Rachel Heath

Intentional Living: learning to be fully present

Archive for the category “Doula Tips”

On Abortion and Women’s Health

The main presidential candidates are really pushing the issue of abortion rights this year. I don’t believe it’s much of a priority for either Romney or Obama, but I expect Obama’s healthcare policies will have an effect on the way abortion is handled in this country.

Full-disclosure: I define myself as neither republican nor democrat. I would call myself generally anti-abortion, but I realize that it’s an incredibly complex issue and I don’t believe there are blanket right-and-wrong answers to be found here.

I’ve heard dozens of commercials along the same theme: republicans want to take “critical” healthcare away from women. Republicans aside, as a birth professional, I’d like to speak to the notion of abortion being “critical” for women’s health.

Today, I’m not addressing the issue of abortion from a religious or political standpoint, but from a healthcare standpoint. No, really! I’m not going to bring up Jesus. I’m not going to endorse a political party. I’m just going to share some research-based evidence.

First, it’s important to explain how abortion is performed and how it affects the body.

Abortion and miscarriage affect the body in some similar ways. A woman’s body has the amazing ability to detect genetic abnormalities and deformities in a developing baby, and 95% of the time, will spontaneously abort a baby that is developing with serious problems. This is what causes most, but not all, miscarriages. Even in a natural miscarriage, the body undergoes a massive hormonal shift that seriously jacks you up (ask any woman who has experienced miscarriage). Most women report that the emotional healing takes much longer than the physical recovery.

Abortion is different because it’s not a spontaneous, natural function of the body. Instead, it’s the removal of a (usually) normal, healthy baby, which confuses the body. There are two types of abortion practiced commonly in the US:

Pharmaceutical Abortion

This is a pill, usually Mifepristone, that blocks progesterone, an important hormone in pregnancy. It is used alone or in conjunction with Misoprostol. Among other things, this causes the uterine lining to break down and be sloughed off, along with the baby, just like in a miscarriage. The FDA has approved Mifepristone for use up to 49 days past your missed period (7 weeks) but on their website, Planned Parenthood says it administers it for up to 9 weeks (I suspect in conjunction with another drug).

The packaging notes risks including vaginal bleeding or spotting, cramps, pelvic pain, vaginal burning, itching, or discharge, headache, tiredness, difficulty falling asleep or staying asleep, anxiety, back or leg pain. The chief among these is very heavy bleeding, but thorough studies haven’t been performed on this particular risk yet. The sudden hormonal shift triggered by a pregnancy loss is often stronger for women who undergo abortion because the loss was caused chemically, instead of by the body’s own hormones.

In my opinion, the biggest risk of this method is that it isn’t always completely effective. In about 5% of women, tissue may be left in the uterus which can cause infection (a very serious risk with a host of other potential side effects), thus necessitating a surgical abortion. Of course, miscarriages can also be incomplete, but I couldn’t find any definitive numbers from sound studies that indicated what percentage of miscarriages end this way.

Surgical Abortion

The most common surgical abortion procedure performed in the US is called Aspiration Abortion. Basically, the cervix is dilated manually (sometimes with the assistance of drugs) and a vacuum device is used to remove the baby, placenta, and other tissue. The farther along you are in pregnancy, the riskier this procedure is, with success rates slipping lower past 6-8 weeks of pregnancy.

Risks include post-partum depression, cramping, severe bleeding, blood clots, infection, cervical tearing, uterine tearing, scarring, incomplete abortion, repeated abortion, undetected ectopic pregnancy, and rarely, death.

Another type of surgical abortion, somewhat common but less often used than aspiration abortion, is D&C, or Dilation and Curettage. The cervix is dilated and a sharp, spoon shaped blade (a Curette) is inserted and used to scrape out the inside of the uterus. Typically, this procedure is performed after an incomplete miscarriage or abortion, but some less-modern doctors still perform D&C abortions routinely.

Risks of Dilation & Curettage include postpartum depression, cramping, hemorrhage, uterine perforation and/or tearing, cervical damage and/or tearing, infection, scarring, incomplete abortion, and rarely, death.

Abortion is presented as a safe way to terminate a pregnancy. However, even apart from the possible risks and complications listed above, a host of statistics show that abortion, particularly surgical procedures, can have a long-term impact on fertility and general health.

1. Abortion can leave you sterile.

Approximately 3-5% of women who have induced abortions are rendered sterile, and the percentage is higher if you had an active venereal disease or infection at the time.

2. Abortion significantly raises your chances of developing future ectopic pregnancy.

Women who experience some kind of post-abortion infection (25-30% of abortion patients) are 5-8 times more likely to develop ectopic pregnancy. Ectopic pregnancy, when a fertilized egg becomes implanted outside the uterus (for example, in a fallopian tube) is almost always fatal to the baby and is an enormous risk to the mother’s life. The number of ectopic pregnancies in the US has more than quadrupled since abortion was legalized, and over a tenth of maternal deaths in the US are due to ectopic pregnancy, a trend that is visible in other countries with legalized abortion.

3. Each abortion significantly increases your risk of future pregnancy complications.

Dilating the cervix manually is a difficult task even with pharmaceutical help, because the cervix is meant to stay hard and closed until labor begins naturally. Minor to severe tears in the cervix and uterine wall often result. One hospital study I found reported that 12.5% of abortions required cervical sutures, while another study reported up to 22% of women needing suturing. Suturing is a service that outpatient abortion clinics usually don’t provide. Alarmingly, the risk of cervical and uterine tearing nearly doubles for women under 17, since their cervix is still maturing.

Incompetent Cervix, or a cervix too weak to hold the weight of a developing baby, is found in 75% of women who have undergone dilation for an abortion. The risk of miscarriage, premature birth, and labor complications goes up by 300-500% in women with this kind of cervical damage.

Risk of placenta previa, where the placenta develops over the birth canal, increases 7-15 times after induced abortion. This condition increases the risk of fetal malformation, perinatal death, and hemorrhage during labor.

4. Each abortion makes it increasingly unlikely you’ll be able to deliver a baby vaginally in the future.

1 in 3 American women have had at least one abortion by the time they are 45 years old. This may help to explain our unbelievable cesarean section rates, since women who have undergone surgical abortion almost always have some degree of tearing (and suturing), and thus, scar tissue. Scar tissue in the uterus can impede its ability to contract during labor, and scar tissue in and around the cervix can make it difficult or even impossible for it to dilate.

5. Abortion increases risk of handicaps in future babies.

The side effects of induced abortion increase chances of premature delivery, complications of labor, and abnormal development of the placenta in later pregnancies. These reproductive complications are the leading causes of handicaps among newborns.

6. Abortion significantly increases your chance of developing breast cancer and other cancers.

A recent study on Chinese women showed that women who had undergone one abortion were 82% more likely to develop breast cancer than women who had not had an abortion, and that number rises with each procedure. “Induced abortion prevents breast tissue from growing from immature type 1 and 2 lobules into mature type 3 and 4 lobules, which makes pregnant women more susceptible to carcinogenesis at extremely high levels of cancer-promoting estrogen during pregnancy,” Doctors Angela Lanfranchi and Joel Brind note in the study. Estrogen levels increase by 2000% during the first trimester, but those lobules don’t mature until the third trimester, so abortion during the 1st and 2nd trimester puts women at a high risk for breast cancer.

Induced abortion also raises a woman’s risk of cervical cancer 2.3 times, and up to 5 times with multiple abortions. Risk of ovarian and liver cancer are supposedly also raised, though I couldn’t find specific numbers.

7. Women who have had abortions report a multitude of emotional and psychological effects.

There is only one positive emotion that researches have consistently found present among women who have had an abortion: relief. 8 weeks after an abortion, one study reports that 60% of women report negative reactions. 55% expressed guilt, 44% complained of nervous disorders, 36% had experienced sleep disturbances, 31% had regrets about their decision, and 11% were on some form of psychotropic medicine.

A study of the medical records of 56,741 California medicaid patients revealed that women who had abortions were 160% more likely than delivering women to be hospitalized for psychiatric treatment in the first 90 days following abortion or delivery, and rates of psychiatric treatment remained significantly higher for at least four years.

Women report over 100 psychological and emotional reactions to abortion including a variety of sexual dysfunctions, depression, post-traumatic stress disorder, self-destructive behavior, personality changes, anxiety attacks, chronic sleeplessness, difficulty concentrating, self-hatred, addiction and/or substance abuse, difficulty bonding with future children, thoughts of suicide, attempted suicide… the list goes on. The risks are exponentially higher for women under 17.

Abortion has a dramatic impact on women’s health. I absolutely believe it is a critical part of healthcare, namely, educating women on the potential cost, long-term effects, and risk of irreversible damage to their bodies. I don’t share this information to condemn women who have had abortions or those who feel it is their only choice. Certainly, I believe there are cases where an abortion is an acceptable option and the risks are warranted.

I share this information because I care deeply about women’s wellbeing and about their reproductive and general health. I care deeply about our right to make informed choices about our healthcare, and these risks are not being presented clearly and consistently to women considering abortion.

If you’d like references to any of the studies I mentioned, please ask in the comments, I’m happy to email them to you. I just chose not to include them because this was already such a long post.

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On Informed Consent and Refusal

I can’t tell you how many women I’ve met who are dissatisfied with their birth experience at some level and, even years later, still have regrets.  Sometimes it’s because they didn’t understand what was being done to them.  Sometimes it’s because they felt pressured by their health care provider to do something they didn’t want.  Sometimes it’s because they had an outcome that, they learned later, probably could have been prevented if they had avoided a certain intervention.

I also know many women who trust their doctors implicitly, and while I never want undermine my client’s health care provider, I realize that the health care system is pretty dysfunctional and doctors are, unfortunately, motivated by many factors in addition to their patient’s well-being… but that’s a can of worms I don’t want to open right now.  My point is, many women expect to walk into the hospital, have their doctor tell them what to do, and be happy with the results, and it very often doesn’t work that way.  You have to understand the process of labor and the many medical interventions that may and probably will be suggested to you at some point.

If you don’t know your options, you don’t have any.  Many wonderful alternatives to standard medical interventions aren’t popular with most doctors because they may take longer, bring in less money, or be less convenient for staff.  And even though some procedures have been proven useless or even harmful, many doctors continue to recommend them routinely.

Did you know that your Health Care Provider must inform you of the following prior to performing a procedure?

  • The nature of the procedure and how it is done
  • Whether the procedure is new or experimental
  • Why they recommend it for you (is it universally recommended, and why?)
  • How it will affect you, your baby, and your labor
  • The benefits associated with the procedure
  • The risks associated with the procedure
  • Any alternatives that are available (a doula may suggest many helpful alternatives)
  • What you can expect your recovery to be like
  • If it’s possible to delay the procedure

It is your legal right to get answers to every single one of these questions.  It is your legal right to refuse any intervention (unless it’s an emergency, in which case doctors may do anything necessary to save you and your baby’s life).  That’s why education is so important before you get the L&D Ward.

When facing a decision during labor, the BRAINED acronym is a great way to make sure you are giving informed consent- or refusal- to whatever intervention your doc is suggesting.

Benefits. Why is this good for me, my baby, and the progress of my labor?

Risks. What are the risks associated with this?  What other interventions are likely to go along with it?

Alternatives. What are my other options? Is this a routine procedure, something that is universally suggested?

Intuition. Don’t underestimate the power of you gut. What do your instincts say?

Nothing. What if I do nothing?  What if we delay this intervention?

Emergency. If this is an emergency and there’s literally no time for an in-depth discussion, try to talk with the staff as they work.

Discuss.  Your Health Care Provider is legally required to give you and your support system (partner, doula, friend, or whoever you want) time to discuss the intervention privately.  You don’t have to make a decision right then and there.

If I could get one message across to women, it’s that you are under absolutely no obligation to consent to an intervention you aren’t comfortable with or don’t understand unless it’s a true life-and-death emergency.  I think many women feel as if they are inconveniencing and annoying their doc or have a fear of being “that” patient, but you have a right to get all the information necessary to make an educated choice.

Get educated before your birth.  Make sure you have a strong support system, like a doula, who will help you understand your options so you can self-advocate.  Remember BRAINED if your health care provider is recommending an intervention you aren’t sure about.

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