health

Okay, I’ll admit it – ever the STD researcher, I was tempted to focus on the recent NYT article, “A Vaccine May Shield Boys Too.”* Instead, I dedicate this month’s column to a recent news item that has not attracted a lot of attention: the FDA issued an advisory warning against the use of mesh implants that are routinely used for surgical repairs of pelvic floor damage.  Warning: This post contains medically accurate language which some readers might find disturbing. (It also contains new medical findings that all readers should find disturbing!)

First, it’s important to know what the pelvic floor is and what functions it serves: in addition to this image from 1918’s Gray’s Anatomy, check out a newer medical illustration included in a recent LA Times article.  This muscular structure has the demanding job of supporting the uterus, bladder, urethra, the walls of the vaginal canal and rectum. In other words, it’s pretty darn important.  Without functional pelvic floor muscles, women can experience urinary incontinence, fecal incontinence, and uncomfortable/painful sexual intercourse.  (Not to mention, it’s more than a little disconcerting to have to manually push your prolapsed organs back into place.)

Surgical repairs of this type of damage are often done to correct prolapses of the uterus and surrounding organs which, to put it bluntly, can feel “as if something is falling out of your vagina.”  The problem is that the mesh devices used in many of these surgeries may be harming the sexual and reproductive health of many of the tens of thousands of women who have surgery each year for prolapse.

You might be wondering, how many women are at risk for pelvic organ prolapse?  Cigna say the top risk factors are full-term pregnancies (which stretch the pelvic floor), the strain of childbirth, and having a hysterectomy (surgical removal of the uterus).  On a recent episode of his TV show, Dr. Oz shared the estimate “almost 50% of women will experience some form or prolapse in their lifetime.”

Thousands of women opt for prolapse surgery every year, and many of these surgeries have involved the use of mesh implant devices to support torn/damaged pelvic floor tissue.  As noted in a July 14^th LA Times article, “The advisory was issued after an increase in reported complications involving the device.”  This article also describes complications as including “pain and urinary problems,” as well as, “erosion, when the skin breaks and the device protrudes, and contraction of the mesh that leads to vaginal shrinkage.”  Back in 2008, the FDA’s Public Health Notification and Additional Patient Information documents cited 1,000+ reports of these kinds of serious complications but considered them to be rare.  Fast forward to 2011 when these serious complications “have jumped fivefold,” no longer rare.

So, how does this impact a woman’s sex life?  The FDA notes, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse.”  And, male partners of these women are also at risk: “men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” 

With the FDA deciding to not remove the mesh implants from the market, did they do enough to protect patients?  Some experts say, “No.”  Dr. Diana Zuckerman of the National Research Center for Women & Families points out that these mesh implants have been used, “despite no clinical trials, no testing on humans to see if they’re actually safe and effective.”  It is time to advocate strongly for research and development of pelvic floor surgical repair techniques which do not involve the use of synthetic mesh implants.

__________

*This article sheds very little new light on a topic I wrote about over a year ago forMs. Magazine and blogged about back in 2009 – Gardasil is not simply the ‘cervical cancer’ vaccine its initial branding advertised; it also offers several potential health benefits for boys and men. 

It’s been a long while since a book kept me up at night — both because I compulsively had to finish reading it, and also because it invaded my dreams. Home/Birth, recently published by 1913 Press did both.

Co-written by two poets I much admire, Rachel Zucker and Arielle Greenberg, the book’s subtitle, A Poemic offers a first cue to the passion and conviction the authors infuse into this original, collage-like work. Interweaving their personal narratives about their home (and initial hospital) birth experiences, they also include the voices of home birth providers (midwives, doulas, supporters), as well as layer in statistics about the safety of home birth and the dangers of the hospital experience — both physical and emotional.  Quoting largely from Jennifer Block’s book Pushed, there is no attempt to portray a spectrum of opinions about birthing.  Their position is focused, their zeal is clear — staying at home is the best option for a woman to have an experience that is empowering to her, causes her to trust in her body, and to holistically bring her child into the world.

For Zucker, a trained doula, and Greenberg, (soon to leave her tenure-track job for a move to Maine and a possible transition to birth education work) clearly, this is a topic around which they feel a deep sense of mission, both in terms of changing the received notions about the safety of home birth, as well as doing political advocacy to overturn restrictions which have limited the scope of midwifery and “normalized” medical intervention.  Greenberg is explicit about how her first home birth (in Illinois) was actually illegal and the limitations this placed upon her care, as well as the demands caused by her sudden second home birth — fleeing the state to temporarily move to Maine so she could be attended legally by a midwife practice.

The medicalization of what is a natural process, (once left entirely in the hands of women, both literally and spiritually) has long been a topic of hot debate, as Block outlines here. Recent movements have (controversially) named “birth rape” as a phenomenon some women experience after acts of obstetric violence have been inflicted upon their bodies during childbirth.  Suffering PTSD after birth has also more recently been acknowledged as an aftereffect of a traumatic birth experience. Then there’s the recent news about how Disney has been barging into the delivery room, another way in which birth has been co-opted for corporate gain.

It’s impossible to not be moved by the testimonies offered in the book — women robbed of a sense of their body’s power, nevermind a profound moment with a new child.  Yet, I am certain many will approach this book with deeply entrenched resistance and even feel enraged by the staunchness of the authors’ position.  A refrain the two insert throughout the text is “What if something goes wrong?” no doubt a line each has been asked continuously.  I found myself wanting to hear this more directly answered, rather than just offered as a rhetorical question.  The stories relayed about home birth don’t all end happily, and the book concludes on a deeply poignant note that offers through example an answer to this question — yes, things can go wrong, but “holding the space” for a woman to meet her child within a sense of connected power is still worthwhile.

It is most difficult to critique Home/Birth as a poem. Collaborative writing doesn’t have a strong tradition within the U.S. and there were moments I wished for more clarity and shape around the narrative(s).  Attention to the line is found most strongly in the interstices between chapters — where the two take phrases previously included and collage them into more precise lines, as in this excerpt:

Never thought this would —

dreamed of —

be my story.

Every child. Changes. You

feel sane, like a witch with her silky moonlight or goddess.

Feel grateful like a feminist, like an activist, like a friend and

the truth is when you saw what you could do —

women watching over —

it changed everything and was safer and feminist

all the drawers and doors and windows

at once and the low noise we make

opening, opening.

I almost longed for Zucker and Greenberg to write a nonfiction book about their experiences rather than knitting the threads of so many others voices together.  Their use of the word “witch” is intriguing, but unclear — is this a straightforward reclamation or modern reconstitution of the word?  Likewise, this is clearly a political topic for both, one that affects a range of women’s health issues, yet I wished their desire to tie this to the feminist movement had been more explicit.  They intersperse T-shirt and bumper sticker slogans about home birth throughout to show both the popular embrace of this movement and counter attitudes to its resistance.  While the phrases are clever and sound lighthearted, (“Childbirth is a natural procedure, not a medical event” “Yes, I gave birth at home.  Now ask your silly questions” and “Peace on earth begins with birth”) they reveal the flame this movement ignites (the countervailing, “Home deliveries are for pizza”).  They serve as poetic tropes of sorts, but I would have liked more rendering of these messages in the poets’ own voices.

Greenberg and Zucker offer a unique pastiche, a chorus of female voices, sometimes speaking simultaneously, sometimes in fugue, as they layer facts, scraps, nuances, and feelings about this topic.  The result is profoundly affecting, and their invention of word “poemic” is the right refraction of polemic, serving as an invented form that allows them to bring their poetic talents to bear about this deeply felt topic.  The book’s opening epigraph by Muriel Rukeyser, “Pay attention to what they tell you to forget,” can also serve as its parting invocation as both authors advocate for remembering what has always been known.

Just in time for Mother’s Day, Save the Children has published its twelfth annual State of the World’s Mothers Report.  This report includes the Mothers’ Index, a ranked list of 164 countries around the world.  Like last year, Norway tops the list for the best place to be a mother.  Afghanistan is worst.  The U.S. fell three places, to number 31 on the list.

In other words, the U.S. ranks closer to the bottom than the top of the 43 developed countries examined in the report.

Of course, as the report reminds us, the numbers don’t always tell the whole story—an individual mother’s situation can vary greatly within the same country.  Nonetheless, national-level comparisons do suggest trends and provide overviews that can provide a valuable framework for digging deeper.

For those of us living in the U.S., these national numbers should give us pause.  Why didn’t mothers in the U.S. fare better?  And why are we falling in the rankings instead of improving?  These startling numbers complicate the rosier picture of motherhood and family that many Americans tend to hold.

The first reason for our low ranking is our maternal mortality rate, an issue I wrote about last month for Girl w/Pen and Ms.  As the State of the World’s Mothers Report points out, the U.S.’s rate for maternal mortality is 1 in 2,100—the highest of any industrialized nation.  In other words, a woman in the U.S. is “more than 7 times as likely as a woman in Italy or Ireland to die from pregnancy-related causes and her risk of maternal death is 15-fold that of a woman in Greece.”

Other reasons for our low ranking include the under-five mortality rate (forty countries beat us on this one) and the percentage of children enrolled in preschool—only 58%, making us the fifth lowest country in the developed world for educating young kids.

Finally—surprise, surprise—our country lags in supporting working women with children, and in creating pathways for women to political office nationally:

The United States has the least generous maternity leave policy—both in terms of duration and percent of wages paid—of any wealthy nation.

The United States is also lagging behind with regard to the political status of women. Only 17 percent of congressional seats are held by women, compared to 45 percent in Sweden and 43 percent in Iceland.

This report made me feel a lot of different emotions about the state of motherhood in the U.S. as well as globally—shock, anger, outrage—not to mention gratitude. I’m fortunate enough to have healthy kids and privileged enough to be able to pay for things like health insurance and preschool. Given the state of things for many mothers, this is no small potatoes! And yet, the more I thought about this report and my reaction to it, the more I began to think about how important it is to use feelings to propel us to something more—understanding, wisdom, action, and working together.

This view of motherhood lies at the origins of Mother’s Day.  Long before Hallmark made sentimentality synonymous with Mother’s Day and restaurants began the tradition of the Mother’s Day brunch (neither of which I plan to reject come Sunday!), Julia Ward Howe imagined a very different kind of occasion.  In her 1870 Mother’s Day Proclamation, she called for a day when women could come together and work towards peace.  In the aftermath of the violence and carnage of the U.S. Civil War, she called for women to

…meet first, as women, to bewail and commemorate the dead.

Let them solemnly take counsel with each other as to the means

Whereby the great human family can live in peace…

After grief, counsel.  After sorrow, solidarity.  After remembrance, action:

To promote the alliance of the different nationalities,

The amicable settlement of international questions,

The great and general interests of peace.

So here’s my Mother’s Day Challenge to myself this year: after enjoying whatever treats my family makes for me, and feeling lots of warm tenderness toward them (note to kids: you will be good), and making sure I have time to write in my journal, and calling my own mother on the phone—I’m going to do one thing, one action, toward addressing one of the issues raised by this report.  I haven’t decided what, quite yet.  But here are some ideas I scribbled down this afternoon, a personal list to start my brain juices flowing:

• Write a letter to one of my representatives about some of the issues that really matter to mothers and families.  (Education!  Parental leave!  Women’s health!)
• Send money to Emily’s List.
• Write an opinion essay.  Send it out.
• Go to a protest, like this one sponsored by Mothers & Others United in the Hudson Valley.
• Find out more about the campaigns to connect kids across the borders of class and geography—the UN’s Girl Up and Save the Children’s k2kUSA are ones I’ve recently run across.  Think about how to plug my own family into these networks.
• Find out more about efforts in my own backyard.  (I could start by actually reading all those items in my church’s bulletin!) Ask someone how I and my family can get involved.
• Make a donation to one of these campaigns, or one of the many organizations working for women’s rights and healthy families.
• Write down in my calendar that I will bring up all these issues up again on Father’s Day.

I invite anyone and everyone to join me in this challenge.  Share ideas and actions from your own list.  (And be sure to watch the video about Julia Ward Howe below, released from Brave New Foundation in 2009, which includes an inspiring reading of her Mother’s Day Proclamation.)  Happy Mother’s Day!

Last month, the CDC released a report that I’m going to pick on a little bit, though I’ve seen numerous researchers make similar faux pas in surveys I’ve taken and studies I’ve read.  The report, Sexual Behavior, Sexual Attraction, and Sexual Identity in the United States, uses data from the 2006-2008 National Survey of Family Growth to summarize findings on these topics.  I’m just going to harp on a tiny bit of the survey design, because I think it’s illustrative of a broader point about how survey design can reflect and even shape attitudes about what is and isn’t a sex act, and what is and isn’t a sexual relationship.

Now, to be fair, the NSFG is primarily about addressing things like pregnancy, marriage, and STIs.  The portion of the survey that focuses on sexual acts includes same-sex partners but it’s still geared towards things like STI risk, and thus focuses on sex acts that have a high STI risk like penetration and oral sex.  But there’s still a big problem in the way it describes the possible sex acts for males and females.

Note: The portion below the cut may not be safe for work due to frank descriptions of sexual acts.

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In honor of April being STD Awareness Month, I devote this month’s column to a topic that remains near and dear to my heart (and my cervix): HPV, human papillomavirus.  So, it’s a great time to get yourself tested at your local STD testing location, or send an e-card to a loved one who could use a friendly reminder:

This month might have inspired some of you to consider vaccines that offer some protection against HPV: like Gardasil or Cervarix.*  However, don’t get too excited about Gardasil if you happen to be 27 years old (or older) and live in the U.S.  Earlier this month, the FDA decided against expanded the vaccine’s label use for ‘older’ women:

…the Limitations of Use and Effectiveness for GARDASIL was updated to state that GARDASIL has not been demonstrated to prevent HPV-related CIN 2/3 or worse in women older than 26 years of age.

However, as of Tuesday, ‘older’ Canadian women now have more options than their U.S. counterparts:

Merck announced that Health Canada has extended the indication of GARDASIL^® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Recombinant Vaccine] in women up to the age of 45. Merck’s HPV vaccine is now approved for girls and women nine through 45 years of age for the prevention of cervical cancer, vulvar and vaginal cancers, precancerous lesions and genital warts caused by the Human Papillomavirus (HPV) types 6, 11, 16, 18.

So, what’s the deal?  According to a Canadian women’s health expert, this is a good decision:

Whatever the reason, there’s a tendency for women to remain at risk of acquiring new HPV infections as they get older. Whether they are changing their social status or not, women should talk to their doctors about the HPV protection provided by the quadrivalent vaccine,” said Dr. Alex Ferenczy, Professor of Pathology and Obstetrics & Gynecology at McGill University.

If I’m correct in inferring that Dr. Ferenczy’s use of the phrase “social status” refers to a woman’s sexual partner/sexual relationship status, then are we to assume that U.S. women between the ages of 27 and 45 are in more stable sexual relationships than their Canadian counterparts?  I’ve yet to read a study that would support this conclusion.

So, as a U.S. woman who happens to be in this age group, I feel it only right to encourage my peers to ask their doctor about Gardasil, especially if they’re “changing their social status.”

For the boys and men out there, remember that the FDA approved Gardasil in October 2009 for protection against two types of HPV which cause genital warts in males ages 9-26.  Then, last December, the FDA approved of GARDASIL for the prevention of anal cancers caused by two different types of HPV in females and males 9-26 years old. 

However, once again, there appears to be possible age-discrimination: men over 26 years old, consider whether Gardasil might offer health benefits for you.

*Note to readers: I respect that many will decide that a vaccine is not right/healthy/safe for themselves or for their family members.  I highlighted the recent news about Gardasil because I believe that everyone deserves access to vaccine updates.  I’ll conclude by quoting myself:

I don’t know if the pro- and anti-vaccine folks will ever see eye to eye, but there’s absolutely nothing to lose and everything to gain by being pro-HPV-education.

Yesterday marked the one-year anniversary of President Obama signing the Affordable Care Act.  I encourage everyone to become familiar with what the Act has already accomplished, as well as the plans through 2015 (see an interactive timeline online).

Today, I dedicate this month’s column to reflecting on one of the new consumer protections that is scheduled to become effective January 1, 2014, No Discrimination Due to Pre-Existing Conditions or Gender:

Before the Affordable Care Act became law, insurance companies selling individual policies could deny coverage to women due to pre-existing conditions, such as cancer and having been pregnant. 

A WhiteHouse.Gov fact-sheet describes the ways in which, “The Affordable Care Act Gives Womem Greater Control Over Their Own Health Care.”  When I first read it, even as a feminist medical sociologist familiar with health care inequities, a few lines jumped out at me:

Right now, a healthy 22-year-old woman can be charged premiums 150 percent higher than a 22-year-old man.

Less than half of women have the option of obtaining health insurance through a job.

Today, maternity benefits are often not provided in health plans in the individual insurance market.

I appreciate the many positive effects this law has on women, men and children, but I find myself asking: why did the Affordable Care Act not include this provision — to eliminate discrimination to due to gender — among its original 2010 provisions?  A comparable provision was effective as of September 23, 2010 for children:

…health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage.

Now, don’t get me wrong, I’m all for protecting children’s rights to receiving coverage.  As a mom, I understand the instinct to want to protect one’s child before one’s self.  However, it feels like the policy-makers did not take into account the body of research on the direct correlations between maternal health and child health.  To put it simply, an unhealthy mom is not good for the health of her child — whether or not her child has excellent or poor health care coverage.

For example, a 2005 article in the journal PEDIATRICS documents research findings that,

“Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children.” 

Another 2005 article examined the psychological and physical health of adult caregives of children with cerebral palsy and found that:

The psychological and physical health of caregivers, who in this study were primarily mothers, was strongly influenced by child behavior and caregiving demands…These data support clinical pathways that require biopsychosocial frameworks that are family centered, not simply technical and short-term rehabilitation interventions that are focused primarily on the child.

It’s easy to imagine the ways in which a child’s health might suffer if her/his primary caretaker has poor mental and physical health.  And, solely providing health care to the child did not necessarily improve the health outcomes of the caregiving moms.

One more example along the lines of the effects of maternal depression is the case of pediatric asthma.  A 2007 article in the Journal of Health Economics reports a study which shows:

…treatment of mother’s depression improves management of child’s asthma, resulting in a reduction in asthma costs in the 6-month period following diagnosis of $798 per asthmatic child whose mother is treated for depression.

Our health care system will likely save more money once we end insurance company discrimination on the basis of sex/gender.  Now, I recognize that not all women are mothers, but the overwhelming majority of mothers are women.  So, if the gendered division of labors in most families remains such that moms are primarily in charge of maintaing and protecting the health of their children, then wouldn’t we want these caregivers to have access to affordable, quality health care before 2014? 

That said, I am grateful that this law passed and hope that we will continue to work on ways to strengthen coverage for all Americans.

Women’s History Month should be a time of celebration.  Sadly, when it comes to maternal health, there’s not a lot to celebrate this year.

Just one year ago, this wasn’t the case. In April 2010, maternal health was making headlines—with an encouraging story.  Research published in the medical journal The Lancet found glimmers of hope in the downward direction of the global maternal mortality rate.  Though certain parts of the world had experienced rising maternal mortality rates (including eastern and southern Africa, due to HIV-AIDS), the overall picture looked promising.  These trends were supported by data in another report, Trends in Maternal Mortality, researched and written by the World Health Organization, the United Nations Children’s Fun, the United Nations Population Fund, and the World Bank, which found that the number of women who died due to complications during pregnancy and childbirth had decreased by 34% between 1990 and 2008.

In 2011, the Republican budget in Congress is targeting women’s health programs at home and abroad for deep cuts, with serious consequences for mothers and children.  How much money will these proposals actually save, and at what cost to the lives of women and girls?

Let’s revisit recent history.  In 2000, world leaders came together at the UN to adopt the United Nations Millennium Declaration, which identified eight anti-poverty goals to be accomplished by 2015.  The fifth goal was maternal health: to reduce by 75% the maternal mortality rate, and to achieve universal access to reproductive health.  In 2010, while much work remained to be done, the data suggested that most maternal deaths can be prevented, and that the safe motherhood movement was truly making an impact.  Celebratory headlines in newspapers like the one in The New York Times declared “Maternal Deaths Decline Sharply Across the Globe.”  This article quoted The Lancet’s editor, Dr. Horton, explaining that the data should “encourage politicians to spend more on pregnancy-related health matters”:

The data dispelled the belief that the statistics had been stuck in one dismal place for decades, he said.  So money allocated to women’s health is actually accomplishing something, he said, and governments are not throwing good money after bad.

At the same time, U.S. activists were becoming increasingly alarmed at rising domestic death rates.  Amnesty International issued a report, Deadly Delivery: The Maternal Health Care Crisis in the U.S.A., that raised concerns about the two-decade upward trend in the numbers of preventable maternal deaths.  Amnesty International observed that “women in the USA have a higher risk of dying of pregnancy-related complications than those in 49 other countries, including Kuwait, Bulgaria, and South Korea” and called for a legislative agenda that made maternal health a priority.

Who could have guessed that one year later, we would be retreating even further from making maternal health a priority?

Most of us know about the proposed cuts to Planned Parenthood, which provides a wide array of sexual and reproductive health services to women, many of whom cannot afford to go elsewhere.  Proposed slashes in funding to global women’s health are just as serious.  Ms. blogger Anushay Hossain explains what’s on the chopping block globally, and why this is such a big deal:

House Republicans not only proposed to cut U.S. assistance to international family planning funding, they also want to completely zero out any funds going to the United Nations Population Fund, or UNFPA, the largest multilateral source of reproductive-health assistance in the world. The U.S. currently provides 22 percent of the UN’s overall budget, and UNFPA is the only agency within the UN that focuses on reproductive health.

At the recently concluded 55^th Session of the Commission on the Status of Women, the new Executive Director of UNFPA, Dr. Babatunde Osotimehin, listed the three main challenges we must face in order to improve maternal health globally: empowering women and girls to claim their rights, “including the right to sexual and reproductive health”; strengthening health services everywhere “to deliver an integrated package of sexual and reproductive health services”; and ensuring “adequate financing.”  He also spoke about girls’ education as “the most important intervention to avoid maternal deaths.”  I was inspired to read UNFPA’s mission, which reflects an understanding of health in the context of human rights and equality:

UNFPA, the United Nations Population Fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity.  UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect.

This struck me as fairly comprehensive and visionary.  Yet I don’t think I’ve ever seen this picture of UNFPA in the mainstream U.S. media.  Nor have I seen the following question asked—or answered: how might the proposed cuts affect maternal mortality rates, at home and globally?  I would also like to see politicians address this issue.  I was glad to see Secretary of State Hillary Clinton detail the devastating effects of the elimination of funding to UNFPA; her testimony before the House Committee on Foreign Relations is posted on Feministing.  She observed that the quality of women’s health and empowerment in the developing world not only has an effect on their families and their communities, but also on our own security: “This is not just what we fail now to do for others.  It’s how that will come back and affect our own health here at home.”

As one of the truisms of globalization goes, we’re all connected.  Indeed—the security of women everywhere appears to be threatened by the proposed cuts and policies in the U.S. Congress.

Happy International Women’s Day.

Image via Wikipedia Commons.

I’m collaborating on a study of traumatic childbearing experiences, so I’ve been thinking a lot about the types of injuries that can occur as a result of pregnancies, labors, and different types of deliveries.  My research partner forwarded me a recent blog post on a board-certified urogynecologist’s website titled “Cesarean on Demand Does Not Eliminate Risk of Prolapse.”  This post highlights the findings of a 2009 research article published in the International Urogynecology Journal. In this research, three groups of women were studied: “vaginal delivery with sphincter tear (n = 106), vaginal delivery without sphincter tear (n = 108), and cesarean without labor (n = 39).” [The numbers reflect how many women were in each of the three groups.]

Now, I’m no urogynecologist, but I found it hard to believe that c-sections “on demand” (a.k.a. without labor) would not at least reduce the risk of pelvic floor damage, including pelvic organ prolapse (pelvic organs “slipping out of place” when the supportive muscles and ligaments are weakened or torn).  Prolapse can greatly impact the health and quality of life: for example, women with prolapse may suffer one or both types of incontinence and/or painful sexual intercourse.

I recognize that many medical practitioners, authors and laypeople have come to believe we have too high a rate of c-sections here in the U.S.  Research studies, such as the one celebrated in the recent blog post, call into question whether there are any health benefits of c-sections without labor.  As a medical sociologist who teaches research methods, I consider it to be of utmost importance to discuss research findings with the highest degree of accuracy.  No study is perfect: no study is without bias and no study is without limitations.  So, I read the complete research article to find out if it truly supported the blog author’s contention that these researchers “found NO DIFFERENCE in moderate prolapse between the three groups.” 

I was struck by significant methodological flaws and limitations which, while acknowledged by the authors of the original article, were glossed over or flat out ignored by the author of the blog post.  I found myself asking several questions:

Question #1: how healthy were the women before this childbearing experience?  No one knows: the researchers admit, “our findings cannot be attributed with certainty to delivery method, since some women may have developed prolapse before delivery or pregnancy and prolapse was not assessed prior to delivery in this population.” 

Question #2: who were the women who participated in this study?  The women for this study were recruited from prior studies performed through the Pelvic Floor Disorders Network, specifically from the follow-up study to their CAPS Study (which focused on “fecal and urinary incontinence after childbirth”).  How can we rule out a self-selection bias of those women who said “yes” when they were recruited to this initial study?  Could it be certain women who had C-sections, perhaps those feeling some pelvic/vaginal discomfort immediately following delivery were more likely to say “yes” because they saw value in being interviewed about incontinence?

Question #3: did the researchers recruit enough women for each of the three groups to be able to answer their main question?  No.  The authors wrap up their article by noting that “further research would be required to determine whether cesarean delivery before labor reduces the incidence of pelvic organ prolapse.”  So, this research doesn’t actually determine anything about what they claim as their primary research question.  Why not?  The short answer is that they never got enough women to participate.  The authors claim that they would have needed 132 women per group in order to test the statistical significance of the difference in rates of stage II prolapse between those women who had C-sections without labor and those women who had vaginal deliveries.  While they got reasonably close to their sample size goal of 132 for the two vaginal delivery groups (106 and 108), they only got 39 women to participate in the C-section group.  Is this acceptable?  Statistical significance is key to evaluating any study because it means that the results are “probably true (not due to chance).”  The researchers finally own up to the likely irrelevance of their study towards the end of the published journal article: “Furthermore, our sample size was not sufficiently large to exclude a significant difference between groups.”  In plain language: they didn’t study enough women to know whether or not there are not real differences between the health outcomes for women who have c-sections without labor and those experience other types of labor and delivery.

Question #4: can the researchers say anything definitive that might help improve women’s health?  Hmmm.  The only factor they definitively connect with less pelvic floor damage is lower birth weight: I’m betting that it won’t surprise many to find out that smaller babies causes less damage.  But, what are we supposed to do with this finding? 

The author of that recent blog post dares to call it a “beautifully executed study,” and that’s why I had to wrote this post: to help those of us who are not medical researchers better understand what we should value and what we should question when it comes to research studies that can impact women’s health.

*Spoiler Alert: in order to critique this show, I need to reveal some plot points.

Zombies do not discriminate on the basis of sex, race, ethnicity, socioeconomic status, or ability…people do. This sad truth played out in the short but compelling 6-episode first season of AMC’s new show The Walking Dead. Zombies eat any living thing they come across – scary but not evil creatures because they don’t have a functioning brain which would allow them to be human, to distinguish right from wrong.

 Admittedly, I haven’t read the graphic novels of Robert Kirkman, on which this series is based. So, I’m not 100% sure who to credit for the plot twists that portrayed the violent racism of a white supremacist, the vulnerability of daughter and wife to a physically-abusive man, and the terror of a woman fighting off a former lover who is trying to rape her. When the hospital is invaded by “walkers” (a.k.a. zombies), the living soldiers choose to execute ill and disabled patients rather than try to rescue them. [Mind you, the zombies do not seem to move fast enough to cause problems for someone armed with a semiautomatic weapon, but the choice is still made to sacrifice these lower status people.]

 If a common enemy should unite, then social scripts of bigotry and bias should disappear. As one character notes in the season finale, human beings may have reached their point of extinction. The question is whether the zombies or our own human failings are to blame.

With record ratings, the Wall Street Journal and other sources report that this Sunday night’s finale attracted 6 million viewers.  I may not be the typical fan of this show, so I wonder: will most viewers remain focused on the horror of a gruesome, fictitious zombie epidemic? Or, are there others like me, who despite flinching every time a zombie lunged for a bite of human flesh, left the season finale feeling acutely aware of the very real pandemic that plagues almost all societies: that potent combination of bigotry and selfishness which manifests as one of the many ‘isms. I’ve yet to see a ‘walker’ lurching down a street, but I have encountered far too many living human beings who lack empathy, respect, and compassion for each other and for the diversity of life on this planet.

On my other blog, I recently posted a review of the book Origins:  How the Nine Months Before Birth Shape the Rest of Our Lives (Annie Murphy Paul, 2010). I wasn’t particularly fond of the book.  It offers an overview of research being done in the last few decades to determine fetal origins, or the ways in which people are affected—perhaps for generations—by what happens during the time that they are gestating.  Despite the author’s good intentions, I found it to be a troubling book.  As I recounted in my review, even as a woman who isn’t pregnant, I felt uncomfortable reading, like I was being indicted for not being careful enough while I was pregnant, back in the day.  While Paul acknowledges the danger of this research being used to bolster already culturally prevalent “mother blame,” she frames her work in the hope that it can provoke broader cultural change and positive evaluation of mothering, from the point of conception onward.  I said I didn’t think it worked, and that I did, in fact, feel blamed.

What I wanted to talk about here is not my review but the comments it received.  I’ve had a number of responses, and the thing that’s interesting is that many have been lengthy.  Folks haven’t just been weighing in—”I disagree!”—but offering counterarguments or lengthy explanations of how fetal origins research is or isn’t valid.  Some have been arguments based in personal experience, others have been based in professional expertise (medical anthropology, for instance, or anesthesiology).

So my question is, why did this matter enough to readers that, in responding, they essentially wrote blog posts of their own?

I think the answer is that parenthood is a high stakes endeavor, particularly for the middle-class (overwrought?) parents cohort I belong to.  More specifically, motherhood is a high stakes endeavor—and I say this with all respect to my partner, who is an outstanding father to our daughter, but who doesn’t face the pressure that mothers routinely face.

All of us who are in the realm of motherhood—either as parents or as scholars of motherhood—know this.  The internet is full of jokes about “mompetitors” that friends regularly send me.  This piece from Salon maps out the topics you simply can’t discuss, and it’s not wrong:  breastfeeding, attachment parenting, the family bed, and crying babies are topics I’ve found to be so highly-charged that I’m incredibly careful about talking about them, even with very close friends.

The reason I read Origins is that I’m currently doing research into prenatal testing, and that’s another subject that’s so high stakes that many of us simply don’t talk about it at all.  When some of my friends have been pregnant, they haven’t shared the news until after they’ve had the amniocentesis that determined that this is a pregnancy they’re actually going to continue.  I’d hoped that Paul would discuss this aspect of our cultural assessment of the fetus, but she didn’t.  She did, however, share that many of the studies base their assessment of prenatal health on postnatal IQ scores, a fact that I found very troubling.

We’re raising kids in a culture that’s perfectionistic and that seems to believe, by and large, that we—as mothers—are always wrong.  If something “bad” happens involving our child (such as short attention spans, low IQ scores, or asthma), it’s our fault.  Since we’re already pummeled with this viewpoint, scientific research that says, “And it’s true while the baby’s in utero, too!” isn’t necessarily helping matters.  This isn’t to say that the scientific research is or isn’t valid.  I’m not a scientist, and my skepticism about some of the studies Paul reports on isn’t definitive.  What I’m saying is that this science is emerging from and feeding into a culture that has some very troubling, individualizing, and sexist views.  I think my readers are attuned to that culture, as well, and it makes all of us a bit defensive.