Medscape, a website from WebMD targeted primarily to healthcare providers and professionals, has just published an interesting interview with Carol Sakala, PhD, MSPH on the need to transform maternity care in the United States. Sakala is the Director of Programs for Childbirth Connection and co-author of the report, Evidence-Based Maternity Care: What it is and What it Can Achieve [PDF].

In it, Sakala discusses maternity care in the context of healthcare reform, noting the lack of focus on maternity care quality, outcomes, and value despite its “major role in the nation’s healthcare system.” She also addresses overused and underused interventions in maternity care; the need to have evidence-based practice guidelines based upon good quality studies rather than expert opinion; VBAC; provider and birth place choices; and barriers to transforming care.

Asked about her vision for the future of maternity healthcare, Sakala responded:

I’d like to answer this question by paraphrasing the final paragraph from the Transforming Maternity Care Vision paper, and I encourage Medscape readers to read that paper and the blueprint as well, and consider becoming involved in blueprint implementation.

In describing the vision, the Vision Team says that:
The 2020 Vision for a High-Quality, High-Value Maternity Care System will be actualized through concerted multi-stakeholder efforts ensuring that all women and babies are served by a maternity care system that delivers safe, effective, timely, efficient, equitable, woman- and family-centered maternity care. The US will rank at the top among industrialized nations in key maternal and infant health indicators, and will achieve global recognition for its transformative leadership.

The whole interview is well worth a read for a good discussion of U.S. maternity care issues. Medscape requires a free registration in order to view the article. Readers may also be interested in Amnesty International’s recent report, “Deadly Delivery: The Maternal Health Care Crisis in the USA.” [PDF]

As many of our readers will already know, the National Institutes of Health held a consensus development conference last week on vaginal birth after cesarean in the U.S., featuring panelists who spoke about VBAC trends, medical evidence, risks and benefits to women and babies, non-medical factors influencing VBAC availability (such as fear of legal liability), and related topics.

Materials from the conference are available at http://consensus.nih.gov/2010/vbac.htm, including the draft panel statement, archived webcasts from each day of the conference, the previously completed evidence report on VBAC, and call-in access to the archive of a telebriefing that followed the event wrap-up (a transcript will be available soon).

One important topic included perceptions of the risk of trial of labor; a speaker who reviewed factors associated with uterine rupture and other adverse outcomes stated that “there is a major misperception that trial of labor is extremely risky,” calling the risks to women comparable to other common medical procedures. Amy Romano provides additional commentary on uterine rupture risk at Science & Sensibility, noting that “we heard a rather consistent message that uterine rupture itself is not the issue.”

There was an excellent audience question following the presentation about whether, if successful VBAC carries the lowest morbidity, it is ethical for providers to refuse to allow a trial a labor. One panelist’s response was, “I think that’s the point of the conference.” Audience discussion sections for day one start at about 1:41, 3:01, 4:03, 5:55, and 7:19 [hour:minute].

Day one also featured another presenter, Dr. George Macones, who challenged ACOG’s “immediately available” physician and anesthesiologist standard for offering VBAC. This requirement has effectively led to the restriction of VBAC around the U.S.; Dr. Macones called it “overkill,” and argued that “the risk of rupture is comparable to other bad things that happen in labor that lead to an emergency cesarean section.”

As examples, he noted that prenatal diagnosis for Down Syndrome via chorionic villus sampling is routinely offered to all pregnant women and carries a 1% pregnancy loss rate, and external cephalic version requires immediate c-section about 1-3% of the time, making the risks from VBAC not that different from other things that are done “all the time” in obstetrics.

Day three generated perhaps the most heated discussion, in which a panelist stated that it is not a settled matter that women have a right to refuse a cesarean, reminding us of the need to continue to advocate for choices and rights for childbearing women. The relevant audience question comes up at 1:47:20 and comes from Shannon Mitchell of BirthAction. She raises the concern that there is nothing in the draft document that says that women have the right of refusal of a cesarean, an issue of concern given reports of court-ordered cesareans. The moderator refers the question to a medical ethicist, who responds:

That’s a very large topic in obstetric ethics there’s not a settled answer to it. There’s actually — contrary to what you heard yesterday — some serious disagreement in the obstetric ethics literature, but in any case I think it’s beyond the charge of this panel to take that question up.

Courtroom Mama provides further discussion of this issue at The Unnecesarean, including additional commentary from the telebriefing.

Despite this comment on women’s right to refuse a repeat cesarean, I hope that the conference will lead providers and institutions with codified or de facto VBAC bans to reconsider their policies and attitudes. I’m encouraged by this statement from the conclusions of the draft panel statement:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor]. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

Heather Corinna, founder and editor of Scarleteen and author of S.E.X.: The All-You-Need-to-Know-Progressive Sexuality Guide to Get You Through High School and College, is doing a large study on multigenerational experiences with and attitudes about casual sex. The data will ideally be used for publication, but answers are completely anonymous and will only be used anonymously.

In contrast to a lot of the hype and stereotypes about “hooking up,” Corinna is looking for what’s real, both in sexual attitudes and experiences among a diverse array of ages, genders and sexual identities, races and sexual ideologies/constructions. The only requirements for participating in this study are being over the age of 16, and having had some kind of sexual partnership before, even if none has been casual. The study takes around twenty minutes.

Corinna would like the study to show as diverse an array of people as possible, especially since so often media representations or cultural conversations about casual sex are usually only about heterosexual white women or about gay men. She particularly wants to be sure LGBT people, people of color, those over 45 and social conservatives are adequately represented, so please share this link with your networks after you take the survey yourself, especially if your networks include people in any or all of those groups.

To take the survey, visit http://www.surveymonkey.com/s/S97WR6H.

Beginning today and continuing through March 10, the National Institutes of Health is hosting a “consensus development conference” on the topic of vaginal birth after cesarean section.

A free live webcast (with captioning) of the conference is being made available for those who can’t attend the Bethesda, MD event. (You may need to download an appropriate media player to watch it.)

Various experts are discussing the medical evidence on VBAC (audience discussion has been lively already!), including the following key questions:

• What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
• Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
• What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
• What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
• What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

They are also expected to discuss a systematic literature review on the topic prepared under contract with the Agency for Healthcare Research and Quality (AHRQ) which will be completed and released this year and will address these same key questions. The previous AHRQ review on the topic was completed in 2003, and identified significant gaps in the literature and the problems those gaps pose for informed decision-making. A full agenda with listed presenters and sponsors is available online.

Following the conference, a panel will prepare a consensus statement addressing the key questions; you can sign up to be notified when the draft and final statements are available online and/or to receive a mailed copy of the final statement.

The Feminist Breeder is planning to have coverage of the conference on her blog and radio show, and the International Cesarean Awareness Network is planning a blog carnival on the topic of why VBAC is a viable option [hat tip to Jill at The Unnecesarean]. The hashtag #nihvbac is being used for discussion on Twitter.

The full conference will be archived at the NIH website, so if you can’t watch this week, you can view the proceedings later.

Our own Judy Norsigian will be a guest on Internet talk radio show “Saturday Mornings with Joy Keys” this Saturday, March 6 from 11:00-11:30 a.m. EST.

Visit www.blogtalkradio.com/joykeys to listen to the show online, and call (646) 929-0368 to ask questions. You can also go to the site now to sign up to receive a reminder via email or text message.

According to reports, the Mississippi bill that would make non-nurse midwives illegal in the state is dead after “a barrage of calls and e-mails on lawmakers, urging them to kill the bill” from advocates for midwifery and home birth.

We mentioned the bill in a post last week, after it passed the House and was referred to the state Senate’s Public Health and Welfare committee. Committee chair Hob Bryan has now indicated that he will not bring the bill up for a vote, saying that “This is something there’s a good bit of concern about. Several people in the committee said they had gotten calls to oppose it.”

The Big Push for Midwives, mentioned in the story, led the campaign to mobilize against this bill and issued action alerts last week encouraging midwifery supporters  to contact their State Senators regarding the bill. Campaign manager Katherine Prown explained that their opposition was not opposition to regulation of midwifery, but to the limitation of midwifery practice solely to CNMs (who typically do not provide home birth support).

“At least 26 states have laws authorizing CPMs and there’s an effort under way to get more states to license them so the practice of out-of-hospital midwifery is regulated nationwide,” Prown said. Without those laws “you end up with this buyer beware kind of climate and anyone can claim to be a midwife,” said Prown.

The Big Push campaign works to expand access to Certified Professional Midwives and out-of-hospital maternity care, including work to regulate and license CPMs in all 50 states.

A bill has passed in the Mississippi House that could effectively make  midwives who are not also trained as nurses illegal in the state. The bill states that “the practice of midwifery shall only be conducted by Certified Nurse Midwives; to provide that any person who is not a Certified Nurse Midwife who engages in the practice of midwifery shall be subject to criminal penalties and injunctive relief.”

The bill would make it illegal for Certified Professional Midwives — midwives who who are specially trained to deliver babies in out-of-hospital settings– to practice.

Right now, the Midwives Alliance of North America (MANA) categorizes the current situation in Mississippi for non-nurse midwives as “Legal by Judicial Interpretation or Statutory Inference” – in other words, interpreted to be legal but not explicitly provided for in the current law.

The organization provides some documentation from the previous MS Attorney General who concluded in 1991 that, “By its express terms, the practice of medicine as defined in Miss. Code Ann. Section 73-25-33 specifically excludes the practice of midwifery. Thus, it is the opinion of this office that those persons otherwise not licensed as nurses may engage in the practice of midwifery without licensure as a physician and for compensation.”

The current bill, which would add language to explicitly make non-CNM midwives illegal, passed the state House on February 9th and has been referred to Public Health and Welfare committee in the state Senate, whose members bill opponents are contacting. That committee consists of: Hob Bryan, Chairman; Alan Nunnelee, Vice-Chairman; Terry C. Burton; Eugene S. Clarke;Bob M. Dearing; Joey Fillingane; Hillman Terome Frazier; Billy Hewes; W. Briggs Hopson III; John Horhn; Cindy Hyde-Smith; Gary Jackson; Kenneth Wayne Jones; Tom King; Chris McDaniel; Nolan Mettetal; Willie Simmons; Bennie L. Turner; Lee Yancey. Contact information for each Senator is linked from this Senate roster.

MANA is encouraging supporters of Certified Professional Midwives who live in Mississippi to contact their state Senators. Tell them that you do NOT support making Certified Professional Midwives illegal, and ask them to vote NO on HB 695.

In other birth-related legislative news, the American Association of Birth Centers is asking supporters to contact their Senators and Representatives to support the Medicaid Birth Center Reimbursement Act (H.R. 2358 / S. 1423). For further information, see our previous post and information provided by AABC.

The American College of Nurse-Midwives has posted a new position statement on nitrous oxide for labor analgesia [PDF], stating:

“It is the position of the American College of Nurse‐Midwives that women should have access to a variety of measures to assist them in coping with the challenges of labor.”

The ACNM notes that a blend of inhaled nitrous oxide and oxygen is used for pain relief in labor in many other countries, but it not typically available in the United States, where epidural anesthesia and systemic opioids are more common.

Potential benefits of nitrous oxide are outlined in the document, including the ability for a woman to self-administer via face mask, the ability to quickly administer or discontinue the gas, and the lack of known adverse effects on the woman, fetus, or progress of labor.

Concerns about potential adverse effects, especially from occupational exposure to the gas for health workers, are also detailed and addressed in the document.

ACNM concludes:

While nitrous oxide is not without side effects and will not be agreeable to or effective for every laboring woman, it is an inexpensive, simple, reasonably safe and effective analgesic. It is important that midwives know about nitrous oxide analgesia and be able to offer it to women during labor.

See our previous related posts and companion content on the topic for more information and discussion, as well as this archived chat with the author of “Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.”

A new study published in the American Heart Association’s journal Circulation looks at what American women know about the risks for cardiovascular disease and the barriers to disease prevention.

The researchers surveyed women ages 25 and older about their demographics, their knowledge about heart disease (including their awareness of heart disease as the leading cause of death for women), perceived risk factors and prevention strategies, their sources of information about heart disease, preventive actions taken in the last year and barriers to prevention. Findings were also compared to surveys on these topics conducted in 1997, 2000, 2003, and 2006 to see how the responses have changed.

Among the results, 54% of respondents correctly identified heart disease/heart attack as the leading cause of death among women. However,  a disparity exists in this knowledge. Although awareness that heart disease/heart attack is the leading cause of death has doubled in white and Hispanic women and tripled among African American women since 1997, African American, Hispanic, and Asian women are still significantly less likely to be aware of this fact than white women.

Knowledge of heart attack warning signs had not increased significantly from the 1997 findings, with 56% of women correctly listing chest pain and neck, shoulder, and arm pain, 29% correctly identifying shortness of breath, and 17%, 15%, and 7% recognizing chest tightness, nausea, and fatigue, respectively. The authors also found that only 53% of women said they would call 911 if they were having heart attack symptoms; it’s usually recommended that people experiencing heart attack symptoms call 911 right away, even if they’re uncertain of whether they are really experiencing a heart attack.

The authors also noted that many women cited beliefs about effective methods of preventing heart disease that are not currently supported by the evidence, such as use of multivitamins (69%), antioxidants (70%), and special vitamins (58%, such as vitamin A, C, or E). 19% of women still reported a belief that hormone therapy was a useful preventive method, although this has declined from the 47% who held this belief in 1997 prior to the 2002 early halt to the Women’s Health Initiative trial and the accompanying warning that postmenopausal hormone therapy could actually increase cardiovascular risk.

Women reported numerous barriers to living a heart healthy lifestyle, including family obligations/caregiving (reported by 51% of respondents), confusion in the media about what they should be doing (42%), a belief that some higher power determines their health (37%), a lack of confidence in their ability to successfully change their behavior (33%), and a lack of money or health insurance (32%), among others less frequently reported. Lack of clear communication from health care providers (19%) and language barriers (8%) were also cited as concerns.

First, Dr. Mark Sloan, author of Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth, is chatting with readers online through February 21st via the LibraryThing website.

If you don’t have a LibraryThing account (they’re free), you’ll need to sign up first if you want to post questions or comments (you can browse the discussion without signing up). After logging in, scroll down the right side to “Author Chats” and select the chat with Mark Sloan. You’ll be able to post questions and comments, which Sloan is responding to – the author indicates that “all questions, comments, birth stories, new parent experiences, and hard-earned pearls of grandparental wisdom are welcome.”

I haven’t had a chance to read “Birth Day” yet – any readers have comments/reviews to share?

Second, the Baltimore chapter of the International Cesarean Awareness Network (ICAN) is seeking submissions for an art exhibit titled “Cesarean Voices,” which will be “the first of its kind in the country and will be an exploration of the issues surrounding cesarean birth.” Deadline for submissions is April 7, 2010, and artists should contact tiffanyaverill at hotmail dot com if they are interested in submitting artwork or have any questions. From the call for submissions:

We are accepting submissions for artwork to be shown in an ongoing installation to include original paintings, drawings, computer generated art, belly casts, poetry, and tapestries. Artwork must translate to the public the experience of having a cesarean either through your own or someone else’s eyes. In addition to cesarean art, the exhibit will feature an area called the “Birth Empowerment Zone” with artwork illustrating Ten Steps of the Mother-Friendly Childbirth Initiative (http://www.motherfriendly.org/mfci.php#step1) and Lamaze’s Six Care Practices that support having a natural and healthy birth. The six guidelines can be found at http://tinyurl.com/lumqx4

The complete call for entries is available for download [.doc file].

Last week, California Watch, a new project of the Center for Investigative Reporting, released a report describing an increase in maternal mortality in the state over the past decade.

The report shows that the number of California women who died from causes directly related to pregnancy nearly tripled in the past decade.  The report’s authors confirm that this is the most significant spike in pregnancy-related deaths since the 1930s. The findings have prompted enormous concern and many questions about why this is happening.

Dr. Elliott Main, the principal investigator for the California Maternal Quality Care Collaborative, the public-private task force investigating the problem for the state, acknowledged that only a modest amount of this increase was related to factors such as obesity among mothers, advanced maternal age, and infertility treatments. He said it was hard to ignore the fact that cesarean rate has increased 50 percent in the same decade that maternal mortality increased.

While changes in reporting may be responsible for some of the apparent increase, California Watch explains:

In 1996, the maternal death rate in California was 5.6 per 100,000 live births, not far from the national goal of 4.3 per 100,000. Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.

Although the number of deaths is relatively small — and pregnancy and birth are safe for the vast majority of women –  it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

It is difficult to understand all the possible causes for the increasing maternal death rate without more data available. California Watch notes, though, that “The California [California Maternal Quality Care Collaborative] task force isn’t waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women’s medical conditions and to reduce inductions.” (In some hospitals across the country that have already introduced stricter limits on inductions with no medical indication, there is evidence of improved outcomes.)

California Watch notes that the California Department of Public Health has failed to release a report on the trend; initial findings on the increasing maternal mortality rate were presented at a 2007 conference, but a more formal report has been under review since 2008, according to the piece. The Department’s the department’s director of public affairs has responded that “There was no effort to hold that report back. It just needed some more revisions.”

The CA Department of Public Health has released a couple of graphs of basic trend data, one showing an increase in maternal mortality in California over the last 10 years that is greater than the increase in the U.S. overall, and a second showing an increasing rate of maternal mortality for Black women (37.6 per 100,000 live births in 2002-2004) that is much higher than that for Hispanic (11.9), Asian (10.4), and White Non-Hispanic (11.9) women.

For our Wellesley, Mass.-area readers, an upcoming panel discussion on new recommendations for mammography and breast self-examination may be of interest.

Panelists will include Cindy Pearson of the National Women’s Health Network and Ngina Lythcott of the Black Women’s Health Imperative, with moderator Susan Reverby from Wellesley College’s Women and Gender Studies department.

The discussion will take place on Thursday, Feb. 25, in PNW 212 (Pendleton West 212 Amphitheater Classroom) from 5 – 6:15 p.m.

Questions can be directed to ctaylor1 at wellesley dot edu.

A recent ABC news piece and two new journal articles (in The Lancet and Obstetrics and Gynecology) have drawn attention to an emergency contraception drug that is not currently available in the U.S. but apparently has been submitted to the FDA for review.

Emergency contraception pills (EC) currently available in the U.S.  are intended to be taken within 72 hours (3 days) of unprotected intercourse or contraceptive failure.  The drug new drug, ellaOne (ulipristal acetate), can be taken within 120 hours (5 days), providing a longer period in which to prevent pregnancy. [It's worth noting here that women have long been advised that existing EC options can also be taken up to 5 days after intercourse, although that's not the "official" approved recommendation on the drug inserts].

Anti-choice groups such as the American Association of Pro-Life Obstetricians and Gynecologists argue that the pill could cause abortions and be an OTC abortion pill in the U.S., using a definition of “pregnancy” that includes a non-implanted fertilized egg, a definition that is generally not medically or scientifically accepted. These arguments were also presented during debate over the approval of Plan B.

The Lancet study compared ulipristal acetate (30 mg) with levonorgestrel (1.5 mg, the drug in Plan B) among adult women in the US and UK seeking emergency contraception within 120 hours of unprotected intercourse.

The women were followed for pregnancy outcomes, and both drugs significantly reduced the expected pregnancy rate, with the outcomes demonstrating that ulipristal was not inferior to levonorgestrel at preventing pregnancy.

The researchers also looked at rates of pregnancy among those 203 women who received one of the drugs 72-120 hours after unprotected intercourse. They found reduced rates of pregnancy: 0 in the ulipristal group, and 3 pregnancies in the levonorgestrel group, a statistically greater reduction in the ulipristal group (although a couple of changes either way might make a big difference in this result).

The second study, in Obstetrics and Gynecology, also looked at efficacy of ulipristal acetate over various time periods, up to 120 hours, and seemed to demonstrate continuing efficacy beyond 72 hours.

Both studies were funded by the company that owns ulipristal acetate.

A librarian note: searching PubMed for ulipristal acetate only returns a few citations; a search for “CDB 2914″[Substance Name] OR “CDB-2914″ OR “ulipristal acetate” OR “ellaone” is more comprehensive.

For readers around the D.C. area: the National Library of Medicine’s History of Medicine division in Bethesda, MD will run an exhibit through June of this year on the history of African American “granny” midwives. Details below:

Nothing To Work With But Cleanliness: African American “Grannies”, Midwives & Health Reform

For over three centuries, African American midwives delivered babies and practiced folk medicine in rural counties throughout the South. Midwifery came under public scrutiny in the 1910s when progressive reformers blamed the “unsanitary practices” of midwives for the higher rate of maternal and infant deaths. During the next two decades reformers campaigned unsuccessfully to eliminate the practice of midwifery. There simply were not enough skilled physicians or hospital facilities in southern rural communities. Poverty and pervasive racial discrimination also made home births more desirable than hospital deliveries to many of the African American families living in rural counties.

Training midwives was deemed the only viable solution in the South where African Americans midwives were predominate. Midwives received instruction from public health nurses during annual state-sponsored institutes and monthly local midwives clubs. Classes, which emphasized sanitary delivery practices, were taught by demonstration, songs and role playing. From the 1920s through the 1960s this next generation of midwives continued in the tradition of their “granny” predecessors with the added benefit of scientific knowledge.

Through photographs and artifacts, the exhibit tells the story of “granny” midwives and the state and local training programs that educated them and succeeding generations of midwives.

The exhibition, inside and outside the NLM History of Medicine Division Reading Room, Building 38, first floor, runs from February 2010 to June 2010. All are welcome to visit, 8:30 AM to 5:00 PM weekdays, except federal holidays.

Directions, security, parking, etc.: http://www.nlm.nih.gov/hmd/about/visitus.html

For more information: Sheena Morrison, sheena dot morrison at nih dot gov 301.402.8847

[hat tip to a LinkedIn post by Jeffrey Reznick, Deputy Chief, History of Medicine Division, US National Library of Medicine, National Institutes of Health]

By now you may have heard about the Focus on the Family-sponsored anti-choice ad slated to run during the Super Bowl. The ad features football player Tim Tebow and his mother discussing her decision not to have an abortion when pregnant with the star player.

The ad has been controversial for many reasons, including that it marks a change from CBS’s past “no advocacy/controversy” policy (an ad for a gay dating site was declined), glosses over issues related to privilege and the illegality/safety of abortion in the Philippines, and presents a situation in which Tebow celebrates her own choice (to go through with the pregnancy) and its resultant football star while advocating against other women having the same choice.

We don’t yet know the exact form the ad will take, except that CBS has worked with the anti-choice Focus on the Family on the language, and it will highlight Pam Tebow’s decision not to have an abortion with a tagline of “Celebrate family, celebrate life” (as though one can’t do those things and be pro-choice?).

Planned Parenthood has already released a preemptive response video featuring former football player Sean James and Olympic gold medalist Al Joyner espousing a message we can get behind – one of choice and trusting women. Among their comments:

I respect and honor Mrs. Tebow’s decision. I want my daughter to live in a world world where everyone’s decisions are respected.

We are working toward the day where every woman will be valued. Where every woman’s decision about her health and her family will be respected.

Related: Jacyln Friedman writes at The Nation about sex and the Super Bowl, arguing that “the Tebow/Focus on the Family ad is just a new expression of a longstanding Super Bowl tradition in which women are valued only in direct relation to their usefulness to male athletes and fans.”