Reproductive Care in the Face of North Dakota’s Anti-Choice Legislation: Two Full-Spectrum Doulas Explore Fargo’s Reproductive Justice Scene

This post is a slightly modified version of an article that appeared in the Fall 2013 issue of SQUAT Birth Journal.

By BADP volunteer, Vanessa Norton and SFGH Options' Patient Counseler, Lucy Yanow. 

Part 1:

North Dakota has been prominently in the news since March 2013, when Governor Jack Dalrymple signed three anti-abortion bills into law, including a fetal heartbeat law, which would effectively ban all abortions performed in the state. My interest piques at any public debate on abortion, and North Dakota, with only one clinic, the Red River Women’s Clinic (RRWC), sounded like a fraught conversation. So, I decided to travel to Fargo to find out exactly what the situation was.

To my surprise, it was immediately clear that the Red River Women’s Clinic isn’t going anywhere. Clinic Director Tammi Kromenaker feels supported by her community, both at home in Fargo and across the country. The support felt palpable in the downtown neighborhood where the clinic is located. Tammi works tirelessly to oppose the bills, but is also that particular brand of firecracker who works tirelessly on everything. The ideal clinic director, her staff and her neighbors are her community and she cares for them all. Following Tammi around the clinic, you are just as likely to overhear her counseling staff members through relationship issues as you are the work that she has to do for legal defense, or managing patient care.

Knowing that the story was broader than the politics of being enmeshed in abortion care in a state where access is on the defense, I turned to speaking to people involved in the full spectrum of reproductive care. As a pro-choice doula, I see reproductive justice as a spectrum. Choosing whether or not to parent is exactly that: a choice. Some people are able to make that choice when they are good and ready, but not everyone can navigate their reproductive life-cycle without unplanned detours. Full spectrum doulas recognize that people experiencing unplanned pregnancy have three choices: birth, abortion or adoption, and all three are right.

My focus in Fargo shifted to asking doulas, midwives, and clinic supporters how the recent legislations has affected where they locate themselves within (or without) the spectrum of reproductive care. We also wondered if their care would change if abortion became illegal in North Dakota, ie: would they assist people seeking to end their pregnancies? 

Turns out, when faced with anti-choice legislation, people who are already serving in a reproductive justice capacity create contingency plans. Heather Jackson is a doula in Grand Forks, ND and even with a full plate of raising a 12 year old as well as studying for an advanced degree, started mapping out routes to clinics in Minnesota when faced with the idea of the RRWC closing.  Heather lives about 90 miles north of Fargo, has done clinic defense for the RRWC and helped organize a pro-choice rally last March, when the three anti-abortion bills were brought before the Governor. Over 150 people attended the rally, “huge for Grand Forks.” Heather is openly pro-choice, queer-friendly and single-mom friendly on her doula website.  

Lysa Ringquest commented that after 25 years in the operating room, she could probably perform abortions herself and would do so if necessary. With one of the operating rooms named after her, Lysa is famous at RRWC as a highly-gifted patient educator, operating room assistant, and hand holder. Lysa has since moved from Fargo for personal reasons, but her legacy is indicative of the highly developed clinic culture at RRWC. Speaking to Lysa, we were privileged to again experience the intensely honest and intensely spiritual conversations shared by birth workers. It was clear why Lysa had been honored with a plaque. She spoke of “holding space,” of “looking into the woman’s eyes, breathing with her...keeping the patient in a state of calm and in her strength.” She also said, “I felt I was a doula.”   

Unlike Heather and Lysa, others in the midwifery and doula community haven’t paid much attention to the legislation. Crystal Wolf has always been “out” as pro choice, but is busy as an apprentice midwife, an acupuncture student, a doula and a mother to a 4-year-old daughter. When we met at a park in Moorhead, she was also 38-weeks pregnant with her second baby.  She works within the Fargo doula community, and is very outspoken about her political leanings via Motherwise, a facebook page described as: “devoted to evidence-based, gentle, healthy, and intuitive parenting choices”.   

Crystal, who has supported friends seeking to “make their periods come,” said she would certainly do so again if she was asked. Offering herbal information, acupressure, comfort measures and emotional support are within the realms of doula support, and extending that to women trying to terminate pregnancies at home seemed like a normal extension of her work.  Interestingly, she didn’t even know about the Red River Women’s Clinic until access to abortion came under attack.

For one of the doulas that we spoke with, the legislation has been a bit of a revelation.  Janelle Brandon has been taken to task for being pro-choice, but never by a fellow doula.  After she publicly attended a rally to support the Red River Women’s Clinic, a former client confronted her.  Janelle recalled, “she couldn’t believe that I had been there on the most important day of her life [the birth of her child], and that I was a ‘baby killer.’”  

Janelle loves the idea of a full spectrum doula.  “That’s what I am,” she says “I just didn’t know it”.  She feels that she may need to be more “out” as being pro-choice, but doesn’t think that that will change her ability to work in the community.  However, being out is something that she has avoided until now.  Although she is open to supporting clients through abortion, it isn’t something that clients have asked her to do thus far. 

Notes From the Salon: Midwifery Paths and Practices

By Becky Michelson, BADP volunteer

On October 23^rd, the living room of Langton Labs overflowed with people eager to learn more about midwifery paths, lifestyles, and perspectives. To understand the distinctions, nurse-midwifery student Holly Carpenter moderated a conversation with Kim Dau, a certified nurse-midwife (CNM) and Maria Iorillo, a certified professional midwife (CPM). Kim is the Assistant Director of the nurse-midwifery education program at the University of California, San Francisco (UCSF) while Maria has attended over 1100 births, primarily in homes.

Some general points of departure between CNMs and CPMs are their education, places of practice, and privileges. CNMs are initially trained as nurses, may practice in hospitals and clinics, and can provide first trimester non-surgical abortions in some states (and recently in California, thanks to the passing of AB154). CPMs can choose from a combination of midwifery certificate programs and apprenticeships and practice in homes and birth centers. There are many nuances regarding the legality of both roles on a state basis. Many research studies cite the benefits of having a midwife as your primary health provider, such as lower rates of preterm births and interventions.1 The American College of Nurse-Midwives has more information on essential facts about midwives.

The Salon Series was intended to shed light on the different ways of practicing midwifery and their respective certifications, work dynamics, and parameters. Instead of having this instructional focus, the gathering felt more like a community bonding through story sharing. Despite their differing paths, both midwives shared stories that reaffirmed their life’s purpose of being in service at births where they felt in awe of the immense courage and vulnerability displayed by mothers.

Kim’s path began working in a laboratory after finishing her undergraduate studies in Biology. She missed connecting with people in her work and her desire to pursue midwifery was sparked from reading Immaculate Deception by Suzanne Arms and Spiritual Midwifery by Ina May Gaskin. She embarked on a journey west to gain experience by working at birth centers in Oregon, New Mexico, and Texas. After attending the UCSF nurse-midwifery program she worked in North Carolina at Duke University for several years, before returning to San Francisco in clinical capacities at both Kaiser Permanente and San Francisco General Hospital. In the past few years, she has maintained a clinical role at SFGH while fulfilling her dream of working in CNM education as the Asst. Director fo the nurse midwifery program at the University of California, San Francisco. Meanwhile, Maria Iorillo attended midwifery school at age 23 and received her licensure in New Mexico. When she moved to California, midwifery was illegal. She has maintained attending 4-8 births a month and has been practicing her incredible craft for over 28 years.

Upon painting a picture of their paths, the conversation shifted toward what midwifery is about and the elements of inspiration. Maria explained that to her, midwifery is about creating a safe space for women who are being vulnerable and courageous enough to seek their own authentic power. Women often seek her care with a deep belief that they are capable of birthing, and she facilitates their connection with that inner power. Maria told two stories about unexpected c-sections and home deliveries where despite the unexpected changing circumstances of the women’s intended births, they emerged supported and empowered. Kim also shared poignant birth stories that included a family confronting melanoma and a laboring woman who was recently grieving her partner. Kim stayed present in these intense experiences, holding space for the brave families. She also spoke of how offering support during trying situations has led to her own potent self-growth.

The Salon Series also included a handout called, “A Baker’s Dozen Ways for Doctors and Midwives to Preserve Simple Birth.” Kim and Maria’s stories included elements of the handout’s holistic advice that supports birth as not just a clinical but also a social process. A few of these recommendations include:

• Ask permission to touch the laboring person in your own language

• Dissolve fear by providing options

• Keep the baby and mother together

Both midwives also highly recommended Witches, Midwives, and Nurses: A History of Women Healers by Barbara Ehrenreich.

In thinking of a vision for cultural change, both midwives promote women being treated with respect, kindness and as if they are smart enough, which they are, to make their own decisions without the manipulation of hospital staff. Beyond the birthing process itself, Kim is excited that more midwives are sitting at tables they previously have not before, meaning that the midwifery perspective is being taken into account more frequently on issues such as neonatal and infant care on state and management levels. Midwives are still a minority health care provider, but at least in the Bay Area, interest and support for them is rapidly growing.

After an evening of stories filled with with births, unexpected events, midwifery muses, and raw inspiration, Holly exclaimed that the UCSF midwifery program should be expecting many more applicants this year. With the full house of doulas, advocates, allies, and aspiring midwives bubbling with questions, anecdotes, and curiosity- she must be right. Thank you Holly, midwives, Salon Series team, and engaged audience!

1. http://www.huffingtonpost.com/2013/08/20/midwifery-benefits_n_3787058.html 

Meet the Doulas: Vanessa Norton

Who are the doulas who volunteer with the Bay Area Doula Project?  They're amazing, diverse people, doing so much great work in the world, it's hard to believe any of them has time to volunteer with us. We've been using this space to introduce you to many of the BADP doulas.  This week, meet Vanessa Norton.

Vanessa is a full-spectrum doula and freelance writer originally from Buffalo, NY. She is thrilled to work with BADP/ACCESS and sees this work as powerful and personally transformative.

She was introduced to reproductive justice as a high school senior in 1992. As an ACT UP activist, she took part in organizing the local community to successfully defend its clinics against Operation Rescue. For the following 3 years, she worked in clinic defense in Detroit and elsewhere around the country. She has since completed a BA in Anthropology/Gender Studies from Bard College, an MFA in Creative Writing from the University of Oregon, published several short stories, and spent years teaching English and Applied Arts abroad. In 2012, she became a certified birth and postpartum doula through Cornerstone Doula Trainings and fell in love all over again with the world of reproductive justice.

She often travels outside the Bay Area to research the places she writes about. This past summer, she spent a week in Fargo, North Dakota, where she interviewed local people working the full-spectrum of reproductive options: the director and workers at the Red River Women's [abortion] Clinic, birth doulas, midwives, and community members who publicly support the patients at the clinic through creative projects.

Vanessa lives in Oakland, where she loves tending her indoor garden and has recently taken up taxidermy. She plans to pursue a professional midwifery path this winter.

Blog Series: Notes from a Full Spectrum Nurse-Midwifery Student

by Holly Carpenter, RN, UCSF School of Nursing-CNM/WHNP Candidate 2014

Part I: Finding Full Spectrum Nurse-Midwifery

Part II: What are we being taught? What do we "want" to learn?

In the previous post in this series, I introduced the big picture of nursing education in sexual and reproductive health care. This section discusses the extent of training that currently exists within nursing education programs in U.S., including a student-led elective that was piloted at UCSF this past year.

Both APC and pre-licensure nursing students still face a fairly bleak picture in terms of standard SRH training and education. In a preliminary review of existing curriculum and educational programs, the results demonstrate a significant need for further study and development of curriculum. Most importantly, we have zero baseline data regarding the content in RN (or “pre-licensure”) programs in terms of sexual and reproductive health. Without this information, we can only operate on assumptions to make the case for improvement or plans for curricular change.

The sole national survey of APC programs (conducted in 2001 and not updated since) demonstrated that only 53% of schools in the U.S. offer didactic instruction in medication or aspiration abortion, and a mere 21% offer clinical training in these procedures (Foster et al. 2006). This is all despite the fact that “professional associations and accreditation bodies have repeatedly identified the need to include reproductive health in the standard curricula” including The American Association of Colleges of Nursing (AACN), the National Organization of Nurse Practitioner Faculties (NONPF), the AAPA, and the American College of Nurse Midwives (ACNM), all of whom have “...developed guidelines that recognize the need for their graduates to possess competence in providing care related to sexual and reproductive health” (Taylor et al., 2009). Even at UCSF, with the passage of AB154 a firm reality, CNMs only receive two hours of comprehensive options counseling training, and two didactic hours of instruction on medication and aspiration abortion*. Contraception is a very basic, pharmacology-focused online course.

In conversations with other nursing and medical students at UCSF, I have found a shared sentiment of disappointment in this educational gap. Nursing students at all levels are eager for more training and education in sexual and reproductive health - specifically focused on abortion. To meet these demands, a first year medical student and I designed a noontime interprofessional elective entitled “Family Planning and Reproductive Choice”, to which we invited guest speakers who covered options counseling, adoption, values clarification, clinical and public health aspects of abortion, and IUD insertion, among other SRH-related topics. As UCSF students, we were incredibly lucky to have access to the top SRH/abortion researchers and providers in the world, which made the task of selecting speakers very enjoyable. Dr. Tracy Weitz gave an electrifying introductory session on the state of abortion in the U.S., and Dr. Eleanor Drey followed with a comprehensive overview of clinical abortion provision. Residents and Family Planning Fellows taught our IUD and MVA papaya workshop, and Exhale (After Abortion Talkline) hosted a personal experience panel.

Student reception was overwhelmingly positive, and we had packed classrooms throughout the quarter. After presenting on this experience at the National Abortion Federation conference in 2013 and meeting with nursing students from around the country at the conference, it was clear to me that nursing students’ desire to be taught SRH curriculum is a national phenomenon. Anecdotally, their reasons included a desire to achieve competency in patient care provision, desire to increase abortion access in underserved and underinsured populations, and competitiveness in the job market, among others. In collaboration with an incredible, interdisciplinary group of nursing educators and innovators, I’m currently in the process of creating and disseminated the elective as a nationally applicable curriculum. We are planning to implement the first pilots at Oregon Health and Sciences University, Yale University, the University of New Mexico, and the University of Pennsylvania, among others. The elective materials and curricular resources will be added to the Nursing Students for Choice website as well. Through the efforts of dedicated grassroots nursing student activists at these campuses, we hope to demonstrate to faculty and administrators that we strongly believe this content needs to be included in our standard curriculum, not just to satisfy our own interests, but to prepare us to be competitive entrants to the nursing workforce, provide access to high quality sexual and reproductive health care to our patients, and normalize abortion care within the full spectrum of nursing scope of practice.

The final post in this series will review resources and opportunities that exist to build and improve SRH curriculum in U.S. nursing programs at both the pre-licensure and advanced practice levels.

*Due to the admirable efforts of several dedicated faculty, instruction in first trimester MUA is set to be implemented in 2014.

Please direct your feedback and comments to holly.carpenter@ucsf.edu.

References

Foster, A., Polis, C., Allee, M., Simmonds, K., Zurek, M., Brown, A. (2006). Abortion education in nurse practitioner, physician assistant and certified nurse–midwifery programs: a national survey. Contraception 73 (2006) 408–414.

Taylor, D., Safriet, B., Dempsey, G., Kruse, B., & Jackson, C. (2009) Providing Abortion Care: a professional toolkit for Nurse-Midwives, Nurse Practitioners, and Physicians Assistants. University of California, San Francisco. Accessible at: http://www.apctoolkit.org/index.html

On Cynicism and Allyship: Doing the Work

By Poonam Dreyfus-Pai, BADP Co-Director
Originally posted on the CoreAlign blog

Lately, I’ve been thinking a lot about cynicism. With all the legislative restrictions happening in Texas, Oklahoma, Ohio, and countless other states, it’s not surprising that many of us have been feeling discouraged. But it is a curious thing when the responses move from “nothing is working” to “nothing will ever work.” When the Fifth Circuit Court of Appeals blocked a lower federal court’s injunction, thereby reinstating the admitting privileges provision of HB2, my Twitter feed was filled with people who dismissed this decision as emblematic of Texas, of red and rural states, of a system mired in a truly “anti-women” agenda. What’s worse is that many of these nay-sayers are themselves advocates, people who care about expanding abortion access. These advocates were unsurprised at the turn of events, and expected nothing more.

It is too easy to get stuck at this place of lowered expectations; it is also dangerous. For one thing, it alienates the thousands of people who worked to advocate against HB2 and similar rulings in other states: the people who organized, rallied, protested, fundraised, testified, voted, and provided on-the-ground support to people seeking abortions. It dismisses their countless hours of hard work. It minimizes the very real challenges they faced in trying to do this hard work, with constrained resources and a hostile political climate. Quite frankly, the very last thing that these advocates and organizers need is the cynicism of their supposed allies. “I told you so” is not welcomed in any space.

 Because what is cynicism, really? Robert Reich, former Secretary of Labor under the first Clinton administration and current Chancellor’s Professor of Public Policy at the Goldman School of Public Policy at UC Berkeley, refers to cynicism as one of the “four horsemen of the work avoidance apocalypse.” In other words, cynicism is one way people manage not to do the work that needs to be done. The work is hard, no doubt – it is far easier for us to list the barriers and complain than it is to come up with creative, innovative solutions. When the barriers grow, and the onslaught feels constant, it becomes that much more challenging to find ways to overcome them. But this is the trap: cynicism in and of itself is one more barrier, one more obstacle to getting work done. Cynicism comes from a feeling of deep powerlessness, and a fear of vulnerability. It stops us in our tracks. It stops us from taking needed risks.

So how do we overcome cynicism? What work should we be doing, and how do we get re-inspired? For this, I take you directly to the example of the groups in Texas: these are the groups that have had every right to feel discouraged when the game was changed at the 11^th hour. They were already fighting for months. And yet they are not stopping. Though the restrictions of HB2 have forced several abortion clinics to stop providing services, these providers, organizers, advocates, community members are working to build partnerships between groups and clinics, fundraising to help people get the abortions they seek, and are working actively with the ACLU to petition the Supreme Court. These are small but important victories that are worth noting.

And Texas is just one of several states who have been working to keep people committed and fired up in the face of extreme anti-abortion legislation– take Oklahomans for Reproductive Justice (OK4RJ), a group of young organizers who, for several years, have been advocating for the reproductive freedom of all people. Though the 20-week abortion ban has made it exceedingly difficult for people to get needed procedures in Oklahoma, OK4RJ has not let cynicism get in the way of their work. Instead, in February 2014, they will partner with the University of Oklahoma to host the 4^th annual Take Root conference, intended to engage students, organizers, practitioners, advocates, and community members from red and rural states around issues of reproductive justice. Because the emphasis on the red state regional perspective is often missing in national conferences, Take Root aims to highlight this perspective and bridge this gap. At a time when people are saying, “why bother?,” participants at Take Root will instead ask, “what can be done, and how we can do it together?”

If they can keep going, then those of us who consider ourselves allies – particularly those of us living on the coasts or in blue states – should be fighting, too: fundraising, sharing resources, sharing support. We have no reason not to do this work, and every reason to keep at it.

So we must celebrate the small victories. We who live in more amenable political climates must do what we can to support the work of those living in harsher realities. And, perhaps most importantly, we must move beyond a place of fear – fear of failure, fear of vulnerability – into a place of social entrepreneurship. We must recognize, validate, and support the tireless risk-taking, resilience, and innovation of our allies in red and rural states, and let those lessons inspire us as we think about the long game. This is what I personally love about CoreAlign’s 30 year visioning plan  – having a creative, long-term vision allows us to fit these restrictive legislations within a much larger context, one in which we can also see the victories. It allows us to be imaginative, to ask questions about our goals for creating a more just world, to work collaboratively across states and borders, across generations and identities. We’ve no right to be cynical when there is so much work to be done.