On Reproductive Choice: The faith difference between Melinda Gates and Amy Coney Barrett and what that means for women

• 

• 

I recently finished Melinda Gates book, “The Power of Lift”, and was most impressed by the intersection of her strong Catholic faith and her views on reproductive choice. The Catholic church is often seen in sharp disagreement with not only abortion but also the use of contraception. Ms Gates acknowledges this dissonance and then lays out a thoughtful argument as to why she is able to honor her Catholic faith while at the same time using her platform and funding thru the Gates Foundation to increase access to contraception that enables women to make informed decisions about whether and when to have children. It has been proven that spacing of pregnancies reduces maternal and newborn deaths as well as increases the health of children already in the family.

Foremost, Gates admits that it is not only difficult but also misogynistic for a celibate male hierarchy to be allowed to make decisions about the reproductive life of woman when these same rules can harm the mothers and the children they birth by perpetuating the cycle of poverty. It is her empathy with poor women and children, per the Franciscan teachings of the church, that has led her foundation to provide funding for innovative contraceptive options as well as increased access to these options. Thru her travels in the developing world, she came to understand that contraception prevented millions of unsafe abortions by preventing unwanted pregnancies. While 93% of Catholic women in the US have used contraception, the Catholic church was working to prevent women outside of the US from having those same choices.

Amy Coney Barrett is also Catholic but has chosen to use her faith as a way to limit reproductive options for women in this country. If she becomes the next Supreme Court Justice she may be the deciding vote in overturning access to legal abortions. Even more timely are her views on the Affordable Care Act and what that means for women and their reproductive health. Prior to the ACA, women were required to pay for contraception and could be charged more for health insurance as having babies is a costly endeavor. After the ACA was passed and the more reliable, but costly, long term contraceptive options became available for free, unintended pregnancies and teen pregnancies plummeted and the abortion rate hit its’ lowest point, dropping 14%.

Ms Barrett has a developing world example in her own home. Two of her children are adopted from Haiti. Abortion in Haiti is illegal and reliable contraception difficult to obtain. Poverty is endemic as is the role of men in controlling women’s lives. When women are unable to feed their growing families, they often place a few of their children in a religious sponsored orphanage with the intent that “when my situation improves, I will go back and get my children”. Most of these mothers are never reunited with their children because their poverty does not improve.

I have worked intermittently in Haiti as an ob/gyn physician since 2006. Some of the most horrific situations I have encountered are when desperate woman seek an illegal abortion. The maternal mortality can be exceedingly high when unskilled providers perform medical or surgical abortions. This may be the future of our country if we restrict access to contraception at the same time that we make abortion illegal.

Religious faith can be a powerful force for doing good, as evidenced by the work of Melinda Gates and her leadership in increasing access to contraception, which she believes, and has been factually proven, to lift women out of poverty. . It can also be a force that demonizes the tragic choices that women in poverty sometimes have to make in order to support their children. That is the faith of Amy Coney Barrett.

The life of a woman in Vietnam

International Women’s Day, a day to celebrate the accomplishments of women both past and present, was celebrated earlier this month.  During my recent trip to Vietnam helping to care for women patients, I had the opportunity to hear many women’s stories, see their hard work both in the hospital and in the shops and visit the Women’s Museum in Hanoi.

Each day on my walk to the hospital I encountered women that had arisen before dawn to start food preparation at their street-side restaurant or had traveled to the wholesale market to purchase fruit for sale at their sidewalk stall during the day. Many of these women have husbands and children who live hours away in a rural location who they only have the opportunity to visit a few times each month. The income earned in the city makes it possible for their children to attend school, as public school carries fees of $25-30 each month.

Women who remain in rural locations closer to their families are responsible for all the domestic work in addition to working in the families rice plot. The rice plot is a source of not only food for the family, but also cash income as some of the rice is sold. While Communism has afforded women the opportunity to be employed outside of the home, it has not coerced men into assuming any of the household responsibilities. A Vietnamese meal is delicious, but time-consuming to prepare as it contains no processed components. Due to lack of refrigeration, prepared food is consumed immediately and there is not the availability of saving food for a future meal.  In the urban areas, many of the married men in their 30-40’s helped with some of the food prep and child care. This cooperative marriage model has not filtered out to the 65% of Vietnamese who live outside of the cities.

 

 

Similar to China, Vietnam has a 2 child policy that was implemented in the late 1980’s to control population growth. A patriarchal society that depends on a son to carry on the family name often comes into conflict with the reality of a family that consists of 2 daughters. This has led to utilizing abortion for sex selection and upsetting the gender balance of the society. Although contraception is free there is a lack of sex education and general taboo against pre-marital sex, resulting in many unplanned pregnancies outside of marriage. Young girls bear the brunt of these cultural beliefs, often visiting clinics or hospitals in secret to have an abortion.

Approximately 1/3 of the ob/gyn residents I worked with were women, most unmarried and living at home with their parents. Only a few of the attending physicians were women, a prevalence that was familiar from my early residency days. One of the attending physicians lamented the dual roles that Vietnamese culture places on professional women – achieving personal high educational performance and job status in addition to perfection in raising children and household responsibilities. Young women physicians worried that their “advanced age” of 25-27 years was making them less eligible for marriage. It seems that women in Vietnam and the US share many of the same concerns regarding careers and home.

Family is very important to Vietnamese, influenced by the Confucius culture of China. The most important job for a woman is to bear children and her worth within the community is influenced by this ability. Having sons is considered the highest praise. Adoption is only considered if a couple is unable to have children of their own. Each day as we saw many women in clinic, one of the first items discussed in their health history was whether or not they had children. It was assumed that all women wanted 2 children, without asking the woman. For this reason, there seems to be an unwritten taboo against birth control, as even health professionals falsely believe that it may influence a woman’s future ability to become pregnant. Unfortunately this mindset has resulted in Vietnam having the highest abortion rate in Asia. Abstinence only education doesn’t work in either America or Asia!

Walking the crowded hallways of the hospital on the obstetrical floor afforded me a brief glimpse into the world of women as they supported each other during the process of childbirth. Sisters, mothers and mother-in-laws often surrounded the pregnant women as she labored on a narrow cot or weaving her way down the packed hall. Food was cooked at home and brought in, urine buckets were taken away and emptied, arms were offered for support. Older women help new moms to breast feed and care for newborns. After a 7 day stay in the hospital (compared to 2 days in the US), moms are proudly escorted home by their husbands on the back of a scooter – the primary means of transportation in Vietnam. If employed, they are eligible for 6 months maternity leave.

Compare this family centered care to the medical care of women in labor or gynecology. Acquisition of technology to advance medical care has markedly improved in the past 10 years, but there has not been a similar interest in developing patient centered care. Women deliver their babies on a unpadded metal table with no family or friends nearby and nurses and doctors that are too busy to provide comfort. During gynecology clinic, patients are led into a room containing 10-15 students/residents/attending physicians that are all discussing her medical record. The nurse helps her climb up onto the exam table, again unpadded, so that she can undergo 4-5 pelvic exams while everyone continues to watch and discuss. Sometime after she leaves the room, a physician has a brief conversation with her and her family in the crowded hallway with a treatment plan. Most of these women feel privileged to be able to afford this care as it is only available to those who can pay the yearly fee for health insurance.  They have the opinion that “the doctor knows what is best for me” and don’t question recommendations. This is changing as patients in private hospitals are demanding more interaction with their physicians and lawsuits have started to climb.

As in many parts of the world, the power and influence of women is changing age-old traditions. The overall rapid progress of change in Vietnam elevates the voice of women as they advocate for change that benefits their role as well as that of policies that benefit their families. Our role in the West is to provide educational support while allowing leaders within Vietnamese health care to create systems that work for their people.

 

 

 

 

 

 

Dear Anti-Abortion/Pro-life Protester, Come to Haiti

You would love it here. Abortion in Haiti has always been illegal and always will be. 90%+ of Haitians are Christian with the 2 predominant religions, Baptist and Catholic, conservative and anti-abortion. Most of you probably identify as conservative Christian also. You certainly don’t need to worry about equal rights for women or the #Metoo movement , as male dominance is very prevalent in both church and home. Abstinence outside of marriage is the preferred method of birth control for young people and for married people “children are a woman’s duty and gift from God”.

But if you decide to visit, please don’t dig any deeper than the surface, as the reality is much different from what you will hear. In speaking with one health care worker who has been here for many years, they estimate that 70% of Haitian women have attempted to end an unwanted pregnancy at some time in their life. This may only be an estimate but was based on a 6 month survey of women. Read that again … 3 out of 4 women have tried to end a pregnancy, most without success. A “didn’t want” pregnancy can be ended thru misoprostal (this is one of the drugs that is used in the US for medical abortions) bought from a street vendor, Pitocin from a bootleg pharmacy, a surgical abortion from a doctor who has a clinic to make extra income, drinking some type of poison and on and on. The doctors here think that things have improved for women since they have been able to obtain misoprostal as there are less women trying to end a pregnancy with sharp objects stuck in their vagina, perforating tissue and the uterus.

If you come, please bring health education and particularly sex education materials. Although contraception is provided free by the government in family planning clinics, many women have misperceptions about the benefits of contraception and don’t use it. This is also likely due to the perceived sin of using artificial means of contraception within the Catholic church. In only 1 week here, I have heard from patients that they will lose weight, not be able to have future children, develop mysterious aches and pain and build up too much blood in their system. The best excuse – Their partners don’t like them to use anything.

Don’t bring your thoughts and prayers. They don’t feed your 2 young children when you are too sick from pregnancy to go to work. They don’t protect you from a husband that beats you. They don’t make your married boyfriend answer his phone after you have told him that you are pregnant. They don’t prevent your parents from making you stay home from school when they find out you are pregnant age 16. They don’t stop the boy next door from raping you one night on your way home. These are the circumstances that many Haitian women find themselves in and why they choose to end a pregnancy. They take the risk of bleeding, poisoning or bodily damage because the alternative of continuing the pregnancy is much worse.

If the United States overturns Roe v Wade, some states will make abortion illegal. They will also limit access to contraception and education for women.  Women will still get pregnant with a “didn’t want” pregnancy and become desperate to change their situation. Parts of the US will look like Haiti. Be careful what you protest for.

 

Dear Kellyanne Conway – This is what feminism looks like

Ms Conway spoke at the CPAC convention last week on the contemporary definition of feminism as anti-male and pro-abortion. I consider myself a feminist and don’t identify with either of these definitions. I heard about her commentary as I was driving between appointments and reflected on my “feminist” activities on the same day as she was speaking at the convention. Following is the run-down of what a feminist does on her day off from her usual job as a physician serving women – the ultimate feminist job.

1. Awake at 6 am to make breakfast for daughters as they head out to high school.
2. Text with 26 year old son about upcoming interview for nursing school.
3. Spend 2 hours on Haiti non-profit, Helping Haiti Work, that grants microloans to women and operates a sewing center that constructs reusable menstrual pads for sale in the community. Women that participate in this program are empowered to be leaders in their families and communities.
4. Volunteer at a local public elementary school tutoring first graders in reading and math. 90% of the students in this school are children of color. The teachers are dedicated and constantly working to involve each child in the curriculum.
5. Grocery shopping for the week. My husband and I split this task, but he often does more than 50%. Arrive home and start dinner in crockpot for husband and daughters as we will be eating at different times. I cook because I love to and not because I am the mother. Husband also does his share of meal prep.
6. Drive across town to the MN legislature. I have volunteered to speak before the Health and Human Services Committee in opposition to 2 bills that are being introduced to restrict access to abortion. I am NOT pro-abortion, but rather pro-choice and pro-contraception. Along with many of my colleagues, I feel that government should stay out of the room when a physician is counseling a patient.
7. Attend a year-end meeting of our independent medical clinic, one of the few non-hospital owned clinics left in our area. I am a board member of this clinic and up for re-election so give a 5 minute speech about the value of independence and what measures we need to take in the future to stay that way. My value as a board member is based on experience, working hard and ability to appreciate other’s opinions. Being the only female board member is a responsibility I do not take lightly.
8. Head back to St Paul to attend a visit to an Eastern Orthodox church, arranged thru Tapestry, an interfaith group of women that works to break down religious and cultural barriers thru education and service. I am proud to be one of the 3 founders of this growing organization but saddened to know that our existence is needed now more than ever. It was interesting to hear the stories behind the iconography that is so much a part of the Eastern Orthodox religion, but also to reflect on the similarities between the Jewish faith and to view the women in the pictures as wearing the traditional head coverings or hijab. During the social hour following the church tour, I lamented with my Muslim friends about the difficulties of encouraging our teens to stay involved in their respective religions. We found that we shared many of the same difficulties as well as joys.
9. Arrived home around 9:30 and discussed husband’s experience at local town hall political meeting that was attended by 1000 constituents but not our legislator. We made plans for future involvement in politics and discussed our shared values with our daughters.
10. Crawled into bed around 11 pm as I had an early morning surgery and clinic the next day. This is where the real feminist is unleashed – advocating for free birth control, vaccinations, knowledge about our bodies and how they work and access to health care as a human right and not a privilege.

Feminism is the right to be treated as an equal human being and to be able to make our own choices. That is not anti-male or pro-abortion. That is human decency and what I teach both my sons and my daughters.

 

How Roe v Wade is affecting the upcoming election – and how we can change the discussion.

Life must be interesting for Ruth Bader Ginsburg. As the oldest member of the Supreme Court, she is the most likely to retire/pass away in the next 4 years, allowing the next President to change the dynamics of the Supreme Court. Either it remains with a conservative majority or changes to a more liberal bench. The SCOTUS (Supreme Court of the United Sates) appointment is the reason many conservatives still back Mr Trump, even though they confess  they don’t believe he is Presidential material.  With a conservative majority, their hope in the future involves the defeat of Roe v Wade and the outlawing of abortion.

One of the frequent arguments against abortion involves the practice of partial birth abortion. In fact, in the third presidential debate Mr Trump described partial birth abortion as “ripping a baby out of the womb only days before birth”. As an obstetrics doctor, I routinely do this. I refer to it as a cesarean and would use the nomenclature cutting rather than ripping. Spreading false rhetoric only works to push people apart. We need to look at how we can find common ground in this debate.

These are the facts. 91% of abortions are performed before 13 weeks of pregnancy and only 1.3% occur after 21 weeks of pregnancy. The majority of these later terminations are due to fetal anomalies that are not diagnosed until the 5 month ultrasound. Heart-wrenching decisions need to be made by parents in a short time frame, as most states outlaw terminations beyond 23 weeks, only 3 weeks after a diagnosis is made. In the past few years, I have been involved in 2 of these scenarios that resulted in different decisions. One child was diagnosed with a lethal heart defect that would require multiple heart surgeries to allow the child to become old enough so that she would be a potential candidate for a heart transplant. Years of surgeries, hospitalizations, medications for at best a 20% chance of life. The other mother was diagnosed with rupture of the amniotic sac at 20 weeks of pregnancy, preventing full and complete development of the baby’s lungs. One couple chose to continue the pregnancy, the other to terminate. The important point is not which option these couples chose, but that these parents were able to make a CHOICE. A decision that made sense for their family now and in the future.

Rather than focusing on the 1.3% of abortions that are classified as late-term, why not focus on the 91% that are performed prior to 13 weeks. The number of these abortions can be dramatically reduced by reliable contraception. For example, use of long acting reversible contraception (IUDs and implants) by teens has been shown to reduce the pregnancy rate by 50%.  It is always amazing to me the number of women I see for a pregnancy confirmation that have not been using birth control because they are worried about all the “bad side effects”,  but yet didn’t want to become pregnant. Do they understand that an unwanted child is a “bad side effect”. An educational campaign focused on contraception,  healthy pregnancy and involving men in contraceptive decision-making would pay back large dividends in reducing health care dollars spent on unwanted pregnancies that are often high risk.

An unwanted pregnancy that may end in abortion was not created by just one person. But it is the woman who is blamed for the decision to terminate the pregnancy. Why don’t we hold the male partner accountable? They could have used a condom if they didn’t want their partner to become pregnant.

Overturning Roe v Wade and outlawing abortion is not the answer. I have worked in many developing world countries where abortion is illegal. This does not mean that abortion does not happen, only that it becomes expensive and dangerous. Unlicensed and unqualified practitioners put women’s lives at risk in order to make money. These are some of the same countries where birth control is difficult to obtain and rape of women, both by their spouses and others, is common. During one of my trips to Haiti, I was able to save a woman’s life (the mother of 4 children) when she suffered a perforation of the uterus and horrific bowel injury by an unqualified physician. If our surgical team had not been operating that week, she would have died and left 4 children orphans. Her response when I told her that we had to remove her uterus in order to save her life was a grateful thank you because she would not have to worry any further about pregnancy. One ward of a hospital in Port-au-Prince is devoted to women who have suffered complications of abortions. Many of these women die due to lack of antibiotics and the funds to pay for adequate care.

If you are against abortion, work to increase education and access to contraception. Educate men and boys about their responsibilities. This will work to reduce 91% of abortions; those that occur prior to 13 weeks and are often due to lack or failure of contraception. Leave late-term abortion decisions to women and their families. This is a personal decision that is different for every woman. We as physicians are able to provide factual information and support women in their decisions. This should not be decided as a one size fits all policy.

 

 

Dear Senator Rubio: Stop the abortion shaming!

 

Dear Senator Rubio,

I am an ob/gyn physician and would like you to know how your actions and words have greatly impacted my work and the life of my patients. Before the height of the mosquito season was upon us, congress had the opportunity to approve funding for Zika research and prevention. The best method of prevention is contraception. In low-income communities, the providers of health care and contraception often include Planned Parenthood. Due to the steadfast opposition to Planned Parenthood by Republicans, Zika funding was blocked and legislators left to enjoy their mosquito laden summer. I can see why this wouldn’t be important to many of you because you are either male or beyond the childbearing years. You have access to DEET to prevent mosquito bites and you can change your travel plans if needed. Pregnant women in your state, Florida, are not so lucky. They often need to use public transportation to get to their jobs, exposing them to mosquito bites during the day. When you are barely getting by, the expense of DEET is not an option.

And if all of that wasn’t enough of a burden on pregnant women, you recently made a blanket statement for all women who may be unfortunate to not only be exposed to Zika but to also find out that they are carrying a child with microcephaly. You do not believe that they should have the option to terminate a pregnancy, because YOU are strongly pro-life, even though you acknowledge that there will be a lifetime of difficulties.

Mr Rubio – let me tell you who will be shouldering the burden for that “lifetime of difficulties”.  It is the mother. Many male partners/spouses in these situations find that the life of difficulties is too much to bear and leave the family. The overwhelming majority of the time it is the mother that is the primary caregiver and often needs to quit her job in order to care for a child who requires assistance 24 hours a day. Would you be willing to forgo your future in politics to provide all of the daily cares for a child who can’t speak, eat by himself or walk?

I also wonder where the outrage is against the men in Florida who are not using condoms, both to prevent spread of Zika and pregnancy. Free distribution of condoms would bypass the Planned Parenthood institution that you dislike and an education campaign on how and why to properly use condoms would take the burden of an unintended pregnancy off of women. We could also require by law that the father of a child with microcephaly needs to provide 50% of the lifetime cares.

Women are strong – we make babies, house them for 9 months and often provide the majority of daily cares for the next 18 years. We are also smart – we know when a “lifetime of difficulty” is something that our family is ready to face and when it may not be the best option. Women need to be in charge of the decision to continue a Zika infected pregnancy. Not you, Mr Rubio. And women and men need access to free contraception until we get this Zika problem figured out.

Fortunately, I live in Minnesota, where we have mosquitoes but also cold winters that kill the type of mosquitoes that carry Zika.  Due to climate change and warming temperatures, which you have previously denied, this may only be the first of many tropical diseases that your state will be forced to deal with.

Sincerely yours,

Leslee Jaeger, MD

The harsh reality of obstetrics and how it relates to the recent controversy over Planned Parenthood

I am a coward. Although I have always supported Planned Parenthood, both in financial terms and when I used their contraceptive services as a young adult, I seldom find the time to speak out on their behalf at rallies or volunteer at their locations.  It is much easier to write a check than to face the opposition crowds that gather at their front door. But with the release of the recent heavily edited video that is being used as leverage to ignite anger and calls to defund the organization, I feel that it is the duty of those of us who have quietly supported this organization to become more vocal. Thus, this coward is moving out of the shadows and trying to inform the general public about how easily this video could have been created.

As a second year resident, I was faced with telling a patient that her infant had lost a heartbeat at 4 months of pregnancy. She was young and distraught, wanting to terminate the pregnancy as soon as possible and with the least amount of pain. The senior resident offered her a dilation and evacuation of the pregnancy in the operating room under anesthesia. She quickly accepted and was scheduled for the next day. I had never performed such a procedure or seen one performed. At the end of clinic, the senior resident spent time explaining to all of the junior residents about the procedure.  The cervix needed to be dilated mechanically, the bag of waters ruptured and the fetus extracted (not whole, but in pieces), followed by the placenta. Before the procedure could be considered complete, the parts of the fetus had to be reassembled to make sure that none were missing. Although gruesome, this was the safest and quickest route to terminate the pregnancy at this stage. What if someone had recorded this conversation and edited out the part about the fetus being demised?

A second encounter that generates some rather unpleasant conversation regards a fetus that is further along in pregnancy and has been demised for more than a week. Much of the tissue has started to deteriorate and extremities can become easily separated from the body during a vaginal delivery. As a resident, we had discussions about techniques to deliver these infants that would be most successful in giving the parents an intact infant to hold. This conversation could also easily be edited to make us appear heartless.

When a stillborn infant is born, we often collect tissue samples (at the heart of the controversy in the Planned Parenthood video) from the thigh of the infant and blood thru a needle stuck in the infant’s heart. This is considered the tissue that is most likely to grow in culture and produce a possible reason for the fetal death. In order to learn these techniques, residents need to watch someone more experienced perform the biopsy and blood draw. I will leave the discussions to your imagination.

While no one wants to think about what happens to aborted fetuses, the live tissue can be quite valuable in the research lab in regards to human illnesses such as Parkinson’s, Multiple Sclerosis etc. Since these illnesses do not exist in animals, only human tissue will be of benefit. Planned Parenthood is clear that the money obtained is used to pay for the service of collecting and preserving the tissue and no woman is coerced into donating tissue. In fact, only a few centers throughout the country offer the service.

90% of Planned Parenthood’s services support contraception, STD testing and health screening for women, many of whom are poor and unable to afford a visit to a traditional clinic. The best way to decrease the abortion rate is thru education and provision of effective contraception. This is the primary aim of Planned Parenthood. We should be increasing their funding, rather than debating whether to defund the organization. If all of the creative energy and monetary funds that went into creating this video were used in a public health campaign regarding the safety and availability of contraception, abortion could become a safe but rare occurrence.

If you, like me, have quietly supported Planned Parenthood, now is the time to become more vocal and educate others. Let’s turn the tables on those who seek to destroy, and make it an opportunity to talk about the benefits of contraception to decrease the incidence of abortion.