Dear Provider: Conversations on Birth Work and Improving Queer Rural Healthcare

By Naomi Rachel Ullian

This past month I sat down with friend and local midwife Alex Holding, who runs Fiddlehead Midwifery. Over a cup of chamomile-and-mint tea, Alex talked with me about birth work, midwifery history, and the state of queer rural healthcare. Read on for our explorations on how providers and patients alike can move healthcare toward more inclusive and resilient practices.

GMC: Will you talk about your training and health politics and how these relate to your work as a provider?

AH: I went to BirthWise Midwifery School in Bridgeton, Maine, for my academic training, and for 10 years I have worked in apprenticeships with a variety of midwives both before, during, and after my academic training. I am a certified professional midwife licensed in the state of Vermont and certified in the state of New Hampshire. It's a little bit of the Wild West in Massachusetts because midwifery is alegal outside of the hospital. So that means my scope of practice is different depending on which state I'm in. Generally, I can provide fertility care, pregnancy, birth, and postpartum care, as well as, wellness care -- an annual exam and cancer screening, not including prescribing birth control. Part of fertility care involves supporting people in their insemination process, for families that are inseminating to have kids.

GMC: Which is something that often, but not always, relates to queer families.

AH: Yes. My academic training was very centered around serving women (my wellness curriculum was called "Well Woman Care"), so in my apprenticeships, I really sought out midwives who were providing care to queer people. Because I have lived rurally for so much of my life and plan to continue to live rurally, it felt really important to me to seek out practices that were working with queer clients.

GMC: Can you talk about the intersection of being rural and queer for you?

AH: I think the way that I am queer is wrapped up in my rural identity -- I learned to build queer community and have relationships with other queer people in a rural place. I've lived in more urban places as a queer person, but those spaces and communities have never felt as intrinsic to the ways I understand being queer. I just had lunch with one of my first girlfriends, who lives in the town where we grew up, her sister is a midwife, and her other sister is one of my best friends.

GMC: Which is pretty rare for a queer person, right? Your story feels pretty different from many folks' stories of growing up queer and rural and often not choosing to remain in rural or small town locations.

AH: Yeah. That importance of building where we are from feels really centered in the ways that we can continue to be family. When we talk about "queer family," what and who do we actually mean? Those constellations don't necessarily look like nuclear family and they also don't look necessarily like this mythic urban "queer community." I am from New Hampshire and chose to move to Vermont with my partner, partly because some of our queer family was settling here, and we kind of agreed as a family group that this is where our queer family was going to be.

GMC: Can you talk a little more about the formation and practice of your healthcare politics?

AH: One of the things that has always been a point of cognitive dissonance for me is being engaged in community organizing and feeling that the healthcare work that I'm doing, my investment in healthcare, is separate. You know, feeling like working at a needle exchange, for instance, is not the same kind of radical as going to demonstrations or doing trainings.

GMC: I see those things as really comparable in terms of how radical or transformative they can be. To me, birth work seems inherently political. The very existence of midwives seems to me to combat white supremacy and patriarchy.

AH: Me too! In terms of integrating a social justice ethos, I've had to figure out how this deep investment in healthcare and the health of the communities that I've been in is linked to a larger investment in dismantling white supremacy culture. There's a long lineage of midwives in the US, many of whom were from, trained in, and served Black communities rurally. The grand midwives were systematically eradicated by the AMA (American Medical Association) along with the increasing medicalization and professionalization of birth. Many of those disenfranchised midwives were black, but you see in midwifery communities today that the face of midwifery is very very white.

GMC: My understanding is that this really moved the power and control over birthing into the hands of white men, because many of the rural midwives who successfully delivered thousands of babies were women of color, poor, and/or immigrants. The race and class factors that made it easy for the AMA to interfere with the existing birthing traditions, tragic for so many reasons including the millions of hours of handed-down knowledge that resided in those midwives. Something that occurs to me is the decrease in autonomy and culturally-relevant care that a community has when it loses its midwifery tradition, because healers who come from a community have deep knowledge of the community and embody the possibility of self-sustaining healthcare systems with less dependence on depersonalized healthcare industries.

AH: And what happens when you cut off traditions that are apprenticeship-based, and when you have people who are not of those communities becoming the people providing care? I didn't always train in the communities that I planned on working in. I went to California and Oregon, partly because I wanted to train with midwives who worked with queer communities, or worked with communities that were different from the very limited scope of the midwives I was working with here. And I think that my choice to do so is important to critique.

A huge component of what is essential to me about midwifery care is about body autonomy and about an informed choice that really centers the client and their relationship to and choices about their body. This is why local midwifery thrives when it is culturally relevant and invested in the community. Community enfranchisement and providers that center body autonomy can feel really different from medicalized and professionalized birthing practices. For instance, not everyone but many clients want to know how to do their own pelvic exams, you know, insert speculums themselves and locates the cervix. That is something that is more likely to happen in your home with a midwife providing your care.

GMC: And it isn't something people often get in the doctors office or hospital, the experience of a provider as an ally, rather that as the expert. In my experience with all sorts of providers, providers who carry the narrative of medical expertise are a lot less likely to emphasize empowering their clients. If you see yourself as the ally, walking alongside or walking with during care, you're a lot more likely to hand the reins over to the client, or encourage them to take responsibility for their own care. This can be so important in queer healthcare.


AH: Being accountable as a provider! If you are of that community and you are acting as an ally, you become accountable to your clients, and that is something that feels wildly missing in healthcare in general and especially rural healthcare, where there aren't a lot of options. Often in a rural setting you are one of a handful of people available to provide care -- you can talk a big game about body autonomy and client choice, but if there isn't actually another choice --

GMC: Then it’s not really a choice. Have you had any particular experiences accessing healthcare yourself as a queer person in a rural area?

AH: Part of this situation is that I feel really clear about the ways in which I want to have healthcare provided, and I'm not always up for articulating that or advocating for myself in every situation, so sometimes that looks like just not accessing healthcare. However, I'm pretty good about dissociating for the length of my care and not being traumatized about it afterwards, and also: I'm not trans. So I'm way more likely to receive adequate healthcare based on those things.

GMC: What do you see generally as the state of rural queer healthcare either in New England or specifically in Vermont?

AH: Its not that the cities I've been in have providers who are so much more queer-competent, it’s simply that there are more providers to choose from, so finding a person who is a good fit for you is more realistic. You automatically start in a different place with rural healthcare, not having the same variety of options. The disparity becomes really clear in rural places, where if you're denied health care, there's maybe not another option for you. In southern Vermont, we have Sojourns, a clinic in Westminster that has nurse practitioners, chiropractors, naturopaths, and in general they're good with insurance, including medicaid, and people have had good luck there.

Something I've seen consistently in rural places is that queer people can be good at communicating with each other about who their providers are. Through the grapevine you can find out, Yeah my provider knows absolutely nothing about providing hormones but is also willing to do blood work and figure it out. So finding gender-confirming healthcare can be really contingent on communication and a willingness to talk about your body and your healthcare with other people.

GMC: This seems dependent on whether you're hooked into a network of other queer people, because there are a lot of rural queer people who are not. I know so many folks who have either experienced outright discrimination in a doctor's office, fear of the potential discrimination, or discomfort with the lack of competence of the provider that folks put off or choose not to access care.

AH: Injustice at Every Turn is a national transgender discrimination survey that came out in 2011, and the information on health care disparities was really significant. 19% of trans people reported being refused medical care because of their trans status specifically. That's almost 1 in 5 trans people, so if you're living in a rural area where access to care is limited, that's so significant. The survey also reported that 28% of trans people postponed getting medical care, due to prior experiences of discrimination, and 48% reported postponing medical care due to not being able to afford it. When you compound employment statistics and employment discrimination for trans people with lack of access to health care, those statistics become really stark really quickly, even in a place like Vermont where there is, theoretically, universal health care.

As a health care provider, you're not interacting with a blank slate. So many people have previous experiences of mistreatment, lack of actual care, not being visible and therefore not receiving the care that is appropriate. As a provider, I'm often having to recognize and meet those histories in my clients.

GMC: How do you think birth work is different for queer rural families compared to queer families birthing in urban areas or even a small town like Northhampton, which is packed with queer folks?

AH: A funny thing about midwifery is that the care is based in the home for a long period of time. In general, it doesn't seem relevant for clients to know the details of my life, so often my clients don't know that I'm queer. Depending on how many people read this blog, potentially a lot more do know now! But something that has always been very important to me when I'm describing what my care looks like, such as on my website, is to be explicit about the fact that queer families and queer individuals are not only welcome but a priority.

GMC: How do you make that known to potential clients? I just talked to an herbalist friend who was struggling with this, trying to communicate that their practice isn't just "queer-friendly" but queer-experienced and active in queer community.

AH: Michelle Esperanze, a midwife in Florence, Massachusetts, has materials which say, "This practice serves families of all constellations." Which I like a lot. I just say that I have familiarity working with queer families and individuals in my descriptions of me and my practice, and it’s clear to me that queer people use this information to get in touch very quickly. Like people who haven't gotten an annual exam in x amount of time and really need one. It's clear that there's this void and people are not having the option or access to healthcare that they need. I also facilitate workshops on trans health for midwives and other birth workers, and consistently the feedback I've gotten from trans people in terms of best practices is that making queer competence apparent to potential clients and patients is key.

GMC: Will you talk about how you came to be offering trans-competency workshops for birth workers?

AH: To start, I want to say that as a non-trans person, I don't actually think I'm the best person to be providing these workshops, and it’s something that I would like to transition out of, but I have had a lot of access to other birth workers, and there has been a lot of interest in this information. I do think there are specific things that, as a non-trans person, I can offer up in accountability to trans communities.

GMC: It seems like there could be a role for non-trans providers to step into a co-teaching role. I could see how having a workshop taught by two folks coming from different personal experiences of gender could help different students wrap their minds around information that might feel so different from what their socialization has taught them.

AH: Yes, the workshop was originally developed as a workshop to be taught in tandem, developed in partnership with both trans and non-trans health care providers over the past 8 years. Most recently I've been teaching it at BirthWise Midwifery School, and for midwives in this area when there's been interest. I'm happy offer the curriculum to anyone who wants to know more or potentially teach.

GMC: So if there were a provider or group of providers interested in increasing their trans competent skill set, you or someone you recommended could offer this workshop.

AH: Yes!

GMC: Can you talk a little bit about the current state of birthing in rural areas, for queer folks and families?

AH: Its different in every rural area, but one of the things that queer parents are often dealing with is second parent adoption or issues of legal parentage in the eyes of the state. Vermont offers folks in a civil union a place to have the non-gestational parent on the birth certificate. That's not true in every state. If you have clients who are queer and don't have a civil union or are not married, it’s good to know what the laws are in your specific area, what the adoption process might be like, what your resources look like. For instance, do you have a lawyer in your area who is particularly good at second parent adoption or at donor contracts? etc.

GMC: Have you noticed any patterns or commonalities among queer families' birth practices or experiences?

AH: It really depends on that family. Midwifery care means supporting a family to be fully themselves, centering the dynamics they choose. Sometimes, the non-gestational parent might be interested in breastfeeding or chestfeeding, so they might want to know how someone would want to induce lactation. Having familiarity with things like that means that I can be resourceful for that specific family dynamic. I like to make sure I am clear on what that family wants in terms of support for the non-gestational parent because it’s really easy for that role to feel not centralized, especially if that individual is not biologically related to the child. So I like to try to figure out the ways in which I can center the role of that parent. It’s a thing that non-gestational parents in non-queer relationships can also come up against, but it’s something that may be often more glossed over within hetero-patriarchy, owing to this idea that dads are just not as involved in the way that mothers are.

GMC: What are some other things you think providers need to know if they are working with rural LGBTQ individuals and families, and especially birth workers?

AH: Know your resources. If a client needs to see a chiropractor or endocrinologist, know or research queer-competent referrals. Be willing to do the legwork. Having a good referral list is one of the central things we can do to improve access for queer folks in rural areas, as a provider being a hub or center point for those resources. There's this idea that as providers we have to be able to provide everything, and I just don't think that's realistic or actually what our jobs are. Being resourceful is my job.

Make sure that everyone in your network, clinic, or practice is trained in queer competencies, from the person at the reception desk to the person who takes blood pressure to your backup or person on call. If you are a queer-friendly provider but a patient has already had an incorrect pronoun or name used for them at the front desk before they've gotten to your office or exam room, it doesn't matter how good you are, because that experience has already been traumatizing. That's not good health care.

This may seem like a simple thing, but it’s good to remember that just because I feel competent or well-versed in "what the queer community wants" that you are necessarily going to be the right fit for every client, or that was has worked well for someone is necessarily going to work for someone else. I might think that the language around, say, "non-gestational" parent is really great language and it worked for some folks, but that doesn't mean that for the next family it’s going to work. So providers should really be trying to sit with a family, understand where they are at, and try to meet their individual needs.

Talk to other providers about best care practices. Seek feedback regularly from clients, informally and formally, having lots of avenues to have feedback given, and really deeply studying that feedback. I'm working on figuring out how to make this option more anonymous this is my practice.

Also formal and informal peer review and debriefing, either in circles or group or with a peer provider you have relationship with. Peer reviews are mandatory for midwifery care, anyway, but if you're a provider trying to become more queer competent, check in with peers.

Hosting really good trainings would be awesome. Understanding the health disparities for queer folks in rural communities could help providers who want to provide good care understand where they need to educate themselves to bridge those disparities.

Be okay with messing up! You are going to mess up a pronoun or something else some time, and what makes you a safe provider is being open to being corrected and educated, being willing to engage with care relationships that are new to you. Be accountable to your patients, peers, and community.

GMC: So what happens in rural healthcare when the options are slim, and you might not be the best option for a client, but you are the least bad option?

AH: Recently I've been assisting a midwife of color caring for a family of color, and I, as a white midwife, am suddenly in their intimate healthcare world. As a white provider, no matter how invested I am in providing good healthcare for queer people, I am also carrying a legacy of white supremacy with me, in my body, when I walk into a room, so I'm not necessarily going to be the best provider for someone for whom that is really present. So I'm invested in figuring out how to only step in when asked for and be quickly willing to step back when asked.

GMC: I keep thinking about this idea of provider as expert, and when your job and society is putting you in the role of expert, it can become that much harder to ask questions or admit you don't know the answers.

AH: To return to Injustice at Every Turn, 50% of trans people report having to educate their providers on trans care, just the nuts and bolts of the biology, not even thinking about how to be particularly respectful. Some of the best healthcare that trans people I know describe receiving is not even from someone who knows exactly how to provide trans competent care, but is willing to say, I don't know and I will find that out. I know that I am far from perfect in term of my trans-competent care, but I want to always be working to get better at what I do. I feel so deeply humbled all the time by that reality.

GMC: Many of the trans folks I know have stories about encountering providers who think, "Well this person is outside of my ordinary population and how often am I really going to encounter a person like this, so I just don't really need to know or care." This seems like a message trans people get too often in the doctor's office.

AH: It's always best when we don't wait for clients or patients to push us to become better providers. Centralizing the needs of marginalized folks before they even come to us means we won't be playing catch-up, that we may be actually able to provide what's needed.

GMC: What are some things you recommend people ask when they are looking for a provider?

AH: Know that you can bring an advocate with you, which may look like someone being at the appointment with you, or it might just be someone strategizing with you before the appointment, helping you assess what is important to you or a deal-breaker for you, thinking through these ahead of time. Know that you get to ask your provider questions and the provider should answer them. It's totally reasonable to ask your provider if they've worked with queer people and how extensive is that experience. What has happened when there is conflict or disagreement about care practices and how have these been resolved? You get to ask me details about how the care works. Do I know appropriate childbirth education classes or communities? What will I do if we have to transport to the hospital? Do I know the hospital that will be the most queer competent? What are the options for the role of the non-gestational parent? Some providers have clients or patients who have agreed to give feedback, so ask if the provider has any patients who are available for that.

GMC: Alex, thanks for the deep conversation! If folks are interested in learning more about Alex and her practice, you can reach her through her website www.fiddleheadmidwifery.com