Vague Ethnography and Healthcare Access

Liora O’Donnell Goldensher // In late 2017, I began full-time fieldwork towards a dissertation about contemporary professional non-nurse midwifery in the United States, joining the practices of several homebirth midwives. I organized my multi-sited approach with an eye to various of what those in my home discipline of sociology might refer to as “axes of variation”: I made plans to spend time in rural and urban areas. I arranged to shadow midwives who were avowed conservatives, as well as those who called themselves progressives and liberals and left-radicals.  I chose practices active in six different states, in four different regions of the US.  And I made sure that those practices represented the vast variation in statutory and regulatory regimes governing the practice of non-nurse midwifery, selecting practices active in states in which licensure is available to CPMs and celebrated by many midwives, states in which licensure is available but restricts practice or invites punishment for many midwives, and states in which licensure is unavailable.  Because of that last category, I knew when I began the research that I’d be spending time with people who were breaking or pushing the limits of the law, and I wrote a detailed IRB protocol about how I’d offer multiple opportunities for parents and midwives in unlicensed states who participated in my dissertation research to modify their participation or withdraw, and how deeply I’d anonymize their identities.

This approach was undoubtedly naïve.  I knew that many midwives in states where licensure is governed by Boards of Medicine feel that physicians on those boards, many of whom follow the American College of Obstetrics and Gynecology in questioning the safety of out-of-hospital and especially homebirth and of many of the common practices associated with homebirth midwifery, are hostile to their practices and looking for opportunities to open investigations that might shut them down.  But I had somehow expected that the data I’d find about illegal or quasi-legal practice would mostly come from states in which midwives operated without licensure, and in that respect I was completely wrong.  Parents in prenatal visits in licensed states discussed their plans to cross nearby state lines should they find themselves “out of scope” for homebirth midwives in their state, but not neighboring states.  Midwives told me stories about charting strategies, verbal consent scripts, and sequences of actions they used to stretch the limits of the regulations under which they practiced, finding ways to stay within the letter of the law while preserving the availability of choices for their clients that the spirit of the regulations attempted to prohibit.  It quickly became clear to me that this was a crucial issue of access to healthcare: where regulation prohibited particular care options, parents and midwives were finding routes around those prohibitions to preserve the availability of that care.

A reader of the opening paragraphs of this piece might reasonably stop me here.  What, they might ask, were those parents and midwives doing? What scripts and charting strategies were they using?  What were the regulatory limits parents were going elsewhere to evade?  How far did they have to go? What happened when they got there?

Vagueness is both a maddening and, for those who value precision in their ethnographic accounts, an unscientific style of writing. Yet I’ve found myself torn about the question of how and to what degree to reveal the details of these matters.  The arguments for doing so seem clear: it would satisfy disciplinary conventions of specificity, adding analytical purchase.  And, moreover, it would admit some difficult truths into the official record (to the extent that a dissertation constitutes such a thing!) about homebirth and midwifery in the twenty-first century. I know parents and midwives told me these stories in part because they wanted me to represent the constraints on their practices and birth experiences, and they wanted me to represent ithe risk-taking required to preserve care options in what I wrote because it was part of the story of homebirth and midwifery in these places and times.  But I also worried I was providing any regulator who might wish to foreclose these methods of preserving care options with a roadmap to identify and preclude them in future rule-making.  And the more specific my accounts, the easier such tightening of regulations would be.

I was recalling, as I began to consider these concerns, discussions that followed the release of Alice Goffman’s On the Run, particularly those that spotlighted what reviewer Dwayne Betts called its “unrelenting focus on criminality.”  Much as Betts argued that Goffman’s rendering was “just as likely to encourage more arrests and surveillance than to convince people that mass incarceration should end,” I was concerned that fully detailing the stories I’ve been told might encourage more investigation and limitation of midwifery practice.   “Unwittingly,” Betts contended, “Goffman gives ammunition to tough-on-crime politicians who want to believe that urban areas are breeding grounds for crime and lawlessness.”  This risk seemed pressing in my work, too, and I did not want to provide evidence for a longstanding characterization of midwives as reckless and lawless in the way critics noted that Goffman’s book had reinforced tired and dehumanizing stereotypes of young black men as violent criminals—particularly given the consistency with which the legal regimes surrounding midwifery in the past century have, as anthropologist Gertrude Fraser put it, “mixed arguments about the need to reduce maternal and infant mortality and to improve healthcare with those confirming the importance of maintaining the racial and social order” (Fraser 1998:72).  And yet more specifically, I felt wary of replicating what Christina Sharpe called Goffman’s “revelation of black fugitive practices.”  Sharpe’s review of Goffman’s book quotes Frederick Douglass, who wrote of the public description of routes by which enslaved people escaped to Northern states, “They do nothing towards enlightening the slave, whilst they do much towards enlightening the master. They stimulate him to greater watchfulness, and enhance his power to capture his slave.” Particularly as a growing share of Black parents seek out homebirth as an alternative to the killing racism of the US perinatal care system, these warnings about the costs of illuminating escape routes seem crucial (see, for instance, pieces by Bashir [2019] and Atikunde [2017]).

In the end, I consulted directly with one of the midwives I shadowed.  Her suggestions—including seeking out stories to document the permeability of borders between regulatory environments in areas with less punitive regulatory environments, describing the longstanding nature of the strategy of travel across state lines for the purpose of obtaining desired reproductive care, and using the rapid state of change of midwifery licensure in many states to tell stories that are now less risky to reveal publicly than they were at the time they occurred—deserve attention in other research.  Ethnographers of healthcare access must take care not to reveal the ways their informants generate access by finding routes around rules without attention to the costs to access those revelations might introduce—even at the expense, perhaps, of specificity.

 

Cited:

Atikunde, Anthonia.  “More Black Women are Considering Home Births—And What They Should Know.”  Mater Mea. Updated 21 January 2017. Retrieved 12 April 2019.

Bashir, Imani.  “Pregnant Black Women Are Dying at Terrifying Rates—That’s Why I Chose an Unassisted Home Birth.”  Glamour. 1 March 2019.  Retrieved 12 April 2019.  https://www.glamour.com/story/i-chose-an-unassisted-home-birth

Betts, Dwayne.  “The Stoop Isn’t the Jungle.”  Slate. 10 July 2014.  Retrieved 12 April 2019.  https://slate.com/news-and-politics/2014/07/alice-goffmans-on-the-run-she-is-wrong-about-black-urban-life.html

Fraser, Gertrude.  African American Midwifery in the South.  Harvard University Press 2009.

Sharpe, Christina.  “Black Life, Annotated.”  The New Inquiry. 8 August 2014.  Retrieved 12 April 2019.  https://thenewinquiry.com/black-life-annotated/

 

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