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Texas Health and Human Services Says Women Don’t Want to Change Providers—Actually, Many Can’t

12:58 pm in Uncategorized by RH Reality Check

Written by Andrea Grimes for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Doctor with stethoscope

Texas women struggle to see doctors they trust after changes to health care programs.

Without Planned Parenthood, the new Texas Women’s Health Program (TWHP) has seen a 23 percent reduction in medical claims and thousands fewer Texans enrolled in the program in the first half of 2013 as compared to the same period last year, when the program was still the Medicaid Women’s Health Program. The state’s explanation? Women just don’t want to change doctors.

“We expected to see a drop off in the number of claims when we moved to the state program because we knew some women wouldn’t want to change doctors,” said Texas Health and Human Services Commission (HHSC) spokesperson Stephanie Goodman in a statement this week.

Goodman’s statement is at best glib and at worst a kind of victim-blaming that puts the responsibility for the state’s failure to provide low-cost reproductive health care squarely on the shoulders of the very people it is supposed to be serving.

The TWHP provides contraceptives and well-woman exams to low-income Texans. From 2007 to 2012, it operated as part of Medicaid, receiving a 90 percent federal match in funds and, at peak enrollment, saw almost 130,000 clients. But in 2012, the state kicked Planned Parenthood out of participating in the program because it considers the organization to be an abortion “affiliate” and thereby ineligible to provide health care using public funds in Texas. At that time, the federal government dropped its support of the program because the arbitrary exclusion of any qualified health provider from a Medicaid program is a violation of the Social Security Act, which dictates that Medicaid enrollees have a right to receive care from the physician of their choosing. To fund a program that denies Texans the ability to see the qualified doctor of their choice would, according to the Center for Medicaid Services, be a violation of its own law.

Undeterred, Texas launched a new, entirely state-funded Women’s Health Program in January of this year, and so far it has seen its service numbers plummet without the involvement of Planned Parenthood, which historically saw about half of all Women’s Health Program patients.

According to preliminary data provided by the Texas HHSC, current enrollment in TWHP is estimated to be about 97,000 clients, the lowest number of enrollees since September 2009, when the program was just two-and-a-half years old. This July, the TWHP counted over 10,000 fewer enrollees than it did in the same month last year. Add this to the fact that, according to the University of Texas’ Texas Policy Evaluation Project (TPEP), more than 60 family planning clinics in Texas—most of which were not Planned Parenthood facilities—have closed since 2011 due to family planning funding cuts, and it’s clear that there’s a serious, and growing, hole in Texas’ reproductive health safety net.

And yet the state says that if fewer and fewer low-income Texans are receiving publicly funded reproductive health care, it must be because women don’t want to change doctors. Considering the very real logistical, physical, and emotional challenges women face now that they have been forced by the state government to find new reproductive health providers, the HHSC’s statement seems an egregious simplification of a deeply complex and personal issue.

Amanda Stevenson, a TPEP researcher who studies the impact of family planning budget cuts on low-income Texans, told RH Reality Check that research shows changing doctors is not simply about personal preferences, but rather about the complex ways Texans choose their providers and the many factors that influence their decisions.

“There’s lots of other complexities that are hidden by [Goodman's] statement,” Stevenson said, citing spatial distribution and capacity of providers as just two factors that affect whether someone is able to switch to a new doctor. “Maybe you don’t want to go to a doctor who is 50 miles from you, but you also sort of can’t,” she said. “Preference is not the right framework for this.”

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‘He Said/She Said’ Journalism: A Growing Threat to Public Health

10:38 am in Uncategorized by RH Reality Check

Written by Tara Murtha for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Jenny McCarthy

Why does the mainstream media give crackpots a voice?

The recent announcement that actress Jenny McCarthy is replacing Elisabeth Hasselbeck on the popular ABC morning talk show The View has sparked an intense wave of backlash.

The problem is that after McCarthy’s son was diagnosed with autism, she became convinced it was because of the measles, mumps, and rubella (MMR) vaccine, and over the last several years she has reinvented herself as the leading celebrity voice of the anti-vaccine movement. Although the study that originally sparked the MMR vaccine-childhood autism panic has since been completely discredited, many parents have stopped vaccinating their children, in part because of anti-vaccine advocacy carried out by McCarthy and others. As a result, measles cases have spiked in recent years.

Critics say that McCarthy’s anti-science views are a public health hazard, and giving her a platform, on a morning talk show or in other media outlets, legitimizes her view. For instance, “Larry King had [McCarthy] debate a doctor, as though her disproven ideas should be given the same equivalence as those of a medical expert,” The Nation editor and publisher Katrina vanden Heuvel wrote recently, adding, “False equivalency is one of journalism’s great pitfalls, and in an effort to achieve ‘balance,’ reporters often obscure the truth.” As Brendan Nyhan, writing at the Columbia Journalism Review, argued, uncritically repeating discredited statements just amplifies the spread of misinformation.

False equivalence is the worst of what New York University journalism professor Jay Rosen and others have called “he said/she said” journalism. It takes much less time—and subject expertise—to frame a story as a “controversy” than to give it informative context. (Not to mention that a non-scientific minority opposition to the vetted facts does not qualify as a “controversy.”)

When it comes to covering health and science, the “he said/she said” short-cut is downright dangerous.

It’s unfortunate then that media coverage of reproductive health issues often falls into this trap as well.

Reproductive Health

Hasselbeck, the former Survivor contestant whom McCarthy will replace, once argued to one of her co-hosts on The View that taking the morning-after pill is “the same thing as birthing a baby and leaving it out in the street.” She said that she believes emergency contraception (EC) disrupts a pregnancy. In fact, EC prevents ovulation from occurring, preventing fertilization in the first place.

Since the medical definition of pregnancy is successful implantation of a fertilized egg, effective use of EC means you can’t get pregnant in the first place.

Yet there was relatively little outrage over Hasselbeck’s remark or the dispute, which was described in many outlets, as usual, as a “cat fight” between hosts.

When it comes to reproductive health, we have a much higher tolerance for hearing anti-science beliefs with serious public health consequences. Of the many fake-science falsehoods published every day on reproductive health issues, only the most obvious draws McCarthy-level heat. Most memorable is the belief, shared by an ever-expanding number of lawmakers, that women’s bodies contain magic lady-venom to prevent pregnancy in cases of rape.

While these legislators draw much deserved public ridicule, it’s the less obvious anti-science and evidence-free statements published every day that are most dangerous.

For example, the federal 20-week abortion ban being pushed by Rep. Trent Franks (R-AZ) and other bans like it are premised on preventing fetal pain, even though scientific studies have consistently found that fetal pain is unlikely before the third trimester.

Rep. Franks has as little expertise about the science of fetal pain or the public health consequence of banning abortions at 20 weeks as Jenny McCarthy does about vaccinations. Yet he’s pressed the issue, despite the fact that the bill has little to no chance of passing the Senate. Why would Franks make such a production of a failing endeavor?

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Why Admitting Privileges Laws Have No Medical Benefit

12:55 pm in Uncategorized by RH Reality Check

Written by Imani Gandy for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Hospital surgery with team

Forced hospital admitting privileges don’t protect women seeking abortions.

Last week, a federal judge in Wisconsin extended a temporary restraining order that prevented Wisconsin’s latest legislative attempt to reduce women’s access to safe abortion care—by requiring abortion providers to obtain admitting privileges from a local hospital—from going into effect.

Section 1 of Wisconsin Act 37 (SB 206), which was proposed by the Wisconsin legislature on June 4 and hastily signed by Republican Gov. Scott Walker on July 5, requires that physicians who provide abortion services have admitting privileges at a hospital within 30 miles of the location where the abortion is performed. The law was enacted ostensibly to reduce the risk to patients who suffer serious complications during an abortion, and to prevent abortion providers from abdicating their duty of care and leaving such women to fend for themselves. In reality, however, these laws place a substantial obstacle in the path of a woman seeking an abortion and contravene the constitutional principles set forth in Planned Parenthood v. Casey.

At first blush, these laws may seem sensible enough, especially if you believe that abortion is a dangerous procedure and providers should have hospital admitting privileges in case something goes horribly awry. Such is the concern of anti-choicers pushing for the Wisconsin law, as Susan Armacost, legislative director of Wisconsin Right to Life, noted in a July 5 statement. “Apparently, Wisconsin’s abortion clinics don’t believe their abortionists need to have hospital privileges at a hospital located within 30 miles of their clinic … or anywhere at all,” she said. “Currently, when a woman experiences hemorrhaging or other life-threatening complications after an abortion in Wisconsin, the clinic puts her in an ambulance and sends her to a hospital ALONE where she is left to her own devices to explain her medical issues to the emergency room staff. The abortionist who performed the abortion is nowhere to be seen. This deplorable situation must change.”

But documents submitted to the federal court in Wisconsin overseeing the case paint a very different picture of the admitting privileges law. According to Dr. Douglas Laube, a board-certified OB-GYN since 1976, the admitting privileges requirement is “medically unjustified and will have serious consequences for women’s health in Wisconsin.”

As Dr. Laube explained to the court, abortion is one of the safest medical procedures in the United States, alarmist claims to the contrary notwithstanding:

The risk of death associated with childbirth is 14 times higher than that associated with abortion. The risk of death related to abortion overall is less than 0.7 deaths per 100,000 procedures. (As a point of comparison, Dr. Laube states that the risk of death from fatal anaphylactic shock following use of penicillin in the United States is 2.0 deaths per 100,000 uses.) Less than 0.3% of women experiencing a complication from an abortion require hospitalization.

Abortion is an extremely safe procedure that rarely results in serious complications, and despite anti-choicers’ vehement efforts to cloak such laws in feigned concern for maternal health, current medical practices are such that risk to patients won’t be reduced by restrictive rules requiring admitting privileges.

When something goes wrong during a surgical abortion and hospitalization is required, the practical reality is that if a patient is transported by ambulance to a hospital, the EMT will make the decision about which hospital the patient should be taken to. Similarly, in cases of medical abortion, if a pregnant person experiences medical complications at home, she will likely be transported by ambulance to the nearest hospital, and not necessarily to the hospital nearest to the abortion clinic, or to the hospital for which, under the new act, the abortion provider will be required to have admitting privileges.

Moreover, such requirements do not account for modern practices for inpatient hospital care. Currently, typical hospital practices seek dedicated staff physicians to provide inpatient care, and whether an abortion provider has admitting privileges at a particular hospital plays little or no role in determining which hospital may be best suited to care for the patient.

Ultimately, as U.S. District Judge William Conley noted in his ruling,

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Talking to Men Who Are Clinic Escorts

11:08 am in Uncategorized by RH Reality Check

Written by Chanel Dubofsky for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Button: Will You Stand with Planned Parenthood?

The stories of male allies at abortion clinics.

Recently, I was having a conversation with some other reproductive justice-inclined folks about cisgender men who are clinic escorts. Escorting, regardless of your gender, can be taxing. (It can also be powerful, rewarding, and beautiful.) You wake up early and stand outside an abortion clinic for hours. You may have to answer questions from people who are just walking by and want to know what’s happening, without knowing whether or not they’re going to be sympathetic. Anti-choice protestors will try to make your job harder via verbal or physical harassment.

For the most part, it is women who take on the job of escorting at clinics, but on occasion there are men. Generally speaking, in the abortion conversation, men are either providers, the partners of those getting abortions, or protestors. “I am constantly having to stop myself,” said MB, a female clinic escort, “from asking both the dude protestors and the dude escorts, what does this mean to you? Why are you here?”

I decided to track down some men who are clinic escorts to get answers to these questions. And I read their answers with this quote from Natalie, a clinic escort in Los Angeles, in mind: “Some cis male clinic escorts are great, and it’s an honor to volunteer with them. I think cis men who choose to get involved with clinic escorting have a responsibility to be conscious of what they bring to the dynamic. They have the power to present a male-inclusive feminism to patients, protesters, and passers-by, or to perpetuate the status quo.”

P is a 25-year-old data scientist who lives in Boston. He has escorted at a private clinic in Philadelphia and at a Planned Parenthood office in Boston.

RH Reality Check: Why did you decide to start escorting?

P: My girlfriend and I met in college. She had been a clinic escort with her mom before college and was continuing that before we started dating. She told stories about these crazy people who would protest, so after we started dating I was feeling like there was this remote possibility that something bad would happen to her while she was escorting, and if it did then I would feel terrible. So I started going along with her. It’s worth noting that she had been escorting by herself for a long time, so it wasn’t like I thought anything would happen. But I was appalled at the thought of not being there if something did happen. I also am pro-choice, but as in this paragraph, that was a bit of an afterthought.

RHRC: How do you think your identity as a cis man has affected your experience as an escort?

P: I think there was some extra special vitriol from anti-abortion protestors in some cases. One time I was volunteering in Philadelphia and there was this old white dude who was protesting, and he came up to me and started telling me how unmanly I was in various ways. The most memorable part was that he called me a “sissy bitch.” The clinic has a non-engagement policy for the volunteers, so I didn’t respond to him.

RHRC: What’s been the best part of escorting for you?

P: Like any kind of volunteering, it always feels good to have people express their gratitude. This wasn’t usually from patients so much, because they were usually pretty stressed out, but passers-by would sometimes say “Thanks for being here” or give thumbs up or whatever. That’s always nice.

Eric is 39 and works in high tech marketing. He escorted at the Summit Women’s Center in Bridgeport, Connecticut.

RHRC: What was your motivation to start escorting?

Eric: Some good friends of mine were organizing these escorts at a clinic in Bridgeport, about 40 minutes from where we were at college. I came from a family of activists, and I myself had participated in political and issue activism going back to middle school. I was eager for the opportunity to make a difference in individuals’ lives and experience life in the middle of the abortion conflict.

RHRC: How do you think your identity as a cis man has affected your experience as an escort?

Eric: We had some strict rules about how men could escort. Two escorts would walk with every woman, and at least one of them had to be a woman. But we also occasionally had other groups join us for escorting, and they didn’t abide by these rules, which annoyed me. I understood that these women were going through hard times, such as being told by a male-dominated society that they were murderers for making their own decisions about their bodies. So I respected our rules.

Harry Waksberg is a 25-year-old writer who volunteers at a clinic in Los Angeles.

RHRC: What was your motivation to start escorting?

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Stigma on Steroids: On Kansas Banning Abortion Providers From Schools

11:09 am in Uncategorized by RH Reality Check

Written by Carole Joffe for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

No school district, employee or agent thereof, or educational service provider contracting with such school district shall provide abortion services. No school district shall permit any person or entity to offer, sponsor or otherwise furnish in any manner any course materials or instruction relating to human sexuality or sexually transmitted diseases if such person or entity is an abortion services provider, or an employee, agent or volunteer of an abortion services provider.

Kansas High School

Kansas schools now forbid anyone with ties to abortion clinics.

The above provision is contained in a nearly 50-page bill that recently went into effect in Kansas. (A judge temporarily blocked two other provisions of the law, but allowed this one to remain.)

To be sure, the relentless assault on abortion that we are currently seeing in other state legislatures—Texas, Ohio, and North Carolina, among others—are far more consequential in the short run. Ambulatory surgical center (ASC) and hospital admitting privilege requirements really do have the capacity to shut down clinics. Should the Texas bill currently being considered become law—as is likely, despite the heroic efforts of the thousands of orange-shirters gathered at the capitol—the number of Texas abortion facilities would go from 47 to five in that huge state. Already, due to a similar ASC requirement, earlier rammed through the Pennsylvania legislature as a cynical response to the Gosnell scandal, a number of clinics in Pennsylvania have closed. And the bans on abortions after 20 weeks, adopted by a number of states, will affect a relatively small number of women, but typically those in desperate medical and/or social condition.

But other provisions of abortion legislation, of which the Kansas one cited above is a prime example, do a different kind of damage. They further the stigmatization and marginalization of abortion providers by making clear that these individuals are not welcome in that most central of community institutions: the schools. It is not just participation in sex education from which Kansas providers are barred. As Stephanie Toti, senior attorney at the Center for Reproductive Rights, which is challenging this law, told me, “This is unprecedented discrimination against abortion providers. … The prohibition on providers serving as ‘agents’ of a school district has the effect of barring them from serving as chaperones on field trips and engaging in most other volunteer activities.”

So abortion providers are at this moment banned from Kansas schools—and supposedly this will promote the safety of adult women getting abortions, as is the typical sanctimonious rationalization of the various laws we are seeing.

I asked several lawyer colleagues if they knew of other instances in which a whole occupational category was banned by law from volunteering in schools. They did not. Indeed, as far as I can tell, only sex offenders as a class are de facto banned from school grounds.

This shocking ban on abortion providers’ involvement in the schools leads me to recollect other instances I have encountered of attempts to isolate this group and keep them from community involvement. I think of a provider I’ve written about who I call Bill Swinton (not his real name), a family medicine doctor in a small town in the Pacific Northwest. He was deeply involved in both his church and his community, and served for three terms on the local school board. But he was defeated for a fourth term in the late 1980s, as the abortion wars intensified; needless to say, his status as a provider was the key factor in his defeat. I think as well of another doctor I’ve written about named Susan Golden (also not her real name), in a town in the Midwest, who integrated abortion provision into her family medicine practice. When she and her partner planned to take part in a community health fair, presenting on the care of newborns, the entire event was abruptly cancelled by the anti-abortion owner of the facility where the fair had been scheduled to take place.

As disturbing as these incidents were, they did not have the force, or the legitimization, of law. The Kansas provision does—and as such, takes the stigmatization of abortion providers to a new level.

Assuming the Kansas law, including this provision, is not overturned, we can only speculate as to what effects it might have. Speaking personally, I remember as a child the enormous pride I felt when my father, a cardiologist, came to my elementary school with his microscope and showed the class wondrous things. As a working mother, I recall how much I valued occasional volunteer stints in my daughters’ schools, getting to know both their classmates and other parents. It is very disturbing to contemplate that providers and their children will be deprived of these experiences. And it is equally disturbing to contemplate the messages that others in the community will receive from such a ban.

This provision truly is stigma on steroids.

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For Decades, Authorities Let Rogue Abortion Provider Harm Women, Despite Pleas From Legitimate Doctors

1:01 pm in Uncategorized by RH Reality Check

Written by Sharona Coutts for RH Reality Check.

Hospital bed

An illegal abortionist was tolerated by the state for years despite many injured women.

On August 13, 2010, an 18-year-old New Jersey resident arrived in a clinic in Elkton, Maryland, to undergo a surgical abortion. She was 21-and-a-half weeks pregnant, and had driven just over an hour from a clinic in Voorhees, New Jersey, where the day before, Dr. Steven C. Brigham had initiated the procedure.

Just 15 minutes into the surgery in Maryland, the patient suffered major injuries. Her uterus was ruptured, and her bowel had been perforated and was protruding into her vagina.

Instead of immediately calling 911 for emergency assistance, her doctors—Brigham and his associate, Nicola I. Riley—waited nearly two hours, according to findings from the Maryland State Board of Physicians. They then dressed the patient, who was still sedated and slumped over, and lifted her into a wheelchair. They rolled her outside, put her in a car, and with Brigham at the wheel, took her to a nearby hospital. Her injuries were so severe that hospital staff had her airlifted to Johns Hopkins Health Center for emergency treatment.

The patient survived, and as was reported Thursday morning in the New York Times, her story now forms a key part of the evidence that is being used in an administrative proceeding brought by New Jersey’s attorney general to have Brigham’s medical license permanently suspended or revoked.

However, what has not yet been reported is the extent to which legitimate providers in the states where Brigham practiced went to warn state officials of the threat Brigham posed to the health of the women he served.

In numerous complaints, emails and phone calls over a period of more than two decades, legitimate abortion providers from New Jersey and neighboring states alerted authorities to Brigham’s dangerous conduct, furnishing warnings they say went largely unheeded. Doctors provided copies of many of these complaints, as well as extensive logs of their calls, to RH Reality Check.

An investigation by RH Reality Check shows that New Jersey officials responsible for overseeing healthcare in that state could have prevented injuries to this and subsequent patients, had they acted on warnings about Brigham that predicted this exact scenario.

“If they had listened right in the beginning and taken appropriate action, I think these harms would have been prevented,” Jen Boulanger, a clinic administrator who has spent years amassing complaints about Brigham and his associates, told RH Reality Check. “I think state agencies were afraid of raising eyebrows about abortion, but they just should have handled it like they do any other field of medicine.”

A spokesman for the New Jersey attorney general’s office, which has ultimate oversight of the New Jersey Board of Medical Examiners, said the office could not comment on Brigham, because of the ongoing dispute over his medical license.

Attempts to reach Brigham, as well as attorneys listed as his representatives on official documents, were unsuccessful.

Brigham has now had his medical license suspended or revoked in up to six states, but public records show that he remains at the helm of an abortion chain called American Women’s Services, which is based in New Jersey, and owns or is affiliated with 15 clinics in four states. There is no requirement that the owner of a medical facility actually possess a medical license, state officials said.

The issue of abortion has once again leapt to the forefront of state and national politics. Already this year, dozens of anti-choice laws have been proposed or have passed at the state level, and a 20-week abortion ban recently passed in the U.S. House of Representatives.

Anti-choice advocates, including activists, and state and federal politicians, have capitalized on the case of another rogue provider—Kermit B. Gosnell—to falsely claim that he represented the norm in abortion care.

TIMELINE OF EVENTS

1986: Brigham graduates from Columbia University College of Physicians and Surgeons. In the coming years, National Abortion Federation leaders grow concerned about his skill level. Brigham fails to complete his NAF training, and his application for membership is denied.

APRIL 1992: Brigham agrees to voluntarily retire from practicing medicine in Pennsylvania in exchange for the state dropping a pending investigation regarding him. His license is placed on permanent inactive status, and he is ordered not to ever apply for renewal or reinstatement.

NOVEMBER 1993: The New Jersey attorney general’s office files its first complaint about Brigham with the board of examiners. Two more complaints are filed in July and December of 1994.

JANUARY 1994: New York suspends Brigham’s license, calling him an “imminent danger to the health of the people of New York.”

FEBRUARY 1994: New Jersey restricts Brigham’s license, determining that his unrestricted practice presents a clear and imminent danger to the people of New Jersey.

NOVEMBER 1994: New York revokes Brigham’s license, finding him guilty of gross negligence and negligence on more than one occasion in practicing medicine.

FEBRUARY 1995: Florida suspends Brigham’s license.

JUNE 1996: Florida revokes Brigham’s license.

AUGUST 1996: Upon a favorable ruling by the Office of Administrative Law on the three complaints filed by the New Jersey attorney general, New Jersey reinstates Brigham’s medical license subject to conditions that Brigham only perform abortions during the first trimester of pregnancy in the state.

SEPTEMBER 2005: A complaint lodged online by a doctor with the New Jersey Board of Medical Examiners warns that Brigham was performing second-trimester abortions in New Jersey.

SEPTEMBER 2009: Pennsylvania bans Brigham from owning or running abortion clinics in Pennsylvania.

FEBRUARY 2010: A group of New Jersey doctors, abortion clinic administrators, and counselors send a collection of complaints to the enforcement bureau of the New Jersey attorney general’s office and to William Roeder, executive director of the New Jersey State Board of Medical Examiners.

AUGUST 2010: An 18-year-old patient is injured at Brigham’s Elkton, Maryland, abortion clinic and is airlifted to Johns Hopkins Health Center for emergency treatment. Maryland issues a cease and desist order to Brigham, demanding that he stop practicing medicine in Maryland without a license.

OCTOBER 2010: New Jersey suspends, but does not revoke, Brigham’s license.

FEBRUARY 2013: A patient dies at Brigham’s Baltimore abortion clinic.

The documents provided to RH Reality Check, however, show that reputable providers tried for years to sound the alarm on a rogue provider. In Brigham’s case, they made sustained efforts to prompt officials in New Jersey, Pennsylvania, and Maryland to enforce the regulations that already existed to ensure safe abortion care. The documents provided show that authorities were often slow to respond to those warnings, if they acted at all.

For the providers who spent years trying to stop the problems they saw at Brigham’s clinic, the fact that he is still involved in women’s health—and being used as justification for restricting access to abortion—signals systemic problems with how the authorities and politicians treat reproductive health issues. They also said they believe many of these new legal restrictions—in addition to being medically unnecessary—could push more women into the hands of rogue providers, such as Brigham or Gosnell.

“It’s heart-breaking,” said Claire Keyes, who worked for more than 30 years as director of the Allegheny Reproductive Health Center in Pittsburgh, where she treated dozens of patients who had been to clinics owned by Brigham. “This isn’t throwing women under the bus. This is like backing up over and over and over them.”

A Long History of Problems

Brigham had already accrued a long history of harming patients by the time he botched the abortion in 2010.

Over a period of more than two decades, Brigham has left patients with severe bowel injuries, severed ureters and sweeping lacerations to the uterus, and requiring emergency hysterectomies for procedures that, when done by a properly trained provider, has a very low risk of complication, public records show.

In fact, Brigham first came to the attention of national abortion providers shortly after graduating from Columbia University College of Physicians and Surgeons in 1986. His prestigious education and natural charisma led many colleagues to give him a warm welcome into the professional community.

“We were very enthusiastic about this doctor when he first came,” said Suzanne Poppema, a former board chair of the National Abortion Federation (NAF) and Physicians for Reproductive Health. “He was young and socially adept and seemed to say all the right things, and asked good questions that you would expect someone just starting out to ask.”

But that impression changed quickly, Poppema said. Colleagues noticed that Brigham continued to ask the same questions at subsequent meetings, which struck them as odd. And then they began to hear troubling reports about the young physician’s medical practices.

“Right away we started hearing that he was moving into both early and later second-trimester abortions. And he had a complication,” she said, referring to a problem with an abortion procedure.

In the hands of a skilled provider, abortion carries a very low risk of complication, even after 20 weeks’ gestation, and certainly lower than the risks associated with giving birth. However, the risk of complication increases as the pregnancy progresses, and like any complex medical procedure, specialized training is required. NAF board members believed Brigham lacked those skills, and decided to confront him to express those concerns.

“I sat down with him and three other physicians, and we said to him, ‘You have to promise that you will not do any second-trimester abortions until you have spent two weeks with one of our senior physicians,’” Poppema recalled.

But Poppema said Brigham never completed that training. NAF rejected his application for membership, and lodged their concerns with Pennsylvania authorities, including the attorney general and the State Board of Medicine.

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Why Does the ACGME Want to Eliminate Contraceptive Training for Family Physicians?

12:32 pm in Uncategorized by RH Reality Check


Written by Dr. Linda Prine and Dr. Ruth Lesnewski for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

In one of the clinics where we work, a 16-year-old girl came in with a sprained ankle.  She left with a prescription for birth control.

This turn of events is not as surprising as it seems:  As family physicians, we treat the whole person.  A quick update revealed that our 16-year-old patient had recently begun to have unprotected sex — and had no plan to get birth control. One of the reasons we love practicing family medicine is that we get to know our patients over time and provide the preventive care they need at every possible opportunity.

That is why we are dismayed that the Accreditation Council of Graduate Medical Education (ACGME) has proposed changes to the guidelines for family medicine residency programs removing the requirement that residents learn to provide contraception. These changes will go into effect in 2014 unless the ACGME is convinced otherwise, during an open comment period taking place this week.

A majority of U.S. women get their basic health care from a family physician or other primary care provider, and often that includes reproductive health care. Especially in rural and low-income areas, family physicians do it all! They not only provide birth control but also provide prenatal care, deliver babies, manage miscarriages, counsel patients about unintended pregnancies, and, increasingly, offer pregnancy termination so that their patients do not have to travel long distances and see unfamiliar doctors for these services.

ACGME’s motivations are legitimate:  It seeks to simplify the rules for the nation’s family medicine residency programs — numbering over 450 — and to allow for more creativity and flexibility. In some areas of practice, this makes sense. Many programs will continue to teach contraception; it will depend on the culture of the institution. However, residency programs based in religiously-affiliated hospitals (which operate nearly 20 percent of inpatient community-hospital beds in the U.S.), will most likely drop birth control training immediately.

Because the ACGME currently requires birth control training, religiously-affiliated institutions must figure out a way to comply. Many rotate their residents through external clinics to learn these skills — which are essential since 99 percent of women in the United States who have ever had sexual intercourse have used a method of contraception other than natural family planning at some point in their lives. Without this requirement, residents in religiously-affiliated programs may get no training at all in contraception.

Just last week, we attended a meeting where an assistant residency director expressed satisfaction at the prospect of no longer needing to teach residents how to counsel patients with unintended pregnancies of all of their options. This is our concern: Limiting the training of family medicine residents in birth control will have a disproportionate impact on the millions of low-income and rural women and teens who rely on their family doctors to provide the full-spectrum of reproductive health care. The Affordable Care Act greatly expands access to contraception for millions of women in the United States. But, if clinicians aren’t trained in providing contraception, then that access is meaningless, even if it is covered. We need to make sure all clinicians who provide primary health care for women are trained to provide high-quality contraceptive care.

Our next generation of family physicians must learn and practice more contraception, not less. Otherwise our shamefully high rate of unintended pregnancy (the highest in the developed world) will rise further.

There is time to make a difference. The ACGME is accepting comments on the proposed guidelines until April 25, 2013. Click here to download our suggested version of the official comment form.  Fill in your information and email it to familymedicine@acgme.org.  The Reproductive Health Access Project has an online campaign for all of us to tell the ACGME that their changes affect our health care.

In El Salvador, Yet Another Woman’s Life Subordinated to Non-Viable Fetus

1:36 pm in Uncategorized by RH Reality Check

Written by Kathy Bougher for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Women in El Salvador sort coffee beans.

The women of El Salvador are denied life-saving access to abortion.

Beatriz wants to live. A 22-year-old Salvadoran from a poor, rural community, Beatriz (a pseudonym to protect privacy) suffers from chronic and severe medical conditions. She is the mother of an infant. And she is roughly 18 weeks pregnant with an anencephalic fetus, a fetus without a brain. Doctors at the Maternity Hospital determined that the pregnancy is life-threatening, and Beatriz requested that Salvadoran medical personnel perform an abortion, but a 1998 law in El Salvador prohibits all abortions, without exception.

The Salvadoran feminist organization Agrupación Ciudadana por la Despenalización del Aborto Terapéutico, Ético y Eugénesico (Citizen Group for the Decriminalization of Therapeutic, Ethical and Eugenic Abortion), which has been working to decriminalize abortion in the country since 2009, petitioned the Salvadoran Supreme Court on April 15 to intervene and to direct medical personnel to provide without fear of criminal prosecution the procedures Beatriz needs to save her life. Under current law, both Beatriz and any medical personnel involved in an abortion would face criminal charges and prison time. The court responded with a temporary directive that medical personnel provide the care necessary to guarantee her life and health while they make a decision regarding the petition for an abortion. Medical personnel were also directed to present to the court within five days a report on the condition of the mother and the fetus to inform their deliberations.

Within the past few days Amnesty International has initiated a petition asking for life-saving medical care, including an abortion; the United Nations has spoken; and the Salvadoran Minister of Health, Dr. Maria Isabel Rodriguez, has requested that the Supreme Court approve the request. Dr. Rodriguez emphasized that Beatriz’s kidney function continues to deteriorate as the pregnancy advances, and that the public health system is ready to perform an abortion. The Salvadoran Attorney General for Human Rights also supports the request.

At a press conference the Agrupación convened in San Salvador on April 18, Esther Major, an Amnesty International representative in El Salvador, characterized the way Beatriz is being treated as “nothing less than cruel and inhuman.”

“While we are talking, while the Court is thinking and the government is delaying, Beatriz is suffering. … The Salvadoran government has clear obligations, international as well as domestic, to protect Beatriz’s life, and to assure that Beatriz can access vital treatment as soon as possible.”

Legal reforms in 1998 in El Salvador, promulgated by conservative religious forces, outlawed  abortion without exception. Previously it was permitted if the pregnancy resulted from rape or incest, the mother’s life was in danger, or the fetus was not viable. In addition, a constitutional amendment was added declaring that life begins at conception, which means that prosecutors can charge women who seek abortions with aggravated homicide, punishable by 30 to 50 years in prison, rather than the lesser crime of abortion, which carries a term of two to eight years.

Threats of prosecution and prison terms are not to be taken lightly under the 1998 law. The Agrupación has mounted legal and educational campaigns to secure the release of six women from prison. Since no comprehensive data exist in the country, the Agrupación is conducting its own research, which reveals that currently at least 24 women are serving prison terms of up to 40 years for abortion or aggravated homicide related to abortion charges.

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Plan B Vending Machine Survives Anti-choice Misinformation Campaign

2:09 pm in Uncategorized by RH Reality Check

Written by Eleanor J. Bader for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Plan B contraceptive wrapper

Plan B emergency contraception is available 24 hours a day via public vending machine at one college, much to consternation of anti-choice advocates.

A little more than a year ago, during the same week that the Susan G. Komen Foundation  announced that it would no longer provide funds to Planned Parenthood, Shippensburg University, a previously little-known state college in Pennsylvania’s Cumberland Valley, captured media attention throughout the United States. The sudden spotlight on Shippensburg came as a result of a decision administrators had made five semesters earlier — at the end of the fall 2009 term — to sell Plan B Emergency Contraception (EC) from a vending machine located in a remote corner of the campus.

According to Dr. Peter M. Gigliotti, Executive Director for University Communications and Marketing at Shippensburg, roughly 300 students a year had swiped their college IDs to obtain access to the machine in the two-and-a-half years it had been operating. Each was given an opportunity to confer with a counselor in person or by phone before inserting $25 to obtain Levonorgestrel, AKA Plan B, a medication that prevents fertilization, preventing pregnancy if taken with 72 hours of unprotected intercourse.

Gigliotti believes that someone on campus — he does not know if it was a disgruntled student, faculty member, or staff person — tipped off the press that Shippensburg had a Plan B vending machine and within hours the story was garnering headlines and energizing anti-choice and abstinence-only advocates across the country. “What we did by making Plan B available in a vending machine is very emotional for a lot of people,” he begins. “When the story broke we immediately received more than 1000 calls and emails. Right away it became clear to us that people were confused about what Plan B is and how it works. The largest number of contacts came from people who oppose Plan B on a moral or religious basis and they did not want to listen to facts. In their minds Plan B is an abortion and no amount of scientific information will change their minds. They told us that we were killing babies and were all going to go to Hell.”

In addition, impassioned callers berated college administrators, arguing that they were kowtowing to the demands of a misinformed student body, 85 percent of whom had previously indicated — through a 2008 student survey — that they wanted on-campus access to the drug. “My ‘favorite’ email asked us if we would give dynamite to our students if 85 percent of them wanted it,” he laughs. “It was absurd. What they failed to recognize is that Plan B is legal and available in most pharmacies, without a prescription, to anyone who is over the age of 17.”

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What’s Up With Women and HIV-Prevention Method PrEP?

2:52 pm in Uncategorized by RH Reality Check

Written by Anna Forbes for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

"You are either affected or infected with HIV."

Why did a study show women had difficulty using a new HIV prevention drug?

At the 20th Conference on Retroviruses and Opportunistic Infections (CROI) in Atlanta this week, researchers reported that, in a large scale trial among African women, neither oral Pre-Exposure Prophylaxis (PrEP) nor the daily use of vaginal gel containing an anti-retroviral (ARV) drug had shown effectiveness in reducing HIV risk.

The clinical trial, Vaginal and Oral Interventions to Control the Epidemic (VOICE), enrolled 5,029 HIV-negative women and randomized them into five study arms. In one group, women were asked to take an oral tenofovir (an ARV tablet) daily. In a second arm, women tested the daily use of oral TDF/FTC (a two-ARV combination called Truvada), and in the third, women were asked to insert a vaginal gel containing 1 percent tenofovir gel that had been shown in a previous study to provide moderate protection against HIV.

The fourth and fifth arms were placebo controlled; women received either a pill or a gel that looked identical to the study products but contained no active ingredients. Comparing the rate of new HIV infections occurring among women in the control arms with those of women in the various intervention arms allowed the researchers to see if the use of the interventions reduced women’s rate of HIV acquisition. Participants in all arms were also regularly provided with free condoms, counseling about the need to use condoms consistently, and testing and treatment for sexually-transmitted infections (STIs) to reduce their HIV risk to the greatest extent possible.

Despite the fact that other trials of oral PrEP have shown some effectiveness in women, none of the VOICE interventions resulted in decreased HIV acquisition rates. Dr. Jeanne Marrazzo, co-principle investigator for the VOICE study, reported in her presentation at CROI that it appears relatively few participants in intervention arms of the trial actually used the products daily as instructed. By testing blood samples for the presence of the ARVs in the body, the researchers saw that only 25 to 30 percent of the women were using the products as instructed. A similar lack of adherence to daily product use also led to discontinuation of the FEM-PrEP trial in 2011.

The VOICE results are particularly frustrating and sad because of the high rates of new HIV infection that occurred among women in the trial. Even with the benefits of medical care, free condoms, condom counseling, and more, the rates were high — 6.3 percent among women in the oral tenofovir arm, 4.2 percent in the placebo oral arm, 4.7 percent in the Truvada arm, 5.9 percent in the tenofovir gel arm, and 6.8 percent in the placebo gel arm. The researchers reported that the greatest number of new infections occurred among women who were under the age of 25 and unmarried. The rate of women becoming HIV positive was less (although still high) among women who were over the age of 25, married, and/or who had partners over the age of 28. This pattern is prevalent globally. Even in the United States, younger women are at greater risk of HIV than their older cohorts.

This is also frustrating because we know that PrEP works when people use it. Data demonstrating this led to the Food and Drug Administration’s approval of Truvada for HIV prevention in the United States last year. In a 2010 study called iPrEx, Truvada reduced HIV risk among men and transgender women who have sex with men by 44 percent. Data from this study suggested that participants who took the drug strictly according to schedule and did not miss doses were up to 73 percent less likely to become infected. Adherence is a challenge across the board, however. About 50 percent of iPrEx participants were estimated to be adherent to the study protocol.

Other studies enrolling both women and men have also produced encouraging effectiveness data. In Partners PrEP, a study enrolling couples in which one partners was HIV-positive and the other was HIV-negative, effectiveness was shown to be 75 percent and adherence was estimated at 80 percent. The Centers for Disease Control and Prevention’s (CDC) TDF trial also showed adherence of about 80 percent, and the HIV risk of participants using the product was lowered by 63 percent.

So why is it that the two studies conducted exclusively among women did not yield evidence of effectiveness, when other studies enrolling both women and men did? What are the barriers to adherence that result in women finding themselves unwilling or unable to use this intervention daily? No answers to these questions are immediately apparent, although both the VOICE and the FEM-PrEP data are being further analyzed to look for clues.

If PrEP works for women (and men) when they use it, then why don’t women use it? Finding these answers will likely require additional research into the structural and cultural factors that shape behavior, perceptions of risk, and decision-making about sexual and health issues.

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