Archive for the ‘Research & Studies’ Category

August 28, 2013

How Do You Afford Healthcare in Prison on 50 Cents Per Hour?

Women entering prisons often have poor physical health, in part due to poverty and lack of access to treatment for concerns such as addiction, abuse and mental health. An article in the Journal of Health Care for the Poor and Underserved looks at a different aspect of the health of incarcerated women: how healthcare systems in prison create further harm.

For “Factors Contributing to Poor Physical Health in Incarcerated Women,” researchers Holly Harner and Suzanne Riley conducted 12 focus groups and asked 65 women in a U.S. maximum security prison what they thought about factors affecting their their physical health while imprisoned.

The women reported a wide variety of concerns, with one of the major issues being limited and complicated access to care.

While it’s a widespread belief that inmates have all of their medical care paid for, cost was a significant barrier for the women. The women earned 50 cents per hour in their prison-based jobs, and some of that income was diverted for fines and fees related to their incarceration, making even the mandatory $5 co-payments difficult. Once they have accumulated $5 for a visit, the inmates are only allowed to address one health concern per visit.

The women also reported being discouraged from seeking care, as well as fear of disciplinary action if they questioned a health care provider.

One woman reported: “I went to Medical, telling them I had more than just a cold. I got yelled at, called a hypochondriac, and escorted out with the threat of [being written up for] misconduct. Later I had an asthma attack and was diagnosed with asthma.”

Another reported that routine gynecological care such as Pap tests for cervical cancer is discouraged: “They try to make you not want your Pap because there are so many people waiting. They say, ‘You know, you don’t really have to have a Pap, right?’ They make you feel guilty if you want it.”

Poor dental care and eye care were also mentioned, with consequences that go beyond the medical. One woman with poor eyesight described not being able to do her mandatory homework because she could not obtain glasses, and she feared being disciplined for misconduct as a result. When dental care could be accessed, the women were concerned that the dentists would simply pull their teeth instead of providing other treatments.

The women also expressed concerns about the unhealthy diet causing weight gain and limited opportunities for exercise. Exercise classes were often scheduled during the prisoners’ work hours frequently canceled. Women who expressed a desire to quit smoking often could not afford the offered therapy — nicotine patches cost $187.50 for six weeks (375 hours of work at 50 cents per hour).

Women with disabilities face additional problems. Those using wheelchairs were assigned other inmates as “pushers”; these women received only 15 minutes of training on how to maneuver wheelchairs.

Harner and Riley do not offer solutions for the poor health care offered to women in prison, but they do provide characterization of the problems as expressed by the women themselves. The authors conclude with this statement: “Incarcerated women deserve timely, evidence-based, and respectful health care in prison.”

Related: Learn more about women in prison from the Sentencing Project, the ACLU, and Women + Prison, a website and publication created by incarcerated women. Also see “‘She’s Out of Sight’: Women, Healthcare and the Prison System,” an article by Monique Hassel in Manifesta, and “Inside This Place, Not of It: Narratives from Women’s Prisons,” compiled and edited by Robin Levi and Ayelet Waldman. For issues related to childbirth, see the Prison Birth Project, whose founders were among our 2010 Women’s Health Heroes. In July, the Center for Investigative Reporting broke the story that women in California were sterilized without approval. OBOS has also reported on the persistence of shackling incarcerated women during labor and pregnancy.

August 23, 2013

Studies Show How Abortion Restrictions Hurt Women; New Investigative Report Shows Why More Restrictions Are Medically Unnecessary

We recently wrote about the Turnaway Study, a research project that involved following women who were denied an abortion because they were past the provider’s gestational age limit and comparing their outcomes to women who received an abortion (either during the first trimester or at near-limit, when the women were almost out of time). Women were recruited for the study from “last stop” abortion clinics — those where there’s not a provider with a later gestational age limit within 150 miles.

A new paper released in the American Journal of Pubic Health begins to present results from that study, focusing on the reasons for delays in seeking abortion care. The research has been conducted by the Advancing New Standards in Reproductive Health group at UCSF’s Bixby Center for Global Reproductive Health.

One of the findings provides further evidence of important disparities in access to abortion care: the women who received abortions in the first trimester instead of near the limit were more likely to have a college degree and to have a higher income.

For women who were turned away or had near-limit abortions, “money” and “finances” were the most likely reasons for delay. The authors report that reasons for delay among women who were turned away for being over the gestational age limit included travel and procedure costs (58.3 percent of “turnaways” reported this issue), not recognizing the pregnancy (almost half of turnaways), insurance problems, not knowing where to find abortion care (reported by a third of turnaways), and not knowing how to get to a provider.

Interestingly, the near-limit women in this study reported less difficulty deciding to have abortions than the women who had the procedure during the first trimester. This finding runs counter the anti-abortion notion that women who have late-term abortions have simply been irresponsible in waiting so long to make a decision.

The authors also performed some calculations to try to estimate how many women are turned away each year due to gestational age limits. They concluded that 4,143 women in 2008 were forced to carry their unwanted pregnancies to term because of gestational age limits. This does not include additional women who would have been turned away for medical, financial or parental consent reasons. We can only assume this number will increase if the current anti-abortion push for 20-week limits gains ground.

In related news, the National Women’s Law Center has released a new report, “‘Shut That Whole Thing Down:’ A Survey of Abortion Restrictions Even in Cases of Rape.” A year after former Missouri Rep. Todd Akin’s remarks on abortion and rape (Happy Road Trip Anniversary!) NWLC has analyzed state and federal abortion restrictions proposed in the first six months of 2013 for how they would affect victims of rape.

Astonishingly, NWLC found that the vast majority of proposed legislation would create barriers to abortion for rape victims. For example, 27 provisions in the 38 state provisions restricting women’s access to abortion would apply to a woman whose pregnancy resulted from rape. These include provisions such as forced ultrasounds and requiring women to listen to a fetal heartbeat where there were no exceptions for rape victims.

“The GOP could have learned an important lesson: Picking on rape victims, even in the context of abortion, doesn’t play very well with the voting public,” writes Jill Filipovic at Salon. “Instead, the Republican party seems to have internalized the message that marginalizing rape victims is ok, as long as you don’t brag about it.”

And in case you missed it, RH Reality Check published an impressive series of investigative stories this week that proved abortion is already highly regulated and overwhelmingly safe. There’s a huge database of state documents available for review.

August 2, 2013

Racism, Mistrust in Medical System May Affect Black Women’s Use of Genetic Testing for Breast and Ovarian Cancers

Black women in the United States face many health disparities. The CDC recently provided data showing the average life expectancy for black women (at birth in 2010) is 78 — 3.3 years shorter than that for white women.

One of the many diseases for which there are unequal outcomes is breast cancer. Black women are less likely than white women to develop breast cancer, but are much more likely to die of the disease. One hypothesis to explain at least some of the disparity is that black women may be more likely to carry forms of the BRCA1/2 genes that increase their risk for breast and ovarian cancer.

Genetics alone, though, is probably not enough to explain the difference. A recently published study looks at how racism and mistrust in the medical system may also affect black women’s use of genetic testing to inform the monitoring and care they receive.

The authors studied 100 black women at high risk for breast cancer. They looked at whether the women knew how to get, pay for, and what to do with the results of BRCA gene testing, their knowledge of a U.S. law forbidding discrimination based on genetic findings, and their level of mistrust in the medical system, alongside whether the women knew about or had received genetic counseling and testing.

While it’s a small study, the researchers found that the more women knew about how to get and pay for the tests, and the more trust they had in the medical system, the more likely they were to have had BRCA testing.

It should come as no surprise that the more mistrust the women had in the medical system, the less likely they were to undergo genetic testing and counseling. In fact, some of the researchers on this study are affiliated with Johns Hopkins, which back in the 1950s oversaw the (now) widely publicized experiments using the cells of Henrietta Lacks for research.

There’s a long history of abuse — and resulting mistrust — between the medical and scientific establishment and the black community in the United States. Books such as “Bad Blood: The Tuskegee Syphilis Experiment” and “Killing the Black Body” review this history and are crucial to understanding how past injustices may contribute to ongoing disparities.

The study authors acknowledge this likelihood, and comment on how the era of “personalized medicine” may not benefit all patients equally due to this history of racism:

If minority communities have distrust of the medical system and have not benefited from traditional technologies, it is possible that disparities will persist or even widen in the pharmacogenomics era.

Despite being considered high risk, fewer than 1/3 of the women in the study had ever been referred for BRCA genetic testing by their healthcare provider.

Although the researchers didn’t measure it, the women in the study may have been more likely than many black women to have been referred for BRCA testing in general, as they were largely college-educated women and almost all of them had health insurance.

“Black women who are uninsured or those who have lower levels of education may have less genetic testing and counseling awareness and engagement than we found in our sample,” the study’s authors wrote.

The authors also note that women who are underinsured or uninsured may have trouble accessing these tests, which are expensive. Our Bodies Ourselves was a co-plaintiff in the recent lawsuit against Myriad Genetics, opposing the patenting of BRCA1/2 genes. We hope that the recent Supreme Court decision on those patents will lead to more available, affordable gene testing options for all women.

As an action item for potentially reducing disparities, the authors urge physicians and genetic counselors to “improve medical care by ensuring that risk assessment and risk reduction strategies include a clear presentation of the benefits, not just the risks of testing, and by addressing patient trust and concerns about the medical system.”

Read the full study, “Medical Mistrust and Self-efficacy Influence Black Women’s Level of Engagement in BRCA1/2 Genetic Counseling and Testing,” which is available online for free.

June 26, 2013

Who (if Anyone) is Providing Teen Girls Information on Contraception and Safer Sex Practices?

The topic of sex education is often a controversial one, with much attention focused on how much (if any) education teens should receive. Implementation of abstinence-only approaches remains widespread, despite objections from health experts and evidence that comprehensive sex-ed is more effective at reducing teen pregnancy and sexually transmitted infections (STIs).

An article just published in the Journal of Adolescent Health explores the type of sex education teens report receiving, and from whom.

Most of the 2,001 teens ages 15 to 19 who took part in the national study describe themselves as white and living in the suburbs, and most of their mothers have at least some college education. The researchers only looked at teens with heterosexual experiences and make no attempt to address how their responses might differ from those of other teens from different backgrounds.

The findings, however, show some clear gaps in sex education. Among teen girls who were already sexually experienced, only about 2 in 3 had received any information on birth control from a parent (the results were about the same for STI prevention), while about 3 in 4 had received birth control information from a teacher.

Almost all girls (95 percent) reported receiving STI-prevention information from a teacher, but it’s not clear how many of those messages may have reflected abstinence-only education. About 1 in 5 girls had not received any birth control information from either parents or teachers.

Boys fared worse on this measure; more than 1 in 3 boys had never received birth control information from a parent or teacher, unless you count simply being given condoms with no additional information. Boys received STI-prevention information from parents or teachers about as often as girls did, and more of them got info from a healthcare provider when they had no other source, but the rates were still low.

Health care providers do not appear to be filling in the information gap for girls. Among the girls who had not received *any* birth control or safer sex info from parents or teachers, less than 1 in 10 got information from a health care provider. In other words, if girls aren’t getting messages about safer sex and contraception at home or school, they’re not likely to get it at all, even from their doctors and nurses.

The authors encourage improved distribution of sexual health information (SHI) in healthcare settings: “Because the majority of sexually experienced adolescents interface with the healthcare system, healthcare providers are missing many important opportunities to deliver SHI to this population.”

They do not provide any specific guidance for providers, but note that with expanded coverage for preventive and sexual health services under the Affordable Care Act, providers may have more opportunities to see teens and address this issue.

June 21, 2013

WHO Releases Global Report on Health Effects of Violence Against Women

Violence Against Women: Health Impact

The World Health Organization has released a new report, “Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence,” [PDF] that attempts to quantify how many women around the world are exposed to physical and sexual violence at some point in their lives, and describes many of the associated poor health outcomes.

The findings are probably not surprising, but they are still disturbing.

WHO reports that 35 percent of women worldwide — more than 1 in 3 — have been physically and/or sexually abused. These figures do not include emotional/psychological abuse.

Most of the violence is committed by intimate partners. WHO estimates that almost one third (30 percent) of all women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner, while 7 percent of women have been sexually abused by a non-partner.

Among the key findings on health outcomes:

• Globally, as many as 38 percent of all murders of women are reported as being committed by intimate partners.

• Forty-two percent of women who have been physically and/or sexually abused by a partner have experienced injuries as a result of that violence.

• Women who have experienced partner violence have higher rates of several important health problems and risk behaviours; compared to women who have not experienced partner violence, they:
– have 16 percent greater odds of having a low-birthweight baby;
– are more than twice as likely to have an induced abortion;
– are more than twice as likely to experience depression.

• In some regions, they are 1.5 times more likely to acquire HIV, and 1.6 times more likely to have syphilis, compared to women who do not suffer partner violence.

The authors describe a number of factors that likely contribute to high levels of violence against women, including economic factors, social norms that support male dominance over women, cultural acceptance of violence against women, and gender inequality in access to wages and education.

The report ends with an important call to action:

This report unequivocally demonstrates that violence against women is pervasive globally and that it is a major contributing factor to women’s ill health. In combination, these findings send a powerful message that violence against women is not a small problem that only occurs in some pockets of society, but rather is a global public health problem of epidemic proportions, requiring urgent action. As recently endorsed by the Commission on the Status of Women, it is time for the world to take action: a life free of violence is a basic human right, one that every woman, man and child deserves.

June 19, 2013

Groundbreaking Study Follows Women Who Underwent Abortions and Those Who Were Turned Away

Women in the United States are often subject to numerous restrictions when seeking abortions, including burdensome waiting periods and gestational age cutoffs that vary depending on state. Some abortions are delayed due to a lack of funds or no insurance coverage, or a shortage of available providers. All of these factors contribute to women not being able to obtain legal abortions once they choose to do so.

Last week, The New York Times published a great article about research into what happens when women are denied abortions. The ongoing project is called the “Turnaway” study, and it involves a group of UCSF researchers, led by Dr. Diana Green Foster, a demographer and an associate professor of obstetrics and gynecology at the University of California, San Francisco.

The researchers are following three sets of women: those who had first trimester abortions; those who had abortions near the gestational age limit; and those who were denied an abortion because they were just over the gestational age limit.

This research is important for a couple of reasons. First, studies looking at mental health effects after abortion often make inappropriate comparisons between women who had abortions and women who never sought them. (Anti-abortion advocates often try to cite mental health effects as a reason to deny women abortion, even though reliable evidence does not support the notion of a “post-abortion syndrome.”) These studies ultimately end up ignoring the emotional effects on women who wanted but were denied abortions.

Second, other research has not typically followed women forward in time (instead of asking them to remember) to see how they fare in terms of physical and mental health, education, employment, relationship status, and other factors. Foster is tracking the study participants via interviews conducted every six months for five years.

As the researchers explain:

The Turnaway Study is an effort to capture women’s stories, understand the role of abortion and childbearing in their lives, and contribute to the ongoing public policy debate on the mental health and life-course consequences of abortion and unwanted childbearing for women and families.

Foster’s research is increasingly relevant as states attempt to pass more restrictions on abortion access that could lead to costly delays and denied procedures. Nationally, the House just passed a ban at 22 weeks of pregnancy (20 weeks post-fertilization). It stands little chance of being enacted (assuming it could pass the Senate — highly unlikely — the president would likely veto it), but it does reflect the GOP’s intent to shrink the amount of time women have to obtain an abortion — which would lead to more turnaways.

A few publications have already resulted from the Turnaway group, mostly focusing on issues such as patient education, the effect of anti-abortion protestors, and commentary on how to reduce turnaways. It looks like some articles about denials in general and women’s emotional responses have been written and accepted by journals, but are not yet available to the public. We’ll keep an eye on those and provide an update when results are available.

In the meantime, read the full New York Times article, which describes the research in-depth and covers one woman’s story of being denied an abortion. After being turned away by a Planned Parenthood clinic in one state and a detour through a crisis pregnancy center that further pushed her past the gestational age limit, she found herself out of time, gas money, food, and other resources.

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 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 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.

April 25, 2013

How Can We Help Teen Mothers Avoid and Cope With Postpartum Depression?

Although there is a fair amount of information and research available on postpartum depression in general, very little of it seems to focus specifically on the needs or care of teen mothers.

A pilot study published in the American Journal of Obstetrics and Gynecology in March attempts to fill in this gap — and it shows some promising results.

First, the authors explain why the risks of PPD in teens are important:

PPD puts adolescent mothers and their children at risk during an already challenging time in their lives, and this hardship may be a major determinant of poor outcomes for these young mothers and their children. Untreated, depression is associated with school dropout, suicide, and substance use. Among adolescent mothers, evidence suggests that depression may prevent them from engaging in health-promoting behaviors for their infants and themselves.

The study is based on a randomized controlled trial of the REACH program (Relax, Encourage, Appreciate, Communicate, Help), which is designed to help expectant mothers develop stress management and other skills. The program was offered as structured therapy during pregnancy, followed by a postpartum “booster” session.

Participants in the therapy group used interpersonal therapy to work on effective communication skills, conflict management, improving their social support systems and building healthy relationships, and goal setting. They, as well as the control group, received a handbook of typical pregnancy and postpartum/newborn health information. A total of 106 teens age 17 or younger and without pre-existing mental health issues were randomized to the therapy or control groups.

The researchers looked for major depressive episodes within the six months after birth. Although only 12.5 percent of the REACH teens developed postpartum depression, compared with 25 percent of the control teens, the results were not statistically significant, as the study was fairly small and very few teens (19) overall developed postpartum depression. A larger study may be needed to better determine the utility of the program.

Despite a lack of clear effect, the study highlights a need for further investigation into the postpartum mental health needs of teens. As the authors explain:

Although validated treatments for adolescent depression exist and include interpersonal therapy, cognitive behavioral therapy, and antidepressant medication, teen mothers with mental health problems are mostly under treated. To date, only one published report of 2 small open-trial pilot studies addressed treatment for depression in pregnant adolescents. Despite the potentially high burden of depression to young women and their families, studies on the prevention of PPD in pregnant adolescents are virtually nonexistent.

Another lesson learned in this study was that teens preferred individual therapy sessions over the planned group sessions, so sessions were adjusted to be one-on-one. The researchers also took care to specifically design the REACH program to be culturally appropriate for a diverse group of racial and ethnic backgrounds.

April 23, 2013

Study: IUDs Offer Safe Contraception Option for Teens But Rarely Prescribed

Intrauterine devices (IUDs) are a fairly safe, long-acting form of contraception, but many myths about the devices persist. For example, it’s somewhat common to hear that women who haven’t already had a baby, and especially teenagers, are not good candidates for IUDs; neither of these is true.

For a new study published in the journal Obstetrics & Gynecology, researchers reviewed data from health insurance records of more than 90,000 women who had IUDs inserted (including both hormonal and copper IUDs). They looked specifically at how many records indicated a IUD-related complication, discontinuation, or pregnancy.

When the researchers looked at the data by age group, they found that women ages 15-19 did not discontinue using IUDs any more frequently than older women. Teens were slightly more likely than older women to experience dysmenorrhea (menstrual cramps) or absence of menstruation within one year of insertion, or failure of the IUD to prevent a normal pregnancy, but rates for both of these were very low. Only 1.8 percent of teens using a levonestrogel-releasing IUD experienced a pregnancy (3.6 percent for copper), and 2.4 percent experienced cramping (6.2 percent for copper).

Pelvic inflammatory disease occurred in less than half a percent of teens. Women of all ages using a copper IUD were much more likely to stop using it than women using the hormone-releasing IUD, and this was most true for teens, although it’s not completely clear why. Rates of removal within 30 days for any complication were estimated to be very low for teens (2.9 percent for hormone IUD, 5.2 percent for copper) as well as older women.

The researchers conclude:

Overall, these data indicate that the IUD is an appropriate contraceptive for younger women and is not likely to cause serious side effects among teenagers. Physician recommendations play an important role in their patients’ decision-making, and their recommendation of the IUD could increase the use of this cost-effective and safe method of birth control among teenagers. Thus, physicians should include information about this highly effective method when they counsel young patients on their contraceptive options to help reduce the unintended pregnancy rate among teenagers in the United States.

The authors cite evidence that teens may indeed face clinician education barriers when seeking an IUD. One survey found that “only 19% of obstetrician–gynecologists surveyed in a 2010 study stated that they would offer an IUD to an unmarried 17 year old who had never been pregnant.”

With more evidence like the current study on hand, we hope it will become easier for teens to access this long-acting, effective form of contraception.

Related: Revisiting the IUD for Contraception – Pros and Cons for Women looks at the rise in IUD use and the safety record.

April 10, 2013

Eating Disorders in Adolescence Can Have a Long Term Effect on Women’s Health

Despite the prevalence of eating disorders in adolescent girls, it’s difficult to find information about longer term health consequences in adults, as little follow-up has been done. A new article in the journal Maturitas on the long-term health consequences of the female athlete triad, a syndrome that may include eating disorders, is an important contribution to the research.

First defined in the early 1990s, female athlete triad used to be defined as the combination of an eating disorder, amenorrhea (lack of a menstrual period), and osteoporosis.

The definition was adjusted in 2007 to focus more on a spectrum of health and now includes low energy (with or without an eating disorder), menstrual function, and bone mineral density. These are interrelated; it is thought that the lack of energy due to excessive exercise or disordered eating leads to changes in menstrual cycles and loss of bone mineral density.

While it’s not original research, the new review by Jill Thein-Nissenbaum of the University of Wisconsin-Madison’s physical therapy program points out some important health issues for women beyond the teen years.

Of major concern, based on a review of the literature, are the long-term effects of decreased bone mineral density associated with the triad. Women who restricted their energy intake may have missed crucial bone mass building time, and this bone density may not be made up even with eating disorder recovery.

Thus, as women age, they are losing additional bone mass from an already depleted system. Thein-Nissenbaum notes that women with the triad may also be at greater risk of musculoskeletal injury, and these injuries may have negative effects throughout life.

Thein-Nissenbaum suggests that women who currently have or have recovered from female athlete triad discuss with their healthcare provider their history of eating behaviors and menstrual history, dating back to adolescence, and review details from previous bone scans.

She also cites the need for bone mineral density assessment in women who have had a history of disordered eating behaviors, menstrual irregularity, or more than one stress fracture.

The National Eating Disorders Association provides a toolkit for coaches and athletic trainers that includes a section on the female athlete triad, including causes, treatment, and behaviors to look out for. The guide also has information on other types of eating disorders and the role of coaches and trainers in prevention and early intervention.

Plus: Eating disorders are most commonly associated with adolescents, but adults are also susceptible to anorexiabulimia, binge eating and other disorders, and they face a unique set of challenges, says Cynthia M. Bulik, author of the new book ”Midlife Eating Disorders.” Women’s eNews recently published an excerpt.

“If we look at the numbers,” writes Bulik, “the most common profile of someone with an eating disorder is a woman in her 30s or 40s who struggles with weight control and suffers from binge eating disorder. But countless women and men in midlife and beyond — from all racial, ethnic and socioeconomic backgrounds — wake up each morning to an ongoing battle with eating and body image, with many suffering from anorexia nervosa, bulimia nervosa, purging disorder, binge eating disorder and night eating syndrome.”

April 9, 2013

The Saga of Michael Klein: A Poem in Praise of a Pristine Perineum

by Allison Saran

Some of the world’s greatest medical discoveries never receive the attention they deserve. For Canadian physician Michael Klein, the attention came late, but it’s been growing ever since.

And thanks to one very humorous and talented fan, Klein’s work is immortalized in rhyme.

Dr. Jerry Kruse, the newly named executive associate dean of the School of Medicine at Southern Illinois University School of Medicine, where he had been chair of the department of Family and Community Medicine, has a flair for writing poetry and limericks – often under the pseudonym of Dr. Kreuss, which, yes, rhymes with “Seuss.”

Kruse’s talents were on full display last December at the annual meeting of the North American Primary Care Research Group. In the video above, he pays tribute to Klein, who is widely known for his landmark randomized control trial that showed routine episiotomies during childbirth (an incision on the perineum and the posterior vaginal wall during second stage of labor) cause an increase in the very complications they aim to prevent.

Klein believed that women given routine episiotomies experienced deeper perineal tears than women who were not given episiotomies. Though his study confirmed this, it was initially met with resistance within the medical community. In 1992, eight years after the original request for publication in an accredited journal, Klein’s findings were finally published.

Once released, the study caused a medical, and thus cultural, shift. Routine episiotomy was slowly abandoned by medical caregivers (“scissors were thrown to the floor with disdain,” notes Kruse in his poem) and with that, severe perineal injuries declined.

The results of Klein’s trial helped to decrease episiotomies not only in Canada, but throughout the world. In his opening remarks, Kruse credits Klein with “improving the lives of millions of women.”

In “The Saga of Michael Klein,” billed as the story of Klein’s “search for truth regarding episiotomy,” Kruse begins with a description of Klein’s holistic obstetric practice. Klein had advocated that women in labor should not be treated as if they have a disease, and that the first intervention during labor often leads to a cascade of other interventions, disrupting a natural process.

Here’s an excerpt:

Michael knew in his heart, way deep down inside
That obstetrical knowledge was not well applied.
“Technology’s great, for those who are ill,
But for those who are healthy it’s really no thrill
To be strapped down and poked, and scared stiff as a board.
This just isn’t right!” his fervent voice roared.

One thing more than others, did gnaw at his heart,
Made his blood boil, and stung like a dart.
He just couldn’t stand it, to see a long slice,
A cut, an epis – what a terrible vice,
Disruption of skin for no reason at all,
A snip with the scissors that starts very small
But rips and extends as the baby comes through
Tears into the sphincter and up the wazoo.
A third, then a fourth, oh my what a mess
“They must like to sew,” was his only guess.

So Michael rose up, and he raised his right hand
And opened his mouth, and took a firm stand:
“I’ll study this problem,” he said with a shout,
“And when I am finished there won’t be a doubt
That these cuts are no good—the whole world will see—
This idea’s a good one, they’ll have to agree.
I’ll start up a randomized, single-blind study
And I’ll work with Michel who’s my very good buddy
And we’ll put ole’ McGill right here on the map.
This study of perineal trauma’s a snap.

“The Saga of Michael Klein” concludes with a clear message: Never give up on your cause if the research is true and good can come of it.

Klein’s quest is one of many that healthcare providers and birth advocates have completed to make birth healthier and safer for all women. No matter if you are a doctor, midwife, nurse, pregnant woman, or just someone who cares about childbirth, “The Saga of Michael Klein” encourages you to laugh – and to carry the hope of bettering birth.

Ed. note: You can view the full poem in Family Medicine journal (October 2012), along with a complete bibliography.


Allison Saran is a senior at Brandeis University, majoring in anthropology and public health. She is a keen advocate for evidence-based birth and is excited to continue her studies at the Yale School of Nursing (CNM speciality). 

April 5, 2013

Study: Expand Abortion Access by Expanding the Types of Professionals Who Can Provide Care

In the United States, 87 percent of counties have no abortion provider, forcing some women to travel potentially long distances for reproductive health services, while others delay making a decision until later in the pregnancy, when an abortion is more costly and restrictions are more severe.

One way to increase access is to increase the range of providers who are permitted to do abortions, such as nurse practitioners, nurse midwives, and physician assistants.

Currently, non-physician clinicians can perform surgical (aspiration) abortions legally only in Montana, Oregon, New Hampshire and Vermont. In some states, these providers can oversee medication abortions, though that, too, has become a contentious issue as more legislatures seek to restrict women’s access to abortion.

Are laws requiring physicians to perform surgical abortions necessary, from a patient-safety perspective? Not according to a recently published study.

Tracy Weitz, director of Advancing New Standards in Reproductive Health, a collaborative research group and think tank at University of California, San Francisco, and Diana Taylor, ANSIRH’s director of research and evaluation, primary care initiative, set out to answer the question of healthcare outcomes and applied for a waiver of California legal statutes that limit surgical abortion to physicians. They note:

In 2008, 1.21 million abortions took place in the United States, with more 200,000 (18%) in the State of California. Nationally, 92% of abortions take place in the first trimester, but Black, uninsured, and low-income women have less access to this care. In California, only 87% of women using state Medicaid insurance obtain abortions in the first trimester. Because the average cost of a second-trimester abortion is substantially higher than that of a first-trimester procedure, shifting the population distribution of abortions to earlier gestations would result in safer, less costly care. Increasing the types of health care professionals involved in abortion care is one way to reduce this health care disparity.

For the purpose of the study, 40 certified nurse midwives, nurse practitioners and physician assistants in ANSIRH’s Health Workforce Pilot Project, who already had experience with medication abortions, were trained to perform surgical abortions. (ANSIRH’s Early Abortion Training Workbook, which is used in medical schools around the world, is also available online.)

The authors compared the outcomes of abortions performed by those medical professionals to outcomes of abortions performed by 96 physicians. Patients were not randomized to a provider type; they were asked if they would agree to have the non-MD provider on duty perform their first trimester abortion.

Complications were rare in general, with only 1.3 percent of the 11,487 abortions resulting in any type of complication. While the newly trained CNM/NP/PA group had slightly more complications than the group with abortions performed by more clinically experienced MDs, the difference was not considered significant.

The authors conclude that “only 1 additional complication would occur for every 120 procedures as a consequence of having an NP, CNM, or PA as the abortion provider,” and these would largely be minor complications, such as a low-level infection or bleeding that could be treated at home or at an out-patient clinic.

The study was published in the American Journal of Public Health. Based on the findings, the authors argue in favor of expanding the types of providers who can perform abortions:

The benefits of expanding access to abortion for California’s women outweigh the small initial difference in risk, particularly because it would likely move many second-trimester abortions into the first trimester, significantly decreasing the overall risk of complications, which increases with gestational age. Expanded access is also likely to afford more women the opportunity to obtain care without the additional indirect costs associated with traveling to a geographically distant abortion provider.

We would hope, after reading this study, that more state legislatures would consider removing restrictions on non-physician clinicians, but we know such a move would require great amounts of political will, as the trend in recent years has been to restrict rather than increase access.

March 29, 2013

Access to Contraception Increases Social and Economic Benefits for Women And Society

The Guttmacher Institute recently published a report examining how access to and the use of effective birth control affects women’s lives.

The Social and Economic Benefits of Women’s Ability to Determine Whether and When To Have Children“ reviews more than 66 studies over the past 30 years. According to researchers, access to contraception and avoidance of unplanned pregnancy have led to:

  • increases in young women obtaining at least some college education
  • increases in college-educated women pursuing advanced professional degrees
  • increased participation in the workforce by women
  • increases in women’s earning power and decreases in the gender gap in pay

The researchers identify several gaps in the literature as well as areas where additional research is needed, such as how contraception benefits older women and women with low incomes, of racial and ethnic minorities, single mothers, and women with other sociodemographic factors that might prevent them from getting the full benefits of contraception.

The authors conclude with an important call for ongoing efforts to enhance access to contraception:

Clearly, access to reproductive health care and the recognition of reproductive rights cannot be addressed in isolation from the rest of an individual’s life, or from the rest of society’s inequities. Rather, policies and programs that advance contraceptive access and those that affect whether a woman is still able to achieve her life goals if and when she becomes a mother should be considered as part of a greater whole.

By helping women and couples, regardless of background or income, determine and exercise their own reproductive choices, government and organizational policies can help advance broader economic equality and social justice for individual women, families and society.

The report is available online as a PDF; a summary with links to more information is also provided. Also check out OBOS’s Brief History of Birth Control and discussion of Global Access to Birth Control.