The cost of being a woman

 

Two headlines caught my attention this week. One focused on the luxury tax for tampons that is part of the law in 46 of the 50 states. The other headline was buried in all of the news about the Republican sponsored Health Care Act.  Tom Price, head of HHS, would like to see the co-pay for contraception reinstated. As part of the ACA, contraception is free under the majority of health care plans. Both of these costs are charged to women. On a monthly basis this may not seem too costly. But let’s look at the average sum that a woman would need to pay over her lifetime for both tampons and contraception.

Tampons: an average woman uses 30 tampons for each menstruation. A box of 36 tampons costs $7 at Target. That amounts to 360 tampons per year or $70. When multiplied x 35 years that costs a woman $2450.

Contraception: Prior to the ACA, an average co-pay per month for birth control pills was $30. If a woman were to start pills at age 20 and continue to age 45 it would cost $9000 for contraception.  The average family size is 2 children, so you could subtract $1000 for the time it takes to become pregnant and the pregnancy itself. I would argue that there are other costs during that time that offset the $1000 (maternity clothes, nursing bras etc…) but those are probably considered “luxury items” by society standards.

$10,450 is the total cost of tampons and contraception for a woman during her lifetime. But some of our lawmakers want to extend this burden even further, questioning why men should have to help pay for maternity care as part of health insurance. Despite the backing of Ivanka Trump, I doubt that the current legislature will approve any bill that provides for paid maternity leave. Women caregivers are the norm for elderly parents who need assistance and many choose to decrease their paid work commitments to provide this care.

At what point will our society honestly discuss the financial inequalities that exist between men and women?  Male partners should share the finances of contraception – much cheaper than the cost of supporting  a child to age 18.  Women should not be the only members of society that are burdened with the cost of maternity care.  Removing the luxury tax on tampons is a no-brainer as I have never heard any woman describe her period with the work luxury.  And I have heard many words used to describe periods! Paid maternity leave is present in  every  country in the world other than the US and Papua New Guinea. If we want to make this country great, maybe we should start with the women.

 

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Dear Kellyanne Conway – This is what feminism looks like

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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.

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

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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.

 

 

Female Body Parts 101 – a course for college freshman and Donald Trump

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I started writing this post a few weeks ago and then realized I needed to publish it after the recent comments by Donald Trump following the Republican Presidential debate. It seems that he took offense at questions directed to him by the female moderator and later claimed that she had blood coming out of her eyes as well as “where ever”. Most took “where ever” to mean her vagina. If Mr Trump has a chance to read this blog to the end, I hope that he will realize that the female eyes are not connected to the reproductive parts!

Knowledge of female reproductive parts is important for young women so that they are better able to make responsible decisions regarding contraception, sex and health in the future. But inevitably, I am trying to convince women that the information I give them in the office is more accurate than the information they have gleaned from mothers, friends and the internet. Following are some of the comments that I have heard over the past few months.
1. “I feel a string in by armpit. Do you think my IUD might have moved out-of-place?”
2. “I don’t want any foreign objects in my body.” This from a patient who was sexually active without birth control and a smoker. Tobacco, a baby and a penis are all foreign objects with much more serious consequences than an IUD or birth control pills.
3. A patient was concerned that she would not be able to urinate after having a procedure done on her cervix.
4. A woman was told by her boyfriend that her labia did not look normal. She remained skeptical about by reassurance that her external genitalia were within the range of normal. Unless he is a male gynecologist, I wonder how many lady bottoms the boyfriend has seen?
5. The vagina is a closed tube. Objects (tampons, contraceptive ring or pessary) cannot become lost.
6. “I had a pap smear done in the ER and they said everything was fine.” A pap smear screens for cervical cancer only. It is never done in the ER even if a speculum is placed. It does not check the health of your ovaries or your uterus.
7. “I don’t need a mammogram because there is no family history of breast cancer.” 90% of breast cancer is not hereditary and the major risk factor is obesity.
8. “I don’t want to breast feed because it doesn’t seem natural.” What do you think is the function of the breast?
9. “Pubic hair is disgusting”. Shaving it can cause ingrown hairs and contribute to recurrent vaginal infections.
10. “I won’t have a hysterectomy because then I won’t feel like a woman anymore.” Female hormones are made by the ovaries and not the uterus. A hysterectomy refers to removing the uterus and usually leaves the ovaries intact. And who thinks hemorrhaging each month makes you a woman?!

This is a plea for women to educate themselves about those parts below the waist or “down there”. It will make your doctor’s job much easier when you can name a part of your anatomy rather than referring to “something in my girl parts” when you have a concern.

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

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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.

An Unlikely Hero: Melinda Gates

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I first became fascinated with Melinda Gates when I saw a TedTalk she had done concerning the importance of  birth control for women in the developing world.  She was passionate about the idea that women should be able to control when and how many children they should have. Less children for a poor woman meant that her children would have a better chance for education and eat more nutritious meals. She also addressed the influence of the Catholic church regarding birth control as she was raised Catholic, had aunts that were nuns and attended parochial schools. The video can be found here.

Contraception and prevention of unintended pregnancies has been a cause I speak to patients about daily in my practice. Nationally, the issue of abortion could be a non-issue if each pregnancy was a planned event.  Contraception is of even more importance to women in the developing world, where maternal age at first childbirth is much younger and women are burdened with far more physical labor and inadequate nutrition during pregnancy. Now I have found someone who speaks much more eloquently than I and is associated with a famous name who can advocate for contraception on the international stage. Even more important to me is that Melinda Gates didn’t need to take on such a contentious issue. Given her famous husband and previous career as a software engineer, there are many more glamorous topics that she could have pursued.  But by lending her name and financial backing (The Bill and Melinda Gates Foundation) to increase awareness and innovation in contraceptive methods, she has affected the lives of innumerable women and their unborn children. These women will never know who Melinda is, but they will know that they have more education and access to contraceptive methods than their mothers did.

Now others have the opportunity to be a smaller version of Melinda Gates. As part of the 2015 Gates Annual Letter, Melinda and Bill Gates have created globalcitizen.org as a way to increase awareness, raise money and motivate others to volunteer their time for those global citizens who are less well off. Rather than responding to a specific natural disaster, such as a tsunami or earthquake, we are made aware of the day to day suffering that poverty or disease can cause. And imagine the conversation that you can start during a lull in the dinner talk with your friends – something about the newest injectable contraceptive being trialed in rural African villages, how malaria may become eradicated in the next 15 years, the benefit of drought resistant corn to subsistence farmers in Subsahara Africa.  The possibilities are endless and you will be known as the life of the party. Please consider signing on as a global citizen and creating awareness both for yourself and others.