Archive for the ‘Pregnancy & Childbirth’ Category

January 27, 2014

Bill Regulating Certified Professional Midwives Needs a Push

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


January 13, 2014

A Woman’s Life Has Ended, but Hospital Insists on Life Support for Fetus Against Family’s Wishes

Right now in Fort Worth, Texas, 33-year-old Marlise Munoz lies in a hospital bed, brain dead after experiencing a blood clot in her lungs. Munoz’s family has been prohibited from honoring her wishes to be removed from life support.

Why? Munoz is pregnant.

When her clot happened, Munoz was 14 weeks pregnant; she’s now 20 weeks pregnant. Texas is one of 12 states in which a pregnancy at any stage invalidates a woman’s advance directive for her end-of-life care. The other states are Alabama, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, South Carolina, Utah, Washington, and Wisconsin.

According to the Center for Women Policy Studies, additional states can invalidate a pregnant woman’s wishes and force her to be kept on life support if it’s “probable” that the fetus will develop to the point of live birth. A few more states have similar rules but limit them to women whose fetuses are already viable.

The New York Times notes that some experts in medical ethics have said they believe the hospital is misinterpreting Texas state law prohibiting medical officials from cutting off life support to a pregnant patient. At this point, Munoz’s fetus is not viable outside of her uterus, and it’s unclear whether it was compromised by the amount of time she went without medical attention following her collapse or the subsequent deterioration of her body: 

Mrs. Munoz’s parents and her husband, Erick Munoz, 26, remain in limbo, even as they and other relatives help care for the Munozes’ 15-month-old son, Mateo. Mr. Munoz has returned to his job as a firefighter but continues to sit by his wife’s side at the hospital. She had been due to give birth in mid-May, but the hospital’s plans for the fetus — as well as its health and viability — remain unknown. Mr. Machado [Marlie Munoz's father] said he had been told by the hospital’s medical team that his daughter might have gone an hour or longer without breathing before her husband woke and discovered her, a situation he believes has seriously impaired the fetus. “We know there’s a heartbeat, but that’s all we know,” he said.

Mrs. Machado said the doctors had told her that they would make a decision about what to do with the fetus as it reached 22 to 24 weeks, and that they had discussed whether her daughter could carry the baby to full term to allow for a cesarean-section delivery. “That’s very frustrating for me, especially when we have no input in the decision-making process,” Mr. Machado added. “They’re prolonging our agony.”

Lynn Paltrow of the National Advocates for Pregnant Women has commented:

What is quite stunning about these statutes for women is that they don’t even take into account a woman’s pain. A woman could be in excruciating pain and near death’s door and they still would force her to suffer. These are extraordinary laws creating separate unequal status for pregnant women in which they lose control of medical decision making, the right to bodily integrity and right to be free of excruciating pain.

Not being allowed to die in peace, or watching a family member be denied their wishes, is the stuff of nightmares. This extreme situation, however, isn’t the only one in which pregnant women’s freedoms have been restricted.

In October, there was some media coverage of Alicia Beltran’s case. Beltran had beaten a drug addiction and was 14 weeks pregnant when her doctor and a social worker tried to force her to take an anti-addiction drug and took her to court when she refused.

The National Advocates for Pregnant Women has documented hundreds of U.S. cases of pregnant women who were subjected to or threatened with incarceration, detention, or forced medical or other interventions that the state decided were in the best interest of the fetus — not the woman.

A petition has been launched asking Texas Attorney General Greg Abbott to leave this decision to Marlise Munoz’s family. To learn more about “pregnancy exclusion laws,” read “Marlise Munoz Case Shines Light on Dehumanizing ‘Pregnancy Exclusion’ Laws,” by Lynn Paltrow and Katherine Taylor.


January 3, 2014

How to Fix the “Travesty” of U.S. Maternity Care – And Ensure Women Have a Full Range of Choices

Anna Fettby Anna Fett

“So, when am I going to get a grandbaby?”

We have not even been married a month and already my mother-in-law has begun peppering my husband and me with this loaded question.

Babies are still the furthest thing from my mind. I moved to Cambridge with big dreams of pursuing a master’s degree and then plowing onward toward doctoral studies. I know very few people who attempt graduate studies and motherhood simultaneously, and for me the former currently takes precedent over the latter.

Besides the occasional prodding from my family, I rarely think about becoming a mother — that is, until I happened to read a startling headline on the JAMA Forum that caught my attention: “Transforming the Costly Travesty of U.S. Maternity Care.”

My curiosity was piqued; while I knew there are problems in the healthcare system, I was unaware that maternity care in particular was suffering a “travesty.”

The article by Dr. Diana Mason begins by ranking the United States as 46th in the world on maternal mortality “with a rate that has doubled since 1987 and is twice that of 31 other nations.” I was shocked.

The fact that the United States could be so far behind other countries was disturbing, but even more troubling was my ignorance on this issue. How did I not know this? Why are we not all discussing the quality of maternity care?

Moreover, how could this be? — especially given the fact that maternal and newborn care is also the most costly reason for hospitalization in the United States.

My brain attempted to process this debacle. We are paying too much for maternal-newborn care without meeting the same standards of quality of many other countries in the world.

Even though pregnant women in America comprise “a largely healthy population that needs few procedures or technological interventions,” writes Mason, the system is set up to encourage unnecessary procedures, such as cesarean sections — “now the most common operating room procedure in the United States” — despite the fact that normal vaginal births cost 30 percent less.

Suddenly “travesty” did not seem such a stretch.

The goal of Mason’s article is to develop ways of improving maternal-newborn care while also reducing costs, which she believes can be done by shifting to the midwifery model of care. I admit hearing the term “midwifery” instantly conjured images of the Middle Ages for me, but in reality midwives still play prominent roles around the world, and in the United States there is a push to expand midwifery services.

There are now 250 birth centers that follow the model that “maternity services should be provided by certified and licensed midwives and family physicians,” while obstetricians should be reserved for “high-risk pregnancies.”

Maternity care at these facilities could be a much more cost effective option than hospitals if health insurance companies and Medicaid were required to pay “birth centers at 100% of the rate of hospitals for the same or equivalent codes, such as for normal vaginal deliveries,” writes Mason. Families have difficulty taking advantage of what would be a cheaper option because their insurance does not cover deliveries by family physicians or midwives.

As I absorbed this article, a deeper concern struck: The transformation that Mason envisions must also encompass the American way of thinking about maternity care. Instead of viewing the professional provider as the one who delivers a mother’s newborn, the midwifery framework holds that the mother gives birth “with the support of the professional” and “with physician and hospital back-up as needed.”

If we aligned our public policy with the midwifery framework, we could appreciate returning the power of choice to American mothers. Women should be able to decide where to give birth — in the hospital, birth center, or home — and they should be able to decide who will attend them: midwives, family physicians, or obstetricians.

But this can only happen after improving insurance and Medicaid coverage, implementing policies that allow women to choose among these options, and ensuring that midwives receive the education and protection they need, as Mason writes, to “practice to the full extent of their training.” Only by tackling the factors Mason raises can we ensure that women have the full range of choices they need to get the maternity care that is right for them and their family.

When, or even if, my husband and I decide to have children, it is a choice that we get to make when it is right for us — despite my mother-in-law’s best attempts at interference. When we have so many choices ahead of us in life, it seems obvious that we should also have options of where and how to receive maternity care.

I am now joining the ranks of those who want to make the transformation of U.S. maternity care a reality.

Anna Fett is a master of theological studies candidate at Harvard Divinity School with a focus in women and gender studies as well as Islamic studies. She will graduate in May 2014.


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.


September 24, 2013

How Can You Be Sure You’re Getting An Insurance Policy That Covers Maternity Care?

Michelle Andrews of Kaiser Health News answers an important question about maternity care coverage. Read more from the KHN series Insuring Your Health.

Q. My wife and I are newlyweds. We are looking into family insurance plans and are curious about maternity coverage, rates and any limitations. I’m seeing a lot of companies don’t cover maternity benefits or impose six-month restrictions. It seems really complicated and not helpful, to say the least. Any information you can provide will help.

A. This is one of the problems that the health law was designed to address.

The Pregnancy Discrimination Act requires companies with 15 or more workers that offer health insurance to provide maternity coverage for workers and their spouses. But the law doesn’t apply to plans sold on the individual market.

Only 12 percent of those individual plans provide maternity coverage, according to an analysis published last year by the National Women’s Law Center. Plans that do cover maternity services may have a separate deductible of up to $10,000 and impose a waiting period of up to a year before members can use the services, the study found.

All that will change next year. Starting in January, the Affordable Care Act requires all new individual and small group health plans to cover 10 “essential health benefits,” and maternity and newborn care is one of them.

Insurers can’t impose waiting periods for maternity coverage nor charge women higher rates than men, as typically occurs now.

If you buy a plan on the individual market now, chances are you’ll pay extra for maternity coverage, if you can find it at all. But even if you buy a plan now, there’s nothing to stop you from shopping for a plan that meets the new maternity coverage requirements when your state’s health insurance marketplace launches in October. Your new coverage could begin in January, says Carrie McLean, director of customer care at online vendor eHealthInsurance.com.

If you and your wife do become pregnant before year’s end, you may benefit from another provision of the Affordable Care Act. Under current law, insurers on the individual market typically consider pregnancy to be a pre-existing medical condition and refuse to issue policies to people who are pregnant.

Starting in January, “Nobody can ask them if they’re pregnant and then deny them coverage,” says Judy Waxman, NWLC’s vice president for health and reproductive rights.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. 


August 30, 2013

Want to Reduce Unintended Pregnancies? Provide Health Education & Support

Almost half of all pregnancies in the United States are unintended. These pregnancies can result in worse health outcomes for both women and their babies, due to potentially poor health prior to pregnancy and delays in obtaining prenatal care and making changes such as quitting smoking.

For a new, small study published in the Journal of Midwifery & Women’s Health, researchers spoke to women in three Michigan neighborhoods characterized as low-income, urban, culturally/ethnically diverse, and medically underserved — basically the type of neighborhood where unintended pregnancy rates are higher than average.

The researchers conducted six focus groups with a total of 41 women, ages 18 to 44 years, who were either pregnant or had been pregnant within the last three years. They sought the women’s input on three important questions:

  1. What could be done to encourage women to recognize their pregnancies early (within six weeks from their last menstrual period)?
  2. What should be the primary action to help women recognize their pregnancy early?
  3. What are the most important things that could help women to be sure of their pregnancies early?

The women identified a few main themes and provided numerous suggestions for addressing these issues, including:

  • Promoting knowledge of reproductive changes in the body: Teach women about their female reproductive system and its cyclic changes, such as timing of ovulation, number of days in a cycle, and how to keep a menstrual calendar.
  • Promoting early testing or confirmation of pregnancy: Assist women to know symptoms of pregnancy and to recognize their pregnancies early through the use of home pregnancy test kits or going to the doctor or clinic to confirm a pregnancy.
  • Providing informational support: Provide a list of locally available pregnancy-related resources, such as clinics, prenatal classes, and educational sessions on women’s health.
  • Providing emotional support: Have a friend to talk with or have nurses, midwives, and other health professionals to go to for guidance during the preconception and prenatal periods.

While small, this type of study — and the prison health study we wrote about earlier in the week — are very much needed, because they ask the people most affected about their needs and experiences.

In this instance, community health workers (residents from each neighborhood employed to promote health and access to health care) were already familiar figures in these neighborhoods, and a participatory research model was employed that was sensitive to the residents’ needs. For example, the researchers provided transportation *and* childcare so the women could participate.

In their “implications for practice” section, the study’s authors urge future research along the themes the women identified. Teaching women about the menstrual cycle, along with the signs and symptoms of ovulation and pregnancy, can help women to take more control over their health and their lives.

As one woman in the study said, “I guess just being taught more in an individual sense of how to recognize things in your own body instead of being lumped, that it would be the standard, like I said earlier, 28-32 days. I mean, if women could really have that sense of, like, knowing how they are, it’s much easier to plan around that, or at least to be aware.”

The researchers also urge systemic approaches to reducing unintended pregnancy and the associated health effects, including comprehensive reproductive education (starting even before adolescence), policies that promote access to pregnancy-related resources and facilities, and access to early pregnancy testing.


July 31, 2013

The Medical (and Political) Problem with 20-Week Abortion Bans

July 15 protest rally in Austin against anti-abortion legislation

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

The recent wave of anti-abortion legislation has caused much confusion and concern over what the future of reproductive healthcare might look like in a few years.

Texas recently enacted a 20-week abortion ban, and 13 states have passed similar bans. In Congress, Republican senators are pushing to bring a 20-week abortion ban up for a vote after the August recess, reports The New York Times.

Let’s first look at the language in these bills, which usually reference “20 weeks post-fertilization.” Aside from the restrictive issues, these post-fertilization bans present a major problem — that’s not how pregnancy is measured.

When a doctor or midwife indicates that someone is “20 weeks pregnant,” what they mean is that it has been 20 weeks since the first day of the last menstrual period (or LMP). This can be a bit confusing, because the first day of the last period is not when ovulation followed by fertilization actually occur.

This LMP method is used because it’s the easiest to measure. While ovulation is often estimated at about two weeks after the start of the last menstrual period, it can occur at different times for different people, making it impossible to know exactly when ovulation — or fertilization or implantation, for that matter — occurred.

LMP, however, is something we can point to on a calendar and is easily knowable. That’s why healthcare providers ask the question.

To recap the terms:

  • 20 weeks “pregnant” = 20 weeks after the first day of the last menstrual period (LMP); used by medical providers to date pregnancies.
  • 20 weeks “gestational age” = usually the same as above, measured since the first day of the last menstrual period; used by medical providers to date pregnancies.
  • 20 weeks “post-fertilization” = may be approximately 22 weeks “pregnant” by the normal method of measuring; used by politicians to promote 20-week abortion bans.

In other words, nobody but politicians uses fertilization as a way of dating a pregnancy. For the record, a pregnancy does not start at fertilization; implantation must occur for the pregnancy to progress.

So why are politicians using “post-fertilization”? For one, politicians may simply have very little understanding of pregnancy. This would not surprise us in the anti-science era of “legitimate rape.” (Though we really wish members of Congress would read their copies of “Our Bodies, Ourselves.”)

More cynically, politicians may be deliberately fostering confusion in order to make it more difficult for women to determine whether they are within their legal right to obtain an abortion.

For example, a woman told she is “22 weeks pregnant” by a healthcare provider may assume she’s past the cutoff and no longer able to obtain an abortion. In reality, she may be just 20 weeks post-fertilization and still eligible for a short period of time.

Anti-abortion advocates justify 20-week post-fertilization limits based on the widely disputed idea that fetuses may feel pain at that point. The so-called “Pain-Capable Unborn Child Protection Act” (HR 1797) that the House passed in June specifically referred to 20 weeks after fertilization as the cutoff for legal abortion, based on the widely disputed idea that fetuses can feel pain at this point.

However, a 2005 systematic review on the topic concluded that “pain perception probably does not function before the third trimester.” Similarly, a 2010 report by the Royal College of Obstetricians and Gynaecologists (UK) concluded: “Interpretation of existing data indicates that cortical processing of pain perception, and therefore the ability of the fetus to feel pain, cannot occur before 24 weeks of gestation.”

For all the supposed concern about pain, it’s almost unheard of for anti-abortion activists to discuss the counterbalancing notion of pain, illness, injury and potential death that a woman may face carrying a pregnancy to term — see Jessica Valenti’s most recent column in The Nation for more from this perspective.

It’s also important to remember, as Paul Waldman points out, that these bills contain provisions that aim to shut down abortion clinics, including onerous Targeted Regulation of Abortion Providers (TRAP) laws that are costly and do nothing to increase safety:

Abortion clinics often require doctors from out of state to travel to the clinic, because of the harassment, threats, and even assassinations that local doctors have been subject to? Then we’ll require that every doctor have admitting privileges at a hospital within a certain number of miles, which out-of-state doctors won’t have. And we’ll throw in some rules on how wide your hallways need to be (not kidding), meaning in order to stay open you’d have to do hundreds of thousands of dollars of remodeling. Failing that, we’ll make sure that women who need abortions will have to suffer as much inconvenience, expense, and humiliation as possible.

Ultimately, the GOP’s concern is not so much about minimizing human suffering, but about advancing strategies for keeping women from exercising their right to safe, legal abortion. Writing at RH Reality Check, Imani Gandy does a  good job explaining the anti-choice litigation strategy, noting in part:

The push for 20-week abortion bans is part of a national strategy implemented by anti-choice advocates to create exactly the sort of legal mess that will force the Supreme Court to reconsider Roe v. Wade and Planned Parenthood v. Casey, and to revisit the viability standard that has served as the constitutional foundation for abortion rights for 40 years.

An analysis by RH Reality Check suggests that the strategy deployed by anti-choicers is deeply subversive. It capitalizes on personal feelings and anti-abortion hostilities by enticing judges and legislatures to abandon empirical science in favor of biased, agenda-driven science or, as it is sometimes called, “junk science.” Proponents of junk science, which has become a cottage industry among anti-abortion advocates, confuse the issue of fetal viability, invent claims about fetuses feeling pain (or masturbating in utero), and call into question established medical standards.

The strategy is a smart one, to be sure. Anti-choicers understand that once junk science has been incorporated into legislation, courts are not inclined to question those scientific findings—no matter how agenda-driven they are—and will simply apply the law to those “facts.” In cases when junk science is presented to a court, a judge (or justice) hostile to abortion rights requires only the flimsiest reasoning to ground their legal opinion in fact, even if those “facts” are anything but factual.

As the American Congress of Obstetricians and Gynecologists wrote when addressing political attempts to limit abortion based on ideas about fetal, pain: “Facts are important.”

Let’s hope the courts think so, too.


July 22, 2013

Night Sweats: A Memoir on an Unplanned Pregnancy

Librarian Laura Crossett has just published a memoir of her unplanned pregnancy, “Night Sweats: An Unexpected Pregnancy.”

I’d recommend it on the merits alone, but here’s another reason: Laura is donating half of her proceeds from book sales to Our Bodies Ourselves.

Crossett describes her experience as a 35-year-old single woman — one month into a relationship and six months into a new job — facing a very unplanned pregnancy.

As the book description notes, her predicament is not uncommon, though her story is:

Almost half the pregnancies that occur in the United States each year are unplanned. Some of them happen to married women, some to unmarried; some occur due to failure to use contraception; some due to contraceptive failure. Some happen to women who hope one day to have children; some to women who never wanted children at all.

In a political climate that polarizes around issues of sexuality and choice and a popular culture that glamorizes pregnancy and fetishizes motherhood, we rarely hear the stories of women who did not seek to become pregnant. Night Sweats is one of them.

Despite the serious nature of her situation, there are some really funny bits in “Night Sweats” that made me chuckle. Discussing how pregnancy books assume certain kinds of family structures and access to resources, Crossett writes: “It’s like 1952 in pregnancy books, only with organic baby food and no BPA.”

The book is structured around the church year of the Episcopal Church, but if you are unfamiliar with its traditions (as I am), it’s not confusing (or preachy). Crossett is very straightforward about considering abortion when she learned of her pregnancy, and it’s interesting to explore her thought process.

We know that more than 70 percent of women seeking abortions are religious, but we don’t always get to hear these everyday stories amid the political rhetoric around the procedure.

You can purchase “Night Sweats” directly from Crossett if you happen to be in the Iowa City area, or you can buy it online:

In the acknowledgements, Crossett cites “Our Bodies, Ourselves: Pregnancy and Birth,” along with Ina May’s “Guide to Childbirth,”as “the best books” she has read on the subject.

During an email exchange, Crossett expanded on her appreciation for OBOS’s approach: “I picked up the ‘Our Bodies, Ourselves Pregnancy and Childbirth’ book (I’ve always been a fan of OBOS), and there, finally, was a book that never made an assumption. It talked about planned and unplanned pregnancies and people of color and GLBTQ people and people with mental illness and addiction and people who’d been raped and people with partners and people without — it was just so great.”

Learn more about and read excerpts from OBOS’s “Pregnancy and Birth,” or order it online for yourself or in bulk for health clinics or groups providing health-counseling services (there’s a steep discount!). Finally, if you’re interested in directly supporting our work, please make a donation online!


July 12, 2013

State by State: Laws Restricting Abortion and Family Planning as of Mid-2013

 abortion restrictions enacted at midyear for 2007 through 2013

If you’re having trouble keeping up with the assault on abortion rights across the states, you’re not alone.

While we’ve been hearing a lot out of Texas, and some from North Carolina and Ohio, many other states have enacted regulations restricting access to healthcare.

These include obstacles such as requirements for hospital admitting privileges for providers, bans on medication abortions by telemedicine and abortion after 20 weeks, and biased counseling laws — requiring, for instance, that women be provided with information falsely linking abortion to breast cancer.

Other new laws, such as restrictions on family planning funding, have further affected women’s access to reproductive health services.

How bad is it? According to updated information from the Guttmacher Institute, states enacted 106 provisions related to reproductive health and rights in the first six months of 2013 alone. This includes 43 restrictions on access to abortion — the second-highest number ever at the mid-year mark, and as many as were enacted in all of 2012.

Guttmacher points out a glimmer of sunshine as well: Among the numerous restrictions, some states saw new laws to expand comprehensive sex education, make STI treatment of partners easier, and increase access to emergency contraception for women who have been sexually assaulted.

Rachel Maddow this week looked at the overall impact of state-by-state anti-abortion laws, showing how states under Republican control since the 2011 elections are restricting access. Maddow also provides more information on some of the individual states.

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July 8, 2013

Lessons Learned: Why Midwives Should Matter to Everyone

by Eliza Duggan

eliza duggan“Interesting! … What’s that?”

This is the typical response I received when I told people, especially my peers, that I was writing my senior thesis on midwifery. I became accustomed to saying, “I’m writing on midwifery — midwives,” since most people have at least heard the term “midwife.”

The initial lack of knowledge was discouraging; however, the best parts of my project were the conversations that followed. The more I researched and wrote on midwifery, the more it became clear to me that not only are young people interested in birth and midwifery, but this knowledge could be vital to our futures.

As The New York Times recently reported, U.S. maternity care is the costliest in the world. And yet according to the 2010 World Health Statistics, we rank behind dozens of countries when it comes to such benchmarks as maternal, neonatal and infant mortality rates.

A Times follow-up story on the lack of insurance coverage for midwifery care notes that “in many European countries, midwives attend to most pregnancies, often in clinics, resulting in maternity charges that are a fraction of those in the United States.”

Growing up in a small town in Maine, a place where midwives are well known and well respected in the community, I have always been familiar with home birth. Even with this experience, I did not really think about the political complexity of midwifery, nor the unique position that midwifery holds in relatively rural areas like mid-coast Maine, until I moved away.

I went to Boston for college, and in 2011 I took an internship with the women’s advocacy organization Our Bodies Ourselves. For one of the projects I worked on, I promoted midwifery legislation in Massachusetts that aims to expand the rights of nurse-midwives and license and regulate home birth midwives. The bill didn’t pass then, but it has been reintroduced in the 2013-2014 session.

The more I dove into the issue, however, the more I became surprised at the ambivalent and sometimes even hostile reception to the very idea of midwifery. I had assumed that the famously liberal citizens of Massachusetts would generally have the same attitude towards midwives and home birth that I had. When brainstorming ideas for my senior honors thesis at Boston College, I was compelled to investigate this issue further.

In the fall of 2012, I began doing extensive research on the history of midwifery and how it had become so marginalized in Massachusetts. I interviewed countless home birth midwives, nurse-midwives, childbirth educators, public health experts, and consumers in order to gauge attitudes toward maternity care in Massachusetts.

One of the most troubling things that I found was not only were few people interested in this issue, but the vast majority of people who were involved already had children. Most people my age were unfamiliar with midwives and the topic of childbirth as a whole.

This isn’t surprising; we’re usually not encouraged to consider how we feel about childbirth until we or someone we know becomes pregnant, so often we don’t have a clear sense of our options or knowledge about the process. After getting over their initial discomfort, my friends and classmates became intensely curious about childbirth, and most of them had lots of questions.

While working on my thesis, I realized that there is a need for discussion about childbirth before pregnancy. We need to know our options so we can make informed decisions about how we want our children to be brought into the world — and so we can support public policies that are best for mothers and babies.

This, I believe, should be an easy fix. The countless conversations I had with my peers have shown that pregnancy and birth are interesting topics, and young men and women are eager for accurate information, too.

Eliza Duggan is a 2013 graduate of Boston College, where she majored in English and women’s studies. Her time at OBOS and her thesis work inspired her to pursue women’s advocacy. She will be a first-year law student at the University of California at Berkeley Law School in the fall.


June 13, 2013

Single Embryo Transfer Recommended in Most IVF Procedures

The process of in vitro fertilization – in which embryos are created outside a woman’s body and then implanted in her uterus — has become increasingly common in the United States. In 2010, 61,564 infants were born using an a form of assisted reproduction technology (ART), and almost all of those resulted from IVF.

A common IVF practice has involved transferring multiple embryos to a woman’s body in one cycle. This was thought to increase the likelihood that at least one embryo would successfully result in a live birth. The average number of embryos transferred at one time is two to three.

While this strategy makes sense theoretically, it is not risk free. Transferring more than one embryo creates a risk for multiple pregnancies, such as twins or triplets, which makes the pregnancy higher risk and increases the risk of premature birth and low birth weight. (Single pregnancies created via IVF are also thought to be at a higher risk for prematurity, low birth weight, and congenital anomalies, though researchers aren’t certain whether this is due to the IVF techniques or the underlying infertility problem.)

Recently, researchers have been studying whether single embryo transfer might be a better option. Some have suggested that birth rates might be similar when single embryos are transferred.

The research has been convincing. In a joint practice committee statement, the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine concludes that with improving technology, single embryo transfer (SET) is an increasingly better choice for achieving pregnancy while avoiding multiples.

The statement notes that SET may be particularly appropriate for women with the best chance of a good outcome, such as those who are under 35 or on their first or second treatment cycle, and that women ages 35 to 40 could also elect SET if they have “top quality” embryos of the proper stage available for transfer.

The authors also note that the United States has “lagged behind” the rest of the world in focusing on SET. For example, the National Institute for Health and Care Excellence (NICE) in the UK recommends single embryo transfer for most women and no more than two at a time for anyone.

For more on single-embryo transfers, read this excerpt from “Our Bodies, Ourselves.”


June 4, 2013

New Survey on Childbirth Details Experiences, Problems with Hospital-Based Births

Listening to Mothers III: Pregnancy and BirthChildbirth Connection, a nonprofit organization that produces evidence-based information and resources on pregnancy, labor and birth, and the postpartum period, has released its third major survey on the experiences of childbearing women in hospitals across the United States.

The results of Listening to Mothers III provide insights into numerous issues, including childbirth education; the use and need of government services such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); medical interventions during birth; provider choice; and health disparities.

The 2,400 women who completed the online survey were 18-45 years of age, gave birth in a U.S. hospital to a surviving single baby at some point between July 1, 2011 and June 30, 2012, and could participate in English. The research firm Harris Interactive collected the data.

Among the findings, the number one factor driving a woman’s choice of maternity care provider and hospital was acceptance of her health insurance plan. Insurance compatibility ranked higher than  recommendation by a provider, friend or family member, and higher than familiarity due to a previous birth.

Only about half of the women ever saw information that allowed them to compare the quality of potential providers and hospitals, but when they did have that information, 80 percent used it as a factor in their decision.

Pregnant women reported difficulty communicating with their providers at times — 30 percent said that at least once they had let a question go unasked because their provider seemed rushed, and 15 percent reported that their prenatal care provider “always” or “usually” used medical words they did not understand.

The survey provides a variety of data about various medical interventions, including induction, mode of birth, pain relief, labor support.

Close to one-third (31 percent) of survey participants had Cesarean-sections, which is pretty similar to the overall national rate.

There are a number of data points that suggest practices that are not evidence-based or are otherwise problematic, including hospitals not allowing VBAC attempts, somewhat high (17 percent) rate of episiotomy, reports of pubic hair shaving (10 percent for vaginal birth), c-sections performed because the provider had concerns about the baby being too big, and providing formula samples/coupons to moms and bottles with formula or water to babies, even when the moms wanted to exclusively breastfeed.

While it’s not clear how accurately the provider rationale and medical interventions were self-reported by the women, they’re worth a look for women’s perspectives on their care before, during and after childbirth.

The report includes women’s stories about these interventions, and the sometimes-poor communication they experienced with their providers. One respondent commented: “I was not told that I was going to need an episiotomy, and it was done without my permission. I just would have liked to know what an episiotomy was, why it happens, and what it’s like to deal with and take care of after giving birth.”

Another woman reported: “I felt bad because the doctor delivering my baby didn’t give me details. He just told me my baby was in danger and that I needed a c section. I believed him because I care about my baby.”

A companion report, “Listening to Mothers III: New Mothers Speak Out,” will explore postpartum experiences and further explore childbearing and maternity care. It is expected to be released later this month.


May 31, 2013

Reproductive Justice: The Movement Whose Time Has Come

The Reproductive Justice: Activists, Advocates, Academics in Ann Arbor (“A3 in A2″) conference taking place this week aims to foster learning, dialogue and collaboration around reproductive justice issues. OBOS Executive Director Judy Norsigian, one of the conference advisory board members, is leading a session on informed consent and moderating Friday’s final panel.

Until recently, the term reproductive justice was used mainly by a relatively small number of people involved with abortion rights and women’s reproductive health (read about its history at SisterSong). The phrasing is more inclusive than abortion rights and takes into account all aspects of women’s ability to control their own reproduction, including social inequalities that affect the ability and right to have or not have children and to parent children in healthy environments.

The term has been discussed, and debated, quite a bit lately. Over at RH Reality Check, Jon O’Brien, president of Catholics for Choice, recently argued why reproductive justice cannot be a substitute for the terms “choice” or “pro-choice,” prompting this response from reproductive justice activists (who, it should be noted, consider Catholics for Choice an ally). Their response notes in part:

Women of color struggled within the pro-choice movement to bring their needs to the forefront, and they also created new organizations built on a broad, intersectional analysis and understanding of reproductive rights and health. The shift from choice to justice does not, as O’Brien says, devalue the autonomy of women who face obstacles. Instead, locating women’s autonomy and self-determination in human rights rather than in individual rights and privacy gives a more inclusive and realistic account of both autonomy and what is required to ensure that all women have it. Advocating for reproductive justice was not counter-posed against being “pro-choice” or supporting abortion rights. Rather, reproductive justice re-framed and included both.

The push toward a more comprehensive understanding of reproductive rights has also been adopted by the Unitarian Universalist Association (UUA) of Congregations. Delegates at last year’s General Assembly meeting selected “Reproductive Justice: Expanding Our Social Justice Calling” as the 2012-2016 Congregational Study/Action Issue — meaning congregations and districts are invited to engage and reflect on it, in any way they see fit — and the subject will be the focus of this summer’s GA meeting.

Earlier this year, Billy Moyers invited Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health, and Lynn Paltrow, founder and executive director of National Advocates for Pregnant Women, to discuss the topic.

“What’s happened is that women are beginning to recognize that what’s at stake is more than abortion,” said Paltrow. “It is their personhood — their ability to be full, equal, constitutional persons in the United States of America.”

For more information: Check out the Reproductive Justice Briefing Book. Produced by the Pro-Choice Public Education Project, it offers a comprehensive look at a variety of topics, including sex education, abortion, adoption, pregnancy, disability, incarceration, immigrants, LGBT issues, race, and class.


May 22, 2013

Supporting Women – At Home and Around the World

First in an occasional series by OBOS staff about their work and their lives.

Ayesha and her daughter, Tara

Ayesha and her daughter, Tara

I was welcomed into the Our Bodies Ourselves family in January 2006, soon after I moved to Boston from India. As a die-hard reproductive justice advocate (and unabashed “Our Bodies, Ourselves” fan), I was euphoric to join the team.

The OBOS Global Initiative, which supports women’s organizations developing and using culturally specific materials based on “Our Bodies, Ourselves,” offered the perfect opportunity to weave together my commitment to women’s rights and cross-cultural movement building.

Eight years later, I have helped shepherd the development of resources based on “Our Bodies, Ourselves” in 12 additional languages (with more in development), and coalesced a global network of social change activists.

I have been privileged to meet, learn from, and grow to love this group of women, each on the frontline of human rights work in her country. I know that OBOS’s partnerships with these visionary and tenacious leaders represent a community of shared interests that is pivotal to protecting the lives of women and girls on the ground.

Beyond OBOS, I nurture my decade-long love affair with reproductive justice by supporting families with newborns. As a postpartum doula trained by DONA International, the oldest and largest doula association in the world, and young mum (and as a child who benefitted enormously from the loving arms of extended family), I am personally affected by and committed to changing the state of postpartum care in the United States — one mummy at a time!

My doula-ing started rather unexpectedly and informally in 2009, with the birth of my niece. Though I have always been acutely aware of the growing global crisis in maternal and postpartum care through my work overseas and at OBOS, being with my sister and her family during and after the birth was transformative — the proverbial eye-opener. I quickly became aware of the awesomeness of their task; a task that really does take a village.

At the time, my goal was simple: to love and provide everything my sister and her partner needed to stay nourished and focused on their baby and each other. From hot meals and daily grocery runs, to endless loads of laundry and late-night, sleepy-eyed banter to keep my sister awake (and laughing) through yet another round of pumping, I did my best and loved (nearly) every moment of it.

OBOS, with its four-decade journey and networks of women’s health activists, has connected me with women who, like me, are drawn to the sides of expectant and new mothers. With these relationships, I am now gaining stride in my doula-clogs.

I thank the families that have let me into their homes and lives; I am honored and humbled by their trust. As OBOS expands its global reach, I thank the women who have become our steadfast co-conspirators in a collective struggle. I am inspired by the fire in their bellies.

And to all of you: I thank you for cheering us on and hope you will remain our committed partners as we plough ahead, forging a global community where women live without fear, with dignity, wrought as a fundamental human right.

Ayesha Chatterjee is the OBOS Global Initiative program manager.


May 16, 2013

Truth in Medicine: Vast Majority of Assisted Reproductive Technologies Fail

by Miriam Zoll

In an essay recently published in the Wall Street Journal, Sarah Elizabeth Richards, author of the new book “Motherhood Rescheduled,” encourages women to ward off age-related infertility by simply freezing their eggs — like she did.

Between the ages of 36 and 38, Richards spent $50,000 to freeze 70 eggs that she plans to thaw, fertilize, and insert into her uterus when she is 44 or 46.

“Egg freezing,” she said, “stopped the sadness that I was feeling at losing my chance to have the child I had dreamed about my entire life.” Still looking for a mate at almost 40, Richards says she now goes onto Match.com and has the confidence to tell men that she can “have kids whenever I want.”

While Richards’ decision appears to have provided her with a sense of hope and temporary emotional equilibrium, it may prove to be illusory. Sadly, as millions of women, including me, can attest, the vast majority of assisted reproductive technologies fail.

In 2012, of the 1.5 million treatments performed globally, 1.1 million failed: a 77 percent failure rate. In the United States, the overall failure rate was 68 percent. Once optimistic and hopeful about the promise of reproductive science, I endured four failed in vitro fertilization (IVF) cycles, one miscarriage, and two donor egg attempts in which both donors were diagnosed as being infertile.

But it is no wonder that Richards believes she will be able to bear children with her frozen eggs whenever she wants to. A $4 billion industry is driving the public discourse about often unproven discoveries through a lens that focuses attention on the minority of successes rather than the whole messy, complicated story.


Related: What’s Wrong With Fertility Clinics and Online Advertising



Growing up in a culture that reveres science, she has been bombarded with overly optimistic and one-sided media stories touting the miracles of creating babies in laboratories. The truth is, many women signing up for treatments do not realize until later the extent to which they are participating in a vast experiment, where evidence-based medicine has yet to establish a reasonable foothold.

The only current independent effort to track the health of all women going through treatments remains largely invisible to patients who might sign up to have their health — and that of their offspring — tracked over time.

The voluntary Infertility Family Research Registry is based at the Dartmouth Hitchcock Medical Center and is funded in part by the American Society for Reproductive Medicine (ASRM). To date, the vast majority of large fertility centers in the United States are not displaying the registry’s placard in their waiting rooms, greatly reducing the potential benefits such a long-term study would provide. [Ed note: Our Bodies Ourselves is actively encouraging infertility clinics and centers across the country to promote awareness of the Infertility Family Research Registry.]

Richards’ desire to protect her ability to bear a biological child is heartfelt, and her willingness to undergo egg freezing procedures that were considered experimental at the time speaks to her commitment — and her panic — to try anything to preserve that opportunity. But her statement that this decision was “the best investment” she ever made is premature, to say the least.

The general public knows virtually nothing about the failure and success rates of vitrification — a new flash-freezing technique that has been used to preserve the eggs of women younger than 30 who are facing life-threatening illnesses. While an estimated 1,000 babies have been born from this technology worldwide, there is virtually no data that tells us if these live births were the result of 3,000 or 10,000 trials.

We have no idea how many miscarriages or still births may have ensued, and there are few, if any, long-term infant health studies evaluating how flash freezing half of a child’s DNA might affect that child later in life. The one study Richards cites found that 900 babies exhibited no more risk of birth defects than babies conceived naturally by young mothers, but is one study really enough?

Apparently the ASRM believed it was proof enough for them to lift the “experimental” label from the still young procedure last fall. The ASRM Practice Committee said it was not yet ready to endorse widespread use of egg freezing for elective use. However, while randomized controlled studies were rare, the committee did find sufficient evidence to “demonstrate acceptable success rates in young, highly selected populations.”

Citing a lack of data on safety, efficacy, cost-effectiveness, and potential emotional risks, their report states, “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage them to delay childbearing. Patients who wish to pursue this technology should be carefully counseled.”

As would be expected, once the ASRM decision became public, their caution about women’s age and infant health was obscured and eventually obliterated by the dust kicked up by a stampede of panicked but hopeful 30- and 40-something women running to the nearest fertility clinic to have their eggs harvested for future use — for anywhere between $10,000 and $15,000 per harvest, or more.

One must wonder why the ASRM felt so compelled to provide a stamp of approval for a procedure still lacking in reliable safety and efficacy data. As legal scholars Debora Spar and Naomi Cahn have written in their books, “The Baby Business” and “Test Tube Babies,” respectively, in the context of an unregulated industry in the United States, it is virtually impossible to separate the medical and market forces at play when new techniques and procedures are advertised to potential clients.

The blurred boundaries between fertility clinics wanting to provide patients with safe, evidence-based procedures while also needing to generate business to meet their bottom lines puts that much more pressure on consumers to know what they are signing up for. But when evidence and information is scarce, biased, or non-existent, well-heeled consumers like Richards feel they have no choice but to close their eyes, write a check, and jump off that technological cliff called “hope.”

For Richards’ sake, I hope she succeeds. If not, she may well join the ranks of millions of men and women who, since the first IVF baby was born in Britain 35 years ago, have experienced involuntary biological childlessness as a result of delaying parenthood and relying on science for last-minute miracles.

Miriam Zoll is an award-winning writer and an international health and human rights advocate and educator. She is the author of “Cracked Open: Liberty, Fertility and the Pursuit of High Tech Babies” and is on the board of Our Bodies Ourselves. This article was originally published at RH Reality Check, and is reprinted with permission.