it happened. I pay close attention to my body, particularly my reproductive system, so when I began spotting in a way that was unusual for me, I knew something was up. I remember it was the first day of March when I quietly went to work and stopped at Walgreens to buy a pregnancy test. I went to my office, put my bags down and made a beeline for the bathroom. The line was faint but it was there. I took two tests. I then asked a trusted coworker to get me a pregnancy test as privately as possible. Another line, albeit faint. All I could feel was an incredible amount of joy and happiness, with the normal fear of losing this new creation before giving birth to it. Telling my partner was wonderful and the time we shared basking in the excitement is something I will always hold dear to my heart.
I woke up on the tenth day of March and noticed my previously tender and swollen breasts were a little less full. While I was laying on my back getting ready to start my day, I felt a trickle of liquid come out of my vagina. Immediately, I put my hand to my vulva to see what it was. There was the unmistakable sight of blood on my fingers. I ran to the bathroom and sat on the toilet to then feel a stream of blood come out of my body. “No, no, no! Oh please God, no!”, I cried between sobs as the inevitable continued to happen. My partner was there with me, trying to comfort me and tell me it would be okay. Unfortunately that was not the case. I kept bleeding that morning, and crying profusely. When I think about that moment in my life, what haunts me most is how I pleaded with God and begged it to please don’t do this to me. I don’t remember sobbing and crying the way I did that whole day. The last time I felt that desperate escapes my memory.
I wanted so much to be pregnant. For so many years, I have struggled with my reproductive system. It has taken and takes a lot of work to undo the belief that my body is broken in some way because I have polycystic ovarian syndrome (PCOS). PCOS has many side effects; it has manifested in me as irregular periods and periods of anovulation (lack of ovulation). Being pregnant for 10 days before the miscarriage felt victorious. It felt like confirmation that my body was completely functional and that I would be able to carry and sustain another life. Having a miscarriage shattered that victory. In retrospect, I’m not fully sure why I went to work that day. The bleeding stopped by the time I was showered and dressed, so I prayed the whole time on the way to work that it was just a threatened loss. When I got to work, there was more blood. I began to sob in my office.
You look nothing like your mother. You look everything like your mother. – Warsan Shire
I called my mother first in tears. My mind immediately reminded me that she has experience with this very same pain. She urged me to go to the clinic, in an attempt to save this creation that I was quickly losing. I remember struggling to tell the doctor what was happening through my tears. She did her best to be compassionate and reassure me that this was normal and that it didn’t mean I could never have children. In that moment of grief and the months that followed, all the midwifery training and the rational evidence-based knowledge I knew about miscarriage flew out the window. I didn’t want to hear that I could have a baby in the future. I had to stop short of yelling at my mother for her prescriptive advice and comforting that cited this personal tragedy as God’s will. At the time, it did not feel like God’s will but rather a punishment for all the myriad of reasons that raced through my mind in the first few weeks. The grief brought up past sexual trauma and insecurities that I had to painfully work through. I was now part of the sisterhood of loss – a silent mass of countless women who silently grieved the loss of their dearly beloved children who never got to reach full gestation. I found an article about coping with miscarriage during that time and the first thing it mentioned was this notion of embarrassment. I got teary eyed when I read that. I hadn’t had the words to describe the feeling of embarrassment. It’s hard to pinpoint. It feels like embarrassed because maybe I should have known better than to tell anyone so early. Embarrassed because I feel like it was a lie. Embarrassed that I got people excited for nothing. Just embarrassed.
March 15th –
It’s been a couple of days without you. 5 days to be exact. I spoke to your father yesterday about this nostalgia I feel, like I’m missing something. Missing you. You’ve been a part of me for years now. I met you when I got the strong urge to be a mother 9 years ago. I remember all the dreams I had of all the children I’d mother. I was hoping to finally meet one of you this November. I was already planning how I’d spend my first holiday season as a new Mami with a newborn. I began to wonder if you’d share a birthday with any of my favorite Scorpios born around your due date, or if you’d come on the day your great grandfather passed, or even on Thanksgiving!
I feel like my body betrayed me. There are many thoughts I’m having about this, varying from thanking God that they took you from me early so I wouldn’t suffer having to birth a bigger mass of tissue, angry that I lost you, numb because I don’t know how to feel, relieved knowing you would have been born sick or ill, embarrassed that I made plans about and for you, and sad that it didn’t happen. There is an underlying feeling of knowing that everything happens for a reason starting to creep in. I am not devastated the way I was Friday. Those emotions are slowly becoming a distant memory. You, however, are a clear and present one.
It has been one of the most painful experiences of my life. It has also been one of the most healing. My partner and I grew closer through this experience. It was the first major tragedy we had to go through together. In my pain, I released a lot of sadness and anger that I had harbored for years. I mourned the years I had spent doubting my body and spirit, as well as the spiritual miscarriages I had with the man who violated. I mourned the promised children in that relationship who never were conceived. It gave me an opportunity to confront the shame I’ve live with in regards to having an irregular cycle and feeling that I had been punished by God for being molested at age 6. I lived the storm of my life and have become better for it. I still feel sad when I think about it too long. My spirit baby’s name is Grace. The concept of grace, which in Christianity refers to the free and unmerited favor of God, as manifested in the salvation of sinners and the bestowal of blessings and also means to honor another person with one’s presence, got me through the darkness times of my grief. I have long viewed God as a punitive tyrannical entity and to view the healing and blessing that it truly was to have this being in my body for a little over 10 days as being graced by God supported me so much. It finally has given me the opportunity to shed the belief that I was in some way undeserving or tainted in the eyes of the Christian God that governed much of my childhood and adolescence.
I cried when I saw Beyonce perform at the Grammys earlier this year. Those tears were out of happiness for her, knowing that she knew the pain of miscarriage and was being blessed with not just one but two babies. I cried the first time I heard the title track 4:44 from her husband because I got another glimpse of the excruciating pain and loss she had to live through. It made her pregnancy even that much more powerful and triumphant for me. And of course, I cried when I saw her recent photo of her with her twin boys. It brought it full circle for me. I had received a lesson and blessing through my own miscarriage a few months ago. Beyonce’s picture was a reminder that healing can be glorious. It was a reminder that I too can look forward to such glory in my own body. Most of all, through my journey I stopped marking the health and value of my reproductive system by its ability to carry and sustain life. I would love to give birth to my own children. There is no denying that fact. Yet, this experience has taught me how to give birth to myself in a deeper and fuller way. I think about Grace nearly every day. And I thank her for changing my life by losing her.
*originally published by SQUAT Birth Journal, Issue 19 (2015)
Having access to a healthcare provider who is familiar with your culture, language and appearance is an understated necessity. I’ve held this sentiment for as long as I can remember. I was an interpreter for my mother many times in my life and helped her by translating from English to Spanish and the other way around. Because of this experience, I understand how much is lost in translation. My time studying midwifery on the border of El Paso, TX and Ciudad Juarez, Mexico, providing prenatal care solely in Spanish to the women of Juarez, has made me understand the urgent need to act and create awareness about the importance of culturally relevant care and support. Especially in reproductive and maternal health, there is no longer room for half-hearted treatment and sub-par care based on institutionalized racism and unchecked privilege.
It’s been both a rewarding and infuriating experience being a student midwife here. My level of fluency in Spanish has grown over the last 9 months because I speak it nearly every day. I quickly learned how to explain pregnancy and childbirth to women who aren’t usually cared for as closely as they are at Maternidad La Luz. It is wonderful to be able to go in depth in ways some of my fellow midwives cannot because they lack fluency in the language and do not always understand the nuances of the Latino culture (though I am AfroDominicana and my clients are Mexicanas). I can see and hear the sigh of relief when I open my mouth and a steady flow of their native tongue comes out. It is a true joy to be able to share and communicate beyond a beginner’s level of language.
I know that a lot of times they do not get everything care givers try to explain to them because of the language barrier. I become outraged when I realize a procedure or important information was not covered thoroughly. I notice that English-speaking clients and Spanish-speaking clients are treated differently. It holds true that someone who speaks English here can advocate for themselves in ways that a native Spanish-speaker cannot. Language is a huge deal. It is the primary means by which one communicates ideas, desires and, in this case, concerns and needs. A very deep feeling of powerlessness occurs when you cannot be understood because no one speaks your language. And, if you cannot communicate, others can control you and do what they want with your body and life.
Privilege is one hell of a drug. It blinds well-intentioned individuals from seeing the things in their lives that they never have to think twice about. It makes it so that those of us who have to think about the nuances of language, culture and race are very easily dismissed and looked over. The racism in healthcare is real. The institutionalized racism of this particular country is rampant; and in the medical system, it is expressed by the way we treat African American and Latino bodies as expendable, sites of experimentation and genocide.
In an article entitled, “Confronting Race in Health Care”, Pamela F. Ciprano reports that the Centers for Disease Control and Prevention (CDC) Office of Minority Health and Health Equity found that racial and ethnic populations suffer lower life expectancy, higher infant mortality, and higher rates of disability and preventable diseases than non-minorities. Based on my experience, I suspect one of the reasons why this is occurring is because these populations do not feel cared for by the healthcare providers available to them. They may not feel comfortable or feel they can trust the White doctors who sometimes look and talk down to them. The effects of racism do in fact shorten and complicate the lives of those who experience it. It has been found that even affluent racial and ethnic populations suffer from similar statistic, proving that not even social mobility makes you immune to racism.
While blatant discrimination may not always be the problem, subtle micro-aggressions are incredibly persistent. From my experience living in the Bronx, I have noticed a clear socioeconomic segregation at play when Lincoln Hospital in the South Bronx, for example, is juxtaposed against Beth Israel in downtown Manhattan. Low income communities often have sub-standard hospitals and medical professionals available to them while well-to-do neighborhoods fare better in quality and care. Furthermore, this segregation and difference in the quality of care is expounded by the difference in treatment that people receive.
When it comes to reproductive health, women bear the brunt of the lack access to resources and to adequate healthcare providers. This country does not protect women and their health; and marginalized women, such as African American and Latina women, have it much worse than their white counterparts. According to the Black Women’s Health Imperative, more than 34 percent of 45 million Americans who lack health insurance are women of color. The reality is that they live in underserved and under-resourced communities, where they lack appropriate access to primary health care, and endure more chronic illnesses. Very often their diseases go undiagnosed and/or are not treated adequately, resulting in shortened life expectancy and unnecessary deaths. Furthermore, Latino/as also have the highest uninsured rates of any group in the United States according to Latino Healthcare Forum. Lack of health insurance prevents many women from getting medical attention; and sometimes women will not or are unable to seek healthcare because of their immigration status.
The disparities in childbirth alone are staggering: African American women die in pregnancy or childbirth at a rate of three to four times the rate of white women. Latina women are less likely to receive prenatal care earlier in pregnancy, if at all. The Center for Reproductive Rights’ article “Addressing Disparities in Reproductive and Sexual Health Care in the U.S.” supports the notion that racial disparities are particularly pronounced in reproductive and sexual health. Women of color fare worse than white women in every aspect of reproductive health. The Centers for Disease Control and Prevention have recognized that access to prenatal care can reduce maternal mortality and other negative pregnancy outcomes. Most pregnancy-related deaths occur after a live birth, and women who do not receive prenatal care are three to four times more likely to die after a live birth than women who attend even one prenatal appointment.
My sentiment is that women who look like me do not receive the care they deserve and need because the medical system in the United States is white supremacist and capitalist. Historically, white men have used our bodies as sites of experimentation, best exemplified by Dr. J Marion Sims’ years of torture on enslaved African women, the eradication of the Black granny midwives in the South to eliminate competition and have poor African American women to practice on and forced and covert sterilization practices (La Operacion comes to mind here, the reproductive tragedy that many Puerto Rican women have dealt with).
My decision to become a midwife was directly influenced by my study of these facts and my realization that one of the solutions to these issues is to have culturally sensitive and competent healthcare providers. Meaning, racial and ethnic populations would benefit greatly from medical professionals that can connect with them on a cultural and linguistic level. Recently, I had the experience of having a pregnant woman reach out to me and she cited that one main reason she felt comfortable with me was because my skin tone and Afro look like hers. She asked me if I spoke Spanish. Our conversation became a rhythm of prenatal recommendations and we connected on a sister to sister level in Spanglish. I felt so happy after that conversation, knowing that she felt comfortable speaking to me with such ease because we connected on a cultural and ethnic level.
This solution seems impossible but is in fact achievable. First and foremost, there needs to be more emphasis on supporting existing clinics and hospitals who serve communities of color well and opening up others which are culturally sensitive, well-supported and have trained medical professionals who can address the needs of the community. In regards to medical professionals, there is a need for them to reflect the community they are serving but also to have a strong sense of social justice, understand the socioeconomic dynamics of their community and have the ability to be compassionate and genuine.
Furthermore, reproductive health education needs to be more readily available. Creating more programs for women of all ages is imperative in empowering them to seek and decide how to foster healthy lifestyle choices. I would like to see the widespread implementation of sexual education for middle school and high school girls. Along with this, I want more women of color educators addressing and facilitating this education while serving as real-life role models for these young ladies. This education should include attention to specific cultural traits and to the myths that influence the student’s lives, such as Catholic overtones in Black and Latino communities and internalized oppression and its manifestation. Some examples of myths would be the idea that menstruation is something disgusting and negative in a woman’s life, that Black and Latina women are inherently seductive and promiscuous and , and other fabricated misconceptions of a woman’s life cycle.
In the article, “Closing The Black-White Gap in Birth Outcomes: A Life-Course Approach”, the author(s) also recommend increased access to interconception care, preconception care, quality prenatal care and health care throughout the life course in the form of a 12-point plan. The article also calls to address family and community systems that influence the health of pregnant women, as well as the social and economic inequities that underlie much of the health disparities. The life course perspective conceptualizes birth outcomes as the end product of not only the nine months of pregnancy but the entire life course of the mother before the pregnancy. I would like to propose the implementation of Dr. Michael C. Lu, Vijaya Hogan, Loretta Jones and Kynna Wright’s plan to dramatically change birth and life outcomes for vulnerable populations. The goals of the 12 -Point Plan to Close the Black-White Gap in Birth Outcomes are to: 1) improve healthcare services for at-risk populations, including communities of color and low-income families, 2) strengthen families and communities, and 3) address social and economic inequities over the life course. The 12-Point Plan is different from other approaches addressing racial disparities in birth outcomes because it goes beyond prenatal care and the traditional medical model and offers to address family and community systems, and social and economic inequities.
At the political level, there must be committees or working groups created to tackle the inequities in regards to healthcare insurance. With the dawn of the Affordable Care Act and the various grievances that have come with it, including the fact that it is not in fact affordable at all, advocating for the fair implementation of this act in disenfranchised communities can provide insurance to the most vulnerable part of the population.
Black and Latina women deserve to be understood, cared for, and given all the resources and opportunities to lead healthy lives for themselves and their progeny. Understanding and addressing the inequities in healthcare is imperative. With the proper education, access to resources and health care professionals that can relate on a deeper level with racially and ethnically diverse women, more changes can come about to brighten the future for all of us.
A few weeks ago, I bought a women’s health book on the suggestion of a dear colleague. I was excited to dig into the wealth of information that this book shares, and it did not disappoint. Not completely. Understanding my endocrine system and the ways in which my diet affects my hormones was incredibly helpful. The diet changes and recommendations were great, and I have incorporated some of them slowly within my financial capacity. I feel the changes from adding some supplements and shifting some foods while removing others that I knew were harming me, so I have since recommended the book to many of my acquaintances so they too can add another tool to their healing journeys. Midway through my reading of the book, I put it down and realized that it was lacking the very same thing that other books, authors, and websites lack as well: cultural relevance. They are written by white women for white women.
Something that I’ve learned from my midwifery practice is that I have to meet people where they are. This concept allows me to serve birthing people appropriately by modifying recommendation based on their particular reality. Well-meaning advice can be perceived as inaccessible at best and condescending at worst. As a person who has the privilege of being a first generation woman of color with college education and a post-graduate professional diploma, I know that I can access most food and supplement recommendations from white women health books because I know where to go. Yet, when I visit my local neighborhood grocery store, I am made aware that seeking healthy food options for both a college educated person and a person with some high school or less are difficult if they stay local.
I asked myself, as I searched through the wilting dark leafy greens, the more-than-acceptable bruised & rotting fruit, and the soon-expiring salad mixes, how is anyone in my community supposed to find healthier food attractive when it looks like it’s rotting? Or worse, what is a person who wants to eat better supposed to do if the options in their neighborhood are subpar? The stores I go for better quality produce like Trader Joe’s are more than 30 mins away. I am personally willing to make that trip weekly but when I stop to think about the people who live in my community and what I know about people, if it’s not readily accessible, the chances of following the recommendations start to decrease. It is important to also address that low-income communities tend to be obesogenic environments where fast food and liquor stores are more abundant than health food stores and more attractive than the poor selection of fresh food. This is a food justice issue. Food justice, according to Just Food, is communities exercising their right to grow, sell, and eat healthy food.
In the same vein, the recommendations are not culturally appropriate. It is insulting to me when I notice that many of my cultural foods are absent from health food conversations. I was not surprised when there was no mention of platanos, yucca, guineo, bacalao, for example. I know that many of the foods that are staples in my Afro-Dominican diet are full of nutrition – platanos are an excellent source of vitamin B6, vitamin C, magnesium and potassium, yucca is a good source of energy, etc. I begin to then think of all the various ethnic groups that make up my community and other low-income communities, also observing that they have their own cultural foods. It is both short-sighted and oppressive to erase cultural foods and replace them with foods that may be incompatible with someone’s diet.
Furthermore, many of us have a emotional link to our cultural foods. Some people who struggle with their weight understand that emotional eating is one of the habits many of us struggle with – we end up eating or overeating because it is how we respond to our emotions. If we take that a step further, we can also find it difficult to stop eating cultural foods because they make us feel connected to our homelands, remind us of our immigrant family members as well as family that stayed behind, and is served when we are with family. In the same breath, these books do not compassionately address the ostracization that can occur when a person rejects their cultural foods. Food is very personal, and some of us cannot risk offending mothers and grandmothers because of our diets. Though at time it is necessary for our health and well-being, it is not realistic to suggest that we reject our grandmother’s food constantly without support for how to navigate these types of situations. There is also evidence that eating as close as possible to the way our ancestors ate is more beneficial health-wise for us. Thus, these health books do not take into account cultural incompatibility, by excluding foods that are actually healthy for one ethnic group and recommending foods that may not agree with that person’s constitution or cultural background. This is not to say that we should only restrict our eating habits to just our cultural food – that would also be erroneous, as some foods can aid in better nutrition regardless. This does speak to the nature of colonization and how it often erases and devalues a colonized people’s culture.
Another way these white women’s health books fall short is lack of context and a life course perspective. It is not enough to speak about patriarchy and the for-profit health care system of this country when describing the underlying reasons for why women are sick or why their hormones are out of wack. There is little context provided that describes why marginalized people (Black and Latino being my own personal focus) eat the foods they eat, why some ethnic groups mistrust the doctor, the ways in which intergenerational and current stress related to race & class affect health and viable treatments for conditions that disproportionately affect certain groups of people (i.e hypertension in Black people, diabetes in Latinos, etc.). As a result of lacking a culturally and politically relevant analysis on health and wellness, the recommendations fall short for the average individual. Writing health books without such analysis insinuates that a white middle class person is the default profile, and feeds the idea that all bodies need the same type of food to be well.
To address these gaps that have been found in most mainstream health food advice, there are various individuals and organizations that do work to both address food justice and speak from a culturally relevant place (I also included books specific to Black and Latina women):
More work has to be done to cultivate healthier communities. Self-help books are useful but fall short of having political and cultural analysis that can be relevant to larger groups of people who are struggling with colonization-induced illnesses. I know that as I continue on my wellness path, I will continue to be conscious of who is excluded from the conversation and topic of books and health food topic.
I love my Abuelita. That’s my pana full right there. She’s the sole reason I’d move to the Dominican Republic for a couple years just to be near her. Like most mothers and daughters, she has an interesting relationship with each of her five daughters, to say the least. I know the most about her relationship with my mother naturally, and it’s funny to me how the challenges they’ve had are the same my mother and I have had. I am constantly stunned by the matrilineal blood line and life, having often been brought to tears when I’ve attended a birth with the birthing woman’s grandmother and mother in the room. There are no words for the moment when three women become mother, grandmother and great grandmother. It is a special moment regardless of the culture or language it occurs in, but there is something that moves me to the core when it comes to Latinas. (more…)
One of the biggest tragedies of contemporary Afro and Indigenous descent people’s reality is this myth that lives in the white imagination – and by virtue, the collective imagination – that we are a passive people who are constantly new to resistance and uprising. I believe that this myth is upheld by the mideducation so many of us receive in the schooling system we are subjected to that is mediocre at best. This miseducation preserves white supremacy in teaching history full of white heroism and Black, Latinx and other ethnic groups deemed racially inferior as mere pawns who are supporting actors in this offensive comedy being played to the white imagination. Using birth and Afro Indigenous reproduction as the center of my analysis, I am constantly reminded in my birthwork that Black and Latinx people are not helpless victims of their unscrupulous white oppressors but instead are active agents that have fought for their self-determination since the first and subsequent attempts to be brought under control.
If I could describe my mother and the matriarchs in my family in one word, it would be resilient. Nothing about how I experienced my mother, godmother and grandmother is describable as passive. I tell my mother that I got my spirit of resistance and perseverance from her, that my defiant and rebellious nature comes from her. This is a intentional removal from the perception that immigrants are docile and voiceless instead of truly understanding that we are both quietly and openly resisting colonization while the imperialist state tries to silence us. In my studies of birthing justice and midwifery, I gradually came to understand that the narrative about midwifery’s supposed death and resurrection fed into the larger white savior complex. This complex as it applies to black midwives and reproduction tells a sanitized story of how white male physicians killed off the practice of granny midwives and then midwifery, mainly white midwifery, made a heroic comeback fighting for licensure and a presence in maternity care. It ignores the system of medical apartheid and obstetrical apartheid – a convergence of patriarchal medical heroics, racialized medical violence, economic exploitation, and cavalier disregard of black women’s well-being. Birthing Justice: Black Women, Pregnancy, and Childbirth contextualized this previously unnamed discomfort I’ve had with modern midwifery – the discomfort with the forgetfulness of white midwives in regards to the ways they have benefited in the field of obstetrics and gynecology from the subjugation and violence wrought on black and racially diverse bodies.
This forgetfulness is infuriating because of its implications. It continues to portray black women as passive people who never take charge of their lives. This may be true of some members of this targeted oppressed group but be that as it may, the fact that Black people choose to give birth and control their reproduction is and always will be an act of resistance. We have gone from the use of black women as breeders for human labor during the enslavement to including an active genocide attempting to decimate our numbers. There are so many layers of control that we must resist against to avoid exploitation from the moment we are born. This is why Afro and Indigenous descendant birthworkers cannot compartmentalize their work to the delivery room. Most of us understand that the fight for self-determination only starts at birth. Our involvement in the birthing process of Black, Latinx, First Nation and other racially diverse individuals is a move to begin dismantling the harmful effects of white supremacy. I always include First Nation because our forgetfulness starts with the people who first inhabited the Americas. The indigenous midwives I have met along my journey always remind me that they too actively resist and are part of this legacy.
I have said often that midwifery is my form of direct action. The transformation that can occur at birth is profound enough for me to want to support and hold space for that process. I am aware of the ways the population control and eugenics theories affect the lives of Black and Latinx people. By consistently pushing the myth that there are too many people on the planet, the real message that there are too many nonwhite people on the planet gets lost in this slight hysteria. It allows us to shame women who have bountiful wombs. It gives room for the complete neglect of Black individuals and their well – being in healthcare because of biological racism – the notion that Black people feel less pain and that disease manifests differently in our bodies, to put it simply. For me, birth is at the nucleus of the various issues such as incarceration, gentrification, inadequate education systems, and poverty.
This is why knowing our history is important and why it has been suppressed. It has been intentionally kept from us that we did not simply go along with the enslavement of African people nor the violence wrought upon the First Nations throughout the Americas. Seeing babies birthed by women of color has shown me firsthand that resistance has always been parallel to oppression in that we as a people were not meant to survive on our own terms. What I have witnessed in my life is anything but acceptance of our conditions. I was blessed to be surrounded by fiercely loyal and loving people whose main way of resistance has been love and maintaining community at all costs. Mothers have been at the center of that maintenance, and by virtue, granny and ancestral midwives have held that space. This is why it has been difficult for me to approach my midwifery work with capitalist notions. The people who I truly want to offer my skills and knowledge often are in a position of being unable to access financial freedoms that middle class white people often do. As a birth justice activist, it is my duty to be intentional about my birthwork being available to people for whom it is a necessity and not just a luxury.
Some find it hard to hold the tension of race and birth. I believe all people regardless of socioeconomic status have a right to safe and respectful perinatal care but am also clear that white women are not experiencing obstetrical violence at the same rates as their black and indigenous counterparts. They have benefited from what my ancestral mothers had to suffer through. I don’t need an apology or anything, just accountability. I need for white midwifery to not play white saviors when it comes to the maternal and infant mortality rates but instead examine how their neglect and positions of privilege contribute to this crisis. Most of all, at this point, it is important for me to remind myself and others that we get so much of our spirit of resistance and resilience from our ancestors. We get it from our proverbial and actual mommas.
Most of my weekend found me knee-deep in research as I read up on the state of childbearing people in the United States and internationally. It is easily depressing to read horrible stories of obstetric abuse and neglect in the midst of a racist, sexist, capitalist and ableist healthcare system. I read to keep myself knowledgeable and also to continually arm myself with facts and information to better raise awareness about the crisis women of color are experiencing. I saw the performance early this morning after realizing she had taken the stage at the Grammys Sunday night. Immediately the tears fell and I started sobbing for a good part of her performance. Her grace, beauty and power radiated through in such a profound way that it was initially hard to put words to all that that struck a nerve. Beyoncé’s postpartum work in particular, as I began to explain last year, has blown me away on so many levels. Her provocative images and words stir up emotions specific to the Black women’s experience. It is evident to me that her birthing journey has made her tap into a fierce mother self, awakening to her goddess within and also activating her social justice consciousness.
There have been plenty of criticisms of her politicized performances and videos, described by some as commodifying revolutionary ideas and figures. Regardless, Beyoncé’s work as a Black woman is important to me. I am choosing to focus on the emotions and thoughts her music and visual artistry than to critique her. It’s not that I don’t have critiques but the Internet and this society are often unkind to her and many artists; I prefer to offer a “yes and…” approach especially when there is so much rich imagery, symbolism and narrative coming through her art. Revolutionary work is not a one-time event nor is it a performance; however, it is part of the revolution to have artists use their platforms to make people uncomfortable with the social ills they highlight. Furthermore, I think of the young people who are exposed to these artists that may become their entry point into social justice work. It would be damaging to my commitment to respect individuals’ process to not integrate these expressions of consciousness into the fight for the liberation of all people.
The first thing for me to address is one that I’ve spoken very briefly on regarding Lemonade and the spiritual elements that spoken to me immediately. I don’t claim to know all the layers of symbols and religious iconography that was incorporated into the visual album, yet the presence of the divine feminine was felt. Many, including myself, read Ochun off her Lemonade and her Grammy performance. The thing is, feeling that energy from a performance is not me conflating symbolism with Beyoncé’s own spiritual journey; rather, the archetypes blended through her work last night, be it Ochun, Virgin Mary, Aphrodite, Venus, Inanna, or any other divine deity that Beyoncé evoked in her viewers, are the multiple dimensions of the womanhood experience. One does not have to be initiated into these religions to understand what these goddess archetypes represent – love, fertility, sensuality and the erotic. One also does not have to be initiated to let these archetypes influence and guide their work. Archetypes are themes – collectively-inherited unconscious ideas, patterns of thought, images, etc., that are universally present in individual psyches. For women, we have the maiden, mother and crone; those can be conceptualized as The Queen, The Mother, The Wise Woman and The Lover. It is in these archetypes that we manifest ourselves as powerful, creator, spiritual being and erotic human to varying degrees as individuals. Beyoncé’s work throughout her performance and her two recent albums explore these themes of womanhood, inviting each of her viewers to take this journey with her.
She in no way speaks to the lives of every woman, and I am aware of the lack of representation for diverse body sizes and the full breadth of Black womanhood and motherhood. Beyoncé instead speaks to her own life with common themes and necessary affirmations for the struggle to protect, honor and respect Blackness. This representation is important, particularly the elevation of the Black woman as a goddess, because we are often depicted as everything but powerful and divine. Furthermore, Beyoncé chose to still embody her sexuality in her presentation, which is also important. Pregnant women are sometimes criticized for being a mother and also daring to still be sexual. She was able to be fierce in her sensuality, showing us that pregnancy and sexuality are not mutually exclusive; in fact the complete opposite is true – sex and sexuality permeate our very beings from the moment of conception. We often forget that we were born and we came out of a part of our lives that is demonized and taboo to talk about in a comprehensive way.
Throughout my birthwork and journey in womanhood, as well as my training in Television/Radio Productions in my undergrad, I have been sensitive to how the media influences our perceptions of ourselves and of the stages in our lives. Pregnancy and childbirth have been depicted in grossly dramatic and inaccurate ways, demonstrating medically erroneous progress of labor, out of control laboring women and complete submission to medicalized birth. Moreover, people of color are not afforded the space in the media and the collective conscious to be represented in healthy families, beautiful pregnancies and optimal birth outcomes. This is why the image of Beyoncé, Tina Knowles and Blue Ivy struck me. It is rare to see intergenerational depictions of Black families, and this speaks to the strength of our matriarchs that we hold dear in our families with our mothers and grandmothers. While the societal issues that plague people of color in all aspects of their lives are perilous, especially in health and maternal care, we struggle to see our lives celebrated. There is not enough celebration of Black motherhood; we are instead reminded that our infant and maternal mortality and morbidity rates are awful, our families are being ripped apart by the criminalization of people of color, and that we can only amount to being “Welfare Queens”. Beyoncé’s awe-inspiring performance, as well as her pregnancy photo shoot is important for me. I am not suggesting that the way our families and communities exist is shameful but I am saying that we have the right to exist in a variety of realities, both onscreen and in real life. I remain aware that there is much work to do in our communities but am moved by seeing a Black pregnant woman celebrate and share her ability to carry and sustain life. Beyoncé also reminds me that affluence for people of color means little when it comes to life course outcomes – affluent women of color suffer the same birth outcomes regardless of their finances and expanded options for maternity care due to the stress of racism.
I hold that it is revolutionary for people of color to give birth in a world that is actively trying to carry out the genocide of our people. We need images such as Beyoncé to aid in the narrative we are creating for our present and future – one of claiming and protecting our joy, daring to dream of liberation and seeing ourselves in the media we consume as whole multidimensional beings. Another reason her Lemonade album and last night’s performance was so profound is the incomparable Warsan Shire’s poetry woven throughout the images and lyrics. Teaching My Mother How to Give Birth and for women who are difficult to love contain parts of the words Beyoncé recites that drive home the message of strength, heartbreak, resilience, womanhood, and power. “Do you remember being born? Are you grateful for the hips that cracked the deep velvet of your mother and her mother and her mother?”, she asked. It is relevant that Warsan Shire is a Kenyan-born Somali poet and writer who uses her work to document narratives of journey and trauma. The words allow Beyoncé to share her own pain from her miscarriage, maturity, heartbreak and being her whole self in a real way that is both vague and specific. Poetry has a way of touching the depths of our subconscious and evoking feelings with such few words. The visuals and the poetry are what brought me to tears.
Seldom in our society do we see childbirth and the power of pregnant women celebrated. The violence experienced by birthing people in their labor and delivery journeys is horrific, as well as the fact that pregnant women are vulnerable to more violence during their gestation. Beyoncé calls forth the need for us to put women, particularly Black women, in a place of dignity and reverence. We need more depictions of Black families and Black birthing people in not just despair but also glory; I hope that other people bring forth these images and not condemn Beyoncé for not being able to capture every experience not represented. There is still a lot of work to do. A performance is not the end all be all, but I refuse to throw the baby out with the bathwater. I believe bodies that give birth are the closest to God we can ever get. Her work is demanding ever so gently and firmly that we love God herself, and specifically love Black women in all their dimensions.
I’ve kept a public blog for about 17 years on and off since high school . I remember the reason I first started to share my writing online was to be connected to my friends at the time. In my teenage angst, being able to document my mood changes and emotional challenges while receiving affirmation was paramount. I refined my writing abilities this way. In college, I didn’t blog as often but became a part of the poetry scene. The poetry that poured out of my peers and I was deeply personal, revealing childhood and adolescent memories, secrets and struggles. Those poetry ciphers served to develop sincere friendships born of mutual growth, art and support with the themes that we had in common. Reading my words out loud changed my reason for sharing from not only connecting with others but realizing I am quite skilled with putting my feelings and thoughts into words. This skill made others feel relieved that their very struggles are reflected in my work; college was the first time I had people come up to me after I spit a poem to tell me how healing my words were. For a long time, I shared my poetry so others would feel the same catharsis I did.
I don’t regret the things I’ve shared. My later work after college, including my book Hija De Mi Madre, became more and more personal as I documented my struggles with my family, mainly my mother, sexual trauma, spiritual journey, victories, failures and everything in between. Again, these pieces have been healing to both the writer and the readers. As I got older, reading my book, which I wrote at age 23, became difficult. I found myself embarrassed and in disbelief about how many details about myself I shared. To this day, I have not read that book from cover to cover in years. The book was a necessary work of literature. It contributed to healing much of my early life, gave me the opportunity to present and connect with different audiences, opened the door to making sense of adolescence and has provided other AfroLatinx people, particularly women, a memoir and research that give them the same context I needed to make sense of my cultural identity. In retrospect, however, I feel that I have overshared details of my life. I cringe to read my book because at this age, I have learned that some things are meant for me. Not everything that has happened to me belongs in the psyche of others.
As I prepared a manuscript of essays written after Hija De Mi Madre, I asked a sister friend of mine to write the foreword for it. I didn’t anticipate that her essay would make me hit pause on the process. Offering intimate details about myself without context invites the reader to create a story about me, and ultimately judge me. She made me realize that my journey out of trauma into healing is mine and sharing it to the world is a privilege I am conferring to my audience. Before the advent of the internet age, the trials, tribulations and gifts that my healing journey has given me would normally be shared with those who have earned it. My responsibilities as a writer are to myself, I realized, and though my story is ever unfolding, I must be careful with how I share my story to the world. People are not always so kind nor generous with their reactions to our personal sagas.
I began to write less about my personal life over the last few years and have taken on a more journalistic voice, using my writing to speak on human rights with a focus on reproductive health. I felt the need to protect my story and my journey from being prematurely exposed to the rest of the world. There has been an overwhelming increase of oversharing because of social media – intimate moments are livestreamed for the entire world to see. Nothing seems sacred anymore, from birth to spiritual rituals to a child’s entire life being documented without their consent. Folks have gotten into the habit of sharing both random and incredibly personal details of their life, giving others full access to their thoughts, feelings and lifestyle. The oversharing has spilled into offline life, where we share details with people who don’t deserve to know them. This has also caused me to withdraw and protect my personal life.
Have you ever had a delicious meal put before you with all the hopes of enjoying it yourself? Usually, you get to savor each bite without having to ration it off to everyone who walks by. Parents of small children don’t always have this luxury and have hidden their favorite food/snack so that they can enjoy it alone without small hands grabbing for it. This is how I feel about my personal journey. As it gets more vibrant, colorful and complex, I want to savor it. I want to clap for my damn self; I don’t want a standing ovation. I crave to connect in person with the very small circle of people who have earned the right to celebrate my joys and support me through my lows. Another reason I have taken up this move to keep my life to myself is because, quite frankly, not everyone wishes me well. Not everyone is offering commentary out of a place of love. Furthermore, the false sense of familiarity that is developed online has rubbed me the wrong way. Being public with my life in the past has made me susceptible to people becoming enamored with the idea of who I am, with the assumption that learning a personal part of my life has granted them access to me in often uncomfortable ways.
Let me be clear that this post is not about dangerous secrecy, the type that keeps an abuser safe and leaves you in danger. I have shared those secrets that needed to be told. With that said, I know there is a way for me to share my story in ways that honor me and what I have lived through. For now though, this is my meal. These lessons are my medicine before they are anyone else’s. My audience will hear from me and will see ideas put forth from me as the compassionately fierce human being I am. I will push myself to finish essays that contribute to the evolving landscape of reproductive justice and healing journeys. This is about having boundaries and sticking to them – for if I violate my own personal world by letting trespassers come and go as I please, that world is vulnerable to being distorted and desecrated. My life is mine to live and to decide how to share. Not everyone deserves access to the innermost soft and delicate parts of me.
My reproductive health journey has been affected by being a woman* of color. Living in my Afro-descendant female body comes with historical and current narratives that want to dictate how I manage my health and wellness. I was introduced to contraception in my early 20s because of a supposed irregular cycle, subtly coerced into using hormones to “fix” something that I came to learn was never broken. From time to time, I have wondered if my critique and apprehension of modern reproductive health technologies is ill-formed; being so in tune with my body and spirit dismisses those thoughts because I have also learned that the way I feel is not exclusive to me. The need to find other folks that have concerns in regards to contraception is why I seek out gatherings and resources such as the webinar I tuned into yesterday.
Part of SisterSong’s Collective Voices webinar series, LARCs: Access, Coercion and Reproductive Justice brought together leaders from different organizations who are doing work to ensure the access to long-acting reversible contraceptive methods (LARCs) for women is free of coercion, particularly for young women, elderly women, women of color, LGBTQ individuals, and low-income women. The panel of speakers did an excellent job discussing the history and current ongoing reproductive coercion for women of color in this country. That resonated deeply with me as I recalled both personal and collective trauma related to reproductive health and racism. I suffered psychologically on birth control pills without getting a real understanding of what they were nor having a provider dedicated to helping me understand; I didn’t know what to ask because of my then-limited knowledge of my body. The IUD experience was terrible enough for me to never consider it again. While not every woman experiences what I have, the enthusiasm to get women on birth control can often downplay the side effects of these technologies.
I am skeptical of the promotion of LARC because of the recent push for funding to expand access. I have seen my community of low-income ethnically diverse people be targeted in ways that remind me of population control theories and eugenics. Before even getting to the issues I have with contraception, Aimee Thorne – Thomsen, Vice President for Strategic Partnerships at Advocates for Youth, said something important in the webinar that encompasses a sentiment I’ve held because of my own. “We live in a society that is set up to not support our development into sexually healthy people,” she said, speaking to the lack of comprehensive sex education throughout this country; this absence is further compounded by race and class.
I am a firm believer that people cannot make informed decisions about their bodies without having access to resources and information that is comprehensive, age-appropriate, and free of Puritan, paternalistic and patriarchal undertones. To get a better idea of the deficiency of sex education in the United States, 24 states require public schools teach sex education (21 of which mandate sex education and HIV education), 33 states and the District of Columbia require students receive instruction about HIV/AIDS; of those states, 20 states require that if provided, sex and/or HIV education must be medically, factually or technically accurate. State definitions of “medically accurate” vary, from requiring that the department of health review curriculum for accuracy, to mandating that curriculum be based on information from “published authorities upon which medical professionals rely.” Additionally, 35 states allow parents to opt-out on behalf of their children (National Conference of State Legislatures). This is wildly disturbing and makes it so that those of us who did not receive comprehensive sexual education arrive at the doctor’s office with little to no information about our own bodies, much less the contraception (and the side effects) we are being offered and often coerced into.
Reproductive coercion of women of color has a ugly history in the United States. Jamila Taylor, Senior Fellow at Center for American Progress, opened up the webinar with a concise history of the reproductive coercion of enslaved Africans and their African American descendants. She spoke of starting with the enslavement, where countless people were raped, forced to breed to produce free slave labor, and had their loved ones ripped away from them. “Women of color were experimented on and then a movement to expand options began rooted in racism and classism,” Taylor continued, highlighting the population control movement and eugenics that began in this country. La Operación, which refers to sterilizing a large percentage of Puerto Rican women from the late 1940s until the late 1960s, often comes to the forefront of my mind when I think of contemporary examples of coercion and vulnerable bodies; this same population of women were also victims of the first large-scale human trial of birth control pills in the 1950s that causes severe side effects due to the high dosage of hormones. I think about the recent documentary, No Más Bebes, and the recounting of the similar horror experienced by Puerto Rican women but instead taking place in California to Mexican and Mexican – American women at the same time. Jamila Taylor’s words made me recall the history of American gynecology, specifically Dr. J Marion Sims (whom I lovingly refer to as “that sick motherfucker”) and his multiple experimental surgeries on enslaved women for the benefit of white middle class women. The reminder that this is not a thing of the past came again from Taylor as she shared that in the 1990s, Norplant marketed specifically to low-income Black women and teenage girls, with cash rewards to entice low-income women on public assistance programs to use it.
The webinar also included the expertise of Victoria Gómez Betancourt, Communications and Development Director at Colorado Organization for Latina Opportunity & Reproductive Rights (COLOR) Anu Gomez, board member at National Women’s Health Network, and Tannia Esparza, Executive Director at Young Women United, spoke about the ways young women and teen pregnancy is targeted through expanding access to LARC. Specific topics also included how to nonconfrontationally address coercion with health professionals from Anu Gomez and supporting unintended pregnancies without shaming teens from COLOR. This further delves into solution-based responses from different organization centering the voices of people vulnerable to being coerced.
Currently, there is an increase in funding and attention being given for the expansion of access to LARC. I feel that many of us who are in the reproductive justice field are concerned about who is being targeted for the use of LARC. Because of my personal experience with LARC and all the stories I have heard from women and their experiences with contraception, one of my main grievances is the lack of attention to the apprehension women have about contraception, particularly emotionally, physically and mentally. I suspect that the actual amount of women who have side effects from birth control pills and LARC is not reflected in the amount of women providers say have adverse reactions. For all the focus on having quantitative studies and the subsequent obsession with statistics, the truth is that not everyone reports their side effects. This is further compounded by the quality of healthcare that is available to low – income ethnically diverse population. The reality is that the hospitals that are in low income communities are subpar and the providers there are often not invested in their patients; many of these providers are white and/or culturally disconnected from their patients on some level. These hospitals tend to be teaching hospitals as well, with residents that are eager to practice their skills. There is an influx of people seeking the services of these institutions and an insufficient amount of staff and facility resources to handle the volume of patients. Ideally, a medical visit should give both the patient and the provider enough time to fully discuss the patient’s health concerns and questions; this is not the case. The medical staff then is faced with the tough choice between the quality of the care provided and the demands of the quantity of patients being served, which creates a profit over people model of providing services. In this profit-over-people model, the amount of time spent on thorough patient education is overshadowed by the need to treat as many patients as possible.
I want to be clear that I am not accusing public hospitals and federally qualified health centers (community based facilities that receive reimbursement from the government to serve all people regards of insurance; by default, many of the patients are low income people of color) of promoting population control tactics and coercing their patients into LARC. What I am saying is echoing the concerns of various leaders in the reproductive justice movement surrounding the unconscious (and sometimes conscious) promotion of population control by targeting and aggressively pushing birth control. The situation I explained above makes it easy to have providers who have unchallenged biases about their patients and views on birth control as well as who should be on it coerce women by aggressively promoting LARC as the best option (in their opinion), subtly persuading patients to use LARC for learning purposes, while not ensuring proper follow up with women to see how they are faring on the LARC.
I find it suspect that money is so readily available for the provision of LARC and yet, the other resources needed to fully support women and their families have bee underfunded for decades if not centuries. Even the notion that one should consider planning for their family is a slippery slope; it is often a privilege to be able to plan far in advance when folks are living paycheck to paycheck. This is not to say that it’s impossible nor it is saying that impoverished community members are incapable of planning, but being in survival mode drastically reduces a person’s ability to conceptualize the future. Caring so much about a woman’s reproductive lifespan as it relates to birth control but not the classist and racist restrictions to access is also characteristic of white feminism. White feminism has done a lot of work around reproductive rights but does not always center reproductive justice for ethnically diverse and low income women in their struggle to secure their ease of access.
To expand access to LARC particularly for young women, elderly women, women of color, LGBTQ individuals, and low-income women is not in and of itself a worthless endeavor. I feel that it is important to make sure more women can get the birth control they desire to receive. What I take issue with is directing women towards LARC based on a provider’s and public health official’s assumptions about the woman’s identities. The Long-Acting Reversible Contraception Statement of Principles put forth by SisterSong and the National Women’s Health Network is a concise document of detailed guidelines and principles to support the inclusion of LARC in the options available to women while combating questionable and coercive practices. Recommendations and statements include:
The Long-Acting Reversible Contraception Statement of Principles is available to read in full and to add your signature in support of it. I encourage more people become informed and sensitive to the nuanced approach that expanding access to LARC comes with. This essay is by no means conclusive nor an authoritative piece. For more information, here are some links that informed my thought process:
*I use “woman” and “women” throughout this statement and recognize that these terms do not encompass the full range of people who utilize contraception and who may be impacted by coercive practices.
To The New York City Department of Health and New York City Council:
The Bronx needs doulas. There is a serious lack of access to these services for women in the Bronx for a multitude of reasons, the main one being that they live in some of the poorest congressional districts in this country. For this fact and more, the Healthy Women Healthy Futures program came as a welcomed solution. Women from the Bronx and other boroughs were moved to receive birth and/or postpartum doula training so that they could serve women in their communities. Many of us are mothers ourselves and understand the necessity of having this invaluable support in communities that do not foster healthy families. All of us have given countless hours helping women through this significant part of their lives. To be able to continue giving quality care to our fellow women, we demand the agreed upon compensation for our work immediately, both retroactively and currently.
My understanding since the winter of 2014 is that bureaucratic barriers have kept this project from reaching its full potential, which includes paying the doulas recruited for the initiative in a timely fashion. I have also understood that the New York City Council agreed to provide this funding and the Department of Health is responsible for releasing the money to the appropriate organizations. Therefore, everyone involved is responsible for this delay by their negligence. We are infuriated with the lack of progress, and find it inappropriate to be continually asked to volunteer our time for compensation that will be given at some undetermined time. First and foremost, it is unprofessional to offer compensation to anyone and lack follow through nor a set timeline for expected payment. Secondly, the women that this project seeks to help can easily be one of the doulas. We are community members and experience the same financial barriers that our constituents do. Because of the systemic disparities, we also are surviving on public assistance and struggle to make ends meet. To block and delay our rightful compensation is to keep every woman and family connected to this project at a deficit. Intentionally or not, this type of behavior keeps the very boroughs and people meant to be assisted impoverished and with no resources. Why do you claim to want to uplift the Bronx if you cannot properly see to it that we all get our basic needs met? Furthermore, repeatedly asking for our rightful compensation is dehumanizing. It has been painful to continually show up to meetings and get inadequate answers about our compensation. “Eventually” would never work for any of you. If your biweekly checks were held up, you too would be up in arms. What’s the difference? Is it a class issue? Do you see us as less valuable and less human, or less deserving of ensuring our own survival in such difficult conditions?
This great project has not been given a fair chance to thrive and you are all responsible, be it with your silence or having no sense of urgency. We are demanding that the funds be released to the partnering organizations, including Bronx Health Link, within 24 hours of receiving this letter. If the grant money is for some reason unavailable, we demand the discretionary funds of every organization involved, and this includes the Department of Health and City Council, be tapped into to solve this problem immediately. To even dare ask ethnically diverse women to volunteer their time and effort is offensive given the legacy of violent colonialism, racism, economic exile from our homelands, and insidious manmade impoverishment. This type of exploitation is cheating both doulas and families of the potential of this great program. We demand our humanity be honored by ensuring our means of survival, in this society being money, is made available so that we doulas can in turn contribute significantly to the reduction of infant and maternal mortality, cesarean sections, postpartum depression and restoring humane treatment in labor and childbirth.