As I step back and look through my last year of posts I am astonished to the extent to which politicians are getting deeply involved in the particulars of my profession, Obstetrics and Gynecology. This week's post underscores this in no uncertain terms. Is this really where we want government and politicians, right in the middle of a very specialized medical field, and right in the middle of the doctor patient relationship ?
The New York Times has reported the the Trump administration plans to expand exemptions to the so called “ contraceptive mandate”. They are not abolishing the contraceptive mandate at this time. However, they are allowing employers to chose plans that do not cover birth control. These employers or insurers must be exempted on basis of “sincerely held religious beliefs”.
It is my assumption that it is employers’ assumption that such plans which do not cover contraception are less expensive. However I feel entirely comfortable asserting that insurance companies know precisely where their dollars go, and they will not, for one minute, pass the savings on to the employer. That is because in about nine months after institution of this policy, there will be no savings. Seriously, do people really think that pregnancies and miscarriages will cost less than contraceptives ?
As far as religious objections go, there are ostensibly several considerations. First, social conservatives have argued that the use of contraception encourages what they view as illicit or teen sex. This has been proven not to be the case. Moreover, they may object saying that contraception causes abortion. IUDs do act in part by preventing implantation of fertilized eggs, but they also act by causing cervical mucous to become viscous and block the cervical canal, preventing fertilization in the first place. So in this sense, a few fertilizations may take place which cannot implant. However, and critically, without any IUD or other birth control in place, as many as 25 % of fertilizations which do occur simply do not implant naturally, or they implant and naturally fail. Thus, with an IUD, a very small percent of fertilizations occur and do not implant. Without an IUD or other birth control method, 25 % of fertilizations fail and are lost, most before the period is even missed. In the end, there are many more natural abortions that there are IUD related abortions. If an abortion is an abortion, and one wants to minimize their numbers, one would certainly want to provide as much contraception as possible. A true anti-abortion advocate should espouse both IUDS and other forms of birth control, especially pills which prevent ovulation.
But it seems those who are anti-abortion are interested in more than just preventing abortion. They are interested in legislating a world view and lifestyle. They see a world where there is only one right way to live, and that those who live this way should have power over those who don't. I can only conclude this because of the “don’t bother me with the details” approach of much of the GOP on numerous scientific and medical issues such as contraception. If the GOP really cared about strengthening families, preventing abortion, and the health of infants and children, they would choose policies scientifically proven to meet these goals. ACOG ( The American College of Obstetricians and Gynecologists) has already come out against the bill since it is at odds with those goals.
It becomes somewhat misleading to write so much about abortion policy since there are so many other pressing medical policy issue of the day. However, so much is happening in this area that it behooves me to report on it. For example, the ACLU (American Civil Liberties Union) has sued in Federal court in Hawaii challenging restrictions on the use of Mifiprex, the so-called abortion pill. They have argued that it should be available by prescription in a pharmacy. At present, a clinic or hospital visit is necessary. Particularly in the Hawaiian islands, access to clinics is variable. Mifeprex has been determined safe and legal, so ACOG has supported this suit. My concerns with pharmacy dispensing is that patients with positive pregnancy tests should have a reasonable idea of their gestational age before they take the medication, and that ectopic or tubal pregnancy not be missed.
The House just approved the “Pain Capable Unborn Child Protection Act” which bans all abortions after 20 weeks. ACOG’s position is that a fetus cannot feel pain until 24 weeks. You just have to continue asking yourself, how do organizations and people formulate their opinions ? What data do they use ? Do they use data ? Would they know bad data from good data ?
Forget alt facts. This next report shows us how far certain members of the GOP are wiling to go in their separation of politics from reality. Former Congressman Tim Murphy, a Republican from Pennsylvania, was a staunch anti-choice politician. However, he was recently caught telling his mistress to get an abortion. Think this is this height of hypocrisy ? Think again. Mr. Murphy promptly recused himself and resigned. Not Scott Dejarlais. This physician and Republican Representative from Tennessee circa late 1990s, called himself “pro-life”. However, he had multiple affairs with 3 co-workers, a “drug rep” and at least 2 patients ! At his divorce, he testified that he had supported his then girlfriend and now ex-wife to get two abortions. You would have thought he too would leave politics. However he has since been re-elected twice. The people have spoken and will get what they deserve.
Finally, in a surprising turn of events, the Republican Governor of Illinois, Bruce Rauner, has signed a bill allowing Medicaid to cover abortions. He has stated that he does not feel women of different means should face different options. He has gone on record as a pro-choice Republican.
Meanwhile the entire hurricane belt suffers under a burden of destruction and disease. There is a shortage of just about everything, from basic needs, to power, to medicine, doctors, and means of transportation to get all of it where it needs to go. Shortages of pharmaceuticals in particular may be felt all through the US based on the increased need in the South.
In medical news, we shift our attention to yet another case where beliefs seem to supersede science. Witness the practice of certain women of a more "natural" bent taking their placenta home to consume. It’s meat, right ? It’s even your own tissue, so what’s the big deal ? Most mammals do it. Modern women can have it various ways, but the most refined way is to have it “ encapsulated”. It turns out that “placentophagy" can make you and even your baby infected and sick, through pathogens (bacteria) that would have been killed by your own immune system, but aren't since they are separated from it and encapsulated into little gelatin capsules for swallowing. Moreover, the hormones in the placenta are NOT what you want after birth. The whole mechanism of uterine involution (contracting to prevent bleeding) and nursing is triggered by the expulsion of the placenta and it’s hormones. It is the expulsion of the placenta that changes you from pregnant to non pregnant. If you had complications in pregnancy like hypertension, you won’t get better until all your placenta and it’s hormones are gone.
A new study has shown that those who drink four cups of coffee per day have a 64% lower risk of early death. I would like very much to see that stratified by sex and age. Men do not have to worry about osteoporosis ( bone thinning) as much as women. Caffeine does thin the bones, and bone fractures in old age are a tremendous source of morbidity in older women. Women who are pregnant certainly should not drink that much caffeine. We ask our pregnant patients to limit their caffeine intake to 200 mg per day which is alot less than four cups. More than 200 mg per day of caffeine is associated with poor fetal growth. Whenever hearing results of a research study, ask yourself several questions. To whom does it apply ? Did they include women in the study ? What does this mean for women, or for a person like me ?
Once again we have new evidence linking obesity with more than just diabetes and heart disease. A new report from the CDC (Centers for Disease Control) has indicated that “excess body fat accounts for at least 13 different kinds of cancer. This study looked at over 600,000 people in the US in 2014. Obesity rates have increased even more since then. Results like this should change the way we think and teach about obesity.
We have already mentioned the Southern United States in this post - the Hurricane belt. That same area is also know as the fat belt, also the bible belt. New data also shows that those in the deep south and midwest have higher smoking rates than the national average. In that area 22% of adults smoke, compared with 15% in the rest of the US. Could there be cultural reasons for the smoking and obesity ?
A few years ago there was a bit of a scandal pertaining to a drug to treat preterm labor. Sold as a name brand, it was exorbitantly expensive. Generic, or even compounded, it was very cheap. It came down to FDA approval as to whether it could be sold as generic. First it couldn’t, then it could due to public and medical outcry, then it couldn’t again due to concerns about safety efficacy. However, now a new study published in JAMA Internal Medicine has indicated that the two preparations are equivalent. It will be interesting to see how long this data takes to get translated into policy, and we can once again buy cheap generic and have it be covered by insurance.
In the good news department, breast cancer rates are declining. The American Cancer Society reported that breast cancer deaths increased through 1989. Thereafter, they have been on a steady decreased, altogether down 40 % since 1989. This attributed to better treatments and medications.
Stay tuned for more fascinating news from the world of Obstetrics and Gynecology, next week, on Medical Monday.