Belly Tales

Let’s face it: the economy sucks right now.  We haven’t yet hit rock bottom, and it’s going to be awhile (probably a long while) before things begin to recover.  In the midst of this harsh financial reality, companies and industries are scrambling to find ways to save money.  Birth activists have been trying for decades to convince this country of the benefits of midwifery based on its safety and track record of better outcomes, not to mention improved client satisfaction, but hey, this is America—the only thing people really pay attention to in this country is the bottom line.  So maybe midwifery has finally found the argument it needs to affect actual change.  In the midst of one of the worst recessions since the Great Depression, NOW is the time to increase access to midwifery care because it’s excellent care for a heck of a lot less than what we’re currently spending on maternity care.

In early December, shortly after the nomination of Tom Daschle as Secretary of Health and Human Services (HHS), the Big Push for Midwives launched a campaign to get Mr. Daschle to attend a community meeting on midwifery and its advantages.  Per the change.gov initiative, discussions on healthcare reform will be occurring around the country between 12/15 - 12/31, and Senator Daschle has promised to attend a few of them in person.  Thanks to the Big Push for Midwives, he was invited to several heartland discussions, including this one in Lees Summit, MO.  I haven’t been able to find any updates or reports from this meeting yet.  I’m not sure if Senator Daschle was able to attend, but it’s definitley the sort of discussion he (and the Obama administration) should be listening to. (Was anyone actually able to attend that meeting?  If so, give us an update, please!!  I’ve been searching the internet for reports on the meeting, but I haven’t found any yet.)

As this excellent recent article in the LA Times (Midwives Deliver by Jennifer Block) points out, midwives deliver much safer care for much lower cost:

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. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.The Obama administration could save the country billions by overhauling the American way of birth.

It seems like instead of encouraging midwifery care, the opposite is happening.  Birth Centers around the country are closing at a rapid pace, and Medicaid has recently started to resfuse to fund birth center care:

Over the past few years, CMS (the federal agency that runs Medicaid/Medicare) has begun disallowing federal matching funds for state Medicaid payments for freestanding birth centers services. Birth centers have been recognized by CMS (and earlier, by HCFA) as a Medicaid provider type in State Medicaid Plans since 1987. Recently, however, CMS has disallowed such payment by several state Medicaid Agencies, including Alaska, South Carolina, Texas, and Washington State, claiming that it lacks clear statutory authority and direction to do so. CMS has directed its regional offices to stop federal payments to any state for birth center services.

As this article points out, this is going to cause a huge squeeze on birth centers around the country, and we’ll soon be seeing even more of them close unless something is done.  This is an urgent call to action.  The AACB has several resources on their website listing ways to contact your senators and let them know about this issue, including using this lovely flyer which lists all of the important talking points you’ll need when composing your e-mail or making your phone call (calls are preferrable, apparently, since e-mail is more likely to be lost in the midst of all the e-mails on the federal bail-out).  The reason this is so important is that Medicaid generally sets the standard for insurers.  If Medicaid stops insuring birth center care, other insurance companies will follow suit.  Birth centers are a crucial link in many communities, providing quality health care to diverse populations (including women on Medicaid - you only have to look at the work of Ruth Lubic and the Morris Heights birth center to appreciate that), and we need to keep as many of them open as possible.  Not only does it make great health sense, but it saves money too.

And here’s another great cost-saving suggestion: stop insuring preterm elective cesareans.  When I read this article I just about choked.  I can’t believe insurance companies are willing to pay for this when research has consistently shown that there are still a lot of complications with “near-term” infants (babies born between 34 - 36 wks) such as respiratory distress, jaundice, temperature instability (hypothermia), delayed brain development and feeding difficulties.  Forget the fact that a cesarean delivery is several thousands of dollars more expensive than a vaginal delivery; the real damage in this practice is caused by the increased number of preterm babies and the burden of care they demand.  Prematurity and NICU care accounts for one of the largest chunks of healthcare expenditure.  Even the March of Dimes is calling for a decrease in preterm cesareans.

I’ve always been consistently amazed that HMOs, managed care systems and Medicaid haven’t latched onto midwifery with more enthusiasm.  I wonder sometimes if this is because ACOG and the AMA are able to counteract the economic practicality of midwifery care with a tons of lobby money.  The economic angle isn’t anything new.  The Business of Being Born said the same thing in 2007, and Michel Odent, Ina May, Naomi Wolf, Suzanne Arms, Robbie Davis-Floyd etc. etc. have been saying the same thing for decades.  Maybe in the midst of the recession, the message will finally get through: midwifery care is better AND cheaper.

This is a site I found through Women’s Health News, but I felt it really deserved a post all its own.  A midwifery student decided to take a picture of her cervix every day for one entire menstrual cycle, and the pictures are absolutely amazing.  I want to print them out and show them to all of my clients who are trying to conceive as a way of illustrating what fertile cervical mucus looks like, and when they should be having sex!  She has entitled the website My Beautiful Cervix, and I can’t think of a more appropriate name.  I really need to get a mirror in my exam room and start to show women their cervix during our exams.  Women really need to see their cervix to understand.  There’s something so powerful and so positive and affirming about seeing this amazing, hidden, little secret thing inside of you that you never get a chance to see, and yet is always humming along, doing her thing.  It’s truly eye-opening.  I will never, ever forget the very first time I saw my own cervix.  In fact, I am somewhat tempted to take pictures of my own cervix for a month, and join her project.  Anyway, massive kudos to her courage and ingenuity in getting these pictures online.  Hopefully she won’t be forced to move the website again, due to heavy traffic and complaints about “inappropriate images”.  It’s only a cervix, after all.  Just think of how much more peaceful our world would be if the defining symbol underlying our culture was a cervix instead of a phallus.

This is an interesting story about how difficult it was for a woman to obtain Plan B from Walgreen’s, over on the Consumerist.  Apparently the folks at her local Walgreen’s in Oxford, MS, tried to insist that she wait for one hour before getting the Plan B, as well as giving her literature on adoption, as well as just giving her a hard time and writing down her drivers’ license number.  I’m curious: has anyone else had difficulty in obtaining Plan B?  It seems like there’s a lot of confusion about it, especially in terms of the fact that it’s actually BIRTH CONTROL and not an abortion.

One week after our historic election of Barack Obama as the 44th president of the United States, here’s a very interesting article on what his presidency might mean for Women’s Health (of the non-”airquotes” variety), namely improved access to birth control and sex education (i.e. the federal government no longer funding abstinence-only programs), a reversal of the “conscience” legislation which is now allowing doctors, nurses and pharmacists to legally refuse to perform any service they morally object to, including prescribing birth control, and stopping the global gag-rule which prohibits federally-funded health clinics in foreign countries from performing abortions or even referring women to other facilities that will. It’s all good stuff, and worth checking out (with a nod to Women’s Health News who found the article in the first place).

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

As reported by the Daily Kos, a rigorous new poll shows that Measure 11, South Dakota’s latest attempt to ban abortion, might not pass as easily as everyone originally thought.  South Dakota’s initial attempt to ban abortion in 2006 was defeated by 56% to 44%, mainly because the bill included no exceptions for victims of rape and incest, or provisions for the mother’s health.  Now, in 2008, these exceptions have been inserted into the wording of the referendum, but as the Daily Kos points out, these provisions are largely superficial, and offer no real practical exceptions.  The general idea was that as soon as this wording was inserted, the South Dakota abortion ban would pass by a landslide, but thanks to a hard, uphill battle waged mainly by the South Dakota Campaign for Healthy Families, the latest polls show that Measure 11 might be shot down again, just like its 2006 counterpart.  According to the poll, if the vote were today, 44% would vote No, and 42% would vote Yes.  Which is really exciting, encouraging news, although the race is too close for comfort.

Even so, none of this changes the fact that women trying to access reproductive health care in South Dakota face a really tough challenge.  There is only one clinic in South Dakota which performs abortions, and they are done by a rotating staff of doctors who are flown in from neighboring states.  And again, as the Daily Kos has pointed out, the hoops that women in SD have to jump through before actually having the procedure done are incredibly daunting:

The woman must receive state-mandated “counseling.”

The woman must wait at least 24 hours after the state-mandated “counseling” before procedure may be provided.

If the patient is a minor, a parent or guardian of the patient must be notified.

The doctor must offer the woman an opportunity to view a sonogram, and must then record any responses in her permanent medical records.

The doctor must deliver a government-dictated script to women designed to intimidate her and discourage her decision. The mandatory language includes statements of fact which are contrary to all available medical research.

Usually by the time a woman is sitting across from me (a midwife) for her initial prenatal visit, she’s already made up her mind to keep her baby.  But every now and then I come across a woman who’s still conflicted, and we usually have a frank and very difficult discussion about whether she really wants this pregnancy or not, and everything that keeping this pregnancy entails.  This is a hard decision to make in a hospital like mine, sitting across from a provider like me who is resoundingly pro-choice, and is not at all judgemental or discouraging of the woman’s thoughts or decision.  These women are often young, alone, and already scared and intimidated, but if they really don’t feel like they can keep this pregnancy (for whatever reason–and we do talk about the reasons, but only to make sure that she’s thought everything through), I gently refer them to the termination of pregnancy clinic, with compassion and support.  No one is judging them.  Judgement is the LAST thing you should find in your health care provider’s office.

Now, imagine this were South Dakota.  Imagine how much harder it would be to make such a decision if I were legally required to read these women a script containing statements which are medically false and which do nothing but make the woman feel even more intimidated and guilty about her decision.  If I were forced by state regulations to make it very clear that I think abortion is a terrible idea, it would take a very staunch woman indeed to be able to stand up to something like that (and this is not because I’m so terribly persuasive, but only because the power of the white coat is astounding: people automatically trust you a little bit more and believe you’re speaking the truth, just because you’ve got a white coat on.  If you tell them that they need to eat more iron-rich foods because they’re anemic, they generally listen to you.  If you tell them that what they’re doing is wrong, they listen to you too).  And then, to top it off, I’d have to offer these women a sonogram, just so they can see that heart beating some more, and feel even more like a monster for doing what they feel they have to do.  The cruelty of it makes my skin crawl.

In any case, the reproductive rights of the women of South Dakota hang in the balance (and by proxy, the women of the rest of this country too, because if this referendum passes in South Dakota, it’s just opening the door for every other state).  And do not be fooled: the inclusion of exceptions into the wording of the bill in no way changes the fact that this referendum will basically make all abortions in South Dakota illegal, because there is absolutely no practical way to carry out these exceptions, and no doctor willing to test it.  So, what can we do about it?  We can donate money to the South Dakota Campaign for Healthy Families, and we can…(to put a rather neo-conservative spin on it)…pray.

Chlamydia is the sexually transmitted infection du jour in our clinic. On a daily basis I probably encounter at least one, often 2, and sometimes 3-4 women per day who have it. For the majority of the women I see, learning that they have an STI is often like a wake-up call. They usually get treated, then their partner gets treated, and then, to their credit, they often remain STI free for the rest of their pregnancy. Many of them choose to break-up with the partner that infected them, or stop sleeping with him/her altogether, or else become religious in their condom use. However, sometimes it’s not that easy. In one woman whom I’ve been taking care of since I started my new job (i.e. over 5 months now) she’s had chlamydia 3 times. In other words, she’s been reinfected twice after being treated, probably because her partner has 1) never been treated or 2) keeps getting reinfected himself. In another case, a woman has been treated twice for chlamydia now because her husband has multiple wives, and obviously we still haven’t gotten all of them treated yet. I spend much of my day talking myself hoarse about safe sex, strict condom use and the importance of getting partners treated. And then the CDC releases studies which show that nearly half of all adolescent African American girls have had at least one STI, compared to only 20% of all white and Mexican-American teenagers (keep in mind that the predominant populations in our clinic are African American and Hispanic). It makes me want to cry. We get fifteen minutes alloted to us on our templates to take care of an OB or gynecology revisit. That’s fifteen minutes to conduct an entire interval history, address any questions or concerns, follow-up on lab results and order upcoming tests, do the physical exam (listen to the fetal heart tones, Leopold’s, measure the fundal height etc.), and then write a note on it. Fifteen minutes is barely enough time to tell a woman she has chlamydia, what the treatment is, how important it is that she get treated and then not reinfect herself, how crucial it is that her partner is also treated, and how essential condom use with future partners is. It’s like the tip of the ice berg when really these women need so much more than just counselling on safer sex and strict condom use. They need to learn how to assert their power—how to put their foot down with a partner that may potentially be cheating on them, how to say emphatically “no condom, no koochie” and not buckle in to seduction or pressuring, how to choose and insist on respectful partners. It’s like staring at a huge, roaring wildfire, and your only weapon against it is a tiny fire extinguisher. So what do we do? Keep trying to extinguish the chlamydia, one case at a time, and keep talking ourselves hoarse about safe sex.

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

I got a phone call last night from a good friend from college, who has just recently been diagnosed with an ovarian cyst, and had been told by her doctor not to worry too much about it and was prescribed birth-control pills to help manage the symptoms. She wanted a second opinion, and I told her what I knew about ovarian cysts (i.e. that they’re very common, usually benign, usually do not affect fertility, and usually spontaneously resolve in a few months without incident), but I did promise that I’d do some more research on the subject for her. So here you go: more than you probably ever wanted to know about ovarian cysts!

An ovarian cyst is a fluid-filled sac that forms on the ovary. The majority of ovarian cysts are benign, and are classified as either functional or organic. We’ll start with functional cysts, because they are simpler and easier to understand.

Functional cysts are fluid-filled sacs which most often form during a normal menstrual cycle—either during the follicular phase or the luteal phase. Follicular cysts are more common and are often undiagnosed because they are usually asymptomatic. During the follicular phase of the menstrual cycle, the follicle ripens while the egg matures and becomes a small, fluid-filled sac in the process. During normal ovulation, when the egg is released the sac breaks open, the fluid is released along with the egg, and the remnants of the sac are eventually re-absorbed. If for some reason the egg is not released (i.e. there is no ovulation), the ripened follicle can remain as a cyst, and may continue to grow through the next menstrual cycle. Follicular cysts can occassionally grow quite large, and the risk of torsion or rupture increases the larger the cyst becomes. However, the majority of follicular cysts usually spontaneously disappear within one to three months.

Luteal ovarian cysts, or corpus luteum cysts, occur during the second half of the menstrual cycle, after ovulation has occurred. Once the follicle has ruptured and the egg has been released, the remaining follicle sac becomes the corpus luteum, which produces progesterone and maintains the endometrial lining of the uterus. If the egg is not fertilized and pregnancy does not occur, the corpus luteum normally disappears through a process called luteolysis, which occurs with the onset of menses. In some cases, though, the corpus luteum does not disappear, and instead seals off after ovulation, fills with fluid and forms a cyst. Luteal cysts are less common than follicular cysts and usually disappear on their own within a few weeks. However, they can sometimes grow up to four inches and may cause bleeding, torsion, or pain.

If a small blood vessel ruptures inside a functional cyst, the cyst fills with blood instead of clear fluid, and is then called a hemorrhagic cyst. However, like follicular and luteal cysts, hemorrhagic cysts rarely rupture, are often self-limiting, and will most likely spontaneously resolve on their own.

Organic cysts are the second type of ovarian cyst, and are much less common than functional cysts. They’re referred to as complex cycts because of how they appear on ultrasound, and may contain blood, serous or solid material inside them. The type of cyst that forms depends on the type of ovarian tissue the cyst arises from. “Mucinous or serous cysts arise from mucinous or secretory ovarian glandular cells and can become very large, though they usually grow slowly.” (Schuiling & Likis, 2006). Another type of organic cyst known as a dermoid cyst arises from ovarian germ cells. Because germ cells have the capability of forming any material in the body, dermoid cysts sometimes contain unusual substances such as hair cells, skin cells, bone cells, tooth enamel or other body material. Dermoid cysts tend to grow rapidly and can become very large. They are rarely malignant, however, because they don’t spontaneously regress and there is some (albeit small) chance of malignancy, dermoid cysts are most often surgically removed . Another kind of organic cyst is known as a cystadenoma, which forms in the stromal tissue on the outside of the ovary, and can also grow quite large and cause a fair amount of pain.

Ovarian cysts can also be caused by other illnesses. Endometrial tissue begins to grow outside the uterus in women with endometriosis, and can sometimes attach itself to the ovary, forming an endometrioma, which is a solid cyst. Women with polycystic ovarian syndrome (PCOS) form multiple functional cysts within their ovaries from repetitive anovulatory cycles, and are often infertile. While neither of these kinds of cysts are malignant, managing these types of cysts requires dealing with the underlying etiology—either endometriosis or PCOS—and these cysts usually do not resolve on their own without assistance.

Because ovarian cysts are usually asymptomatic, many women have them without realizing that they do, and they often resolve on their own without the woman even being aware. Otherwise, the woman may experience pressure or fullness in the abdomen, pain during intercourse, persistent low-back ache, urinary frequency, chronic pelvic pain or pain during menstruation. Ovarian cysts are sometimes detected during a routine pelvic exam if a large mass or fullness is felt around the ovaries. However, diagnosis is most often made by ultrasound (either abdominal or transvaginal ultrasound), and management depends in part on the size of the cyst.

For most functional cysts, nothing needs to be done. Simple cysts don’t require therapy unless they’re larger than 8 cms, rupture or lead to ovarian torsion. The “watch and wait” approach is most often used, since these cysts usually spontaneously resolve on their own. If there is minor pain associated with the cyst, medication like Motrin or Tylenol is usually enough to manage the pain while waiting for the cyst to disappear. Follow-up ultrasounds at 1-3 months after diagnoses are sometimes performed, but aren’t mandatory unless the symptoms persist or worsen. If the cyst is between 5-8 cm, repeat visits to your doctor or midwife may be needed to follow the growth of the cyst. Surgery may be required to drain and remove larger cysts (anything greater than 8 cm), and is usually done either through laparoscopy or laparotomy. Other tests, such as a blood test to check for CA-125, a tumor marker which can indicate malignant growth, may also be performed for larger cysts just to rule out cancer. Oral contraceptive pills can be prescribed to help reduce the likelihood of repeat cyst formation, and may be especially helpful in women who keep having ovarian cysts. Since ovulation and the ripening of a follicle are often the causes of functional cyst formation, birth control prevents this from happening by preventing ovulation.

Organic cysts are generally more complex and usually require medical treatment. An MRI or cat-scan may be used in addition to ultrasound in order to diagnose the exact type of cyst (dermoid, cystadenoma, endomerioma etc.) The tumor marker CA-125 will most likely be checked to rule out cancer, and larger cysts greater than 8 cm will most likely be removed via surgery.

Warning signs for the rupture of an ovarian cyst include nausea and vomiting, fever, sudden, severe abdominal pain, fainting, dizziness, weakness or rapid breathing. In the case of very large cysts, rupture can be quite dangerous, so emergency care should be sought immediately if any of the warning signs appear. Otherwise, as in the case of my friend, who has some type of functional cyst by the sound of it, I’d agree with her doctor’s assessment that she shouldn’t worry too much about it. The cysts will probably go away on their own, and using oral contraceptives will make the likelihood of future cyst formation very, very slim.

References and further resources:

Shuiling & Likis (2006) Chapter 22: Benign Gynecologic Conditions. Women’s Gynecologic Health, pp. 584-587, Boston, MA: Jones and Bartlett.

Varney, H. et. al. (2004) Chapter 14: Common Diagnoses in Women’s Gynecological Health. Varney’s Midwifery: Fourth Edition, p. 406, Boston, MA: Jones and Bartlett.

Women’s Health.gov: Ovarian Cysts

Emedicine: Ovarian Cysts

So, I’m back in the blogosphere again, and realizing that I’ve been missing a lot of important news by taking a vacation for a few months. Here’s a quick overview of some of the stories I’ve found most pressing (and/or impressive) lately, even though some of these stories are old news by blog standards, and many other people have already done a much better job at covering them than I have.

First, Verizon Wireless, the cellphone megagiant, has gotten itself into a heap of trouble by initially refusing to allow NARAL Pro-Choice America to host a text messaging service on its network. Verizon initially claimedthat company policy allows it to refuse “highly controversial” and potentially “unsavory” messages from being distributed on its network. NARAL quickly shot back with an action alert and Verizon was flooded with thousands of e-mails and text messages from angry subscribers, and several anti-censorship groups also joined the fray. Quickly realizing it had made a huge mistake (especially when it discovered that other cellphone networks like Sprint and AT&T had approved the NARAL text messaging service without a whiff of protest), Verizon reversed its position, allowing the NARAL text service to go forward, and issued a statement in the press, but NARAL is still hounding Verizon to put its new public policy in writing. Interstingly, since the issue dealt with text messaging and shortcodes, the story was picked up not only by pro-choice and anti-censorship news carriers and blogs, but by sites like Ars Technica and Slashdot.

Sticking to the technology theme, the website Facebook recently started banning pictures of women breastfeeding from user accounts, and in some instances has banned specific users altogether (for example, Karen Speed from Australia, who has chronicled the entire event on her blog, One Small Step for Breastfeeding). Facebook banned certain pictures on account of their “obscene content” and asserted its right to remove pictures as a violation of its terms of use policy, but as the Sydney Morning Herald points out, it’s not exactly clear what constitues an “exposed breast”, which is the specific violation, and Facebook hasn’t provided any further. clarification. Right. So, breastfeeding is obscene, and women aren’t allowed to post their own pictures of themselves breastfeeding on their own facebook accounts. If this bothers you as much as it bothered me, go join the new facebook group entitled Hey, Facebook, breastfeeding is not obscene!

In other news, a 43 year old Russian woman has recently given birth to a 17 lb. baby, her 12th baby to date. Wow!!

Finally, this is a quick reminder to local folks that the 5th annual Miles for Midwives will be occurring this weekend, Oct. 6th, at Prospect Park. The 5K run/walk helps to raise awareness for midwifery, as well as raise money for the ACNM local NYC chapter, and Friends of the Birth Center. My beloved boy and I will both be there, of course, running and sweating in the sunshine. Race time is 10:00 am, rain or shine. If you’re interested in joining the race, you can register at Active.com.

Finally, the long-awaited SUNY Downstate Gala will be occurring this coming weekend, celebrating 75 years of continuous midwifery education. SUNY Downstate is actually the oldest and longest running midwifery program in the country, and is commerorating the event by a day-long educational symposium featuring speakers such as well-known author Barbara Katz Rothman and keynote speaker Joyce Thompson, CNM, followed by a dinner-dance. Sounds amazing! Go Downstate!

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!