“E” is For Excellent at Rewire

Amie Newman

Rewire is "E" for Excellent! And we're passing on the love.

This is like a chain letter that you actually want to receive and pass along.

The amazing Rachel, writer of the blog Women's Health News, and contributor to Our Bodies, Our Blog showed Rewire's blog some love when she gave us the "Excellent" award!

Women's Health News is a great source for news and information on a range of women's health issues – and she's got a great resource page with links to direct service and advocacy organizations that women can contact with information on everything from cancer to birth to sex-ed.

So, without further ado, here are the blogs Rewire would like to bestow the "Excellent" award upon:

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  • Birthcontrolwatch.org – Cristina Page is always on point when discussing contraception and abortion. We love her and never cease to learn something new from her posts on the blog at birthcontrolwatch.org!
  • Radical Doula – If you haven't read any of Miriam Perez's blog posts on Rewire or Feministing, you're missing a lot. Miriam blogs at Radical Doula and works at the National Latina Institute for Reproductive Health. Her perspective – as a reproductive health activist as well as a doula – is so unique and necessary!
  • Pandagon – What can you say about Amanda, Pam and the rest of the Pandagon bloggers? There are no words minced. Amanda doesn't pander when it comes to writing about sexual and reproductive health and rights – thank god.
  • Reproductive Rights Professors Blog – If you want the most current news on reproductive rights around the country, from state-level legislation to President Bush's latest stomping on women's reproductive rights, check out this blog. You won't be sorry. And it's written by a real professor!
  • Women's Bioethics Project Blog – Fascinating look at the bioethics of women's health written by scholars and public policy analysts. It's even got its share of pop culture posts as well.

I'd love to know what blogs you'd give an "Excellent" award to! Comment away and let us know!

Analysis Abortion

Misoprostol Is a Game-Changer for Safe Abortion and Maternal Health Care. Why Isn’t it More Widely Available?

Francine Coeytaux & Elisa Wells

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide—postpartum hemorrhage and unsafe abortion—why have we not taken more advantage of it?

Misoprostol: Have you heard about this small, inexpensive, and most importantly available pill that can save women’s lives? Pragmatic Brazilian women first discovered the potential of misoprostol (or Cytoteca, in their parlance) in the 1980s. According to the label on this widely used peptic ulcer drug, it was not to be taken during pregnancy as it could induce bleeding. Living in a country with very restrictive policies and little access to safe abortion services, they recognized the opportunity to circumvent the system and, by word of mouth, spread the word to other women about this easily obtainable pill that could help them safely end an unwanted pregnancy.

Thirty years later, women in countries around the world are beginning to do the same—continuing to spread the word, talking to each other about misoprostol, and trying to get their hands on these pills. The women who are accessing the drug in their communities and taking it by themselves have shown us that there are relatively few health risks involved with misoprostol. What began in Brazil as a natural public health experiment has been validated by rigorous clinical studies conducted by international groups such as the World Health Organization and Gynuity. These studies have shown that the use of misoprostol for abortion is very safe, especially when taken early on in the pregnancy; while not as effective as when taken in combination with mifepristone (another abortion pill), misoprostol taken alone will safely terminate 75 to 90 percent of early pregnancies when taken as directed.

Misoprostol has also been proven to have numerous other lifesaving properties, including the ability to prevent and treat postpartum hemorrhage and to induce labor. It is registered in more than 85 countries, usually as an anti-ulcer medication, and is used off-label by clinicians around the world for numerous reproductive health indications. In addition to these clinical uses, we are beginning to see positive public health outcomes from community-based use of misoprostol. In countries where abortion is restricted and women are using misoprostol, we have seen a reduction in infections. And in under-served communities, where women delivering at home are taught to take misoprostol immediately after delivery, postpartum hemorrhage is significantly reduced.

If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide—postpartum hemorrhage and unsafe abortion—why have we not taken more advantage of this exciting technology? Given the global attention being paid to meeting the fifth Millennium Development Goal (MDG 5)—that of reducing maternal mortality—it is difficult to fathom why we continue to squander the opportunity misoprostol offers us.

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The public introduction of any new technology takes time and is not easy; the introduction of emergency contraception is just one of the latest examples. Reproductive health advocates have been working for decades to increase women’s access to this safe, effective, and non-abortifacient technology. While much progress has been made around the world, the recent action of the Obama administration to prevent full over-the-counter access in the United States is a sad illustration of the hurdles women face in accessing reproductive health technologies. The hurdles we face in introducing misoprostol will be even higher given three inherent characteristics:

  • It has multiple indications, including abortion.

  • It is only “second best” to existing drugs, competing with a “gold standard.”

  • It can be used by women without the assistance of a provider.

The Challenge of Multiple Indications

Misoprostol’s greatest clinical asset—the fact that it can be used for numerous reproductive health indications—also poses enormous challenges for implementation. As mentioned, misoprostol has many uses: to both prevent and treat postpartum hemorrhage, to induce labor, to induce abortion, and for post-abortion care. But these multiple indications pose two major challenges for implementation, one political and the other educational.

The political challenge lies in overcoming the stigma of abortion. A survey we conducted in 2010 of organizations that were working with misoprostol for postpartum hemorrhage revealed that the second biggest barrier to the introduction of misoprostol was its association with abortion. To quote one respondent who was asked about the challenges and opportunities for its introduction: “Hypersensitivity of misoprostol as an abortifacient [is a barrier]. We see this in clinical providers, government officials, even donors—a disproportionate concern that if misoprostol were to be made available for PPH prevention and treatment, it would be used for abortion. This is a major obstacle in accepting misoprostol for other OB/GYN indications—the abortion stigma.”

This political fear is strong, despite the evidence that all indications of misoprostol use are potentially life-saving. And because of this fear, there is a great deal of sidestepping going on as organizations begin to introduce misoprostol at the community level for postpartum hemorrhage while trying to stay clear of its potential use for abortion. “We feel there is tremendous promise for use of misoprostol for [postpartum hemorrhage], so we do not want to jeopardize that application by highlighting the other indications,” said another respondent.

The political controversy only exacerbates the programmatic challenge of informing women, their partners, and their health-care providers of the different doses and the proper timing of administration needed for different indications. This is usually facilitated by the registration and labeling of products in appropriate doses for each of misoprostol’s various indications. But because the vast majority of misoprostol use is currently done “off-label”(it’s being used for an indication other than the one the product is registered for) there is an urgent need to find ways to get women accurate information about how to use it for the different reproductive health purposes. Mobile technologies are beginning to open the information door to some women, but challenges remain. We need to find ways of achieving a broader level of knowledge about correct use, and to help women differentiate between the proper uses for each indication, including abortion.

The Challenge of Competing Against a “Gold Standard”

For both indications—abortion and postpartum hemorrhage—misoprostol is the second best option, up against another drug long considered the “gold standard.” For abortion, the most effective medical abortion regimen is mifepristone combined with misoprostol; when used together, the success rate is 93 percent, and when misoprostol is used alone it is 78 percent successful. Thus, where mifepristone is available, such as in the United States, it is the drug of choice.

In the case of postpartum hemorrhage, injecting oxytocin is the first line of treatment because, when oxytocin is at full potency, it is more effective than misoprostol. But oxytocin, unlike misoprostol, needs to be refrigerated. As a result, the quality of the drug is easily compromised by exposure to heat—a problem in many Global South countries. Finally, the administration of oxytocin requires that the women deliver in a health-care facility, another “gold standard” established by the medical community.

In reality, in many places in the world, we are not meeting these “gold standards,” in spite of decades of trying to do so. Mifepristone is far from universally available, oxytocin stock-outs are common in many places and/or the quality has been compromised, and many women continue to deliver at home, without skilled attendants. In these situations, misoprostol is a very good alternative and even has the advantage of being in pill form, making home use possible and safe.

Which brings us to the third challenging characteristic…

Women Can Use it Without the Assistance of a Provider

Another survey respondent summed it up nicely: “This is a gender issue. Misoprostol faces this unbelievable barrier because it is a drug for women.”

Therein lies both the greatest opportunity and the greatest challenge. Misoprostol has the potential to be a game-changer when it comes to maternal health precisely because it can be used safely and effectively by women themselves. The foremost obstacle to achieving MDG 5 is the weak health-care infrastructures of many countries. Misoprostol offers the opportunity to circumvent this obstacle for two of the three principal causes of maternal mortality—postpartum hemorrhage and unsafe abortion. Yet despite growing evidence that women can safely and effectively take misoprostol by themselves, in their homes, for both uses, health-care practitioners are insisting on controlling access to the drug, viewing it as an important addition to their clinical tool kit and a service only they can “provide” instead of as a pill that can be used by women, to help themselves, with little or no assistance from a health-care provider. The failure to relinquish control over the use of misoprostol not only gets in the way of women who are intent on helping themselves, it risks negating the most attractive aspect of this new technology: it’s self-use properties. To quote another respondent to our survey: “Many people are more concerned about what might happen with an intervention (i.e., side effects) than what might happen without an intervention (i.e., maternal death). In this case, women are more likely to be harmed by omission of the intervention than from any danger posed by the intervention itself.”

Obviously, as we work to make misoprostol available at the community level we need to acknowledge that it is a powerful drug and that incorrect use can lead to serious consequences—such as uterine rupture during labor induction. While some would use this as an argument for placing restrictions on access, we see this as a call to put accurate and comprehensive information about its safe use into the hands of women.

The Way Forward

This week policy makers from around the world are gathering in Malaysia at the third Women Deliver Conference to continue to share ways of reducing maternal mortality. Misoprostol is the single-best opportunity to do just that. But the true potential of this simple and cost-effective technology lies in our willingness to abandon our “provider” frame and put the pills directly in women’s hands. Our challenge is to let women be the shapers and the users of this new technology, not the beneficiaries of what we can provide or what we think they need. Can we stop worrying about women’s “misuse” or “abuse” of misoprostol and show that we truly trust women with their own reproductive health care? Let us remember that it was women who discovered this drug in the first place, specifically to circumvent the weakness of the health-care system. Let us give them back this powerful tool and get out of their way.  Our responsibility is to ensure that women have easy access to the pills and all the knowledge necessary to use them effectively and safely.

Commentary Abortion

After “Pro-Choice:” What’s Next for Our Messaging?

Janna Zinzi

A reproductive justice framework is critical—but it's not the same thing as "pro-choice."

The Planned Parenthood Federation of America (PPFA) recently announced that it would move away from “choice” language in its messaging. As PPFA President Cecile Richards argued, the term “pro-choice” no longer resonates with many younger advocates and voters, nor does it reflect the complexity of reproductive health decision making. But the move raises an important question that the movement now must answer: what’s next for our messaging?

During the recent media coverage surrounding Roe v. Wade’s 40th anniversary, the term “reproductive justice” was often cited as a framework that better appeals to young people since it encapsulates economics, race/ethnicity, environment, sexual orientation, and other contexts that affect access to reproductive rights. While many of us advocates welcome the opportunity to have a discussion about reproductive justice (RJ), it’s important to note that individuals in the media are often unclear about how to discuss RJ and may not fully grasp what it means.

A recent segment from MSNBC’s “Now With Alex” (see above) on the Roe v. Wade anniversary exemplifies many of the obstacles we face in having effective public conversations about RJ. In an interview with PPFA President Cecile Richards, host Alex Wagner quoted a Time magazine article that mentions RJ as an emerging framework for young people. But the description did not include mentions of race, ethnicity, or culture, which are central to why Black women and women of color created RJ in the first place. Furthermore, there was no one from the RJ community on the panel to make that distinction.

Richards then shifted the discussion back to her talking points: that attitudes about abortion have stayed largely the same over the last four decades, that abortion is a deeply personal decision, and that youth don’t relate to the terms “pro-choice” and “pro-life.” However, “youth” are not a monolithic community. (The lack of youth voices in mainstream media panel discussions is a subject for another article.)

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As communications strategist and full-spectrum doula Miriam Zoila Pérez noted in a recent post, “Reproductive justice isn’t a simple concept that can be explained in a sound bite. But because of that, it also better mirrors the complex world we live in than a label like pro-choice or pro-life ever could.” Furthermore, RJ isn’t an identity, so it isn’t a replacement for “pro-choice.”

The fact that Planned Parenthood, the biggest, most well-known reproductive health provider in the nation, is abandoning “pro-choice” terminology is a sign that the movement needs to find more relevant ways to talk about these issues—ways that better connect to people’s real-life experiences. When abortion access is under attack at the local, state, and federal levels, holding on to stigmatized messaging that doesn’t work inside or outside the Beltway is obstinate and myopic.

Later in that “Now With Alex” segment, former GOP Chairman Michael Steele raised an issue that concerns many fans of “pro-choice” terminology: that intersectional conversations about reproductive justice will diffuse discussions about abortion.

In fact, moving away from “pro-choice” language won’t mean that discussions about abortion will be displaced. Many vocal RJ leaders and advocates do significant work on the ground to promote abortion access. But an RJ framework is more inclusive than that; it allows us to deconstruct the conditions that limit access to abortion, contraception, comprehensive sex education, and more.

Eesha Pandit of Men Stopping Violence and the National Network of Abortion Funds points out that even if we drop the term “pro-choice,” mainstream reproductive rights organizers won’t suddenly adopt the RJ framework. “On one hand, there’s the co-opting of ‘reproductive justice’ within reproductive rights and reproductive health communities. That’s problematic because it makes the real point of reproductive justice and the work that women of color have done in creating the framework, completely invisible. Just using the term ‘reproductive justice’ does not mean that the framework or the perspective is in an intersectional frame,” she told Rewire. Changing language is irrelevant if the reproductive rights community doesn’t shift its approach. But introducing RJ as a framework can help the media make these important connections.

Case in point: in that MSNBC clip, when Alex Wagner reads a (limited) definition of RJ, she then states that reproductive rights are connected to civil rights, and cites transvaginal ultrasound legislation as a violation of both. This illustrates how using an RJ framework to combine policy issues with storytelling could help bring more nuanced discussions of these issues to the media.

If we want politicians to create supportive reproductive health policies, then it’s our job to educate them—and the public, via the media—about why women need safe, legal access to abortion and the many barriers to access in our society. We must effectively connect abortion access to other issues so politicians can see how progressive reproductive health policies have positive effects for a greater group of constituents than just those who identify as “pro-choice.” An RJ framework makes connections across movements and opens the door to a larger group of voters and constituents.

The potential end to “pro-choice” language is an opportunity for our movements to rethink their overall strategies. As RJ advocate and Racialicious Associate Editor Andrea Plaid told Rewire, “This is not the time to be selfish—protective, yes, but not selfish—with reproductive justice ideas and the framework, especially since other people are moving away from ‘pro-choice language.’ In fact, this is the perfect opportunity to get the ideas and issues of reproductive justice ‘out there.’”

It’s also worth noting that the conversation about dropping “pro-choice” language is largely missing a discussion about the real limitations that surround the concept of “choice.” An RJ framework addresses how “choice” doesn’t resonate for many people because many people’s “choices” are dictated by societal factors, such as the economy and the environment. A woman who cannot afford time off work to travel for hours, or even days, because of forced waiting periods does not have a real “choice,” for instance.

This debate reminds me of how liberals scoff at the irrelevance of the GOP, with its narrow platform that doesn’t represent our diversifying country. The reproductive rights, reproductive health, and “pro-choice” movements could take a note from that critique.

That said, a shift in language shouldn’t be the end goal here. According to RJ advocate Aimee Thorne-Thomsen, who’s the Vice President for Strategic Partnerships at Advocates for Youth, it is not important for the media to use the term “reproductive justice”—it’s more about the work being done. “I don’t need RJ to be a message, I need it to be a movement led by people most affected by reproductive oppression,” she told Rewire.

There’s much debate about whether labels matter. But the bottom line is that if we can’t connect our labels to something tangible, something that shows people how they are personally affected, then those labels won’t mean anything for our movement. It’s Marketing 101: “What’s in it for them?” The terms “pro-choice,” “pro-abortion”, “anti-choice,” “pro-life”—none of them matter as much as we sometimes think they do outside of our movements. So when we we waste the small amount of media coverage we get to debating them, we are automatically losing.

Change is scary, and it’s often much easier to hang onto old practices, even if they’re outdated and stifling. However, the future of our movement depends on us moving away from fear and territoriality and towards having more inclusive, nuanced discussions about the intersections of reproductive health, rights, and justice.

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