Commentary Maternity and Birthing

Eight Babies and the End of a Doctor’s Career

Pete Shanks

The Medical Board of California has revoked the license of Dr. Michael Kamrava, effective July 1st. This is the doctor who became notorious after his patient, Nadya Suleman, gave birth to octuplets following fertility treatment.

Cross-posted from Biopolitical Times, the online publication of the Center for Genetics and Society.

The Medical Board of California has revoked the license of Dr. Michael Kamrava, effective July 1st. This is the doctor who became notorious after his patient, Nadya Suleman, gave birth to octuplets following fertility treatment. However, the Board emphasized (pdf linked here) that:

This is not a one-patient case or a two-patient case; it is a three-patient case, and the established causes of discipline include repeated negligent acts (all three patients), gross negligence (two patients) and inadequate records (one patient).

Overruling the recommendation of the Administrative Judge who held in the original hearing that Kamrava should be put on probation, the Board argued that “the revocation of [his] certificate is necessary to protect the public.”

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The report emphasized that Kamrava’s decision to transfer 12 embryos at once constituted “gross negligence” and noted that even the doctor testifying for the defense described that as a “lapse in judgment.” That witness was Dr. Jeffrey Steinberg, who has a long history of pushing the boundaries of acceptability for fertility treatments, including a brief and controversial attempt to offer pre-pregnancy genetic selection for hair color, eye color, and skin complexion.

Steinberg supported Kamrava all along, asserting in 2009, “Who am I to say that six is the limit? There are people who like to have big families.” In an interview with the AP after the judgment, he insisted that patients were often adamant about implanting more than the recommended number of embryos:

“One-on-one, physicians talk about it all the time. We all pretty much feel like we have to wing it and hope for the best. … In the end that tissue belongs to the patients. We worry about them turning around to accuse us of murder or some such thing if we don’t do as they say.”

No mention there of worrying about the health, physical and mental, of the patient. Or of the consequences for the health of the babies, since multiples — even twins — tend to be premature and to suffer far more medical and developmental consequences than singletons. Or of the American Society for Reproductive Medicine (ASRM) guidelines [pdf], whose goal is singleton births. Or of the financial costs to the family. Or indeed of the responsibility of the expert to guide those who come for care.

Steinberg also suggested that Kamrava was not a very successful practitioner, which seems to be true. According to the CDC’s most recent report (covering 2008, which includes Suleman’s pregnancy), his clinic performed 39 total cycles of IVF using fresh embryos from nondonor eggs, which resulted in 7 women giving birth, 5 to singletons, 1 to twins, and one, notoriously, to octuplets. The success rate for small numbers, the report notes, “may be misleading” but it’s lower than the national average: For women under 35, 41.1% of cycles resulted in live births, nationally; in his clinic, 5 of 17. Steinberg commented:

“Kamrava had very low pregnancy rates and that’s why he got so courageous with those embryos.”

It’s a strange use of “courageous” — “reckless” might be more to the point. Kamrava did ask his patient to agree ahead of time to “multi-fetal reduction” should a multiple pregnancy occur, but in the event she refused. Which should not have been too much of a surprise, given that she had expressed a desire for a family of 10 and specifically for twins. Indeed, Dr. Victor Fujimoto of UCSF, who testified for the prosecution, thought he should have referred the patient to a mental health professional. Given her subsequent, and continuingerratic behavior, that does seem plausible. (Incidentally, William Heisel has made a compelling case for dropping the nickname “Octomom,” though Suleman at one point attempted to trademark it.) The professional had a duty of care, and a patient is more than a customer. Sean Tipton of the ASRM, which expelled Kamrava in 2009, said, “[L]osing his license is sort of like the sad but obvious ending in a tragic novel.” But it’s not the end for the patient, and still less for her children.

Kamrava is now appealing the loss of his license in court, but Suleman supports the permanent ban, calling him a “danger to humanity.”

News Abortion

Study: Telemedicine Abortion Care a Boon for Rural Patients

Nicole Knight

Despite the benefits of abortion care via telemedicine, 18 states have effectively banned the practice by requiring a doctor to be physically present.

Patients are seen sooner and closer to home in clinics where medication abortion is offered through a videoconferencing system, according to a new survey of Alaskan providers.

The results, which will be published in the Journal of Telemedicine and Telecare, suggest that the secure and private technology, known as telemedicine, gives patients—including those in rural areas with limited access—greater choices in abortion care.

The qualitative survey builds on research that found administering medication abortion via telemedicine was as safe and effective as when a doctor administers the abortion-inducing medicine in person, study researchers said.

“This study reinforces that medication abortion provided via telemedicine is an important option for women, particularly in rural areas,” said Dr. Daniel Grossman, one of the authors of the study and professor of obstetrics, gynecology, and reproductive sciences at the University of California San Francisco (UCSF). “In Iowa, its introduction was associated with a reduction in second-trimester abortion.”

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Maine and Minnesota also provide medication abortion via telemedicine. Clinics in four states—New York, Hawaii, Oregon, and Washington—are running pilot studies, as the Guardian reported. Despite the benefits of abortion care via telemedicine, 18 states have effectively banned the practice by requiring a doctor to be physically present.

The researchers noted that even “greater gains could be made by providing [medication abortion] directly to women in their homes,” which U.S. product labeling doesn’t allow.

In late 2013, researchers with Ibis Reproductive Health and Advancing New Standards in Reproductive Health interviewed providers, such as doctors, nurses, and counselors, in clinics run by Planned Parenthood of the Great Northwest and the Hawaiian Islands that were using telemedicine to provide medication abortion. Providers reported telemedicine’s greatest benefit was to pregnant people. Clinics could schedule more appointments and at better hours for patients, allowing more to be seen earlier in pregnancy.

Nearly twenty-one percent of patients nationwide end their pregnancies with medication abortion, a safe and effective two-pill regime, according to the most recent figures from the U.S. Centers for Disease Control and Prevention.

Alaska began offering the abortion-inducing drugs through telemedicine in 2011. Patients arrive at a clinic, where they go through a health screening, have an ultrasound, and undergo informed consent procedures. A doctor then remotely reviews the patients records and answers questions via a videoconferencing link, before instructing the patient on how to take the medication.

Before 2011, patients wanting abortion care had to fly to Anchorage or Seattle, or wait for a doctor who flew into Fairbanks twice a month, according to the study’s authors.

Beyond a shortage of doctors, patients in Alaska must contend with vast geography and extreme weather, as one physician told researchers:

“It’s negative seven outside right now. So in a setting like that, [telemedicine is] just absolutely the best possible thing that you could do for a patient. … Access to providers is just so limited. And … just because you’re in a state like that doesn’t mean that women aren’t still as much needing access to these services.”

“Our results were in line with other research that has shown that this service can be easily integrated into other health care offered at a clinic, can help women access the services they want and need closer to home, and allows providers to offer high-level care to women from a distance,” Kate Grindlay, lead author on the study and associate at Ibis Reproductive Health, said in a statement.

News Abortion

How Long Does It Take to Receive Abortion Care in the United States?

Nicole Knight

The national findings come amid state-level research in Texas indicating that its abortion restrictions forced patients to drive farther and spend more to end their pregnancies.

The first nationwide study exploring the average wait time between an abortion care appointment and the procedure found most patients are waiting one week.

Seventy-six percent of patients were able to access abortion care within 7.6 days of making an appointment, with 7 percent of patients reporting delays of more than two weeks between setting an appointment and having the procedure.

In cases where care was delayed more than 14 days, patients cited three main factors: personal challenges, such as losing a job or falling behind on rent; needing a second-trimester procedure, which is less available than earlier abortion services; or living in a state with a mandatory waiting period.

The study, “Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients,” was published online Thursday by the Guttmacher Institute.

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The national findings come amid state-level research in Texas indicating that its abortion restrictions forced patients to drive farther and spend more to end their pregnancies. A recent Rewire analysis found states bordering Texas had reported a surge in the number of out-of-state patients seeking abortion care.

“What we tend to hear about are the two-week or longer cases, or the women who can’t get in [for an appointment] because the wait is long and they’re beyond the gestational stage,” said Rachel K. Jones, lead author and principal research scientist with the Guttmacher Institute.

“So this is a little bit of a reality check,” she told Rewire in a phone interview. “For the women who do make it to a facility, providers are doing a good job of accommodating these women.”

Jones said the survey was the first asking patients about the time lapse between an appointment and procedure, so it’s impossible to gauge whether wait times have risen or fallen. The findings suggest that eliminating state-mandated waiting periods would permit patients to obtain abortion care sooner, Jones said.

Patients in 87 U.S. abortion facilities took the surveys between April 2014 and June 2015. Patients answered various questions, including how far they had traveled, why they chose the facility, and how long ago they’d called to make their appointment.

The study doesn’t capture those who might want abortion care, but didn’t make it to a clinic.

“If women [weren’t] able to get to a facility because there are too few of them or they’re too far way, then they’re not going to be in our study,” Jones said.

Fifty-four percent of respondents came from states without a forced abortion care waiting period. Twenty-two percent were from states with mandatory waits, and 24 percent lived in states with both a mandatory waiting period and forced counseling—common policies pushed by Republican-held state legislatures.

Most respondents lived at or below the poverty level, had experienced at least one personal challenge, such as a job loss in the past year, and had one or more children. Ninety percent were in the first trimester of pregnancy, and 46 percent paid cash for the procedure.

The findings echo research indicating that three quarters of abortion patients live below or around the poverty line, and 53 percent pay out of pocket for abortion care, likely causing further delays.

Jones noted that delays—such as needing to raise money—can push patients later into pregnancy, which further increases the cost and eliminates medication abortion, an early-stage option.

Recent research on Utah’s 72-hour forced waiting period showed the GOP-backed law didn’t dissuade the vast majority of patients, but made abortion care more costly and difficult to obtain.

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