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Life Begins At Conception. That’s Not the Point.

12:57 pm in Uncategorized by RH Reality Check

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

Life begins at conception.

A human embryo.

This is perhaps the favorite phrase of anti-choicers seeking to eliminate women’s basic right to control over their own bodies. It is, for example, the premise of policies pushed by the United States Conference of Catholic Bishops (USCCB) and fundamentalist evangelicals. It is the cornerstone of the so-called personhood laws defeated by large margins in ballot initiatives undertaken in both Colorado and Mississippi. And it is the basis for the “Sanctity of Life” bill co-sponsored by Congressmen Paul Ryan (R-WI) and Todd Akin (R-MO) in the House of Representatives. The end game in all of these efforts is a radical shift in women’s lives, including a total ban on abortion without exception, and bans on many forms of contraception, in vitro fertilization, and health care for women who are or who may be pregnant.

“Life begins at conception,” is repeated incessantly by politicians such as Richard Mourdock, as though this were a revelation, something not previously known, that should inform our thinking on whether women are people with the same fundamental rights as men, or if they are essentially incubators whose ability to participate in society and the economy, and, quite literally, whose ability to live is dependent on whether they are, might be, or might become pregnant.

But the phrase is highly — and purposefully — misleading because it confuses simple biological cell division both with actual pregnancy and with actual, legal personhood, which are all very different things.

During the October 11, 2012 vice presidential debate, for example, moderator Martha Raddatz asked Vice President Joe Biden and Congressman Paul Ryan (R-WI) to discuss “the role religion has played” in their personal views on abortion.

Ryan responded by saying:

Now, you want to ask basically why I’m pro-life? It’s not simply because of my Catholic faith. That’s a factor, of course. But it’s also because of reason and science.

You know, I think about 10 1/2 years ago, my wife Janna and I went to Mercy Hospital in Janesville where I was born, for our seven week ultrasound for our firstborn child, and we saw that heartbeat. A little baby was in the shape of a bean. And to this day, we have nicknamed our firstborn child Liza, “Bean.”

Now I believe that life begins at conception.

Here is a startling revelation: I am a mother of two and a woman who earlier in her life had an abortion. I am unapologetically pro-choice. And I know life *begins* at conception (which itself is the product of a complex process), because I kinda already knew that having a child required, as a first step, the successful integration of a sperm and an egg, or fertilization.

In other words, “life” begins at conception, if by “life,” we mean the essential starting place of a potential human being. Neither my 16-year-old daughter nor my 13-year-old son would be here if they were not first conceived, if the fertilized eggs had not gone through the process of cell division, successfully implanted in my uterus and developed into healthy embryos, and subsequently gone successfully through the many other phases of development leading to their births.

The fact that life begins at conception is why women and men use birth control to prevent it from happening and why they have been trying to prevent it from happening since time immemorial. While they may not have had high-resolution microscopes and photography to reveal biological-level activity, women do not and did not need modern “reason and science” (to which anti-choicers now love to refer) to tell them they get pregnant from sex; as Homo Sapiens they have been conceiving, carrying, and bearing babies for at least some 160,000 years, and they’ve been trying to prevent pregnancy and induce abortions for just as long.

Evidence of condom use has been found in cave drawings in France dated between 12,000 and 15,000 years old and in 3,000 year-old illustrations in Egypt. Throughout history, people have variously practiced “outer course” (encouraged even by Christian clergy at some points in history!), and used pessaries, herbs, and other objects to create barriers to fertilization when having sex, not to mention trying many other more dangerous and less effective means, such as drinking lead and mercury or wearing blood-soaked amulets in the hopes of preventing fertilization, a subsequent pregnancy, and later, the birth of a child. I understand that seeing the sonogram of a wanted child is a powerful thing and a connection to the potential person whose birth is much awaited. But if it took Paul Ryan to see a sonogram of his daughter in utero to get him to believe his wife was pregnant and that his daughter’s “life” began with conception, the state of GOP knowledge on sex and biology is even worse than I thought.

The question is not when life begins. That just obfuscates the real issues.

The fundamental issues are:

Read the rest of this entry →

Disability, Prenatal Testing and the Case for a Moral, Compassionate Abortion

11:18 am in Uncategorized by RH Reality Check

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

by Sierra @No Longer Quivering

Note: If the headline didn’t already clue you in, this is controversial subject matter. If you come away from this article thinking that I advocate genocide of a disabled population or the coercion of women pregnant with disabled fetuses into abortion, that I hate disabled people or think that Down syndrome people don’t deserve to live, you have failed to understand my point. Please walk away from the computer, breathe deeply, and start again from the beginning.

I believe that it is possible and desirable to respect disabled people while still working to eliminate genetic disorders so that children who might have had Down syndrome or cystic fibrosis (or any other disease) have a chance to be born without them. I believe that abortion of a disabled fetus can be a compassionate choice made for morally sound reasons, and does not at all conflict with the respect due to disabled people. I am firmly pro-choice, and I believe strongly that the wellbeing of all born persons in a family is paramount before considering the needs of a fetus. My position is that fetuses are incapable of being self-aware and therefore cannot experience suffering the way born persons do. The prevention of suffering is central to my moral beliefs.

If you’re already angry, please stop reading and go get yourself a nice cappuccino. Have a beautiful day. And then, if you still really want to read this, take frequent breaks to punch a pillow with a "hello, my name is Sierra" badge stuck to it.

Her.meneutics, the "for women" arm of Christianity Today, recently ran an article by Sarah Eekhoff Zylstra on prenatal testing:

What You Need to Know About the Hidden Benefits (and Costs) of New Prenatal Tests

Apparently, science can do something awesome: tell you the genome of your fetus within the second trimester:

Using a blood sample from the mother and saliva from the father, scientists at the University of Washington mapped out the entire genome of a child while he was in the womb. The discovery, which was published June 6 in Science Translational Medicine, makes it possible to spot disorders from sickle cell disease to cystic fibrosis to Down syndrome in the second trimester of pregnancy.

Best of all, at least for those of us who shiver at the thought of an amniocentesis, is that it’s noninvasive.

About 10 percent of the free-floating in a mother’s blood belongs to her baby, and by comparing her blood with her own and the father’s DNA, scientists can pinpoint which DNA belongs to the baby. From there, they can sequence the child’s entire DNA code. Or at least, they can get pretty close. Their accuracy rate was about 98 percent in the infant boy they tested.

Zylstra says that, "at first blush," this information looks "incredible." Yes, it does. Because it is. This kind of technology gives us more control over our own reproduction, which means that we’re better able to make ethical decisions about our parenting. As Zylstra points out, parents who are expecting a special needs child can prepare in advance for what that means.

But there’s a catch, says Zylstra:

You can be emotionally prepared for his birth. You could choose a C-section if that was warranted, or line up services for him, or join a support group.Or abort him.That’s the rub, said Gene Rudd, president of the Christian Medical and Dental Associations.

It’s hard to imagine this test wouldn’t be the instigation of selective abortions, since many women with prenatal diagnoses of Down syndrome currently abort, he said. "It’s search and destroy that we do that now with Downs," he said. "And to what benefit do we do that? If we look at the statistics or surveys that come from families that have raised a Downs individual, 97 percent said it was rewarding."

It’s a life worth living, and many see that, says Amy Julia Becker, who has written extensively about her daughter with Down syndrome. Heart conditions and respiratory troubles often suffered by those with Down syndrome can be treated, life expectancy has risen from 25 to 60, and by all accounts, raising a son or daughter with Down syndrome can be a wonderful gift. The numbers are tricky, but Becker says that about 70 percent of babies prenatally diagnosed with Down syndrome are aborted.

"Ultimately, the problem is that we have a society that says it’s okay to kill unborn babies," Rudd told me. "If that weren’t permissible, this information wouldn’t be misused." Prenatal testing in a country with legal abortion lets parents decide if that child is "good enough" to live, he said. But as imperfect, capricious, sinful beings, how do we figure we’re smart enough, or good enough, to judge anybody else’s shot at life?

"Who are we to say that cystic fibrosis is such an overwhelmingly terrible disease that they shouldn’t be allowed to live?" Rudd said. "Do we say that about a one-year-old who is diagnosed? What’s different about a younger child?"

There are a lot of pieces to this pie, so I’m going to address them problem-by-problem. Ready? Here we go. This article:

  1. Fetishizes disability.
  2. Dehumanizes children.
  3. Downplays economic concerns and long-term viability.
  4. Minimizes the suffering of children and caregivers.
  5. Is logically inconsistent.
  6. Conflates fetuses with born children, and therefore
  7. Devalues labor, delivery and motherhood.
Before we go any farther, here is my main point:
 
Having an abortion to prevent a child from being born with Down syndrome or another disability can be a positive moral choice. Okay, now let’s go on (assuming you’re not already plotting my demise).
 
1. Fetishizing disability
 
The disability rights movement is hugely important and I support it. It’s especially vital for individuals with mental illnesses, who are often judged as "not really disabled" because there’s nothing visibly wrong with them. Disabled people have a long history of being medically abused, used as test subjects without consent, being abandoned or forced to live in squalor, and being generally reviled, disrespected and treated like freaks. We need a movement to rectify that and prevent it from ever happening again. I’m glad we have one.
 
Now. Here’s where I depart from Zylstra and other activists.
 

Respecting the rights of disabled people does not mean honoring or celebrating disability itself. Apart from the perspective and political activism that many disabled people have found via their experiences as a discriminated-against class, I’d wager most people who are disabled would rather not be. Just like poor people value their wisdom but would really rather not be poor. I’ve been a poor kid. I’m still pretty poor. I’ve learned a hell of a lot about empathy from being poor. But would I choose to be poor? No. Would I want others to be poor kids? No. Would I jump at the chance to end poverty once and for all? Yes! I want people to listen to what I’ve learned, but I don’t want them all to have to learn it the hard way, like I did. I would wager that at least some disabled people feel the same.

When you argue that children with Down syndrome are "special gifts" or that raising them is a "rewarding experience" for parents, you are appropriating their difficulties and fetishizing their difference. That is the opposite of respecting a disabled person. I get that who we are is shaped by experience and that many disabled people consider disability to be integral to their personalities — just as I see poverty as a formative experience for me — but I doubt they would have chosen to be disabled in the first place. Would they have voluntarily given up able bodies for the wisdom earned from being disabled? Would they refuse treatment, if it were available? Would they choose to suffer disabilities just so that their parents could have the "reward" and "special gift" of raising them?

Amy Julia Becker of Thin Places writes:

I hate the thought that there will be fewer people with Down syndrome in the world as a result of advances in prenatal testing. As I’ve written before, it impoverishes us all when we selectively abort babies based upon particular characteristics (gender, for instance, in China and India… disabilities here in America).

I understand this argument. I do. I get how parents of Downs children learn from their experiences and love their children fiercely and imagine how empty and cold the world would be without children like theirs. But this line of reasoning makes me profoundly uncomfortable. By all means, love your child! By all means, share your hard-earned wisdom! But to wish for Down syndrome to never go away? to never be cured? Why would you wish that?

I can’t help but think that it’s not about the children’s quality of life (wouldn’t you choose a life for your child that didn’t include Downs, if you could?) but about the parents’ inability to distinguish between their love for their kids and the condition from which their kids suffer. By all means, celebrate your child and his or her wonderful uniqueness! (I say this without irony.) But don’t reduce your child to the mere fact of having Downs, as though having Downs makes them a kind of endangered species and that Down syndrome must continue forever because kids like yours would never exist again without it. Your child would be special, you would have that bond, with or without Downs.

Wanting to eradicate a condition that causes suffering or dependence in a population is not the same as wanting that population to die. Imagine for a moment that we’re not talking about abortion. If it were possible to "cure" Down syndrome prenatally, preserving the same fetus, would you deny your child the treatment because you’d hate to see fewer Down syndrome children in the world?

Which brings me to #2.

2. Dehumanizing children

Focusing on the "rewards" to parents of raising a special needs child means privileging parents’ personal growth over the best interests of their potential child.  If parents choose to bring into this world a child that cannot be reasonably expected to care for himself as an adult, they are gambling with their child’s future. Who will care for him or her when the parents are gone? Do they have the resources to provide for their child’s medical needs? Do they have other children who would be neglected because of their parents’ intense focus on caring for the special needs child?

Now, I understand that many, many Downs people are able to function in the world without immediate care, but others can’t. I think it’s awfully brazen and selfish not to consider one’s potential child’s quality of life for the entire duration of that child’s life before deciding what to do. I think it’s necessary to ask tough questions of yourself, to honestly answer the question of whether or not you can provide that child with everything he or she will need for life.

Special needs children aren’t high-maintenance pets that exist to teach you lessons about fortitude and compassion. They are people. And it’s because a special needs fetus will become a person at birth that abortion should be on the table. Responsible, moral reproductive choices involve doing the hard math and yes, making decisions to either give your child the best possible long, independent life or to terminate the pregnancy early if you know you can’t.

Clinging to a soundbyte belief system that makes your decisions for you ("Abortion is murder!") or abdicating responsibility ("God will provide as long as I don’t get an abortion!") means shirking your fundamental duty as a parent: to make decisions with your child’s best interests at heart until your child can do so herself. That responsibility may lead you to give birth to and raise a disabled child — and more power to you! — as long as you’re doing it with your eyes open and taking every possible precaution to make sure you can deliver on the promise of care you are making your newborn child. But it may also mean having an abortion.

It intrigues me that religious people, the ones who are the first to point out the flaws and fallen nature of the world, are the last to acknowledge the result: that horrible things happen, and those situations require hard decisions. Birth defects and excruciating diseases happen. To refuse to act to minimize suffering (indeed, to prevent it) is at best selfish and at worst abusive. To pretend that there is always a perfect answer to a problem in this imperfect world is to effectively close your eyes and live in your own imagination.

3. Classism

Not every family can afford the medical care of a special needs child. Not every family can afford the time spent caring for a special needs child, especially if they already have multiple children. To demand that families that know they lack these resources nonetheless give up everything to bring a child into a world where it will be neglected, inadequately treated by doctors, and in all likelihood end up in foster care or, as an adult, homeless, is cruelly insane. To focus on mere "life" to the exclusion of the quality thereof is not just stupid, it’s evil. It is deliberately inflicting suffering on others to soothe your own conscience.

And in case you’re wondering, the cost of a lifetime of care for a Down syndrome child has been recently estimated at 2.9 million dollars.

(Though, given that the estimate was made in the context of a lawsuit, it’s probably a little on the high side.)

4. Minimizing the Needs of Others

Parents and caregivers are people, too. They do not forfeit their own needs when they have children; indeed, doing so is actually harmful to children. Recall the many times I’ve said that having a stay-at-home mother made me feel hopeless and guilty about becoming a woman. I was put in the impossible position of either following in her footsteps, thereby ensuring that every female in our line would do nothing but sacrifice for her children and never get to have her own dreams, or not following in her footsteps and feeling guilty that I was (a) rejecting her by rejecting her lifestyle and (b) doing my own potential children some kind of injustice, even though I didn’t want my children facing the quandary I was! I wished my mother had more of a life outside of raising me, because then I would be freer to have a life, too.

If parents choose to welcome a special needs child into their family, they must consider how it will affect not only that child, but also themselves and their other children. They must make room for breaks and self-care to preserve their own health, mental and physical. In my own church, there was a woman with two children who got pregnant and found out her child had a fatal defect. She decided against having an abortion, believing that God would honor her and heal her child (or at least provide for it). The child lived 13 years in unspeakable pain, without cognition, undergoing surgery after surgery until she died — and by this time the family had exhausted its resources, the other two children had been practically abandoned. The mother had worked herself to the bone, endured a failed promise from God, and had to mourn the child all over again at the end of it all. That child was not a "blessing." It was not a "rewarding" experience — though the mother might tell you so out of sheer love and the need to justify her situation. The child’s birth destroyed her family, and she was never even aware enough of her own existence to realize she was loved. How is that the hand of God?

5. Logical Inconsistency

First, we get the argument that raising a special needs child is a blessing:

[Says Rudd:] "If we look at the statistics or surveys that come from families that have raised a Downs individual, 97 percent said it was rewarding."

That is abhorrent abuse of statistics. First, your entire sample (people who have chosen not to abort) is already biased toward the belief that what they’re doing is rewarding. Where are the surveys for women who chose to abort Downs fetuses? You’re comparing this 97 percent to an empty page. They might say that their abortion was a blessing, but you can’t print that, can you? Not on a Christian blog.

Second, the parenting discourse in Western culture is so punitive that parents of "typical" children aren’t even free to express that they dislike the drudgery of parenting without being accused of being sociopaths and hating their kids. That’s why such statements as "I hate being a mom" show up anonymously on Secret Confessions and have been called the Greatest American Taboo. How much more pressure is there on parents of special needs kids never to admit that they wish they weren’t?

Then, we get this:

"Who are we to say that cystic fibrosis is such an overwhelmingly terrible disease that they shouldn’t be allowed to live?" Rudd said. "Do we say that about a one-year-old who is diagnosed? What’s different about a younger child?"

Little is different about a younger child. Everything is different about a fetus. A fetus does not have cognition. A fetus lives inside a woman’s body. A fetus has never drawn a breath. A fetus has not lived a life to miss. Those are significant differences.

Also, when did we go from talking about the relative independence of some Downs individuals to the horrible suffering inflicted by cystic fibrosis? Read this description and see if you think it’s an apt comparison: 

Cystic fibrosis is a disease passed down through families that causes thick, sticky mucus to build up in the lungs, digestive tract, and other areas of the body. It is one of the most common chronic lung diseases in children and young adults. It is a life-threatening disorder. Lung disease eventually worsens to the point where the person is disabled. Today, the average life span for people with CF who live to adulthood is approximately 37 years, a dramatic increase over the last three decades. Death is usually caused by lung complications.

Would you utter a sentence like this?: I hate the thought that there will be fewer people with cystic fibrosis in the world as a result of advances in prenatal testing. Would you tell parents how "rewarding" it is to raise a child with cystic fibrosis? Who are we to say that the disease is overwhelmingly terrible? Rudd asks. Well, here’s who we are: Caring parents. Compassionate, educated doctors. People who don’t want to inflict unnecessary suffering by bringing a not-yet-conscious fetus into the world to experience a waking nightmare and die, choking or suffocating, at half the normal life expectancy. That’s who.

There’s also the little problem that the article jumps back and forth between arguing about the intrinsic worth of life and the rewards of being a caregiver. These two competing perspectives make the argument hard to follow.

6 + 7. Erasing Motherhood

It’s a common trope of the pro-life movement that "a moment before birth" a fetus is a baby, and therefore abortion is the same as infanticide. This is not only scientifically inaccurate, it’s misogynistic. It erases the woman, her wellbeing, and her labor from the entire equation. Childbirth is momentous. It matters. It is not just a legal flagpole where personhood is arbitrarily assigned. It is the moment at which a child begins to occupy the world as an independent being.

It is also a moment made possible by the bodily work (pain, sweat, blood and tears) of a woman. If we grew children in plastic incubators with green fluid and Classical music playing gently in the background, then the "moment before birth" comparison might be apt. But it isn’t, because children live in their own bodies, and fetuses live in their mothers’. While that fetus is in its mother’s body, she does have sovereignty over the decision whether or not to bring the child into the world. That is her sacred right as a mother. It is her sacred right as a woman not to have her body violated against her will — be it by another adult, a child or a fetus. Alone, a fetus cannot be brought into the world to become a baby. Therefore, you can’t talk about a fetus as though it exists without regard for the woman upon whom its existence depends. To alienate the pregnant woman from a discussion about pregnancy is like having a conversation about the weather on an asteroid.

Zylstra concludes her article:

It’s not that the test is bad. To be able to map a child’s DNA while they’re still in the womb is fascinating. But so is the fact that many mothers believe that it would be worse to live in an imperfect body than not to live at all.

There’s a huge problem here. Cystic fibrosis is a serious disease. Downs syndrome can be serious. Genetic diseases can leave children’s independence stalled, their mobility hampered, their bodies aching, their minds wracked with torturous bouts of depression and anger, their futures uncertain and their families stressed to the breaking point. This isn’t about perfect and imperfect bodies. This is not the difference between passing on genes correlated with overweight and comparing your potential child to fitness models. The perfect/imperfect body dichotomy is a red herring. No body is perfect. It’s disingenuous and manipulative to assert that having a serious genetic disorder is equivalent to having a few pimples and a crooked nose.

If I somehow (metaphysics be damned!) had a choice to be born in a body that would slowly disintegrate on me, like that of Stephen Hawking, or not to be born at all, I’d pick the latter. This does not mean that I think Stephen Hawking shouldn’t be alive. He is a great scientist. He has done marvelous things with his life. But that does not make the pain and horror of his situation any less. If I could prevent my own child from being born into a life like that, I would. I consider it my moral imperative. And if Stephen Hawking and I were hanging out in the metaphysical waiting room before descending to earth, and he told me he didn’t want to be born into all that suffering, it would be unfathomably selfish of me to demand that he endure what he has endured just so that I (and other healthful people) could benefit from his mind.

My Points:

If you made it this far, congratulations. Here’s the rundown:

  1. Respect disabled people for their personhood, but don’t promote the continued existence of disabilities. That doesn’t do anyone any favors.
  2. Don’t treat disabled children as special projects to improve their parents’ character.
  3. Don’t act like everybody can afford to live by your conscience.
  4. Don’t prioritize the wellbeing of a fetus over the entire family.
  5. Don’t force special needs children into families that don’t want them, and will abuse, neglect or abandon them. They have it hard enough in families that want them and have the resources to care for them.
  6. Don’t conflate serious disorders with minor imperfections to guilt parents into a choice to raise a child they don’t want to have.
  7. Don’t abuse statistics to lie about the satisfaction rate of parents with special needs children.
  8. Don’t minimize the labor of mothers or pretend that you can talk about fetuses without women.
It is possible to choose abortion based on a positive screening for genetic disorders because you are morally opposed to inflicting suffering on others. It is possible that women who abort fetuses with Down syndrome or more series disorders do it not because they hate Downs people or like genocide or are Selfish Career Bitches(TM), but because they honestly believe it’s what’s best for their families. The anti-abortion crowd is not the only one with a flagpole stuck in the moral high ground.
 
Now, finally, a thought experiment.


Why is it a "blessing" and a "rewarding" experience to raise a child with Down syndrome, but not one with Fetal Alcohol Syndrome? If there’s something inherently valuable about disabilities themselves that improves the lives of people who have them and whose loved ones have them, why does the origin of the disability make such a difference? Why is taking every precaution to avoid FAS, to the point of making pregnant women neurotic, a worthwhile societal goal? Why does no one hate to imagine a world in which there are no children with FAS?

I suspect the answer has something to do with control. Because if you can control an outcome (or at least think you can), people will be justified in blaming you for an adverse outcome. But if you can’t prevent suffering (or think you can’t), your reputation remains untarnished. If you see suffering in your future and evade it, those who are suffering will attack you for your selfishness and arrogance. ("How dare you have it so easy?") But is that feeling of moral superiority actually moral superiority? I don’t think so. It sounds more like a cry of pain at the unfairness of the world — which is something we should be trying to fix, not perpetuate.

Sierra is a PhD student living in the Midwest. She was raised in a "Message of the Hour" congregation that followed the ministry of William Branham. She left the Message in 2006 and is the author of the blog The Phoenix and the Olive Branch.

Using Special Powers, Brazil’s President Passes Law Requiring Compulsory Registration of All Pregnant Women

8:17 am in Uncategorized by RH Reality Check

Written by Beatriz Galli 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 the dead of night on December 27, Brazilian President Dilma Rousseff enacted legislation that will require all pregnancies to be registered with the government. Provisionary Measure 557 (PM 557) created the National System of Registration, Vigilance and Monitoring Women’s Care during Pregnancy and Post Childbirth for the Prevention of Maternal Mortality (National Registration System).

She used a provisionary measure—intended only for urgent matters—that allows the president to pass a law without congressional approval. Congress only gets to debate and approve the law once it has been enacted. Rousseff claims that PM 557 will address Brazil’s high rates of maternal mortality by ensuring better access, coverage and quality of maternal health care, notably for high-risk pregnancies. Both public and private health providers must report all pregnancies—providing women’s names—with the National Registration System so the state can then track these pregnancies, from prenatal to postpartum care, presumably to evaluate and monitor health care provided.

How does simply monitoring pregnancies reduce maternal mortality? There is no guarantee that care will be available to all pregnant women and no investment in improving health services included in the legislation.

And what’s the benefit to women? PM 557 does authorize the federal government to provide financial support up to R$50.00 (roughly US$27) for registered pregnant women for their transportation to health facilities for pre-natal and delivery care. However, to receive the stipend women must comply with specific conditions set by the state related to pre-natal care. Let’s face it, that paltry sum may not even cover the roundtrip for one appointment depending on where a woman lives.

In fact, PM 557 does not guarantee access to health exams, timely diagnosis, providers trained in obstetric emergency care, or immediate transfers to better facilities. So while the legislation guarantees R$50.00 for transportation, it will not even ensure a pregnant woman will find a vacant bed when she is ready to give birth. And worse yet, it won’t minimize her risk of death during the process.

The biggest problem with maternal mortality in Brazil is not access to health-care services but rather the quality of health care in public health facilities. The majority of preventable maternal deaths actually take place in public hospitals, disproportionately affecting poor women, women who live in rural areas, youth and minorities.
Last but certainly not least, MP 557 violates all women’s right to privacy by creating compulsory registration to control and monitor her reproductive life. In fact, it places the rights of the fetus over the woman, effectively denying her reproductive autonomy. A woman will now be legally “obligated” to have all the children she conceives and she will be monitored by the State for this purpose.

It’s unclear why Rousseff sought to enact this legislation so quickly and with so little opportunity for debate or public opinion. What is clear though is that women’s real interests and health needs are not the focus here—just their uteruses.

UN Special Rapporteur: Abortion Restrictions Don’t Work

1:02 pm in Uncategorized by RH Reality Check

In front of the United Nations, NY (Photo: Rob Young, flickr)

In front of the United Nations, NY (Photo: Rob Young, flickr)

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


See all articles in this series here.
Restrictions on abortions just don’t work in that they don’t result in the desired outcome.  This is the predictable, yet bold, conclusion of a report to be presented at the United Nations on Monday, October 24th by Anand Grover, a UN-appointed independent expert on health.  The report, which is part of an annual report-back from various human rights experts to the United Nations’ General Assembly, consolidates years of legal analysis and empirical evidence from other experts and concludes that abortion restrictions are unworkable and damaging to women’s health. Instead, the report advocates access to full, accurate, and complete sex education and information about contraception, as well as to all forms of modern contraception, because these services and state support for women’s equality actually do work to reduce the need for abortions.

Abortion restrictions are generally justified by reference to a desire to lower the number of terminations, be it by limiting access to abortion for all women, as in Chile, El Salvador, and Nicaragua, or just for the “undeserving,” as in most of the rest of the Americas including the United States. Some explicitly prefer pregnant women to die rather than having access to a life-saving abortion, but most refer to some sort of makeshift hierarchy of morals.

“Most people, of course, should have access free of charge,” a high school friend from Denmark told me the other day. “But women who just keep having abortions: there really should be some sort of punishment for them.” Read the rest of this entry →

Hormonal Contraception and HIV: Weighing the Evidence and Balancing the Risks

7:51 am in Uncategorized by RH Reality Check

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

An article in yesterday’s New York Times by Pam Belluck suggesting that injectable contraceptive use might double the risk of HIV transmission among women and their partners sent a wave of anxiety through the global public health community. The story is based on a study conducted in Africa by Renee Heffron and her colleagues and published online this week in The Lancet. Heffron’s study suggests that HIV-negative women using injectable contraception might face a two-fold risk of acquiring HIV from their infected partners, and that HIV-positive women using injectable contraceptives may be twice as likely to pass the virus on to their uninfected partners.

The Heffron study also found that pregnancy doubled women’s risk of HIV infection, underscoring the complex interplay of sexual and reproductive health.

If the findings on injectable contraceptives are confirmed through further research, the implications are profound. Women make up 60 percent of those infected with HIV in sub-Saharan and are highly vulnerable to HIV infection for a range of economic, social, and biological reasons.  Women are simultaneously at high risk of death and disability from complications of pregnancy and unsafe of abortion.  Ending the spread of HIV, filling the unmet need for contraception, and preventing the large number of unintended pregnancies in Africa are critical and highly-intertwined global health goals which, if reached, would save millions of lives and dramatically improve prospects for women and children.

Remove injectable contraceptives from this mix and the picture becomes rather bleak.  “The injectable birth control shot has revolutionized women’s access to modern contraception in developing countries,” said Latanya Mapp Frett, Vice President-Global, of Planned Parenthood Federation of America. “This method allows women with infrequent access to health centers to prevent unintended pregnancy, thereby reducing rates of complicated pregnancies, unsafe abortion and maternal death. We need to seriously weigh the evidence before restricting women’s access to this life-saving resource.”

As the Times noted, the World Health Organization (WHO) plans to convene a meeting in January 2012 to review the Heffron study in light of existing evidence and examine the meaning of these findings for delivery of health services.

The possibility that one proven and highly effective health intervention–injectable hormonal contraception–is exacerbating another public health crisis is of course cause for deep concern, and raised reasonable questions among advocates as to why WHO would wait until January to convene a meeting on these issues, and whether distribution of injectable contraceptives should be halted immediately.

Experts say: “Not so fast.”

Public health and women’s rights experts are taking the study very seriously but also caution against drawing conclusions from the NYT story in part because it overstated or misrepresented some of the study’s findings while neglecting to mention several potential weaknesses. And because the stakes for women are so high, they also say it is important to take a step back and look at the broader range of evidence on this issue carefully, especially in an era when promotion of evidence-based public health interventions such as family planning and safer sex have become so politicized and misinformation spreads rapidly.

There appears to be consensus among public health experts on three basic steps:

1) Consider the effects of methodological weaknesses in the analysis and whether these may have influenced the conclusions.

2) Weigh this study against the existing evidence and conduct research specifically designed to examine these questions.

3) Balance the risks women face from both HIV and unintended pregnancy.

A discussion of each of these points follows:

1) Examine possible methodological weaknesses.

The Heffron study was originally designed to examine the effectiveness of the antiviral medication acyclovir in preventing HIV infection associated with Herpes simplex virus in both sero-discordant couples (in which one partner is HIV-positive and the other HIV-negative) and concordant couples (in which both partners have the same HIV status). It was not designed to examine the connections between hormonal contraceptives and HIV transmission. Findings on their initial research question were inconclusive so Heffron and her colleagues went back through their data to look for other outcomes including the association between hormonal contraception and HIV transmission.

While evaluating the kinds of data they collected for these outcomes is a highly complicated exercise, reviewers of the paper say the study that resulted is in several ways methodologically stronger than earlier studies examining these questions. The analysis also, however, contains weaknesses that could make the results less conclusive than initially appears to be the case and certainly less than the Times story suggested.

In a research note published in the same volume of the Lancet, Charlies Morrison and Kavita Nanda of the international health organization FHI 360, write:

The main strength of the study is that exposure to HIV was known. The study population consisted of HIV-serodiscordant couples, and analysis was limited to HIV infections genetically linked to the index partner. As such, the study was able to provide direct data on the risk of HIV-infected women using hormonal contraception transmitting the virus to their male partner. By contrast with many other studies, self-reported condom use was similar between hormonal and non-hormonal groups. Finally, the investigators used sophisticated analytical techniques and were able to adjust analyses for the plasma viral load of the infected partner.

However, they also note that:

[S]imilar to all observational studies, this study was open to aetiological pitfalls. Potential selection bias and confounding could have distorted interpretation. Furthermore, like all but two studies on this topic, this study was a secondary analysis of an HIV-prevention trial—not specifically designed to examine hormonal contraception and HIV risk. Few women used hormonal contraceptives (only 196.6 [11%] of the total person-years of follow-up were among hormonal-contraceptive users) and few HIV infections (ten for DMPA and three for oral contraceptives) occured for these users.

In selecting quotes, the Times article glazed over these and other possible limitations of the study, including the fact that contraceptive use was self-reported and not confirmed by the researchers through examination of clinical records.  Contraception was not provided in all 14 sites used in the study and therefore not consistent across them. Participants in the study often switched contraceptive methods: Almost half of the women who reported using hormonal contraceptives also used non-hormonal methods at some point, but switching was not taken into account in analyzing the data. All of these are methodological weaknesses that could skew the results.

The Times also over-stated the conclusiveness of findings on condom use.  Belluck, for example, wrote:

The researchers recorded condom use, essentially excluding the possibility that increased infection occurred because couples using contraceptives were less likely to use condoms.

This is not accurate. Condom use in the study was self-reported. It is very difficult to accurately measure condom use from self-reporting because people tend to overstate to researchers the consistency with which they use condoms (a well-known phenomenon), and there was no way to measure whether couples in the study reporting condom use actually used condoms during all sex acts, some sex acts and not others, or even consistently and correctly over the three-month period. The researchers did control for condom use but based on data that were not systematically collected to answer these questions.  Because of this, Morrison and Nanda note that the researchers’ “analytical adjustment for condom use might be insufficient.” A USAID expert, speaking off the record, suggested that while the findings of this study absolutely require further examination, the analysis of condom use alone was cause for “healthy skepticism” of whether the findings were conclusive.

Also not taken into consideration in the Heffron study and not reflected in the Times article were considerations such as whether women using injectable contraceptives had more frequent sex, which may have been their motivation in seeking out long-acting contraception in the first place. More frequent sex would mean more frequent exposure to unintended pregnancy and its potential complications, but also to HIV from an infected partner, especially in the absence of consistent and correct use of condoms or “dual protection” (contraception for pregnancy prevention and condom use for prevention of infection). Sexual coercion or lack of control over the timing and nature of sex may also leave women more vulnerable to unsafe sex, HIV infection, and unintended pregnancy, and might further confound the analysis.

2) Weigh the evidence.

Experts underscore that while this study should be taken seriously, it does not, according to Heather Boonstra, Senior Public Policy Associate at the Guttmacher Institute, “change the weight of the body of evidence to date, which currently suggests no relationships between hormonal contraception and HIV transmission or acquisition.”

In a guidance memo sent to field offices after the initial presentation of the Heffron study at an AIDS conference ealrier this year, USAID states:

Previous studies have examined these issues. Some found similar associations (including one of the largest studies on this topic); most have not found HC [hormonal contraception] to be associated with HIV acquisition or transmission in a general population. The new [Heffron] findings raise concerns, particularly since the analysis involved a large sample size of serodiscordant couples, used sophisticated statistical techniques, and may provide biological support by measuring viral shedding.

Still, continues the memo, “a cautious interpretation of the findings is justified as the scientific community gathers additional information. Like previous analyses, these findings were derived from observational data, which may be biased by self-selection.”

The memo concludes that because there is as yet insufficient information and analysis on the study and its implications, “USAID does not believe that a change in contraceptive policy or programming is appropriate or necessary at this time” and stated it will:

continue to offer a wide variety of contraceptive methods, and ensure that women and couples have access to a wide variety of contraceptive methods, are counseled about the known risks and benefits of those methods (including that all methods other than male and female condoms provide no protection from sexually transmitted infections (STIs), including HIV), and are able to select the method that best fits their individual needs.

The WHO meeting in January is intended to bring together a range of experts to look at this and previous data in as many as 12 other studies, and examine the body of evidence as a whole.

Virtually everyone agrees that carrying out systematic research examining as a primary question the possible connections between hormonal contraception and HIV infection should be a high priority.

3) Balance the Risks.

In the lives of women in sub-Saharan Africa, nothing involving sex and reproduction is “risk free.” In low-resources settings characterized by extremes of gender bias, the combined lack of consistent access to basic family planning methods, prenatal care, trained birth attendants and emergency obstetric care all make pregnancy a dangerous undertaking.  Lack of access to family planning to prevent unintended pregnancy and lack of access to safe abortion services mean millions of women each year suffer dire consequences trying to exert some control over their lives. Lack of control over sex and reproduction contribute to both high rates of unintended and unwanted pregnancies, and to high rates of HIV infections.

Injectable contraceptives are widely used in sub-Saharan Africa in large part because these methods give women control over whether and when to become pregnant. Approximately 12 million women between the ages of 15 and 49–six percent of all women in this age group–depend on this method.  If it is found that use of hormonal contraception does indeed increase the risk of acquriing or transmitting HIV infection, we are faced with the potential loss of a major public health intervention. Removing the method from the mix of options leaves women vulnerable to different but also dangerous risks from unintended pregnancy, which may also increase their risk of HIV infection, or unsafe abortion or both.

Irrespective of whether conclusions from the Heffron study stand up to further research and examination, there is are no easy answers.

Still, to some degree, some answers are already clear.

First, at the most basic level, it is critical to the health and lives of women and their families to expand, not reduce, access to essential family planning services, continue to improve the quality of services, and continue to underscore the critical nature of dual prevention strategies, via the use of effective methods of contraception combined with correct and consistent condom use, including both male and female condoms.  Expanding integrated family planning and HIV prevention services is also critical and can not be over-emphasized.  Unprotected sex can lead to both unintended pregnancy and to HIV infection. We know how to prevent both, but we must both invest in these services while ending the stigma associated with safer sex practices.

Second, we need to invest more in expanding the range of reproductive technologies.  “What the debate over this study underscores more than anything is the need for more methods that protect couples from both unintended pregnancy and HIV,” said Vanessa Cullins, MD, Vice President of Medical Affairs at PPFA. “Until these products are developed, women and their partners need better access to condoms; and they should not have their birth control taken away.”

Third, we must greatly expand efforts to promote and secure the rights of women, economically, socially, and culturally.  High rates of maternal mortality and illness, and high rates of HIV infection among women are but symptoms of the broader social illness rooted in gender discrimination, gender-based violence, and the lack of investment in health, education, and economic power of women and girls.  Only when women’s health needs are made a priority by every government everywhere, and when women can exercise their rights will we eradicate HIV and make maternal morality a very rare event.

Stop Entrapping Providers: What I Told the Kansas Department of Health and Environment

7:03 am in Uncategorized by RH Reality Check

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

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As Jodi Jacobson reported earlier today, public hearings were held in Kansas today for the abortion regulations created by the Kansas Department of Health and Environment.  I presented the following testimony on behalf of Kansas NOW.

I’m the State Coordinator for Kansas NOW, which means that I stand before you today as a grassroots women’s rights activist and equality advocate.   I stand before you today, as a voice for a whole lot of Kansas women who cannot be here to tell you how they feel about these regulations.  These women want me to express what they think about the possibility of losing their access to existing abortion clinics within their state.  These are good women who have either used these clinics personally, or simply take comfort in knowing that these facilities exist should they need them.

While I may not be a public health professional, my understanding as a graduate student of Public Administration is that government enacts regulations when a public need for protection presents itself, in the case of Kansas Department of Health and Environment, when some public health concern or externality needs to be addressed.  As employees of an agency that is supported by public tax dollars, deliberative, non-ideological processes are to be expected, especially with regard to the health and well being of the citizens they work for.  I do not believe that this regulatory process met those deliberative, non-ideological tenets. Read the rest of this entry →

What New Legal Obstacles to Safe Medication Abortion in Ohio Mean for Women

10:55 am in Uncategorized by RH Reality Check

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

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The legal landscape for abortion is changing rapidly in Ohio, as it is in many states. Our governor recently signed into law a measure requiring as-yet-unspecified “viability testing” on women seeking abortions past 20 weeks.  At least half a dozen other restrictive measures were recently passed or are on the horizon, including the “Heartbeat Bill,” which seeks to outlaw abortions as early as 6 weeks (before many women know they are pregnant). It’s unclear what this will all mean for clinics and for women.  At my clinic, Preterm, the largest independent abortion provider in the state, women are calling us daily asking if abortion is still legal.

At the same time, Ohio clinics and our patients are now dealing with the effects of a restrictive law passed several years ago. Caught up in court challenges until last spring, this law dictates the way medication abortions—induced by a combination of mifepristone (mife), also known as RU-486, and misoprostol (miso)—must be performed in Ohio. It requires doctors to use an outdated FDA regimen, established during trials in the 1990s, instead of a lower-dose evidence-based regimen that has been used safely and effectively all over the U.S. for more than a decade.

Essentially, the FDA regimen shortens the time a medication abortion can be used from 63 days to 48 (or from 9 weeks of pregnancy to just under 7), triples the amount of mife used (and at $90 a pill that adds up!), and increases the required number of clinic visits from three to four, so that a doctor can watch the patient swallow the miso at the clinic rather than allowing her to dissolve it inside her cheek at home.

Our First Case

The first medication abortion patient we saw at Preterm after the new regulations went into effect was exactly one day over the new legal limit for taking the combo of pills that is used to end an early pregnancy without surgical intervention.   Read the rest of this entry →

Women’s Reproductive Rights Under Threat in Colombia

10:32 am in Uncategorized by RH Reality Check

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

Cross-posted with permission from The Women’s News Network (WNN).

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At 11 years of age, Nina was raped by her stepfather. Traumatized and pregnant, she sought an abortion. But every doctor she met claimed conscientious objection and refused. She was forced to travel 35 miles to another city, where she eventually tracked down an obstetrician willing to help.

She was one of the lucky ones.

Despite a landmark ruling five years ago – when Colombia’s Constitutional Court decriminalized abortion in cases of rape, fetal abnormality or to save the mother’s life – less than 0.5 percent of procedures are carried out legally each year. Many doctors simply turn girls like Nina away.

There is endemic confusion about the status of the law, especially the rules for conscientious objection, coupled with a widespread reluctance to obey it. Unsafe abortion remains the third leading cause of maternal deaths in a country where, according to government figures, over 300,000 take place each year.

Upon its inception the law has been the target of an aggressive anti-choice campaign, led by conservative political forces and supported by the Catholic Church. These forces are now threatening to unravel the little progress made.

Since coming into office in 2009, the Procurador-General, Alejandro Ordonez – the official appointed to protect the constitution and promote human rights – has led a vociferous campaign to dismantle the legislation. Read the rest of this entry →

On Catholic World Youth Day, Advocates Spread the Message that “Good Catholics Use Condoms”

8:25 am in Uncategorized by RH Reality Check

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"Condom" by passero on flickr

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

This week marks the 26th celebration of Catholic World Youth Day – a misnomer as the event which began in 1985 is no longer confined to just one day. Though registration was lower than expected this year, the six-day event should draw close to one million young people to its host city of Madrid. Events include teaching sessions around the city each day and a youth festival each night designed for young people ages 18 to 35.  Tonight, attendees will be able to watch “Stations of the Cross,” a reenactment of the last few hours of Jesus’s life, and tomorrow night they can sleep out under the stars after an evening vigil with the Pope. The celebration culminates with a Mass on Sunday led by Pope Benedict XVI.

Though discussions of condoms do not appear to be on the official agenda for the week, Catholics for Choice and its Condoms4Life campaign has sent a group of youth advocates from around the world to make sure attendees hear its message: “Good Catholics Use Condoms.”  As Marissa Valeri, a lead organizer of the youth coalition explains:

“The young people in our coalition came from all over the world to proclaim at Catholic World Youth Day that good Catholics use condoms. HIV and AIDS are realities in the lives of young people and we know that in good conscience Catholics can use condoms to protect those we care about.”

The group also wants to remind people of comments made by Pope Benedict XVI that seemed to soften the Vatican’s stance on condoms. Valeri explained in a press release:

“We welcome that the pope has come out to say that condoms can prevent HIV transmission. We now want him to go further in publicly backing condom use and facing down Vatican conservatives because lives can be saved with a more realistic and compassionate view of condoms and sexuality in our church.” Read the rest of this entry →

In a Victory, Virginia Prisons Will Limit the Shackling of Pregnant Women

10:54 am in Uncategorized by RH Reality Check

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Shackles by publik15 on flickr

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

The Virginia Department of Corrections (DOC) Director Harold Clarke has led the DOC though a forward-thinking policy change that should begin a statewide conversation and passage of legislation before the Virginia General Assembly.

House Bill 1488, a bill that would have limited the use of restraints on pregnant inmates, failed in the House Militia, Police, and Public Safety Committee in the 2011 legislative session. However, Director Clarke and staff at the DOC took seriously the conversations sparked by the Committee debate over the bill. Supporters of the bill, which was introduced by Delegate Hope, put pressure on the DOC to change their policies in the absence of legislative action.

As a result, the DOC will now adopt regulations that protect a pregnant inmate’s dignity and health, and the health and safety of her pregnancy. DOC regulations will now state that pregnant inmates will only be retrained during transport outside the prison perimeter by handcuffs alone. Ankle restraints or restraints that in any other way restrict the woman’s movement will not be used during transportation outside the prison, or during labor, delivery and post-partum recovery. Additional restraints can be applied if a determination is made that the inmate is a danger to herself or others, but should additional restraints be used, they must allow for the woman to walk around, stand up, and turn over. If additional restraints are applied, an incident report must be submitted that states the restraints used and the reason why in order to ensure compliance and accountability. Finally, all restraints must be immediately removed if medical staff so direct.

The new DOC regulations are sound public health policy. Read the rest of this entry →