Archives for category: Health

American Heritage Dictionary (my personal favorite) defines treatment in a medical context as

a. The use of an agent, procedure, or regimen, such as a drug, surgery, or exercise, in an attempt to cure or mitigate a disease, condition, or injury.
b. The agent, procedure, or regimen so used.
Notice the terms cure and mitigate.
If we go back to the dictionary, cure is
a. A drug or course of medical treatment used to restore health: discovered a new cure for ulcers.
b. Restoration of health; recovery from disease: the likelihood of cure.
c. Something that corrects or relieves a harmful or disturbing situation:
and mitigate is
a. To make less severe or intense; moderate or alleviate.
Thus, we should expect that any medical treatment should make us better than we would be without it.  Yet reporting on a systematic review in JAMA,  the New York TImes recently ran a piece called “If Patients Only Knew How Often Treatments Could Harm Them.”
Perhaps in these cases, we might want to reconsider using the term “treatment.”
The JAMA review, “Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests,” concludes
The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.
But where are patients getting this information?  While some may see advertisements for a handful of drugs, for the most part, patients get information on “treatment” from their doctors.  A commentary on the review suggests limiting advertising and changing product labeling to be more transparent (big thumbs up from me on the second one in particular).  It also says that
[A] physician must first understand the risk herself (or himself) and must then communicate it effectively.  It is not clear that physicians do either of these things well.
Addressing OB care, the JAMA article notes that only 9% of women accurately identified the benefits of a trial of labor after cesarean (TOLAC) over an elective repeat cesarean (ERCS), and only 37% accurately identified risks of a TOLAC. Patients also incorrectly identified the benefits of a fetal abnormality scan (90% overestimated the benefits), and 57% could not accurately identify the risks of amniocentesis.
One of the original articles from the review, Trial of Labor After Repeat Cesarean: Are Patients Making an Informed Decision, states
Women in both groups [TOLAC or ERCS] were insufficiently informed about the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, our patients were not familiar with
  • the chances of a successful TOLAC,
  • the effect of indication for previous cesarean section on success,
  • the risk of uterine rupture,
  • the increased length of recovery with ERCS versus TOLAC
  • the increased risk of maternal death, neonatal respiratory compromise, and neonatal intensive care unit admission with ERCS.

In addition, if our patient felt her provider had a preference, she was more likely to choose that mode of delivery, whereas when patients felt their providers were indifferent or if they were unaware of their providers’ preferences, 50% chose one mode and 50% chose the other.

 Note there is no indication that the women who did not feel the provider had a preference were making their own decisions based on accurate information.
Anecdotal evidence indicates that providers rarely provide accurate information–and sometime provide no information, simply saying, “Let’s schedule your cesarean.”  Some examples:
  • Jessica: I was told I need not waste my time trying to attempt a vaginal birth because it would be another long birth that would ultimately end in another section.
  • Jenerra: “I was always told by my doctors that because I had my first c-section that I would have to keep having them, even though my first c-section was the result of an induction gone wrong.”
  • Kiara: I do believe that [my primary cesarean] was the best outcome for everyone, but I knew that I didn’t want that
    experience again. When I discussed this with my OB, she said ‘Oh, we don’t do VBACs in this practice. When you get pregnant again, we’ll just schedule you like a hair appointment. Easy!’
  • Jamie: [My OB said], “You don’t want to VBAC. You don’t need to tear up your little bottom.”
The JAMA article, which is not focused on obstetric care in particular, does not address other common obstetric “treatments.” For instance, many physicians conduct ultrasounds routinely during pregnancy.  A friend of mine said her doctor never measured her fundal height, instead conducting an ultrasound at every appointment, even though there is no indication that having ANY ultrasounds improves pregnancy outcomes.   Other “treatments” for which women may not be adequately informed of benefits and risks include elective inductions,  Pitocin augmentation, and episiotomies, along with any number of other “treatments” offered in prenatal care, labor, and childbirth.
Women often believe they have no say in these procedures at all, as they are often presented as something that is going to occur rather than a choice that the woman can make.  Unfortunately, though ACOG offers excellent guidelines on informed consent, in practice informed consent is rarely more than a women signing a form that she has no time to read, and informed refusal is never on the table at all.  In fact some recent cases have indicated that in some cases doctors override a woman’s informed refusal, as in the case of Rinat Dray’s forced cesarean and Kelly X’s forced episiotomy.
The New York Times report on the JAMA review states:
This study, and others, indicate that patients would opt for less care if they had more information about what they may gain or risk with treatment. Shared decision-making in which there is an open patient-physician dialogue about benefits and harms, often augmented with use of treatment decision aids, like videos, would help patients get that information.
Unfortunately, shared decision making operates as a buzz phrase rather than a practice most of the time.  Perhaps this uninformed approach to “treatment” is why Marinah Valenzuela Farrell, a certified professional midwife, and president of the Midwives Alliance of North America notes in the New York Times series “Is Home Birth Ever a Safe Choice?” that hospitals carry their own risks.
They just don’t inform you about them.

Sociological Images addressed two issues that have been pet peeves of mine for a long time, namely the sexualization of breast cancer and the sexualizing of breastfeeding.  The piece compares the admonishment of the author’s sister-in-law for allowing her “breast to fall out” when she fell asleep nursing on a plane and this 2012 ad for breast cancer awareness:

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To create momentum to fund breast cancer research, breast cancer has been both feminized/infantilized through pink marketing, and sold as a way for men to save body parts to which they want to preserve sexual access.  Breast cancer awareness is all about the breasts.  Hence, you see bumper stickers that say

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or

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As if what is being preserved through breast cancer research and treatment are breasts, not human lives.  It is hard to imagine a campaign to raise awareness of testicular cancer that promoted blue teddy bears and selling beer with blue ribbons on it, along with bumper stickers saying “save the wienie beanies” or “save the family jewels” or “save the nuts” (which is what we are if we think such a campaign would ever occur).

While the 2012 ad featured in Sociological Images does include partial faces, many breast cancer awareness ads do not:

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While it is possible for nubile young women to get breast cancer, most women who get breast cancer look more like this:

Portrait of a happy nurse and patient

Bodies and breasts getting cancer treatment, even when headless, look more like this:

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and despite the blonde locks on the tatas model, many women battling breast cancer do not have hair, having lost it to chemo treatments:

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Somehow, these sexy tata images, including apparently naked women (or women’s torsos), are okay to display because they are for the higher purpose of fighting breast cancer, and perhaps more importantly, preserving breasts so men can be titillated by them (yes, titillated, haha).

While it may be possible to find breastfeeding a baby sexy, usually it is fairly dull.  Most women-infant pairs look something like this while breastfeeding:

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though many new mothers don’t look this good on a regular basis.

But the media also tends to portray breastfeeding as an activity of a breast rather than a human:

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even when the intent is not remotely sexual:

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But many photos of breastfeeding women are sexualized.  Beautiful women with no postpartum paunches wear attractive bras or negligees or form-fitting tops and pull the top down (rather than wearing a loose shirt and lifting it up from the bottom):

mother breast feeding her child, focus on the child

  While some women do feed their babies this way, usually it’s not the first-line choice for feeding in the presence of strangers.

Somehow, this image gets translated to the typical breastfeeding women, who is chastised for allowing her breast to show, or sometimes merely because she is breastfeeding, even if no one can see anything at all other than fabric:

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No one excoriates women for having cancer in public.

The problem with breasts is, apparently, that they are attached to women.  Women need to go out in public to work, shop, get sunshine, see other people, and all of the reasons that human beings generally leave the privacy of their homes.  And when they go out, they take their breasts with them.  And when a woman gets cancer, the pain and fear are experienced by a human being, not a breast.

It’s fine to think breasts are sexy.  it’s not so fine to define them as separate from the women who have them.

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Imagine, if you will, a whole community of short people… Given the argument sometimes made in our society that short people are unable to be firefighters because they are neither tall enough nor strong enough to do the job, the question arises: Would all the houses in this community eventually burn down? Well yes, if we short people had to use the heavy ladders and hoses designed by and for tall people. But no, if we (being as smart as short people are) could instead construct lighter ladders and hoses usable by both tall and short people. The moral here should be obvious: It isn’t short biology that’s the problem; it’s short biology being forced to function in a tall-centered social structure.

–Sandra Bem, The Lenses of Gender

So let us then imagine a society of people who spend at least some portion of their lives being pregnant and who also need to have jobs to support their families.  Oh, wait–for almost half of society, this is already the case.  It was the case for Peggy Young when she was let go by UPS because she was not supposed to lift more than 20 pounds–even though her job was mostly lifting envelopes, and she had a colleague who could lift the rare 20 lb-plus package.  Why is it difficult to think that it might be an ordinary expectation that employers would adjust to the needs of pregnant workers for the brief period of their lives that they are pregnant?

When we assume that men’s bodies are the norm, it is easy to see a policy that doesn’t recognize the needs of pregnant workers, a “pregnancy blind” policy as reasonable (UPS had a pregnancy blind policy when Young worked there).  After all, if you can’t get pregnant, you never need accommodations for pregnancy.  But if we assume human bodies are normal, then we know that pregnancy is a condition experienced by almost half of all humans, sometimes on multiple occasions.

We expect that humans need to eat, and thus time to eat is scheduled into normal workdays.  We also assume humans need to urinate, and we provide accommodations for this function.  We do not have a “hunger blind” work policy or a “urination blind” work policy that allows employers to forbid workers who need to eat or pee from holding a job.  Even when some people do not have a need but others do, such as a need for leisure time, we do not institute “leisure blind” policies that allow 15 hour workdays 7 days per week because only some people need some time off from work.  We used to, but we decided (with the help of labor unions) that this was an unfair policy.

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Pregnancy is a normal human condition, whether everyone experiences it or not.  Workplaces should expect to accommodate it as they do all ordinary conditions of being human–no matter how inconvenient. And usually it isn’t even inconvenient.

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I read a comment once about depression as a “minor” side effect of taking oral contraceptives: depression is a minor side effect that merely ruins the entire quality of a woman’s life.  While pretty much everyone feels sad once in a while, depression is not the same as situational sadness.  Here is some basic information on depression from the National Alliance on Mental Illness (NAMI):

Major depression is a mood state that goes well beyond temporarily feeling sad or blue. It is a serious medical illness that affects one’s thoughts, feelings, behavior, mood and physical health….Without treatment, the frequency and severity of these symptoms tend to increase over time….[symptoms include] depressed mood (sadness), poor concentration, insomnia, fatigue, appetite disturbances, excessive guilt and thoughts of suicide. Left untreated, depression can lead to serious impairment in daily functioning and even suicide, which is the 10th leading cause of death in the U.S.

Fortunately depression is treatable, and one main component of treatment is often taking selective serotonin reuptake inhibitors (SSRIs), which include commonly prescribed antidepressants such as Zoloft and Prozac.  Treatment for depression not only impacts quality of life, but life itself.

Imagine my surprise, then, to read New York Times writer Roni Caryn Rabin‘s comparison of giving up prescribed antidepressants to giving up smoking.  And imagine how much more surprising it was when she compared giving up antidepressants to giving up brie.  Yes, brie, as in a single type of gourmet cheese.

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I’m sure that anyone who has ever confessed to loving brie more than life was being hyperbolic.

The piece goes on to quote Barbara Mintzes, an associate professor at the University of British Columbia School of Population and Public Health:

If antidepressants made such a big difference, and women on them were eating better, sleeping better and taking better care of themselves, then one would expect to see better birth outcomes among the women who took medication than among similar women who did not.  What’s striking is that there’s no research evidence showing that, [but on the contrary] when you look for it, all you find are harms.

Who is harmed by the continued use of antidepressants, you might ask?  After all, if they were harming the woman, wouldn’t she have stopped taking them on her own?  Wouldn’t it be likely that she would have stopped taking them before she became pregnant?

Well, it turns out that the “harms” of taking antidepressants accrue only to the fetus–maybe.

Among the possible harm that the article lists are autism, attention deficit hyperactivity disorder (ADHD), lower language competence at age 3, preterm birth, birth defects, a lung disorder, REM sleep disruption, and lower birthweight and Apgar scores.

The problem is, most studies were of low scientific quality.  In some of the studies, when further controls were used, many of the negative outcomes were associated with having a mother with depression, whether or not she took antidepressants.

The article does not distinguish between different SSRIs–although these drugs all impact seratonin, they have different chemical formations.  The only concession to this that the article makes is to note that Paxil in particular is associated with birth defects, but information about Paxil strongly recommends against using it in pregnancy, and the FDA changed Paxil’s labeling and pregnancy category in 2005.

Many women actually do give up antidepressants in pregnancy.  For instance, one study of over 100,000 women in the UK found that “Only 10% of women treated before pregnancy still received antidepressants at the start of the third trimester. In contrast, 35% of nonpregnant women were still treated after a similar time period.”  The study does not indicate whether women who continued using antidepressants had different outcomes.

Rabin’s piece does quote Dr. Roy Perlis, an associate professor of psychiatry at Harvard Medical School and author of a study that found a connection between fetal antidepressant exposure and ADHD. Depite this research, he says,

The downside of these studies is that it ends up scaring women away from treatment…the severity of the depression or anxiety can make it very hard for [women] to take care of a child, and is such that their life is at risk if they’re not treated.

The article then closes with an implication that Dr. Adam Urato, a maternal-fetal medicine specialist at Tufts Medical Center, thinks women should stop using antidepressants in pregnancy in favor of non-drug options such as counseling, exercise, and bright light therapy.  I am in favor of all of these things as first line treatments, but if they are not sufficient, what should a pregnant woman do?

The response from pregnant women and young mothers who read this piece doesn’t indicate that Rabin’s information was helpful.  Isn’t it bad enough to be depressed without being shamed for seeking treatment?

Alexis, the mother of a 7-week-old, says

Well I guess I’m a horrible person and mother…Now I feel guilty about the drug that I was prescribed following a suicide attempt 2 years ago, a drug that literally saved my life.

Rachel, currently pregnant, writes

OMG, I am totally freaking out! I have been taking Prozac for symptoms of anxiety for the last few years. When I became pregnant, my ob/gyn, my current therapist, a past therapist whom I consulted, and my prescribing doctor all assured me, in no uncertain terms, that it would be better for my baby if I stuck to this regimen than if I were to discontinue it. Now I am about to start my second trimester, and I read here, also in no uncertain terms, that all my doctors were wrong! Now what am I supposed to do?! Help!!!

On a brighter note, unlike many articles that generate sympathy primarily for the fetus at the expense of the woman, many commenters here point out the deficits in Rabin’s presentation and her argument.  A number of them  are physicians or nurses, and many are also outraged at the comparison of antidepressant use to smoking and eating cheese.

Here’s Nicole:

As an obstetrician I am mortified that this article starts off by comparing quitting smoking and not drinking alcohol to weaning off SSRIs, and it blames the mother for staying on them while barely mentioning that it can’t happen without providers like me who do the prescribing.

And Alabama Doc:

First, medication for a serious brain disorder is nothing whatsoever analogous to buying cheese…There is muddling of several separate issues here, with the assumption that the women and their doctors are using an ineffective medication just for… what, a lifestyle preference? Yes, we have evidence that non-medication treatment can be highly effective for mild to moderate depression and that there may be no clear benefit of SSRIs for mild depression. For severe depression, however, medication appears to have significant benefit. Notice how all the discussion of risks/ benefits centered around the infant and really nothing was said about the mother? Is the mother’s life so unimportant?

and Caroline Cylkowski, Nurse Practitioner:

Shame on NYtimes for publishing an article completely based on pseudoscience. The author cites the opinions of one MFM doctor and one public health researcher as the basis for her argument. What is scary is that pregnant mothers, who already worry that everything they do might harm their future child, will read this this and discontinue their antidepressants. Antidepressants are not optional medications. The disease they treat has debilitating and sometimes life-threatening consequences.

In contrast to Rabin’s piece, sources from medical institutions take a very different tone.  For instance, Massachusetts General Hospital points out

Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.  Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.

The MGH site goes on to point out that each medication is different and some carry more risks than others.  They identify several antidepressants that appear to have no association with birth defects and point out that symptoms of neonatal withdrawal from antidepressants are generally mild and disappear within a few days.

What is perhaps most disheartening about Rabin’s piece is the addition of women’s legitimate medical treatment to the Pregnancy Outcome Blame Game.  Major causes of birth defects include environmental contamination and domestic abuse.  Major causes of preterm birth are racism and lack of prenatal care.  But these require broader social intervention to mitigate.  How much easier to blame individual women for poor birth outcomes, especially when they are too depressed to defend themselves.

Let’s say you are CPR certified and the woman next to you on the morning commuter train goes into cardiac arrest.  Is your first thought, I had better let this woman die because if I perform CPR, I might hurt her fetus?  Apparently this is the attitude of many health care providers.
The Society for Obstetric Anesthesia and Perinatology (SOAP) has issued a new consensus statement regarding cardiopulmonary resuscitation (CPR) for pregnant women.  Pregnant women may have special needs regarding CPR, especially later in pregnancy when the size of the fetus compresses veins sending blood back to the heart.
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Sometimes a hysterotomy (basically a cesarean, but the idea is to get the fetus out of the woman’s body) is the best way to preserve the woman’s life.  Some might be concerned about hysterotomy because of the concern for the life of the fetus being born prematurely.  We might then ask, what happens to a fetus inside of a woman who has gone into cardiac arrest and dies?  Well, the fetus generally dies too.
One of the things the new guidelines state is the importance of administering care that prioritizes saving the pregnant woman’s life.  Generally when a person goes into cardiac arrest, saving that person’s life is the goal, and it is alarming that it has to be stated that the life of a pregnant woman is equally valuable to the life of any other person who goes into cardiac arrest.
In a Q & A with Brendan Carvalho, Chief of Obstetric Anesthesia at Stanford University Medical Center, Dr. Carvalho notes that pregnancy CPR guidelines are important because pregnancy can increase a woman’s risk for cardiac arrest (and all women, pregnant or not, are at some level of risk).  It is laudable to recognize the normalcy of pregnancy in a woman’s life and determine how to provide appropriate medical treatment.  While Carvalho notes that U.S. maternal mortality has decreased dramatically over the last century, he does not mention that it has increased dramatically over the last two decades, with a rate that is now among the worst in the developed world.  The U.S. rates 60th nationally–59 countries have lower maternal death rates.
Perhaps part of rising maternal mortality stems from an attitude toward pregnant women that their humanity is suspended while they perform as vessels for fetal growth.  Such an attitude has been evidenced in the case of  Marlise Munoz (see here), the Texas woman whose dead body was kept artificially functioning against her wishes and those of her family so that it could serve as an incubator for her fetus. Louisiana has created an official law (which is expected to be signed by the governor) that mandates women’s dead bodies be artificially sustained as incubators for any fetus inside them that has reached 20 weeks.   Pregnant women are routinely criminalized for behavior that is not prosecuted in other adults, such as alcohol consumption or refusing to follow the recommendations of a physician (see here), indicating that pregnant women cannot be accorded basic human rights–the kind of rights accorded to all other adult humans.
Carvalho says,
Caregivers are often reluctant to administer medication to pregnant women because of potential harm to the baby. The consensus statement emphasized that caregivers can use the same drugs they typically give to a nonpregnant patient who has a cardiac arrest. The best thing you can do for baby is to provide the mom the best possible care and not withhold any drugs or procedures that would normally be used managing a critically ill person.
The key word here is person.  What justification would there ever be to intentionally withhold treatment from a critically ill person whose life could be preserved?  If pregnant women were truly viewed as people, no one–not Carvalho, not anyone–would ever have to make this statement.

There are two legal ways to have an abortion in the United States, through surgery or medication.  Medication abortions are those induced through taking mifepristone pills (which were called RU486 when they were developed).  Mifepristone is not Plan B (levonorgestrel, a synthetic form of progesterone) or Ella (ulipristal acetate, which suppresses progesterone production). Plan B and Ella have nothing to do with abortion; both stop ovulation in order to prevent pregnancy.  Mifepristone causes the expulsion of an embryo in an established pregnancy, much like a spontaneous miscarriage.

There are three main restrictions put on medical abortions in the United States:

  1. Pills must be provided by a licensed physician (not a nurse practitioner, nurse midwife, or other qualified health practitioner)
  2. Pills must be provided through an in-person patient-physician visit
  3. Pills must be provided according to the original FDA protocol (much lower doses of the pills have since been found to be effective)

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White states have the least restrictive policies, and dark green states have the most restrictive.  You can find an interactive version of this map at the Mother Jones website (the map does have some inaccuracies; Iowa and Arizona in particular currently have stays against some of their restrictions).

Restriction #1: Licensed Physicians 

That the pills can only be provided by a licensed physician is a restriction that is not solely promoted by opponents of abortion. It is a restriction in place in states that receive an “A” from NARAL Pro-Choice America on choice related law (find your state’s laws and grade here).

Physicians often oppose legislation that would allow medical practitioners who are not physicians–including midwives, advanced practice nurses, or pharmacists–to provide care that is within their scope of training.  Doctors often make the same argument that abortion opponents make: that they are trying to keep women “safe”  (e.g. doctors protect women from midwifery care in New York; doctors protect people from receiving primary care from nurse practitioners in Texas; doctors protect people from vaccination by pharmacists in Florida).

In her novel The Handmaid’s Tale, a story of a futuristic society in which the United States is taken over by the Christian Right, the characters identify differences between “freedom to” and “freedom from.” If you haven’t read the book, go get it and read it immediately.  In any case, Aunt Lydia, who trains women to accept their role in the new society, says,

There is more than one kind of freedom…Freedom to and freedom from. In the days of anarchy, it was freedom to. Now you are being given freedom from. Don’t underrate it.

“Freedom to” gives women agency and choice.  “Freedom from” restricts them in exchange for safety and protection.  In the novel, “freedom from” involves wearing burkah-like clothing, not being allowed to read, and bearing children for religious couples with political standing.  This supposedly frees women from rape, responsibility, and thinking.

In any case, the paternalistic “protection” of making physicians the only practitioners who can provide medication abortions seems to have an underlying agenda–moral or financial–that has nothing to do with women’s health.

Restriction #2: In-Person Physician Encounter

Telemedicine is increasingly used to serve rural communities in particular.  Many people in rural areas are far from hospitals and other sources of medical care.  You can see in this map that there are large areas without critical access.

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To provide needed care in the Mountain West, St. Luke’s Health System has established a virtual intensive care unit, which monitors 69 critical care beds in 5 hospitals and provides critical care consultation in 5 emergency departments in Idaho.  Here is a video about it:

Critical care is being offered to people on the brink of death through telemedicine, but some states have seen fit to decide that medication abortions offered through telemedicine are dangerous.  Over the past year, this restriction has generated attention in Iowa, where Planned Parenthood has safely offered medication abortions through telemedicine to thousands of women since 2008.  In September 2013, the Iowa Board of Medicine, made up of political appointees, voted to ban telemedical abortions, in addition to imposing other restrictions and requirements.

Delaying access to abortion care narrows women’s options, as medication abortions are only considered safe through the first 9 weeks of pregnancy.  After 9 weeks, a surgical abortion becomes a woman’s only abortion option (see here for a comparison of surgical and medication abortions).  While there are risks and side effects from medication abortions, most of them are uncomfortable or annoying rather than dangerous.  According to the FDA, no deaths have been directly attributed to medication abortions.

As Jill June, President and CEO of Planned Parenthood of the Heartland, said,

It’s evident that this ruling was not based on the health and safety of women in our state – it was based on politics. There was no medical evidence or information presented to the Board that questions the safety of our telemedicine delivery system. It’s apparent that the goal of this rule is to eliminate abortion in Iowa, and it has nothing to do with the safety of telemedicine. The reality is, this rule will only make it more challenging for a woman to receive the safe health care she needs.  Iowa women deserve to have access to the newest medical technologies and all of the heath care services they need, regardless of where they live.

A judge halted Iowa’s ban through a stay until the court case is settled.  The Iowa legislature, which is controlled by Democrats, was unable to pass a bill to instate the restriction through law; however, this restriction is in place in other states.

Restriction #3: The Original FDA Protocol

The Guttmacher Institute offers this chart comparing the original protocols for administering mifepristone pills established by the FDA, and the newer protocols adopted by the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOG) based on evidence that has emerged since the FDA’s original approval:

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Abortion opponents have argued that adhering to the FDA protocols protects women, even though the Agency for Healthcare Research and Quality, a government agency as is the FDA, has published guidelines for mifepristone administration in their National Guidelines Clearinghouse.  The following guideline is level A evidence, the highest and most reliable evidence available:

Compared with the FDA-approved regimen, mifepristone-misoprostol regimens using 200 milligrams of mifepristone orally and 800 micrograms of misoprostol vaginally are associated with a decreased rate of continuing pregnancies, decreased time to expulsion, fewer side effects, improved complete abortion rates, and lower cost for women with pregnancies up to 63 days of gestation based on last menstrual period.

I have argued against non-FDA-approved use of Pitocin to induce labor electively.  However, there is no evidence base for the use of Pitocin for non-medically indicated deliveries.  As you can read in my previous posts (here and here), Pitocin is a high-alert medication with many dangerous side effects.  Its elective use has no known benefit other than convenience.  The new guidelines for mifepristone use, on the other hand, are based on evidence and involve giving a woman less medication rather than more.

That legislators would ignore a large, reliable body of scientific research does not inspire my confidence in their understanding of safety.  If they really care about the health and safety of women and babies, restricting off-label Pitocin use would be a much more effective technique.

It should be noted that while a law was passed in Arizona imposing this restriction and was upheld by a federal judge in Tuscon on April 1, 2014, the 9th Circuit Court of Appeals issued a stay on the legislation on April 2.  Thus, the only state implementing this restriction as of April 2014 is Texas.

If you view yourself as a human rather than a political pawn, you might want to say so.  If you value your freedom to rather than your freedom from, you might consider fighting for that freedom.  And if you are a woman in Texas who cares about her health, you may want to move.

Medical practice has many issues around informed consent, with many procedures being routinely performed with no shared decision making process, no informed consent, or no permission at all.  Rebecca Dekker of Evidence Based Birth wrote than in her training as a nurse,

I was taught to say, ‘I am going to listen to your lung sounds now.’ My instructors told me that the patient would be less likely to refuse if I simply stated what I was doing, instead of asking permission. I practiced that way– and even taught nursing students that way– for several years. (emphasis mine)

This seems relatively innocuous when it involves listening to lung sounds, but has more onerous implications for pregnancy and childbirth.  Training to make statements is training for practitioners to say, “I am going to cut an episiotomy now” or “I need to do a cesarean.”  It may be true that the procedure is a good idea, but it is not acceptable to tell a woman that you are going to do something to her body.  A woman needs to have to opportunity not only to consent to a procedure, but also to refuse it.

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Sometimes practitioners do not even say what they are going to do–they just do it.  Sometimes they tell the woman after it has been done, as in this case from My OB Said What?:

‘I gave you an episiotomy.’ – OB to mother after birth. Nothing was mentioned about an episiotomy being needed during the birth, and when the mother screamed in pain when the OB touched her, both the OB and the L&D nurse insisted the OB was just ‘stretching’ her.

Or this one

‘We will go ahead and schedule your cesarean section now.’ —OB to mother with two prior cesareans, at the mother’s 10 week prenatal appointment, after the mother indicated that she wanted to have a VBAC.

Sometimes the practitioner doesn’t tell tell woman anything, and she finds out what happened by reading her chart or talking about her case with a different practitioner, as in this report from Cookieparty at Community Baby Center:

I remember my OB saying he was stitching me and I was like oh I must have torn. He didn’t even tell me he did [an episiotomy], I found out later that day or the next day I think, when one of the nurses was tending to it. [It] pissed me off!

Instruction on “Patient Rights” from The Birth Place of UCLA Medical Center make it sound that their belief is that women do not have the right to refuse what health practitioners want to do in any case.  Their responsibility is to follow the rules and cooperate (emphasis mine):

Patient Responsibilities
As a patient, you have the responsibility to:

  • Treat those who are treating you with respect and courtesy.
  • Be considerate of the rights of other patients and hospital personnel.
  • Observe the medical center’s rules and regulations, including the Visitor and No Smoking policies.
  • Be as accurate and complete as possible when providing information about your medical history and present condition, including your level of pain.
  • Cooperate fully with the instructions given to you by those providing your care.
  • Fulfill the financial obligations of your health care, know your insurance benefits and eligibility requirements, and inform the hospital of changes in your benefits.
  • Provide a copy of your Advance Directive (Durable Power of Attorney for Healthcare) if you have one.

In their Committee Opinion “Elective Surgery and Patient Choice,” the American College of Obstetricians and Gynecologists (ACOG) says that OBGYNs may perform unnecessary surgeries upon a woman’s request, including cesareans, as long as the woman is adequately informed of the risks and alternatives and the OBGYN believes the surgery is not an undue health threat:

Performing cesarean delivery on maternal request should be limited to cases in which the physician judges that it is sufficiently safe, given the specifics of the woman’s pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.

In their Committee Opinion “Maternal Decision Making, Ethics, and the Law,” ACOG points out

  • Appellate courts have held…that a pregnant woman’s decisions regarding medical treatment should take precedence regardless of the presumed fetal consequences of those decisions.
  • [M]ost ethicists also agree that a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions
  • [I]n the vast majority of cases, the interests of the pregnant woman and fetus actually converge.
  • Because an intervention on a fetus must be performed through the body of a pregnant woman, an assertion of fetal rights must be reconciled with the ethical and legal obligations toward pregnant women as women, persons in their own right….Regardless of what is believed about fetal personhood, claims about fetal rights require an assessment of the rights of pregnant women, whose personhood within the legal and moral community is indisputable.

Two of the main conclusions of this committee opinion are

  • Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
  • Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.

However, the obstetric community continues to bully women into acquiescing to procedures that the obstetric team wishes to perform, and women are still persecuted for refusing procedures both legally and socially, even when these procedures are not evidence based.

Even when medical professionals do explain risks and benefits to a procedure, they often expect a woman to draw the same conclusion that they do regarding what should be done.  The flip side of informed consent, however, is informed refusal.  Women not only have the right to know what their options are, they have the right to choose the option they believe is right, regardless of what their health practitioner believes.

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