Birth Options Essential to Reproductive Justice

Working part-time as a pregnancy options counselor at a busy abortion clinic and also as an apprentice midwife in an out-of-hospital birth practice, I see firsthand the obvious parallels between birth and abortion every day. Given that clear connection, I am continually disappointed by the lack of attention the mainstream reproductive rights agenda has shown to birth options.

For those of us who work in abortion care or are advocates for reproductive freedom for all, we know that sex and pregnancy are more than just biological events. They are social and political events as well and can carry very different meanings among individuals. The ability to access abortion services, as well as birth control and comprehensive sex education, are dependent on cultural and geographical factors. It has been widely acknowledged that the mainstream reproductive rights movement has historically fallen short because of its compulsory and singular focus on access to safe and legal abortion specifically for economically privileged white women. What many of us have missed in our critique of these shortcomings is that the same oppressive cultural mechanisms that restrict women's abilities to make fully informed decisions about when to have children also affect their decisions regarding where, how, and with whom to birth those children. It is clear that the current reproductive rights agenda has overlooked the broader reproductive experiences of women and families, including those who choose out-of-hospital births attended by midwives. This absence is to the detriment of pregnant women, children, and families.

Birth Options

Part of our responsibility as advocates for women's health and reproductive freedom is to educate ourselves on the full range of birth options in order to help facilitate well-informed birth options and also to support and protect the practitioners who provide out-of-hospital birth, prenatal and postpartum services. Midwives in the U.S. have attended births at home for hundreds of years and have a strong history of offering professionally trained, highly skilled, woman-centered care during the childbearing year and beyond. Current research reflects what many consumers of midwifery care have known for years – that planned home births for low risk women attended by Certified Professional Midwives are safer and ultimately involve much less intervention than births attended by doctors in hospitals. Of course, giving birth at home or in a birth center is not appropriate for high-risk pregnancies or women with severe health problems, as well as those women who do not desire to birth out of the hospital. But for women and families who do desire out-of-hospital birth, it is a valuable and necessary option that must be protected.

There are many reasons that women choose to give birth out-of-hospital, and this includes the fact that hospital birth can be an unpleasant, and even traumatic, experience for some people. The current state of mainstream obstetrics in the U.S. reflects steeply rising cesarean rates and increasingly "actively managed" births using technological and medical interventions to alter the course of labor, birth and the postpartum. Currently in the U.S., more than 1 million cesarean sections are performed each year, amounting to more that 29 percent of all births. However, the World Health Organization has calculated that the optimal c-section rate is between 10 and 15 percent. Despite the increased documented risks of undergoing cesarean section rather than giving birth vaginally, the numbers continue to rise. While access to cesarean in the case of true obstetrical emergency is essential to the health of women and babies, it does bring up many ethical questions when it becomes an overused and even non-medically indicated option. Some pregnant women have found that the best way to avoid these risks altogether is to choose the care of midwives. As more women and their partners question the practices and protocols of obstetricians, midwifery care has become a common alternative.

Midwifery and Medicine: An Uneasy Alliance

The relationship between midwifery and medicine is complex on many levels and the two models have struggled in conflict with one another since childbirth started to become medicalized during industrialization. The medical opposition to midwives and the transition of childbirth away from the home and into the hospital has been well documented by historians. This history of intense scrutiny that midwives have undergone in the U.S. is directly related to the current marginalization, and even criminalization, of contemporary midwives.

Many aspects of reproductive freedom are affected by the conflict of theory and practice between midwives and doctors, and it is an issue that the reproductive justice movement must take on. The fact that abortion care is so enmeshed within the medical model presents trouble on many levels for a potentially inclusive movement. It is particularly problematic that the mainstream reproductive rights agenda has historically focused almost exclusively on abortion rights, especially for economically privileged white women, in that it inherently bonds the movement solely to the medical model, and thus prevents true alliance with the midwifery model at times when it is appropriate. In simpler terms, birth and abortion are separated within our culture as entirely different events, having nothing to do with one another, while in fact both are defining elements of the reproductive experiences and choices of women. While it may seem subtle, this separative dynamic serves to block coalition building and mutual support among a full scope of health care providers.

Abortion Remains Elusive in Midwifery Community

Doctors are not the only ones responsible for this ideological division. Within the midwifery community, abortion remains a somewhat elusive topic. Regardless of its relevance and importance to women's reproductive health, abortion is missing from much of the midwifery literature, education curriculum, and community conversations. In her article Mi Companera, RH Reality Check contributor Miriam Perez writes about this controversial issue as it relates to the new phenomenon of abortion doulas. Clearly, abortion is an issue that midwives are likely to come across in their careers. According to the Alan Guttmacher Institute, over 60% of abortions are among women who have had one or more children. It seems logical then, not only from a clinical perspective, but also emotionally and culturally, that abortion would be a valid and important matter of discussion among midwives.

Despite this, the topic remains distinctly unspoken. The only midwifery organization to speak out about reproductive choices is the American College of Nurse Midwives, although they don't at any point in their literature specifically use the word "abortion." For many pro-choice midwives, doulas, and other birth professionals, this avoidance of the topic of abortion can be alienating and often seems unfounded. Some members of the community maintain that birth activism and pro-choice activism go hand in hand. On a personal level many of these midwives, doulas and birth advocates are communicating with each other about the place of birth options in the reproductive justice movement, and also the role of abortion within midwifery. To these birth advocates, it is apparent that strong bridges must be built between the midwifery model of care and the reproductive justice movement and that coalition building among us is essential.

But abortion is clearly a divisive issue. Some midwives do not consider abortion to be a valid reproductive option and do not want to align themselves with any pro-choice movement. And conversely, many pro-choice medical providers do not want to align themselves with direct entry midwives or out-of-hospital birth communities. This dynamic is at the crux of our cultural struggles for control over reproduction and the female body.

Personal and political action is needed to help us to achieve the ultimate goal of providing a full range of birth options to all women and families. This includes fully integrating midwifery care into the health care system of each state, including pushing our state medical programs and private insurance companies to cover midwifery care. Currently, many families who choose to give birth out of hospital with the help of licensed midwives are forced to pay out of pocket, even if they are insured.

Birth options advocates in several states are hard at work fighting for insurance coverage, and in New Hampshire this month the House voted to require insurance coverage of home births. Nationally, activists have launched "The Big Push for Midwives" campaign, advocating for regulation and licensure of midwives in every state. The media too, not just politics, has begun addressing these important issues. The new documentary from Ricki Lake and Abby Epstein, "The Business of Being Born," examines and questions childbirth in the U.S. and advocates for wider acceptance of midwifery care.

And in addition, we need to fight cohesively and effectively to legalize the practice of midwifery nationwide and to ensure the availability of state licensure.

Pregnancy, reproduction and birth practices are significant social and cultural issues that greatly effect women and their families. For midwives and reproductive rights activists alike, the inclusion of birth options into the conversation will offer an essential connection within this movement. Comprehensive birth options have an appropriate, and even necessary, role within this movement. We can help further this role by demanding a new framework for understanding "choice," as well as creating a more comprehensive philosophy that includes and honors the varied reproductive experiences of all women. I encourage those of us who are involved in any way with reproductive health and the movement for reproductive justice to expand our conversation past merely protecting the decision of when to give birth, but also advocating for a full range of options of how, where, and with whom to give birth.

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  • invalid-0

    Thank you so much for this article. It is true that this shift needs to take place on a cultural level. I can think of so many midwives and doulas that do not speak the word abortion for fear of losing clients. Until it is widely accepted that abortion and and childbirth are two sides of the same coin, two very legitimate choices, providers will continue to keep their mouths shut on the issue. The place I would love to see this begin is between OB/GYNs and homebirth midwives. I think each group is not fully aware of how their stance damages the options of the women they aim to serve.

  • invalid-0

    Another option that is not considered by the media or ignored by many is UNASSISTED HOMEBIRTH – giving birth without a doctor or midwife. Unassisted Homebirth brings dignity to women, is emotionally appealing and often physically pleasurable. Visit my website for more information and secrets on how to have a satisfying and successful birth.


  • invalid-0

    That was a terrific post. What you’re describing in the birth industry parallels lots of things in the funeral industry, weirdly enough. Thanks for this food for thought.

  • invalid-0

    I’m very active in promoting home birth midwifery and am a strong advocate for full reproductive choice, including access to safe, legal abortions. However, in doing my midwifery advocacy I work closely in this with many conservative Xtian anti-abortion women.

    The bottom line: we simply choose to disagree and avoid the subject that could otherwise divide our community and instead focus on our smilarities and common desire to help women have greater birth options.

    I have to say I don’t see many women’s “reproductive rights” advocates give one hoot about childbirth choices. I’ve been trying for 10 years to reach out to them, and, aside form a national NOW resolution from several years ago that resulted in no real practical action, I see little or no support for an admittedly tiny minority of women who want to give birth safely at home but have no legal midwives near them.

    Nurse-midwives are legal in all 50 states but almost always practice in the hospital; fully 99% of babies delivered by nurse-midwives are either in the hospital or a birth center. Clearly the solution is to license the other kind of nationally certified midwife, the certified professional midwife, but they can only be licensed in about half of all states.

    I don’t see this as a two way street; it’s simply not possible for us. I see this as a one-way funnel in which both reprodctive rights supporters and family rights supporters can support home birth but not necessarily the other way around.

    Why not do something b/c it’s the right thing to do (support birth choices without expecting reciprocation)? Why not use your greater numbers to support your home birthing sisters?

    I hope everyone reading this will be inspired to find their own state’s “friends of midwives” group, get informed on their own state’s laws and write a letter to their state lawmakers asking for a real change by licensing certified professional midwives.

    You can visit or to find local state contacts.

  • invalid-0

    How, praytell, do you expect midwives and doulas to vocally support safe legal abortion when they’re literally struggling for the very existence of home birth options, which continue to be illegal in nearly half of all states? I hope more reproduce rights advocates will help us win this battle first, and then maybe we’ll be freed up to continue to support this cause and be more public about it. (BTW — I am sometimes a clinic escort in my free time so don’t think I’m not doing anything and I’ll assume your’e doing what you can to help make sure women in your state have access to legal home birth providers.)

  • invalid-0

    I agree with Anonymous. I’m very active in both the pro-choice movement, (I was an options counsler at PP) and the midwifery movement in MO, my home state. When abortion comes up on our listserve it proves to be very devisive so we’ve agreed, and have managed, to keep it out of the discussion. I do however wish more feminists were aware of just how much the way, with whom, and where we birth are very much feminist issues and about the control of women’s lives and bodies. I wish we could get pro-choice candidates to come out in support of midwifery and home birth because to my mind they are part of the continuum that is reproductive rights. Read Jennifer Block’s book Pushed for an incredible illustration of how doctors and insurance companies are fighting to control women’s bodies. I think you will be horrified and angry and perhaps moved to act to liberalize the midwifery laws where you live.

  • erin-wilkins

    I don’t expect all midwives and doulas to vocally support safe legal abortion, but rather I am calling for the reproductive justice movement to recognize the struggle for birth options as essential to the movement. I agree with you that I hope more reproductive rights advocates will help work for the legalization of midwifery in all states. Our struggles are one in the same, and so as advocates for reproductive freedom we don’t have to abandon one issue or area in exchange for another. We can be actively pro-choice and actively pro-midwife at the same time, for example.

  • invalid-0

    while I hesitate around most company to compare abortion rights and birth rights, they are comparable. My stance has always been, regarding abortion, while I did not choose it for myself I will do everything I can to make sure its always a safe option. It is the same for birth. Its an issue closer to my heart because I did choose to have a baby at home. I’m glad this point has been brought up, women need to support each other’s rights to choose how and when to reproduce, whether or not we make the same choices.

  • invalid-0

    I totally agree with all the article and the posts. The outlawing of midwifery is just another example of government intrusion into out private lives on behalf of the medical insurance industry and big pharma. It is also related to the outlawing of naturopathy and other alternatives to the allopathic medical model.
    Home birth creates spiritual and emotional bonding between mother, infant and other family members that is often not possible in the hospital setting. Joseph Chilton Pearce has written in depth on this subject in several very inspiring books as have others.