Tuesday, February 28, 2017

Home Birth, Hospital Birth, and the Myth of the Good Mother - Reflections from a Bad Mother

Written by Leslie McNolty

In the eyes of many, I started out in motherhood as a bad mother. I decided to birth my first child in a free-standing birth center with a midwife instead of at a hospital with a “Level 3 NICU” (as I’ve often seen advertised to pregnant women).

Things only got worse from there.

I chose to birth my next two children at home. My daughters were born in our dining room in the presence of their siblings, grandparents, and great-grandparents.

I did a lot of research about place of birth before choosing to have my babies outside of a hospital. Ultimately, I decided that I was more likely to emerge from the transformative experience of birth physically and emotionally intact if I avoided modern obstetrics practice.

But I think it’s fair to say that the popular consensus is that my choices were irresponsible at best and selfish at worst.  Irresponsible because the place of birth study that has gotten the most popular press attention is the Wax Study which purports to demonstrate a statistically significant increased risk of neonatal death in home births. And selfish because the dominant cultural narrative around motherhood is one of sacrifice. Mothers are expected to sacrifice their own interests for their children. In choosing home birth, in part to protect my own health and in pursuit of the birth experience I wanted, I flouted this sacrificial requirement of mothers.

My lecture on March 8th will explore some of the pressing ethical question that arise when women exercise autonomy in ways that resist the professional medicalization of pregnancy and birth and defy traditional gender stereotypes about maternal sacrifice:

What makes a good mother?

How are women’s choices shaped by cultural understandings of who makes a good mother and what good mothers do?

How are these cultural narratives reinforced in obstetric practice?

How should decisions about birth be made? Who should make them?

I’ll discuss how bioethics can help sort through questions like these and provide clarity in matters of life and death.

Leslie McNolty is a Program Associate at the Center for Practical Bioethics. She received B.A. degrees in Philosophy and Political Science with a Secondary Degree in Women's Studies at Kansas State University before taking her M.A. in philosophy from Rice University in Houston, TX. Currently, she is completing a doctorate in bioethics from Albany Medical College. She teaches in the philosophy department at the University of Missouri-Kansas City and in the bioethics department at the Kansas City University of Medicine and Biosciences.

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Friday, February 10, 2017

The Affordable Care Act: It will not depart the same way it entered.

By Kathy Greenlee, JD
I recently learned the Irish superstition that you should exit by the same door through which you entered. The Affordable Care Act will most likely not have that option. The door it entered is closed.
I also recently revisited the unusual circumstances that allowed the ACA to become law. In early 2010, the Democrats held a 60-vote majority in the United States Senate. Then, in August, Massachusetts Senator Ted Kennedy died. In the election for his successor, Massachusetts elected Scott Brown, a Republican. Between the November election and Scott Brown’s swearing in, the Senate approved the ACA. When Senator Brown took office, the Democrats lost their super majority. The House had already passed the law, so they quickly moved to pass the Senate bill.
Having 60 votes in the United States Senate is a big deal. The Senate rules are such that the chamber requires a supermajority – 60 votes – to cut off debate and take a bill to the floor for vote.

Law, Regulations and Money
The ACA is anchored by three things: the law, regulations and money. Currently, the Republicans have a majority but not a supermajority. They don’t have 60 votes to pull the law off the books. They do, however, have enough votes to control the money. The ACA will be made ineffective and inoperable because the funds needed to make the law work will be removed. Money supports the subsidies for qualified people who purchase insurance through the exchanges. Federal money is used to match state money for Medicaid expansion and long term care rebalancing incentives (incentives for states to purchase community rather than institutional services for long term care). It takes money to close the Medicare prescription drug plan donut hole.
The first and most active battles in Congress will focus on money. And that battle has begun. The current 2017 federal fiscal year began on October 1, 2016. But, Congress has not passed a budget for this current year. Congress intends to use the current budget to gut the provisions of the ACA that are budget related. Then, immediately thereafter, the Trump administration will present Congress with a proposed 2018 budget and Congress will begin to work that budget this summer. The ACA will likely remain on the books, but won’t be operable as a comprehensive law. The non-budgetary sections will remain but will be largely inert.
While Congress assures the money dries up, the Trump Administration can begin the process of rolling back the thousands of pages of regulations that support the implementation of the law. Repealing regulations is time and labor intensive. ACA regulation repeal will be a steady slog likely to drag on through most of 2017 and into 2018. Regulations are behemoths.

Democratic Allies Needed
As you watch events unfold, keep in mind the three anchors I mentioned earlier: the money, the regulations and the law. The Republicans in Congress and in the White House will drive the budget and the regulations. They won’t need Democratic support to do so. But, to pull the remnants of the law and to pass a new law, Senate Republicans will need to find Democratic allies to help them get the 60 votes they need to cut off debate and pass legislation. The Democrats had 60 votes when the ACA passed; the Republicans currently do not. The 60-vote door will have to be unlocked in order to make new law.
Next up: Let’s talk in more detail about an ACA budget hot topic: Medicaid.

Kathy Greenlee joined the Center’s staff as Vice President for Health Policy and Aging in November 2016 after serving the past seven years as Assistant Secretary for Aging in the U.S. Department of Health and Human Services.

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