Our Bodies Our Blog

Earlier this week, the so-called “Pro-Life Freedom Ride” (alluding to the civil rights freedom rides) arrived at the King Center in Atlanta to demonstrate in opposition to abortion rights. The “freedom ride” campaign is being organized by Priests for Life to “build…on a method that the Civil Rights Movement used effectively forty years ago,” and consists of anti-abortion activists taking a bus to cities “with strategic significance for the movement” (such as Atlanta and Birmingham) to demonstrate against abortion.

The “ride” to Atlanta follows up on previous efforts in the state targeting women of color with the goal of restricting abortion. Atlanta was the target earlier this year of an anti-abortion billboard campaign targeting Black women by referring to Black children as an “endangered species.” Also this year, race-focused anti-abortion legislation was defeated in the state; it was opposed by groups of women of color including SisterSong, SPARK, and SisterLove, who were also active in organizing protests of the “pro-life freedom rides.”

Loretta Ross of SisterSong filed this report {PDF] from their protests of the “Ride” at this week’s events, writing that:

…it was surreal seeing all these white folks carrying signs that said “Abortion is the #1 Killer of Black America.” Can you imagine the optics of the scene? Here’s a group of white folks claiming to save Black babies being protested by mostly African American women and men who are shouting “Trust Black Women!”? Once we saw their signs, Paris instantly created a new chant: “Racism is the #1 Killer of Black America, not Black Women!”

In a statement [PDF] prior to the event, the organizations wrote that the “rides” were “no more than a ploy to turn back the clock on Black women’s right to reproductive freedom,” and Ross got to the heart of the offense of the event, including the appropriation of an important civil rights legacy in the service of restricting the rights of women of color:

We are offended by their cynicism, opportunism, and outright distortions of historical facts. Both Dr. Martin Luther King, Jr. and Coretta Scott King firmly supported reproductive justice for women. Lies by anti-abortionists, no matter how often repeated, cannot change those historical facts.

As Dazon Dixon Diallo of SisterLove stated:

The actions planned by Priests for Life [the group organizing the rides] are insulting, disrespectful, and completely antithetical to the struggle for women’s human rights. They should be ashamed of themselves, and it is our job as Black women and people of color to shame them!

We would expand that to it being the job of *all* people who are pro-choice advocates for human rights and reproductive justice to resist these campaigns.

For more, see:

• SPARK Reaffirms the Agency and Power of Black Women and our Civil Rights Legacy
• SisterSong has photos from the event on their Facebook profile
• Anti-choice “Freedom Rides” Distort the History and Message of Civil Rights Movement – from the National Latina Institute for Reproductive Health

If you’re in Massachusetts, please ask your state representative to urge House Speaker Robert DeLeo to bring an important midwifery bill to a vote. Text of the bill — House 4810: An Act Relative to Certified Professional Midwives and Enhancing the Practice of Nurse-Midwives – can be found here.

The bill was just released from the House Policy and Steering Committee and is now in Third Reading, chaired by Rep. Vincent Pedone of Worcester.  The legislative session closes on Saturday, July 31. If it’s not voted on by then, the bill would die and have to be reintroduced in the next legislative session.

If you’re able to discuss the bill with your legislator or a staff member, please be aware that some legislators have misinformation about the midwifery bill’s content, especially regarding the items below. Here’s some background:

1. The Massachusetts Medical Society strongly objects to CNMs functioning without direct MD supervision, yet has articulated no sound basis for this objection. Nationally, ACOG already supports the elimination of direct supervision of CNMs by physicians, acknowledging that it is not required for safe practice, and 44 other states no longer have such requirements.

2. Some legislators incorrectly think that the bill would provide new prescription-writing privileges for nurse-midwives — this is not really the case. Nurse-midwives already have prescription-writing privileges but can now exercise these privileges only if an MD is technically providing supervision, which amounts merely to a review of sample prescriptions on a quarterly basis.

Because of hospital accrediting rules, this clause prevents CNMs from admitting patients in labor under the midwives’ own names; prevents CNMs from serving on hospital committees that determine maternity care policies; and bars them from control of their own practice environment. This undermines the ability of CNMs to provide the most effective care. (CNMs already have independent prescription authority in most other states, including New Mexico, New Hampshire, Washington, Arkansas and Oregon, and the District of Washington.)

3. Although the legislation has already been rewritten to accommodate concerns about the age at which a midwife could begin training (it was changed from 18 to 21), legislators are still being misled about this fact. There are, by the way, no such age requirements that we have been able to find in the Massachusetts statutes with respect to the education of nurses.

4. Another objection is that the bill does not require a midwife to carry malpractice insurance. In almost all states, malpractice insurance is not required by statute, and it would be unfair to single out one professional group in this regard. Some would argue that such a requirement would violate equal protection clauses.

Because the “risk pool” of homebirth midwives across the country is small, malpractice insurance has never been available for homebirth midwives, despite the concerted efforts of national and local organizations over several decades. Requiring CPMs to adhere to a standard that is impossible is another mechanism to restrain trade and prevent access to home birth midwives.

Childbearing women who want to be protected by malpractice insurance have the option of delivery in facilities, where such insurance coverage is required. Moreover, the Massachusetts legislature could follow a few other states in making disclosure of this absence of malpractice insurance coverage part of a required informed consent procedure. The malpractice insurance issue is not a credible objection to this bill.

Please share this news, and thanks for taking the time to take action on this important piece of legislation!

Following up on last week’s ACOG release of an updated VBAC practice bulletin – this one with an increased emphasis on maternal autonomy – we thought we’d take a look around the web for what others are saying about the new statement.

From organizations:
Lamaze International calls the new guideline “a step in the right direction, clearly stating that women with one previous cesarean should be offered VBAC,” but wonders if there is too much of the “immediately available” language still in the current version.

Choices in Childbirth applauds the new version for “encourag[ing] autonomy for women in their maternity care decisions.”

The International Cesarean Awareness Network expresses that ACOG is going to need to take “an active role in educating both women and practitioners about healthy childbirth practices; practices that not only encourage VBAC but discourage the overuse of primary cesareans” in order to “reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates.”

From the blogs:
Birthing Beautiful Ideas expresses that the importance of the new guideline is “not because it will effect any immediate policy changes but because it gives women a tool to help them facilitate discussions with their care providers and/or their local hospitals so that they can advocate for their birthing options.”

Jill at The Unnecesarean asks How will ACOG handle the PR challenge of promoting VBAC as a safe option? and wonders how the organization and individual physicians will approach the shift in attitudes toward VBAC that the new bulletin represents. She also has links to coverage at several other blogs.

The Well-Rounded Mama is lighting virtual fireworks over the bulletin’s Good News for Vaginal Birth After Multiple Cesarean! (The new guideline says that women with two previous low transverse incisions can be considered candidates for a trial of labor)

Amie Newman at RHRC, Babble, and Broadsheet also discuss the new guideline.

Seen other online commentaries or responses worth a look? Please share them in the comments!

When the U.S. Preventive Services Task Force (USPSTF) released new recommendations in 2009 calling for less frequent screening mammograms for women under age 50, the news caused quite a ruckus.

Many women’s health organizations, such as Our Bodies Ourselves, National Women’s Health Network and Breast Cancer Action, applauded the new guidelines — and had, in fact, been recommending the same approach for pre-menopausal women for many years. But understanding the science behind the logical, if somewhat counter-intuitive, recommendations requires a nuanced analysis.

Now, a New York Times examination of breast cancer cases explains, in very personal terms, the problems with diagnosing breast cancer — especially early detection methods, which are “prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant.”

As a result, pathologists are over-diagnosing and doctors are over-treating small growths in the breasts that are often benign.

While the initial reaction might be, “Wait, isn’t it better to treat all potential signs of cancer than leave them untreated?” the NYT does a good job explaining the very real dangers that can result. Moreover, the root problem is that we still don’t have a truly accurate diagnostic tool, and diagnosis can vary depending on one person’s reading of a tiny speck.

As the Times explains, ductal carcinoma in situ, or DCIS (also called Stage 0 or non-invasive cancer) was a rare diagnosis before the 1980s, but today more than 50,000 women per year in the United States alone are told they have DCIS. Typically the abnormal cells in the breast ducts are removed via surgery — which can result in disfiguration of the breast — along with drugs and radiation. DCIS may progress to a more invasive cancer about 30 percent of the time, according to estimates in the Times article, but in some women it can take decades to do so.

Stephanie Saul’s reporting chiefly concerns pathologists, who are responsible for determining whether cells from a biopsy are malignant:

Advances in mammography and other imaging technology over the past 30 years have meant that pathologists must render opinions on ever smaller breast lesions, some the size of a few grains of salt. Discerning the difference between some benign lesions and early stage breast cancer is a particularly challenging area of pathology, according to medical records and interviews with doctors and patients.

Diagnosing D.C.I.S. “is a 30-year history of confusion, differences of opinion and under- and overtreatment,” said Dr. Shahla Masood, the head of pathology at the University of Florida College of Medicine in Jacksonville. “There are studies that show that diagnosing these borderline breast lesions occasionally comes down to the flip of a coin.”

There is an increasing recognition of the problems, and the federal government is now financing a nationwide study of variations in breast pathology, based on concerns that 17 percent of D.C.I.S. cases identified by a commonly used needle biopsy may be misdiagnosed. Despite this, there are no mandated diagnostic standards or requirements that pathologists performing the work have any specialized expertise, meaning that the chances of getting an accurate diagnosis vary from hospital to hospital.

In the face of studies that have shown the high risk of misdiagnosis (in anywhere from 7.8 to 20 percent of cases, depending on the study), the College of American Pathologists is vowing to start a voluntary certification program for pathologists who read breast tissue. But as Saul notes, “Some pathologists have found the response to these types of studies slow and inadequate” — especially since studies going back as far as 2002 have revealed the problem.

The physical and psychological scarring that ensues is, in many cases, unnecessary — along with the potential long-term effects of radiation therapy.

Where you live and what kind of insurance coverage you have can also affect the accuracy of the diagnosis. Rural, community hospitals are more likely to have less experienced pathologists on staff. And insurers have not encouraged second opinions.

“Some insurance plans pay as little as $10 to pathologists who are performing second opinions on DCIS,” Saul notes in response to a comment left by “MK,” who made an excellent point: “If insurers had a requirement that any slides in which cancer was suspected were automatically sent to a board-certified pathologist, it would save patients having to search for a second opinion and save the insurers the cost of unnecessary treatment.”

It should be noted that percentages of misdiagnosis, as Saul reminds “MK,” includes both false negatives and false positives. Under-diagnosis and under-treatment is also an issue. The danger of a positive diagnosis, however, goes beyond whether it is false:

Fear compounds the confusion, and even though D.C.I.S. is 90 percent curable, there is growing concern that women and their doctors opt for more aggressive surgery, radiation and drug therapy than is needed.

A mastectomy is sometimes offered as an option for D.C.I.S., although experts say it is usually not advisable unless the D.C.I.S. is large or appears in several sites in the breast.

Yet more women who are faced with the diagnosis of D.C.I.S. become so fearful that they elect to have both breasts removed, often against their doctor’s recommendations.

“The patient gets paralyzed with a fear of cancer,” Dr. Masood said. “They want the breast off.”

Among women who had surgery for D.C.I.S., the rate of double mastectomy rose to 5 percent in 2005, from 2 percent in 1998, according to a study last year.

Dr. Ira J. Bleiweiss, chief of surgical pathology at Mount Sinai Medical Center in New York, said that ideally, all breast cancer diagnoses would be referred for a second opinion. He warns patients and their doctors: “Don’t rush to the operating room.”

In related news …

New Study Links Breast Cancer Risk, Household Products: Speaking of caution and prevention, a new study in Environmental Health found a higher breast cancer risk among women with higher use of household cleaning products.

The study by Silent Spring Institute was based on telephone interviews with 787 women diagnosed with breast cancer and 721 comparison women. Many of the products contain endocrine disrupting chemicals or mammary gland carcinogens, making them suspect as contributors.

There are, of course, limitations inherent to this type of study, including the potential for recall bias. Researchers recommend further study.

Julia Brody, executive director of the Silent Spring Institute, said, “When women are diagnosed with breast cancer, they often think about what happened in the past that might have contributed to the disease. As a result, it may be that women with breast cancer more accurately recall their past product use or even over-estimate it. Or, it could also be that experience with breast cancer influences beliefs about its causes. For example, women diagnosed with breast cancer are less likely to believe heredity contributes ‘a lot’, because most are the first in their family to get the disease.”

Plus: Interested in taking action — personally and politically? The Silent Spring Institute offers a number of action kits full of helpful information, including how to reduce risks in your home.

Recommendation to Revoke Avastin: An FDA advisory committee has recommended revoking approval of the drug Avastin, for which the FDA had given conditional approval in 2008 to treat breast cancer (part of an accelerated process for drugs that treat life-threatening diseases but have less than complete evidence of effectiveness).

If the FDA, which usually follows these recommendations, takes the very unusual step of revoking approval of a drug, Avastin will still be available, since it is approved for a variety of other cancers. This would leave it open to “off-label” use for breast cancer, but insurers would be reluctant to pay for it and it would no longer be part of a program that caps its annual cost to patients.

Breast Cancer Action program manager Kimberly Irish responds to the decision: “We agree with the committee’s recommendation, and we’re saddened that after all this time there’s still no good option to offer patients when current treatments have failed.” Read the written comments BCA sent to the committee here (PDF).