Deconstructing my White Ladyness

Last night, I hosted a White Lady happy hour, in which 20 of us explored the relationship between our whiteness and being socialized as women.  We came together to learn more about characteristics of whiteness and those of white women specifically, so that we can more readily resist and disrupt these characteristics and the systemic oppression that flows from them.  I had a stack of books on my table that have been important to me in my journey to disrupt white supremacy as a white woman.  This is certainly not an all-inclusive list and the books are not listed in any particular order.  This is simply a list of books that have been helpful to me.  Enjoy!

Killing the Black Body: Race, Reproduction and the Meaning of Liberty, Dororthy Roberts.

This one is not in the picture because I can’t seem to keep a copy around.  It is one of those books that rarely gets returned.  Which is ok with me because this is one of the most impactful books I have read in the past 10 years.  While I knew bits and pieces of this history, I truly had no idea how much lack of consent and coercion women of color have faced in the US.  And not during ancient history, during my lifetime.  In my opinion, this book should be required reading for all white birthworkers in this country.  I think it is essential that those of us who are white understand the privilege that whiteness has afforded us in all sorts of reproductive issues. 

Between the World and Me, Ta-Nehisi Coates

This letter from the author to his 15 year old son is a tremendous read.  It truly gave me a glimpse into a culture far from my own.  I came away understanding just a little bit more about what it is like to experience life in America as a black person.

This Bridge Called my Back: Writings by Radical Women of Color, eds. Cherríe Moraga and Gloria Anzaldúa.

An amazing collection of essays by women with a variety of stories and backgrounds, highlighting the importance of the intersecting identities in all of our lives.  The book “intends to reflect an uncompromised definition of feminism by women of color in the United States.”  It does just that and, for me, challenged notions of my own feminism.  This helped me see more clearly what parts of my own personal feminism are specifically white feminism and should only be viewed in that specific context.

Birthing Justice: Black women, Pregnancy, and Childbirth eds. Julia Chinyere Oparah and Alicia D Bonaparte.

A collection of writings on birth by black women.  Authors include trailblazer who have shaped black women’s birth justice in the US such as an introduction by Shafia Monroe, an amazing chapter by Loretta Ross and an enlightening discussion with Jennie Joseph on her successful model of care in Florida.

Undivided Rights: Women of Color Organize for Reproductive Justice, Jael Silliman, Marlene Gerber Fried, Loretta Ross, and Elena R. Gutiérrez.

This book opened my eyes to a wide history of reproductive justice that I had only known snippets of before reading.  It is dense, but absolutely filled with critical information on reproductive justice from a non-white perspective.  I particularly enjoyed reading about COLOR, the Colorado Organization for Latina Opportunity and Reproductive Rights, the org that has been Elephant Circle’s fiscal sponsor since 2009. 

Trauma Stewardship, Laura van Dernoot Lipsky. 

Anyone who encounters trauma in life or work – their own or others – should read this book.  It is a practical guide to recognizing trauma responses in ourselves and others with ideas for appropriate responses.  I have found Trauma Stewardship to be essential to the resilience and sustainability of my work in the past years.  It is a particularly good tool for those of us exposed to secondary trauma regularly.

Mastering Respectful Confrontation, Joe Weston.

The name says it all.  I can’t recommend this book enough - particularly to those of us socialized as white women.  We have learned to avoid and assuage discomfort and to have fear of open conflict.  That can lead us to be passive aggressive to gain power.  The tools in this book more much more effective and empowering!

Colonize This! Young Women of Color on Today’s Feminism, eds. Daisy Hernandez and Bushra Rehman.

I first read this book a number of years ago and it blew my mind.  I had never (!) really considered the role of colonialism on white culture in the US and this book changed all that.  Once I started to make connections between settler colonialization and the way that white supremacy functions today, I was more effective in recognizing and disrupting systemic oppressions. 

Towards Collective Liberation: Anti-racist Organizing, Feminist Praxis and Movement Building Strategy, Chris Crass.

This book promises to speak to “activists engaging with dynamic questions of how to create and support effective movements for visionary systemic change.”  It doesn’t disappoint!  Chris Crass is a longtime white organizer who has spent his lifetime considering movement building with white folks.  His words are inspiring, concrete and practical.

Racing to Justice: Transforming our Conceptions of Self and Other to Build an Inclusive Society, john a. powell.

john a. powell is a professor at Berkeley and holds the Robert D. Haas Chancellors’ Chair in Equity and Inclusion.  He is a tremendous thinker, speaker and writer and this series of essays is brilliant and eye-opening.  It has been called “Essential reading for everyone implicated by race in America – and that means everyone.”  I agree!  My personal copy is dogeared and well-loved from the many times I refer to Dr. powell’s words.

The New Jim Crow: Mass Incarceration in the Age of Colorblindness, Michelle Alexander.

If you don’t know much about mass incarceration in this country and the role racism plays in its development and persistence, this book is a must read.  It lays out, in startlingly straightforward fashion, how incarceration was designed to function as legal slavery in this country.  It also addresses the idea of colorblindness and the harms it propagates and amplifies.  Very hard read and unbelievably dense, but the information is extremely important and worth the time and energy.

Towards the “Other America:” Anti-racist Resources for white People Taking Action for Black Lives Matter, Chris Crass.

By the same author as the book above, this book explicitly deals with how white folks can seek genuine solidarity with the Black Lives Matter movement.  It is a series of essays about real people who are engaged in real action, including information about participating in anti-racist organizing for families with kids.  It is inspiring and left me feeling like my voice is important and all I need to do to lean into action is to (simply) lean into action.

Lies My Teacher Told Me: Everything Your American History Textbook Got Wrong, James W. Loewen.

This book is one of those WOW books.  Nearly every page is filled with the sense that history, as we were and are taught in school, was misrepresented.  I was looking to re-learn the whitewashed history I know I learned, but was unprepared for such a critical examination of the making of history textbooks and the resulting implications on what students learn.  It was eye-opening and a great read for parents with kids learning history in school.  It has helped me help my kids as questions about what they are learning – to question the roles of hero and victim in all the stories they read in their history books. 

What books have inspired you lately?

The Politics of Defining Gender and Sex

Gender. Sex. By the time you’re two you think you have a pretty good idea what those things are. But it turns out we generally have a very rudimentary understanding at best. Many have attempted to define the difference between gender and sex, and it’s worth looking into.  But for the purposes of this blog I want to focus on two things, first, that the definitions of both are not clear-cut, and second that defining gender and sex are political.

I recently finished reading Hermaphrodites and the Medical Invention of Sex by Alice Domurat Dreger. In seven chapters the author describes a specific historical moment and how it contributed to the definition of sex. That moment is the late 19th and early 20th century, and the biomedical treatment of hermaphrodites in France and Britain during that time. I find this history particularly interesting as it follows the foundation of modern obstetrics and the subsequent architecture of Western maternity care that we live with today.

Indeed, the boundaries of gender and sex have been a hot topic in the midwifery world recently. When the Midwives Alliance adapted its Core Competencies document to be more gender neutral in 2014-2015 some midwives protested, others responded in support, and even Snopes had to weigh in on the drama.

Gender has also been in the forefront nationally with the presidential campaign and its surrounding gender issues, the protest of hundreds of thousands of people at the Women’s Marches worldwide, and the recent Trump Administration reversal of federal policy on the use of gendered bathrooms in schools.

The Medical Invention of Sex suggests that these overlapping issues at the forefront today are no accident, and in fact, can be traced back to the late 19th and early 20th century. Indeed, can be traced back to the way that various white, male doctors, including obstetricians handled what Dreger calls “social challenges to sex borders.” Those doctors created a binary system of sex, not because that is what the evidence pointed to, but to “restore order in the laboratory, in the surgical clinic, in marital beds, in military barracks, on the streets.” 

Dreger suggests that for medical men of the era to admit what they were finding (that there were indeed people who did not fit neatly into categories of male or female in terms of both how they acted and what their bodies were like) would have added to the contemporary threat of people like “feminists and homosexuals.” So instead of a world that could make sense of and include feminists and homosexuals, the medicine men of this era invented a scientific basis for binary sex that would help keep them at bay.

As demonstrated by the backlash to gender-neutral core competencies for midwives, some people calling themselves feminists have fallen for the allure of this tidy system. They reason that childbirth is exclusive to women and that encroachment into that sex border is a fundamental threat. But the historical and scientific reality is not so tidy.

Binary notions of gender and sex were not designed by or for “women.” They certainly were not designed by or for those women, like the one introduced in the prologue to Dreger’s book who was told by a Belgian doctor in 1886, “But my god woman you are a man!”  In fact, binary notions of gender were designed by the same doctors who had women give birth in the lithotomy position and who considered midwives inherently (biologically?) inferior. 

It’s worth emphasizing that this binary does not really exist. Major mainstream publications now recognize this. Take for instance the January 2017 issue of National Geographic magazine devoted to gender.  And the Time News article entitled “Gender Laws Are at Odds With Science,” by California Superior Court Judge Noel Wise. In response to the spate of “bathroom bills” and other legal efforts to define binary sex he states:

If modern science recognizes that sex has countless natural permutations, and if birth certificates, physical observation and even chromosomal testing cannot reliably categorize every individual as either male or female, then our judiciary cannot be required to make gender findings antithetical to that reality.

Indeed, feminists, homosexuals, midwives, and those who love them should resist the notion of binary sex not only because it is inaccurate and “inconsistent with science and incongruous with the historic and modern understanding of sex throughout many regions of the world,” but because it is being used as a tool to limit us, to keep us in boxes, and serve political and religious motives that do not have our best interests at heart. In fact, it is used as a tool to determine that we can’t define ourselves.

Human diversity is real. Defining that diversity is political.  Honoring diversity as experienced by those whose definitions of themselves have not been seen, read, heard or honored is essential.

Words

It is my turn to write a blog post this week and I had a cannabis post (mostly) ready, but I just didn’t feel inspired.

I did, however, wake up this morning thinking about language and words, so, in an unusual spur of the moment decision, I am going to write about words instead. 

I have always adored words.  As a kid I devoured books and I loved the words as much as the stories.  When I heard a word that felt nice in my mouth, I would use it as much as possible.  Once, I read a book about a neonatologist, and I told everyone that was what I wanted to be when I grew up – mostly so that I could say that word over and over because it felt magical in my mouth. (And, confession time…..I also very much appreciated the way big words impressed grownups…)

Here are 5 words I have been wrestling with or thinking about in the past few weeks. What words or phrases have you been working with lately?

White privilege/white supremacy:

I am learning to talk about race and whiteness and these words have been two I have journeyed with for a while now.  I like the punch of white privilege – it reminds us of the unearned benefits of whiteness – but I know that for some, it feels incongruent with their experience.  I use white supremacy as often as I can – I like that it is a bit startling and that it can sometimes create room for a conversation -  about how this word does not only mean folks in white hats, but it is the culture white folks learned and were raised in.  We are supreme.  To unlearn this, I must face this.  I use the word, even when it feels scary or hard, because it pushes me along this journey of unlearning my own white supremacy.

Ladies:

Never been a big favorite of mine.  I have tried to be a lady a number of times throughout my life.  It is not a very good fit for me.  I bristle when, in an order to be more personable, someone calls a group of us “ladies.”  I know that this is an attempt at familiarity (think restaurant servers) and we learn it early in our lives (“Ladies and Gentlemen!”), but genderizing folks is actually creates distance for many of us.  Moreover, it reinforces the idea that biologic sex and gender are binary, which we know they are not (see here and here).  But I digress…..despite my ambivalence about the word lady, I was raised as and to be a white woman.  So, again, in my journey to disrupt white supremacy, I must look deeply and reckon with the white lady inside me.  Even if some days she feels like an imposter.

Illegal immigrants:

I have been teaching myself more about immigration in the US and the communities we call “illegal immigrants.”  Before I continue and just for clarity - I do not care for this term.  Saying someone is working illegally or living here illegally is preferable to me.  And I really object to the term "illegals" as a noun.  I do not believe people, in and of themselves, are ever illegal.  Even if they participate in illegal activities. 

I have learned a tremendous amount about this community but want to highlight just one -  the idea that these undocumented immigrants do not pay taxes.  This simply is not true. The US government estimates that at least half of undocumented immigrants pay income tax, and analysts told VICE News the population will contribute at least $12 billion to the federal government this year, and at least $10.6 billion to state and local governments via income and payroll taxes (see more here.).  Undocumented workers pay their part despite the fact that they are explicitly banned from taxpayer-funded programs such as Social Security, Medicare, welfare, and food stamps. Undocumented immigrants contributed about $12 billion to the Social Security Trust Fund in 2010, according to the Social Security Administration. 

Transgender:

This term is in the press regularly lately, but one recent story caught my eye.  Mack Beggs, the transgender wrestler forced to wrestle girls because girl is listed on his birth certificate, was booed as he entered the arena for the final match (see more here).  This expression of hate didn’t surprise me, but what lies underneath it scares me a lot. Texas’ regulating wrestling agency won’t allow Mack to wrestle his peers and then we, the sports viewing public, criticize him and surround him with hate for not wrestling his peers.  Mack Beggs asked to wrestle boys and would like to because he identifies as “a guy,” but Texas won’t let him because he doesn’t exist in their legal books.  And then when he does exist, and he WINS, we want him to choose to go away.  To decide on his own to stop competing to address the discomfort we created for ourselves.  Just like with bathroom bills, what we are really doing is creating an environment that attempts to make it nearly impossible for trans folks to exist in the public arena.  In the most horrific example of this erasure, there have already been EIGHT transgender people murdered in 2017.  #saytheirnames: Mesha Caldwell, Jamie Lee Wounded Arrow, JoJo Striker, Jaquarrius Holland (Brown), KeKe Collier, Chyna Gibson, Ciara McElveen, Sean Ryan Hake.

Resilience:

This could be an entire blog post.  One of my favorite definitions of resilience is “the decision to bounce back and try again” and this has been on my mind regularly and especially since last November.  What does resilience mean to you?  What role does intentionality play for you?

Colorado Laws Related to Pregnancy and Substance Use

The Colorado Children’s Code defines abuse and neglect for the purposes of reports and findings at Colorado Revised Statutes 19-1-103 and 19-3-102 respectively.  The definition of abuse and neglect that occurs at 19-1-103 (VII) and 19-3-102(1)(g) means that if a baby tests positive for one of these substances at birth that baby is abused and neglected regardless of the health of that child or the care of their parent:

Any case in which a child tests positive at birth for either a schedule I controlled substance, as defined in section 18-18-203, C.R.S., or a schedule II controlled substance, as defined in section 18-18-204, C.R.S., unless the child tests positive for a schedule II controlled substance as a result of the mother's lawful intake of such substance as prescribed.

A child can also be adjudicated as “neglected or dependent” under 19-3-102(c) if “the child’s environment is injurious to his or her welfare,” this is the provision that is often used to establish abuse and neglect related to substance use, including non-scheduled substances like alcohol, or post-birth exposure as through breastfeeding

Pregnant people in Colorado are protected from the use of drug and alcohol screenings done during prenatal care in criminal proceedings under Colorado Revised Statute 13-25-136, which states:

A court shall not admit in a criminal proceeding information relating to substance use not otherwise required to be reported pursuant to section 19-3-304, C.R.S., obtained as part of a screening or test performed to determine pregnancy or to provide prenatal care for a pregnant woman.  This section shall not be interpreted to prohibit prosecution of any claim or action related to such substance use based on evidence obtained through methods other than the screening or testing described in this section.

But this protection does not extend to child welfare or custody matters, it doesn’t prohibit the use of evidence to prosecute a pregnant person for substance use if the evidence was obtained by other means, and it doesn’t address breastfeeding.

Breastfeeding in Colorado is protected by Colorado Revised Statute 25-6-302, which provides that, “A mother may breast-feed in any place she has a right to be,” but I am not aware of this law being used to protect a breastfeeding parent in a child welfare or criminal case.  The Workplace Accommodations for Nursing Mothers Act, Colorado Revised Statutes 8-13.5-101-105 established standards for employers, but does not extend breastfeeding protection or accommodation beyond the employment context.

Further, the Children’s Code at section 19-3-304 requires that certain people including doctors and nurses report suspected abuse or neglect:

 (1) (a) Except as otherwise provided by section 19-3-307, section 25-1-122 (4) (d), C.R.S., and paragraph (b) of this subsection (1), any person specified in subsection (2) of this section who has reasonable cause to know or suspect that a child has been subjected to abuse or neglect or who has observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect shall immediately upon receiving such information report or cause a report to be made of such fact to the county department, the local law enforcement agency, or through the child abuse reporting hotline system as set forth in section 26-5-111, C.R.S.

Since “circumstances or conditions that would reasonably result in abuse or neglect” under the definition of 19-1-103 (VII) and 19-3-102(1)(g) include a pregnant person’s substance use, health care providers are often in the position of providing care and participating in investigation of pregnant people.

Providers are not obligated by law to tell their patients when they are simultaneously providing care and participating in an investigation.  Ethical guidelines provided by the American Medical Association (which clearly prioritize the clinical relationship and constrain the amount providers must share with authorities) have so far been insufficient to clarify or establish patient protection. AMA Code of Medical Ethics Opinion 2.02 – Physicians’ Obligations in Preventing, Identifying, and Treating Violence and Abuse states:

 …physicians should only disclose minimal information in order to safeguard patients’ privacy. Moreover, if available evidence suggests that mandatory reporting requirements are not in the best interests of patients, physicians should advocate for changes in such laws.

Federal legislation establishes data collection, standards and reporting requirements related to funds for child welfare services, through the Child Abuse Prevention and Treatment Act known as CAPTA (42 US Code 67), and the Comprehensive Addition and Recovery Act of 2016 known as CARA (42 US Code 67, Subchapter 1). 

CAPTA is clear that the federal government wants to know about and track infants affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a Fetal Alcohol Spectrum Disorder. CAPTA also wants health care providers to report such cases but, “such notification shall not be construed to— (I) establish a definition under Federal law of what constitutes child abuse or neglect; or (II) require prosecution for any illegal action.”

CARA replaces the term “illegal substance use” with “substance use,” to account for things like alcohol and wants states to have substance use disorder treatment available not just for infants but also their family.

Federal statutes establish a baseline for states. The federal parameters do not exceed those established under Colorado law. Currently, legislative and regulatory efforts are underway to ensure Colorado meets the federal requirements, to better collect data about substance use in child welfare cases in Colorado, and to refine the definition of abuse and neglect as it relates to babies who may have been exposed to substances in utero.

Other states vary, but will also meet federal requirements, and will have many of the same components described above, with laws related to pregnancy and substance use including criminal, civil child welfare, custody, and mandatory reporting.  

My thoughts on the National Academy of Sciences recent report: The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research

The National Academy of Sciences (NAS) is a non-profit, independent organization of scholars.  Their reviews are generally good, rigorous and thorough and this is no exception.

If I simply reviewed 10,000 abstracts, I would generally agree with their interpretation of the literature.  However, having followed this body of literature for more than 10 years, this is my analysis of the findings that made headlines.

Read the report here

Reviewed 10,000 abstracts

Abstracts are advertisements, they represent what the authors want you to take away from their data.  An evaluation of auto safety by looking through advertisements is not as good as seeing and evaluating the cars themselves.  In my experience, much of the marijuana research here in the US is funded by the National Institute of Drug Abuse and that perspective is often seen in how the data are represented in the abstract.

In addition, this review is not evaluating 10,000 separate and distinct studies as many of the 10,000 abstracts come from three longitudinal studies. These studies, by their authors own admission, are limited by the confounders of tobacco use, race and poverty. The report itself mentions this limitation to the body of evidence they reviewed.

“Substantial evidence for low birth weight”

Low birth weight (LBW) is particularly affected by these variables – a point that has been documented in recent independent reviews of the marijuana literature (see S. Conner et al., AmJObGyn, 2016 and Leemaqz et al., Repro.Tox, 2016). These reviews found that when tobacco use is accounted for, marijuana is not an independent risk factor for LBW (SGA). In my opinion, the substantial risk cited in this report is more attributable to cigarette smoking than marijuana use alone.    

I certainly know stories of folks who smoked marijuana prenatally and had LBW babies.  But generally they were heavy users (daily or more) and/or they had another risk factor for LBW, suggesting that marijuana is part of a risk analysis for LBW, but should not be considered the only element. 

But if you simply read the abstracts, you would indeed come to this conclusion.

“Some evidence for NICU admission”

I struggle with NICU admission as a birth outcome data point.  This is, in part, a result of my 25 years of clinical research experience and how I see newborns handled after birth in hospitals with NICUs.  Unfortunately, NICU admission is clinical parameter that is very dependent on individual practitioners and is not well standardized.  Policies for NICU admission vary across hospitals and providers and, in my experience are also multi-factorial. 

If a LBW baby is born, they will most likely end up in the NICU for observation, even if nothing is wrong.  Does that NICU admission reflect the harm of marijuana or reflect the way the system works?  Further, I have heard stories of babies being observed in the NICU because their parent refused a drug screen upon admission to the hospital in labor.  While some of those babies indeed had been exposed to marijuana prenatally, their NICU admission reflects medical concern, not health outcomes. 

Finally, because I am a physiology junkie, I know that NICU admissions are sometimes the result of a deviation from physiologic, mammalian birth. When a just born human mammal is separated from their caregivers, they decompensate physiologically. Their heartrate increases, their adrenal response spikes, their oxygen saturation decreases (increasing their respiratory rate) and they are less able to regulate their temperature.  In my experience, when you add the layer of suspected substance use, you begin a cycle that can increase NICU admissions.

I hear this story regularly: a baby is suspected of being exposed to marijuana so they are removed to the warmer for immediate evaluation. While some babies’ physiology is resilient enough to maintain their vitals in this state, some mammals really do require immediate extragestation after birth to maintain their physiology. So the baby who needs extragestation decompensates because of the separation, presents with abnormal vitals and heads to the NICU. What is the underlying cause of this NICU admission?

Biologic outcomes related to marijuana use that require an increased level of health care or is this an indication that the system response to suspected or confirmed substance use ITSELF increases NICU admissions? In a post-liberalization climate of Colorado, we must pay very close attention to the bias inherent in our health care systems so that we do not create harm to families.

The schizophrenia element

I have done some research on this relationship over the years because I am asked about the impact of marijuana on schizophrenia regularly.  I do believe that marijuana use – particularly regular use – can impact mental health in positive and negative ways.  With respect to schizophrenia specifically, my understanding is that schizophrenia is usually associated with a reduced endocannabinoid system.  Since schizophrenia is quite genetically linked, marijuana use might very well (and indeed does) run in those families. The comment by NAS that they didn’t account for genetics is good truth-telling and allows us to interpret their data accordingly.  I would think there is a possibility that folks with a history or increased risk of schizophrenia might be more likely to self-medicate with marijuana.  My reading of the literature does not support that the use of marijuana increases schizophrenic symptoms per se because I do not know if people with increased symptoms are more likely to use marijuana or if increased use increases symptoms.

The problem of the null hypothesis

What doesn’t make news are the non-significant findings and there were some biggies in this review.  Two of the questions I am asked most regularly is whether prenatal marijuana use increases the rate of SIDS and/or decreases academic performance in adolescents.  The NAS literature review found there was “insufficient evidence to support or refute a statistical association between maternal cannabis smoking and later outcomes in the offspring (e.g., SIDS, cognition/academic achievement, and later substance use).”  

This received little to no media coverage and is a clear example of the bias against the null hypothesis.  We humans love to demonstrate differences because we struggle to explain similarities.  But in this case, the lack of findings are important and should be noted by the press and health care providers.  I do not believe that this report will change many minds that already believe that prenatal cannabis use increases SIDS or decreases academic performance.

{PSA: To be clear, I don’t think developing teenage brains should use marijuana and that THAT DOES cause problems for some.  And poverty also increases risks for these outcomes.  But the perception that prenatal use affects adolescent behavior is very strong and currently accepted as truth among health care providers and policy makers.  At least in Colorado.}

In sum, this report makes clear the danger of reading just abstracts to interpret a body of literature.  It also highlights our inherent bias against the null hypothesis, which makes changing minds and policies very difficult.  My hope is that future policies and reports are built on a deeper reading of the literature.

An Intro to Systemic Racism

This simple and accessible video series on systemic racism by Race Forward looks at race-based disparities in the areas of wealth, employment, housing, government surveillance and incarceration in one about one minute each. 

Each short video points out how disparities exist along racial lines in that area. Taken together you can start to see that when your wealth, employment, housing, level of government surveillance and likelihood of incarceration are so effected by your race it amounts to a whole set of things working together to create a race-based system.

Maternal and newborn health could easily be added to the list. While the rate is low compared to other countries, black women in the United States are four times more likely to die during childbirth than white women. Black infants are born preterm and with low birth weight twice as often as white infants.1    

These health outcomes, like wealth, employment, incarceration, also contribute to the set of things working together to create a race-based system. This system doesn’t require that individual people have racist thoughts, do or say racist things. But ignoring this race-based reality does help perpetuate it. While working to dismantle the race-basis of any of these things will help dismantle the whole system. 

Folks interested in dismantling systemic racism in maternal and newborn health can begin by learning about these disparities. That may leave nagging questions about how such disparities came about in the first place, and how they are perpetuated. That inquiry may require learning more about implicit bias and how racism is woven into the fabric of many institutions. 

For more on those issues try taking an implicit bias test, or look into how racism is being “taught” to computers being programmed for artificial intelligence. You can also follow the Standing Up for Racial Justice  (SURJ) political education guide. Just begin!   

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1.  Hamilton BE, Martin JA, Osterman MJK et al. Births: Final data for 2014. Natl Vital Stat Rep. (2015);64(12). Center for Disease Control and Prevention. Pregnancy Mortality Surveillance System, (Dec. 13, 2016), https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.

Also see our publication, “Racial Disparities in Birth Outcomes and Racial Discrimination as an Independent Risk Factor Affecting Maternal, Infant, and Child Health” 

My Take On It: What I learned from Thomas Hale, R.Ph., Ph.D.

Background

Dr Hale is a professor of pediatrics and associate dean of research at Texas Tech University Health Sciences Center, acting executive director of the InfantRisk Center and author of the bestselling reference book “Medications in Mother’s Milk.”  He is considered one of the foremost experts in the field of perinatal pharmacology and the use of medications by pregnant and breastfeeding mothers. 

In the late fall of 2016, Dr. Hale and his colleague Dr. Teresa Baker received IRB approval for their research study on the transfer of marijuana into human milk specifically examining the kinetics of delta-9-tetrahydrocannabinol (THC) in breastmilk.  In other words, their study seeks to answer the question: How long does the primary psychoactive metabolite found in marijuana (THC) remain in breastmilk after a known quantity of cannabis flower is smoked?

Good research includes community feedback during the planning process and Elephant Circle has enjoyed being involved in the strategic and execution stages of this study.  Both Dr. Hale and Dr. Baker have been extraordinarily responsive to feedback and thoughtful about many elements of the study.  For example, the original study design had breastfeeding parents collect milk for 24 hours, but given further discussion about how hard this could be on breastfeeding parents, the protocol was changed to a collection time of only 6 hours.

Even more importantly, Drs. Hale and Baker listened carefully to concerns about how subjects could participate without risking a visit from Child Protective Services.  They created a protocol that allows breastfeeding parents to participate with complete anonymity and confidentiality.  This was essential to Elephant Circle’s continued involvement, and we are pleased with how the study has been structured to protect subjects.  

The reason for the lecture in Denver

The study is currently in the subject recruitment phase and so Drs. Hale and Baker came to Denver to talk about what is already known about marijuana use during both pregnancy and breastfeeding.  They presented a good summary of the known literature, highlighted there is almost no good research on marijuana use and breastfeeding and answered some critical questions from the audience.  I have summarized what, in my opinion, were the most important concepts found in their talk.

Major concepts from the lecture

1. Cannabis is not concentrated in breastmilk.

The single study that prompted this idea had only two subjects who consumed marijuana 1x and 8x per day respectively, fitting the definition of heavy users.  According to Dr. Hale, the data are “worthless” because there was no attempt to account for previous cannabis use or quantify the amount or timing of the cannabis consumed before the analysis.  In addition, the concept that THC is concentrated in breastmilk isn’t supported by what is known about the physiology of human lactation and human cannabis metabolism. 

·      THC and its metabolites (11-OH-THC and THC-COOH) are cleared quickly from human plasma (when smoked, generally less than 60 minutes – see the graph at the bottom of this post) and are initially redistributed to highly vascular tissues (lung, heart, liver), with 1% initially distributed to the brain 1,2.  Subsequently, the metabolites are distributed to more fatty tissues, primarily adipose tissue, where they are completely metabolized to THC-COOH, the inactive metabolite 1,2.  The fat/brain ratio is 21:1 after 7 days of exposure and 64:1 after 27 days of exposure, highlighting that adipose tissue is the primary long-term repository for the inactive metabolite (THC-COOH) 1,2. 

·      Breastmilk content reflects plasma content in real-time 3.  This suggests that THC is cleared from breastmilk in the same timeframe as THC is cleared from the bloodstream and THC might be difficult to detect in breastmilk an hour after smoking.

·      There is no obvious mechanism by which THC would increase in the breastmilk after it has been cleared from the bloodstream.

·      Any long-term storage of marijuana metabolites that might occur in breast tissue (which would be very low) exist in the form THC-COOH, the inactive metabolite. 

·      Long-term detection of this inactive metabolite THC-COOH does not reflect the long-term presence of the active metabolite THC 2. 

2. Even though babies are “full of fat,” this does not increase their exposure to the psychoactive metabolite THC.

·        It is more likely that most of the inactive metabolite THC-COOH is stored in the parent’s adipose tissue, not in the adipose tissue of the baby.

·        It is important to differentiate between adipose tissue and fat cells.  Cannabis metabolites are preferentially stored in adipose tissue but not concentrated in particular fat cells (such as those found in breast tissue or breastmilk) 1,2. 

3. THC is the primary psychoactive molecule in cannabis and it is quickly converted into 11-OH-THC and then into the inactive metabolite THC-COOH.

·      THC-COOH is the molecule used in detection but it is inactive, meaning that it does not create a “high.”

·        Babies might be exposed to the psychoactive THC molecule in breastmilk in the first hour(s) after smoking, but they are not exposed to THC long-term.  Any active THC they consume through breastmilk is most likely quickly converted into inactive THC-COOH. 

·        Even if small amounts are stored in babies’ adipose tissue, they are slowly metabolized and excreted through the urine.  This baby is not stoned during this metabolism as the inactive metabolite is inactive.

4. There is substantial evidence to suggest that endocannabinoids (the cannabinoids that exist in the body already) drive critical elements of blastocyst implantation and exposure to cannabinoids from outside the body (like THC) may increase the risk of miscarriage 4.

References

1.        Huestis MA. Chem Biodivers. 2007.

2.        Sharma P et al. Iran J Psychiatry. 2012.

3.        Riordin J. Breastfeeding and Human Lactation. 2005..

4.        Fonseca BM et al. Int J Endocrinol. 2013.

Practice Poetry

“Poetry is the way we help give name to the nameless so it can be thought. The farthest horizons of our hopes and fears are cobbled by our poems, carved from the rock experiences of our daily lives.” – Audre Lorde, Poetry is Not a Luxury

This week millions all over the world took to the street together to stand shoulder to shoulder in solidarity at the #WomensMarch. I was among them, and struck by the multiple, organic reasons so many of us were motivated to be there.  Reflected in creative signs, posters, t-shirts and chants, we were clearly not gathered for one reason, but for many. Even those who were not there contributed to the whole with their deliberate absence, or their contribution to someone else’s presence.

Some critics think this indicates a lack of clear vision, worse, mere whining, or an inability to manifest real change. But in fact it indicates that we can and will effectively stand together despite our differences for a series of interconnected ideas, beliefs and values without a single charismatic leader, agenda, or centralized message to unite us. 

This multiplicity is the way forward.  This multiplicity is more poetry than platform.

Allow yourself to be inspired, challenged or confused. Grapple. Savor. Use not just your mind but your senses; use courage and love, take your time.

To thrive in the world today we must cultivate the ability to see, hear, witness and create this kind of poetry.

This poetry requires us each to look beyond our own stanza, phrase, line, and language, and connect to some line or language we couldn’t imagine but can believe in.

Some call this intersectionality, which is a good word. But don’t get stuck on any one word. Don’t get stuck on any one action. Be with the flow of the life force.  Hold loosely to new words to allow the creative process that we need, and that inspires your action, to unfold.

Elephant Circle is a multidisciplinary organization. We use science and deductive reasoning, we use legal argument and persuasion, we use art and imagination, empathy and solidarity. In this blog and in our work we invite you to join us in developing a multidisciplinary toolbox so we can cobble together the farthest horizons of our hopes and remedies to our fears. 

by Indra Lusero