The War on VBACs

For those who haven't stayed up all night checking to see if mom's ready to push, a VBAC is a Vaginal Birth After a C-section. During a Caesarian, besides cutting through mommy's belly, mommy's uterus gets cut as well. When a woman has another child, the worry is that since the uterus has already been cut before, the spot of healing isn't as structurally sound as the original uterine wall, thus the pressure placed on the uterine wall during subsequent pregnancies would then result in uterine rupture, and the need for emergent surgery. Emergent surgeries carry a multitude of greater risks than elective procedures.

But then some studies cited in this NPR story mention that the actual rate of uterine rupture in VBACs isn't that large, but when a uterine rupture DOES occur during a VBAC, outcomes are comparably terrible. This lead ACOG to recommend that adequate surgical faculty be available when a woman was attempting a VBAC. The problem arises when smaller hospitals simply don't have the resources to ensure those adequate surgical backups are at hand, and hospitals then ban VBACs because they simply can't afford to keep a full back up team on call.

Which creates the interesting public health versus personal autonomy dilemma we've all come to know and love. Women absolutely have a right to attempt a VBAC (and yes, "attempt" is the correct terminology) with a fairly low threshold for proceeding to a repeat caesarian should complications arise. And hospitals have a right to not offer services they simply can't afford to offer when medically acceptable alternatives exist. "Medically acceptable" and "personally acceptable" are, of course, not always in agreement.

Where I've trained, the VBAC was always an option, mostly because the hospital is equipped with the staff to handle any complication that could arise because patient volume and the high-risk patient population justify their use. On a population level, the risk is astronomical. On a personal level, the risk is miniscule.

Of course, the naturalist spin is that obstetricians are evil bastards who want to cut so they can go home and get some sleep so they'll have time to wake up early enough to spend their hefty salaries. Actually, obstetricians, like other physicians, don't like the idea of folks dying during an emergency from a partially preventable incident.

The woman in the NPR story gives the most revealing quote, however. She is rightfully upset that she is being forced to have a VBAC. When presented with the rationale for why this is so, she replies:

"That's what they hospital is there for, to handle emergencies. And so, in that respect, the policy never made sense to me."

No, emergency rooms are there to handle emergencies, as long as by "handle," you mean do the best that anyone can to stabilize an unstable situation, recognizing that some unstable situations simply cannot be stabilized, and should be avoided if possible.

Hospitals exist to provide inpatient medical care following complicated medical algorithms in which physicians and patients take action to minimize the risks associated with illness and treatment. If a particular hospital can't handle a particular risk, it shouldn't try to do so. It should refer to a tertiary care center, and it should be blatantly honest with its patients about local limitations.

We don't send burn victims or trauma victims to any old hospital and expect that hospital to be staffed to handle those emergencies. We have regional burn centers and a tiered-trauma centers so that patients can receive quality care, and our society can afford to provide that quality care.

A woman has every right to demand an attempt at a vaginal delivery after a caesarian section for a prior pregnancy. Heck, I imagine if I were a woman on my second pregnancy after having a C-section the first time, I would almost certainly demand a VBAC. However, no hospital can be expected to offer a service it simply can't afford to offer. If I want the VBAC, I have to go find a facility that does offer that service, since I'm probably unwilling to spend the extra zillion dollars required to keep sufficient surgical staff available during my delivery. And my current providers have an obligation to help me find that facility.

For the most part, Starbucks has an obligation to give you precisely what you want, because coffee isn't dangerous, and they can charge you whatever that coffee is worth to them.

For the most part, your medical provider has an obligation to give you precisely what you want, as long as what you want is reasonably safe, economically viable, and consistent with what can comfortably be called standard of care. For example, elective abortions and emergency contraception meet each of those criteria, and thus each woman has a right to receive them. In some contexts, a VBAC doesn't meet those criteria (according to ACOG... that's certainly up for further debate). Thus, the provider's obligation is limited to directing the patient to a context in which the patient's preferences do meet those criteria.

Update: The Onion offers the proper supplement to this story:

Woman Overjoyed By Giant Uterine Parasite

NEW BRIGHTON, MN— "I'm so happy!" Crowley said of the golf ball–sized, nutrient-sapping organism that will eventually require hospitalization in order to be removed.

Ezra on the politics of Knocked Up

Apparently a few bloggers on either side have deemed Knocked Up to be a pro-life movie since Katherine Heigl's character makes a choice not to have an abortion. Ezra volleys masterfully:

The flick is pro-choice in the most literal sense of the term. Katherine Heigl's character receives advice in both directions, and then makes a decision -- a decision the audience may very well conclude is the wrong one. But she has a choice; nothing is forced on her, and the most explicit scene on abortion features an eloquent speech by her mother advising her to end the pregnancy because, at this point, she's not ready, and these are not the right circumstances. Heigl, it turns out, disagrees, but that's a perfectly allowable, and indeed respectable, decision within the choice framework.

Due to my eerily busy travel schedule, it'll probably take a week or two to get to the twilight showing at Quality 16 (the only theater in Ann Arbor I step foot in, for appropriately complicated reasons), but I'm pumped. You see, as my wife can embarrassingly confirm, I was a massively strange fan of Seth Rogen's character on Freaks and Geeks. His appearance in The 40-Year Old Virgin made the movie for me, and now, Judd Apatow gives him his own movie? Beyond my wildest Freaks and Geeks dreams.

I had a huge crush on the quasi-nerd version of Linda Cardellini, completely unable to predict that she'd turn into the hot nurse on ER, the sort of neo-Abby of emergency resident dreams. Lindsay Weir was the archetypal cute high school brunette smart-girl nobody noticed in their apoplectic fit of adolescent tunnelvision, not the Ennis-seducing blonde saloon girl from Brokeback Mountain. So Cardellini's ascent into mainstream hotness makes me uncomfortable in that pimply, meso-pubescent sort of way. I might have been able to manage a coffee date with Lindsay Weir, but Samantha Taggart would be making fun of the awkward medical student to her fellow nurses by the fridge in the conference room. So that paves the clear path for Seth Rogen to be my official favorite Freaks and Geeks alum (a venerable position, indeed). All hail Seth Rogen!

Why does rape or incest matter?

Samhita at Feministing (one of the greatest blogs in the sphere) takes Sam Brownback to task for his comments on abortion and rape and incest the other night:

Yeah you heard it right. Senator Sam Brownback actually argued on Wednesday that, "We talk about abortion, but abortion is a procedure. This is a life that we’re talking about. And it’s a terrible situation where there’s a rape that’s involved or incest. But it nonetheless remains that this is a child that we’re talking about doing this to, of ending the life of this child."

Now, I grew up in a fundamentalist household, and I've simply never understood the rape-and-incest line of argument, as if somehow whether the fetus is a product of rape or incest changes the fundamental facts of the abortion question.

I feel like I do a better job than most really breaking down the debate, but we'll see.

A fetus is one of two things:

• A) A human being, and should thus have full protection under whatever laws we could scrounge together to protect it, or
• B) A clump of cells living in a woman's uterus that, if given the opportunity, would likely somehow escape the uterus and begin development as a human being.

By tone of writing, its readily apparent that I support the latter definition.

From B), two options seem reasonable to me:

• 1) Mother decides that the clump of cells living in her uterus represents a future human being that should develop as her child. She wants that child, and she wishes for that child to escape her uterus and begin development, and from this point has a legal obligation to protect the child.
  
• 2) Mother decides that the clump of cells living in her uterus does not represent a future human being that should develop as her child. She thus decides to have abortion to have an unwanted mass of cells removed from her body.
  

So, where does rape or incest fit into ANY of this paradigm? I see no morally defensible middle ground between A) and B) or between 1) and 2).

Between A) and B), we could insert these notions:

• i) A fetus is a human being but does not enjoy the rights of a human being outside the womb.
• ii) At some arbitrary point during gestation the fetus changes from being a clump of cells to a human being, irrespective of a mother's wishes.

But neither make any sense to me. i) requires arbitrary notion of a second-class citizen. ii) requires that there's something magical about a cellular process independent of a social construct. I reject both of these outright as absurdities, although I find these are two popularly held beliefs. They're convenient, and let people make decisions about abortion de facto (and set silly regulations about so-called partial birth abortions or legislate abortion regulations differently depending on trimester of gestation) without actually considering any consistency with other moral beliefs. These notions might be useful shortcuts, but they don't seem logically defensible.

So I only see two morally defensible takes on abortion:

• A*) Abortion is wrong because a fetus is a human being who deserves all the rights and protections of law, except possibly in the case of a mother's life being in danger, where all of this paradigm breaks down, and more subheadings would be required.
• B*) Abortion is on average morally neutral and a decision left to a woman who has the right to make decisions about her own reproductive health regarding a pregnancy at any point prior to its termination through abortion or delivery.
  

Again, by tone of writing, its readily apparent that I support the latter definition.

I just don't see how rape and incest fit into this paradigm. Either a fetus is a human being, and killing it is murder, or a fetus is a prospective human being, and killing it is not murder.

I'm a firm believer in B*, but I do believe that A* is morally defensible, even if I absolutely reject it, because I know of no absolute way to differentiate between A and B. Now, in some cases, such as when Sam Brownback starts talking, A seems flat out hateful and ignorant. "You got raped and became pregnant? Tough shit! Go to church, you filthy harlot! They have free nursery during services!"

But I know a handful of rational, pro-women pro-lifers who subscribe to A and A*, and they are intelligent and thoughtful enough for me not to reject their ideas as ignorant. A and A* can certainly be included in a rational progressive agenda that supports women in poverty, provides unfettered access to proper contraceptive and reproductive health resources, and punishes perpetrators of violence on women. But give me B and B* any day, because they simply make more sense to me, and allow women more control over their lives.

I'm actually asking for answers here, and I know of at least a few regular readers that have the backgrounds to make reasoned comments. Why does rape or incest matter when determining whether an abortion should be permitted?

How could you write any less intelligently about menstruation?

I know nothing about Stephanie Saul, and I don't know anything about having a period. I know a lot about living with someone who has them and constantly complains about them, and yet doesn't really have any interest in not having them. I can accept that sort of doublethink just fine. God knows I probably exhibit behavior and attitudes at least that discordant.

Let me be absolutely clear: If a woman has a complicated relationship with her menstrual cycle that relates to her identity and personal relationship with her body, that's great. Seriously. I don't bleed. I don't know what it's like. If there's something symbolic about it for you, that's cool. If it helps you understand your relationship to your body, awesome. I can at least imagine it on a literary level. I can't think of any exact analog for a guy's relationship with his sexual anatomy, but if there was one, I bet I'd have a complicated relationship with it too.

But if a woman doesn't have a complicated relationship with her menstrual cycle, then my God, why does she have to bleed if she doesn't want to? Since when has feminism become about limiting a woman's choice?

So here's a brutal jump-around fisking of Ms. Saul's pseudofeminist drollery.

For many women, a birth control pill that eliminates monthly menstruation might seem a welcome milestone. But others view their periods as fundamental symbols of fertility and health, researchers have found. Rather than loathing their periods, women evidently carry on complex love-hate relationships with them.

Oh my God! Women don't agree on everything! Holy shit, there's more than one valid opinion on a matter in this world! How will we ever survive until next week without our unity?

This ambivalence is one reason that a decision expected next month by the Food and Drug Administration has engendered controversy. The agency is expected to approve the first contraceptive pill that is designed to eliminate periods as long as a woman takes it.

Alberto Gonzales: controversy. Gun control on college campuses: controversy. Approving a new birth control pill that ruins the old misogynistic proverb "never trust something that bleeds for a week and doesn't die?": Yawn.

“My concern is that the menstrual cycle is an outward sign of something that’s going on hormonally in the body,” said Christine L. Hitchcock, a researcher at the University of British Columbia. Ms. Hitchcock said she worries about “the idea that you can turn your body on and off like a tap.”

Two points here. The first one, valid. Amenorrhea is an outward sign that something isn't working quite right, and this pill would mask that. Valid point. The second one, the "turning your body on and off like a tap" thing, is this woman for real? Who cares? If people want to contemplate the symbolic nature of their own menstrual cycle (which I certainly do not oppose), that's cool. But to unilaterally say that every woman out there, whether she finds her cycle to be something personally important to her or not, should necessarily have to have the thing, with only poetry to back you up, is pretty dumb.

That viewpoint is apparently one reason some already available birth control pills that can enable women to have only four periods a year have not captured a larger share of the oral contraceptive market.

Oh my God! The market can handle a diversity of goods!

“It’s not an easy decision for a woman to give up her monthly menses,” said Ronny Gal, an analyst at Sanford C. Bernstein & Company.

Or its just not a necessary decision. If a woman is on a birth control regimen that works for her, and the benefit of not having a period isn't worth having to fiddle with that regimen, that seems pretty reasonable to me.

Doctors say they know of no medical reason women taking birth control pills need to have a period. The monthly bleeding that women on pills experience is not a real period, in fact.

Okay, this is when Ms. Saul really loses my vote. "Hey birth control pill users, you phonies, you don't even have real periods!!! That's not blood dripping from you for five days every month, that's really just cherry slurpee the drug company implanted in you while you were asleep! Fooled you!"

What the hell? No, you don't have an egg to shed when you're on the pill, because you don't ovulate. But you still shed some endometrial tissue, and unless I just totally failed my GYN rotation, I'm pretty sure that constitutes a "real" period. Labeling an on-the-pill period as "fake" seems a little, well, nutty? To make such a claim, you either a) have a really bad understanding of science, b) believe everything you're told, or c) have a very specific agenda.

And studies have found no extra health risks associated with pills that stop menstruation, although some doctors caution that little research has been conducted on long-term effects.

Welcome to drug research. How do you conduct research on long-term effects if people don't take the medication for long periods of time? It's not like we have a colony of research-people on the moon we can feed Seasonale for the next fifty years to see if they grow an extra arm on their head or something, and then get back in our space ship-time machine to come back to 2007 to tell everybody that it's totally safe, except for that arm-growing-out-of-your-head thing. We don't have long-term research on most of the birth control regimens in existence now, as most research I've seen just lumps OCPs into one big catch-all category. That might be totally appropriate, but maybe this progestin analog causes arms to grow out your head, and another one doesn't. We won't know for fifty years.

The topic has, however, inspired an hourlong documentary by Giovanna Chesler, “Period: The End of Menstruation?,” currently screening on college campuses and among feminist groups.

Ms. Chesler, who teaches documentary making at the University of California, San Diego, said she became concerned about efforts to eliminate menstruation when she first heard about the idea several years ago.

“Women are not sick,” she said. “They don’t need to control their periods for 30 or 40 years.”

Geez, and I thought the "Left Behind" people needed to get a life. No, women are not sick, but they take birth control pills because they'd like to actually be able to enjoy sex without having seventeen children. If stopping ovulation with pills is okay, why is stopping menstruation with pills somehow worse? At least, medically.

There has also been a backlash among groups that celebrate the period as a spiritual or natural process, like the California-based Red Web Foundation. “The focus of our group is to create positive attitudes toward the menstrual cycle; suppressing it wouldn’t be positive,” said Anna C. Yang, a holistic nurse and executive director of the organization.

What a bunch of hippies. Nobody's FORCING this stuff down your throat. If you love your menstrual cycle, knock yourself out. If you want to celebrate your menstrual cycle as a central theme of womanhood, have fun. But leave women alone who don't think it's fun to bleed 20% of the time for thirty years.

Eliminating menstruation is not a completely new concept. Women who take any kind of oral contraceptive do not have real periods.

Because the hormones in pills stop the monthly release of an egg and the buildup of the uterine lining, there is no need for the lining to shed — as occurs during true menstruation.

Not again. Space cadet.

At the alternative Bluestockings Bookstore on the Lower East Side of Manhattan early this month, several dozen women gathered for the New York premiere of “Period: The End of Menstruation?,” Ms. Chesler’s hourlong documentary. It explores the idea of suppressing the menstrual period but leaves the viewer to make up her own mind.

One who attended the screening, Aviva Bergman, a 22-year-old student at Goucher College in Maryland, said she would not use products that suppressed her period because it seemed unnatural.

You know what else is unnatural? Being able to have sex without worrying about getting pregnant. Injecting yourself with insulin because your pancreas doesn't work. Getting a heart transplant. Nuclear bombs. Soy milk.

You know what's perfectly natural? Earthquakes. Floods. Hurricanes. Puppies. Rainbows.

Natural doesn't seem like the best proxy of goodness. Seems like most of us evolved with intellects that can stomach a bit of nuance and context here and there.

“I just feel that there’s a reason you’re getting it every month,” she said.

Feel away! It's your menstrual cycle. Do what you want with it. But it's your menstrual cycle, and not that of the woman sitting next to you. Make your own decisions, and leave other people alone.

Yeah, there's a reason "you're getting it" every month. It's because (oh hell, you can look it up on wikipedia, if you're that interested in reproductive endocrinology). I'm pretty sure there's nothing magical about pulses of GnRH, although I'm not a medical student at Hogwarts, and may be out of my league on this one.

I don't anticipate that anyone is actually going to read down this far. If you did, please keep all these comments in focus with the overriding thesis.

1. Women should get to decide what they do with their own bodies.
2. There's nothing feminist about trying to limit the choice of other women for poetic reasons.
   
3. We don't know much about the long term effects of suppressing periods indefinitely. but we also don't have much medical reason to think that regimens that suppress periods indefinitely will really be much of a problem in comparison to contraceptive regimens already available.
   
4. There's nothing magic about things that are natural. Cancer is natural. Air conditioning is unnatural.
   
5. I've never had a period. I'm only qualified to speak about the medical and political implications of this stuff. I do not question anyone's personal experience with menstruation.
   

What do 5 members of the SCOTUS and near-sighted gynecologists have in common?

They all have wet noses! (Apologies to the 98% of you that don't get the reference)*

I held off posting on the Supreme Court's decision to be supremely retarded, figuring someone else would write something more measured and that would hit all the points I wanted to hit. Lynn Harris at Salon did a pretty good job.

In general, critics of "partial-birth abortion" bans -- which are also on the books in 26 states (though enjoined in 18) -- have long argued that not only is there no such medical term as "partial-birth abortion," but that such laws define it so as to appear to also include a variation of dilation and evacuation (D&E), by far the most common -- and safest -- method of second-trimester abortion (which is relatively rare itself; at least 85 percent of abortions take place in the first trimester). In other words, the ban could be interpreted to outlaw abortion procedures used very early in the second trimester (not to mention those used for women who have learned via amniocentesis, as late as 20 weeks or more, that they're carrying a fatally abnormal fetus).

And even better:

Make no mistake: "This ban is not just about later-term abortion," says Janet Crepps of the Center for Reproductive Rights, who argued Gonzales v. Carhart. "The options for all women -- particularly women facing serious medical conditions -- have been dramatically reduced. No longer can women and their physicians decide what's in their best interest. Now there's the added concern about whether what's in their best interest will be in violation of federal criminal statutes." Among opponents of the ban, gallows humor was the order of the day. As in: "I'd like to give you the best possible care," your doctor might say, "but first let me check with my lawyer."

*The UMMS 2007 Smoker included the joke "What does my dog Winston have in common with a near-sighted gynecologist? They both have wet noses!"

NB: My dog is not named Winston.

And I thought my high school biology teacher was an idiot (not clairvoyant)

I REALLY wish I had made this story up, rather than being forced to document the sad truth about secondary science education in the Bluegrass State.

Imagine fifteen year old Garrett:

[Biology classroom, fifth period right after lunch. Garrett resumes his daily routine of walking into biology class and promptly falling asleep on his back pack. For some reason, Garrett can't sleep today, and feels a little guilty for being so flippant about a science class. He tries to feign some interest in Ms C's biology lecture]

Ms C: So, you get twins when two sperm fertilize the same egg...

Garrett: [mystified that the state of Kentucky would pay someone to say something like that in a biology class, sits up] Wait, did you just say that twins are caused by two sperm fertilizing the same egg?

Ms C: Yeah, that's how we get twins.

Garrett: [looks around room to other people he knows with IQs over 12, fails to find anyone else even remotely paying attention] But...

[Ms C continues with lecture on nothing, Garrett is able to return to his post-lunch nap with a clear conscience]

But now, Ms C's delusions are newly-minted medical science. Semi-identical twins, produced by the fertilization of one egg with two sperm, have now been documented.

[Cue Fade Music: "It's the End of the World as We Know It (And I Feel Fine)"]

Now if that whole Creationism thing would just pan out, Ms C might win the Nobel Prize.

Eating-disorder education shows unintended effects

I keep accumulating all of these eating disorder research blurbs I want to blog, so here goes this one:

Yale University researchers found that when they presented female high school students with videos on eating disorders, it met the intended goal of boosting their knowledge about anorexia and bulimia.

However, the team saw that the students didn't necessarily find the results of eating disorders unappealing. Teens who watched a video featuring a woman recovering from an eating disorder became more likely to view girls with eating disorders as "very pretty," and some thought it would be "nice to look like" the woman in the video.

Health educators are clearly losing the battle in the prevention of eating disorders when students don't find vomit and electrolyte abnormalities particularly unappealing.

[T]he girls were more likely to say after [watching the educational videos] that "it's not that hard" to recover from an eating disorder. They were also more likely to believe girls with eating disorders have "strong" personalities.

At some point we have to wonder if such a study isn't just a strong cautionary tale against not pilot testing your educational materials. Our understanding of the teenage psyche somehow immediately disappears around the time that we can legally drink alcohol. Adults can pretend to understand why teenagers would think girls with eating disorders have strong personalities. We could draw flow charts and propose mechanisms, but I'm betting we'd never "get" it. That of course doesn't mean we shouldn't try to advance our understanding of disease context in eating disorders to its fullest. But we better be pretty humble in our pursuits.

The strongest message we might draw from this study might be that assumptions are futile in child psychiatry. And as soon as we know something, its probably changing due to social dynamics that defy our best mathematical models.

A drug in search of a disease, part two

A few days ago I rambled about gabapentin for pain for kids with chronic neurologic disorders. Today, it cures hot flashes!