Making the Case for Indigenous Midwifery
Making the Case for Indigenous Midwifery: Battling White Saviors’ Conquest for Control
By Nicolle Gonzales, CNM
During a recent trip to the Navajo Nation - Window Rock, Arizona - to attend a birth as a certified nurse midwife (CNM), I experienced a contentious “catch-22” situation. Not surprising is that many Indigenous health workers who are trying to provide services to marginalized communities often face this same dilemma.
The sovereign territory of the Navajo Nation overlaps New Mexico, Arizona and Utah. Like many reservations, the Navajo Nation has its own governing body and laws, while also adhering to U.S. government regulations. It is this complex relationship that makes it nearly impossible to build new structures, support new businesses, or even to provide basic necessities like electricity to its residents.
I knew full well that catching this baby in the wrong state--but still working within the primary boundaries of Navajo Nation--could potentially land me in jail. That’s why I went straight to my lawyer to discuss the terms of my CNM licensing on the Navajo Nation and how my insurance liability covered me and this situation, or left me legally vulnerable.
I hold 5 different licenses to practice Nurse-Midwifery in New Mexico. I am regulated by the New Mexico Department of Health and the New Mexico Board of Nursing, and I am certified by the American Midwifery Certification Board. I am also CPR and NRP (Cardiopulmonary Resuscitation and Neonatal Resuscitation) certified, and I have to adhere to the New Mexico Board of Pharmacy standards. Even with this level of expertise, I still had to worry about going to jail while attending this birth on the Navajo Nation territory, outside the boundaries of the federally-established Indian Health Services. I often wonder how many of the white colleagues that I interact with at professional conventions throughout the year, have ever had to face this kind of profoundly unsettling career dilemma.
Many consider the Indian Health Services to be the backbone of health care for tribally-enrolled members, but it has been falling short of that since its inception. This public health irony—or cruel joke depending upon your perspective—underscores the absurdity of organizations like the American College of Nurse Midwives, American College of Obstetrics and other legislative bodies attempting to define what “safety” or “midwifery” is in Native American and Indigenous communities.
These governing bodies simply do not have the knowledge, tools, or insight to produce empathic, effective strategies and protocol--but that is exactly what is happening all over the United States and Hawaii where legislation like Senate Bill (SB) 1033 was signed into law on April 30, 2019. SB 1033 mandates that regulation of midwifery as a “profession” is necessary in Hawaii, and that the term “midwife” connotes an expectation of care by the consumer and the community. It defines who engages in the practice of midwifery, by standards of settler colonizers who are not beholden to the cultural infrastructure that has kept communities well for centuries.
Although the bill contains language intended to allow for temporary exemption from licensure requirements for birth attendants and traditional Hawaiian healers, the attempt to craft a legal definition of midwifery assumes that we all navigate our communities’ birthing practices in the same way, which we do not. Those in the position to define terms and legislation for Indigenous midwives generally need a lot of education about our communities. Many of us who travel to other locations spend the majority of our time explaining the historical context of our plight to those in positions of authority.
Over the past 100 years, and in the name of “safety,” state and government legislative bills like SB 1033 have forced Indigenous midwives to assimilate into the western medical system. This has created barriers, not only for Indigenous midwives who have been practicing for years, but also for the communities they serve.
Indigenous communities across the nation share many common truths when it comes to surviving the impacts of colonization and the settlers on a conquest for riches and ownership. Many of us, Indigenous midwives, are forced to mitigate complex spaces of white privilege in pursuit of our education and our current day medical systems. Those of us who have chosen this route had the intention of bringing those skills back to our communities. However, what we face after coming home is an overlay of restrictive laws, and closed or outdated healthcare systems that don’t allow us flexibility to help people the way they want to be helped, and in ways that we know will be successful. We face a high cost to work in our communities. Some midwives have even fashioned underground workforces of traditional midwives who may or may not be working at their full capacities. Those of us who were called to midwifery and have had community support for apprenticeships with traditional midwives are being forced to give up our sovereign rights to practice because of laws like SB 1033. These legislative bills don’t just impact the practicing traditional Indigenous midwives in Hawaii. Though legislation like this is often enacted with a lot of fanfare, too often it sets a negative precedent for the entire country. If you were to read reports on health provider shortage areas, you would find many of our communities’ geographic areas zoned as such. But guess who serves those communities? Traditional Indigenous midwives.
Indigenous midwifery is being defined and fought for by Indigenous women who are coming into their power as birth keepers. Native American midwives make up 1% of Nurse-Midwifery and 0.5% of Certified Professional midwives practicing in the United States. State to state regulations where many of our traditional territories and sovereign land overlap leave us navigating the limitations of state-mandated regulations that strip away our rights to provide midwifery care in our own territories.
When laws are put in place by those who do not understand the territories we live in and our social structures that give us the ability and trust to work as midwives in our communities, it actually creates more systematic barriers to health care in our communities.
While we look for ways to address the Native American maternal health crisis, Hawaii’s Senate Bill 1033 reminds us how the potential land mines of over-regulation, state-to-state licensing boundaries and regulations devoid of cultural context can mortally wound Native American midwives’ ability to serve their own communities.
All in the name of “safety,” defined by those who have no idea what that means for the people they’re trying to protect.
Nicolle L. Gonzales,
BSN, RN, MSN, CNM
Nicolle is Navajo and grew up on and off the Navajo reservation near Farmington, New Mexico. She attributes her accomplishments to the many prayers and ceremonies done on her behalf as she was growing into the woman she is today. While obtaining her graduate education, it became apparent that traditional healing practices and philosophies about “health” and “wellness” were vital to the care she provided as a Nurse Midwife. It is with this deep understanding and respect for our way of life as indigenous peoples that her worldview are based on and are reflected in the projects she participates in. Nicolle’s primary goal as a Nurse Midwife is to keep birth sacred and in native communities, by integrating and applying traditional knowledge.
Addressing Maternal Health Disparities In Native American Communities. Beyond the MysticisM
As a Navajo Nurse-Midwife, a question I often get from other midwives and scholars is “what are the traditional birthing practices that Native women have?” For me this speaks to the continued misconception and mysticism that surrounds Native culture and unfortunately has guided past research focus, rather than measuring objective accounts of racial discrimination and root causes for today’s maternal health crises in Native communities. If you were to do a literature review for the barriers that Native American women experience in accessing health care, you would find outdated information and many articles written by non-Native researchers talking about our traditions and healing practices. There are no personal accounts or recorded lived experiences by Native American women on how they perceived the care they received in a colonial settler medical system.
On February 12, 2019, for the first time in history, a congressional briefing was held on Native American Maternal health in Washington D.C.. Indigenous women leaders who are doing the actual work to address specific maternal health disparities in the areas of missing and murdered indigenous women, reproductive rights, and barriers to accessing healthcare were invited as key advisors to share their perspectives. Following the hearing it was clear that despite policy changes and medical technological advances over the last decade, the needs of Native American women are still not being adequately addressed.
By all accounts, reproductive rights continue to be a battle that Native American women have to fight. From forced sterilizations in the 1970’s, to fighting for access to Plan B and abortion care within government systems like the Indian Health Services. And now, there is a big push to place Long Acting Reversible Contraceptives, or intrauterine devices (IUD), immediately following birth. The historical timeline of violations around our reproductive rights can be mapped out by Indian Health Policies and pharmaceutical advancements over the years.
Understanding maternal health disparities in Native American women goes deeper than the pictures of death and the dying being toted around to sound the alarms that there is a problem with our healthcare system. To educate anyone who has intentions of working with Native American communities, it becomes a full history lesson of discrimination, racism, exploitation, capitalism, and warfare. The harms of yesterday, are still the harms of today. A recent manual surfaced called “Indian Babies, How to Keep Them Well.” The 1916 manual described how the government and the church would assimilate Indian children from childbirth and do away with tribal systems, by way of removing their culture, language, and identity.
Until now current accounts of discrimination by Native American women have not been validated by the government or medical community. Rather what is holding more water is our statistical outcomes, of high rates of diabetes, obesity, hypertension, breast cancer, cervical cancer, sexual transmitted diseases, high numbers of teen pregnancies, missing and murdered women and single parent homes. Yet, I get more and more calls about people wanting to know about our “traditional birthing practices.”
As more Native American and Indigenous women answer the call to become doulas and midwives to address maternal health disparities, the unveiling of invisible barriers continues to surface. The intersections between Indigenous feminism, reproductive justice, and indigenous midwifery continue to evolve, as they take into account our historical narrative, as told by Indigenous women and not by non-native historians or scholars. The challenges that Indigenous midwives face today, is creating policy changes and healthcare systems that address the real needs of their communities. While the rest of the world is focused on bringing skills to rural communities and community birth attendants, midwifery in the United States is still stuck on licensure to validate and qualify who can practice midwifery. The “who” can practice midwifery, in the United States is still disproportionately affected by race, color, gender, and class. Those of us who have had to navigate educational systems to gain the knowledge to return to our communities as midwives, can speak to the challenges we faced accessing the financial capital to support our education and families. We further had to endure institutional educational systems and midwifery placement settings that were racist and paternalistic in nature.
Addressing the Maternal Health crises in Indian country isn’t just about returning birth back to communities and reviving our traditional birthing practices, it’s acknowledging that the missing murdered indigenous women’s movement is part of that crises. It’s acknowledging that having access to reproductive services like abortions is also part of addressing that crises. It’s acknowledging that lack of funding for community-centered healing solutions is also part of that crises. It’s acknowledging that if our land, water, and traditional foods are polluted by unnaturally occurring chemicals, it’s also part of the maternal health crises. We cannot say we stand with Native American communities and women, if we cannot stand together on these issues.