Teaching Diverse Populations.

In the spring of 1998, during my last semester in college, I volunteered once a week at the ALACE office in Cambridge, MA. At the same time, in order to complete my major in anthropology, I was searching for ideas for an independent study project related to birth.

Initially, I was interested in mothers' experiences of birth and how factors such as race/ethnicity, class, or sexual orientation can circumscribe a woman's freedom to choose among various options for care and how such factors impact the care a mother does receive. I then realized that I was going about this project in the wrong way, because while I wasn't dealing with mothers themselves, I did have access to a vast network of ALACE childbirth educators.

So instead of asking them about the mothers' experiences and perceptions, I focused more on childbirth educators themselves: their views on birth and the medical system, and the treatment pregnant women receive, and in turn, why they have chosen to work in childbirth education, why they feel it's important, and how they locate themselves in the complex framework of care offered to mothers.

Specifically, I retained an emphasis on "marginalized" populations because I was interested in various groups with whom A LACE childbirth educators were working and how they perceived the needs of disadvantaged groups with regard to pregnancy care. The most commonly identified groups were: low-income women; Spanish-speaking women; women of color; teen mothers; lesbian mothers; and women interested in homebirth.

I examined each of these groups separately, while grappling with this issue of dissecting and separating identities. The following is a summary of the results of my interviews with various ALACE childbirth educators (the ALACE office has a complete copy of the paper).

Insurance and the cost of care is a common concern of many childbirth educators, especially those working with poor women. One teacher who works at a pregnancy care center that sees mostly young, single, and/or low-income mothers wrote:

   I have been labeled "low-income" most of my adult life. I could remember
   the choices (not many) that were offered me when I myself had been pregnant
   so in this way I was fortunate to have that insight. I have been able to
   sort through some of the most basic issues that affect my students. Usually
   it's a feeling of powerlessness of their life situation and then the very
   basic day-to-day issues like "how am I going to eat today?".

Another childbirth educator said of her class that "some folks are very withdrawn and body conscious, while some seem very disturbed by any `authoritarian' figure such as a teacher." Yet another educator who teaches in a hospital expressed difficulty with low-income mothers missing class and not calling in advance to notify her. She said the retention rate among mothers with public health insurance was very low, possibly because they feel uncomfortable in a classroom-like setting, or because they are less interested in learning than mothers who pay out-of-pocket. In addition, all the women in her classes receive their care from midwives and perhaps the mothers feel they get everything they need from their appointments and don't need extra classes.

Among educators working with teens, a common theme that arose was facing reality and taking responsibility. The mothers are young, they are scared about the pain of birth, and they often have very little understanding of what it will mean to be a mom.

"Working with teens has been an eye-opener," one educator said. She said that education programs for teens need a special focus because, at the most basic level, she has had to simplify her handouts down to a "seventh grade reading level." She also makes work and reading assignments mandatory, just like in school, otherwise, she says, the girls would never learn anything.

One educator observed that teen mothers do not think about the day of birth, even though they are anxious about the pain, or about being a parent. They need to "wake up and face reality" and "be empowered," she said. She discusses the birth process with the girls, hopefully to lessen the fear, and informs them of the various medical interventions that may be used in the hospital. She emphasizes that the best birth is whatever works for them, and that they have to make assertive, informed decisions for themselves. Still, they usually follow doctors' orders over anything else. This educator felt that because she is a "layperson" everything she says "goes in one ear and out the other. Their parents tell them to listen to the doctor, `this woman doesn't know anything.'"

Almost all of the teen moms with whom A LAC E educators work give birth in hospitals with doctors attending. One educator expressed a desire for greater access to midwives and the need for "sensitive doctors" to accept public insurance. She observed that most "doctors and hospital staff put [teen mothers] on the back burner and doctors act as moral judge and jury."

A frequently linked factor with teen pregnancy and poverty is race. Women of color who are poor have to deal not only with financial burdens, but possibly with racism as well. A disproportionate percentage of teen pregnancies are among poor, black girls. One childbirth educator works with African-American teen mothers who live in neighborhoods where poverty, lack of education, rampant crime, and drug use are daily realities. She said the girls at the clinic are "luckier than some" because they see midwives and not doctors, and they have access to childbirth education classes. Many of them don't bother coming to class, however, unless they happen to have an appointment the same day. The educator said that "they have this attitude that `I don't need that' or their friends or mothers tell them that." Generally, she said, teen pregnancy is perceived as normal and is not stigmatized in the community where she works. She observed that the fathers are not held accountable and play no role in caring for the mother or the child:

   Women don't assume that men have to have anything to do with the kid. They
   want and expect this because this is what their mom and their grandma did.
   Their mom had them when she was sixteen, sort of thing. I'm working with a
   nineteen-year-old now who's on her seventh baby. I try not to judge but I
   mean, how many do you want? Ten? Twenty?

She acknowledged her cultural biases and, it seemed, tried not to rely on or enforce stereotypes of inner city and/or African-American youth.

For Spanish-speaking mothers, the language barrier is obviously the most pressing concern. They may not be able to communicate with their care providers, which presents a challenge to getting the care they need and having their questions answered. One educator who teaches Hispanic parenting classes at a hospital said the women she works with often do not have a good education and are not well informed of their options or what they could expect during birth. She felt that having classes in Spanish dealing with these issues helps the mothers "feel at ease." Many of them have questions about "myths" that they have heard from their mothers and grandmothers that have made them afraid of pregnancy and birth.

If these classes were not offered in Spanish, many women would be left uninformed about and unprepared for the birth process in the hospital. The educator also said the classes help the mothers "feel like someone cares. They feel alone because their husband or boyfriend is not involved."

The central issue for lesbian mothers, according to the childbirth educators I spoke with, is feeling safe and supported. One of the educators, who is also a lesbian, said, "Yes, I think we do have specific needs. There is a need to feel safe when one is particularly vulnerable. The need to feel safe is a big need." She had personal experience with this when she herself was pregnant and attending childbirth education classes with her partner. She and her partner were the first lesbian clients this teacher had had, and although she knew they were a couple and seemed to be accepting, "she didn't Change the paperwork to say `partner' instead of `husband.' You know, you'd think that would be a small thing since she knew." They were out to all of the other couples in the class too and although "everyone meant well" she said it felt very alienating at times.

In addition, "there are issues around biological and non-biological mothers. It was an issue for my partner that she was not biologically connected and they didn't address this at all in the class." This woman and her partner eventually chose to have a homebirth because, she said, "I knew that in the hospital we wouldn't be welcomed as a family and that is really important to us. At home we would be welcomed as a family."

Another childbirth educator said that she gets referrals for lesbian classes since "not too many hospital classes are too supportive of lesbian parenting." She really enjoys teaching all-woman classes, she said, and has sent a proposal to a community health center to teach classes specifically for lesbian parents. She also said that for lesbian parents "it's important to have your own support group and have the hospital services support those choices. You need to have people back you up, and there are lots of lesbian midwives."

Women who want to birth at home do not have unique needs in the same sense that the five other groups do. Choosing to have a homebirth is more of a response by mothers to a system that, for one reason or another, was not working for them. As one educator who teaches for a homebirth practice wrote: "Most people who select the homebirth option have done so from an aware, educated standpoint. They seem to be for the most part willing to read, take care of themselves, eat well, exercise." For her, "the most important issue in our area is keeping the homebirth option viable."

Challenges arise because homebirth is not within the standard structure of care, so special arrangements must be made with care providers who work outside of the normative framework. Opting out of hospital care (except, perhaps, in the most rural of areas or among the poorest of families, where this is not an option to begin with) requires a certain financial stability that eliminates many women who might otherwise elect to have a homebirth. Since women who choose to have a homebirth tend to have sufficient income and therefore a greater range of options for pregnancy and birth, the concerns that they face are somewhat more sophisticated, and less urgent, than those of mothers without adequate resources.

Themes that came up again and again with the ALACE childbirth educators included: "empowered," "informed choice," "awareness of options," and "making own decisions." As one educator wrote:

   I see myself as one voice in few in this area that is willing to present a
   more balanced view of birth and pregnancy. I suppose I'm a bridge between
   what is not easily heard to those that want to hear. I try to give each
   family a sense of "this is your baby and your birth experience, so don't
   let anyone steal its preciousness away from you. You have a right to be
   heard and respected."

--Jana Anderson graduated from Tufts University in May 1998 with a degree in Anthropology and Community Health. She is currently in South Africa, where her mother lives, traveling and doing volunteer work with various health projects, focusing particularly on women, children, and HIV/AIDS. She aspires to be a midwife.3