Archives for posts with tag: human rights

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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.

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.

Is this a bowl of eggs or a a bowl of chickens?

fetilized eggs

The eggs are fertilized, so by the logic of those who believe a fertilized human egg is the equivalent of a human being, this is indeed a bowl of chickens.

And this is a fried chicken:

fried egg

 

The claim that fertilized eggs are human beings reminds me of the joke (often attributed to Abraham Lincoln),

Q: If you call a tail a leg, how many legs does a dog have?

A: Four, because calling a tail a leg doesn’t mean it is one.

One of the main arguments in Hobby Lobby’s case against providing comprehensive contraception is that  morning after pills and IUDs are abortifacients.  Many have pointed out that morning after pills (which are NOT the same as the pills that actual do induce abortion) work by preventing ovulation, and IUDs generally work by thickening cervical mucus and otherwise creating an inhospitable environment for fertilization to occur.  Olga Khazan offers a concise explanation of the whole thing at The Atlantic.

The only method that could possibly meet any definition remotely connected to abortion is the Paraguard IUD, which when inserted up to 5 days after intercourse, appears to prevent pregnancy in ways that no one has entirely determined.  It is remotely possible that one of these ways could be to prevent the implantation of a fertilized egg.

This hypothetical fertilized egg has not developed into an embryo, much less a fetus, even less a baby (or child, adolescent, adult or senior citizen).  You can see slide show showing the process of ovulation to implantation here.  The passion with which some defend the life of a fertilized egg is mirrored only by the passion with which some defend an elephant fetus as a human being (seriously, click the link–the anti abortion crowd passionately defended the humanity of the elephant fetus).  Just in case you are curious, here is a photo of a fertilized human egg:

fertilized egg

And here is a photo of an elephant fetus:

elephant fetus

By the logic of the “personhood” movement, the top image is a person and the bottom image is an elephant.

There are many problems with assigning human status to fertilized human eggs (or elephant fetuses).  But the greatest problem comes when a woman becomes not a human being in her own right, but the vessel for the development of potential humans.

Thus, the argument that Hobby Lobby and others with their beliefs make is that it is immoral for a woman to make her body inhospitable to the implantation of a fertilized egg.  We already know that the methods of contraception that they claim prevent implantation actually prevent fertilization in the first place.  But let’s go ahead and pretend that implantation of a fertilized egg might be prevented.

Why is this a problem?  About half of fertilized eggs do not implant even when a woman is not using any form of contraception at all.  By the logic of the anti-IUD crowd, women should be banned from doing ANYTHING that might interfere with implantation of fertilized eggs.  This might include things such as being underweight.  If a fetilized egg is more likely to implant in heavier women, shouldn;t we force all women to be the ideal weight for implantation?  In fact, if a fertilized egg is a person, and that “person” has the indisputable right to grow inside of another person until it decides it can survive on its own, perhaps we should force all fertile women to take drugs that make implantation more likely.

If women use contraceptives, including IUDs, they are actually less likely to expel fertilized eggs because the eggs are less likely to become fertilized in the first place.  Libby Anne at Love, Joy, Feminism has a great explanation of how using birth control is the best way to prevent the deaths of fertilized eggs/zygotes/blastocysts.  And as I have argued, if we really believed fertilized eggs to be human, we would insist on funeral services and other respectful disposal of them instead of allowing them to pass along with ordinary vaginal discharge (the fertilized egg would be expelled before menstruation; implantation occurs about 5 days after ovulation, but menstruation occurs about two weeks after).

Believing that a fertilized egg is a person does not make it so.  Believing that morning after pills and IUDs cause abortions does not make it so.  And believing that a woman is an obligatory vessel not deserving of human rights does not make it so either.

 

Dr. Patrick Johnson is the director of Personhood Ohio, “an organization committed [to] the restoring the personhood rights of unborn children through an amendment to the Ohio constitution.”

Dr._Patrick_Johnson

In case you are wondering if a woman is a person in Johnson’s intolerant mind, here is the Personhood Ohio argument against abortion:

The Ohio constitution states the following:

Article 1, Section 1: All men are, by nature, free and independent, and have certain inalienable rights, among which are those of enjoying and defending life and liberty, acquiring, possessing, and protecting property, and seeking and obtaining happiness and safety.

Article 1, Section 16: All courts shall be open, and every person, for an injury done him in his land, goods, person, or reputation, shall have remedy by due course of law, and shall have justice administered without denial or delay.

Thus (according to Personhood Ohio):

The Ohio Personhood Amendment will insert Section 16(b):

“Person” and “men” defined:

(A) The words “person” in Article 1, Section 16, and “men” in Article 1, Section 1, apply to every human being at every stage of the biological development of that human being or human organism, including fertilization.

Apparently if one gives constitutional rights to defend life and liberty and obtain happiness and safety to fertilized eggs but not women, then we have personhood.  Because everyone knows that women are not people.

In any case, Johnson has a new obsession, and that is preventing children and married men from seeing women’s breasts.  here is another area in which a woman’s breast becomes separate from the human breast.  All people have nipples and breast tissue.

There are innumerable arguments about the sexualization of women’s breasts being a social construction.  Here are a few points:

In many indigenous societies, women go topless as a matter of course, and the exposure of breasts is incidental to existing.  Here is a woman farming in Cameroon:

woman farming

In the Victorian era, when women’s sexuality was repressed and showing an ankle was scandalous, breastfeeding was a sign of mothering, which was not considered sexual.  Thus, the ankle, not the breast, was sexualized:

victorian breastfeeding

Throughout history, Mary, who was so desexualized that many worship her as a virgin, has been depicted breastfeeding with exposed breasts:

Maria-Lactans-Mary-and-Child-detail-by-Gerard-David-1490-640x784

And going topless on the beach is typical for women of all ages and sizes in much of Europe (not just for the stereotypically sexy).

Yet we have worked Americans into such a tizzy about human women’s breasts that I once had a class of fifth graders completely freak out when exposed to this image:

nude-with-oranges-1951-1

This is just black lines.  The person represented doesn’t even have a face.  Yet the very idea of a breast is somehow outrageous.  It is somewhat like thinking one must dress a zucchini in a burquah.  Or like the Shel Silverstein poem about putting a bra on camel humps.

Men have breasts, and while people might not like to see them when they are large, they can be exposed with no one challenging the legality of exposure:

imgres

Yet a flat chested women’s breast are somehow obscene:

007bflat

Women’s and men’s breasts are not particularly different.  It is actually possible for men to breastfeed.  Seriously.  There’s even a very short, highly amusing movie about it, “Milk Men,” which you can watch here.

But preventing women from exposing their breasts, particularly when exposure is incidental to breastfeeding, is a way to have men define women’s sexuality and thus demand to control women’s bodies.  When people tell women to cover up, sit in toilet stalls, or stay home because they are feeding babies, they are telling women that they cannot be female in public.  They are privileging certain people’s perceptions of a woman’s body over the actual woman in that body.

People have nipples.  Everyone is born with them.  It is not an exciting concept:

nipples

Can you even be certain which of these belong to women and which to men?

Then whose body will you know to control?

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?

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)

Image

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.

hospital access

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:

Screen Shot 2014-04-02 at 10.00.16 PM

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.

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.

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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?

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Controversies around breastfeeding surged once again last month with Social Science and Medicine‘s pre-release of Cynthia Colen and David Ramey’s article, “Is Breast Truly Best?  Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons.”*  That’s not a very snappy title, so the news sources that picked it up went with the pithier “Breastfeeding Benefits Overstated” (CNN Health) and “Is Breastfeeding Really Better” (New York Times) or with other much shorter versions of the article title.  The article looks at sibling pairs in which one child was breastfed and the other was not.  Statistical comparisons of the children at ages 4-14 on a host of factors showed that the breastfed sibling did not appear to have health, learning, or attachment advantages over the sibling who was never breastfed.

One of the problems with making any assessment of breastfeeding is that it has become a battlefield for Mommy Wars.  One side claims that breastfeeding will guarantee a gifted child who is never ill, and who will always remember to call his mother after graduating from an Ivy League school–plus it will give you an alternative to gas for your car!

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The other side retorts that most adults were formula fed and came out just fine, so there can’t possibly be any benefit to breastfeeding, plus it ties women down, shuts fathers out of parenting, and is kind of icky anyway.

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The more each side trumpets its point of view, the more entrenched each side becomes. Thus, while many news outlets represented the study’s findings as absolute truth, reporting “breastfeeding [is] no better than bottle feeding,”  Melissa Bartick, MD, who spearheaded the Ban the Bags campaign, referred to the Colen and Ramey study as “sensationalism.”

No one is helped when the main breastfeeding support organization in the U.S. states that a tenet of their philosophy is that “Mothering through breastfeeding is the most natural and effective way of understanding and satisfying the needs of the baby,” implying that mothers who don’t breastfeed can never be as attached to their babies and can never satisfy a baby’s needs the way breastfeeding mothers do.  And no one is helped when the United States is among the only countries in the world that has not implemented a single aspect of the World Health Organization’s International Code of Marketing of Breast-Milk Substitutes because no one wants to stand up to the lobbying of a multi-billion dollar formula industry.  (Just so you know, there’s not much of an industry around breast milk production).

Groups like the American Academy of Pediatrics, the World Health Organization, and health arms of the U.S. government promote the benefits of breastfeeding without much consideration of what benefits there might be in not breastfeeding.  The one-note message of these health groups tends to over-inflate breastfeeding’s benefits and to imply that mothers who breastfeed love their children more or are better mothers than those who do not.

The promotion of breastfeeding to individual mothers without equal or greater promotion of breastfeeding in the culture and structure of society is a recipe for guilt.  Colen and Ramey say,

The line between providing information about the health benefits of breastfeeding and stigmatizing mothers facing structured, valid, and often difficult trade-offs in the care and financial support of their children or in fulfilling their own human potential must be drawn sensitively.

This is a very important point.  In the United Arab Emirates, the belief in breastfeeding’s benefits is mirroring some of the U.S. body politic around pregnant women: legislation was introduced that would compel women to breastfeed.  To force one person to use her body for the benefit of another against her will is a human rights violation.  To pit mothers against their children in the name of “child rights” is unconscionable.  (Seriously, click on the link–it’s mind boggling).

This is the climate in which Colen and Ramey conducted their research.  It is perhaps not surprising that as sociologists, who generally abhor structural inequalities, they conclude that structural changes should take precedence over individual-level breastfeeding promotion:

[A] multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of ‘total motherhood’ in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks  associated with a failure to breastfeed are vastly overstated.

While I agree with the sentiment of their conclusion, I do think we need to further examine the research process that led to a finding that breastfeeding has no benefit that extends through middle childhood.

Here is a summary of their methods:

  • They used the data set from the National Longitudinal Survey of Youth 1979 (NLSY79)
  • To determine if a child had been breastfed, they used two questions, both reported by the woman. One asked if the mother had ever breastfed the child (status); the other asked her to estimate how old the child was in weeks when she stopped breastfeeding (duration).
  • The full sample included 8,237 children.  The “discordant” sample (siblings groups with one child who had been breastfed and one who had not) included 1,773 children.
  • They measured the following outcomes: body mass index, obesity, asthma, hyperactivity, parental attachment, behavioral compliance, and 5 tests of intelligence or academic achievement.
  • Outcomes were only investigated for the children from age 4-14.

Let me say emphatically that all studies have flaws and that no one study can address all research concerns.  This is why we have a body of scientific literature, and no one study should absolutely convince us of anything, especially if it is not a large, well-constructed randomized control trial.  Colen and Ramey have made an important contribution to the literature, but it is also important that they and their promotors do not overstate their case.

Current health recommendations are that all children breastfeed exclusively for 6 months.  In the U.S., it is generally advised that children continue to breastfeed in addition to eating food for at least a year.  The World Health Organization recommends at least two years.

The Colen and Ramey study

  • had no measure of exclusive breastfeeding at all;
  • had no measure of “intensity”–those who reported breastfeeding could have been breastfeeding only once a day while their child consumed primarily formula;
  • found no significance for breastfeeding duration in weeks, but did not discuss longer periods of time that would mirror recommendations (for instance, children who breast fed for 6 months and for a year);
  • did not discuss the sample sizes for each week of duration (I am guessing that the sample size for each week decreased dramatically as the weeks wore on; it is difficult to find statistically significant differences when the sample size is small);
  • did not appear to control for a number of factors that could have been important, such as the financial status of the family at each child’s birth or the child’s place in the birth order.

Colen and Ramey also are not able to examine other crucial health measures, such as the impact on the woman herself (breastfeeding is thought to have heath benefits such as reducing the incidence of diabetes and some cancers) or the impact on the children past age 14 (breastfeeding is thought to have a protective effect against some diseases that emerge in adulthood, such as Crohn’s disease).

Perhaps most importantly, they did not look at what happened to children who never consumed any formula at all, but who were fed according to standard health guidelines for infant feeding.

Ultimately, Colen and Ramey measured what the breastfeeding literature typically calls “any breastfeeding,” meaning the child was fed any breastmilk at all even once.  It is of concern that they conclude (and the reporters report) that the benefits of breastfeeding do not extend into middle childhood, rather than that the benefits of any breastfeeding do not extend into middle childhood.  Though Colen and Ramey concede that there are benefits to breastfeeding for infants, I am not certain that there are any measurable benefits to having been fed a few drops of breastmilk on one occasion.

I agree with the conclusions of an Agency for Healthcare Research and Quality (AHRQ) review,

A history of breastfeeding is associated with a reduced risk of many diseases in infants and mothers from developed countries. Because almost all the data…were gathered from observational studies, one should not infer causality based on…findings. Also, there is a wide range of quality of the body of evidence across different health outcomes.  For future studies, clear subject selection criteria and definition of “exclusive breastfeeding,” reliable collection of feeding data, controlling for important confounders including child-specific factors, and blinded assessment of the outcome measures will help. Sibling analysis provides a method to control for hereditary and household factors that are important in certain outcomes. In addition, cluster randomized controlled studies on the effectiveness of various breastfeeding promotion interventions will provide further opportunity to investigate any disparity in health outcomes as a result of the intervention.

Colen and Ramey meet only the sibling analysis recommendation.  Ultimately, their article may have done nothing more than to fan the flames of the breastfeeding battles, sending each side further into their own trenches while doing nothing to promote structural changes that might support women’s desire to breastfeed.

*You need a subscription or access to an academic library to get a copy of the full article.

There is a sense in the United States that a woman has a right to give birth in the hospital.  In fact, most people can’t imagine giving birth anywhere else.  Fewer than 2% of births in the U.S. occur outside of a hospital.  Hospitals are required to accept birthing women–even undocumented immigrant women receive emergency Medicaid to cover the cost of a hospital birth.  Insurance policies often do not cover homebirth but they are required to cover hospital birth.  While some state Medicaid programs cover homebirth (e.g. Washington), most do not.  But does a woman have the same right to birth at home that she does to birth at a hospital?

Working through ACOG and its journal, Obstetrics and Gynecology (aka The Green Journal), obstetricians vociferously push their view that homebirth is dangerous.  While there certainly may be dangers in birthing at home, recent studies have relied on birth certificate data to indicate dangers.  Marian McDorman, a senior statistician with the National Center for Vital Statistics, has said repeatedly (most recently in the Daily Beast) that vital records data are not appropriate for research: “There are quite a few limitations in using that data for that kind of analysis.”  Vital Statistics reports are descriptive in nature for this reason.

In a recent workshop I attended on linking Vital Statistics data with Medicaid claims, the statistician leading the workshop pointed out  flaws in a recent study of Apgar scores and neonatal seizures in home, hospital, and birth center births.  Among the flaws:  hospital birth certificates are generally filled out within 24 hours (while for home births, they are generally filled out later), thus truncating the time during which a seizure could  be reported for a hospital birth.  A senior statistician for the state of Washington also pointed out that homebirth midwives reliably fill out every field in the birth certificate while most hospitals rarely do.

It is hard to tell whether hospital birth is really safer than homebirth (or vice versa) for low risk births.  Politics take over the debate, and women are left with rhetoric rather than information.  For high risk births, however, there is some agreement from both sides that the intrapartum and neonatal death rates* are higher when a woman births at home.

High risk births include breech presentation, vaginal birth after cesarean (VBAC), maternal complications such as preeclampsia or gestational diabetes, and multiple gestations (e.g. twins).  While women in these circumstances are more likely to be subjected to interventions in the hospital that may be unnecessary, they and their babies have a lower risk of dying in the hospital.  These high risk conditions sometimes result in complications that simply cannot be handled adequately at home and may not present in such a way that a hospital transfer can occur in time.

Death is the ultimate negative outcome in medicine.  Long term disability for the infant or woman is also  a poor outcome.  While medicine acknowledges short term morbidities such as maternal hemorrhage or neonatal respiratory distress, these are generally not taken particularly seriously as long as everyone appears to be all right in the long run.

The question is then, should women who are well informed of the risks and benefits of home vs. hospital birth be allowed to choose where to birth?

At the Institute of Medicine Birth Settings Workshop, I chatted with a number of Certified Professional Midwives (CPMs), the kind of midwives who generally attend births only outside of a hospital.  I asked if they were willing to attend high risk home births, such as breech births.  They replied that the choice of birth setting was entirely up to the woman.  They explain the risks thoroughly, and if the woman still chooses to birth at home, they will attend her.

ACOG’s official position is remarkably similar: a woman may make choices that entail risk, even if the doctor does not agree, and should not be prosecuted or persecuted for her choices (though that doesn’t mean the doctor should provide the care). Among their recommendations in their Committee Opinion, “Maternal Decision Making, Ethics, and Law,” is

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

ACOG’s Committee opinion, “Planned Home Birth” even reluctantly acknowledges a woman’s right to birth at home:   “Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.”  (Though they do not support physicians’ attending home births.)

In an ironic twist, ACOG supports physicians who actively act in ways they believe are not in the best interests of a woman’s health as long as they explain the risks to the woman and she still wants the procedure.  While they are not obligated to perform the procedure, ACOG’s Committee Opinion, “Elective Surgery and Patient Choice,” says it is ethical for the physician to perform operations such as ovary removal or cesarean section on patient request.

In addition, as Marian McDorman has pointed out, even in high risk situations, the absolute risk of a bad outcome from homebirth is very small.  I would point out that in contrast, the absolute risk of unnecessary clinical intervention in hospitals (and associated morbidities), including administration of high alert medications such as Pitocin and unnecessary cesarean surgery, is very, very high.  In the case of a woman wishing to have a VBAC, the chance of of cesarean in a given hospital may be 100%, even if the woman meets ACOG criteria for safe VBAC.

Personally, I would choose to birth at the hospital if my pregnancy indicated that my birth would be high risk.  But that is my choice.  I would not want someone to force me to birth at home because that person thought that the relative risk of morbidity at the hospital was higher than that of death at home, or because hospital birth in the U.S. is outrageously (and unnecessarily) expensive, or because some hospitals cannot be trusted to act in the woman’s best interests as a matter of policy, or because U.S. hospital births have among the worst maternal and infant outcomes in the developed world.

A practitioner does not have to attend a high-risk homebirth (or any homebirth), just as a practitioner is not obligated to perform a maternal request cesarean.  But if it is not wrong to put a woman and infant at risk from unnecessary surgery because the woman believes that is the best decision for herself, then why is it wrong to support a woman in homebirth if she believes that is the right decision?

We need to separate ethics, which are often personal, from the law, which is universal.  As long as a woman’s body is her own, she has the right to determine where it should be, when she is giving birth, and always.

*The intrapartum rate refers to deaths during labor and delivery; the neonatal rate technically refers to the first 28 days, but it is often truncated to refer to the first 24 or 48 hours.  A study should explain which definition it is using.

I am away for a bit and leave the following to stimulate your mind and feminist sensibilities in my absence:

Updates on Marlise Munoz (see Living Wills are Not for Incubators)

Recent Thoughts on enforcing the Contraceptive Mandate (see Contraception and Forced Pregnancy and Reproductive Health, Undue Burden, and the Church of the Holy Cinder Block)

New Abortion Restrictions (see Questions from Priests for Life and “Hard’ Questions about Abortion)

 

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