Tag Archives: Contraception

Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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Reply turned post, from abortion to homebirth style

Hello! Hey, I’m a doctor!

Please go read this excellent article at RH Reality Check: Why Birthing Rights Matter to the Pro-Choice Movement.

Here is a great quote from the author Laura Guy, who is a doula (yay!) and a certified lactation consultant (IBCLC) (double yay!):

But let’s be clear about something. Reproductive justice means that everyone has complete control over if, when, where, how, and with whom they bring a child into the world. It means that people have accurate, unbiased access to information regarding all facets of their reproductive lives, from contraception to pregnancy options, from practices surrounding birth to parental rights. It means that our choices are not constrained by politics, financial barriers, or social pressure. In other words, how can the right to give birth at home – safely and legally – not be on a reproductive justice advocate’s radar?

As I commented on the article, I was thrilled when, during the keynote address at my first Medical Students for Choice meeting, the speaker mentioned out of hospital birth. Reproductive rights are full spectrum. They start before sexual activity begins – bodily autonomy begins with birth, stretches through childhood with protection from oversexualization, extends through accurate sexual education, includes contraception and freedom to choose when and how to become sexually active, and definitely doesn’t end once one decides to carry a pregnancy to term. The ability (or lack thereof) of women to choose the site and mode of their delivery, among other important issues of autonomy during pregnancy, are key ways that women’s rights are challenged daily in this country. Pregnant women are not human incubators.

So, seems like a bunch of mutual appreciation society activity here. Where is the angst that usually prompts the reply-turned-post? Well, on the RH Reality Check link of Facebook, one commenter says: “This is great and it’s also important for women to have the right to medical interventions (like elective C-sections) they feel are right for them.”

Here is my reply:

‎@Kathleen – within reason. Feeling something is right is one thing, but unnecessary medical intervention is not a “right” per se.

It’s a very nuanced issue that may not fit well in the comments section on Facebook. For example, evidence and expert position statements warn against early induction. Feeling like an induction is right is not enough of a reason to get one. Take it from someone who has been in the paper gown, sick of being pregnant, and in the white coat – many women feel like an induction before the end of pregnancy.

Also, someone who is a really poor candidate for vaginal delivery (placenta previa, for example), may feel like they want a vaginal delivery, but it is not medically advisable. Same goes for women who are poor candidates for homebirth. I think homebirth is an excellent option for good candidates. Not all. There is a role for practitioners to play here, too.

As a physician and most likely a future ob/gyn, I will be one of many practitioners who need to constantly work that balance between respecting a patient’s autonomy, providing good informed consent, and practicing good medicine with a good conscience. Medicine is more than ordering off a menu.

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Awesome free resource!

I am so thrilled with the free books available at Herperian.org. They are designed for ease of use and medical accuracy, and take into account limited resources in remote locations. Each of the books is available in multiple languages.

squatting position for pushing stage

I downloaded “Where There Is No Doctor”, “Where Women Have No Doctor”, and “Book for Midwives.” I haven’t had time to read them completely. Each one is more than 500 pages! I glanced through the midwifery book first, and was thrilled with what I saw. The section on the second stage of labor discourages frequent cervical checks, for example. It also has illustrations of alternative pushing positions, or in this case, physiologic pushing positions. The section on breastfeeding has accurate, non alarmist but very true information that formula can be harmful, including an illustration of an emaciated baby with diarrhea, warnings about unclean water sources, and the valid point that formula companies use predatory advertising practices to sell their product.

“Where Women Have No Doctor” has some overlap. There is a great section on abortion, with nonjudgmental language, and emphasis on safe abortion and management of complications. the chapter begins with reasons why some women choose abortion, and the first one is “She already has all the children she can care for.” Many people ignore the fact that most women who choose abortion are already mothers, and in developing countries with high maternal mortality rates, there is real danger to their already living children if their mother has an unwanted pregnancy. The midwifery book has a training chapter on manual vacuum aspiration.

Safe abortion is a safety net

Both books have good sections on family planning. Even though they are designed for practitioners in remote areas and perhaps minimal training, there is a good balance between necessary actions and not overstepping and perhaps causing harm by doing interventions with a lack of training. For example, the section on IUD insertion states that insertion can cause injury or infection, and should be inserted only by someone who is trained, but does not have alarmist contraindications. And, the book warns against putting in IUDs without permission, and the right to refuse an IUD.

The women’s health book also has a nonjudgmental section on sex workers, with information on risk reduction and negotiating condom use. It also has a section on women with disabilities.

I downloaded the Spanish version of the women’s health book. I figure I can read it to improve my medical Spanish, and I may be able to use it as a translation tool.

OK, I have gushed about the books enough. Go check them out!

Thanks, KK!

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Reply turned post, Trisomy 18 and mental masturbation style

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

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All board review and no play…

I have my USMLE Step II CK on Saturday, and my COMLEX Step II CK August 1st. So, sorry I haven’t had time or mental functionality to blog much. I have tons of stuff I have wanted to share. Let’s see if my medical fact clogged brain can remember a few of them.

NPR has been rockin’ lately. First, I heard Morocca say “hula doula” on Wait Wait, Don’t Tell Me” recently. They have been running a really great series on birth called “Beginnings: Pregnancy, Childbirth and Beyond”. It included a great piece on elective inductions that provoked a lot of comments when I shared it on my Facebook page.

NPR’s Facebook feed also tipped me off to a new report by the Institute of Medicine, “Clinical Preventative Medicine for Women: Closing the Gaps” which recommends mandating insurance coverage of contraception,” since it is preventative medicine. To quote Rachel from Women’s Health News, “Duh!”.

In addition to copay-free coverage of birth control, the Institute recommended:
screening for gestational diabetes:

*human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
*counseling on sexually transmitted infections
*counseling and screening for HIV
*lactation counseling and equipment to promote breast-feeding
*screening and counseling to detect and prevent interpersonal and domestic violence
*yearly well-woman preventive care visits to obtain recommended preventive services

Hear, hear.

Anyway, I should be studying. Wish me luck.

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Hands on in the boondocks

Howdy. I have been busy, as usual. Not only working at a new rotation site, which has been wonderful, but driving more than three hours a day to get to and from this site.

Our medical school requires that we do three months of rural rotations. I am doing two at a community health center in the middle of the state. The surrounding town is a farming town, with a large migrant population.

I am absolutely loving it. I am starting off with the ob/gyn, and we do gynecology, family planning and obstetrics. It is a very hands on rotation with an attending physician who is eager to teach. I have done many pap smears, STD tests, contraception counseling, cervical checks on full term pregnant women, and I GOT TO INSERT AN IUD. That plus a journal club, a training on human trafficking and a training on contraception compliance. Not bad for the first week and a half!

Our first two days consisted of orientation, and the longest time slot was given to the lactation consultant, who I love. She is working on a “Men and Women’s Health Day.” When I gently pointed out to the Medical Coordinator of the site that it was trans exclusive, they took me seriously. I am going to be the point person for any individuals identifying as trans (or anyone else who has questions in that area) the day of the health fair. Apparently they had some there last year and were at a loss. I am going to start with the resources linked to by Rachel at Women’s Health News and go from there.

I’ll try to check in again. If I could type while I drove, I’d have a ton of posts. Instead I am listening to board review materials. And looking at the swamp wildlife. And trying to avoid a speeding ticket.

I can easily see myself working at a community health center. This is totally my bag.

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Reply turned post, IUDs as EC style

Sungold has a great post up at Kittywampus about the little known use of the copper IUD as emergency contraception. I wrote a reply, and figured I would share it here:

No one seems familiar with this whenever I bring it up, and that includes ob/gyn clinicians. In the US, IUDs are supposed to be just as acceptable to insert in nulliparous (never had a baby) women as parous (has had a baby) women. As Sungold pointed out, that is not the reality for all women. I was actually told by my ob/gyn that I wasn’t a good candidate, even though I had already had a baby, because I was divorced. (!!)

According to a midwife who taught me about birth control, the reason why IUDs were not recommended for nulliarous women were because so many of them successfully sued over the Dalkon shield. The company had to pay a much higher settlement to women who never got to have children due to their injuries than they did to those who already had children. The indications for the newer IUDs, including the copper T, originally said the ideal candidates were parous women, but that is no longer the case. New recommendations say that pretty much any woman who does not have active pelvic inflammatory disease is a good candidate.

The Dalkon shield was a completely untested, unresearched, unregulated piece of scrap metal. The copper IUD is a much more carefully created and substantiated device. It has a higher rate of continuance of use than any other form of birth control. Not only do I have an IUD, but the IUD is an incredibly popular form of birth control among female ob/gyns I have very unscientifically surveyed.

The main issue I can see with using IUDs as emergency contraception is that the standard of care is to screen for and treat STDs, particularly gonorrhea and chlamydia, before insertion. With conventional screening, time for results, and then treatment if necessary, you are probably running over the 5 day window. So, even if USian practitioners were comfortable with using the IUD as emergency birth control theoretically, this protocol may be a barrier.

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