Commentary Maternity and Birthing

Epidural Please: Respecting All Choices in Childbirth

Martha Kempner

There is a subtle message--often coming from other women--that to truly experience childbirth, women must eschew medical interventions, including pain medication, and go "natural." But some women are happy to put their deliveries in the hands of the medical establishment with its rules and regulations, its operating rooms, its NICUs, and its drugs. That's a good choice, too.

One day last week, my five year-old and I stumbled on an episode of TLC’s A Baby Story, a half-hour documentary-style show in which viewers meet a couple on the verge of having a baby and see the delivery.  I wanted to turn the channel because I was afraid it would make her scared of childbirth as a lot of the women are visibly in pain; many cry, others scream, and, as we witnessed yesterday, some throw up (something my daughter already fears).  In fact, before I had children my husband banned the show from our house knowing that it could have the same fear-inducing effects on me.  But, Charlie insisted that she wanted to see it and I didn’t feel like watching another episode of Team Umizoomi, so we watched as a woman named Melissa had a C-section. Charlie was fascinated by the operation and asked a lot of questions about why she didn’t have to push, why the baby was bloody when it came out, and what the umbilical cord did. It seemed educational, so this morning when she asked to watch it again, I agreed. 

Today’s episode focused on a woman who found out she was pregnant right before heading to Vietnam to adopt twin girls.  By the end of the episode, she and her husband would be the parents of three children under the age of one.  (Far scarier than childbirth or anything that could happen in a delivery room, if you ask me.)  She explained her “birth plan” in interviews prior to delivery saying that she wanted to have natural childbirth (meaning no epidural) because she wanted to experience childbirth completely, including the pain.  And she certainly did; we watched as she was in labor for at least twelve hours.  Over and over she explained to the camera that it really hurt but she was determined to have a true birth experience and not to get an epidural. 

Though I have total respect for this woman’s choices – including her choice to broadcast such a personal event, something I would never want to share with the world – I worried that the message to some viewers might be that those who choose to get epidurals are not experiencing childbirth fully or having a true birth experience. It’s a message that, though often subtle, I think women hear a lot, and pretty much always from other women. 

In what my father would consider a coincidence (he sees them everywhere), when I turned off the TV and turned on my computer, a story popped up entitled “When Did Birth Become a ‘Birth Experience?’”  The author starts out explaining that:

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“Women are being set up by promises of the perfect birth and end up feeling like failures….Though having options about where and how to give birth is worth fighting for, the emphasis on ‘choice’ can feel like pressure rather than freedom.”

Based on the introduction, I expected this article to echo the concerns I was having as a watched this morning’s episode; to argue that women were putting too much pressure on other women to be “strong” and “brave,” to experience this event without the assistance of modern drugs, and above all else to avoid a C-section.  I was wrong; in fact, the blog took almost the opposite approach; once again chiding the medical establishment for having too much control over childbirth, pushing epidurals, and over-using C-sections: 

“In my childbirth classes I have lots of students who hope for a ‘natural birth’ and whose faces start to fade when I mention that in the hospital they will be on an external fetal monitor 20 minutes out of every hour, unable to move. Or when they hear how helpful water is in labor but that there’s no tub in their hospital…. and that one in three births is a C-section. They ask if they can switch to a birth center but for all of Manhattan there’s only one birth center and it can be hard to get into, especially late in the game. So do these women really have that many “choices”? Some might say they should be more “open” (i.e.: just get the epidural, it’s awesome), others might say, get out of the hospital next time.”

The author goes on to say:

As good feminists and Americans, we chant the word “choice” all day long. It’s associated with good things, especially vis-a-vis reproduction, but it’s also definitely bound up with our predatory consumer culture. And it can screw us up when it comes to childbirth (which is unpredictable and messy and incredible but hard and grunty and raw).

I absolutely agree, and I love the description of childbirth as being “grunty and raw.”  However, I would argue that some of the forces that “screw us up” when it comes to childbirth are the very same good feminists who chant the word “choice” all day.

When a friend of mine who lived in the Silicon Valley announced in her prenatal yoga class that she was going to have her baby at Stanford Medical Center, she was met with horrified stares: “But they’re so medicalized there,” her fellow moms-to-be scoffed. When I explained to a friend, who had opted for no pain medication, that I was planning on an epidural from the get go, she reminded me that it slows down labor (something my OB disagreed with), that I’d have to lie in a bed (she’d given birth on all fours), and that they’d probably put me on a fetal monitor the whole time. All of these were presented as obvious negatives that I was too naive (or brain-washed by Western medicine) to see. The conversation (and possibly the friendship) ended with her saying something akin to: “well, if you think you’ll need it.” And, when I chose my new hospital, many people warned me about its higher C-section rates without acknowledging that, by virtue of having the best neonatal intensive care unit (NICU) in the area, it was bound to get more than its fair share of high-risk births.

There is no doubt that many health care providers have their own opinions about how labor and delivery should progress and that some do not take the desires of their patients into account.  I also believe that some women who don’t want epidurals are talked into them by doctors and nurses. I am sorry that some hospitals don’t allow women in labor to walk the halls, soak in tubs, or be visited by an acupuncturist if that’s how they prefer to handle the pain. And, I know that many health care providers are way too quick to order a C-section.  I’m also acutely aware of how much of this is influenced by the threat of lawsuits and the burden of malpractice insurance. I certainly would never argue that our health care system—maternity care included—is anything but broken.

That said some women are happy to put their deliveries in the hands of the medical establishment with its rules and regulations, its operating rooms, its NICUs, and its drugs. As my Silicon-Valley-friend put it: “I know it’s medicalized—that’s why I chose it, you know women die doing this.”

Maybe I’m reading too much into them but I often feel a condescending tone when I get emails recounting a wife’s or a daughter’s medication-free birth which include phrases like “she was so brave, she didn’t even get an epidural,” or “she was so tough, she did it without anything for the pain.” If that’s what she wanted, that’s great and I’m happy for her.  Just as I am glad that the woman in today’s episode of A Baby Story was able to go through with her birth plan.  But as someone who got an epidural as soon as possible both times, I want to say, loud and clear, that I was brave and tough too. 

When we say we are for choice, we have to be for all choices—without condescension, without assumptions, and without judgment.      

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.