This Week in Abortion: Stepping on Our Own Feet, Tuberville, and EMTALA case prep

A collection of good reads, events from the week, and policy insights.

Welcome back to This Week in Abortion - Your weekly substack roundup of good reads, news updates, and policy insights on abortion.

This week, I’m very excited to bring you the second feature piece from Sharita R. Thomas (MPP), “Stepping on Our Own Feet,” which argues that traditional funder paradigms hinder birth equity. But first, I’m sharing some info on the Supreme Court oral arguments next week and highlights from the news. 

Getting Ready for the Supreme Court 

The Supreme Court is hearing the EMTALA case next week. Here are a few primers: 

• What’s EMTALA and what is the controversy?

• What exactly is the Supreme Court considering? 

• I’m pretending to clean my house, can you give me some video, preferably from local news and with a guest who might have gotten into a fight right before taping? Sure! (Look at his right arm and hand.)

• What about some audio with a classic NYC accent? Definitely  

• Most commentators see this as a pretty simple issue that shakes out in favor of access, what are the anti-access people saying? (ADF represents Idaho in this case)

• Can I listen next to the arguments on Wednesday? Yes

Top Abortion Updates

• 👎 Senator Tuberville is back. This week, he filed a bill that would require the Dept. of Veterans Affairs to provide detailed quarterly reports on any abortions it performs. His bill is part of a wider effort to eliminate the privacy of individuals who get abortions, as explained by Jessica Valenti. 

• 👎 According to Julie O'Donoghue, Louisiana legislators are moving on legislation to triple the amount of money going to anti-access pregnancy centers (from $1 to $3 million) and - at least in some good news  - are moving away from using the federally funded TANF program as a source for that funding.

• 👍 According to rules published on Monday under the 2022 Pregnant Workers Fairness Act, covered employers ( employers with 15 or more employees, unions, employment agencies, and the Federal Government) must give pregnant employees time off for an abortion. Though it requires disclosure of private information, this could be very meaningful in states where abortions are banned. The rule is controversial so I’d count on it being challenged in court or changed if and when an anti-access administration moves in.

• 👍 Arizona legislators approved an exception to their rules, which, Gloria Rebecca Gomez reports, will buy them more time to consider a repeal of the 1864 law that will ban all abortions in the state starting in June. While the deadline looms, the politics are getting tense for Republicans.

Stepping on Our Own Feet: How Traditional Funder Paradigms Hinder Birth Equity

Sharita R. Thomas is a Ph.D. candidate in health policy and management at UNC, focusing on health inequity. She is also working on her Birth and Postpartum Doula Certification. Check out her layperson’s intro to the practice of systems thinking, published last November. 

Thomas and her partners are presenting their work at the 2024 Mom and Baby Action Network Summit in Chicago on June 10th.  You can also email them if you are a relevant group interested in small tutorials or teaching sessions.

Since at least 2011, Black birthing individuals have faced up to four times the maternal death rate of their white counterparts. Last November, in Brooklyn, New York, 30-year-old Christine Fields, a Black woman, lost her life due to a hospital’s egregious error. Fields' death has once again put a spotlight on the systemic disparities in maternal and child health (MCH). The increased media scrutiny of these inequitable outcomes has catalyzed a surge in resources directed toward MCH initiatives.

Diverse groups of funders, from private entities to public bodies, allocate resources to MCH initiatives that they feel they can best support. While funders may vary in the initiatives they choose to fund, they all want to have an impact. In a project supported by the Pritzker Children’s Initiative and managed by the Association of Maternal & Child Health Programs (AMCHP), I collaborated with a team to employ Systems Thinking  (ST) methodologies to dissect and understand the funding mechanisms underpinning MCH initiatives. The team included Kristen Hassmiller Lich (PhD), Vijaya Hogan, (DrPH), Jess Simon (MSW), and Hiba Fatima (MS). Our efforts brought to light a fundamental disconnect: While the intention to foster meaningful change is genuine, the conventional funding models fall short of addressing the root causes of inequity in MCH. In other words, investors in MCH are stepping on their own feet. 

Identifying the Problem

Since the issues of MCH involve complex systems, consisting of interdependent elements, my team first created a visual representation of the factors and conditions necessary for MCH birthing equity. This helped lay a foundation to categorize data and to facilitate conversation with participants. Using ST methods, we then collected perspectives and experiences of the barriers to birth equity from actors of 39 different MCH-related organizations to produce a Birth Equity Iceberg Model.  Our aim was to distill complex systemic issues into understandable and actionable insights. The Birth Equity Iceberg serves as a visual representation of the underlying structures, mental models, and assumptions that perpetuate inequities, thereby providing a foundational framework for our subsequent actions.

The iceberg model is a useful tool on its own. The model helps distinguish the events that we experience as individuals from the underlying systems and behaviors that lead to those events happening again and again across many thousands of people. To continue the water theme, the whole point of systems thinking is to push problem-solving beyond plugging immediate holes, and towards building a better boat. In our model, we see that merely increasing the total MCH funding available does not rectify persistent disparities in infant and maternal mortality. The boat might look bigger, but fundamentally it’s still a sinking ship.

Mapping the Solutions

Once we had a view of the underlying problems, we then crafted the Birth Equity Action Map. The map's development was a collaborative endeavor, fueled by rich discussions and collective intelligence of participants from those same 39 organizations across our virtual workshops. 

These sessions were not just meetings but incubators for innovation, where diverse actors from the birth equity spectrum shared their successes, resources, and needs. This collaborative process allowed us to capture a wide range of perspectives which we translated into a strategic map that connects needed actions with the best situated actors. 

The Birth Equity Action Map helps actors identify leverage points and specific actions critical to overcoming barriers to birth equity. I encourage readers to explore the map for themselves. The green circles represent meaningful actions that came to light through our conversations and information on some of our partners like Black Mamas Matter Alliance. 

Funding Birth Equity

The map can be a lot to digest when you first get into it. But, we chose this tool because it allows users to go from the forest to the trees and back again. Looking specifically at large private funders  (click the orange circle with “Private Funders” and then the “Focus” button on the side) you will see a set of actions that private funders are best positioned to take within the equity ecosystem. These actions fall under larger themes of restructuring institutions, expanding workforce capacity, leveraging collaboration, transforming paradigms through communication initiatives, improving coordinated care, and shifting funding structures. 

One thing you will not see in the set of actions is “fund research.” In fact, there is only one research-related action item that we suggested in our map and it is aimed at those actively conducting research. In prior years, we needed research to describe the problem, so that the world could understand that it was there and be moved to act. But our engagement made it clear that today, the important players understand that there is a problem. The world does not need to be convinced in the way it previously did.

Yet, according to our literature review and workshop sessions, research aimed at proving there is a problem is still where a significant portion of private funding in the space is going. A pivotal insight from the Birth Equity Action Map is the realization that funders, in striving for impact, have ironically stepped on their own feet, misallocating resources by awarding research grants that do not directly lead to measurable and sustainable change in MCH equity. We also found that funders favor programs that link pregnant people to social services. However, in at least some cases the recommended social services don’t exist or there is no capacity to accept new cases. It’s like passing a ball without looking to see if there is someone there to catch it. 

For example, one supportive need we saw in literature and echoed in every participant session was affordable housing or housing grant programs. Participants in the collaborative workshops also championed the issue of supporting the capacity and holistic wellness of employees of community-based organizations to ensure they can sustain their work. 

Most of those we spoke with were looking for private funders to push the birthing system to improve operations and grow. Suggestions included facilitating meaningful data sharing and best-practice exchange among state and local actors, supplementing salaries of birth workers or community members who offer lived experience, and investing in grantee capacity.

Unfortunately, the very funding models that led private philanthropy to fund outdated research, have also led to disinvestment in these other critical areas. Thus, perhaps our most important finding was a need for improved funding policies that provide multi-year, flexible general operating support and permit more funding for indirect costs so that organizations can experiment, learn, and strategically grow their work.

We all know how important resources, especially monetary resources, are to supporting communities. Private funders largely steer the direction of MCH initiatives. However, the grantees who depend on them aren’t always able to communicate or aren’t heard on how best to utilize funds. Some grantees may even adjust their programs to meet the interest of funders, rather than the observed needs of the community.

MCH needs improved funding policies that provide multi-year, flexible general operating support and permit more funding for indirect costs so that organizations can experiment, learn, and strategically grow their work.

This revelation challenges us to confront the realities of our current investment strategies and compels us to consider a more nuanced approach to funding. Private funders can pivot from inadvertently undermining their impact by building upon the strategic actions identified in the Birth Equity Action Map. The path that we recommend today is to fund direct interventions rather than perpetuating the cycle of research divorced from action. By strategically investing, funders can ensure that their contributions lead to substantial and sustained improvements in maternal and child health equity.

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Although I swear we didn’t plan it, this feature came just in time for Black Maternal Health Week. There were so many exceptional articles I wanted to share, but I know attention is limited. So I’m only sharing one: Uncomfortable Conversations, a local Atlanta program, with host Makayla Richards covers the challenges for Black maternal health in Georgia and echoes many of the observations Thomas makes in her piece.