After signing off yesterday, I had some lunch then promptly attended three educational sessions in a row, two of which I paged. The first was entitled Cervical Ripening: What We Know and Why A Paradigm Shift is Needed for Reducing the Incidence of Preterm Birth, which focused on how our preterm labor treatments (tocolytics) are very utero-centric and concerned only with stopping contractions, while cervical ripening is often a much predictor for preterm labor. There is a lot of new research in this area, and new therapies aimed at counteracting cervical ripening might be more effective in stopping preterm labor than simply stopping contractions (which may, but often does not stop cervical ripening in any way). The speaker was very knowledgeable on her topic, which was her area of research and interest, but aside from presenting her own research, which is microscopic tissue analysis of the cervix under ultrasound to assess for markers of tissue disruption and increased water retention (precursors to ripening), there was not much which was immediately applicable to take away from her lecture. You get the sense, however, that in another 5-10 years, there will actually be drugs and assessment tools and treatments available to combat this aspect of preterm labor, which is very exciting.
The next educational session I went to was on sexual dysfunction, presented by a doctor who has spent years heading up a sex clinic in downtown Chicago and mentoring other medical and nursing students in sex therapy. While she had many, many (often sad, often hilarious) fascinating stories to relate, she really didn’t get into the nuts and bolts of sexual dysfunction in any great detail, at least not in any way that is immediately clinically applicable in terms of helping, counselling and treating couples with dyspareunia, anorgasmia, vaginismus, unconsummated mariages and premature ejaculation (although apparently you can use SSRIs, which notoriously have libido-killing side effects, to help delay and slow down men who have rapid ejaculation problems). Still, it was overall a fascinating topic, and really made me realize how little I know about sex therapy and sex counselling, which is indeed something a midwife should be pretty well versed in. While I certainly feel comfortable asking women about their sex lives, and discussing all aspects of sex and a person’s sexuality, specific treatments and counselling techniques are not at all in my repertoire, which is something that can be fixed with a little bit of reading and education.
The third educational session I attended was Menopause: Case Studies of Hormone Therapy, which was fabulous. I was astounded by how well the researchers knew the material. They made the very valid point that even though the Estrogen/Progesterone arm of the Women’s Health Initiative (WHI) was ended in 2002 due to the alarming increase in the rate of breast cancer, the other arms of the trial continued, and information is still pouring in from all sides, as well as from other studies that are now in progress. One of the speakers (Mary Brucker, CNM) termed it “research sushi”: after a large randomized control trial such as the WHI, you’re often left with more questions than answers, and in the ensuing years different aspects of the larger study are often chopped up (like sushi) into more specific questions and newer, smaller studies are mounted to try to tackle all of the questions raised. With hormone replacement therapy (HRT) at the moment, we’re apparently very much in the research sushi phase. It’s still a very grey, very unclear and ambiguous area, with very few clear guidelines or answers. While the WHI did a great job of scaring people so much that HRT is now often avoided at all costs (even when it can be very beneficial on a short-term basis for symptomatic relief of menopause), some of the information gleaned from WHI is actually, surprisingly saying the opposite. While the combined estrogen/progesterone arm increased the risk of breast cancer, apparently the estrogen alone arm of the study actually had no increased risk in breast cancer among the women treated with estrogen , and and a nearly significant decrease in risk (28% in the estrogne-alone arm, v. 34% in the placebo arm), which raises the question of whether all hormones are bad, across the board, period, end of story, or whether some hormonal therapy might actually have a very valid place in symptomatic relief (it also raised the question of what to do about women receiving unoposed estrogen without progesterone to balance it out, which has been shown to increase the risk of endometrial cancer). As you can see, very confusing stuff. They also delved into alternative treatments, such as the use of soy and phytoestrogens, Tibolone (which is used in Europe and actually had a worse Relative Risk for developing breast cancer than the combined and estrogen alone arms of the WHI), and compounded, bio-identical hormones, which also might not be the be-all-end-all cure that they are often touted as. Really, really fascinating stuff. I wish I was better versed in all of this, too, but I still find menopause and HRT very confusing.
Today started bright and early after a fairly late night dinner with a few other student midwives from Florida and North Carolina, mostly spent comparing our program experiences, mutually stressing about the board exams, and reviewing test questions that one of the students had from the test prep workshop she’d attended earlier that day. This morning I attended a great lecture on the Social Marketing of Breastfeeding, and how commercial marketing techniques can be very effectively used to market breastfeeding, especially when you break it down in terms of product, pricing, placement and promotion. She had all kinds of examples of ads from formula companies, which we then deconstructed in the class to root out the hidden, and often very sneaky and damaging hidden messages in them. Again, realizing how important language is: using the word “breastmilk repleacement” instead of “formula”, which makes it sound like a far inferior version of breastmilk, rather than a special, carefully planned, secret recipe which is just as good as breastmilk. We also talked about the importance of not only talking about the benefits of breastfeeding, but the risks involved with not breastfeeding. Again, none of this was new to me, but it was a very well put together and very concise presentation, full of good tips and suggestions, and it has really inspired me to work harder on my breastfeeding promotion and education (”selling” this amazing product—breastmilk!).
The schedule got a bit messed up, there are a few announcements on room changes and cancellations and switching of times, so the lecture on hormonal contraception counselling which I really wanted to attend, I missed. Instead, I ended up in a fascinating discussion panel on the horrific health disparities which still exist in our country, and the ways that midwives can work harder to amend these. We watched a small section of an upcoming PBS special entitled “Unnatural Causes: Is Inequality Making us Sick?”, which will air this winter in a 7 part series, and was incredibly eye-opening and terrifying in many of its implications. For example, the clip we watched demonstrated again and again that the areas of a county or city or state which have the lowest socioeconomic standing (which goes hand in hand with the highest crime rates) also have the highest rates of heart disease, pre-term birth, infant mortality, death by diabetes, hospitalization for asthma, lowest environmental standards, highest pollution and toxin exposure…the list went on and on. From the PBS website on the series:
Former U.S. Surgeon General Dr. David Satcher and his colleagues calculated that in 2002, 83,570 African Americans died who would not have died if black-white differences in health did not exist, a rate of 229 “excess deaths” per day. That’s the equivalent of one Boeing 767 being shot out of the sky and killing everyone on board every day, 365 days a year. And they are all Black. According to a by-now landmark study by Dr. Colin McCord and Dr. Harold Freeman, African American males in Harlem are less likely to reach age 65 than men in Bangladesh.
There are by now thousands of studies tracing the pathways by which racial and socio-economic status affect health. But there is virtually no popular media—no print, TV, nor web—that translate this research into forms that can build public understanding of how social policies are de facto health measures. As a result, the ‘common-sense’ wisdom remains that the poor and peoples of color get sick because they have unlucky genes, or they are just too lazy and undisciplined to to eat right, exercise and abstain frm drugs and booze. Similarly, it’s still widely believed that top executives who are dropping dead from heart and artery disease when in truth it’s their subordinates.
After watching the clip, we then moved into a very fascinating, (and very encouraging!) roundtable discussion. Midwives have always traditionally worked with underserved, indigenous populations, and it was amazing to hear about some of the changes and work that is being done around the country right now. You could feel the energy building in the room as people continued to come to the mircophone to speak. By the time the sesssion ended, the conversation had barely gotten started. Because the session is going to be repeated tomorrow, it was suggested that rather than starting over, we simply pick up the conversation again where we left off, which may or may not happen depending on how many people from today’s lecture attend the session tomorrow. In any case, though, I would watch the PBS documentary when it comes out, because it is going to raise A LOT of questions, and cause a media-world storm to descend on this long ignored issue.
Which now brings me to the present moment. Time to find some lunch, and then sit in on an afternoon session review of the 2006 STD Guidelines (because, while I’m here, might as well attend lectures which will be useful on our board exam). Tonight is the opening ceremony and dinner, followed by the long-awaited opening of the Exhibit Hall. I can feel my money disappearing already. Can’t wait! Much more to come!
