Posts by Rachel

December 13, 2013

Digital Mammography: Is Newer Always Better?

Mammogram machineYou may have noticed last time you got a mammogram that the facility used digital imaging rather than traditional X-ray film.

Why is that? And, are there any benefits to the newer techniques?

In 2009, when the U.S. Preventive Services Task Force (USPSTF) reviewed the evidence and updated its recommendations on breast cancer screening, it concluded there was not enough evidence to assess the benefits and harms of digital vs. film mammography, due to a lack of studies on the effectiveness of the two methods. (To re-cap, the USPSTF recommends that for women with no increased risk of breast cancer, the decision to start screening before age 50 should be an individual one, rather than a general recommendation. After age 50, the USPSTF recommends screening every two years, up to age 74. There has been some controversy about the guidelines due to concerns about harms of routine mammograms – for for more information, see our related posts, The Benefits and Harms of Routine Mammograms and Do Screening Mammograms Do More Harm Than Good?)

The USPSTF noted that both screening methods may detect some cancers that are not identified by the other, but that overall detection is similar for many women. It found that the chance of false-positives (indication of cancer where it doesn’t exist) is similar in both types.

The Digital Mammographic Imaging Screening Trial (DMIST), published in 2005, is the most important trial of digital vs. film mammography for breast cancer screening to date. The study compared the accuracy of both methods in almost 50,000 women and concluded they’re similar in their effectiveness — neither technology was able to detect 100 percent of the cancers examined.

That said, researchers found digital to be the better tool for women under age 50, or who have very dense breast tissue, or are still menstruating. But it showed no benefit in terms of accuracy for women with all three criteria. And there was no difference in accuracy by race, breast cancer risk, or type of digital machine used.

The DMIST trial was not designed to compare differences in mortality rates among women who underwent different imaging — so it can’t answer the all-important question of whether digital mammography could save more lives than film.

Still, as the National Cancer Institute notes, some health care providers recommend women with a very high risk of breast cancer — women with BRCA1 or 2 genetic mutations, for example, or extremely dense breasts — get digital rather than conventional mammograms, even though no studies have shown that digital is better at reducing these women’s risk of death.

When examining a new medical technology, one consideration is how much the technology costs compared with how many years of quality life may be gained by using it. At least one trial has indicated that screening all women with digital mammograms was not cost-effective, because digital costs more and doesn’t improve health outcomes when used so broadly. Targeting women for digital mammography based on age (i.e., using digital for women under 50) appears to be more cost-effective than using film or digital for all women. The study concluded that a shift to all-digital mammography “has the potential to result in health gains for younger women (especially those with dense breasts) possibly at the expense of older women (especially those with non-dense breasts).”

Unfortunately, providers may not give women a choice. Some health care systems have simply switched over to digital, and individual providers may refer women for a mammography without indicating which type they will receive. In some cases, referrals for digital mammography may be linked to a provider’s investment in the machines, since evidence suggests that doctors are more likely to recommend expensive medical technologies when they have a financial stake in them, even if the procedure isn’t supported by medical evidence.

Medicare also reimburses more for digital screening exams than for film, creating a financial incentive for clinics and hospitals to conduct digital scans instead of film ones.

Digital mammography does have other benefits over film: digital files can be enhanced and manipulated in ways film cannot, and electronic images can be readily shared with clinicians at other locations, which may particularly benefit rural and underserved communities using telemedicine for reading and interpreting mammograms. Finally, digital mammograms may have a slightly lower radiation dose than film (although this may not be meaningful in terms of radiation-related risks, since the radiation dose with either type is very low).

These potential benefits may not justify a switch to digital mammography for all women. The USPSTF notes: “Consumer expectations that new technology is better than old may obscure potential adverse effects, such as higher false-positive results and expense. No screening trials incorporating newer technology have been published.”

So, when your doctor refers you for a mammogram, ask:

  • Are you referring me for a digital or a film mammogram?
  • If you are under 50 years of age: Why do you believe I need a mammogram at this time? Am I in a higher risk group? (This is important if you don’t know that you have any factors that may put you at increased risk).
  • Do you have a financial stake in the mammography facility?

You can also ask your insurer if a film mammogram would cost you less. Many women’s screening mammograms are completely covered by insurance, but costs can vary widely, so it’s good to confirm what the charges will be in advance.

A version of this article originally appeared in the November/December issue of The Women’s Health Activist, the newsletter of the National Women’s Health Network.

Photo: themozhi’s pixel display

December 12, 2013

Cochrane Review: The Safety and Benefits of Midwives Overseeing Maternity Care

Midwife-Led Continuity Models Versus Other Models of Care for Childbearing WomenIf you’re pregnant and living in the United State, it’s likely that an obstetrician will oversee your maternity care and childbirth. In other countries, however, midwives commonly provide care, assuming the pregnancy is low-risk.

An updated Cochrane review aimed to figure out whether patient outcomes vary by who is leading the care team.

Cochrane compiles findings from multiple studies into systematic reviews, considered top-notch for determining the best evidence-based care. In this instance, the authors looked at outcomes for moms and babies of what the authors refer to as “midwife-led continuity models of care” — defined as incorporating a midwifery perspective of minimizing routine intervention during birth, and midwives acting as the lead professionals in organizing and delivering care before, during and after birth.

They considered 13 studies representing 6,242 women in Australia, Canada, Ireland, New Zealand and the United Kingdom that compared the effects of midwife-led continuity models of care with other models: eight studies compared it to a shared model of care (responsibility is shared between different care providers); three studies compared it to medical-led models of care (what we’re most used to in the United States); and two studies compared it to various options of standard care, including midwife-led (with varying levels of continuity), medical-led, and shared care.

All of the studies looked at licensed midwives in hospital birth settings.

In the final review, “Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women,” the authors report that the midwife-led continuity models of care were associated with some benefits, including a decreased likelihood of episiotomy or instrumental birth, and decreased likelihood of preterm birth or loss of the fetus before 24 weeks’ gestation. Women cared for under this model were more likely to have spontaneous vaginal birth; they also had slightly longer labors and were less likely to use any pain relief.

There were no differences between groups in rates of cesarean birth (although the authors suggest more data may be needed), or overall fetal loss or neonatal death. There were no specific adverse effects attributed to midwife-led continuity of care models.

The Royal College of Obstetricians and Gynaecologists (a UK professional organization) essentially agreed with the message of the review, noting that while other types of specialists should be available for high-risk pregnancies and emergencies, “more women with low-risk pregnancies should be given the option of midwifery-led care.”

While noting that additional research is needed, the Cochrane authors’ recommend what has become standard practice in many parts of the world: “Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”

While the midwifery model of care — especially midwife-led continuity care — is not standard practice in the United States, midwives and other health advocates have been working to change that. Some academic medical centers now incorporate midwives into their care teams for hospital births, for example, though not all teams are midwife-led.

In this JAMA News item, nursing professor and American Journal of Nursing Editor Diana Mason argues for increased access to midwives and birth centers for low-risk births to meet consumer choice and to combat the high cost of maternity care. Mason writes:

We need to question the basic framework for designing maternity services: should it be one in which pregnancy and birth are viewed as normal life transitions or as diseases? This is not just a philosophical issue. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician.

Women’s health advocates are also pushing for broader reform of the maternity care system, including better and increased support of women before, during, and after birth; expanded choice in birth settings; an emphasis on medical evidence; and improved staffing of maternity care teams.

These issues and other concerns are addressed in the 2020 Vision for A High-Quality, High-Value Maternity Care System – prepared for Childbirth Connection’s Transforming Maternity Care symposium — which focuses on woman-centered care that “respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes.”

To learn more about the midwifery model of care, check out this excerpt from “Our Bodies, Ourselves,” and the resources from Childbirth Connection. To find a practice with nurse-midwives in your area, try the ACNM’s Find a Midwife search tool.

December 6, 2013

The Ideal Labia is Your Own: Online Sites Push Back Against “Model” Genitalia

labia library
Cosmetic genital surgery on the labia has been of both increasing interest and concern in recent years. Many attribute this to the fact that the most readily available images of vulvas, which happen to be in pornography, don’t tend to show much variation in shape, color, hair, or other characteristics.

A few resources exist to help promote the idea that there is a much wider range of what is normal than we often see in media. The Labia Library, run by Women’s Health Victoria, is a small photo gallery of labia, primarily of white-appearing women. The site also addresses body image concerns in the section Are My Labia Normal?.

Writing in the Daily Life, an Australian publication, Melissa Brock does a terrific job contextualizing the concerns women have about their bodies (and a ridiculous Catch-22 when it comes to censorship guidelines):

In Australia over the past 10 years, medical rebates for labiaplasty (surgical reduction of the inner or outer labia) and vulvoplasty (surgical remodelling of the vulva) have risen from 640 claims in 2000-01 to 1565 in 2010-11, though the real number of procedures is thought to be much more. At the same time, mainstream pornography has become more explicit, showing extreme close-ups of hairless female genitalia. Previously hidden behind a bush of hair, labia are now under close scrutiny. The type typically featured in pornography are known as the “Barbie” or “clamshell” variety, where everything is neatly tucked away. And just to complicate the matter, Australian censorship and print publication guidelines dictate that the inner labia must not protrude beyond the outer labia. Houston, we have a problem. Many women are not designed this way and have started to question whether they are “normal”.

Brock goes on to describe her own experience visiting the online Labia Library:

I was alone in my bedroom on a computer looking at women’s genitals. Surely I was doing something wrong. I would have to clear my browser history. But that thought was short-lived because, devoid of the lingerie, the ambient surroundings and orgasmic groans of pornography, it was fascinating. I never knew what other women actually looked like down there. It was strangely liberating. It turns out I’m not alone – Butera says the site survey has been “overwhelmed by positive comments”. Hannah Cooper, 38, a personal assistant from Sydney, says of the library, “When a friend suggested I check it out, I thought eeek … but it wasn’t gross and it wasn’t sexy. They were all just so different and it makes sense. Everyone has a different face – it follows that people would have different labia.”

On tumblr, the Large Labia Project includes photo submissions from readers who believe their labia are “large” — the point being that all sizes of labia can be “normal” and beautiful. These resources make it easier for us all to see that outside of pornography, everyone is different. Another excellent resource on this topic is Scarleteen’s article “Give ‘em Some Lip: Labia That Clearly Ain’t Minor,” and the accompanying illustrations from Betty Dodson.

In part because of anxieties about the appearance of their genitals and lack of examples of the wide range of genitals, some women have elected to have cosmetic surgery to make their appearance more “normal.” The New View Campaign has a lot of good info on cosmetic genital surgery, including this set of FAQs.

The Royal College of Obstetricians and Gynaecologists (in the UK) recently released an ethical opinion paper on the subject of genital cosmetic surgeries to guide doctors on this issue. The paper emphasizes the lack of high-quality or long-term evidence about the safety, risks or even patient satisfaction with these surgeries, explaining that doctors “must be aware that they are operating without a clear evidence base.”

There are currently no controlled trials or prospective studies investigating the clinical effectiveness or risks of labiaplasty procedures. There are small case reports and a few larger retrospective studies, all of which offer scant descriptions of methodology or study design. Since the surgical studies are authored by the surgeons who performed the operations, there is little independent evaluation.

RCOG also emphasizes that “so-called norms” presented in media are “digitally modified and should be challenged by those who deal with women requesting labial reduction for ‘aesthetic’ reasons.” To learn more about normal vulvas and issues around cosmetic genital surgery, read previous posts:

And, finally, here’s a video on the difference between porn sex vs. real sex, using food as props. It’s more about function than appearance, but still well worth a look. YouTube Preview Image

December 3, 2013

Science Says: Emergency Contraception Does Not Block Implantation of a Fertilized Egg

Last week, in a post about how some types of emergency contraception are less effective or ineffective in women weighing more than 165 pounds, we mentioned that the European equivalent to Plan B One-Step was getting a new label that will note the problem.

Let’s take a look at the other reason for the label change: European health officials have determined — and want to make clear — that the drug “cannot stop a fertilized egg from attaching to the womb.”

This is a big issue, as abortion opponents have long opposed EC on the grounds that it might prevent a fertilized egg from implanting in the uterus. U.S. labels of levonorgestrel-containing emergency contraceptive pills, such as Plan B, don’t directly refute the possibility.

But as The New York Times noted last year, recent science suggests that this is not the case; the pills work only by preventing ovulation and fertilization.

Last week, NYT reporter Pam Belluck noted how the FDA and other health agencies responded to the scientific studies:

References to the possibility of blocking implantation were then removed from the websites of the National Institutes of Health and the Mayo Clinic. And an F.D.A. spokeswoman, Erica Jefferson, said that “the emerging data on Plan B suggest that it does not inhibit implantation.”

On Tuesday, Ms. Jefferson reiterated that view. The drug agency has not moved to change the label, saying manufacturers must request a change. Plan B One-Step’s manufacturer, Teva Pharmaceuticals, declined to comment. It had previously said scientific evidence suggested that the pill did not disrupt implantation.

Although pregnancy is not medically considered to have begun until a fertilized egg has successfully implanted in the lining of the uterus, media coverage around this topic has often obscured this distinction and promoted a false idea that emergency contraception is the same thing as the abortion pill (RU-486) or abortion in general. Medical professionals generally assert that “emergency contraception is not effective after implantation; therefore, it is not an abortifacient.”

Effect on Lawsuits
Hobby Lobby is one for-profit corporation that filed suit to avoid complying with Obamacare coverage for contraception, claiming that forms of contraception that could interfere with the implantation of a fertilized egg are tantamount to abortion. The Supreme Court will hear the case, focusing on whether for-profit companies can be required to provide coverage that may conflict with the private religious beliefs of the business owners.

As Linda Greenhouse wrote in an op-ed about challenges to the contraception mandate under the Affordable Care Act, a coalition of medical groups, led by Physicians for Reproductive Health, filed a brief in the case, noting in part that “the weight of the scientific evidence establishes that the FDA-approved contraceptives and emergency contraceptive are not abortifacients.”

Read Greenhouse’s column for an excellent look at how the religious-based challenges represent a culture war on “modernity.” For more on the lawsuits, SCOTUSblog is a smart resource.

And we highly recommend the Emergency Contraception website for easy-to-understand fact sheets, such as this one: “Does emergency contraception cause an abortion?

November 27, 2013

Worried About the Effectiveness of Emergency Contraception Pills? Here’s An Alternative

Emergency contraception is tremendously important for women seeking to prevent pregnancy after unprotected sex. Activists and public health advocates have worked for years to make EC pills more readily available, and have been successful in getting pills such as Plan B available without a prescription or age restrictions.

Emergency contraception pills containing levonorgestrel (including Plan B) may not be right for every woman and situation, however. Though the pills can be taken up to five days after unprotected intercourse, the pills are most effective (95 percent) when taken within 24 hours and become steadily less effective as more time passes. A different type of EC pill — Ella, containing ulipristal — is thought to keep a pretty high level of effectiveness for the full five days.

News this week has raised another issue of emergency contraception effectiveness: EC pills with levonorgestrel seem to be less effective in women weighing more than 165 pounds, and lose their ability to work in women who weigh more 175 than pounds.

This loss of effect happens regardless of whether women are considered overweight or obese according to BMI charts, or are simply tall — despite headlines that almost exclusively focus on “obese women.”

As Linda Prine of the Reproductive Health Access Project said in an interview with NPR: “This is barely overweight. We’re talking about a BMI over 25. So this is probably more than half of American women. This medication would not work for them.”

The Food and Drug administration is reviewing whether makers of levonorgestrel-containing pills (Plan B, Plan B One-Step, Next Choice, My Way) should be required to revise their labels to include a weight warning. In Europe, the label for one identical product (Norlevo) has already been changed to warn about the loss of effectiveness.

The European label change is what prompted news coverage this week, though the study that informed the change was actually published in 2011.

For that study, researchers reviewed results from two prior randomized controlled trials to look for factors that could explain rates of emergency contraception failure. Not only did they find that overweight and obese women had much higher risks of pregnancy than “normal” weight women (anywhere from double the risk to more than four times greater), but women with a “normal weight” BMI women who are tall also have greater risks of pregnancy.

The authors note that additional research is needed to determine whether these women could be given higher doses of the drug for improved efficacy.

The researchers also found that while Ella (ulipristal) worked at higher weights than levonorgestrel-containing pills, it, too, lost some effectiveness with increasing weight. At about 194 pounds, ulipristal appeared to lose all effectiveness.

Women in need of emergency contraception do have another option, however: the copper IUD (Paragard).

IUDs are intrauterine devices that not only are considered 99.9 percent effective for emergency contraception, but they can remain in place for up to 10 years and are one of the most effective forms of contraception overall. While in the past doctors may have been reluctant to provide IUDs for younger women and women who have not had children, more current research suggests that their concerns about side effects were largely unfounded.

Copper IUDs work to prevent pregnancy by inhibiting fertilization, primarily by preventing sperm from reaching an egg. They may also help to prevent implantation of a fertilized egg, but they do not interfere with an established pregnancy. (It is important to remember that IUDs do not protect against HIV or other sexually transmitted infections, so barrier methods may be needed as well for protection.)

For more information, read more about the safety of prescribing the IUD for teenagers, along with this post on the pros and cons of IUDs. You can also read an excerpt from “Our Bodies, Ourselves” on emergency contraception, and visit the excellent Princeton/ARHP emergency contraception website for more on EC and body size.

November 22, 2013

Top Hospitals Putting an End to Formula Marketing to New Moms

Despite a wealth of evidence that breastfeeding provides the most health benefits for infants, many barriers — including rigid work conditions and lack of family or community support — can interfere with a woman’s ability to start breastfeeding, or to keep breastfeeding for at least six months.

Health advocates have long criticized the popular hospital practice of distributing infant formula to new mothers, because doing so descreases the length of time that women breastfeed — even when they have indicated a desire to try breastfeeding, and sometimes instead of providing lactation support (read this previous post, which discusses a report on Chicago hospitals in low-income neighborhoods).

According to the Centers for Disease Control, 77 percent of infants in the United States start out being breastfed, which is an increase over recent years, yet fewer than half are still breastfeeding at the six-month mark.

Many hospitals have banned pharmaceutical or other industries from providing marketing materials directly to doctors, in order to avoid conflicts of interest, but many hospitals still provide free formula samples directly to patients.

A new report from Public Citizen, however, suggests that more of the top hospitals in the country are agreeing to limit distribution.

The consumer advocacy organization looked at the top hospitals in the U.S. News and World Report rankings, both those with the gynecology specialty and maternal/newborn services and those on the general Honor Roll. It then surveyed those hospitals about their policies and practices, and checked against data from the national Ban the Bags campaign, which grew out of a Massachusetts effort to stop aggressive formula marketing.

Some of Public Citizen’s key findings:

  • Sixty-seven percent of top gynecology hospitals in gynecology reported not giving out bags sponsored by formula companies, formula samples, or other formula-related promotional materials
  • An additional 11 percent (5 of 45) limited samples and sponsored bags to those who request them, moms who are already planning to formula feed, or to Neonatal Intensive Care Unit patients
  • Eighty-two percent (14 of 17) of the best overall hospitals reported having a policy or practice against distributing these materials

Public Citizen recommends that the remaining hospitals on these lists also ban formula distribution, and discuss other interventions that public health departments and state legislatures can take to restrict the practice. As the report notes:

Numerous studies show that women are likely to breastfeed less, and for shorter durations, if they receive formula samples and promotional materials in hospital discharge packs. Formula bag distribution effectively influences new mothers to use formula because it sends a powerful message that hospitals endorse formula feeding, even where breastfeeding in hospitals is promoted.

One major effort to improve the support for breastfeeding in hospitals is the Baby-Friendly Hospital Initiative, endorsed by several major medical organizations. The Initiative sets standards for baby-friendliness, including breastfeeding support. The Initiative’s guidelines and evaluation criteria states that in baby-friendly hospitals, staff members should not receive donations from breast milk substitute providers, and mothers and their families should not be given marketing materials for formula or gift packs containing formula. The Baby-Friendly principles have been endorsed by several major medical organizations.

Ban the Bags provides a toolkit for advocating against these formula sample bags, which can be downloaded from its website, as a resource for taking action in your own community. As Ban the Bags puts it: “Hospitals should market health, and nothing else.”

November 20, 2013

Is There a Connection Between Endometriosis and Environmental Pollutants?

Endometriosis is a painful and puzzling condition in which the tissue that lines the inside of the uterus — the endometrium — grows outside the uterus, often on the ovaries and fallopian tubes. In addition to causing pain, endometriosis can result in heavy bleeding and infertility. One in 10 women of reproductive age is thought to be affected.

One of the most frustrating aspects of endometriosis is that the cause is unknown. A couple of new studies have focused on environmental triggers, with mixed results. Both studies appear in an upcoming issue of the journal Environmental Health Perspectives.

The first study used data from the large Nurses’ Health Study II, involving more than 84,000 female nurses. The researchers identified those who lived near roadways, exposing them to more particulate matter in the air as adults. (Particulate matter is a type of pollution that can come from vehicle exhaust and other sources, such as coal-burning power plants.) The authors report that they did not find any significant association between exposure and the incidence rate of endometriosis, but also note this is the first human study to assess the relationship between particulate matter exposure and endometriosis.

Future research is likely needed to confirm the result, and other factors may need to be considered, such as the amount of exposure to particulate matter where women grew up or where they work. 

The second study did find a link between another type of pollution and endometriosis. Researchers used data from the Women’s Risk of Endometriosis study conducted in Washington state, analyzing blood samples of women with and without endometriosis to gauge their levels of organochlorine pesticides (OCPs). The researchers found associations between levels of two pesticides — β-hexachlorocyclohexane (HCH) and mirex — and a greater chance of having endometriosis.

Organochlorine pesticides, such as DDT, were commonly used in agriculture and for mosquito control during the 20th century. While their use has been greatly restricted in the United States, these pesticides accumulate in bodies and are still often detected in blood studies. The researchers note that most U.S. exposures are now from consumption of fatty foods, fish, and dairy products where the toxins have built up. Global use of OCPs is also a concern, as the contamination may spread.

These pesticides are known to be potential endocrine disruptors, but the exact nature of any link with endometriosis is unclear. The researchers involved in the study also found that the link was stronger when they looked just at ovarian endometriosis, although they don’t speculate on why that may be, except that ovarian cases may differ in some way from other cases of endometriosis.

All of this points to the need for more research.

For more information, visit the Endometriosis Association, which offers free informational packets and other resources. You can also read excerpts from “Our Bodies, Ourselves,” and learn more about both endometriosis and pesticides via the National Library of Medicine.

November 13, 2013

Researchers Explain How Anti-Abortion Legislation Threatens Women’s Health

Protest rally against Texas HB2 and SB1 on July 15

July 15 protest rally in Austin against anti-abortion legislation / Photo by Mirsasha

There have been a number of recent articles and campaigns detailing, often from a personal perspective, how legislation restricting access to abortion will harm women’s health.

A new article that will be published in the journal Contraception goes a step further — it draws on research to address the specific hardships women face and urges healthcare providers to push back against such restrictive measures.

The authors — researchers from university medical centers and health policy organizations such as Ibis Reproductive Health who have collaborated together before on matters of abortion and women’s health — open with a sharply worded question: “What happens when abortion access is severely restricted for 26 million Americans? Texas is about to find out.”

Texas, as you might recall, passed a law in July — the subject of State Sen. Wendy Davis’s epic filibuster – that mandates hospital admitting privileges for abortion providers; requires abortion facilities to meet the same standards as ambulatory surgical centers; bans most abortions after 20 weeks post-fertilization (22 weeks “pregnant”); and restricts use of medication for abortion to an outdated regimen. A lawsuit was filed to try to overturn some of these restrictions.

The admitting privileges requirement was temporarily blocked this month, then reinstated, causing up to a third of abortion clinics to suddenly close and forcing women to scramble for alternatives. The issue may end up in front of the Supreme Court. (More wrangling took place this week; view the latest coverage at RH Reality Check).

Despite claims that the new restrictions are for women’s “safety,” the authors report that the evidence suggests something different: “Evidence from other countries indicates that severely restricting abortion does not reduce its incidence — it simply makes unsafe abortion more common.”

Among the public health concerns raised in this article is the potential increase in the number women attempting to induce their own abortions:

In 2012, we conducted a survey with 318 women seeking abortion in six cities across the state to assess the impact of the 2011 restrictions. We found that 7% of women reported taking something on their own in order to try to end their current pregnancy before coming to the abortion clinic. This proportion was even higher — about 12% –among women at clinics near the Mexican border. Misoprostol and herbs were the methods women more commonly mentioned. By comparison, a nationally representative survey of abortion patients in 2008 found that 2.6% reported ever taking something to attempt to self-induce an abortion. The confluence of extremely limited access to abortion in the context of poverty, access to misoprostol from Mexico, as well as familiarity with the practice of self-induction in Latin America, makes it particularly likely that self-induction will become more commonplace in Texas.

Early medical abortion with misoprostol is a safe and effective regimen and is  recommended by the World Health Organization in settings without access to mifepristone. But if women do not have accurate information, they may use ineffective dosages and may not realize the abortion failed until much later in pregnancy, forcing them to seek a second-trimester abortion or continue the pregnancy and have a child they do not want or feel they cannot care for. Using misoprostol in the second trimester also increases the risk of hemorrhage that might require surgical intervention or transfusion, as well as the risk of uterine rupture if inappropriately high dosages are used, especially with a history of prior cesarean delivery. And while misoprostol is unquestionably a safe method to self-induce abortion, women may use a variety of less effective and more dangerous methods to end a pregnancy on their own, including taking herbs or self-inflicting abdominal trauma.

The authors also explain that a reduction in the number of clinics, due to the provision requiring clinics to meet the standards of ambulatory surgical centers (ASCs), is likely to cause delays for women seeking care, resulting in later, more costly abortions. They describe the following scenario involving delays and travel burdens:

In 2011, 2,634 women living in the Valley obtained an abortion. Neither of the two existing abortion clinics in the Valley is an ASC, and one of the clinics has already announced its planned closure. The nearest ASC is in San Antonio, about 250 miles away, adding about eight hours of travel time to the process of obtaining an abortion. If a woman chooses a medical abortion, state law requires her to make this long journey at least three times. These barriers are likely to be too great for many women.

The three visits rule is due to a provision in Texas law requiring doctors to follow an outdated regimen for medical abortion. Most U.S. providers, they note, use a newer protocol, which has been found safe and effective — and requires only two visits instead of three. They write:

Texas is only one of several states attempting to regulate abortion out of existence — a trend that should be deeply troubling to the medical community. First, it represents a stunning incursion into the physician’s exam room, allowing state representatives to dictate how doctors should practice medicine. Second, it is in blatant contradiction to evidence-based medicine.

And they call on physicians to be more involved in protesting this type of legislation:

As the fight for abortion rights in Texas moves from the legislature to the courts, it is critical that reproductive health specialists — both clinicians and researchers — add their voices to this outcry, highlighting the negative impact of these restrictions and demanding that all women have the right to comprehensive health care services.

The article, “The Public Health Threat of Anti-Abortion Legislation,” will appear in an upcoming issue of Contraception.

November 7, 2013

Guides to Breastfeeding and Working

The American College of Nurse-Midwives recently published a free guide to breastfeeding and working, which carries tips for preparing to go back to work full-time, what to look for in a breast pump, how often to pump, and how to store milk.

The suggestions are very practical, although some — such as working part-time or working from home for a while — are not realistic for many women, especially in non-office or hourly jobs.

Newer legal protections for breastfeeding workers, however, should make some aspects of breastfeeding and work a little easier to manage. One rarely mentioned benefit of the Affordable Care Act (aka Obamacare) is that the act amended the Fair Labor Standards Act to require employers to provide breaks for nursing mothers to express breast milk for a year after the child’s birth.

Workplaces with 50 or more employees are required to provide “a reasonable amount” of break time for expressing milk as often as needed, as well as a functional space for pumping that is *not* a bathroom.

The employers are not required to pay for the time of these breaks. Employers with fewer than 50 employees might be exempt if they claim it creates a “hardship,” so it’s important to check on if you work for a small business. The Department of Labor provides more resources on this topic for workers and employers.

Some states also have laws that protect breastfeeding women in the workplace. Where the state law does a better job of protecting workplace breastfeeding/pumping, the state law is what applies.

See also: Previous posts and excerpts from “Our Bodies, Ourselves” on breastfeeding.

November 4, 2013

The Ultimate Guide to the Legal Battle Over OTC Access to Emergency Contraception

In the October issue of the journal Contraception, authors from Harvard Law School and Brown University’s medical school trace the legal and political battles over non-prescription access to emergency contraception.

The authors date the legal dispute back to Jan. 21, 2005, when a coalition of organizations in favor of emergency contraception filed a lawsuit accusing the FDA of ignoring the science and safety and applying different standards to Plan B, a type of EC under review at that time, than the FDA applied to other drugs.

Of course, concern about access and the FDA’s process actually goes back further. Organizations had filed a Citizen Petition four years earlier asking the FDA to approve over-the-counter access. The FDA’s failure to respond to that petition, and rejection of the drug company’s application for OTC status, are what ultimately led to the 2005 lawsuit.

The article in Contraception covers the legal battles and notes the various ways the U.S. government interfered in the FDA’s decision-making. You might recall that politically motivated delays under the Bush administration led Susan Wood, a former assistant FDA commissioner for women’s health and director of the Office of Women’s Health, to resign in 2005.

“I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled,” she said at the time of her decision.

After President Obama took office, and amid hopes that sound policy would prevail over politics, HHS Secretary Kathleen Sebelius overruled the agency’s 2011 decision that Plan B could be made available without a prescription or age restrictions. Noting this and subsequent political interference, the authors comment:

The final resolution of this controversy offers an ideal vantage point to examine the vulnerability of the FDA to political influence. While the FDA has “consistently been named or identified as one of the most popular and well-respected agencies in government”, the ability of the FDA to resist political influence is more precarious than its apparent reputation might suggest. After all, the FDA is not an independent agency. Indeed, the FDA Commissioner serves at the pleasure of the President. What is more, the idealized notion that the science-driven decision-making process of the FDA is insulated from and resistant to the political discourse is incommensurate with precedent.

Yes, that’s lawyer speak, but what it translates to is this: The Plan B drama has shown us that the FDA cannot be relied upon to make purely evidence-based decisions. At any time, a presidential appointee (like Sebelius) might step in to overrule evidence-based decisions. And as we’ve seen with Plan B, the resulting legal battle and limited access to a needed drug can stretch on for years.

Without a doubt, as the authors note, “there can be little questioning the foot dragging and active role played by two successive presidential administrations in shaping the emergency contraception debate.”

Plus: For more on the history of the fight for OTC emergency contraception, view a timeline from the Center for Reproductive Rights, and the original Citizen’s Petition, and check out coverage at Our Bodies, Our Blog. Important posts for context include this item on  Sebelius overriding the FDA’s decision, Susan Wood’s response at the time, and more history of the battle for increased access to EC.

October 31, 2013

What Percentage of Older Women Are Satisfied with Their Body Image? Survey Says …

Body image is often thought of as a concern for teen girls and younger women, and the abundance of resources on this topic are skewed toward those age groups.

But a new study published in the Journal of Women and Aging illustrates how few of us are happy with how our bodies look, even as we get older: Only 12 percent of women reported being satisfied with their body size.

While the number is pathetically low, it’s not surprising considering how many of us are self-critical about our appearance. Even if we are not actively dieting, our culture — and sometimes our own families and friends — make it impossible to tune out messages that we should be younger, thinner and prettier.

Researchers from UNC Chapel Hill conducted an internet-based survey of 1,789 U.S. women age 50 and older to find out more about their perspectives. Participants were overwhelmingly white (92.3 percent), and the average age was 59. Close to half (42 percent) had a body mass index (BMI) that put them within “normal” weight ranges for their height.

For the study, participants were shown silhouettes of nine bodies of various sizes and asked which silhouette most resembled their own body, and which body size they preferred. Women who preferred the shape closest to their own were considered to be satisfied with their bodies. Women who preferred a different body shape were categorized as dissatisfied.

In discussing their findings, the authors point out that women who are generally satisfied “appear to exert considerable effort to achieve and maintain this satisfaction, and they are not impervious to experiencing dissatisfaction with other aspects of their appearance, particularly those aspects affected by aging.”

For instance, many of the women who fell into the “satisfied” group were unhappy with specific body parts, including their stomach (56.2 percent), face (53.8 percent), and skin (78.8 percent) — although they reported dissatisfaction at lower rates than the women who were dissatisfied overall with their bodies.

And while the majority (88 percent) of women who were satisfied were considered “normal” weight, 40.6 percent said they would be moderately or extremely upset if they gained just 5 pounds.

Satisfaction with one’s body shape/size also does not grant immunity to negative thinking:

- A third (34.1 percent) reported thinking about their weight “daily” or “always.”
- Half (50.7 percent) expressed envy of younger women’s appearance.
- More than three-quarters (77.1 percent) reported that their shape played a primary role in their self-evaluation — about the same percentage of women who were unsatisfied with their appearance.

The women were also asked about their weight, height, ethnicity, symptoms of eating disorders, diet, and weight-control behaviors (like dieting and frequent weighing), concerns about their weight and shape, and quality of life. There was no difference between the satisfied and unsatisfied groups when it came to skipping meals or extreme/disordered weight control measures.

Satisfied women reported somewhat more exercise (average of 5.1 hours vs. 3.8 hours), and the authors note that “exercise may directly (and indirectly) enhance body esteem in women.”

Women who were unsatisfied with their bodies were significantly more likely to report that a physical or medical condition affected their weight or appetite (30.3 percent vs. 9.2 percent). The were also more likely to do frequent body checking, attempt weight loss, spend more than half their time dieting, and report having tried low-calorie diets or diet plans.

The authors were not able to determine whether these activities led to dissatisfaction, or whether body dissatisfaction more often led to these activities. The study also doesn’t address the effect that negative messages and stigma may have on satisfaction rates.

The authors recommend that health-care providers discuss weight, shape, and aging-related concerns with all mature women, and “maintain sensitivity when talking about weight management.”

For a more personal take on these survey results, read Rachel Zimmerman’s post at WBUR’s Common Health. Zimmerman reflects on how she spends an “inordinate, and frankly embarrassing amount of time thinking about food, planning meals and strategizing about how to control [her] weight.”

And for more information, check out Our Bodies Ourselves resources on body image. For help related to eating disorders, see the National Eating Disorders Association.

October 24, 2013

Medical Groups Call on Health Care Providers to Advocate for Reduced Exposure to Environmental Pollutants

Two major medical societies and an important research group have released a joint statement calling on health care providers to advocate for reduced exposure to toxic chemicals and pollutants that can can cause reproductive health problems, harm to pregnancies, and long-term health complications.

The organizations involved — American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, American Society for Reproductive Medicine Practice Committee, and UCSF Program on Reproductive Health and the Environment – state that although hundreds of new chemicals are introduced in the United States each year, safety data and regulation are lacking:

Because of deficiencies in the current regulatory structure, unlike pharmaceuticals, most environmental chemicals have entered the marketplace without comprehensive and standardized information regarding their reproductive or other long-term toxic effects.

Among the recommendations for health care providers (the target audience for the statement): learn about patients’ exposures before pregnancy and during prenatal visits; encourage pregnant and breastfeeding women to carefully wash produce and avoid fish with high levels of mercury; include information about environmental hazards in childbirth classes; and promote healthy food systems and policy changes that reduce exposure.

It’s great to see the medical establishment recognizing the need for better study and regulation of toxic chemicals — and acknowledging both the impact on reproductive health and the disparities in exposure to pollution and toxins. This new committee opinion, intended as an informative guide for professionals, may bring much-needed attention to these issues among obstetricians, gynecologists, and other reproductive medicine practitioners.

The committee opinion acknowledges that certain recommended actions — like eating fresh, unprocessed foods, selecting organic produce, and avoiding canned food that might expose consumers to bisphenol A — are not realistic strategies for many low-income women and vulnerable populations. The authors rightly note:

In the United States, minority populations are more likely to live in the counties with the highest levels of outdoor air pollution and to be exposed to a variety of indoor pollutants, including lead, allergens, and pesticides than white populations. In turn, the effects of exposure to environmental chemicals can be exacerbated by injustice, poverty, neighborhood quality, housing quality, psychosocial stress, and nutritional status.

The organizations add that “individuals alone can do little about exposure to toxic environmental agents, such as from air and water pollution, and exposure perpetuated by poverty,” and they therefore urge healthcare professionals to help advance policies that reduce exposure to toxins.

Relatedly, Breast Cancer Action is currently seeking signatures on a petition to Congress to increase chemical safety testing. And ACOG has released a brief guide to toxic chemicals and their effects for more information. Also, check out “Our Bodies, Ourselves” and related content on environmental and occupational health.

October 18, 2013

New Study on Youth and Sexual Violence Considers Spectrum of Rape Scenarios

In a new study published in JAMA Pediatrics, nearly 1 in 10 youths in the United States reported committing an act of sexual violence.

As part of a larger Growing Up With Media study on media consumption and exposure, the researchers surveyed 1,058 girls and boys ages 14 to 21 about their experience as perpetrators of sexual violence and their exposure to violent sexual media.

Rather than ask participants if they had ever raped or sexually assaulted anyone, the researchers asked more nuanced questions, including if they had tried to make someone have sex with them when they knew the other person didn’t want to, and if they had succeeded at doing so.

The participants were also asked if they had kissed, touched, or done anything sexual with an unwilling partner. Among the findings:

  • 9 percent of youths surveyed reported some type of sexual violence perpetration in their lifetime;
  • 8 percent kissed, touched, or made someone else do something sexual when they knew the other person did not want to (ie, forced sexual contact);
  • 3 percent got someone to give into sex when he or she knew the other person did not want to have sex (hereafter referred to as coercive sex);
  • 3 percent attempted – but were not able – to force someone to have sex (ie, attempted rape);
  • 2 percent forced someone to have sex with him or her (ie, completed rape).
  • About 3 in 4 victims were a romantic partner.

There was a good amount of overlap: 12 percent reported two different behaviors, 11 percent reported three, and 9 percent reported all four types.

When asked about the most recent time they tried to force or were able to force someone to have sex, tactics were mostly coercive. Arguing or pressuring the person (32 percent) or getting angry or making the person feel guilty (63 percent), were more commonly used than threats (5 percent) or physical force (8 percent). Alcohol was a factor in 15 percent of these situations.

It’s important to keep in mind that survey research like this — even when conducted via the internet — may underestimate true rates of actions like sexual assault, because perpetrators are motivated to avoid reporting their own crimes.

The authors note this as a limitation, adding, “Nonetheless, rates are much higher than the lifetime rate of 0.15% yielded in a national study of adults that was conducted face to face.”

Perpetrators & Victims
Women were much more likely to be the victim of an attempted or completed rape; perpetrators reported that about 80 percent of victims were female. The researchers also found that about 5 percent of victims were transgender.

White youths were more likely than nonwhite youths to report perpetrating coercive sex, and youths living in higher-income households were more likely to report attempted rape.

Perpetrators of any type of sexual violence were significantly more likely to have consumed any type of X-rated material, especially violent materials.

The authors note that while media consumption and violence could not be causally linked by their study, “it seems appropriate to suggest that frequent consumption of sexual and violent material and especially sexually violent material should be a marker for concern for adolescent health care professionals.”

Looking at the gender of assailants, researchers found that boys and young men accounted for almost all rapes and attempted rapes committed before age 18. The study notes that 98 percent of perpetrators whose first act occurred at ages 8 to 15 were male, as were 90 percent of perpetrators involved in an assault at ages 16-17.

Among 18- and 19-year-olds, women accounted for slightly more than half (52 percent) of attempted/completed rape perpetrators (seven women out of 13 total). The authors note that their broad definitions may result in finding an unexpectedly high amount of female perpetrators. They add, however, that it’s important to challenge the widespread notion that women cannot coerce men.

Some may argue that the definitions of rape and sexual assault in our investigation are too broad. Indeed, this may be why the perpetration rate among females is higher than might be posited. Rape includes acts beyond those in which the victim is physically overpowered, however. Restrictive definitions have potentially led to undercounting of sexual assault experiences.

For example, in the National Violence Against Women Survey, respondents were asked whether anyone had ever made them engage in a sexual activity “by using force or threat of force.” Psychological coercion was not clearly specified even though there are multiple coercive strategies other than physical force that can be used in a rape. To ensure that comprehensive rates of sexual assault and rape are identified as well as to begin building the research base on female perpetrators, research needs to include a fuller spectrum of rape scenarios.

Few Criminal Consequences
The findings on attitudes and punishment are chilling.

“Sixty-six percent of perpetrators reported that no one found out about the perpetration. Contact with the justice system was uncommon: 1% of perpetrators reported police contact and 1% an arrest,” note the authors.

They also found that half of perpetrators said that the victim was completely responsible for the incident. Only 1 in 3 said that they, the perpetrator, were completely responsible for the incident.

The authors recommend that more effort should be made on education that avoids victim blaming and emphasizes perpetrators taking responsibility for their own actions. They also suggest further research on factors related to taking responsibility, such as motivations behind the sexual violence and feelings of remorse or regret.

Incidents like this recent one in Maryville, Mo., in which a family moved due to harassment after the daughter was sexually assaulted, highlight the cruelty of victim-blaming and the need for prevention programs that put responsibility on the assailant.

The authors also commend bystander intervention programs, but note that most of that research has been done at the college level, and more work is needed at the high school level.

Plus: To learn more about consent, including essential rules, ways to talk about it, and examples of the enthusiastic consent model, check out Scarleteen’s Driver’s Ed for the Sexual Superhighway: Navigating Consent.

October 9, 2013

Studies Look at Access to Family Planning Services Provided at Federally Qualified Health Centers

A pair of newly published studies in the journal Contraception look at the types and access to family planning services provided at community health clinics that are considered a popular primary care option for low-income women of reproductive age.

The studies, produced by researchers at the George Washington University School of Public Health, examine the services at Federally Qualified Health Centers (FQHCs). These health clinics provide primary and preventive care on a sliding scale, primarily to low-income and uninsured patients. It’s also worth noting that when states attempt to defund Planned Parenthood clinics, these are clinics to which many women may get directed for care.

The authors anticipate that these health centers will become an even more important part of care as the Affordable Care Act is fully implemented and Medicaid is expanded. One of the co-authors is Dr. Susan Wood, who resigned her post as director of the FDA’s Office of Women’s Health in 2005 in protest over delays in approving over-the-counter access to emergency contraception.

In the first study, “Scope of Family Planning Services Available in Federally Qualified Health Centers,” researchers surveyed several hundred FQHCs about on-site care, including approaches to pregnancy prevention and STI/HIV testing and treatment, as well as referrals of patients to other sites, staffing issues, and other aspects of care. While they found that almost all of the FQHCs provided at least one contraceptive method, the type and accessibility of those methods varied.

Slightly more than half of the centers were able to dispense oral contraceptives on site rather than sending patients elsewhere with a prescription. Slightly more than a third (36 percent) offered both oral contraception and longer acting IUDs and/or implants on-site. If a woman has to go to another location, there may be consequences such as incurring lost work time that may make it harder to follow through.

Also, only about a third of the surveyed centers received Title X family planning funding (it’s not clear whether some clinics had not applied, or did apply and were rejected). The researchers found that while pretty much all of the centers provided access to oral contraception, the Title X-funded clinics were more likely to provide the full range of contraceptive options.

A companion paper, “Accessibility of Long Acting Reversible Contraceptives (LARC) in Federally-Qualified Health Centers (FQHCs),” looks specifically at the survey results on long-acting contraceptive options, including intrauterine devices (IUDs) and implants. The study found that slightly more than half of the FQHCs offered IUDs on-site, while about a third offered contraceptive implants on site. For the rest of them, patients would have to be referred elsewhere to receive the devices.

The authors again found that clinics receiving Title X funds were more likely to provide these options.

October 4, 2013

Wendy Davis is Running for Governor in Texas, and That’s a Big Deal

Democratic State Sens. Sylvia Garcia (obscured), Royce West, Wendy Davis and Kirk Watson after the Senate passed the abortion bill on July 13, 2013. Photo by Callie Richmond / Texas Tribune (Creative Commons)

Wendy Davis, the Texas state senator who held off a vote restricting abortion rights by staging an 11-hour filibuster in June, announced on Thursday that she will run for governor.

Davis’s filibuster was an attempt to block legislation intended to reduce abortion access, including a 20-week ban on the procedure, imposition of surgical center standards for abortion clinics, and a requirement for providers to have admitting privileges at a nearby hospital — which would force the majority of Texas’s 42 abortion clinics to close.

The legislation was later enacted; a lawsuit is underway to block the admitting privileges and medication abortion provisions of the law from taking effect.

The state senator’s actions inspired women’s health advocates around the country (and a whole bunch of memes). Her actions capped off a difficult six months, as states enacted 43 provisions aimed at restricting access to abortion — the second highest number on record at the mid-year point, and as many as were enacted in all of 2012, according to Guttmacher Institute. These states are, not surprisingly, mostly led by Republican male politicians.

If Davis is successful in her run (a very big “if” considering Texas hasn’t had a Democratic governor since 1995, when the formidable Ann Richards, mother of Planned Parenthood President Cecile Richards, was in charge), she would join a very small group of female governors throughout the country. At present, there are only five.

But as Danny Hayes, a political science professor at George Washington University, writes in the Washington Post, getting more women to run for office is a very big deal: “[B]ecause the main barrier to electing more women in the United States is getting them to run in the first place, Davis’s emergence — the result of her 11-hour filibuster against an abortion bill in the state Senate in June — may be critical for encouraging other female candidates to throw their hats into the ring.”

While Davis’s views on abortion are clear, female representation is, of course, no guarantee of more sensible approaches to women’s reproductive health. Arizona Gov. Jan Brewer (R) signed a 20-week ban in that state last year.