“President-Elect Obama’s healthcare reform proposals have focused intensely on two key questions: How much would reform cost and how many people would be covered? He also must address the critical issue of why the United States has such poor health outcomes despite all the money we spend,” write Judy Norsigian, OBOS executive director, and Eugene Declercq, a professor of maternal and child health at Boston University School of Public Health, in this Boston Globe editorial.

A report from the Centers for Disease Control and Prevention documents a slight decline in the national infant mortality rate (the number of deaths to babies under 1 year of age) in 2006, but the rate has essentially remained flat since 2000, leaving the United States 29th among industrialized countries.

Advocates of health reform who focus exclusively on access presume that the United States provides effective but expensive healthcare, and that the only real problem is lack of access to this care. The reality is more complex when we examine those mortality figures. The low US ranking is misleading since many of the countries rated ahead (e.g., Singapore, Hong Kong, Norway) have fewer births than an average US state. So, what if we do a fair test - only comparing the United States with other wealthy countries that have at least 100,000 annual births?

There are 16 such countries. Among them, the United States ranks last in infant mortality, third to last in perinatal mortality (deaths in the first seven days and fetal deaths), and last in maternal mortality.

It gets even more interesting — in response to the argument that the problem is not our healthcare system itself, but rather a lack of access and social supports across the board, as well as inappropriate health behaviors, the authors turn the lens on births to white, non-Hispanic, U.S.-born mothers who begin prenatal care in the first trimester. Wondering how high we rank then? Continue reading here.

The Cochrane Collaboration recently released a publication on midwifery-led care for childbirth compared with “other” or “shared care” models. The authors defined midwifery-led care as follows: “the midwife is the woman’s lead professional, but one or more consultations with medical staff are often part of routine practice.”

Other models generally means an ob/gyn as the lead professional (although nurses and midwives may be part of the support team), and shared care might have a varying lead professional depending on where the woman is and whether she is pregnant, in labor, or has already given birth. In other words, the review looks at maternal and neonatal outcomes not by strictly midwife vs. physician, but by who was primarily in charge of the woman’s care over the course of her pregnancy, including labor and the postpartum period.

The authors also note that the included studies were conducted in the public health systems of Australia, Canada, New Zealand and the United Kingdom, so it might be useful to look at the individual studies themselves to assess whether they would be applicable to the U.S. situation and population.

The authors also explain that they selected studies in which women were randomly allocated to midwifery-led vs. other models of care, and that consisted of low- or mixed-risk women. They selected 11 studies, and examined a number of outcomes such as hemorrhage, use of analgesia, induction of labor, c-section, episiotomy, maternal or neonatal death, breastfeeding initiation, and postpartum depression.

The authors concluded that women randomised to midwife-led models of care were less likely to have regional anesthesia/analgesia, instrumental birth, or episiotomy, and were more likely to have spontaneous vaginal birth, to initiate breastfeeding, and to report high perceptions of control during labor. There were no significant differences on a number of other outcomes, such as hemorrhage, neonatal death, labor augmentation or induction, c-section, or duration of hospital stay.

I do have questions about some of the outcomes and limitations of the paper which may require more in-depth analysis of the methods and the original studies. For example, the authors list as a finding that those in midwife-led teams were less likely to experience fetal loss or neonatal death less than 24 weeks; however, they note elsewhere that they included miscarriage and termination of pregnancy in the neonatal outcomes, and it’s not immediately apparent if this might have affected that finding. Readers also might have expected, for example, a lower c-section rate with the midwife-led teams, but it’s not entirely clear how the protocols in place during each individual study affected this decision-making.

Although it is not likely to be a defining paper on midwifery care and choice of birth providers, this Cochrane piece does suggest an interesting consideration - that maternity care often happens via teams of providers working together, and women may want to be better informed about who is primarily in charge of those teams and how that control is negotiated in practice.

On this Veterans Day, we take a look at the services available to female veterans, who face high rates of sexual assault, and the increased dangers of domestic violence among military personnel:

- “Shedding light on the challenges facing women in the military, a new study shows that more than one in seven female Iraq and Afghanistan veterans seeking VA medical care reported experiencing sexual trauma during their service,” HealthDay News reported in October.

The study was conducted by the VA Palo Alto Health Care System’s National Center for Post-Traumatic Stress Disorder in California.

A previous study from 2007 found that 22 percent of female veterans and 1 percent of male veterans — serving in all areas, not just Afghanistan and Iraq — reported sexual trauma in health-care surveys conducted by the Veterans Administration in 2003.

The Department of Veterans Affairs has set up this page to explain the counseling and treatment services it offered to personnel.

Earlier this year, Rep. Jane Harman (D-California), described the rate of sexual assault in the military as “an epidemic.”

“Women serving in the U.S. military today are more likely to be raped by a fellow soldier than killed by enemy fire in Iraq,” said Harman.

- Sharkfu remembers Pvt. LaVena Johnson, who was murdered in Iraq in 2005, just eight weeks after her deployment and days before her 20th birthday. The Army insists her death was a suicide. Read more at Our Weekly.

- In a recent editorial, the Fayetteville Observer called on the Army to redouble its efforts to provide programs and services to prevent domestic violence. Fort Bragg was the recent site of protest against domestic violence — four female service members were slain in North Carolina this year, all allegedly murdered by their husbands or boyfriends, also service personnel.

- Writing at AlterNet, author Penny Coleman notes that when “Barack Obama decides who he will appoint to head the Department of Veterans Affairs in his administration, he should consider appointing someone who also understands how important it is that women’s bodies, souls, dignity and health be taken seriously.”

Tammy Duckworth, who is reported to be at the top of his list, certainly has had personal experience with a health care delivery system she has called “a little bit arcane.”

Duckworth is now director of the Illinois Department of Veterans Affairs, but in 2004, she was a Blackhawk helicopter pilot in Iraq and lost both of her legs in a crash. She describes the care she received at Walter Reed Army Medical Center as “excellent,” but adds, “the comfort package I received contained men’s Jockey shorts, and the local VA hospital carried Viagra but not my birth control.”

There are currently about 1.7 million female veterans in the United States, and the Department of Defense estimates that there are about 200,000 women, 15 percent of the military, on active duty. Thirty-nine percent of those women return from Iraq or Afghanistan with mental health issues, and, for more than a third who seek VA health care, the precipitating trauma was a sexual assault.

Every VA center now screens both men and women for sexual trauma. That is an improvement. Still, Duckworth says, “I don’t think the VA mental health care system is ready for (female veterans).” It would be encouraging to see a VA director who has some understanding of how important that is to fix.

A new report criticizes the FDA for ignoring studies questioning the safety of bisphenol A, a chemical found in many household products. From the Washington Post:

The Food and Drug Administration ignored scientific evidence and used flawed methods when it determined that a chemical widely used in baby bottles and in the lining of cans is not harmful, a scientific advisory panel has found.

In a highly critical report to be released today, the panel of scientists from government and academia said the FDA did not take into consideration scores of studies that have linked bisphenol A (BPA) to prostate cancer, diabetes and other health problems in animals when it completed a draft risk assessment of the chemical last month. The panel said the FDA didn’t use enough infant formula samples and didn’t adequately account for variations among the samples.

Taking those studies into consideration, the panel concluded, the FDA’s margin of safety is “inadequate”. The panel is part of the Science Board, a committee of advisers to the FDA commissioner, and was set up to review the FDA’s risk assessment of BPA.

The FDA’s findings were at odds with a report released in September by The National Toxicology Program, which found that there is “some concern” that BPA can affect neural and behavioral development in fetuses, infants and children. Another study found an association between BPA and cardiovascular disease, Type 2 diabetes and liver-enzyme abnormalities in adults.

The possible connection between chemicals such as BPA and cancer was the focus of a Boston Globe op-ed this week. Rita Arditti, one of the founders of the Cambridge, Mass.-based Women’s Community Cancer Project, writes that “because we still do not know what the causes of breast cancer are, primary prevention remains an elusive goal while mammography and early detection are the focus of attention.”

Here’s what we do know:

Since World War II, the proliferation of synthetic chemicals has gone hand-in-hand with the increased incidence of breast cancer. About 80,000 synthetic chemicals are used today in the United States, and their number increases by about 1,000 each year. Only about 7 percent of them have been screened for their health effects. These chemicals can persist in the environment and accumulate in our bodies. According to a recent review by the Silent Spring Institute in Newton, 216 chemicals and radiation sources cause breast cancer in animals.

Nearly all of the chemicals cause mutations, and most cause tumors in multiple organs and animal species, findings that are generally believed to indicate they likely cause cancer in humans. Yet few have been closely studied by regulatory bodies. There is concern about benzene, which is in gasoline; polycyclic aromatic hydrocarbons, which are in air pollution from vehicle exhaust, tobacco smoke, and charred foods; ethylene oxide, which is widely used in medical settings; and methylene chloride, a common solvent in paint strippers and glues.

There is also broad agreement that exposure over time to natural estrogens in the body increases the risk of breast cancer, so it is important to consider the role of synthetic estrogens in breast cancer development. Many other chemicals, especially endocrine-disrupting compounds - chemicals that affect hormones, such as the ubiquitous bisphenol A, which is found in plastic bottles and cans - are also thought to raise breast cancer risk. Endocrine-disrupting compounds are present in many pesticides, fuels, plastics, air pollution, detergents, industrial solvents, tobacco smoke, prescription drugs, food additives, metals, and personal-care products including sunscreens.

There’s no definitive evidence that these substances cause cancer, but all the information acquired so far makes a strong case for more research and precautionary measures as this research develops. The Massachusetts state Senate this year passed the Safer Alternatives Bill, which would create a program to replace toxic chemicals with safer alternatives when feasible. The bill was not taken up by the House. Advocates for the bill, under the umbrella group Alliance for a Healthy Tomorrow, continue to work on its passage.

This weekend, I read Harriet A. Washington’s “Medical Apartheid,” which documents the shocking history of abuse and unethical practices in the conduct of medical research on black Americans. While many of you may have heard of the Tuskegee syphilis experiment, Washington’s work is much more comprehensive, outlining and tying together events from slavery to recent decades.

While reading this work, I wondered how we can “ask hard questions of the physicians who are recruiting in your community,” as Washington urges. It seems that we often only learn of these incidents long after they have occurred, such as through reading this text, and we should keep an eye not just on ethical problems of studies recruiting in our own communities, but wherever medical research is conducted. How do we know what research is being done across the country, before it is reported in the news or books?

One possibility is to examine trials listed in the freely available database of trials funding by the National Institutes of Health (and some other entities). For example, a search for terms such as “prison” and “incarcerated” can give us a clue about the types of research being done in this vulnerable population, and we can at least see a summary of the rationale and who is being included and excluded from the research. The clinicaltrials.gov advanced search does not provide for easy searching by the study’s population group, but keyword searching for terms such as “prison,” “african american,” “low income” and “pregnant” may be useful.

It’s not the neatest method in the world, but a search of the database for “african american” returned at least one study that raised questions, although it is one that has already been completed (with no reporting publications available). The study, “Metabolism of Nicotine and Cotinine in Pregnant African-American Women,” focused on the use of the nicotine patch in pregnant smokers. Reading the summary, I wondered why they focused on this population (has any plausible biological explanation been offered?), why they enrolled pregnant women who “cannot quit smoking within 7 to 10 days after receiving counseling” (is that a reasonable expectation?), and why they applied nicotine patches to these women after preventing them from smoking for 48 hours, enough time for the nicotine levels in their bodies to drop significantly. It seems that they wanted to study how the substances from the patch were metabolized, but I have to wonder if, after a pregnant woman has been without nicotine for 2 days, whether it might be more ethical to help her continue on that path rather than slapping a nicotine patch on her for up to a day (even though it wouldn’t serve the research goal). The summary does not give any indication of whether the women were further assisted with smoking cessation after the end of the trial.

Although further details might be warranted for critique of this specific study, they are not available in a publication, and this example suggests the kinds of questions and concerns that might be raised through keeping an eye on descriptions of federally funded research. It would be a very big job to independently monitor the numerous existing trials, but this, perhaps, is one place to start.

The New Health Insurance Model: In the first of a three-part series, the L.A. Times looks at the changing insurance scenario — where once working Americans could rely on employer-based benefits, now more people are being forced into the individual market, where coverage is costly, bare-bones and precarious.

Part two looks at the business side of managing health savings accounts, and part three covers the battle between doctors and insurers. Meanwhile, health care costs continue to rise.

Plus: Read more about how the individual health insurance market fails women. It’s a great report from the National Women’s Law Center.

No Candy or Condoms: Divine Mercy Care Pharmacy in Chantilly, Va., drew attention this week for becoming at least the seventh pharmacy in the United States to refuse to sell contraceptives of any kind, even if a person has a prescription. The decision, say owners, is guided by Roman Catholic teachings, though the pharmacy is not affiliated with the Catholic church. Still, it did receive a blessing from Arlington Bishop Paul S. Loverde. From the AP:

“This pharmacy is a vibrant example of our Holy Father’s charge to all of us to wear our faith in the public square,” said Loverde, who sprinkled holy water on the shelves stocked with painkillers and acne treatments. “It will allow families to shop in an environment where their faith is not compromised.”

Too bad everyone can’t shop in an environment where their health is not compromised. In Virginia, pharmacists can turn away any prescription — for any reason.

Prop What?: Heather at Scarleteen gives a good overview of several important ballot measures that will be up for vote Nov. 4 in states from Arkansas to South Dakota, “such as parental notification laws for minors who want an abortion, age of consent laws, same-sex marriage, civil rights, stem cell research, education issues, even a proposal to lower the voting age for primaries in one state (whoohoo!) and another to ban abortion outright (grrrr).”

Plus: Look up ballot measures for your state here.

2009 Sheroes: Next year’s Sheroes Womyn Warriors calendar is now available for sale (check out the beautiful cover art by Ekua Holmes!). The calendar honors change agents, rebels, radicals and revolutionaries of different times and places around the globe.

“This is definitely not a ‘great women of history’ celebrity calendar,” reads the back cover. Instead, this is a calendar “of womyn who have challenged their societies and who have advanced the struggle of the oppressed and exploited.”

Proceeds support the Gustavus Myers Center for the Study of Bigotry and Human Rights at Simmons College.

Plus: Send in suggestions for who should be included in the 2010 calendar.

Seen But Not Heard: Jeannine Stein at the L.A. Times writes: “Researchers at Texas Tech University Health Sciences Center in Lubbock interviewed eight overweight women ages 20 to 61 to learn about their experiences with the healthcare system, then published their findings in this month’s Journal of Advanced Nursing. During interviews about their experiences, four themes became apparent: struggling to fit in, feeling not quite human, being dismissed, and refusing to give up.”

Scary Sexy Costumes for Kids: “Halloween costumes are reflecting an increasingly sexualized childhood. They often reflect the stars and starlets and popular culture role models that girls have, starting with Disney princesses or Hannah Montana when girls are young. But even traditional favorites, like witches and pirates are sexier every year. And French maids are quite the thing for tweens and teens,” said Diane E. Levin in a Q&A about Halloween costumes and gender roles.

Levin is co-author with Jean Kilbourne of “So Sexy So Soon: The New Sexualized Childhood and What Parents Can Do to Protect Their Kids.”

Life’s Lessons: On the other side of what’s good for kids, “Free to Be You and Me,” which has never gone out of print since its 1973 debut, was reissued this month with a new, expanded edition, reports USA Today.

Jessica Reaves of the Chicago Tribune, who also made her debut in 1973, writes about the book’s appeal and the lessons that have remained incredibly relevant for more than three decades:

Some critics of “Free to Be” accused Thomas of advancing a radical feminist agenda. They pointed to the book’s co-producer (the Ms. Foundation for Women) and Thomas’ role on “That Girl,” the first television program to shamelessly promote the career girl lifestyle. (I mean, really: Ann Marie strung that poor Don along for four years before she finally agreed to marry him!)

As a feminist born into a family of feminists, I’m biased: I happen to think adopting a feminist agenda is the best thing that could ever happen to this country. (Trust me, it hasn’t happened yet.) But those long-ago critics were right about one thing. The witty, wise lessons of “Free to Be” do underscore feminism’s fundamental tenet: namely, that everyone — male, female, black, white, brown, young, old and in between — should be treated equally and empathetically. Yes, even the jerks.

You only need to glance at the headlines to know we’re not quite ready to cross that particular item off our collective to-do list. Which isn’t to say we haven’t learned a lot in the 35 years since “Free to Be” was published. It’s just that we may need another 35 years for it all to sink in.

Always Carry Protection: Lucinda Marshall has the goods on the Palin condom.

And did you know that as of Sept. 26, Planned Parenthood took in more $802,678 in donations from 31,313 people made in Sarah Palin’s name?

Donations poured in after an anonymous email was circulated urging donations in any amount and recommending that the personalized thank-you card from Planned Parenthood be sent to Palin at the McCain-Palin campaign headquarters in Virginia.

L.A. Times columnist Patt Morrison took credit for the fundraising, recalling how she first made a similar suggestion after President Bush took office in January 2001.

Every donation generated a “thank you card.” I envisioned a scene out of “Miracle on 34th Street,” sacks and sacks of thank-you cards from Planned Parenthood, delivered to Bush in the Oval Office.

It worked. Boy, did it. Ultimately, more than a million dollars, I was told, was generated for Planned Parenthood in Bush’s name. George Bush became one of the biggest money-generators in Planned Parenthood’s history. The idea won me an award from Planned Parenthood, and a splash in Ms. Magazine. So I am delighted that my ”Mother of All Ironic Donations” notion has been revived for Palin.

Jenny McCarthy v. Amanda Peet: Nothing like turning a disagreement over the safety of vaccines into a male fantasy. Seriously, why/how did this get published?

Chicago’s Toxic Air: Proving real journalism still happens at the Tribune, here’s the intro to a special report on toxic air pollution:

People living in Chicago and nearby suburbs face some of the highest risks in the nation for cancer, lung disease and other health problems linked to toxic chemicals pouring from industry smokestacks, according to a Tribune analysis of federal data.

The U.S. Environmental Protection Agency spent millions of dollars to assess the dangers that air pollution poses but has failed to fulfill promises to make the research more accessible to the public. So the Tribune is posting the information on its Web site, where users can easily find nearby polluters and the chemicals going into their air.

Those who look up Cook County will see it ranked worst in the nation for dangerous air pollution, based on 2005 data. The Tribune also found Chicago was among the 10 worst cities in the U.S.

Plus: The Trib also published a searchable database of health-risk information (based on the EPA’s Risk-Screening Environmental Indicators (RSEI) database) and the health effects of long-term exposure to various industry-produced chemicals.

Bioethicists Challenge Reticence to Include Pregnant Women in Medical Research: A paper to be posted online and later in print in the November edition of the International Journal of Feminist Approaches to Bioethics (IJFAB) argues why more pregnant women must be included in medical research.

“As a society we are ethically obliged to confront the complex challenges of pregnant women in research, otherwise we relegate all expectant mothers to second-class medical citizens,” said Ruth Faden, director of the Johns Hopkins Berman Institute of Bioethics, in this press release about the journal article.

“One of the key messages of this paper is that progress will not happen until we shift the burden of justification from inclusion to exclusion and to an explicit commitment to studying the effects of drugs in pregnancy,” Faden added.

Midwives Fight AMA to Provide Black Maternal Care: “Shafia Monroe’s sixth annual International Black Midwives and Healers Conference, taking place in New York’s Harlem neighborhood Oct. 10-12, comes in the middle of a showdown between home-birth midwives and the American Medical Association,” writes Malena Amusa at Women’s eNews.

The AMA wants to bar licensing to certified professional midwives, who specialize in out-of-hospital births (births at home and in birthing centers) and is backing state legislation that restricts licensing to nurse midwives who have additional nursing training and certification required to work in hospitals.

“Certified professional midwives are a critical component to meet the growing maternal health needs in the black community,” said Monroe, noting that every sort of midwife is needed to reduce maternal morality rates among African American women.

Read more about the history of black midwives at the International Center for Traditional Childbirth. Here’s the description of the conference (PDF), which takes place in Harlem.

Top Psychiatrist Didn’t Report Drug Makers’ Pay:  “One of the nation’s most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules, according to documents provided to Congressional investigators,” reports Gardiner Harris in The New York Times. “The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent figure to date in a series of disclosures that is shaking the world of academic medicine and seems likely to force broad changes in the relationships between doctors and drug makers.”

Cancer Research Briefing: Bloggers recently had a chance to discuss the current state of cancer research and biotechnology with Dr. Gil G. Mor, an associate professor at Yale Medical School and director of Reproductive Immunology and Translational Research in Gynecologic Oncology, and Lori Lober, who was diagnosed with stage IV breast cancer in 2000 and has maintained a diagnosis of “no evidence of disease” for five years.

Treating Vascular Disease in Women: Arterial vascular disease is underdiagnosed and undertreated in older women, according to studies. Earlier this year, medical experts met to discuss the differences between men and women when it comes to the prevention, diagnosis and treatment of vascular diseases such as heart attacks and strokes. Out of that symposium came newly released recommendations for improving research on sex differences.

Losing the Weight Stigma: The Idea Lab section of The New York Times Sunday Magazine questions the “war on fat” and offers examples of how academics and activists are emphasizing health over weight. Robin Marantz Henig writes:

This is a core argument of fat acceptance: that it’s possible to be healthy no matter how fat you are and that weight loss as a goal is futile, unnecessary and counterproductive — and that fatness is nobody’s business but your own.

Many fat-acceptance activists prefer a new approach to dieting that focuses on nutrition, exercise and body image. A new book out this fall, “Health at Every Size,” by Linda Bacon, a nutritionist and physiologist at the University of California at Davis, outlines this approach, which is less about dieting than a lifestyle change that emphasizes “intuitive eating”: listening to hunger signals, eating when you’re hungry, choosing nutritious food over junk. It encourages exercise, but for its emotional and physical benefits, not as a way to lose weight. It advocates tossing out the bathroom scale and loving your body no matter what it weighs.

The philosophy is migrating slowly into mainstream programs, like a spa in Vermont that focuses on “acceptance of ourselves and our wonderful sizes.” But the spas and other programs have trouble with the bottom line of fat acceptance — rejection of weight loss as a goal. Weight Watchers, for instance, uses some of the same slogans, and while it promotes its program as “not a diet,” it still tracks weight loss down to the decimal point.

The National Women’s Law Center has released a new report, “Nowhere to Turn: How the Individual Health Insurance Market Fails Women,” and is hosting a webinar on Thursday, Oct. 16, to discuss the findings. Register here.

The majority of women (and men) are covered either by their employers or through Medicare or Medicaid. But as Lisa Codispoti, NWLC senior advisor, and Brigette Courtot, policy analyst, explain on the NWLC blog, women seeking insurance on the open market face numerous obstacles:

The barriers include being rejected for coverage for reasons that are relevant to women, being charged more than men for the exact same coverage, and experiencing great difficulty in finding affordable health coverage that includes comprehensive maternity care.

There are many federal laws that protect women who get their health insurance through their employer. Those federal protections simply don’t apply when you try to buy coverage in the individual insurance market.

Insurers can reject applicants for a variety of reasons -– many very relevant to women.  For example, a woman can be rejected simply because she had a Caesarean section (in 2005, 30% of all births were by C-section). In nine states and the District of Columbia, it is still legal to be rejected for coverage because you are a survivor of domestic violence.

Emphasis mine — that fact is beyond infuriating.

And if you plan on getting pregnant, good luck:

On the availability of maternity coverage (or lack thereof), of the more than 3500 individual market health plans we studied, the overwhelming majority did not include any maternity coverage.  We found supplemental maternity policies — called “riders” — in Kansas and New Hampshire for more than $1100 a month (no — not a typo); that cost, of course, is on top of the premium for the underlying health plan. We also found maternity riders offered in 25 states that capped coverage at a paltry $2000 during the first 2 years of coverage –- over $5,000 less than the average cost of a best-case-scenario uncomplicated delivery.

As the NWLC notes, federal law, specifically HIPAA, prohibits pregnancy as a pre-existing condition, but it doesn’t apply to individual coverage. The lack of anti-discriminatory protections across the board makes quite a statement about our failed health care system.

The caesearean section link leads to this scary New York Times story from June, which opens with a 39-year-old Colorado women in good health who was turned down for health insurance — all because she gave birth by c-section:

Having the operation once increases the odds that it will be performed again, and if she became pregnant and needed another Caesarean, Golden Rule did not want to pay for it. A letter from the company explained that if she had been sterilized after the Caesarean, or if she were over 40 and had given birth two or more years before applying, she might have qualified.

Plus: The new Raising Women’s Voices blog has really been staying on top of health insurance-related stories and is a terrific resource for news and studies. Check it out.

“The rate of abortion in the United States is at its lowest level since 1974, having declined 33% from a peak of 29 abortions per 1,000 women aged 15–44 in 1980 to 20 per 1,000 in 2004. However, this overall trend masks large disparities in rates of unintended pregnancy and abortion across demographic subgroups,” according to “Trends in the Characteristics of Women Obtaining Abortions, 1974 to 2004,” a new report released by the Guttmacher Institute.

The abortion rate among Hispanic and black women is three and five times higher, respectively, than non-Hispanic white women, according to the report.

Here’s the summary, the full report (PDF) and an extended version (PDF) of the report with tables.

Among the key findings:

• Age: Over the past three decades, the proportion of abortions obtained by teens has dropped steadily, from 33% in 1974 to 25% in 1989 to 17% in 2004. In 2004, more than half of all abortions (57%) were obtained by women in their twenties. Teen abortion rates have also declined — by more than 50% — from 42 per 1,000 women aged 15 -19 in 1989 to 20 in 2004. A large part of the decline in abortion among teens — which began long before abstinence-only sex education programs began receiving federal funding — is attributable to increased use of contraceptives and use of more effective methods.
• Gestation: Overall, trends in second-trimester abortions (those occurring after 12 weeks) have changed little, notwithstanding improved technology and increasing state restrictions. The majority (89%) of U.S. abortions occur during the first trimester, and the proportion of very early abortions (those at seven weeks or earlier, when the procedure is safest) has increased substantially, from 16% in 1994 to 28% in 2004. The continuing shift to earlier abortions most likely reflects increased availability and use of home pregnancy detection kits, greater availability of early surgical procedures and increasing use of medication abortion.
• Motherhood: In 2004, 60% of women having abortions already had children, up from 50% in 1989 and 46% in 1974. Part of the reason for this shift is that fewer teenagers and young women are having abortions than did in previous years. Previous Guttmacher analysis has found that women who are already mothers cite responsibility for their children and families as one of the primary reasons for obtaining an abortion.

“The shift in age, more women who already have children — this really does paint a different picture of women having abortions than the way it’s portrayed in popular culture,” Rachel Jones, a senior research associate at the Guttmacher Institute, tells Time magazine. Jones was referring to the impression given that unintended pregnancy happens to careless teens and college kids.

Nominate a Great Leader: Know an advocate for women who deserves worldwide attention? Women’s eNews has issued a call for 21 Leaders for the 21st Century. Send your nominations to 21leaders@womensenews.org. The deadline is midnight on Oct. 6, 2008. Learn about past award recipients here.

Countdown to Conscience Clause Regulation: You’ve heard about the proposed Health & Human Services regulations that would allow federal health officials to withdraw funding from medical providers and services receiving HHS support that do not let employees opt out of providing basic health care — and information — they find objectionable. Now’s your time to act.

Rachel has written extensively about HHS Secretary Michael Leavitt confusing the public (and health experts) with his justification for the regulations — which would affect not only abortion and contraception, but a whole range of health care services — and she wrote a terrific analysis this week at RH Reality Check on the roadblocks Leavitt and HHS have imposed, making it difficult to get information about the rule and delaying the posting of comments for public viewing.

Sen. Hillary Clinton and Cecile Richards, president of the Planned Parenthood Action Fund and Planned Parenthood Federation of America, joined forces this week to write a great op-ed in The New York Times that asked: “The Bush administration argues that the rule is designed to protect a provider’s conscience. But where are the protections for patients?”

The public comment period ends Sept. 25. You can submit your comments directly (although as of this morning the site was done for “planned system maintenance,” scheduled to return at 1 p.m.). Planned Parenthood and the ACLU have both set up customizable comment forms.

And, while you’re at it, you might nominate HHS Secretary Leavitt for Ellen Goodman’s annual Equal Rites Awards.

It’s Not Just the Rape Kits: On the subject of Alaska Gov. Sarah Palin approving billing sexual assault victims for the cost of forensic rape examinations when she was mayor of Wasilla, Amie Newman writes: “There is good reason to hunt down the facts about the rape kits.  But the larger issue — of rape, sexual assault and how we deal with violence against women in this country — has been overlooked.”

Stop Me if You Think You’ve Heard This One Before: The September 2008 issue of Sexuality Research & Social Policy reviews federally funded abstinence-only programs and finds — surprise — that such programs don’t delay teens from having sex and their continued use is not warranted.

The articles in this special issue were selected from research presented at a January 2007 conference, “Human Rights, Cultural, and Scientific Aspects of Abstinence-Only Policies and Programs,” sponsored by the Heilbrunn Department of Population and Family Health at Columbia University, with the support of the William and Flora Hewlett Foundation.

From the introduction:

Taken as a whole, these articles build a strong scientific and human rights case against AOE. Together, they find that the very idea of an abstinence-only approach to sexuality education is scientifically and ethically flawed. Such programs reflect a religious and cultural belief system of socially conservative groups who have attained considerable political leverage at both state and federal levels. AOE programs not only fail the usual public-health standard of program efficacy but also actively restrict lifesaving information and promote misinformation about scientifically accepted public-health strategies such as condom use.

As the articles in this special issue show, science should drive public-health decision making — which, in turn, should inform public policy on health promotion and disease prevention (Koplan & McPheeters, 2004). In the case of AOE, politics and ideology have influenced public health policy and undermined scientific evidence about the best approaches to preventing unwanted outcomes regarding adolescents’ sexual behavior. Science, not ideology, should shape the future of public-health prevention policies for youth.

Plus: Kaiser Family Foundation has released a new fact sheet (the first update since 2006) on sexual health topics facing teens, including general sexual activity; sexual partners and relationships; sex, substance abuse and violence; pregnancy; contraception and protection; STDs; and access to health care services.

World Wide Web of Pesticides: The Center for Public Integrity’s latest investigation, “Wide Web of Pesticides Can Endanger Consumers,” looks at the practice of selling pesticides over the internet, which allows consumers to circumvent regulations meant to protect the public from harmful chemicals.

The dangers of online pesticide sales are many: little accountability on the extent of the practice; lack of training for those who purchase professional grade chemicals online; overexposure to dangerous chemicals and whether they are being properly used. For most states, the lack of resources prevents them from effectively monitoring online pesticide sales. While Colorado, New York, Michigan, Minnesota, California, and Nebraska are recognized as states working consistently to stem illegal Internet sales, many argue that the EPA should be doing more, highlighting the challenge regulators face of trying to control an online global marketplace where buyer and seller often never meet face to face.

This is the second article in the Center’s new series The Perils of the New Pesticides. The first, “A Checkered Past,” looks at the EPA’s flawed efforts to monitor poisonings by pesticides deemed safe. In addition to the excellent coverage, visitors can search pesticide incidents on file with the EPA by state and by year.

“The EPA’s pesticide incident-reporting system has not been public until now. Called one of the ‘Ten Most Wanted Government Documents‘ by the Center for Democracy and Technology, the database was released under the Freedom of Information Act to the Center for Public Integrity in early 2008,” according to the introduction.

Going Greener: “Innovations in designing green chemicals are emerging in nearly every U.S. industry, from plastics and pesticides to toys and nail polish. Some manufacturers of cosmetics, household cleaners and other consumer products are leading the charge, while others are lagging behind,” writes Marla Cone in the L.A. Times.

Part 2 of the series on a greener future looks at industries that remain dependent on hazardous substances.

The Price of Beauty: Having trouble getting a medical appointment with your dermatologist? Have you mentioned that you’re interested in Botox?

“Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees,” writes Natasha Singer in The New York Times.

“In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.”

Doctors Have Babies, Too: “For the growing number of women entering medicine, becoming a doctor increasingly includes a complication: pregnancy,” writes Liz Kowalczyk in the Boston Globe.

In the last 10 years, most teaching hospitals have adopted maternity leave policies for residents. Even so, new moms face a range of difficulties beyond exhaustion, from time limits placed on maternity leaves by boards that certify physicians in their specialties to resentment from fellow residents who must shoulder extra work while they’re gone. Academic medical centers also feel the pressure when a resident gets pregnant, because they depend on these physicians-in-training to provide most of the round-the-clock care to patients, especially in Massachusetts with its large number of teaching hospitals.

“As far as we’ve come, there still are significant barriers to parenting during residency,” said Dr. Debra Weinstein, vice president for graduate medical education for Partners HealthCare System, the parent organization of Mass. General and the Brigham.

Ain’t I a Mommy?: Great piece at Bitch by Deesha Philyaw, who wonders why with so many motherhood memoirs, so few of them are penned by women of color.

“The absence of black mommy memoirs mirrors the relative absence of black women’s voices in mainstream U.S. media discourse about motherhood in general,” writes Philyaw. “The abundance of ink and airtime devoted to a vocal minority of women promotes the idea that this minority’s experience is somehow universal. Low-income and working-class women, black women, and other women of color don’t see their mothering experiences and concerns reflected in the mommy media machine, and we get the cultural message loud and clear: Affluent white women are the only mothers who really matter.”

Motherhood, Activism and Politics: Writing at The American Prospect Online, Kara Jesella looks at maternalist politics, which have a long history in American culture.

At a public meeting Tuesday before a Food & Drug Administration subcommittee, the FDA stuck to its claim that exposure to Bisphenol A, commonly known as BPA, is safe.

Inconveniently for the FDA, a new study published today found an association between BPA and cardiovascular disease, Type 2 diabetes and liver-enzyme abnormalities in adults.

It was the first large study of BPA in humans, and it comes on the heels of a Yale study that found monkeys exposed to low doses of BPA (the same doses the Environmental Protection Agency says is safe for people) experienced memory and mood disorders.

And that study came out just as the National Toxicology Program reaffirmed an earlier draft report that found there is “some concern” that BPA can affect neural and behavioral development in fetuses, infants and children. (Here’s the NTP’s fact sheet on BPA.)

At this point, the FDA’s denial brings to mind a certain presidential candidate’s insistence that the economy is fundamentally sound as Wall Street burns and financial institutions come crashing down.

In the most recent study, published today in the Journal of the American Medical Association and available in full, researchers from the Peninsula Medical School in Exeter, England, found that adults with the highest levels of BPA had almost three times the rate of cardiovascular disease, more than two times the rate of diabetes, and an increased prevalence of liver-enzyme abnormalities, compared with those with the lowest levels.

The study included a representative sample of 1,455 U.S. residents ages 18 to 74, broken up into quartiles based on urine concentrations of BPA. The data was acquired from the 2003-2004 National Health and Nutrition Examination Survey conducted by the Centers for Disease Control and Prevention.

Previous concerns have focused mainly on fetus- and infant-exposure to BPA; the chemical mimics the human hormone estrogen and exposure to low doses in animal studies has been shown to affect reproductive health and behavior. And since BPA is commonly found in hard plastic food items like sippy cups and children’s toys, as well as canned food items including baby formula, exposure may be more concentrated at young ages.

But BPA is really quite ubiquitous. It’s used in the manufacture of everything from CDs and DVDS to dental sealants, and traces of it have been found in almost all Americans tested.

The most recent study doesn’t prove cause and effect, but it does add substantial weight to the growing body of evidence that BPA just isn’t good for us.

In an editorial that accompanied the study published in JAMA, John Peterson Myers and Frederick S. vom Saal wrote that the results “should spur U.S. regulatory agencies to follow the recent action taken by Canadian regulatory agencies, which have declared BPA a ‘toxic chemical’ requiring aggressive action to limit human and environmental exposures.”

“Alternatively,” the editorial continues, “Congressional action could follow the precedent set with the recent passage of federal legislation designed to limit exposures to another family of compounds, phthalates, also used in plastic. Like BPA, phthalates are detectable in virtually everyone in the United States. This bill moves U.S. policy closer to the European model, in which industry must provide data on the safety of a chemical before it can be used in products.”

You might say we’re a little backward in the United States, since we apparently prefer to determine safety after usage. (By the way, advocates of a new risk paradigm know as The Precautionary Principle have come up with a more sound approach to environmental and public health policy: When there’s a threat to the environment or our health, take precautionary measures, even if no cause and effect has been scientifically proven. This principle shifts the burden of proof on the proponent of an activity, not the victims. Radical thinking, huh?)

At the meeting on Tuesday, Peterson reiterated his concerns. (Listen on NPR)

“It is very clear that the FDA cannot conclude with certainty that BPA is safe,” said Peterson. “That option is no longer open to you given these new data.”

Diana Zuckerman, president of the National Research Center for Women and Families, also spoke before the subcommittee, and she criticized the FDA for reaching its conclusion on BPA’s safety based on studies funded by the chemical industry.

“Since these food containers are not proven safe, the FDA should not be assuring us that they are safe. It does feel like there’s been a rush to judgment by the FDA and that does none of us any good,” said Zuckerman.

The chemical industry, which produces 7 billion pounds of BPA in the United States each year, has maintained that BPA is harmless. The Chicago Tribune today published a front-page, above-the-fold story on the risks of BPA that included responses from industry officials who took issue with the new study.

“Urinary concentrations tell you the exposure over the last 24 hours, but heart disease and diabetes do not occur overnight,” said Steven G. Hentges, executive director of the Polycarbonate/BPA Global Group of the American Chemistry Council. “Bisphenol A would have to be measured over the time period when heart disease or diabetes is actually occurring, so that’s a major limitation of the study.”

Dr. Anila Jacob, senior scientist for the Environmental Working Group, said the study raises questions about the BPA’s role in causing chronic diseases.

“We don’t know causality [in this study], but associations are important in public health,” Jacob said. “The first studies of tobacco found associations between smoking and lung cancer. These types of large epidemiologic studies are important in pointing us in the right direction.”

Plus: The Tribune also published a Q&A on BPA that addresses how BPA gets into our bodies, and it promoted SafeMama.com (on the front page; nice) for information on product safety. Here is Safe Mama’s list of BPA-free bottles and sippy cups.

Fortunately the Nalgene bottles I’m more attached to are also transitioning away from BPA.

The National Toxicology Program this month released a report on the safety of bisphenol A, or BPA, reaffirming an earlier draft report that said there is “some concern” that BPA can affect neural and behavioral development in fetuses, infants and children.

“There remains considerable uncertainty whether the changes seen in the animal studies are directly applicable to humans, and whether they would result in clear adverse health effects,” John R. Bucher, associate director of the National Toxicology Program, said in a statement, as reported by the Washington Post. “But we have concluded that the possibility that BPA may affect human development cannot be dismissed.”

The chemical is commonly found in the liners of food cans and baby formula, and hard plastic containers, such as baby bottles, which makes exposure at an early age a particular concern.

The final report is at odds with the findings of the Food & Drug Administration, which declared in August that BPA does not pose a health hazard when used in food containers. The House Energy and Commerce Committee is investigating how the FDA draft report came to that conclusion. Flags were raised since the report was based largely on data obtained from two studies — wait for it — funded by chemical companies. U.S. companies produce about 7 billion pounds of BPA each year.

“What do you do when one arm of the government says everything is O.K. and another tells you to watch out?” asked a New York Times editorial on Monday. “The answer is a truism in every family rulebook — when in doubt, especially when it comes to children, err on the side of caution. That means it is a good idea to keep the young away from bisphenol-A, or BPA.”

Some businesses are doing just that. Wal-Mart and Toys R Us have already announced that they will stop selling childrens’ products made with BPA as of January. And companies such as Nalgene, which makes refillable hard plastic bottles, are switching over to non-BPA plastics.

Some states have proposed BPA bans, as have some federal lawmakers. In Canada, the main government health department has already declared BPA a “toxic chemical,” and the Canadian government has moved to ban polycarbonate infant bottles.

The Washington Post also reports that researches at the Yale School of Medicine found that the chemical interfered with brain function in monkeys, linking it to memory and mood disorders. The monkeys were exposed to levels the EPA deemed safe for humans.

“Our goal was to more closely mimic the slow and continuous conditions under which humans would normally be exposed to BPA,” said study author Csaba Leranth, a Yale professor of obstetrics, gynecology and reproductive sciences and of neurobiology.

The study was published in the Proceedings of the National Academy of Sciences. “Our findings suggest that exposure to low-dose BPA may have widespread effects on brain structure and function,” the authors wrote.

This marks the first time BPA has been shown to have an effect on primates.

Here are some practical steps you can take while the FDA seeks advice from chemical manufacturers:

* Watch for the numeral 7 on the bottom of plastic containers. That often means they contain BPA.

* Don’t microwave plastic food containers made with BPA. Better to use glass or porcelain.

* Watch out for canned foods for children.

* Search for baby bottles and other baby products that are BPA-free.

A new study in the journal Obstetrics and Gynecology reports on the results of a survey of 1,271 women in El Paso, TX . The survey was designed to assess how accurately women can determine whether they are safe candidates for oral contraceptive use.

Women at a flea market and shopping malls were first simply asked whether they thought oral contraceptives were safe for them, and then completed a checklist of their possible contraindications. The women were then screened by a nurse practitioner, and their results were compared.

Because the participants in this study were not randomly selected and may not reflect those of all communities, I’m including the study’s description of them here: “The participants, on average, were in their early 30s, had completed 13 years of schooling, and had between one and two children. The sample was overwhelmingly Latina, and the majority primarily spoke Spanish or were bilingual. Four out of five of the respondents lived in the United States, and two thirds had completed their schooling in the United States.”

In responding to the initial question about the safety of the pill for them, about 52% said the pill would be medically safe for them, and nearly 48% said it was unsafe or they were not sure. Providers, on the other hand, assessed that oral contraceptives would be safe for nearly 61% of the women. The authors note that “respondents were significantly more likely to incorrectly assess themselves as contraindicated with the initial self-screen than to assess themselves eligible when they were not.”

When the women filled out checklists of contraindications to pill use, their accuracy improved. The authors explain that “the positive predictive value of self-screening using the checklist was 82.8% (95% CI 79.2–86.0%), and the negative predictive value was 89.0% (95% CI 86.6–91.1%).” This means that women who thought the pill would be unsafe for them were correct 82.8% of the time, and those who thought it would be unsafe were correct 89% of the time.

There were two specific contraindications that accounted for the biggest gaps in the women’s knowledge of the pill - previously undiagnosed hypertension (a contraindication) and migraine without aura (only migraine with aura was considered a contraindication) - perhaps suggesting areas where public education may be beneficial. Younger women, Spanish-speaking women, and women with some college education were most likely to correctly assess the safety of the pill for them - interestingly, number of children or contraception use did not seem to have any effect on the rate of correct answers.

I found this study particularly interesting because safety and ability to self-screen is an issue that often arises in discussion of making birth control available over the counter. The authors briefly address this:

“In an over-the-counter environment, however, women who want to use the pill and find that they are contraindicated by self-screening likely would seek the counsel of a clinician rather than deciding definitively that the method is dangerous for them. It is also possible that a truly contraindicated woman who is very motivated to use oral contraceptives might ignore the results of her self-screening and use the method regardless, much as a woman might conceal elements of her medical history, such as smoking, from a clinician to obtain a prescription for pills.”

For additional reading, the blogger at the Well-Timed Period has a summary of a similar study from last year.

Citation: Grossman D, Fernandez L, Hopkins K, Amastae J, Garcia SG, Potter JE. Accuracy of Self-Screening for Contraindications to Combined Oral Contraceptive Use. Obstet Gynecol. 2008 Sep;112(3):572-578.