April 3, 2014

Smoke and Mirrors and Women, Oh My

by Katherine L. Record

Last week, the Supreme Court attracted lots of attention when it heard arguments about whether a corporation can exclude mandatory preventive benefits from its employee health plan, based on a religious objection to certain types of healthcare.

This is a tale as old as time; religion has long been the basis for opposition to reproductive (i.e., women’s) health – including the preventive healthcare now in question, contraception.

Yet this argument has nothing to do with government infringement on the practice of religion.

In fact, the corporation, Hobby Lobby, covered two of the four contraceptive devices in dispute until its lawyers were actually arguing the issue in court, apparently to little detriment to the company’s faith in God. What’s more, Hobby Lobby’s 401(k) includes more than $73 million invested in the companies that produce these objectionable contraceptives (e.g., intrauterine devices, emergency contraception).

This has not stopped Hobby Lobby from arguing that the Affordable Care Act (ACA) is threatening its freedom, as a corporation, to practice religion.

This is a clever argument. We take religious freedom seriously, as we should. Masking coverage of FDA-approved contraceptives, as the ACA requires, as an infringement on faith is catchy. Nonetheless, it is nothing more than smoke and mirrors, which we, as attorneys, have a knack for creating.

Practicing law is often a matter of distilling a problem into sterile elements and stringing them together to form a line of reasoning that favors a given conclusion. Generally, this allows judges to apply the law with an even hand, no matter how complicated life gets.

Yet it also allows us to paint an issue as something it is not. This is particularly problematic when the issue is inequality, a concept lawyers have masqueraded for years (justifying slaves as property, segregation, limited voting rights, a narrow definition of marriage).

Last week we did it again.  Here’s the picture Hobby Lobby painted:

The ACA’s requirement that most health plans cover preventive services, including all FDA-approved contraception, violates the Religious Freedom Restoration Act of 1993 (RFRA). RFRA is a federal law that bars Congress from enacting a law that substantially burdens religious practice, even if it generally applies to all faiths, which passes muster under the First Amendment. In other words, RFRA creates more robust protection of religious freedom than the First Amendment.

Let’s break it down:

(1) RFRA protects the corporation’s right to practice religion just as it does a person’s right to practice (i.e., a corporation is a person, which is the case under the First Amendment, but has never been treated as such under this federal law);

(2) covering certain types of contraception substantially burdens this corporation’s religious practice; and

(3) the government does not have a compelling interest that justifies this insufficiently narrowly tailored intrusion into the company’s faith.

Sounds good, right?

It did to the Court. Last week, the attorney representing the United States and the Justices of the Court focused on this argument just as Hobby Lobby painted it, waxing poetic on statutory interpretation, principles of corporation law, the distinction between for-profit and non-profit tax status, and the intention of Congress as it existed in 1993 – when it enacted RFRA to protect a “person’s” right to religious practice.

All of this is irrelevant.

The legal profession is being dishonest by cloaking the real issue in legal doctrine. Hobby Lobby paints contraceptives as the Scarlett letter of the ACA, alleging that coverage of some types disrupts their Christian faith. Yet the ACA requires coverage of all FDA-approved contraception to protect women’s health – not to promote sex that does not produce offspring. In fact, 98% of sexually active Catholic women use contraception, yet the Catholic Church marches on.

As it turns out, healthcare is healthcare, even if you have a uterus.

Women who do not space out pregnancies are at higher risk for adverse outcomes – both for the mother and the child. Women who get pregnant accidentally – whether unintentionally or unwillingly, are more likely to give birth prematurely, to develop depression, to avoid prenatal care.

Moreover, some women require contraception for reasons entirely unrelated to conception (e.g., amenorrhea or menstrual irregularities, fibroids, endometriosis). And not all women can take the kind of contraception Hobby Lobby deems pious (e.g., an intrauterine device can be medically necessary if a woman cannot take the pill).

In short, women and children are healthier when medically indicated contraception is available – which is why contraception is a healthcare benefit. Requiring companies to offer the same level of healthcare to both female and male employees does not impede religious autonomy, it keeps the workforce healthy.

In June, the Supreme Court will issue a ruling couched in terms of religious autonomy. Yet it will not affect religious practice, Hobby Lobby’s or otherwise. Rather, the Court will determine whether an employer can charge women more than men for preventive services (i.e., provide comprehensive coverage for men and partial coverage for women). In other words, the Court is once again considering equality, masqueraded as a religious threat.

Are women sufficiently person-like to access the same degree of medical coverage as men? The Court very well might say no.

Fortunately, the law is not a foregone conclusion. Indeed, over time, the Court has reversed itself on matters once considered predetermined by our forefathers (e.g., the federal ban on gay marriage, criminalization of sodomy, and the status of black persons as, well, persons). Women might not be equal to men quite yet, but there is hope.

Katherine L. Record is the Senior Fellow at the Center for Health Law and Policy Innovation (CHLPI) at Harvard Law School and a member of the Our Bodies Ourselves board of directors. This post was previously published on Harvard Law School’s Petrie Flom Center Bill of Health blog.

March 28, 2014

Why Contraception is a Health Issue for Everyone

Photo “ritual” by Monik Markus used under CC BY-2.0 from https://flic.kr/p/8YaubV

Some of the media coverage of Tuesday’s arguments before the Supreme Courton the contraception mandate tended to pit women’s rights activists against social conservatives, making contraception seem like a lifestyle choice that only benefits some women — you know, the ones who have sex.

What often gets lost in the debate is why contraception is considered a preventive health issue — and why treating it as such is beneficial for everyone.

During the healthcare debate, the Department of Health and Human Services charged the Institute of Medicine (IOM) with reviewing preventive services that are important to public health and well-being, and recommending which ones should be considered in the development of comprehensive guidelines.

IOM came up with this evidence-based list of preventive services for adults and children, all of which are now covered by insurers with no required co-payment. Take a look at the IOM report, which explains the selection process.

For women, this includes annual well-woman visits, testing for STIs and HIV, support for breastfeeding, and screening and counseling for domestic violence.

It also includes FDA-approved contraception methods, as well as patient education and counseling on contraception. What makes contraception a health issue? Well, with all due respect to Mike Huckabee, it’s not about women’s libidos.

Here’s the deal: When women use contraception, they can avoid unwanted pregnancies and space planned pregnancies to promote optimal birth outcomes.

When a pregnancy is planned, women can start prenatal care, including increasing their intake of folic acid; work with their healthcare providers to address relevant medical conditions, as well as substance abuse; and take other steps that lead to healthier outcomes for both the mother and the infant.

Pregnancies that are unplanned are more likely to be affected by delayed prenatal care, maternal depression, low birth weight, poorer childhood physical and mental health, and other complications. Breastfeeding rates are also lower after unintended pregnancies.

Social conservatives should also take note that 40 percent of unintended pregnancies end in abortion. And there is an economic cost: Two-thirds of unintended pregnancies are paid for by publicly funded insurance programs, usually Medicaid. For more information, Guttmacher Institute has a terrific fact sheet on unintended pregnancies that explains the incidence rate, demographics, outcomes and costs.

When you look at the facts, contraception is smart public health policy.

Of course, for some women, birth control is essential for other health reasons, including acne, fibroids, endometriosis and to reduce problems associated with irregular or very heavy periods.

Despite the proven health benefits — and the benefits to society as a whole — Hobby Lobby and Conestoga Wood claim that the requirement to provide health insurance that includes no-cost contraception violates their religious freedom.

Not surprisingly, the Court’s three female justices were most skeptical of their position. As Jeffrey Toobin writes in The New Yorker:

After Paul Clement, the lawyer for Hobby Lobby, began his argument, twenty-eight of the first thirty-two questions to him came from Ruth Bader Ginsburg (four questions), Sonia Sotomayor (eleven), and Elena Kagan (thirteen). The queries varied, of course, but they were all variations on a theme. The trio saw the case from the perspective of the women employees. They regarded the employer as the party in the case with the money and the power. Sotomayor asked, “Is your claim limited to sensitive materials like contraceptives, or does it include items like blood transfusion, vaccines? For some religions, products made of pork? Is any claim under your theory that has a religious basis, could an employer preclude the use of those items as well?” Clement hedged in response. When Clement asserted that Hobby Lobby’s owners, because of their Christian values, did care about making sure that their employees had health insurance, Kagan shot back:

“I’m sure they want to be good employers. But again, that’s a different thing than saying that their religious beliefs mandate them to provide health insurance, because here Congress has said that the health insurance that they’re providing is not adequate, it’s not the full package.”

At Talking Points Memo, Sahil Kapur wrote:

The most forceful was Justice Elena Kagan, who repeatedly asked aggressive questions throughout the 90-minute argument about the legal dangers of exempting certain entities from laws on the basis of religion.

“There are quite a number of medical treatments that religious groups object to,” she said, positing that a ruling against the Obama administration could empower business owners to seek exemptions from laws about sex discrimination, family leave and the minimum wage. “You’d see religious objectors come out of the woodwork,” Kagan warned, arguing that it’s problematic for judges to test the centrality of a belief to a religion or the sincerity of beliefs that are invoked in court.

Much of the argument also centers around whether companies really have religious freedom, or if that really only applies to people — whether corporations count as “people” has been a major issue before the Court in the recent past. In “The Hobby Lobby Case Represents The Worst Kind Of Anti-Choice Arrogance,” Sarah Erdreich writes:

But even if the owners do have a religious commitment, Hobby Lobby is not pretending that it is a religion. It is a business. That any business should have power over what can literally be the life-and-death health decisions of its employees, well, that’s another issue for another day. But as long as Hobby Lobby sells its supplies to saints and sinners alike, it has no business questioning what its employees do when they go to see the doctor.

Access to birth control is important for everyone — for preventing pregnancies, and to allow women and families to best time and plan healthy pregnancies. Hopefully the male members of the Supreme Court will see it that way, too.

To catch up on the issue, check out this coverage:

March 18, 2014

Experts Discuss Women’s Health Movement and Healthcare Reform

“We are a very rich country, but we have rationed healthcare in a way that is unconscionable.”

Judy Norsigian, Our Bodies Ourselves co-founder and executive director, doesn’t hold back in this March 6 discussion on women’s health with Sonia Pressman Fuentes, National Organization for Women (NOW) co-founder.

Luz Corcuera, program director of Healthy Start Coalition of Manatee, Fla., hosts the dynamic conversation, which covers the history of the women’s health movement and the founding of Our Bodies Ourselves and NOW, as well as current healthcare issues, the effect of poverty on health, and more.

At about half-way in, Fuentes talks about joining the the Equal Employment Opportunity Commission in the late 1960s and being the first female lawyer in the general counsel’s office, where she encountered reluctance to enforce the sex discrimination aspect of the Civil Rights Act of 1964 prohibiting discrimination on the basis of race, color, religion, sex or national origin.

Fuentes wasn’t an activist at the time, but as one of the few women at the Commission, she found herself frequently in the position of representing women’s interests.

“Whenever an issue came up, I always said, ‘Well what about sex discrimination?’ So my boss, the general counsel, took to calling me a sex maniac because I always raised the issue of sex discrimination.”

The whole interview is well-worth watching. Thanks to Manatee Educational TV in Florida for hosting the conversation!

March 12, 2014

Teen Voices Magazine is Back, Improving the World for Girls Through Media

For 25 years, Teen Voices magazine has provided a place for journalism and other writing created by and for teenage girls. This great publication, originally based in Boston, was on the brink of shutting down last year, but Women’s eNews took it under its wing, with plans to build upon its mission of improving the world for female teens through media.

The first stories published by the new Teen Voices are now online and tackle diverse issues including recovering from anorexiawhy some women wear hijab and others don’tfeeling unworthy; and letters to celebrities as role models.

design contest for the new Teen Voices logo is currently open to 12-19 year olds; the deadline is April 3. You can also follow Teen Voices on FacebookTwitter and tumblr.

And if you’d like to support Teen Voices, there’s an IndieGoGo campaign running now through the end of March to raise funds for a “virtual newsroom,” including mentorship and paid writing assignments for teen girls.

We’re excited to see Teen Voices not only keep going, but expand the opportunities for its writers. Women’s eNews explains the need for this program and the goals:

Teen Voices at Women’s eNews will provide opportunities for education and interaction so that young women can develop and amplify their voices and contribute to issues that personally affect them.

Young women in the U.S. and around the globe often have limited knowledge of the policies, practices and rituals that influence their lives directly, giving them little opportunity to voice their approval or objection. Consider this:

  • Alongside nudity and hypersexualization in film, female teens and women between the ages of 13 and 20 are more likely than others to be referred to as “attractive” as their main attribute, according to theWomen’s Media Center’s 2012 Status of Women in the U.S. Media report.
  • Young female characters are outnumbered by boys 3-to-1 among the top-grossing G-rated family films, according to the Geena Davis Institute on Gender in the Media. This trend makes young women invisible, removes role models and results “in negative gender stereotypes imprinting over and over.”
  • Female teens surveyed by the Girl Scouts in 2011 accepted that their lives should be like that of women on reality TV shows and expected a higher level of drama, aggression and bullying in their own lives. The media is influencing young women to believe that “it’s in girls’ nature to be catty and competitive with one another.”

Teen Voices at Women’s eNews will provide honest and objective information about issues directly affecting female teens around the world, and serve as a powerful outlet for young women to express their views on issues of particular concern to them.

The project is being led by Lori Sokol, Ph.D., the new publisher of Teen Voices at Women’s eNews, theWomen’s eNews editorial, marketing and development staff and a diverse board of teenagers who will consult and advise on the issues being covered.

Don’t forget to check out the IndieGoGo campaign today!
Also! Our Bodies Ourselves has multiple back issues of the print edition of Teen Voices that we would like to give away. They are available for the cost of postage, $13 per box. If you are interested, send a check made out to “OBOS” to: Our Bodies Ourselves, 5 Upland Road #3, Cambridge, MA 02140. Be sure to include the address where the magazines should be sent. For more information, email: office AT bwhbc.org

February 28, 2014

Stillbirths and Infant Health Risks Higher in California’s Artificially Conceived Infants

by Miriam Zoll

A new study published in the Journal of Perinatology online has found that in California from 2009-2011 there was a 24- to 27-fold increase in multiple births and significantly higher rates of preterm births, lower birth weights, fetal anomalies and stillbirth among infants born through assisted reproductive technologies (ART) or artificial insemination (AI) compared to babies conceived naturally.

The retrospective study was based on 2009-2011 data from the California Office of Statewide Health Planning and Development and conducted by researchers from the Loma Linda University School of Medicine.

The CDC’s Assisted Reproductive Technology Surveillance report for 2010 indicates that “ART-conceived births were highest in California, followed by Texas and New York,” and that nationwide that year, 46.4 percent of all ART births were multiples, compared to only three percent among naturally conceived infants.

While California has the most infertility clinics of any state in the country, the large increase in multiple births from ART/AI found in the study was higher than but not significantly different from those reported nationally. However, data from the Centers for Disease Control and Prevention (CDC) indicate that California’s rates of low- and very low-birth weight infants, as well as premature and very premature infants, exceed national averages.

According to the new Journal of Perinatology study, in 2009, 18,405 California women underwent ART cycles, which refers to procedures in which the egg and sperm are handled outside the body. Of the total number of women in California undergoing ART, only 3 percent of women underwent AI or intrauterine insemination.  A total of 15,953 embryos were transferred, resulting in 7,155 pregnancies and 5,710 live births. Roughly 1,718 of these births — or 30.1 percent — were multiple births consisting of twins, triplets or more.

The researchers found that when compared to naturally conceiving women, preterm labor and cesarean section were four times higher for women who underwent ART/AI, and their length of stay in hospital was twice as long. Compared to infants conceived naturally, among ART/AI pregnancies, there was a four- to five-fold increase in stillbirths, and a two to three-fold increase in fetal anomalies.

These findings align with those from another California study conducted by researchers at UCLA and published in 2013 in the Journal of Pediatric Surgery. Compared to naturally conceived babies, researchers found higher rates of congenital malformations among ART multiple babies — particularly of the eyes, neck, heart and urogenital tract.

In one case study highlighted in the Journal of Perinatology report, of 92 ART/AI infants born at Loma Linda Children’s Hospital over an 18-month period from 2012-2013, 10 very premature babies died on the first day. Seventeen were singleton births, with half requiring admission to the Neonatal Intensive Care Unit (NICU). Of the 27 pairs of ART/AI twins, one was stillborn, four deaths followed shortly after birth, and 22 sets were admitted to NICU. Three deaths occurred in two out of six sets of triplets and all surviving triplets required admission to the NICU. The average NICU hospitalization length of stay for these ART/AI babies averaged 38.4 days, with a range of anywhere from three to 138 days.

“We need to educate the public about these very serious risks,” Dr. Mitchell Goldstein of the Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine,who co-authored the report, said in an interview. “If elective single embryo transfers became a higher priority among infertility specialists, we would likely see significant reductions in these severe health and stillbirth rates among ART/AI infants and reduced risks for mothers.”

Throughout the United States, the higher incidence of multiple and preterm births linked to ART/AI remains a significant public health concern, particularly for older women and their babies. A 2013 article in the New England Journal of Medicine estimated that 36 percent of twin births and 77 percent of triplet and higher-order multiple births in the U.S. were attributable to medically assisted conceptions.

The American Society for Assisted Reproductive Medicine recommends that reproductive endocrinologists transfer single embryos for most women, yet many doctors continue to transfer multiple embryos with the hope of procuring at least one live birth.

“Once a patient becomes pregnant through ART/AI,” explained Goldstein, “many reproductive endocrinologists lose touch with them and are then completely disconnected from any risks mother and infant may encounter. Neonatologists and infertility specialists must work together to reverse these trends and ensure the least harm.”

The findings from this study reflect one conducted by the University of Adelaide of roughly 300,000 patients in Southern Australia who had received assisted conception between January 1986 and December 2002. Published in January 2014 in PLOS ONE, the study also found higher rates of stillbirth, prematurity, low birth weight and neonatal deaths among ART infants.

But in this Australia study, even singletons from assisted conception were more likely to be stillborn or have low birth weight than babies born from spontaneous conceptions. Outcomes varied by type of assisted conception. For example, very low and low birth weight, very preterm and preterm birth, and neonatal death were markedly more common in singleton births from IVF, and to a lesser degree, in births from intra-cytoplasmic sperm injection (ICSI) where the one sperm is injected directly into the egg. Using frozen-embryos eliminated all significant adverse outcomes associated with ICSI but not with IVF.

In my next post, I’ll look more closely at the financial costs of babies born through assisted technology and what this might mean for insurance coverage.

Miriam Zoll is a member of the Our Bodies Ourselves board of directors, an independent journalist and the author of the new book, “Cracked Open: Liberty, Fertility and the Pursuit of High-Tech Babies.“ 

This blog was previously published on the USCAnneberg Reporting on Health Member Blog and is reposted with permission. Image by TipsTimesAdmin via Flickr.

February 28, 2014

It’s all about equality, right?

by Andrew Gordon

As a lifelong and active liberal, I walked into Dr. Jill Gillespie’s Intro to Women’s Studies class my senior year at Denison University thinking that I knew the gist of what would be taught to me. It’s all about equality, right? Of course women should be treated the same as men.

It never occurred to me that the dialogue would have deeper implications, let alone that I would begin to understand some of what drove my own unhappiness within my own heteronormative identity. Up until that class, I’d never used the word “heteronormative” in my life. Dr. Gillespie used the “Our Bodies, Ourselves” textbook in conjunction with belle hooks’ “Feminism is for Everyone” and other articles to wondrous effect.

The more I read, the more and more I became fascinated with the composition of the male gender identity, particularly that it is, as hooks’ describes it, premised on domination of other identities and, therefore, without a resting identity of its own. These words were so powerful for me because they spoke to my own unhappiness as a man so profoundly.

I began looking at my classmates and myself through a different lens, watching us “perform” what we thought it meant to be masculine, especially in the context of being a romantic partner to a woman. I can vividly remember a mid-semester phone conversation with one of my close friends back home. He bemoaned the futility of a being in a relationship because it was just impossible to be what woman want and that being a “nice guy” wasn’t enough.

I responded that perhaps our fundamental premises about relationships were wrong from the start. To assume that it is always our fault when a relationship does not happen or doesn’t work out not only robs a partner of her agency and the validity of her own preferences, but also fails to hold us as men accountable for the behavior that IS actually problematic. Instead, we just keep striving striving striving under the assumption that the only reason why we are not with someone is that we are doing something “wrong” or unattractive. While subtle, I look back on this moment as something of a personal revelation, even if my friend probably couldn’t appreciate it at the time.

Dr. Gillespie’s use of “Our Bodies, Ourselves” helped deepen our class discussion further and allowed me to build on my own revelation and core takeaways about the masculine identity. More than anything I learned in college, these were ideas that applied directly to my life and my own happiness. As I began to more confidently assert myself as a “feminist,” it was from a much more personal standpoint. For me, feminism was and is the key to unlocking and reshaping masculinity as a non-oppressive force. I came into the class with a bit of arrogance and left with a changed life. “Our Bodies, Ourselves” was big part of that.

February 20, 2014

New Data Shows IVF Use Has Steadily Grown

Photo: IVF Capillary Tube Insertion by ZEISS Microscopy licensed under CC BY-NC-ND 2.0

The Society for Assisted Reproductive Technology has released new data on in vitro fertilization (IVF) use in the United States during 2012, and the numbers are up — way up.

The organization, which represents IVF providers, reports that more than 165,000 cycles of IVF were performed in 2012, making it the biggest year ever in terms of both IVF procedures and the resulting babies born. By comparison, doctors performed about 113,000 cycles in 2003.

More than 61,000 babies were conceived using this technology in 2012, amounting to about 1.5 percent of the 3.9 million births that year.

Another number is on the decline: the number of high-risk multiple births from IVF.

“If we dig deeper into the data, there has been a marked reduction in triplets,” Charles Coddington III, an OB-GYN at the Mayo Clinic in Rochester and president of SART, told NPR. “Everyone is really attuned to reducing triplets.”

In 2003, women between the ages of 35 and 40 had about a 6 percent chance of having triplets during a successful IVF procedure. Now the odds have dropped to 0.7 percent.

The reason for the decline, Coddington says, is that couples and their doctors are choosing to use fewer embryos during each cycle. “It isn’t across the board,” Coddington says. “There are still outliers. But the trend is really good. So we’ve had a better year in terms of triplets.”

The chance for twins is also less than it was a decade ago. But the rate is still high, especially for women younger than 40. About a quarter of all successful IVF cycles for women in this age group resulted in twins during 2012, the study reported.

The problem with twins and triplets, Coddington says, is that they raise the health risks for both moms and babies.

Single embryo transfer is the most effective way to reduce riskier multiple births.

Unfortunately, as the newly released numbers show, many cycles of IVF never result in a baby.

Miriam Zoll, an Our Bodies Ourselves board member and author of “Cracked Open: Liberty, Fertility and the Pursuit of High Tech Babies,” noted in a Reuters article this week that women over age 35 have higher percentages of failures with IVF and that “these treatments have consistently failed two-thirds of the time since 1978,” when the first “test tube baby” was born.

For more information on IVF and related issues such as egg donation, surrogacy and related topics, read our blog posts on reproductive technology, including “What’s Wrong With Fertility Clinics and Online Advertising” and “Truth in Medicine: Vast Majority of Assisted Reproductive Technologies Fail.”

February 14, 2014

New Study Raises More Questions About the Value of Mammograms

This chart, published in British Medical Journal, shows that the breast cancer mortality of patients who underwent mammogram screening vs. those who did not is practically equal.

new, long-term study in BMJ provides perhaps the most compelling argument to date that screening mammograms may not be effective in reducing the death rate from cancer and may in fact cause harm from overtreatment in some women.

The study is based on results from the Canadian National Breast Screening Study. For this research, 89,835 women ages 40 to 59 were randomly assigned to receive either annual mammograms for five years, or no mammograms during the study period. All of the women received breast exams by trained nurses. The women were followed for up to 25 years to see which of them died of breast cancer.

Based on the data, the authors report that there was no difference between those who had screening mammography and those who didn’t in terms of their likelihood of dying from breast cancer. The authors conclude:

Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.

Put simply, this means that one in five cancers do not pose a deadly threat, yet these women may still undergo treatment, including surgery, chemotherapy and radiation.

A New York Times article this week summarizes the research, and provides some commentary from doctors. Among them, Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina, Chapel Hill, commented that the results “will make women uncomfortable, and they should be uncomfortable.”

“The decision to have a mammogram,” he added, “should not be a slam dunk.”

New York Times reporter Gina Kolata explains that the number of cancers treated unnecessarily would be even higher if a precancerous condition had been included in the study:

Many cancers, researchers now recognize, grow slowly, or not at all, and do not require treatment. Some cancers even shrink or disappear on their own. But once cancer is detected, it is impossible to know if it is dangerous, so doctors treat them all.

If the researchers also included a precancerous condition called ductal carcinoma in situ, the overdiagnosis rate would be closer to one in three cancers, said Dr. Anthony B. Miller of the University of Toronto, the lead author of the paper. Ductal carcinoma in situ, or D.C.I.S., is found only with mammography, is confined to the milk duct and may or may not break out into the breast. But it is usually treated with surgery, including mastectomy, or removal of the breast.

These findings are unlikely to result in any immediate change in what doctors recommend to women, and are likely to cause controversy among experts.

An accompanying editorial in BMJ, “Too Much Mammography,” explains the strengths and limitations of the study, and notes that it is difficult to make changes around screening mammography practices “because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.”

Indeed, the American College of Radiology — which represents radiologists who perform and interpret mammograms — has issued a statement criticizing the study. This organization also objected to the 2009 recommendations on routine mammography, put forth by the U.S. Preventive Services Task Force, which we discussed here.

The National Partnership for Women and Families also provides a summary of the research, and Breast Cancer Action has issued a response as well, noting that the findings may not apply equally to all women:

The information that we have seen from this study does not let us draw conclusions for specific communities, many of which are most affected by higher morbidity rates. Given the unequal burden that women of color bear when it comes to breast cancer morbidity and mortality, questions remain as to whether there are different findings for difference communities. Absent this evidence, there are no clear answers for women of color. The growing body of evidence, of which this study is part, continues challenge long-standing and commonplace assertions that mammograms are a driving factor in reducing death rates.

What this research makes clear, however, is that we need more effective methods for detecting breast cancer, and new ways of determining which cancers need treatment.

Previous posts on the evidence about mammograms include:

February 11, 2014

In Memoriam: Dr. Gary Romalis

Dr. Gary Romalis, a major proponent of women’s reproductive health and rights, died on Jan. 30 at age 76.

Dr. Romalis was dedicated to helping women by providing abortion. In a 2008 speech at University of Toronto, Romalis addressed some of the horrible consequences he had witnessed of unsafe abortions, and explained why he chose to provide abortions:

I can take an anxious woman, who is in the biggest trouble she has ever experienced in her life, and by performing a five-minute operation, in comfort and dignity, I can give her back her life.

Dr. Romalis life was threatened multiple times by anti-abortion extremists. In 1994, Romalis was shot by a sniper while eating breakfast in his home. In 2000, he was stabbed by a man as he was entering his Vancouver office. After recovering, Romalis kept working — in fact, after 2000, he limited his practice to only abortions.

Judy Norsigian, Our Bodies Ourselves executive director, remembered the effect this violence had on Romalis and his family:

Dr. Romalis was not only a brave physician who continued to provide abortion services after two frightening attempts to kill him, he was a constant role model for medical students and residents considering a career in the reproductive health field.

I will never forget the day my late husband, Irv Zola, chair of the sociology department of Brandeis, came home after comforting Dr. Romalis’s daughter, then a student in my husband’s class. She was so shaken and bewildered that anyone would want to attack her sensitive and caring father, and being 3,000 miles away from him made it even harder.

Renee Ghert-Zand, a family member of Dr. Romalis, writes in The Forward:

My cousins have lost an exceptionally warm, loving and involved father and grandfather. The Vancouver Jewish community has lost a compassionate and committed member. Canada has lost a courageous physician who let nothing stand in the way of his doing the right thing.

Toward the end of his 2008 speech, Gary said: “After an abortion operation, patients frequently say ‘Thank You Doctor.’ But abortion is the only operation I know of where they also sometimes say ‘Thank you for what you do.’”

Thank you for what you did, Gary.

Our condolences are with Dr. Romalis’s family, as is our gratitude for his lifetime of service.

Remembrances of Dr. Gary Romalis:
NAF Mourns the loss of Member Dr. Gary Romalis
Department of Obstetrics and Gynecology Mourns an Iconic Member
In Memoriam – Dr. Gary Romalis

February 7, 2014

U.S. Abortion Rate Drops, But What Do the Numbers Mean?

The U.S. abortion rate has declined to its lowest levels in four decades, according to a new report from the Guttmacher Institute.

As of 2011, the rate had declined to 16.9 abortions per 1,000 women aged 15–44, almost half of what it was in 1981 (29.3 per 1,000 women) and the lowest since 1973 (16.3 per 1,000).

While the record number of abortion restrictions passed in 2011 may come to mind as a possible cause, the data used largely predate those restrictions.

The Guttmacher report also notes that even states that did not implement new restrictions during the study period also saw declines:

It is crucial to note that abortion rates decreased by larger-than-average amounts in several states that did not implement any new restrictions between 2008 and 2010, such as Illinois (18%) and Oregon (15%). So, even in states like Louisiana and Missouri, we cannot assume that the new restrictions were responsible for the decline in abortion incidence.

More plausible explanations, according to the report, might be the increase in long-acting, highly effective methods of contraception such as IUDs; increasing use of birth control among young women in general; and overall declines in the pregnancy and birth rate.

This doesn’t mean, however, that the surge of restrictions enacted over the past several years will not have a negative impact on women’s access to abortions — it just doesn’t show yet in the data.

Judy Norsigian, Our Bodies Ourselves executive director, had this to say about the numbers:

At this point, it is misleading to suggest that restrictions don’t make a difference.  The restrictions that we are seeing now, after this study was done, are of an entirely different order, because they are causing a dramatic rise in the closing of clinics. Just look at the crisis in Texas now. We know that abortion providers in Texas and other impacted states will continue to do their best to meet the needs of the most vulnerable women who can’t afford to travel to places where abortion services are available, but these providers will face huge obstacles.

It is also important to recognize that although there may be a reduction in the abortion rate overall, the rate rose nearly 18 percent among the country’s poorest women — a trend that might reflect the growing economic challenges facing women now. Of the more than 1.2 million legal abortions reported in 2008, women whose family income fell below the national poverty level accounted for 42 percent of these abortions.

For further exploration of Guttmacher’s results and the reasons behind the numbers, see:

February 5, 2014

Does Viewing an Ultrasound Deter Women from Having an Abortion?

ultrasound viewing study

Source: Relationship Between Ultrasound Viewing and Proceeding to Abortion / Obstetrics & Gynecology January 2014

We all know what forcing women to undergo and view ultrasounds prior to an abortion is supposed to do — influence women to carry their pregnancies to term.

That’s why crisis pregnancy centers, which operate with an anti-abortion agenda, offer ultrasounds even though most are not equipped to provide medical services, and anti-abortion mobile buses park near schools and offer free ultrasounds to pregnant women.

But does viewing an ultrasound really deter women from choosing abortion?

According to research findings, bolstered by a new study, the answer is probably no.

Researchers from University of California, San Francisco and Planned Parenthood looked at data for more than 15,000 women seeking abortions at a Los Angeles Planned Parenthood clinic in 2011. All patients underwent a pre-procedure ultrasound, which can be standard in abortion care, and all were offered the opportunity to view the ultrasound screen. (Mandating that women undergo an ultrasound, view it, and listen to a description of the fetus is a whole other issue.)

Less than half, 6,346 women, chose to view it. Almost all of them, regardless of their viewing choice, went on to have abortions (98.8 percent).

Researchers also considered how certain the women felt about their decisions to have an abortion. Women who were highly certain about their decision did not waver, regardless of whether they viewed the ultrasound.

As might be expected, women who were were less certain of their decision to abort the pregnancy and who viewed the ultrasound were slightly less likely to have an abortion than like-minded women who did not view it (95.2 percent of those who viewed it continued with the abortion compared with 97.5 percent of those who did not).

Other factors, such as gestational age, weighed more heavily on the decision. Women who were 17 to 19 weeks pregnant, for example, were almost 20 times more likely to continue the pregnancy than women up to nine weeks pregnant, regardless of whether or not they viewed the ultrasound. The authors suggest that this may have to do with women’s feelings about terminating a pregnancy earlier vs. later.

The authors caution that their findings may be different from situations in which the ultrasound is forced, but they conclude that mandatory viewing should be avoided:

Finally, these results cannot be generalized to women’s experience of ultrasound viewing in settings where it is mandatory, although given the very high percentage of women proceeding with abortion after viewing the ultrasound image, it is unlikely that mandatory viewing would substantially affect the number of abortions performed. It may, however, affect patient satisfaction and health outcomes, which research shows are enhanced when patients feel control over decisions related to their care. Mandating that women view their ultrasound images may have negative psychological and physical effects even on women who wish to view.

The clinical implications of this study are twofold. First, women should be offered the opportunity to voluntarily view their ultrasound images before abortion. However, because fewer than half of women select this option, mandatory viewing should be avoided. Second, health care providers engaged in ultrasound viewing should be sensitive to how patients react to their images but avoid making assumptions about the effect of viewing on patient decision-making. Patients with low decisional certainty about the abortion decision may need more time and support in reaching a decision about whether abortion is the correct decision for them.

For more on the use of ultrasounds in the context of abortion, read this excellent commentary by Tracy Weitz, one of the study’s authors and director of the Advancing New Standards in Reproductive Health (ANSIRH) at UCSF (and a contributor to “Our Bodies, Ourselves”). Written last March, during the height of political battles around mandating transvaginal ultrasounds, Weitz takes a closer look at the weak rationale for anti-abortion activists thinking that ultrasound viewing would reduce the number of abortions.

To date, she notes, “no peer-reviewed empirical data has supported this proposition that viewing an ultrasound image discourages women from abortion. In fact, what limited information does exist suggests that women seeking abortions have a range of experiences associated with viewing their ultrasound and any mind-changing occurs in a complex context that may or may not include ultrasound viewing along with other factors.”

Conversations about mandatory ultrasound, Weitz argues, should be focused on how these laws drive up costs, make providing abortion care more difficult, do not improve health outcomes, and eliminate patient autonomy.

To learn more about situations and states in which ultrasounds are regulated in the context of abortion, view this fact sheet from Guttmacher Institute. Currently, three states mandate that an abortion provider perform an ultrasound and show and describe the image; eight states mandate the ultrasound and require the provider to offer the patient the opportunity to view the image.

January 31, 2014

Your Ad Here: Help Our Bodies Ourselves Advertise in The Boston Globe!

Boston Globe GRANT program

Can you imagine if Our Bodies Ourselves took out an ad in The Boston Globe? We could announce the launch of our new website (coming soon!) and the important work OBOS is doing to develop and promote accurate information about girls’ and women’s sexual and reproductive health!

If you’re a Boston Globe subscriber, print or digital, you can help make that ad a reality — and it won’t cost a thing.

All subscribers are being sent an email or letter — look for the silver envelope — from the Globe about its new GRANT program (Globe Readers and Non-Profits Together), which enables readers to select a group to receive free advertising in the Globe.

Please write in the name of Our Bodies Ourselves on the GRANT gift check so we can inform the public about our valuable programs in the United States and abroad. And encourage friends and family members to do the same!

Boston Globe GRANT programSeven-day newspaper subscribers’ vouchers are valued at $100; all other subscribers (including web-only readers) have been sent vouchers valued at $50. Nonprofits will be given free advertising space based on the total amount readers allocate.

The deadline for submissions is March 1, 2014. If you are a subscriber and did not get a silver envelope or have misplaced yours, please email customer service (natalie.bean@globe.com), or call the Globe (617-929-3198) to get another one.

Other questions? Here’s a FAQ for subscribers.

Thank you so much from all of us at OBOS!

January 30, 2014

“Voice Male”: New Book on the Social Transformation of Masculinity

When I first started reading Voice Male magazine some years back, I felt a strong sense of appreciation and urgency about this magazine being widely read.

Here at Our Bodies Ourselves, we have long worked with male allies who share common values and goals, but too often their work has been under the radar — both both in terms of media recognition, and visibility within women’s and community organizations that would welcome them as collaborators.

We know some tremendous work is being done around issues of masculinity and, of course, in the arena of gender-based violence. Voice Male has been at the forefront of promoting these efforts.

As my colleague Jackson Katz has written, Voice Male is for the anti-sexist men’s movement what Ms. magazine has been for the women’s movement.

Now comes the new book, “Voice Male: The Untold Story of the Profeminist Men’s Movement,” in which the magazine’s editor, Rob Okun, introduces readers to, as he puts it, “one of the most important social justice movements you’ve never heard of — the social transformation of masculinity.”

It’s a welcome addition to the canon on gender justice. Tackling a topic as comprehensive as the pro-feminist men’s movement is a daunting task, especially when we consider the movement began in the late 1970s. Okun’s approach is both inviting and instructive.

I admit I’m biased (I reviewed the book before publication and provided advance praise), but outside reviews also have been excellent. Publishers Weekly has a good write-up, and Library Journal concluded: “A very worthwhile introduction to the profeminist movement among men. It will reward both casual readers and serious students of the subject.”

Following a forward by well-known sociologist Michael Kimmel, Okun uses the first chapter to tell the story of the movement, offering compelling highlights that bring to life its rich history. And, showing his activist roots (for many years he was executive director of the Men’s Resource Center for Change in Amherst, Mass., one of the earliest men’s centers in the country), he brings the narrative into the here and now, presenting short profiles of 20 of the most effective pro-feminist men’s organizations in North America, and a few overseas.

The next 11 chapters feature around 140 essays, articles and moving first-person stories by both men and women, some famous, some not, spanning three decades of the magazine. The writing runs the gamut — boys to men, men of color, GBTQ issues, fathering, men and feminism, men’s heath, male survivors, overcoming violence, what is healthy masculinity, and manhood after the school shooting in Newtown, Conn. The book includes nearly 15 pages of resources on all of these topics, and has nearly that many pages in a comprehensive index.

“Voice Male” will be eye-opening and inspiring to students in gender studies programs, and a powerful organizing tool for activist organizations. Hopefully, too, it will find its way onto the bookshelves in homes where anyone interested in social justice lives.

Please join OBOS in getting the word out about this new resource, and get a copy for every young man in your life.

January 27, 2014

Bill Regulating Certified Professional Midwives Needs a Push

Once again, a bill that would license and regulate certified professional midwives, or CPMs, has been introduced in the Massachusetts legislature. And it’s time for the Commonwealth to join the 28 other states in this country that already have adopted such regulation.

CPMs are educated to develop hands-on expertise in the home or birth center setting. Maternity care professionals with many decades of experience as well as prominent consumer organizations are supporting this bill because they believe it will increase the safety of home birth for families choosing this option.

Among these professionals writing to the legislature are pediatricians, obstetricians, midwives and academic researchers. Below are excerpts from some of their letters:

Martha Richardson, MD, practicing obstetrician in the Boston area for 33 years: “Home birth is an option in some states and in many countries including some where the overall birth outcomes are better than in the U.S. Bringing home birth under public surveillance in Massachusetts is unlikely to worsen outcomes and could help us address our lack of reliable information.”

Robyn Churchill, former director of midwifery at Mt. Auburn Hospital: “I am a Certified Nurse Midwife with over 20 years of clinical and research experience in maternal health care. I…am now at the Harvard School of Public Health, working on a large trial of the WHO Safe Childbirth Checklist in India … My experience and research has shown that safe childbirth can occur in many settings, within a well-coordinated system, with regulation and oversight of providers.”

Lisa Paine, a certified nurse-midwife and DrPH long involved at the national level with policy development to improve health education and regulation: “For nearly 30 years I have been involved in a variety of clinical, academic and administrative roles related to maternity care, midwifery and public health … My policy and advocacy experiences are numerous and have led to several publications and testimonies, including undertakings directly relevant to my support of this legislation … these fully support House Bill 2008/Senate Bill 1081.”

In its testimony opposing this legislation, the Mass Medical Society (MMS) makes several incorrect statements. For example, it asserted that “CPMs have not adopted a set of criteria based on generally accepted medical evidence or public safety for patients who may be appropriate candidates for home birth, relying instead on the decision of the individual midwife and patient.”

This is not true. Although CPMs respect a women’s right to informed consent in childbirth (as all health professionals should do), the CPM profession, through the National Association of Certified Professional Midwives, has clearly defined professional guidelines and standards. Also, many state midwifery organizations have developed extensive practice guidelines because licensure laws were passed in their states.

One good example is New Mexico, where CPMs are regulated and licensed by the Department of Health. Extensive clinical guidelines have been developed by the state midwifery association and are enforced by the New Mexico state licensing and disciplinary authority. House Bill 2008/Senate Bill 1081 would allow Massachusetts to place similar guidelines on CPM practice here.

No state adopting the regulation and oversight of CPMs has reversed its policy. Some states — Texas, Colorado, and California, for example — have more recently reaffirmed these earlier legislative decisions.

CPMs are specifically educated to develop hands-on expertise in the home or birth center setting.  The CPM credential is overseen and certified by the same national organization that validates the CNM credential for nurse-midwives.

The Massachusetts Medical Society also states: “The curriculum, clinical skills training, and experiences of CPMs have not been approved by any authority recognized in certifying knowledge and skills associated with the practice of obstetrics, including the American Board of Obstetrics and Gynecology, the American Midwifery Certification Board (AMCB), and the American Board of Family Medicine.”

These three entities do not engage in the approval of curricula for other professionals in their fields, so this comment is not actually relevant.

The Committee on Public Health should report this bill out favorably, so it can advance to the next step in the legislative process, and eventually be released to the floor for a vote and enable the state to oversee this growing health profession. 

Failure to license CPMs will make the several hundred home births that occur in Massachusetts every year less safe by failing to create an integrated maternal health care system with enhanced collaboration among all care providers. This bill would affirm that all Massachusetts maternal health care providers are committed to practicing with state oversight and public accountability.

Please make your voice heard by contacting your legislator and by signing a petition in support of the Massachusetts Midwifery Bill, sponsored by the Massachusetts Midwives Alliance and the Massachusetts Friends of Midwives.

This article was originally posted at Cognoscenti, WBUR Boston’s ideas and opinions section, and is re-posted with permission.

January 23, 2014

Free, Online Course on International Women’s Health and Human Rights

International Women's Health and Human Rights Course

Interested in learning more about women’s health and human rights? A free, online course offered by Stanford University kicks off Friday, Jan. 24.

The course is open to everyone — you just need an interest in health and social justice and an online connection.

Anne Firth Murray, founding president of the Global Fund for Women and a consulting professor in human biology at Stanford, is leading the course. A contributor to “Our Bodies, Ourselves,” Murray moderated a panel on global activism at OBOS’s 40th anniversary symposium.

Participants can join in as their schedule allows. Course materials will be released Friday afternoons at 5 p.m. PST, and you can watch lectures and interviews with scholars and NGO leaders, complete interactive activities, and join fellow students in the forum on your own time.

In the video below, Murray explains how this class uses a lens of human rights to look at health issues, going beyond the traditional material on maternal and infant health.

“I knew there were many more issues than that, that women were concerned with,” says Murray.

Here’s the course write-up:

This course provides an overview of women’s health and human rights, beginning in infancy and childhood, then moving through adolescence, reproductive years and aging. We consider economic, social, political and human rights factors, and the challenges women face in maintaining health and managing their lives in the face of societal pressures and obstacles.

We focus on critical issues, namely those that may mean life or death to a woman, depending on whether she can exercise her human rights. These critical issues include: being born female and discrimination; poverty; unequal access to education, food, paid work and health care; and various forms of violence. Topics discussed include son preference, education, HIV/AIDS, reproductive health, violence in the home and in war and refugee circumstances, women’s work, sex trafficking, and aging.

Our open online course (often abbreviated as a “MOOC”) will have a special focus on creating an international network of engaged students. We will ask students to take part in interactive discussions and cooperative exercises and to share their own experiences. We also ask students to engage with the communities they live in, in order to deepen their understanding of the issues and tie academic ideas to real-life circumstances.

The course textbook will be Murray’s book “From Outrage to Courage: Women Taking Action for Health and Justice,” a terrific resource that Our Bodies Ourselves Executive Director Judy Norsigian used when teaching a women’s health advocacy course at Suffolk University. Individual chapters will be posted online.

Participants who complete the course will receive a statement of accomplishment from Stanford University.

Interested? Learn more at InternationalWomensHealth.org.

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