Tag Archives: Reproductive Rights

And, partial birth abortion

I am feeling better enough to post a rant!

A friend posted a link on his Facebook page to this ridiculous distortion of an article on National Review Online, which accuses Supreme Court of the United States nominee Elena Kagan of distorting medical fact and the positions of ACOG regarding the so called “partial birth abortion” ban, when solicitor general for the Clinton administration.

He wrote “This is the woman who may have a lifetime seat on the most powerful Court in the United States” and linked to the article. Here is what I wrote in reply:

Thank goodness if she is appointed, which seems very likely.

She did not contradict the language in the ACOG draft at all. They said it was never the case that there was “no other option”. There are inferior procedures that are actually more dangerous to the mother, and more difficult for the practitioner. Yes, they were options, and are now the only option. She suggested language that said an intact D & X may still be the best option, which was obviously indicated by the rest of ACOG’s position. As a member of ACOG, I am completely comfortable with that.

I think it is disgusting that this rare and difficult procedure that was only used in the already most difficult of cases has been politicized like this. And, now is unavailable to doctors. Physcians can still perform later term abortions where (and when) it is legal and indicated; they just can’t use this safer procedure. This ban had nothing to do with gestational age, just technique.

In fact, a D & X is a procedure that is psychologically much kinder to the mother in this difficult circumstance, because she can hold the intact fetus, (or baby, if you use the vernacular), which was most likely incompatible with life on its own or with her ability to survive until it could be viable, and have a proper mourning period. Physicians are now forced to dismember the fetus in utero before removing it, making this impossible. I hope you realize this is the implications of the ban.

I am assuming, considering what I know of your other political leanings, you are not generally a fan of government telling physicians what procedures they should use, based on politics. ACOG clearly was opposed to the ban, and her language in NO WAY misrepresented their position at all.

This is completely ironic considering that science and medical opinion was completely usurped in many cases in the Bush administration. Look into the history of trying to get emergency contraception approved for over the counter use, for example. I hope you were as adamant about respecting ACOG’s positions then.

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Invasive abortion law is vetoed!

(Trigger warning, description of forced medical procedures)

Governor Charlie Crist of Florida vetoed Florida HB 1143, which would require transvaginal ultrasound (also known as the affectionately as the “dildocam”) for women seeking abortion in Florida, above and beyond what was medically necessary (which would be more likely a much less invasive transabdominal ultrasound if needed for dating purposes). In fact, many women consider being forced to have a vaginal procedure against their will as medical rape.

Gov. Crist said:

“This bill places an inappropriate burden on women seeking to terminate a pregnancy. Individuals hold strong personal views on the issue of life, as do I. However, personal views should not result in laws that unwisely expand the role of government and coerce people to obtain medical tests or procedures that are not medically necessary. In this case, such action would violate a woman’s right to privacy.”

I was one of the many Florida voters who emailed and called to urge for this bill to be vetoed.

Charlie Crist was elected to governor as a Republican. I have been a fan of his since his election. He has continuously been a moderate who is highly practical and responsive to the state’s will and needs. He is running for Senate now, but will be running as an Independent, due to a far right tea party challenger.

I hope this veto helps him with the moderate and liberal vote. I will be voting for him. Sorry, Kendrick Meek, but Crist continues to deliver.

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My first death threat!

I have gotten my share of hostile comments, but I think I have gotten my first death threat. I considered not letting it through the spam filter, but I decided to let it stand in all its hostile, angry glory.

Funny, I thought my first comment wishing death to me and my children would come from an anti-choice troll. Ironically, this seems to be from a childfree, also anti-choice but anti-choice in a different way, troll. I have always thought it was B.S. when people say being attacked from both sides means you must be doing something right. I am still not sure if it’s the case that I am doing something right, but at least I look better than these balls of hate.

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“Accepting responsibility”

When someone tries to defend being anti-choice because women need to “accept responsibility” for their actions (i.e. having sex), it always confuses me. I even heard a classmate use that as an excuse to be against birth control, also. I have always thought avoiding unwanted pregnancy, and not bringing unwanted children into the world was much more responsible than using babies as some sort of punishment for fertile women and girls.

Please read this article in the Nation about birth control sabotage as part of abuse.

Here is a chilling passage (emphasis mine):

In the largest study of this phenomenon to date, “Pregnancy Coercion, Intimate Partner Violence and Unintended Pregnancy,” published in the January issue of the journal Contraception, lead researcher Elizabeth Miller and others surveyed nearly 1,300 16- to 29-year-old women who’d sought a variety of services at five different Northern California reproductive health clinics. Among those who had experienced intercourse, i.e. who could be at risk of unintended pregnancy, not only did 53 percent of respondents say they’d experienced physical or sexual violence from a partner, but one in five said they had experienced pregnancy coercion; 15 percent said they experienced birth control sabotage, including hiding or flushing birth control pills down the toilet, intentional breaking of condoms and removing contraceptive rings or patches. These figures were consistent from clinic to clinic.

Who do we want taking responsibility for what actions? Who are we blaming for unplanned pregnancy? And, who will suffer if these reproductive clinics (like Planned Parenthood) have their funding stripped?

Sorry about the heavy. I will try to bring back some poop jokes.

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Reply turned post, devil’s advocates do the devil’s work style

I am having an interesting interaction in the comments to this recent post about the ACOG convention. I am giving the commenter, Jasmine, the benefit of the doubt when she says she delivered one live birth and had one 24 week abortion with one of Dr. Jody Steinhauer’s friends as the health care practitioner. I do not have a comment policy that excludes discussion just for being, well, strange. Jasmine’s purported reason for commenting is to share her story, then justify abortion at all gestational ages based solely on the “absolute” bioethical principle of bodily autonomy. It seems suspiciously like a contrived straw man argument to me, presented as “devil’s advocacy” tempered with a little “I am the anecdote, so I am the universal truth” logical fallacy thrown in.

But even if Jasmine is someone who has had both a live birth and a subsequent elective 24 week termination, and thinks termination at all gestational ages is defensible due to bodily autonomy, and not a anti-choice troll posing as a cold, logical-fallacy calculating abortion advocate, there is room for her opinion. (Updated to add: She was an anti-choice troll. She linked to a Southern Baptist site as support, and then started leaving graphic, horrid comments about sucking out baby’s brains and killers and liars.) It doesn’t have to represent my reasons for being pro-choice. I don’t mind debate on my blog, obviously, but I really don’t think sparring over how absolute individual bioethical principles are is, well, all that important. I spent years in competitive debate. I can engage with the best of them. I have closed down more than a few comment section battles with my razor sharp management of argumentation (being a bit facetious here) and it really hasn’t saved anyone’s lives. Women are still dying from unsafe abortion and poor access to reproductive care. Children are still being orphaned.

Here is my reply:

Not everyone agrees about bodily autonomy being the only factor involved in this discussion, or that any bioethical principles are absolute. I don’t. Bodily autonomy is extremely important, but not absolute. Prostitution is illegal in this country (not that I necessarily think this is effective or ethical.) One cannot slash ones wrists in public without being restrained and committed.

Ethics is more complicated than that. I am not sure if you are trying to set up a straw man argument.

My argument for the support of abortion lies in humanistic concerns about reproductive rights and maternal death in general. It is actually the opposite of online debate on how absolute one bioethical justification is for abortion. It is acknowledging the reality of women’s lives – that they can be trusted to judiciously use birth control if it is accessible and affordable. That the 50% unplanned pregnancy rate and 22% abortion rate is not what women would choose if they had true free choice in this country. I think abortion is one reasonable health decision when faced with unplanned pregnancy or a pregnancy with medical complications, but that does not mean that I do not also want to decrease unplanned pregnancy or complicated pregnancies!

I am not going to sacrifice real women to some sort of dry sparring in a comments section. 70,000 real women die every year due to restrictive laws and real barriers to safe abortion care. Bodily autonomy? Sure, important. But not as important as them.

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Ugh x 2

(Trigger warning)

Pregnant woman is told she must have a cesarean for her fourth birth, even though her third birth at that hospital was a successful VBAC.

Raped ten year old is refused an abortion in Mexico

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Reply turned post, patient safety and midwife witchhunt style

This is a reply to Amy’s fantastic post about patient safety and the marginalization of midwives. While physicians have flocked to defend and rationalize an induction and cesarean on a non-pregnant woman with pseudocyesis, she points out that the same community often villainizes midwives for less.

She wrote:

The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient.

Dr. Amy swooped in to criticize direct entry midwives (pretty much proving the point) and a midwife named Margie wrote a gorgeous comment defending direct entry midwives that is as worth reading as the original post. For example:

And, if you think that CMN’s are the answer then you need to open your eyes and look around you. You would see communities such as mine where there is a population of nearly 2 million people without a single hospital that allows CNM’s to handle childbirth; a community that doesn’t have a single freestanding or hospital connected birthing center; a community with a cesarean section rate nearly 40%. In our state as in the majority of states, a CNM is regulated by the state nursing board and hey[sic] are pretty much treated like any other nurse in that state, unable to do anything without a doctor taking full responsibility. If, as you stated, these CNM’s are so educated and capable, then why are they still treated as underlings of the birthing community? Why are they not allowed to practice midwifery as they see fit? Why are they not allowed to make serious pregnancy and delivery decisions and only call in physicians when they feel it’s appropriate? Why are they not allowed to do procedures that they feel skilled in, such as vaginal breech deliveries, even though the doctors they work with are not skilled with or comfortable doing? Why are they NURSES first and then midwives?

Once you go and read Amy Romano’s full post and Margie’s full comment, you can come back and read my reply:

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Margie, that was wonderful! *clap clap clap*

Amy, thanks for this post. I wish I had made a comment last night when I read it for the first time, but I needed some time to process it. I still don’t know if I can articulate a good thought, but I’ll try.

This is why I left midwifery and went to medical school. I was training with a direct entry midwife. She was being investigated for delivering an IUFD. It was a known IUFD. The father of the pregnant patient was a practicing ob/gyn in another state. He sat in on an ultrasound, and talked with his daughter about inducing at a hospital or waiting to go into labor and going ahead with a delivery at the birth center. She wanted to deliver naturally at the birth center, and did with his support, blessing, and presence.

The problem came when the midwife needed someone to sign the death certificate. She called around to physicians and the medical examiner, and one of them called in a complaint to the health department.

Apparently, state law requires that a midwife in Florida only participate in the delivery of what should be a healthy, uncomplicated labor and delivery of a healthy, normal baby. Although there was no question as to whether the prenatal care was adequate or if the IUFD could have been avoided, she is still being investigated four years later.

Yes, their constant probing has uncovered disgruntled former employees with dirt to dish, irregularities of paperwork, and the like. But, as my medical jurisprudence professor taught us, anyone can be busted for paperwork or charting errors. Anyone. They will find a technical error. It doesn’t matter what the complaint is about, they will pull years worth of charts (like they did with her – 5 years worth) and pore over them to find any charting error.

She has had to continue to try to run a birth center with all of her charts missing, various inspections and raids, and scrutiny of her past patients and anyone who has ever worked with her. All for delivering a known IUFD with compassion the way the patient wanted it to be, with no complications.

There are a lot of reasons why I decided to go to medical school. I had planned on it before midwifery school, actually. But, this was the event that led me to leave midwifery, especially direct entry midwifery, and go to medical school. I did not want the scrutiny, the bizarre overregulation, (at least in Florida – mandatory transfer of any postpartum patient with total blood loss of more than 500cc, for example), the lack of respect, or the hostility from the mainstream obstetrical community. I didn’t want to sit there with an impending investigation for what I would consider good care, going over five years of charts, terrified that I made a mistake, tempted to go back and “fix” items here and there on charts of uncomplicated, healthy, successful deliveries, to make sure that there were no holes or oversights that would cause me to lose my license.

I figured I could go into medicine and get away with a helluva lot more. I am not going to jump on a physician bashing bandwagon or anything – I respect many, many obstetricians and other physicians, and think that it is a wonderful field, or I wouldn’t be joining it. That being said, after being to a lot of hospital births, either as transfers from our center or as a doula or friend of the patient, I saw just how unsupervised and unscrutinized a private obstetrician with hospital attending rights can be. As long as you are not violating a major policy, like allowing trial of labor for VBAC *eye roll*, or letting patients and fetuses die, or majorly abusing the staff, there is an awful lot of pure, unadulterated autonomy. For all of the malpractice complaints, obstetricians should be happy that their practice patterns and standards of care just have to meet a bare minimum (baby comes out) to not get investigated by the licensing board. If every doctor I know who didn’t give informed consent before an episiotomy, (much less did one as a routine practice!) or had more than 500cc of blood loss without calling in a specialist had to worry about losing their license, it would be a very different atmosphere. Not that I think that is the answer. I just didn’t want to live with that spectre looming over me. I took the malpractice boogeyman instead. (which midwives still have to deal with, too.)

I completely agree with Amy. Punitive measures aren’t the answer. I am not asking to have these obstetricians run out of town, tarred and feathered. I think the whole system needs to be examined, focusing on the needs of the pregnant women, first.

That means recognizing and treating mental illness without doing an unnecessary induction and surgery, and then blaming and ridiculing her afterward. No sane woman goes through a two day induction and cesarean without being pregnant. Sane women who are pregnant want to avoid that! That means not investigating their practitioner for delivering their IUFD in an environment that was safe and good enough for a live fetus. That means allowing near miss reviews and apologies from physicians without placing them in legal jeopardy. That means not pitting obstetricians and midwives on opposing sides of a battle, where it seems women and babies are the ones caught in the crossfire.

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Reply turned post, health care reform style

A Facebook friend posted a link to a news story about how insurance companies still say they will fight to deny coverage of preexisting conditions. I replied that I am sickened (no pun intended) by the people throwing bricks through congressional office windows, spitting on politicians, firing bullets into a congressional office, cutting a gas line at a politician’s family member’s house and calling in death threats, all in the name of defending this horrid status quo.

She asked me in reply “What do you think of all this health care stuff?”

I don’t know how much I have written about it recently, even though I have been following the debate avidly. I got turned off one step at a time with each compromise that was made, when each compromise didn’t earn one single Republican vote. What could have been a progressive reform pretty much got turned into a pretty close copy of the Republican’s answer to the Clinton era Democratic reform proposal. In fact, it uses a lot of ideas from the Republican platform in the 2008 election. We scuttled the public option, contraception coverage, put in extra barriers to abortion, cut the minimum of premiums taken in that had to go to actual medical care, removed end of life counseling, put in mandates, etc. etc. Although I think we have a gutted shell of a reform plan, it is still better than the status quo.

Here is my reply:

I am a big fan of the book “The Healing of America” by T.R. Reid. He looks at health care delivery and payment in several “civilized” countries, including countries like Switzerland that made their transition when we failed during the Clinton era.

It is grossly apparent to anyone who looks, apolitically, at health outcomes, disparities and access that the United States has one of if not the worst health care systems in the industrialized world.

I think we could easily switch over to a single payment system by simply expanding Medicare to pay for all, and then use the best elements from all of the health care systems that already work much better than ours. It’s not like there isn’t ample good examples around. Japan’s cost control and ample access to excellent practitioners and treatments (more visits to physicians per year than the US and best in all outcomes, with a fraction of our cost, and universal coverage), Canada’s self referral system, France’s electronic records card and billing (which would save billions in overhead in offices and hospitals) – for the doctors and business owners, not just the government and patients!), England’s subsidized medical education (in fact, most countries have this), and even Germany’s use of existing private insurance companies to organize the care.

What I don’t like is the knee jerk, angry reaction we have to this kind of reform in our country. In Canada, in Japan, in the UK, this isn’t a left/ right issue. It’s a matter of human rights, and it’s hard to find a politician of any stripe who wants to switch to the US system. In fact, it’s a common insult in the UK in parliament to say that another politician would rather have the US health care chaos, and it’s used by both sides.

As a future practitioner, I would hate to have to turn down a pregnant patient like I was turned down as having a “pre-existing condition” when I was pregnant. Fundamentally, I can’t see why anyone in the health care industry would support the status quo.

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Reply turned post, Dr. Amy’s “egregious” post on KevinMD style

KevinMD invited Dr. Amy to write a post about offering VBAC, simply entitled “VBAC should not be a woman’s right”. Keep in mind on both my blog and on Academic Ob/Gyn, she has agreed the evidence supports offering VBAC. But, on this post, she mocks people who support offering VBAC, using no evidence or data, but links to blog posts and, of all things, an ad on the site of a medical malpractice firm.

The reply:

Why don’t you link to scientific evidence instead of blogs and websites of malpractice lawyers? Using inflammatory words like “bizarre” and pretending women don’t have the right to be active decision makers in their medical care is doing nothing to improve communication between physicians and their patients.

Here is the evidence report of the NIH conference on VBACs. VBAC activists are not a small group of blog writers. This is a mainstream medical cause.

Also, the pattern of obstetricians not offering VBAC has a lot more to do with the wording of a specific ACOG position statement and less to do with real medicolegal pressures. I am in Miami, which has one of if not the highest cesarean rates in the country, one of the lowest if not the lowest VBAC rates in the country, some of the worst malpractice rates and payouts in obstetrics, some of the highest malpractice insurance premiums, and really revolutionary tort reform, in that obstetricians can and mostly do “go bare”, which means that they don’t carry malpractice insurance, and effectively limit awards $250,000.

So, the only thing these docs have in common with obs throughout the country is the rocketing trend to refuse VBAC since the ACOG position statement change in 1999. They have their tort reform. They have their low VBAC rates. Their malpractice premiums haven’t gone down. Their malpractice awards and frequency of being sued hasn’t gone down. Our maternal mortality is horrendous. I can provide citations for any of that, by the way. ACOG does a yearly survey on malpractice, and they print numbers for Florida every year.

Here are two scholarly articles one and two that indicate that refusing VBAC isn’t the key to malpractice. It’s proper documentation (including during VBAC, yes I have read the first article, so don’t try to misrepresent what it says about VBAC) and evidence based standards of care. And, the AHRQ statement out of the NIH conference is the most recent, comprehensive evidence review on VBAC.

There is already good literature on risk and decision making during pregnancy if you want to talk about the rights of the pregnant patient. It reads: “These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” The section on VBAC is enlightening, and calls your type of scare tactics unethical. Do you have a similarly well documented discussion published in an equally reputable journal written by practicing obstetricians that takes your point of view, that women don’t have the right to refuse elective repeat cesarean, when the most recent evidence review calls it perfectly reasonable?

I think we all know you don’t, because I have been linking to the Lyerly et al article for about a year now, and you have yet to come up with anything other than your own writing to support your point of view. Why don’t you use well established bioethical principles, and quote ACOG committee opinions on balancing the rights of women to refuse surgeries? Because they support the fundamental bioethical principles of non-malfeasance, beneficence, and autonomy of the patient. I don’t remember seeing CYA listed as a bioethical principle on weighing the rights of patients.

Calling people who are consistent with ACOG bioethics teams and the NIH “irrelevant”, “bizarre”, “Inane”, “egregious” and and “committed to resentment” is, well, bizarre, egregious, inane and committed to resentment. And, it completely ignores the basic fact that a repeat cesarean IS a procedure, and a trial of labor is the REFUSAL of a procedure. That basic inarguable “semantic” fact is the center of why women DO have the right to refuse an elective repeat cesarean. Using inflammatory insulting words doesn’t make your reasoning right NOR ethical, and when discussing rights, that is what is key.

The NIH report concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Why don’t you work with activists AND the medical establishment to get the ACOG position statement on this, and the presentation of risks, both TO obstetricians about malpractice and TO patients about all risks in pregnancy and delivery in line with evidence and bioethics?

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Commenting policy: I am committed to keeping my comment sections civil. If I criticize Dr. Amy for using verbally abusive, inflammatory tactics, I cannot ethically abide by people using the same in my comments. I am also not interested in people insulting people living with mental health diagnoses by using “crazy” or “forgot to take her meds” as insults for anyone, including me and Dr. Amy.

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Race, pregnancy and birth, link round up and reply turned post

There has been a lot of comprehensive, thoughtful discussion of race and its intersection with reproduction on the intertubes recently.

Do Black Women’s Reproductive Rights Matter? by Renee at Womanist Musings

Race and the Rights of Childbearing Women by Jill at the Unnecesarean

Women of Color and the Anti-Choice Focus on Eugenics by Pamela Merritt (aka Angry Black Bitch) at RH Reality Check

The Facts About Abortion Rates Among Women of Color by Susan Cohen on RH Reality Check

I wrote a reply on the last post, which I will reproduce here:

When I wrote about this on my own blog recently, a commenter mentioned the recently released movie Maafa 21, which was funded by an anti-choice group out of Texas not known for its civil rights history.

I hope this conversation continues, and the dominant voices aren’t the ones that use the horrible history of blacks in America and eugenics to try to deprive them of reproductive freedoms today. I was searching for a womanist, feminist and racially sensitive review (preferably by a woman of color) of the movie, but was only able to find copied and pasted press releases about how “well argued” it is. I don’t think it’s irrefutable at all, nor do I think laws banning or restricting legal and safe abortion help women of color. Rather, they would be the ones disproportionally getting unsafe abortions. I can only assume most people, including pro-choice and / or womanist women of color, don’t want to sit through the film in order to discuss it. I do think watching it is important, but considering all the important work I agree with that I don’t have time to watch, this film is low on my list. And, it doesn’t use my history to argue against my rights, (just the history of some of my ancestors’ enslavement and oppression of blacks) since I am white, so I can only guess that it wouldn’t be as difficult to watch for me as it would be for a woman of color.

That’s the problem when race and racism intersects with other social issues. And it does. With all of them. The fact that racism shows an effect in abortion rates doesn’t condemn abortion, it condemns racism. Racism is present in heart attack treatment in emergency rooms, but that doesn’t condemn treatment of heart attacks. It affects birth, mode of delivery, place of delivery, complication (morbidity) rates for the mom and the baby including preterm delivery, mortality rates, etc. That doesn’t condemn obstetrics in general, but it indicates that racism is pervasive, and is one of the many issues within obstetrics (and emergency care, and reproductive care) that needs to be examined and improved upon.

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