 Okay, and now I am going to introduce our keynote speaker, Hermine Hayes Klein, who is a lawyer and an international birth rights lawyer with extensive experience advocating for the human rights of birthing people around the US and internationally. From 2007 to 2012, Hermine taught international law at the Hague University in the Netherlands, where she was also the director of the, how I hope I say this right, Ben Kershoek Institute Research Center for Reproductive Rights. Was that right? Hermine, did I say it right? Yes, you did. Great. And she, during this time, she organized six international conferences on the topic of human rights in childbirth. Since 2017, Hermine has been focused on direct legal advocacy to advance reproductive justice in maternal health care. She's represented midwives in administrative, civil, and criminal legal proceedings and advocated for their right to work with autonomy and security in many states and nations. She also advocates for birthing people who have experienced informed consent violations, research, and obstetric violence during childbirth. So I am going to make Hermine the presenter and she is- Catherine, before you do that, could you please remove that poll? It's showing up on everyone's screen. Wait a second. All right, hold on. Thank you. I'm not seeing it on mine, Lorraine. I think if people just enter, click one of the options, it goes away. That's what I did. Yes, but it will be in the recording. That's the problem, so I want to get rid of it. I don't see it on my screen. Are you seeing it over the slides, Lorraine? Yes, it was over the slides. I clicked on it and it went away, but I just want to- it's okay. We'll just live with it again. Okay. Well, let's see what happens when I make her the presenter. Make a presenter. Okay. I'm not seeing anything over the slides. Me neither. It should be okay. I think it's going to be okay. Good to go. Just go. Yeah. Okay. Well, thank you so much, Catherine, for that introduction. And thanks to the organizers of the conference for giving me this opportunity to come and have the honor of sharing an opening keynote for the Virtual International Day of the Midwife Conference. It really feels very special to come together with this global group of midwives at this moment to talk about quality of care and trauma-informed care, given especially what we, as a global community, have been going through for the last couple of years and some of the intensities that have developed in recent months. I think that a lot of people all over the world are experiencing increased fear, increased sense of alienation and division and anger. And in moments like this, the need that we all have for midwives becomes all the more clear and the power of midwives working together to perpetuate the care that you provide, again, is underscored. You know, in a time when people are feeling frightened and alone, just the power of what you offer, quality midwifery care that makes people feel held, that makes them feel supported in their most vulnerable life moments. It has the ability to sort of stand as a really effective force in the face of all the confusion and other things that people are facing around the world. So it's really an honor to come together in support of all of the good work that you all do and the power that is just part of you coming together for a conference like this. So as Catherine mentioned, I'm an attorney. I gave birth to both of my children with midwives, one midwife in particular in the Netherlands in 2007 and 2010 while I was also living there and I also taught law at The Hague. And through those experiences of giving birth in a relatively excellent maternal health care system that offered, you know, a fully covered postpartum care, for example, and a meaningful choice of where to give birth, whether at home or in a birth center or in the hospital, I came to really sort of study and look at the way that women are treated in childbirth around the world and the way that systems are constructed, in part because the Dutch birth system is so midwife-centered. Midwives are the first line of care for pregnant people, which made me really look at, well, why do we do things the way we do back in the United States and discovered then that the elimination of midwifery in the United States during the 20th century really never had much to do with the needs of pregnant women or babies any more than many of the standards of care that developed in obstetrics like putting women on their backs with their feed-in stirrups never really had much to do with what was helpful for pregnant women and the births of their babies. And so, 10 years ago, shortly before moving back from the Netherlands to America to Oregon with my family, I organized a conference. My first conference related to childbirth on the topic of human rights in childbirth, together with a group of doulas and midwives and activists called the Geburtbeveging in Holland, a group that came together to talk about the patient's rights in childbirth and how systems can be improved. And we really brought together a conference to look at childbirth through the human rights lens and to really look at the ways in which systems are succeeding or failing at fulfilling the obligations that nations hold to uphold the human rights of all people in that nation, including the people who give birth. And that lens has been very, it's been very powerful in the last decade at causing new inquiries to be made into childbirth. The World Health Organization, the United Nations, they have issued reports and investigations into the way that women are treated in childbirth, looking at issues of disrespect and abuse and the mistreatment of birthing people and even at the issues that Latin American activists have identified as obstetric violence. And bringing that rights frame is very important because it helps us to understand, to remember that human rights are non-negotiable and that when a nation makes a commitment to uphold them, they have to be protected absent extraordinary circumstances. And so that gives us a tool to really look at how are maternal health systems operating in a new and effective way. And that includes looking at the right to midwifery care, which has been violated in nations where anticompetitive obstetric behavior or the pursuit of a medical monopoly over maternal health services has led to restrictions on women's access to midwifery care has led to legal insecurity for midwives and their ability to legally and safely practice and independently practice in all settings. The security of midwives is essential to the fulfillment of birthing women's rights to access midwifery care. And maybe this is a good moment to mention that in the course of our talk today, I will talk about women and I will also sometimes talk about birthing people changeably to acknowledge that not all of the people who have uteruses and give birth identify as women and identify as trans men or as birthing people. But at the same time, I also often refer to women because women do give birth, women are among the people who give birth and many of the ways that women are treated in many nations around childbirth as a result of how they are perceived as women by the people who are treating them that way. So it's important to be able to talk about that. But if human rights has sort of offers one lens that we can use to talk about childbirth and the way that we treat women in childbirth and the ability of midwives to practice within maternal health systems, another helpful frame is that of women-centered care or patient-centered care. Because when we talk about women-centered care or patient-centered care, which has become a priority in many health systems and many hospitals talk about their commitments to patient-centered care, it gives us an opportunity to remind those within the system that what that means is that we're committed to moving away from hierarchical relationships between the care providers that are involved with the care of any given patient to relationships between the care team that really centralize the patient as the sort of, as the central agent in their care and as the person at the center of all of the relationships. And so the shift to patient-centered care and women-centered care, which have been proven to result in better outcomes just as Midwifery care does, is a shift from sort of totem pole-based care. I mean, medical institutions and systems have been developed sort of not on like, you know, little military operations, hierarchical systems or corporate operations where there are systems of command and that can result in hierarchical systems in which there's sort of a doctor and maybe there's a midwife below that and a nurse below that and the patient somehow at the bottom of this totem pole, patient-centered care re-orients all of those relationships because it allows the women to be centralized, their needs to be centralized at the heart of the conversation. Okay, it seems that at least one listener has been offended by my acknowledgement of this complexity around trans-languaging in this issue and hopefully we can all stay in the conversation despite different perspectives on that. I think that this is the most important thing is for us to be able to stay in conversation and to this point that women are mistreated because they're perceived as women or because they are women. I mean, I think that both are true. It's true that women are mistreated as women and it's also true that somebody who doesn't necessarily identify as a woman but is giving birth will be mistreated because they are perceived as a woman regardless of their identity and may face additional layers of discrimination because they are not presenting as non-binary or outside of some expected gender presentation. Those issues are real and need to be acknowledged if the human rights of all birthing patients are to be protected and I believe that we can do that without erasing the word woman from the conversation or failing to acknowledge that women are mistreated as women, indeed. So I know that this issue is controversial one but I'd still like to move forward with some of these issues of framing. Woman-centered care gives us a great opportunity to think about different ways of relating to the system but one that I think has developed in the last few years and is another powerful opportunity to ask all that are invested in maternal health systems to think about the ways that they are oriented and the ways that patients are treated is the frame of trauma-informed care. So that's an issue that I would love to discuss with you today. I'll just go to my next slide. So, you know, trauma-informed care, again, is a phrase that is coming more and more into, say, obstetric ground rounds and into healthcare conversations generally and is of tremendous importance in childbirth and maternal health care as many of you know from your direct care of patients. And so as we think about what does trauma-informed care look like in the childbirth space, it's worth pausing for a moment to ask what would be the goals of trauma-informed care? What is trauma-informed care by definition? And trauma-informed care, I mean, what does it mean to be informed around trauma in the provision of care to a patient? It must mean that there's consciousness of an acknowledgement of past trauma, and that can either mean acknowledgement of specific past trauma that is faced by any specific patient or community, but also recognizes and acknowledges that the patient may hold past trauma, that they have not disclosed to their providers, that they feel unable to discuss for whatever reason. The possibility of trauma can give rise to more sensitive care. So trauma-informed care will acknowledge past trauma, and it will also aim to prevent future trauma. Trauma-informed care does not want to add to the problem if there's a past trauma problem based on trauma, and it also is invested in the prevention of future trauma, whether or not there is an existence of past trauma. Something that is helpful to consider in this respect, an idea that was shared with me recently by a trauma counselor working with some women that were experiencing PTSD from the way that they were treated around childbirth was to explain to me that there's a movement in psychiatry, psychology, and talking about trauma from talking about it in terms of PTSD, which is a way that it has commonly been discussed in the past as post-traumatic stress disorder to PTSD or post-traumatic stress injury. And as she explained to me, I know it's helpful because when people carry trauma, they have symptoms, and those symptoms can be lasting, but that does not mean that they are disordered or broken in any permanent way. Trauma is an injury that people experience, and that injury has symptoms, just like other kinds of injuries do, but like other kinds of injury, the injury can heal. And so that's helpful, as she pointed out, it can be very empowering for people, she mentioned firefighters and others who've experienced trauma to be told that it's not, you're not broken, you're not disordered, but you did have an injury that can be acknowledged and that can be healed. But it's also helpful because it recognizes that injuries can be caused by others. Whether people do that intentionally or unintentionally, injuries can be caused, and trauma is an injury that can be imposed and is far too frequently imposed on burning women by the providers who they entrusted to care for them. So let's talk about how that could happen and how you can help prevent it in systems of care within which you work. I mean, I think that there's one of the powerful ways that all of you can contribute to trauma-informed care. Of course, it's not only the way that you relate to your clients. As midwives, you're already at the forefront of trauma-informed care because individualized care is a cornerstone of your work and informed consent is the cornerstone of your work. But you're also part of dialogues within your healthcare communities about maternal healthcare and hopefully, if you're not at the table with your government and your community systems yet, you'll push your way up there and get your voice heard because you can add the perspectives and the knowledge that will otherwise be missing from those conversations and shaping policy. And so that's, you know, in bringing these, helping to advance these conversations within your community about trauma-informed care, it sort of requires reflection, first of all, of the kind, the forms of past trauma that might affect the needs of the client that any given provider is working with at a given moment. You know, one of the values of the recognition of trauma, trauma-informed care, like we said, it recognizes the possibility of past trauma. If you recognize the possibility of past trauma, then you recognize that the way that the client is presenting around, you know, certain medical decisions or issues might be affected or shaped by that past experience that they've had in ways that they haven't had a chance to talk about or might have a difficult time articulating. You know, specifically relevant in childbirth is the prevalence of the experience of childhood sexual abuse and sexual assault for women in most nations. I mean, in the United States, the low-ball government estimate for the number of women who have experienced childhood sexual abuse and assault is a third. And, you know, it's probably much higher and it's similar or higher numbers in other nations. So understanding that is going, you know, and if there is space within the care and counter for the recognition of that possibility, then it's going to give rise to more compassion on the part of the provider, more respect for the patient's decision-making process. I mean, very important to informed consent decision-making processes is recognizing that the client has the right to make their decision on the basis of their perspective, not your perspective. And that can be difficult or frustrating for providers when the patient is making decisions that appear irrational to the provider, or if the way that the patient is behaving around the decision-making process appears irrational. But training and trauma and understanding how trauma affects behavior explains a huge amount of that and especially, you know, around encounters that involve touching of intimate parts of the body by strangers, even well-meaning strangers during the time when somebody is feeling extraordinarily vulnerable. The possibility of triggers in an encounter in all of the encounters related to childbirth is significant for anybody who's experienced past sexual abuse. But of course, you know, sexual abuse and assault are only one form of past trauma that can be affecting this encounter. There are community traumas like war and natural disaster and disease and other kinds of issues that communities face around the world as well as, you know, home insecurity, domestic insecurity, et cetera. So trauma-informed care is going to recognize the possibility that all of that is coming into the encounter. And then, you know, once you have that recognition that a trauma that many women are carrying into your childbirth encounter with them is the violation of their right to physical autonomy, their right to respect for their sexual body, then you understand how important it is that in this healthcare encounter, when they have to spread their legs for strangers to let their baby out, that their right to physical autonomy and their right to respect for their sexual body is going to be respected. So, you know, many discussions that I've heard of trauma-informed care that are presented by well-meaning medical professionals have discussed, you know, the importance of talking slowly to the woman or telling her slow why we're going to do this or that, but it's very important to understand that communication is important, is an important part of informed consent, but the most important part of informed consent is consent. And especially understanding that the level of trauma that women have experienced through the violation of consent, you understand how important it is that at this moment when they are coming in at their most vulnerable, they'll never be more vulnerable than when they're in labor and wanting so much for something beautiful to happen to be able to welcome their baby and coming in with so much hope and trust with regard to the providers when their rights to ownership of their body and respect for their body are violated, the result is more trauma. And not just more trauma, but, I mean, I heard yet from a woman today, I mean, over and over, they describe it as the most traumatic day of their lives. And I've heard a woman just, I think it was two weeks ago, explained to the head of obstetrics at a hospital where she had been subjected to a forcible vacuum extraction that she had experienced sexual assaults in the past. It was a trauma that she had carried and resolved, but that the trauma that she experienced felt much worse and more of a violation than the sexual assault that she had experienced in the past. And why? And in large part because of the vulnerability and because of the trust and the betrayal of the trust. As Catherine mentioned, I advocate for the right of informed consent and the right to freedom from discrimination to be made meaningful in maternal healthcare with policies and trainings for their protection and with accountability for their violation. And so here in the United States, what we've found is that the only meaningful way to get the hospitals to come to the table and take these claims seriously is through lawsuits, through the filing of lawsuits, because the liability risk is the only risk that they tend to consider meaningful in terms of shaping behavior and practice. And so just an example of the kinds of experiences that lead women to be diagnosed with PTSD following childbirth. And these are just ones on cases that I've worked in or I'm working on now. One involved a nurse that forced a nitrous oxide mask on my client who was a teen mom and the nurse didn't want her making noises and wanted her to be quiet and she wouldn't take the epidural and so she gassed her with nitrous oxide even though one of the most important standards of care for the administration of nitrous oxide is self-administration only. The mask only needed to be held over her face for a short amount of time for her to be permanently traumatized. The use of vacuum and forceps on women without explanation or permission, so there's a blip on the heart screen, everybody runs in, and the women are subjected to these instruments being used between their legs on them with forced violence and sometimes a panicky atmosphere and nobody explains to them why they're doing this, why they want to do this, let alone asks them for permission. That's a violation, I mean of course all of these are violations of the patient's rights. Nobody has the right to do anything to a birthing patient without looking at them in the eyes, telling them what they want to do and why, answering as many questions as they have regarding the risks and alternatives to the thing they want to do and asking the client's permission if they want to proceed with the proposed plan. But as I sometimes say in my discussions on this topic, how much would change in most labor and delivery words if it was really true to everybody in that room that nothing could be done to the birthing patient without looking her in her eyes and getting permission in the way that I just discussed, it would transform the dynamic in that room in many places and if it wouldn't transform the dynamic, if that's what really is already happening at the institution where you work, then you all should congratulate yourself and teach some others how to do that. But in most places, it would be transformative of the dynamic and the reason for that is essentially that there is a significant gap between the law of informed consent and bioethics of informed consent which says very clearly what is supposed to happen before medical decisions are made and the culture of obstetrics in which informed consent is often sort of treated as irrelevant in practice. And in case there's any confusion about whether the presence of the baby means that pregnant women or birthing people lose their constitutional and human right to physical autonomy and medical decision making, they do not. And the European Court of Human Rights has made that clear in a case of Kona Volova versus Russia. The American College of Obigynes has made that clear in statements by its ethics committees on maternal decision making and refusal of medically recommended treatment. Even if the doctor or the midwife thinks the baby is going to die as a result of the woman's decision, they must support her right to make the decision about her body throughout the birth process. And one reason why that's so important is that doctors are often wrong in thinking that the baby's about to die. The electronic fetal monitor is often wrong in predicting fetal distress. And so understanding the limitations of the provider's ability to actually predict what's going to happen again can grant a little bit more humility and more compassion in that consent process to avoid situations that result in the kinds of trauma that far too many birthing people are carrying around after childbirth. But trauma-informed care in order to be effective and make meaningful change has to recognize the trauma of all involved and how the trauma of all involved in the healthcare encounter can contribute to more trauma for all involved because the birthing patients are not the only people whose trauma and past trauma and potential future trauma are relevant to this encounter and playing out in this encounter. So, again, back to that systems perspective, as you're working with your own community system to help care to become more trauma-informed, that's got to involve a system-wide commitment to acknowledging and treating providers' own trauma injuries. And that involves, you know, as I'm sure many of you have experienced or witnessed in other providers, providers can have had themselves a frightening experience, say, with a neonatal death or some catastrophic outcome in childbirth. And with that being unresolved emotionally, they're then bringing that, their fears around that into new encounters with new patients in ways that are not entirely rational and that can cause them to be more bullying, more forceful than they would be if they had been able to really process what happened in some other patient, you know, situation and some other case. You know, burnout, exhaustion, compassion exhaustion, you know, all providers are working in stress systems the last couple years in many different ways, even if you're an independent homebirth midwife, the stress on that system has been affecting you. And so, recognizing the ways in which the stress and strain on the system, on its resources and on the providers themselves impact their ability to relate to clients in respectful ways is critical. And also constructing those patient encounters in ways that allow for the providers to be able to provide care that respects the human rights of their clients. You know, in order, as you know, as midwives, in order to give birth, mammals need to feel safe. And in order for those mammals to feel safe giving birth, the people around them need to feel safe and relaxed enough for that mammal to be able to relax herself and give birth. That fact really underscores the fact that our systems need to allow for the well-being and the mental health of everybody involved in the system. And so, you know, I mean, again, midwives, you are the global leaders in the humanization and maternal health care. The stronger you are within a system, the more humanized the care provided to birthing people is. The more woman-centered the care provided with that in that system is. The more individualized and rights-respecting it is. Through your rediscovery of how physiological birth works in the last 50 years, you have transformed what is possible and what both providers and patients within these systems understood to be possible. And you are still doing that. You are continuing to evolve maternal health care everywhere to systems that are humanized, that understand and support physiology while providing emergency obstetrics when appropriate. And, you know, one more piece of that is this trauma-informed care piece. You can and must lead on this piece. You cannot wait for the medical providers to do so because you are the leaders in understanding the holistic picture on childbirth and how the psychological well-being of that mother affects how her pregnancy goes, affects how her labor goes, affects postpartum, and affects the well-being of her families. And, you know, again, as you work within your systems to challenge some of these dysfunctions, I think it's worth reflecting on the fact, you know, often when we hear about the abuse of women, the C-section pandemic, or whatever else is going wrong within maternal health systems that abuse patients, we hear excuses that are really about system dysfunction, like, oh, well, there's a liability crisis. So that's why we have a 30-plus percent C-section rate. Or, you know, providers are, you know, resources are strained or providers are exhausted or, you know, the list goes on and I think you've all heard the list. But what's worth noticing is that what's being said here is, well, we've got, say, a liability crisis, so, therefore, that woman gets to have a surgery that she doesn't need, that quintriples her risk of dying and that quintriples her baby's risk of dying. That's not acceptable because what we're saying there, when we accept those kinds of excuses, is that it's acceptable to violate the human rights of birthing people in the face of seemingly intractable system dysfunction. But again, the human rights frame offers us the possibility to remember that human rights are non-negotiable. If we commit to respect for your ownership over your body and that you own your body in all situations, including healthcare encounters, then we have to take the violation of that human right off the table as an acceptable solution to whatever system dysfunction is present. So instead of letting the fallout of your system dysfunction always rest on the body of the birthing women, always end up increasing their risks and their trauma, we can commit to their human rights and say, given that we have committed to systems that are nonviolent, that uphold every patient's rights to be the captain of the ship and make the decisions about their care and that are non-discriminatory, then we're going to recognize that if this system dysfunction or that system dysfunction is preventing us from doing that, the only solution we have is to address the system dysfunction and end it because we're not going to accept a solution that violates the human rights of birthing women and that perpetuates that dysfunction. So women need to lead and standing up for their own rights. I know that you as midwives can't stand up for them, but they also need you to stand up with them and to help drive those system changes that make those rights a reality. So thank you all of you for your commitment to this work that you do as you do all over the world to serve your communities and offer humanized support for physiological birth and emergency obstetric services to the people who need you there. So thank you again. I'm honored to have a chance to speak with you today and I'd love to hear what y'all want to talk about. Thank you. Very important, many important concepts there. And what questions do we have for Hermine regarding her work and the thoughts she has shared with us? Celine says that it's inspiring. Marguerite, that it's powerful. Susan Rachel. Oh, shares that. The topic was the foundation of her doctoral research. So great. I have to go to another room. I appreciate you so much. Stay in the fight. Maybe I'll respond to Paolo's question here regarding obstetric violence and whether that's an issue in Latin America. I think, no, it's not only an issue in Latin America. The naming of obstetric violence came out of Latin America. I think, you know, really, in the last 10 to 15 years, activists in, let's see, Argentina, Venezuela, Mexico and other, yeah, Latin American nations came together to pass laws in different nations, naming the abuse of women during childbirth as obstetric violence and trying to create different avenues of legal redress for dealing with it. And the concept of obstetric violence has been taken up by activists all over the world and is, you know, now, it went from being, I'd say, 10 years ago when I started this work, there was really a radical phrase that was being used, but again, what's important to notice is that obstetric violence is the phrase that the women themselves use to describe their experience, as opposed to the mistreatment of women or disrespect and abuse, which are phrases that came out of more policy-level analyses from international NGOs and stuff like this. Obstetric violence has really been picked up by women's groups and now has evolved to the point that you now have the United Nations and the United Nations naming and acknowledging that as an issue that needs to be addressed in maternal health care because it's an issue anywhere that sort of power over dynamics are used to abuse women around childbirth. So that's a good point in terms of resources as more and more organizations are recognizing the issue and developing policy statements on it. But Susania Jevitt would like to know what you think are the most important tools for bringing physicians and hospitals away from their fear of liability. I'm sure as a lawyer you'd love to address this one. I would. So I mean, I think first of all I can say that there is an extensive body of research law and economics and other kinds of research that have looked into the question of whether liability or liability crisis are in fact the driving factors for for example the c-section pandemic and what those studies have shown is that it's not actually so much about fear of liability. That's more of a cultural story within obstetrics that it's more about financial incentives and time convenience incentives that are then sort of maybe happening on an unconscious level and that get sort of covered up with a fear of liability and so that that data is valuable in bringing to those conversations but I'd say the most important tool is what I said at the end which is we hear you about your liability crisis and your fears around this but let's talk about what we're talking about here. You're telling me that your liability crisis is going to make you make her strapped to an electronic fetal monitor that we know massively increases her risk of having a c-section that she doesn't need and doesn't actually offer any benefit measurable benefit for her and her baby and our position is that she has the right to that information and to decide whether she wants to use that monitor as opposed to intermittent monitoring for example or whatever it is that's at stake in the liability conversation if you just bring it back to I understand your fear but we don't get to increase risks for patients based on liability fears and we don't get to violate their patient rights based on liability fears like we can deal with the liability fear but neither of those are acceptable solutions to the fear because really pin them down on this. What you're saying when you say my fear of liability made me push her into a caesarean that I don't really think she needs is that I just increased her risk of dying and her baby's risk of dying because I'm afraid my liability premium might go up. That's privileging a financial again ultimately a liability fear is a financial incentive because that's what's at stake around that so you're privileging a financial incentive over a mortality risk and that's unacceptable so your most powerful tool in addressing this is to like bring it back to what are we actually talking about here good point good very good point I want to scoot back a little bit to a comment during your talk in fact the first one that I mean just if you could clarify because somebody was upset that you mentioned the oppression is because they're perceived as women but that it's actually because there are women so can you clarify whether it's perception or actual a lot of controversy within the you know western birth activist community around like languaging and talking about childbirth and with regard to the inclusion of people who do not like non-binary who do not have a binary gender identification and so you know it's been very important to some people within the birth community that conversations around about childbirth and the people who give birth includes the word people to acknowledge that some of the people who give birth do not themselves want to be called women and that that is just part of the individual situation that they bring to this conversation that needs to be recognized and then there have been others who feel like some of the discourse around this issue of saying birthing people has gotten to the point where they might offend somebody if they refer to birthing women because then people feel that they're automatically excluding the people who don't identify as women I think that a way that you know it's a tricky thing to navigate because it's important for everybody to feel represented and included in a conversation about human rights and all I can do is explain my relationship to the topic which is to both attempt to recognize that there are people who give birth who do not identify as women and to also continue to talk about birthing women with female pronouns because many of the people who are giving birth do identify with those pronouns and also because the issues that I am addressing legally are about gender discrimination and so they are about the mistreatment of women as women and so I think that what Nikki wrote above was women are oppressed because they are women not just because they are perceived as women and again I would just say it's probably both the vast majority of time it's probably as simple as just because they are women and because the person sees that they are women but I think in the case of trans people giving birth you know whose experiences also matter it can be that they are perceived as women and they are being mistreated because they are perceived as women even if they don't perceive themselves as a woman or because they are perceived as a woman and subject to discrimination against them for being a trans person what I have learned about discrimination in my last 10 years of fighting for people's right to non-discrimination in childbirth is that sex discrimination is like a baseline level of discrimination that is driving the fact for example that informed consent is ignored in the culture of obstetrics childbirth is still basically in a pre-feminist state but beyond that I have learned that for every layer of additional discrimination that is projected onto the body of the birthing person by the people who she has entrusted to care for her at this vulnerable time she is more likely to be disrespected and abused her voice is less likely to be heard she is more likely to die in childbirth and she is more likely to see her baby die in childbirth this is why we see one of the reasons why we see mortality disparities for historically marginalized groups all over the world is because again layers of discrimination being projected onto the body of the birthing person discrimination against trans people is just one form that discrimination can take in childbirth that has been considered relevant to the birthing community thank you so much for clarifying and for your very powerful presentation