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What’s new in contraceptive technology?

19 Jun

Lots of great new contraceptive options are coming your way soon if you’re in the United States.  You may have already heard about Skyla, but do you know about Twirla and Cyclofem?  Read on and learn.

Skyla

Skyla (or the levonorgestrel 14 mcg IUD, or LNG-14) recently was approved by the FDA and has received a fair amount of attention.  It is now available from some providers and may be an excellent choice for some women.  The LNG-14 has three claims to fame: its smaller size (and, as a result, smaller inserter), its lower dose of progesterone, and its official approval for use by women who have never been pregnant.

First off, the smaller size: in the grand scheme of things, we’re talking about only a very tiny difference (the IUD itself is 1.1 by 1.2 inches, compared with Mirena’s 1.3 by 1.3 inches, while the inserter is 0.04 inches smaller than Mirena’s; see this great article for more details).  However, that very small difference may in fact make insertion of the device less painful for some women, particularly women who have never been pregnant and may be more likely to have a tighter cervix.  Since the data have yet to be published, I can’t tell you for sure if insertion is indeed less uncomfortable than insertion of other IUDs; however, preliminary presentations of the data (such as here) have indicated that, for women who have never been pregnant, those who underwent insertion of Skyla had less discomfort than those who were assigned to Mirena. 

Skyla releases less progesterone than the Mirena (without losing any of its contraceptive efficacy) which for some women is a good thing, but for others might not be.  One of the features of Mirena that is most appreciated by some users is that almost everyone experiences lighter periods over time, and many women no longer have periods at all.  For some women, that’s fabulous, while others would rather keep seeing their period.  Women using Skyla will mostly have lighter periods, but fewer of them will have no period (though some will, and there is no way to know ahead of time what any individual’s reaction will be).  Although Mirena exposes users to a very low systemic dose of progesterone (a dose low enough that most don’t notice it), for women who are extremely sensitive to artificial hormones it can still be too much.  If you’re in this category but there are reasons why a progesterone-releasing IUD is a good option for you (such as heavy periods), Skyla may be an excellent option.

Finally, on Skyla’s approval for women who have never been pregnant.  This is great news, but really, it’s not news; women who have never been pregnant can safely use any IUD, regardless of what is on the packaging.  We’ve known this for years, and doctors use products and medicines off-label all the time.  There’s nothing wrong with off-label use as long as there is good evidence to show that your practice is safe.  Fortunately, we have decades of data that prove that women who have never been pregnant can safely use any kind of IUD they want.  So the labeling for women who’ve never been pregnant may be generating a lot of buzz, but it’s nothing new.  However, if there are pesky insurance companies out there that won’t pay for IUDs for women who’ve never been pregnant because the label says it’s not OK, this might help push them along, so it can’t be bad.

There’s a lot to love about Skyla.  The smaller size might make it easier and more comfortable to insert for some women, and the lower hormone dose might be beneficial in some cases.  Unfortunately, Skyla only lasts for 3 years (as opposed to 5 for Mirena and 12 or more for the copper-IUD).  For some women who don’t like the idea of something lasting a long time this may a good thing, but for many having to get a new one placed after 3 years could be a drag, as it means another doctor’s visit and potentially more costs.

Twirla

Twirla (also known as AG 200-15) is a new contraceptive patch that uses a combination of progesterone and estrogen, similar to Ortho-Evra.  This method is not yet FDA approved but will likely be approved in the next year.  Twirla has a few claims to fame: its lower estrogen dose and its novel adhesive.  As for the lower estrogen dose, as only a few papers have been published on Twirla thus far, I don’t know for sure if the lower estrogen dose in this patch compared with Ortho-Evra leads to fewer side effects, but it is quite likely it does, and we know that this patch is just as effective as Ortho-Evra.  

So if you’re very sensitive to hormones and want to use a patch, Twirla may turn out to be a great option, especially if the side effects you experience on birth control are related to estrogen (such as nausea, bloating, or headaches) and you have reasons to want to continue using an estrogen-containing method, such as maintaining regular periods or to improve acne.  The novel adhesive may be good news for loyal patch fans who are annoyed by the little bits of adhesive residue that sometimes seep out next to where the patch is applied, or for women who want to use the patch but are among the minority of women for whom it just won’t stay on for the whole week.

Cyclofem

Cyclofem (also known as depot medroxyprogesterone acetate 15 mg/estradiol cypionate 5 mg) is not actually a new contraceptive; rather, it’s a method that’s been around for a while and has never really taken off, either in the US or abroad.  Cyclofem is an injectable contraceptive that was briefly marketed in the US as Lunelle about a decade ago, but has not been available recently.  It is used in some other countries around the world.  It has a lower dose of the progesterone that is used in Depo-Provera, the three-monthly injectable, and unlike Depo-provera also has estrogen.  Cyclofem’s claims to fame: the only combined hormonal injectable method available; convenience of once-monthly dosing.

Although Depo-Provera, or DMPA, is not one of the most popular methods in the U.S., it has loyal followers.  Some of the pros of DMPA are that injections are required only every three months, with a very forgiving window period allowing you to get your shot a few weeks early (in case you’re heading off for vacation) or a few weeks late (up to 15 weeks since the prior injection – considering the busy lives many of us lead, the more likely scenario), and that most women stop having periods within 6 to 12 months of starting the method.  DMPA only includes progesterone; for women who want an injectable that also has an estrogen, Cyclofem could be useful.  Women using Cyclofem generally continue to have regular periods, but the big drawback is that injections have to occur every month.  There are some situations where Cyclofem could be extremely useful; for instance, someone who wants to use a combined hormonal method but can’t swallow pills or someone who requires absolute privacy regarding her use of contraceptives.

Unlike the other new methods I’ve described, it’s hard for me to believe this method will take off in the US context outside of some specialized settings, as the majority of women who can’t take pills will probably be well-served with either a contraceptive patch or ring, and women who need to use an “invisible” method will in most cases do very well with an IUD or a contraceptive implant.  Monthly visits to the doctor for injections are just not practical for most women in a US context.  Despite my pessimism, I do hope that Cyclofem finds its niche; more choices are always better, and there will always be women who find that a given method works very well for them.

What about plans for the next five and ten years?  There are lots of great products in the works, from a much lower-cost generic version of the Mirena IUD being developed by Medicines360 (this could really be a game changer for women in many low-income countries; not only is the levonorgestrel IUD a great contraceptive method, but it also is a first-line treatment for many other gynecological conditions that are currently treated with surgery in settings where it is unavailable) to a contraceptive vaginal ring that can be used for a whole year.  A new female condom that may be easier to use and more comfortable is also in the works.

Acknowledgments: This post was inspired by a great webinar from the Association of Reproductive Health Professionals.

International reproductive Rights, May 24 edition: China, El Salvador, and Contraceptive Progress

24 May

China’s “one child policy” in the spotlight

China enacted its so-called “one child policy” over 30 years ago.  Facing a population boom, the government decreed that no couple could have more than one child (with a few exceptions) and strictly enforced this policy with prohibitive fines and, for those who were pregnant and could not pay, forced abortions.  Although in some cases these forced abortions have been documented and received international attention, it seems likely that every year millions of women in China are forced to undergo abortions they do not want or need.

Just as in most of the world, however, the policy is unequally applied, and exposes deeper injustices.  A recent op-ed in the New York Times highlighted the case of Zhang Yimou, a well-known film director who has 7 children (with 4 women).  According to the article:

The truth is: for the rich, the law is a paper tiger, easily circumvented by paying a “social compensation fee” — a fine of 3 to 10 times a household’s annual income, set by each province’s family planning bureau, or by traveling to Hong Kong, Singapore or even America to give birth.  For the poor, however, the policy is a flesh-and-blood tiger with claws and fangs.

Just as the option to choose when, whether, and how to have children in the United States is increasingly dictated by a family’s ability to pay for contraceptive and abortion services, Chinese women’s opportunities to have the number of children they want is dictated by their ability to pay a fine or travel for the privilege to give birth.  Either way, the end result is the same: reproductive injustice.

Beatriz continues to suffer due to “absolute” abortion ban in El Salvador

Beatriz is the pseudonym of a young woman who has been in a hospital in El Salvador for weeks.  She needs an abortion.  Those of you who are fans of the “Gang” know we don’t believe in exceptionalism; we think when a person says they need an abortion, for whatever reason, they need an abortion.  Unfortunately, most of the world does not agree with us and insists on defining which reasons for abortion are legitimate as a means of restricting access.

Even by the standards of exceptionalism Beatriz seems a likely candidate for access to an altogether too difficult commodity: a safe, legal abortion.  Beatriz has lupus, a disease that can worsen during pregnancy and puts her at increased risk of potentially lethal pregnancy-related complications compared with women who do not have lupus.  She also is suffering from kidney failure, a complication of her lupus that may be aggravated by her pregnancy.  Finally, the fetus she is carrying is anencephalic; it is missing parts of its brain and if it survives birth is unlikely to live more than a few hours.

Unfortunately for Beatriz, she lives in one of the most restrictive countries in the world when it comes to abortion.  While in almost all countries in the world the threat to her life would guarantee her right to an abortion to save her, El Salvador has no exceptions to its abortion ban, and no explicit exception to the ban to save a woman’s life.  Beatriz’s doctors have appealed to the country’s supreme court on her behalf, but it has deliberated for weeks without issuing a ruling.  Meanwhile, Beatriz is suffering.  Click here to sign a petition to the Salvadoran government asking them to uphold their obligation to protect her human rights and her life.

Uneven progress on improving access to contraceptives

A recent study that compared contraceptive use in low- and middle-income countries between 2003 and 2012 found a sharp increase in the number of women wanting to use family planning methods, from 716 million to 867 million.  There was a modest increase in the percentage of women who did not want to be pregnant who were using modern contraceptive methods, but population growth overpowered this effect.  While some progress has been made in some regions, mid and western African countries saw no increase in contraceptive use over the decade.  Another article in the same journal called for sustained efforts to provide contraceptive services to all women and couples who wish to delay or limit future childbearing.

May 5 is International Day of the Midwife! Thank a midwife today

6 May

While some people celebrate May 5th with tequila and nachos, the International Coalition of Midwives wants to remind us that midwives save lives by designating it the International Day of the Midwife. Although what they can do varies significantly by country, midwives provide comprehensive sexual and reproductive health care, including contraception, preventive care like pap smears, prenatal care, and normal deliveries, and also know when their patients require care from a physician. In North America and Western Europe, midwives are preferred over physicians by many women for their traditionally more holistic approach to pregnancy and childbirth. In low- and middle-income countries with severe health worker shortages, midwives are literally saving lives by providing maternal and newborn care, contraceptives, and safe abortion care.

When properly trained and supported, midwives can deliver babies, administer treatment for potentially deadly complications of pregnancy such as pre-eclampsia and post-partum hemorrhage, and provide newborn care. Although physicians will always be needed, much of their work can be shared with midwives. Most low- and middle-income countries need to double, triple, or quadruple their midwife workforce to fully meet their needs. Fortunately, midwives can be trained more rapidly than physicians and may be more likely to stay in rural and underserved areas than doctors. As countries develop, inequality between the rich and poor, and between urban and rural populations increases; training more midwives is a key strategy to ensure that women who are poor or live in rural areas are not left behind.

Countries that have focused on increasing the number of midwives and strengthening the quality of care they provide have seen dramatic decreases in maternal mortality. On this International Day of the Midwife, let’s not forget that reducing maternal mortality is not only about having a skilled birth attendant present at the time of birth; equally important are access to contraception for those who do not wish to be pregnant, and access to safe abortion care for those who are already pregnant and do not want to be. Midwives can insert IUDs and contraceptive implants and perform first trimester medical and surgical abortions as well as physicians and should be empowered to do so. Despite evidence that midwives can safely provide abortions, they are allowed to do so only in a minority of states in the US and countries worldwide. These restrictions are due to ideological objections in some cases, and due to lobbying from physicians in others. Neither objection is based in evidence.

Take a moment to thank your favorite midwife today, and as you advocate for increased access to reproductive health services, don’t forget how much midwives already contribute, and how much more they could contribute if politics weren’t in the way!

International news roundup: Updates on Brazil, Circumcision, and UN Commission on the Status of Women

25 Mar

Brazilian doctors’ group urges decriminalization of abortion

As in many countries in Latin America, abortion is extremely restricted in Brazil. Currently, women can only legally have an abortion if the pregnancy results from rape, if their lives are threatened by the pregnancy, or if the fetus has a brain anomaly. Despite these restrictions, abortion is widespread, with an estimated 1 million Brazilian women undergoing abortions yearly. As in many countries where abortion is restricted, women with money can still get safe abortion care, while poor women must resort to unsafe abortions. The end result is an estimated 200,000 women per year hospitalized due to complications of unsafe abortions, making unsafe abortion the third most common reason for obstetrical hospital admissions and one of the top causes of maternal mortality in the country.

A group representing Brazilian doctors, the Federal Council of Medicine, is now urging federal lawmakers to allow abortions on demand in the first 12 weeks of pregnancy. The group has noted the strong impact unsafe abortion has had on public health in Brazil and also pointed out that current abortion laws in the country “are inconsistent with humanitarian commitments” and act paradoxically against “social responsibility and international treaties signed by the Brazilian government.” The Council represents 400,000 physicians; let’s hope they get more attention than the National Conference of Brazilian Bishops, which has already registered its distaste for this development.

No surgeon needed with new circumcision device

What do circumcisions have to do with abortion? Not a whole lot. But you may or may not know that circumcision does have a lot to do with reproductive justice for men and women living in countries with high HIV prevalence. Male circumcision, when performed by a skilled provider, reduces a man’s risk of acquiring HIV from an HIV-positive woman by about 60%. Unfortunately, it doesn’t appear to work the other way; that is, circumcision of HIV-positive men does not protect their female partners. However, by protecting men from acquiring HIV, their partners are likewise protected. Because many women do not have control over condom use in their relationships, and because try as we might we are still nowhere near 100% condom use, offering voluntary circumcision to men is one of the most promising interventions available to decrease the spread of HIV.

Despite this, scale up of voluntary male circumcision has been slow. Although there are many reasons for this, the skilled health worker shortage in low-income countries is a major barrier to increased implementation of male circumcision. The New York Times reported this month on the PrePex device, an inexpensive tool that, after being left on for about one week, causes the foreskin to drop off. Best of all, applying it takes less time than surgery and no surgeon is needed; nurses and medical officers can learn to use the device quickly.

UN Commission on the Status of Women makes important strides

Although some activists feared that, as happened last year, no outcome document would be agreed upon after this year’s Commission due to attempts from conservative actors (such as the Holy See, Iran and Syria) to derail negotiations, in the end a document was produced (see a draft here).

In addition to reaffirming important previous international agreements made in Beijing and Cairo, the document condemns violence against women, calls upon states to protect women and girls from violence, promotes education for all as a human right, and recognizes the need for women to be fully integrated into economic and social life. It also states that women who have been raped have the right to emergency contraception and safe abortion where permitted by local laws.

I of course would have liked to see more about the right to contraception (which is a right for all women, not exclusively those who have been raped) and safe abortion regardless of context or local laws, but with conservative forces working for months behind the scenes to prevent any progress, I consider this a small step forward.

Savita Halappanavar, Ireland, and the false divisions in abortion laws

15 Nov

As most of you reading this probably already know, Savita Halappanavar, a young woman living in Ireland, died last month at a Galway hospital.  The details are not yet fully available, but it appears very likely that she would still be alive had she lived in a country with less restrictive abortion laws.  Savita apparently went into labor at 17 weeks of pregnancy (far too early for the fetus to survive on its own). According to her husband, she requested a termination, but was told that as Ireland was a Catholic country her request could be fulfilled only after fetal heart activity had stopped.  3 days later, the Savita finally got the abortion she requested; however, it was too late to prevent the fatal infection that developed while she was waiting.  She went into septic shock shortly thereafter and died a few days later.

Although I can only speculate, my best guess is that although Ms. Halappanavar’s treating physicians were aware that her condition was serious, they did not consider it life-threatening.  (Abortion is legal in Ireland according to its constitution when a woman’s life is at risk).  Although we doctors are often asked to determine a prognosis and to make pronouncements as to the likelihood that a disease will get worse or even become life-threatening, the fact is that we often lack the data to do so, and in the end it is a matter of opinion.  Highly-educated, highly-experienced opinion, but opinion nonetheless.  There are simply too many factors to take into account, and too few studies upon which to rely, to make any accurate predictions.  (As an example, I am sure all of you know somebody who was told he or she had 6 months to live and survived several years… or vice versa).

It is bad enough that doctors in Ireland are supposed to somehow determine whether a pregnancy is life-threatening or “only” health-threatening, a task which quite frankly is impossible.  To make matters worse, although they face criminal prosecution (and potentially lifetime imprisonment) if they perform a procedure that is not considered justified, no legal framework exists to help them determine in which situations they can legally perform an abortion.  How sick does a woman need to be for the situation to be considered life-threatening?  What conditions must be present?  What laboratory values must be exceeded?  There are no answers to these questions.

This problem is not new.  In fact, two years ago the European Court of Human Rights determined that Ireland had violated the rights of a woman (pseudonym “C”) who required an abortion on medical grounds for precisely this reason and cited “the lack of effective and accessible procedures to establish a right to an abortion” which “has resulted in a striking discordance between the theoretical right to a lawful abortion in Ireland on grounds of a relevant risk to a woman’s life and the reality of its practical implementation.” (Read more here in this excellent fact sheet from the Center for Reproductive Rights)

Unfortunately, even as the Court held that this woman’s rights had been violated, it found that the rights of two other applicants (pseudonyms “A” and “B”) who sought abortion on the grounds of their personal health and wellbeing were not violated. This judgment unfortunately solidifies a false division between types of abortions; those that are required for a woman’s life to be saved, and those that are required for her health to be maintained.  Whose health is most jeopardized by her pregnancy?

1) The woman with 4 children already in foster care, who suffered debilitating depression during each of her prior pregnancies, who might become suicidal in this pregnancy (applicant “A”); 2) the woman who could not afford to be pregnant or raise a child, who might not seek medical attention after complications from her abortion for fear of legal repercussions (applicant “B”); 3) the woman with cancer in remission, whose disease might get worse during pregnancy (applicant “C”); or 4) the woman who went into labor at 17 weeks (Savita Halappanavar)?

Anybody who claims they can answer this question objectively and precisely is fooling herself.  There is no way to objectively determine ahead of time which pregnancies are life-threatening and which pose a serious health threat.  Of course some are more likely to be problematic than others, but very dire-appearing situations often end up fine, and routine pregnancies can turn tragic in the blink of an eye.  In the end, the seemingly logical and ordered way countries go about restricting access to abortion (some allow abortion only to save a woman’s life, others to preserve her health, others for socioeconomic grounds, and still others without restriction as to reason)  no longer make sense, and the only reasonable thing to do is to leave the decision to the woman whose life is affected.

In response to the European Court of Human Rights’ judgment, the Irish government formed a committee  that was tasked to report back to the Committee of Ministers by the end of October of this year.  Clearly this was too late for Savita.  Let’s hope they have gotten some work done and it’s not too late for the next woman who needs an abortion in Ireland.

Over-the-counter abortion? Why not?

21 Sep

Access to abortion services is becoming more and more difficult around the country, and remains problematic worldwide. One potential way to improve access for the majority of women who need abortion services in the first 9 weeks of pregnancy would be to make the medications that induce abortion available over-the-counter at pharmacies nationwide.

Medical abortion (see below for a detailed definition, but for our purposes, an abortion that is completed at home, with just pills rather than a procedure in a clinic) is an extremely safe and effective way to end unintended pregnancies. The most effective regimen, a combination of misoprostol and mifepristone, works up to 98% of the time. In other words, 98% of women who take these two drugs correctly to induce an abortion at up to 9 weeks after their last menstrual period will expel their pregnancy completely, with no medical intervention whatsoever. So why not take the providers out of the equation?  It would certainly make abortion far more accessible and affordable for many women.

Additionally, such an approach might present a missed opportunity for providing contraceptive care. If women aren’t seeing a medical provider for their abortion, they may lose out on the opportunity to start a contraceptive method immediately after their abortion. In fact, offering contraceptive counseling and providing a method if desired is a key component of quality abortion care. It’s true that in a perfect world, women would be able to start their chosen contraceptive method immediately after their abortion in all cases (and in fact it would be much easier for many women to do so if more contraceptive methods were available over-the-counter as well!). However, it is never appropriate to make availability of one health service contingent on provision or acceptance of another. (Unfortunately, this is common practice; many medical providers still require patients to come in for their preventive care visits before they will renew prescriptions for contraceptives. Just because it’s common doesn’t make it right).

Finally, some may worry that women who are past the recommended 9 weeks since their last period will use the method even though the instructions say not to. First of all, as I mentioned above, many people do not follow the directions for the use of over-the-counter products. It doesn’t mean those products should not be available. Second, although misuse of over-the-counter products such as acetaminophen (Tylenol) are frequent causes of death and disability in the United States, there are no restrictions on their sale. Third, these medications are still safe to use after 9 weeks of pregnancy; however, their efficacy decreases. In other words, women who use the medications in these doses after 9 weeks of pregnancy are less likely to have a complete abortion, although much of the time the regimen will still work correctly. The worst case scenarios, therefore, are an incomplete abortion or an ongoing pregnancy if women do not use the product as recommended. Such situations would require medical attention, but if a good referral service is available women would be able to access appropriate follow-up care.

What would my dream over-the-counter abortion kit include?

1) Clear, easy-to-understand instructions and a 24-hour phone number to call with questions.  Information is key.  The instructions should help women determine if a medical abortion is the right choice for them, based on their gestational age and medical history, as well as provide information on where she can go if a medical abortion at home isn’t the best option for her.  Additionally, women need to have someone they can call at any time if they have questions before, during, or after the process.  The instructions should also point
women to websites and hotlines they can call for information and referrals for contraception after their abortion.

2) Mifepristone and misoprostol.  The mifepristone-misoprostol regimen is the most effective for inducing abortion.  If the method is going to be used by women on their own, it needs to be a method that is extremely reliable.

3)  Several doses of ibuprofen.  The most difficult part of a medical abortion for some women is the cramping; pain control is a key component of abortion care.

4) A low-sensitivity urine pregnancy test.  Women could take this test themselves at home 2 weeks after their abortion.  Although medical abortion is extremely effective, and most women are able to determine from their symptoms alone that their abortion is complete, this test will catch the very rare cases of continuing pregnancy.

Although this may seem to be a radical proposition, the fact is that we have the evidence to support that it would be safe and effective. I would like to see research that it is, additionally, acceptable to women, but it’s hard to believe women wouldn’t be happy about having more choices and more control.  What do you think?

———————————–

Medical abortion: Medical methods of abortion, or medical abortion, is defined by the World Health Organization as follows: The “use of pharmacological drugs to terminate pregnancy. Sometimes the terms “non-surgical abortion” or “medication abortion” are also used.” Medical abortion in the United States is most commonly performed using a combination of mifepristone and misoprostol (this is the recommended protocol as it is the most effective), although sometimes methotrexate is used in combination with misoprostol. In countries where mifepristone and/or methotrexate are not available, misoprostol alone can be used, although it is less effective, that is, less likely to end in a complete abortion.

Low sensitivity urine pregnancy tests: Similar to regular urine pregnancy tests, except they only are positive at higher pregnancy hormone levels. Although it can take several weeks for pregnancy hormone (ß-HCG) levels to become completely undetectable after an abortion, these tests will only turn positive if hormone levels are still high.

International reproductive rights roundup: August Edition

27 Aug

Court victory for victims of coercive sterilization in Namibia

Namibia’s highest court has ruled that the rights of three women were violated when they were sterilized without their consent while receiving care at public hospitals.   Sterilization without informed consent is only one of many violations of women’s rights that has been documented against women living with HIV in Namibia.  While this verdict occurred in Namibia, it may have profound implications for women around the word, as coercive sterilizations have been documented not only for women living with HIV in other countries but also among certain ethnic groups. Of note, many US women are still suffering from our country’s legacy of coerced sterilizations.

Review of the impact of US policy towards abortion on women victimized by rape as a weapon of war

In conflict-affected regions, rape is often used as a weapon of war.  This was true in Bosnia and Rwanda in the recent past, and is ongoing today in areas of the Democratic Republic of the Congo.  The Atlantic published a great review of how thousands of women in conflict-affected countries are being denied appropriate medical care after being raped during conflicts due to the US government applying conditions to aid money as stipulated in the Helms amendment (no exceptions to the rule against funding abortion services) as opposed to the Hyde amendment (exceptions granted for rape, incest, life endangerment).  Those of you who are fans of Abortion Gang know very well that we don’t agree with the “exceptions” mentality and believe that the reason doesn’t matter- but this is an interesting read nonetheless.

The Philippines ratifies the Domestic Workers Convention

Women and girls make up the vast majority of domestic workers worldwide, yet often have few or no rights.  Migrant workers are especially likely to be forced to work with no breaks, for little pay, or to even be confined forcibly.   The Philippine Senate ratified the treaty earlier this month, making the Philippines the second country (after Uruguay) to take an important step to guarantee rights to some of its most vulnerable workers.

How can we meet “unmet need”?

International family planning advocates often talk about the “unmet need for family planning.”  The way it’s calculated is complicated (if you’re interested, look here) but essentially it measures the percentage of women who are at risk of pregnancy (in other words, sexually active and not using a contraceptive method) who actually do not want to become pregnant in the next year. This group of women is considered a key population to target for family planning services because most of them probably will be happy to use contraceptives if they are available, affordable, and provided in an environment that offers respectful, high-quality care.  Over 200 million women worldwide are estimated to have an unmet need for contraception, and it will take a lot of work (not to mention money) to reach all of them. Stephen Goldstein at the K4Health blog does the math to show us which commitments would need to be kept in order to get contraceptives to everybody who has this “unmet need.”

Breastfeeding and choice in New York City

16 Aug

Lots of people have weighed in on “Latch on NYC,” the new New York City initiative to promote breastfeeding in hospital (for instance, here and here). While many breastfeeding advocates are thrilled, some are less so. They argue that the initiative has the potential to restrict choice and to judge women who choose either to supplement with formula or to not breastfeed at all, and is an attack on women’s right to choose.

However, I think the initiative, if implemented correctly and as documented on the NYC Department of Health Website (available here, with a more recently posted and helpful FAQ that clarifies some common misconceptions about the initiative). Here is why I think these changes are important, based on what I have seen as a doctor working in New York City hospitals. (Please keep in mind that examples I provide are based on my personal experiences; there is likely significant variation among hospitals in New York, and even more variation around the country.)

Why keep formula in a separate area so that women are required to ask for it if they need it?

The fact is that it is common practice to put dozens of bottles of formula on the baby’s bassinet regardless of what the mother’s intentions are for feeding. What’s worse, the hospitals strike deals with formula companies; in exchange for free advertising to a captive audience, the formula is free to the hospital. Hospitals that sign up to be part of this initiative can no longer stock bassinets with formula or accept free formula. Formula will be kept with other medical supplies.

For some perspective, in the hospitals I have worked in, while it’s easy to get formula, getting supplies to help moms who wanted to breastfeed can be next to impossible. Nursing pads, nipple shields, and other supplies that women may need are kept locked in a machine with the medications, and I actually am often unable to get those supplies when they are needed; for instance, women with inverted nipples often require nipple shields when they are first starting out with breastfeeding.

What about women with medical reasons preventing them from breastfeeding?

Many women cannot breastfeed due to their own medical conditions or medical conditions of their child, and according to the document they (and women who choose not to breastfeed for other reasons) are provided formula at no cost to them.

What about women who choose not to breastfeed for reasons that are not medical?

The documentation on the website clearly states that women should have full information about their choices, support if they choose to breastfeed, and should be given formula at no cost to them if they choose not to breastfeed. Additionally, staff are directed to refer women who choose to formula feed and cannot afford formula to the WIC program for after they leave the hospital. I will talk about this more below, but I completely recognize a woman’s right to choose not to breastfeed. Women have to do what’s best for them and their infants, and they clearly can be trusted to make this choice. However, it is crucial that they have access to information about breastfeeding and support for whichever choice they make.

Why will medical staff have to document every formula feeding and tell women about the benefits of breastfeeding?

Documentation is a very important part of medical care, to ensure that patients are getting high quality care and all the information to which they’re entitled. Nurses are supposed to document every formula feeding and the medical reason for it, and document that they informed women about the benefits of breastfeeding if there is no medical reason for formula feeding. Although this sounds excessive if you don’t have a medical background, documentation of everything is routine in the medical world. Nurses already document what the baby eats (breastfeeding or formula), and how much, and when, during every shift. This is standard medical care. The nurses also have to document if the mother wants to breastfeed or not. If she wants to breastfeed, nurses need to document if she needs help or not and if that help has been provided, and if not, when it will be. If the mother doesn’t want to breastfeed, the nurse has to document that she has been informed about the benefits of breastfeeding. It doesn’t say anywhere that this has to happen every time, so I imagine it only has to happen once. It really is important to ensure women are given full information, and the only way to be sure of that is to require that it be documented.

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An open letter to Melinda Gates

13 Jul

Dear Melinda,

I would like to start out by thanking you for hosting the London Summit on Family Planning.  This week, because of you, governments in some of the areas with the least investment in family planning have pledged to double, triple, even quadruple their family planning budgets.  Donor countries have pledged $2.6 billion to the global south.  A few years ago, this would have been unimaginable.

Your foundation has tackled, in a big way, the problems no other large foundations were funding: diarrheal illness, pneumonia, vaccines, and maternal mortality.  And now it has pledged over a half billion dollars for family planning services.  This can’t have been easy for you, as a self-described practicing Catholic, although you join many other practicing Catholics who are driven by a vision of social justice.

It’s clear you’re passionate about this, and it’s clear you understand how access to contraception can improve the lives of women and their families.  But I would like to invite you to dig deeper into this issue.  You have stated, “We’re not talking about abortion. We’re not talking about population control…What I’m talking about is giving women the power to save their lives, to save their children’s lives and to give their families the best possible future.” But you cannot truly give women the power to control their lives if you do not acknowledge the human rights aspect of family planning.

Although you (and many others) frequently use the terms “family planning” and “contraception” interchangeably, they are not, in fact, the same.  Contraception refers to methods to prevent pregnancy, and what you called a “Summit on Family Planning” was really a “Summit on Contraception”.  Family planning is much broader; it acknowledges that women have the right to plan their families.  Access to contraception is a key component, but so are access to abortion services, treatment for infertility, and pre-pregnancy care.  And population control policies and contraceptive coercion, which haunt our past and continue in the present, must be acknowledged and fought against.

So we must talk about abortion, and we must talk about population control.  Thank you for all you’ve done for the women of the world so far, and are planning to do in the future, and please continue to listen to women.  If you ask the right questions, they will tell you stories about family members who died from unsafe abortions, friends who were sterilized without their consent, and neighbors who were rejected for being unable to conceive children.  All you have to do is listen.

Lying about abortion: Accurate information without exception

16 May

As some of you know, lawmakers in Kansas have been attempting to pass an execrable anti-abortion bill that, among other things, would seriously interfere with the private relationship between a woman and her doctor.  The bill, which currently appears to be stalled in the Kansas Senate, would have allowed physicians to deliberately withhold information regarding a woman’s pregnancy if they thought such information might lead the woman to choose abortion.  In addition, it would have required abortion providers to tell their patients that abortion is linked to breast cancer, although that theory has been debunked by multiple scientists and organizations, including the National Cancer Institute.

As egregious as this is, it is not the topic of my post.  Instead, I would like to focus on an email I got from Planned Parenthood about the bill.  I truly appreciate the work Planned Parenthood does.  I contribute money to them (as well as to smaller reproductive rights organizations, including local abortion funds) and often call my legislators when prompted by their informative emails.  But this part of the email gave me pause:

“What would this law do? First, it will force doctors to lie to their patients. Despite a complete lack of evidence, state lawmakers will require doctors to tell women seeking to end a pregnancy that an abortion will increase their risk of breast cancer.

Even though this will create additional stress for women who are already making what is, for many, a difficult decision. Even if the woman seeking abortion is a victim of rape or incest, her doctor will lie to her about her risk of breast cancer on the orders of Kansas lawmakers.

Why does this upset me?  I and others on this blog, as well as on other blogs, have written recurrently about this concept of “exceptions” in abortion care, and how it ultimately works against us and against all women who need services.  The idea that giving misinformation to women who are survivors of rape or incest is somehow worse than giving misinformation to other people is ludicrous.  As a doctor, I will always do everything in my power to tell the truth to every single one of my patients.  It doesn’t matter if that person is a murderer, a saint, the CEO of a Fortune 500 company, or a high school student.  If I’m seeing someone who has chosen to have an abortion, I will provide the same factually correct information to everyone, regardless of how she became pregnant or why she wants and/or needs to terminate her pregnancy.

Our allies need to stop using language that reinforces the false dichotomy of “Good Abortions” and “Bad Abortions.”  By creating a separate “class” of women needing abortions (in this case, those who are victims of rape or incest; but women who have health problems or have non-viable pregnancies are often similarly singled out for “exceptional” status), Planned Parenthood is unintentionally validating a deeply-ingrained societal belief that some abortions are more justified, more necessary, even better than others.  The final effect is to strengthen the stigma and shame attached to abortion for all women.

The bottom line: there is never any medical reason to lie to a patient, regardless of her circumstances.  That message by itself is powerful and strong, no exceptions required.