Archives for category: Pregnancy

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.
Advertisements

firefighter4x-383x254

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.

fired-for-pregnancy-375x250

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.

????????????????????????

 

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.

brie

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.
cpr_pregnant
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.

Image The cesarean rate is Brazil has been high for a long time, and it is getting higher.  In private hospitals, almost all women deliver by cesarean; in public hospitals it’s about half.  According to Ricki Lake, who went to Brazil in the process of filming The Business of Being Born, “There was actually a joke circulating that the only way to have a natural birth in Rio was if your doctor got stuck in traffic.”  Brazil’s childbirth practices have come to attention recently because of Adelir Carmen Lemos de Góes, who on April 1, 2014, was taken by police to have a forced cesarean under court order.  Here’s an account of what happened from The Guardian:

…Brazilian mother Adelir Carmen Lemos de Góes was preparing for her third birth. Despite living in a country with one of the highest caesarean rates in the world (82% for those with private insurance and 50% for those without), she was looking forward to giving birth vaginally after previously having caesareans she felt were unnecessary.  However, in the midst of her labour, six armed police banged on her front door. Despite there being no question of reduced mental capacity, doctors had obtained a court order allowing them to perform a caesarean…Adelir was taken from her home, forcibly anaesthetised and operated on without consent.

Attorney Jill Filopovic writes,

A Brazilian court granted a prosecutor’s request for the appointment of a special guardian. And just in case it was unclear whose life gets prioritized when a woman has a c-section against her will, the judge specified that when there is a ‘conflict of interests of the mother with the child’s life … the interests of the child predominate over hers.’

Filopovic quotes Dr. Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo: 

In our culture, childbirth is something that is primitive, ugly, nasty, inconvenient….It’s part of Catholic culture that this experience of childbirth should come with humiliation.

The Atlantic subsequently ran a longer piece by Olga Khazan, “Why Most Brazilian Women Get C-Sections,” which, also points to a confluence of attitudes, practices, policies, and norms that lead to a trend toward universal cesarean.  Humiliation isn’t hard to come by in Brazilian obstetrics.  Khazan reports,

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores….When women are in labor, some doctors say, ‘When you were doing it, you didn’t complain, but now that you’re here, you cry.’

Mariana Bahia, who participated in protests against forced cesarean, noted:

There’s no horizontality between patients and doctors.  Doctors are always above us.

And Paula Viana, head of a women’s rights organization, said,

We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress].  They think they can interfere as they would like.

But much of what these various articles says about childbirth in Brazil is eerily similar to what happens in the United States.  Khazan quotes Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation about birth practices in Brazil:

Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can’t walk, can’t take a bath, can’t hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies.  What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women.

In the United States, Pitocin induction and augmentation are ubiquitous , and episiotomies, though less common than in Brazil, are still greatly overused.  Almost all U.S. hospitals use IV hydration as a matter of policy (rather than allowing women to eat and drink as they please, which is the evidence based recommendation).  And in the U.S., taking a bath in labor may be impossible, as many hospitals do not provide bathtubs out of a misguided fear of women attempting waterbirths. The website My OB Said What documents a seemingly endless stream of U.S. health professionals’ humiliating comments, such as referring to a pregnant women as a “little girls,” criticizing their weight, or belittling their pain.

Court ordered cesareans occur in the United States as well, as Erin Davenport documents in “Court Ordered Cesarean Sections: Why Courts Should Not Be Allowed to Use a Balancing Test.”  Davenport notes that forced cesareans are generally ordered because of concerns for fetal welfare–as in Brazil, U.S. courts often privilege the rights of the fetus over those of the pregnant woman.

Alissa Scheller created infographics on Huffington Post showing how states’ policies are used to persecute and prosecute pregnant in the name of fetal welfare.

Image

National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

Wisconsin has the dubious distinction of being one of three states (along with Minnesota and South Dakota) that allow civil commitment of pregnant women for mental health and substance abuse treatment (you can find your state’s policies here).  In an ironic twist, it is very hard for pregnant women to voluntarily enroll in appropriate substance abuse treatment–many programs will not accept pregnant women, and specialized programs are few and far between (and often have no room).  Only four states prohibit discrimination against pregnant women seeking treatment in publicly funded programs–none of them are states that allow civil commitment.  So when the state of Wisconsin forced 28 year old Alicia Beltran into substance abuse treatment under the “cocaine mom act”–even though she was not abusing any substances at the time–she was held for 78 days in a treatment center, received no medical care, and was forced to take a drug that helps people withdraw from their drug of abuse–even though she had already finished withdrawing from Percocet before entering treatment (verified by drug tests).  She was also not allowed to have a lawyer to represent her at her commitment hearing (she requested one), but the court appointed representation for her fetus.

Image

People in Wisconsin also took notice of the case of Marlise Munoz in Texas. Munoz’s body was kept artificially alive after she was declared brain dead (which is the clinical definition of dead) so that she could incubate her fetus against her previously stated wishes and the wishes of her family.  A judge finally ruled that a law stating that life support could not be withdrawn from a pregnant woman, regardless of her wishes, did not apply in Munoz’s case because Munoz was already dead.    Image

Understandably, some in Wisconsin are concerned that pregnant people are not being accorded the same human rights as other people.  As a result, three new bills are being introduced, the “Pregnancy Protection Package,” sponsored by Rep. Chris Taylor, D-Madison and Rep. Terese Berceau, D-Madison (as reported here):

  • Assembly Bill 860 ensures pregnant women who have allegedly used drugs have the right to an attorney before being detained.
  • Assembly Bill 861 requires a pregnant woman’s advanced medical directives to be respected, just like any other patient’s.
  • Assembly Joint Resolution 111, affirms that “pregnant women be afforded all the rights of non-pregnant people.”

Here is a part of ACOG’s Committee Opinion on substance abuse and pregnancy:

Seeking obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing. These approaches treat addiction as a moral failing. Addiction is a chronic, relapsing biological and behavioral disorder with genetic components. The disease of substance addiction is subject to medical and behavioral management in the same fashion as hypertension and diabetes. Substance abuse reporting during pregnancy may dissuade women from seeking prenatal care and may unjustly single out the most vulnerable, particularly women with low incomes and women of color. Although the type of drug may differ, individuals from all races and socioeconomic strata have similar rates of substance abuse and addiction.

Many people would love to have mental health or substance abuse treatment, but cannot get it.  In other cases, people who are a genuine danger to themselves or others cannot be committed to treatment involuntarily.  Pete Early’s book Crazy details his agonizing quest to get treatment for his young adult son, who was delusional and ultimately broke into someone’s home and was criminally prosecuted.  Early points out that not allowing family members or qualified medical professionals to mandate treatment for the severely mentally ill means that we populate our jails with people who are in desperate need of treatment.  They do not get better in jail, where one psychiatrist is generally responsible for hundreds of severely mentally ill prisoners.

The concern for receipt of mental health treatment for pregnant women generally has nothing to do with the health or well being of the woman.  In the case of Bei Bei Shuai, pregnant and depressed, Shuai’s suicide attempt led not to mental health treatment, but to 435 days in jail and a trial for murder (the baby was born alive by cesarean but died two days later).  It is also notable that fetal protection laws directed against pregnant women are unlikely to help the fetus either — as Beltran noted, she spend her entire 78 days in “treatment” with no prenatal care.  Inadequate prenatal care is a known risk factor for poor pregnancy outcomes for the baby as well as the woman.

Rather than criminalizing pregnant women for legal behavior or criminalizing health conditions only for pregnant women, perhaps we should make sure that all people have access to needed health care, including care for mental health and substance abuse.  And perhaps we should make sure pregnant women have at least as much right to consent and refusal for treatment as people who are actively hallucinating.  And perhaps we should recognize that if we are going to allow for anyone to have advance directives, it is not acceptable to say that pregnant women have no say over their own bodies if the state wants to use those bodies as incubators.

What does it say about our attitude toward the humanity of women that we have to generate laws that say that ordinary human rights extend to them whether they are pregnant or not?

Image

There is an interesting paradox in the arguments of some anti-homebirthers.  They argue both that homebirthing is an elitist practice driven by well-educated, wealthy feminists AND that these women do not know, understand, or have easy access to the “truth” about homebirth (because if they did, they would obviously come to the same conclusion as the anti-homebirthers).

Many of the women driving the rise in homebirth are the most capable of finding information on the risks and benefits of homebirth, and if they make a decision that goes against the anti-homebirthers’ beliefs, they certainly aren’t doing it because of a lack of information on risks.  A simple Google search on “home birth” pulls up many sites; some on the first page include a Wikipedia article that has a research review that indicates a higher rate of perinatal death in American homebirths, a Daily Beast story  called “Homebirth: Increasingly Popular, but Dangerous,” and the website Hurt by Homebirth.  It seems that rather than lacking access to the “truth,” some women simply have different interpretations of the evidence and/or different values than the anti-homebirth crowd.

There is, however, a different crowd of women who plan homebirths—or who have homebirths planned for them—who may or may not have accurate information about the risks of homebirth. If they do, it likely doesn’t matter.  Their choice is constrained by a subordination of their own autonomy to God, or in many cases, their husbands or their church leaders.

Some may have heard of the Quiverfull Movement and the Christian Patriarchy Movement.  The overlap between the two groups is substantial.  Those who are “Quiverfull” believe that they must gratefully accept as many children as God gives them, whenever He chooses to give them.  The Christian Patriarchy Movement believes in, well, patriarchy.  Women must always be under the authority of a man; generally this authority passes from father to husband.  The most well known Quiverfull family is the Duggar family of the TV show “19 Kids and Counting.” Kathryn Joyce has an excellent book on the movements, Quiverfull: Inside the Christian Patriarchy Movement.  Two excellent blogs that discuss the ramifications of Quiverfull and Christian Patriarchy are Love, Joy, Feminism, by Libby Anne, who grew up the oldest of 12 in a Quiverfull family; and No Longer Quivering, by Vickie Garrison, who had seven children before leaving the movement.

Because of the movements’ distrust of secular institutions, some in the movements eschew traditional medical care.  In addition, in part because they start families young and have so many children, many of these families are low income but do not believe in using government programs such as Medicaid.  Of course, many members of the movement go to doctors or licensed midwives anyway, and some even sign up for Medicaid.  But many don’t.  In many cases, it is the husband who makes the final decision about the healthcare of his pregnant wife and the circumstances of her labor and birth.  Sometimes these decisions are in response to the guidance of church leadership.

Amy Chasteen Miller, who conducted a study of unassisted childbirth published in Sociological Inquiry, points out that “women make choices about birth within a web of larger social influences.”  For educated, independent women, these choices may come from a feminist sensibility that leads them to reject a paternalistic and technological model of birth.  For other women, birth choices may be “driven by God.”  In some religious communities,

women see childbirth as fully ‘in God’s hands.’  For these women, seeking medical help for pregnancy and birth reflects a breach of faith and an unwillingness to fully trust ‘God’s will.’

In such circumstances, it is unlikely that women are familiar with the scientific literature regarding risks associated with homebirth, but it is also unlikely that knowing and understanding the risks would have any impact on their decision making–if they had any control over the decision.  Miller writes, “For some women, part of surrendering to God is also deferring to their husbands…”  One woman writes, “I asked [my husband] where we should have the baby.”  Another says, “[My husband] knew we needed to do this baby on our own without a professional birth attendant.”  In these families, Miller notes, husbands “played an active role in monitoring, directing, and evaluating the birth process.”

In her article “My Womb for His Purpose,” Kathryn Joyce tells the story of Carri Chmielewski, a self-described “Homeschooler, Homebirther, Homechurcher,” who had an unassisted childbirth after a complicated pregnancy and suffered an amniotic fluid embolism.  Her baby died.  According to Joyce,

Chmielewski’s husband, who critics charge has erased or hidden much of his wife’s past writing, described her survival as a miracle of God, who spared her even as He took their son.

Melissa, a former Quiverfull daughter who blogs at Permission to Live, was a submissive wife who was active in the web group of Above Rubies, a forum for Quiverfull/Christian Patriarchy mothers.  She says of her prenatal care in the U.S., “I had limited my checkups to only a handful to keep costs down.”  She also got only one of the two recommended shots for her rh-negative blood type and had her children at home.  She could have had comprehensive prenatal care, but her family did not believe in accepting government “welfare” and so went without any insurance at all:

I believed that welfare programs were unnecessary because if every woman just got married to one man and he supported her and her kids there would never be a need for welfare, I believed that Christian rights and privacy were being violated by the government on a regular basis…I remember being on a mommy chat board during my first and second pregnancies and someone started a thread on costs of prenatal care and childbirth. I mentioned that my uninsured home births had cost between six and seven thousand dollars each and felt proud that my costs were so low…
She never mentions anything about her knowledge of homebirth risks, only the “risk” of accepting government assistance.
Anonymous left the following comment at a Recovering Grace post on Quiverfull (ATI is the Advanced Training Institute, a Christian Patriarchy group):
I was an ATI mom for quite a few years and embraced the Quiverfull teachings. After a number of children we had a close call. A home birth and heavy hemorrhaging nearly claimed my life. I was ready to end the child bearing and focus on the children we had, but my husband didn’t agree. Within nine months I was pregnant again. We actually had insurance and I wanted to have the next birth in a hospital, but it was more important to my husband to have a home birth and “prove” his faith. I asked him, “What are you going to do if I bleed to death?” His answer amazed me. “Get a new one.”
This women knew first hand that there were risks to homebirth, ones she did not wish to accept.  Her religion, however, would not allow her to exercise her own autonomy.
According to Birth Junkie, “Born in Zion is a book by Christian ‘childbirth minister’ Carol Balizet, who ‘ministers’ to women during their home births” (I wanted to verify what Birth Junkie writes, but the book is now out of print and is currently selling for $200 per copy, so we’re going to take Birth Junkie’s word for it). She writes of Balizet:

[W]hatever Balizet’s ministry may be, it is certainly not midwifery….her teachings on childbirth are thoroughly unbiblical and even dangerous.  As if all this weren’t bad enough, Balizet believes that to receive any medical care whatsoever is a sin. It is yielding to the “world system” (167) and to the “arm of flesh” (84). Furthermore, taking any drug for any reason is sorcery according to Balizet (171). She refers to people who have never ingested drugs of any kind as “undefiled” and “virgins” (174)….Balizet believes that getting a Caesarean Section is a particularly abominable sin. All women who have had Caesareans have “the same spirit,” the “spirit of Caesar,” who is one and the same with “the Strong Man, the Satanic high prince over the organization and sphere of humanism” because they have “rendered their babies unto Caesar” rather than to God (48). In other words, women with Caesarean scars are idol-worshipers who are demon possessed.

Followers of such a philosophy are likely to be frightened into not seeking appropriate medical care–or bullied into not seeking it by church or family “authorities.”

Vyckie Garrison tells the harrowing story (long but fascinating if you want to read the whole thing) of her belief in her husband’s and God’s authority, and how it impacted her prenatal care and birth.  First she was betrayed by the conventional medical system.  A doctor told her a bone spur made vaginal birth impossible.  When she found out that wasn’t true:

‘Then why have I had three c-sections?’ I wanted to know. Well, it turns out that there really was no good reason–only that the first doctor had run out of patience so declared me to be ‘too small’ to give birth. And because of the first cesarean ~ I had automatically scheduled repeat c-sections for my next two babies.”

Her Christian OB offered severe limitations on VBAC and laughed at her wish for vaginal birth.  Having embraced the Quiverfull lifestyle, she decided to deliver with Judy Jones, an unlicensed midwife and devout Christian.  Because Vyckie had many complications in her pregnancy (for which she did not seek other care), Judy was at their house frequently.  Vyckie writes,

As ‘part of the family,’ Judy was around to witness the way that Warren dealt with the children…She spent a lot of time talking to me about the importance of upholding my husband’s authority…she always backed him up as ‘head of the home’….the wife should pray for the father of her children–but it’s essential that she never contradict him or do anything which might undermine his rightful authority as protector, provider–and priest in the home.

As the pregnancy progressed, Vyckie’s health worsened:

I was feeling particularly horrible…I told Judy that I really needed help–I really needed to go to the doctor. Judy drove to my house and did the usual check and assured me that–although I was still spilling sugar in my urine (+1,000)–I was okay and the baby was fine….Even though we really didn’t have the money for it, I insisted that I needed to go to the OB/GYN. ‘I can’t handle this anymore–I feel like I’m dying!’  I was laying on the couch and Judy got down on her knees beside me and did what she called a ‘diaphragmatic release,’ in which she put one hand under my lower back and her other hand on my lower abdomen and then waited patiently while the uterine muscles relaxed. It did calm me down, and while we waited, Judy told me a bible story…about the time when the children of Israel were wandering in the desert, and the Lord was providing for their every need…[b]ut the Israelites grew…greedy. ‘They had meat in abundance,’ Judy explained, ‘but they suffered leanness of the soul.’  Leanness of the soul … that’s what happens to those who don’t trust the Lord through their trials–those who seek “worldly” remedies and don’t have the faith to believe that God will never give us more than we can handle.

Eventually, after months of complications and a harrowing labor, she had a hospital transfer and an emergency cesarean.  Her recovery was lengthy, and her mother urged her not to have more children.  Vyckie writes,

But what about God? What did He want? His word made it very plain ~ He wanted to bless us and to use our family for His glory. Who was I to say, “No. Sorry, Lord–but it’s just too difficult for me”?

Now that she has left the movement, Vyckie offers the following reflections on her experience:

Because I had made the commitment to welcome every pregnancy as an unmitigated gift from the Lord, and because I also believed that accepting government assistance in the form of Medicaid was tantamount to trusting Caesar to provide for the health and wellbeing of my babies, I desperately sought an alternative to the expensive surgical deliveries.  I know now that it was absurd for a woman with my health issues and high-risk status to eschew all medical care and trust myself and my unborn baby to an unlicensed ‘lay midwife’ – but I was idealistically motivated, and it made perfect sense to me at the time. In fact, I was absolutely certain that it was God Himself who put the idea in my head and lead me to Judy Jones….Judy’s incompetent, negligent, and abusive pre- and post-natal care…seriously endangered my life and my baby’s life, and left me so physically, emotionally, and spiritually traumatized that I suffered severe PTSD for over a year and still sometimes have nightmares almost seventeen years later.

Rebekah Pearl Anast, the daughter of Christian Patriarchy couple Michael and Debi Pearl, married Gabe, a man who quit his job to study the Bible.  The family lived in a rural home outside Gallup, New Mexico, where their electricity has been turned off because they can’t afford to pay the bill.   Rebekah has 6 homebirths assisted only by Gabe.  She does seem to have enjoyed them (at least the first 4):
Now, I have had 4 “unassisted” homebirths. It did save us 20,000 dollars all told, and has been a thrilling and bonding experience for both my husband and I.
However, she has so subsumed her own desires to those of her husband that it is unclear whether she knows how to have her own feelings.  Of her relationship to God, her home, and her husband, she says (DH means Dear Husband),
[I]f your worship of God IN ANY WAY short-changes your husband or son, or makes them feel shut out, then IMO, it is not in spirit and in truth….Remember that your husband is your lord….It really helped me to remind myself ‘this kitchen belongs to DH, the food belongs to DH, the meal is all about DH, and both me and our daughter are helpers for DH…’
Rebekah’s entire life is dictated by the whims and desires of her husband, so whatever knowledge she has of the risks of unassisted childbirth are likely to be irrelevant.
There definitely appears to be a group of women homebirthing under questionable circumstances regarding their knowledge and autonomy–but it isn’t privileged feminists beholden to misinformation campaigns of hippie websites.
%d bloggers like this: