Personhood bill in Florida

The radical anti-choice lobby has brought a so-called “Personhood” Bill to Florida. This would try to extend human rights to conceptus “at the beginning of biological development”.

If the physiology of pregnancy (like, there is no biological test for conception, and the vast majority of fertilized eggs do not implant, and no major medical organization defines that as the beginning of life) and the major ethical concerns with this don’t already sway you to sign this petition against the Personhood amendment in Florida, maybe this will:

Call to action on breastfeeding

The HHS has a call to action on breastfeeding that is currently open for comments. (h/t to Our Bodies, Our Blog.)

I commented on Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care, and Paid Maternity Leave so far, but could easily comment on all of the topics. I hope they get lots of good feedback. Please comment!

My conscience clause comment

My comment to the Department of Health regarding the proposed rescission of the Bush era conscience rule. For information on making your own comment, please visit Rachel at Women’s Health News.

This comment is in regards to the rescission proposal.
I am a medical student, a future ob/gyn, a mother, and a concerned citizen. I think there was no current need for the new conscience clause ruling. The former HHS secretary, Mike Leavitt, purposefully mischaracterized the state of licensing for ob/gyns in order to forward a political ideology. The American Board of Obstetrics and Gynecology publicly demanded that the HHS show even one case of discrimination against a practitioner who exercised his or her right to refuse to participate in an abortion, and Secretary Leavitt was unable to produce even a single example.

The Obama administration states that it is committed to changing the unfortunate recent history of overlooking science and truth in order to advance political ideology in health policy. In fact, most of these decisions have been based on opinions that only represent a minority ideological belief of the citizenry. The rescission of this ruling is imperative to reestablish faith in our national health policy.

The current conscience legislation is already too overreaching. I am concerned that requiring health care entities to pre-certify that they do not discriminate in hiring, specific to conscience refusal, will hamper the ability of certain organizations to fulfill their mission statements. For example, in my high risk area, South Florida, the Department of Health has family planning clinics established and funded for the sole purpose of providing birth control to the underserved. With the climate encouraged by this recent legislation, it is entirely plausible that these facilities would be forced to hire employees that are opposed to birth control.

In fact, some sections of the rule do not refer to abortion at all, and could be construed to apply to any practice that a potential employee finds unethical. Birth control is not abortion according to medical definitions of pregnancy and the methods of action of birth control, but many extremists see forms of birth control as abortion, and the law caters to such a worldview. How long until observant Christian Scientists are applying for jobs at surgery centers with the intent of obstructing surgical procedures? It seems like this rule is likely to increase costly lawsuits. It also seems like health care entities will be almost forced to hire employees that will expressly NOT fulfill their job duties in order to avoid such lawsuits. Where is the pressing need to increase such lawsuits? In actuality, there is a pressing need for more abortion providers and more contraception access, not less. There is a pressing need to reduce health costs, not increase them. There is a need to increase common ground, not accentuate difference and encourage uncooperation when there is already more than adequate provisions protecting conscientious objection in health care.

Don’t cave, Obama!!

I was disappointed to hear on NPR this morning, on Shakesville, and in my email inbox from the National Family Planning and Reproductive Health Association (NFPRHA), that Obama has caved to Republican pressure and has personally called Henry Waxman to remove provisions from the bailout that would increase funding for birth control for low income women.

First of all, there is no argument that this would increase jobs, both at clinics and at pharmacies. Secondly, it would DECREASE ABORTIONS. 40% of unplanned pregnancies end in elective terminations. Low income women are MUCH more likely to get pregnant and to choose abortion than higher income women. Third, it would decrease unplanned pregnancies that are carried to term by women who are on public insurance and other social welfare services. More pregnant low income means more government on WIC, welfare and Medicaid. A lot of that is state money. States are really strapped right now.

I cannot believe Obama is caving on this issue. Women’s reproductive issues have already been the red headed stepchild of this administration, when they buried ending the Gag Rule in some effort to make it seem less controversial. We need to stop letting the minority define this position. Also, I don’t believe for one second that taking that provision out will increase Republican support for the bailout. I think it’s pretty clear that the main Republican strategy for rejuvenating its base after this last catastrophe of an election is to oppose the bailout. Throwing poor women’s uteri under the bus is not going to change that one bit.

If anyone wants to take action, check out the action alert at the NFPRHA site.

Health Care Community Discussion

I participated in a Health Care Community Discussion at a local freestanding birth center last night. I volunteered to be the note taker and put it together. Here is what I just turned in:

Background research:
Declerq, E , Norsigian, J. Troubling data on infant deaths. Boston Globe, Nov. 11, 2008. http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/11/17/troubling_data_on_infant_deaths/. Accessed online Dec. 30, 2008.

“Advocates of health reform who focus exclusively on access presume that the United States provides effective but expensive healthcare, and that the only real problem is lack of access to this care. The reality is more complex when we examine those mortality figures… [T]he United States ranks last in infant mortality, third to last in perinatal mortality (deaths in the first seven days and fetal deaths), and last in maternal mortality… While the US infant mortality rate improved marginally – 3 percent – since 2000, the 15 comparison countries, which already had much better rates, improved by 21 percent in the same period. Put in concrete terms – if the US infant mortality rate merely equaled the current average rate of the other 15 industrialized countries, there would be more than 11,000 fewer infant deaths every year in the United States.

The biggest recent shift in maternity care has been a 50 percent rise in the cesarean rate since 1996 to 31.1 percent (third highest among the 16 countries) in 2006. This is testimony to the US belief that more medical intervention, regardless of cost, is better – even when the evidence doesn’t support such a claim. A blind acceptance of medical interventions is a systems problem that won’t be solved by expanding health insurance coverage.

The first step in improving outcomes is recognizing that our problems go beyond access to care. Our poor showing can’t be shrugged off as a function of some subgroup – the uninsured, minorities, immigrants (some generic “them”) having health problems that undermine otherwise solid outcomes. This is not just about who gets care, but about how they’re cared for. Expanding access to a system that doesn’t work won’t change these embarrassing rankings.”

Block, J. Midwives Deliver. Los Angeles Times, Dec. 24, 2008. http://www.latimes.com/news/opinion/la-oe-block24-2008dec24,0,2046506.story. Accessed online Dec. 30, 2008.

Not only is childbirth the most common reason for a hospital stay — more than 4 million American women give birth each year — it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation’s maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison… The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices… The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better… The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Washington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%.

Introductory discussion: This discussion group will be primarily focusing on maternal and pediatric health. Not only is that the vocations, areas of expertise and interest of our participants, but it is a critical area of importance and area in which a great impact can be made in outcomes and in costs.

Informed choice, informed consent is key. Patients cannot make true informed choices without adequate, non biased information and access to all of their options in care. This includes alternative birthing options, such as freestanding birth centers, and the ability to refuse or delay treatment, such as vaccines in children with autoimmune disorders.

Practitioners at the meeting have seen midwifery care integrated into hospital systems seamlessly in other countries with better infant and maternal mortality and morbidity rates than the United States: Ireland is an example. One pediatrician at the meeting trained for a year in Ireland and saw the majority of low risk births delivered by midwives with excellent outcomes. (Ireland ranked lowest in the world in maternal mortality rates, 1 in 100,000 live births, while the United States had 11 in 100,000, WHO Maternal Mortality in 2005, http://www.who.int/whosis/mme_2005.pdf, Accessed Dec. 30, 2008)

Simply improving access isn’t enough. Leading a horse to water isn’t enough if it’s bad water. Practitioners are not practicing evidence based medicine. Standard of care is not based on evidence based medicine. Malpractice suit outcomes and testimony are not based on evidence medicine. This is leading to expensive interventions, worse outcomes for mothers and their children, and tension between different types of practitioners.

There are also problems in the current system – practitioners are not getting paid. Midwife centers are not getting paid, ERs are not getting paid, and major hospitals are closing their doors. With all of the money we are spending, people are not getting good care, and practitioners are not getting reimbursed. The birth center sponsoring the meeting estimates that they are not reimbursed for 25% of their health services delivered, and Florida law is more progressive than some states in supporting coverage of midwives by insurance, including Medicaid.

Questions:
1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?
• Not every state has legalized midwifery or legalized homebirth. We need consistent access and consistent licensing. This should apply to nurse midwives and lay (certified professional midwives) midwives. Midwives should have access to medicines and licensing and insurance to cover treatment of minor complications of low-risk, normal births within the scope of their training.
• Women are not informed about their health choices, such as choosing an alternate practitioner or location for birth. For example, at one Ob/gyn practice, a member of the group observed a pamphlet entitled “Birthing options” included only cesarean section or vaginal birth, with or without an epidural, at a hospital.
• There is a serious problem with the definition of standard of care. If practitioners in the local geographical area do not support midwives, do not support low intervention birth, do not support evidence based practices such as birth in freestanding birth centers, allowing trial of labor for attempted vaginal deliver after cesarean delivery (VBAC), intermittent fetal monitoring, food and drinking during labor, continuous labor support, avoidance of episiotomy, freedom of movement in labor and delivery, etc, then these practices can be vulnerable to malpractice cases and ostracization in the local medical community, including a lack of reimbursement and hospital privileges. This hostile environment discourages practices that save money, provide patient choice and satisfaction, and save lives of mothers and children. The cesarean rate in South Florida is rapidly approaching an astonishing 50%, and that should not be an appropriate standard of care for ob/gyns to defend in malpractice cases.
• In pediatrics, locally there is a lack of continuity of care. Pediatricians are not following contemporary recommendations by professional health organizations. This is especially a problem with nutrition and breastfeeding.
• There is a problem with overtreatment and overmedicalization in pediatrics, also. The pediatrician and the midwives have noticed a tendency for many practitioners to lumbar puncture every child that presents with a minor fever. Doctors are prescribing medicines, such as albuterol, that they know don’t work. Doctors need to keep up with continuing education and evidence based recommendations for practice.
• Is there anything that holds pediatricians to evidence based standard of care? If the American Academy of Pediatrics recommends one practice as a standard of care, but the doctors in the community are making other recommendations contrary to the recommendations, what recourse do consumers have? Even the most educated consumers have problems discerning good medical information on the internet, and many practitioners are not open to patients who advocate for their own care, especially if their information is contrary to the advice of the practitioner. One midwife in the meeting described being “fired” by her children’s pediatricians for bringing in information supporting extended breastfeeding. In regards to informed consent, the only recourse right now for consumers to inform themselves.
• One member of the group suggested public service messages that advertise phone numbers and websites that give out individualized health advice and that complete, unbiased health options (access to other practitioners, like midwives should be available from these sites.)
• Start educating children in health classes in school, or sex ed, making people aware of their options for out of hospital birth.
• Career days are a good option for alternative practitioners like midwives at all levels of education, starting in elementary school.
• Insurance companies should talk about midwives and out of hospital birth as options.
• Maternity care should always be covered by all insurance plans. One member of the group had an experience in which she was insured, but wanted to add maternity coverage. The insurance company refused to allow her to add maternity coverage unless she took a series of negative pregnancy tests. Pregnancy should never be a preexisting condition, especially if a woman has received no prenatal care yet. Early and consistent prenatal care is so important; no one should have to forego prenatal care based on insurance bureaucracy.

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

• People usually get references from educated consumers or references from friends in the field.
• Most people in the room go to who is covered by insurance, but there is little information from the companies about the nature of the practice.
• Interviewing the practitioner is important.
• Check how the office staff responds to you.
• People would have improved options with universal single payer coverage.
• Doctors who make home visits would be nice.
• See answers to question #1 regarding public health information websites and phone lines, and standards of care based on evidence based medicine, not local practitioners.

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?

• Yes, many people have had problems paying bills.
• Single payer universal program would solve this problem.
• No one should go bankrupt to pay hospital bills. No one should choose between medicine and food. No one should choose between her current children’s day care and prenatal visits.
• Insurance companies and employers have saving accounts to pay health bills. We could pay taxes to make these savings accounts.
• Health care costs could be decreased by preventative programs (fitness, nutrition).

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

• Some people don’t have employers to cover them. This system fails small business owners and the self employed.
• Public system preferred by all. People can buy supplemental insurance or pay for elective procedures if they wish.
• Single payer universal plan preferred by all.

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

• Employers and individuals pay way too much for inadequate health plans.
• Employers can pay taxes and stop having to pay for the insurance and stop having to pay salaries to human resource personnel who handle negotiating complicated insurance plans.
• They can play a role in preventative care and dispersing information. They can provide time for exercise, provide healthy food, sponsor groups like Weight Watchers.
• Small businesses struggle with being able to provide special perks and extra flexibility. It would be better if they had more support, tax breaks, and financial incentives.

6. Have you gotten the prevention you should have?

• Birth control is essential to preventative medicine. Women spend 5 years trying to get pregnant, and about 25 trying not to. 98% of women in the United States use birth control at some point in their lives, and about 50% of pregnancies are unplanned. About half of these unplanned births end in abortion.
• All insurance should provide birth control. All pharmacies should provide birth control and emergency contraception. All hospitals should offer emergency contraception.
• As for preventative care of all kinds, don’t just note how many people didn’t receive it, note how many weren’t offered the preventative care. But, allow people to decline. People need informed consent.
• Some people don’t notice people not knowing about flu shots and mammography. We live in a dense, urban area, however.
• Universal dental care, especially for children.
• Universal mammography and new technologies such as MRI for breast cancer screening should be supported.
• Optometry and hearing care for children should be provided through schools, including hearing aids and glasses. If children get screened, there should be follow through and access to care and devices.
• Parents need to know how to work the system. People should not have to work so hard to access care.
• Longer maternity leave!!!!
• More sick days.
• Women sit in clinics for 7 hours to get a 15 minute prenatal visit at a public clinic. They avoid prenatal care and have higher complication rates. This is why women show up in labor without adequate prenatal care.
• High schools should have good information and access to adequate sex education, access to birth control, access to prenatal care and access to daycare and health services for children of teenage mothers.

7. How could public policy promote healthier lifestyles?

• We need to retrain health care professionals. They are too centered on drugs and overmedicalization.
• Mandating PE and recess programs need to be enforced in schools. More indoor facilities for PE.
• Treat healthy patients like healthy patients. Don’t overmedicalize patients in labor.
• Accountability! For practitioners to practice evidence based medicine.
• Good food and nutrition in schools.
• Public schools with gardens. Public gardens in cities.
• Access to healthy food in all neighborhoods and areas.
• Less environmental pollution and pesticide use, more local growing of foods.
More funding of alternative medicine, more promotion of these alternative methods. Expand federal funding of alternative and complementary medicine, and cooperate with other countries to learn from their successful integra

Dr. Vaginsky

I found out that some men have gotten together and created a supportive ally-type production called the MENding Monologues as an adjunct to the Vagina Monologues. Finally, I have something to say when the next oh-so-original shmoe asks me why there are no Penis Monologues. Well, other than making some inappropriate insinuation that he is referring to his own mastabatory habits.

Here is a fantastic monologue from the production. (Well, I am not crazy about the accent but I’ll get over it). Enjoy!

Please vote against the fringe

Aol News and U.S.News and World Report both have polls up regarding the proposed HHS rule that defines a fertilized egg as a human being, mistakenly equates some forms of birth control as abortion, and supports health care practitioners who want to work in a field in which they can refuse birth control to people.

(What’s wrong with radiology, right wing docs and nurses? Oncology? WWJD? Wouldn’t He choose infectious disease? What about the lepers? Get out of family practice and ob/gyn if you don’t support birth control, a health care decision that 98% of women will choose at least once in their reproductive years.)

Anyway, I know they are just unscientific polls, but those are both large media conglomerates. The numbers are overwhelmingly supportive of a women’s right to choose birth control and discouraging this ridiculous definition. I hope the results are used throughout the AOL and USN&WR universe.

(Hat tip, RH Reality Check)

Angry enough to write?

Feel free to write to Secretary Leavitt about the proposed rule defining a fertilized egg as a human being, pregnancy starting from contraception, and attempting to guarantee front line health care jobs to people who agree.

Beautiful, indeed

Fortuitous is one of my favorite words. Not only is it fun to say, but it is inherently such a good thing when something fortuitous happens.

I am the president of the student interest group for obstetrics and gynecology this year (SAOG). (Eep!) And, I am vice president of our chapter of the American Medical Women’s Association (AMWA) and Medical Students for Choice(MS4C).

Notice a pattern here?

I decided to change our charity group this year for SAOG. We raised money for the Komen foundation last year. I definitely think breast cancer research is a good cause. However, breast cancer is not normally diagnosed or treated by ob/gyns. It is diagnosed by radiologists and pathologists and treated by oncologists.

So, I wanted to switch to a charity for repairing obstetric fistulas. One of the physicians who came to speak to us, a gynecological oncologist, travels to repair fistulas once a year. I just ran it by my exec board, and then Rachel posted about the movie “A Walk to Beautiful”. I already have one board member say that she didn’t think it was a compelling enough charity. (She and I don’t see eye to eye on very much – her favorite SAOG lecture from her first year was someone discussing labiaplasty and other plastic surgery on the vagina). I think showing the video during a lunch meeting will be a good idea.