Archive for the 'Women’s Issues' Category

Update on Abortion

Saturday, April 7th, 2012

Many years ago I worked for three weeks in Swaziland, South Africa. A memory still haunts me.

Most mornings we saw one or two young women through the emergency ward. Almost all of these women were from surrounding communities, were “visiting an auntie” and they hadn’t eaten breakfast. All were carrying early pregnancies and reported bleeding. Indeed, on examination there was blood and the cervix had started to open.

Bleeding and cervical dilatation in pregnancy usually ends up as a miscarriage, and can lead to a serious infection unless a D&C is done to empty the uterus.

Another doctor told me this pattern had been happening for a long time. We surmised that some doctor in this city was using instruments to make it appear that these patients were about to miscarry. It would be easy to instrument the cervix, tell the young woman to go to our hospital in the morning—and to skip breakfast. “I hope all goes well tomorrow at the hospital. And have your boyfriend wear a condom next time,” I can imagine that doctor saying.

In Swaziland abortion is only legal to save a woman’s life. The physician who opened the cervix was taking a big risk, allowing him to charge an outrageous fee.

Don’t laws that prohibit abortion decrease its frequency? No, apparently not. Norway, known for its excellent medical statistics, found that the incidence of abortion did not rise when it was legalized in 1978. This finding was borne out by a recent article in the world’s premier medical journal, Lancet.

The study looked at all the world’s countries. 84 have liberal abortion laws; the remaining nations (like Swaziland) prohibit abortion, with few or no exceptions.

Outlawing abortion does not prevent women from terminating unwanted pregnancies. Where it is illegal, however, women are subjected to unsafe procedures and risk their health and very lives. Surprisingly, this study found the incidence of abortion is higher in places where it is outlawed. This may be because these are also places where women are not esteemed, and where contraception is difficult to obtain.

Wherever laws permit safe abortion, two observations are made. Maternal mortality from unsafe abortions decreases drastically, and women are treated with more respect.

More surprises are to be found in another research paper from England. It is an exacting review of the psychological effects of abortion. Although many studies in this field are of poor quality, the researchers found 44 high quality studies.

To reduce the possibility of bias and to ensure transparency, the reviewers sent out a request for comments. Several anti-abortion (as well as pro-choice) organizations responded, and their comments influenced the final report.

The questions the multi-faceted panel of experts set out to answer are: How prevalent are mental health problems in women who have an induced abortion? What factors cause poor mental health outcomes after an abortion? Are mental health problems more common in women who have an abortion compared with women who deliver an unwanted baby?

The report’s findings are summarized:

•            Unwanted pregnancies are associated with an increased risk of mental health problems, and the rate of problems is the same whether women had an abortion or gave birth.

•            The most reliable predictor of post-abortion mental health problems was having a history of mental health problems before the abortion.

•            There are additional factors associated with an increased risk of mental health problems specifically related to abortion, such as pressure from a partner to have an abortion and negative attitudes towards abortions in general.

The study recommends:

“…it is important to consider the need for support and care for all women who have an unwanted pregnancy because the risk of mental health problems increases whatever the pregnancy outcome. If a woman has a negative attitude towards abortion, shows a negative emotional reaction to the abortion or is experiencing stressful life events, health and social care professionals should consider offering support, and where necessary treatment, because they are more likely than other women who have an abortion to develop mental health problems.”

We are lucky in La Plata County to have wonderful assistance for women carrying unintended pregnancies. The Pregnancy Center supports women who plan to deliver, while Planned Parenthood provides access to safe, compassionate abortions. I am concerned, however, that the people who demonstrate outside Planned Parenthood may not provide accurate information to women who are considering abortion. The demonstrators may have a negative influence on those women who are at risk for mental health problems.

© Richard Grossman MD, 2012

Goodbye Obstetrics

Sunday, March 4th, 2012

I helped with the birth of my last baby here in Durango in November. He is a healthy boy who weighed just under seven pounds.

More than 35 years ago we chose Durango as the best place to raise our two sons. They are now both married and left town long ago. My wife, Gail, and I still enjoy living in La Plata County—it is our home.

Durango was not the most lucrative place to practice back then, and it still isn’t. My starting salary was just $2,000 a month, and often I worked eighty hours or more a week. The work is strenuous, but helping women and families achieve their reproductive goals has been very satisfying.

At age 68 most people are already looking forward to full retirement. I still have goals to achieve, and am happy to be healthy enough to continue working. But I do enjoy sleeping a lot!

Perhaps I should hold my former neighbor, Dick Edwards, responsible for some of my reluctance to retire. Shortly after moving in to our first home on Rio Vista Circle I met Dick on the sidewalk. He said that retirement is dangerous—that a lot of people get sick or die shortly after they quit working. Of course there may be an error in this thinking, since some people retire due to bad health.

About 15 years ago I decided to work less and to be more active in the community and with global issues, and was able to do so. Although my income decreased, our sons had finished college and expenditures also had decreased. Working less allowed me to be active in volunteer organizations. Now I am involved in one local—Durango Nature Studies; one national—a committee of Planned Parenthood; and one international—Quaker Earthcare Witness.

I will continue practicing office gynecology. One of my goals is to take part in a Food and Drug Administration study of Quinacrine Sterilization. This is a means of permanent female sterilization that can be done without anesthesia. It is so simple that midwives have performed thousands of these procedures. QS uses a drug, quinicrine, that was developed in the 1930s as a replacement for quinine to prevent or treat malaria. It was prescribed to millions of GIs during the Second World War. The FDA has approved quinacrine for several uses, but not yet for sterilization. I hope to participate in a study of QS that will start in 2012. Quinacrine sterilization holds the promise of providing inexpensive, safe control of fertility for the millions of the world’s women who want to prevent pregnancy permanently.

Through the years I have been amazed by this community’s support. For instance, the Ballantine family has published this column for over 16 years. They allow me to own the articles’ copyrights so some of the articles have been reprinted, and I distribute them to 75 people in several countries by email. I plan to continue writing Population Matters! which may be the only regularly published newspaper column in the world that focuses on human population issues.

Providing safe, legal and caring abortion services has been controversial, but one of my priorities. I know that many people oppose abortion; I honor their feelings. But I also appreciate that there are many, many who support access to abortion. Twice in the past week strangers have come up to me to thank me for being a doctor who performs abortions.

It has been just 35 years since I started working here—more than a third of a century. The time has come for new people to take the reins. I would like to introduce Dr. Brie Todd, who has just joined Four Corners OB-GYN. She is a perfect fit with the rest of the staff of the organization—compassionate, up-to-date and technically excellent. I will continue working a few days a month in the office. For pregnant women or those who need frequent visits, I am happy to turn their care over to Dr. Todd and the other physicians, nurse practitioners and physician assistant at Four Corners.

            On this day, Christmas, I would like to recall a very important birth that is celebrated by two billion people worldwide. Two thousand years ago childbirth was dangerous, especially in a stable. In many parts of the world it still is perilous. We can be thankful that we live here and now, and that the little boy who was born on this day, and his mother, both did well.

© Richard Grossman MD, 2011

Honor Girls–4-2011

Wednesday, August 3rd, 2011

I noted that Mrs. Lee was early in her third pregnancy when I was getting ready to see her in the office.

“How are you today?” I asked

“Very well, thank you. The morning sickness is getting better,” was her accented reply.

My examination showed that the size of her uterus was compatible with her 14 week gestational age and the fetal heart rate was average at 140 beats per minute. Then she had a question that I did not expect.

“How do I arrange an amniocentesis?” she asked.

Usually this procedure is done only if there is an increased risk of a genetic abnormality. It involves inserting a thin needle into the woman’s uterus to remove a tablespoon or so of the amniotic fluid that cushions the fetus. An amnio hurts a little bit and carries a small amount of risk of miscarriage.

“I don’t know why you should have an amnio. The blood test that could be done next week—the quad screen—is cheaper and without risk.”

“We already have two daughters and I want to see if this is a boy.”

Something clicked in my head. The Lees, being recent immigrants, wanted a son. “What would you do if you are carrying another daughter?” I asked.

“Well, we would have to think about it,” she answered evasively.

Many cultures favor males over females. In Hindu India, only a son is able to release a dead parent’s soul to go on its journey of reincarnation. Without a son to perform the ritual, the parent’s soul will be trapped forever in the corpse. Furthermore, since child mortality rates are very high in much of the developing world, it is safest to have two or three boys. Dowry is another motive. For a poor family a dowry can require a large proportion of the family’s wealth, making a girl child more of a liability than an asset.

When we traveled in China some fifteen years ago I photographed a beautiful tile picture, permanently imbedded in a wall at the railroad workers’ housing compound in Guangzhou. It showed a proud couple with the smiling father holding a baby up in the air. The child was obviously a girl, and no writing was needed to know the picture’s message. Although China hasn’t been very successful in convincing people to value girls as much as boys, South Korea has. Once females were treated inferiorly there, but now women have almost equal status with men. It is possible to change a society’s attitudes.

In some parts of the world one can pay for an ultrasound just to determine fetal gender. If female, it is likely that the mother will seek an abortion. Both India and China have outlawed these practices, but sex selection sonograms are still readily available.

Worse is what happens if a girl is born where female infanticide is still practiced. When a newborn is an undesired girl, she may be left outside to die. Even where femicide is not practiced, girls may be given short shrift. They may not be fed as well as their brothers, they are less likely to be taken for medical care when sick, and they are less likely than boys to go to school.

Without sex selection, more boys are born, but male infants are more likely to die than female. Overall, women live longer than men. Thus there should be more females alive than males, but sex selection has changed this. Males now exceed females worldwide by one percent.

In China there are 117 boys under age fifteen for every 100 girls. The ratio in India is slightly better at 113 to 100. Lots of young men will have difficulty finding wives!

The Chinese deal with their strong desire for a son in another way. Because of the limitations on most parents in China to raise only one child, many girls are abandoned to orphanages. They are usually well cared for there, but not all are able to go to school. Lucky American parents adopt a few of these Chinese children, who are almost all girls.

Back to my patient: should I do as Mrs. Lee asked?

“I will not do an amnio just to find out the fetus’s gender, without a medical reason,” I told her emphatically.

For many reasons we need to honor and empower girls, not select against them. One is that who girls are educated and have control over their lives will have smaller families when they grow up.

© Richard Grossman MD, 2011

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.