At my state meeting this week someone asked me what I hoped to come out of my TED talk. What was my goal? I hadn’t directly been asked that before.  I hadn’t thought about it in those terms, but it was a good exercise. When I applied to do the talk I had only thought of informing a broader audience of the problem for women in rural areas and the rising maternal mortality rate. I hadn’t thought about tangible results. I had to think for a minute about what I hoped would come out of it. I wanted to raise awareness. I want there to be a thriving birth center in every rural hospital run and staffed by midwives. I want excellent care to be affordable for all women. I want the c-section rate in this country to be lowered from 34% to 12%. I want maternal mortality to be the lowest in the world.  Of course I want all that. I didn’t say that at the meeting, though. I can’t remember what I said.  Something about raising awareness, getting us all to look in the mirror at our part in the dysfunctional system. I want us to acknowledge that we need to speak out more, stop enabling, call out the doctors who abuse women. I started ranting. It probably wasn’t very helpful.

I’ve thought a lot about what speaking out against a system means. In our own clusters we can admit to the abuse we see, we complain, but complaining is rarely productive.  Midwives have always felt marginalized. Historically, before it was culturally acceptable for men to be part of the care of women, there was an aura of mystique around the profession. But since the birth process has been medicalized, it has been one uphill slog after another just to be allowed to practice and get reimbursed for our time and effort. When there is money to be made, we are persecuted.  When there is little money to be made, we are dumped on. It all depends on the insurance reimbursement du jour. The fact that study after study shows better outcomes with midwifery care doesn’t seem to make a difference.

If we continue with this current model, there will be no option in rural areas aside from home birth and there are still places where this is illegal. So the midwives who risk their livelihood to assist women with no other option (except to travel three or four hours  in labor) can be prosecuted. And with fewer places to transfer in an emergency, it’s less and less safe. How on earth have we devolved to this?

An argument made by a male doctor, without shame, was given as: “I’ve never been sued for doing a c-section, whether it was needed not.” It doesn’t seem to matter that he then endangers the women’s lives. I hear other medical professionals cringe at this, knowing it is abhorrent. I ask, “Why don’t you turn him in? Sue him for mutilating women unnecessarily? Inform women of his practice methods.” The response is always, “If I do, then he can sue me.” Even when the abuse gets so egregious that doctors are fired or sanctioned, there is a gag order, so we can’t inform patients of his/her wrongdoing. Excuse me? Wasn’t there a tiny bit of criticism of the Catholic church for doing just this? But it’s ok in medicine?

What are the risks of speaking out? Being blackballed? Maybe. When a dysfunctional system, that more and more depends on private donations, gets publicly criticized, there is a lot to lose. And that keeps the dysfunction well fed. It is just so wrong. I get it, I get it… we’ve all got bills to pay and we need the job.  But why is this different from abused women who stay in the abusive situation out of fear or because she needs someone to pay the bills? Isn’t this what we are doing when we don’t speak out? How much are we willing to risk?

So what will come of the talk? Who knows? It doesn’t seem enough to just have the pie-in-the-sky goal. I need to stop and think what the next step should be. One nine minute talk can’t be the end of it. When will enough be enough? How many more women need to die unnecessarily, in childbirth, in 2016, in the United States? Why is it that logic has become so obsolete?  Or was it ever in fashion? How can we get more midwives into rural areas? That must start with more midwives, which, has been a goal of my national organization for decades. Our numbers are rising but not fast enough. I wonder when there will be enough of us that we all feel safe speaking out?

In the meantime, I guess I’ll watch my back.