Commentary Contraception

The Copper IUD: A Better Plan B

Peter Belden

The copper IUD, known as Paragard in the US, is an overlooked option which offers a number of benefits over EC pills.

The increase in the use of emergency contraceptive (EC) pills highlighted in Ellen Chesler and Andrea Flynn’s post, Emergency Contraception Use Spreads, but Many Women Are Still Left Out, is great news indeed. However, the little known secret is that there is an alternative form of emergency contraception that is ten times better than EC pills, and yet medical providers rarely tell women about this more effective option. 

The copper IUD, known as Paragard in the US, is an overlooked option which offers a number of benefits over EC pills. A systematic review of over 40 studies found an overall failure rate of less than 1 in 1,000 (0.09 percent) for the copper IUD when used as EC, compared to failure rates over ten times higher, 1.4 percent for UPA and 2 percent for oral LNG, two common types of EC pills.  

When women seek medical care they expect and believe that their medical provider is telling them about the most effective treatment for their condition as well as the reasonable alternatives.  For women who have recently had unprotected sex this means telling women that the copper IUD is the most effective option, and that EC pills offer a reasonable alternative. 

A recent study documented that when women were offered the choice of a copper IUD as EC, a significant proportion, 40 percent, chose the copper IUD over EC pills. The Hewlett Foundation has supported a pilot project to help document the practical steps other health centers can take to effectively offer this option. 

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As members of a movement that stresses the importance of reproductive choice and patient autonomy we can celebrate the increased access to emergency contraceptive pills. However, it is essential that we also speak out and insist that our health centers, which still see large numbers of women seeking EC, inform women about the copper IUD as EC. When talking to their medical provider, women have a right to this information so that they can make an informed choice. 

Commentary Human Rights

The Democratic National Convention Was a Remarkable Victory for Disabled People

s.e. smith

This year's convention included disabled people every evening, as part of a larger inclusive policy that made 2016 a banner year for disability rights activists.

Read more of our coverage of the Democratic National Convention here.

On Thursday night, Hillary Clinton formally accepted the Democratic Party’s nomination for president. Her speech included many of the elements one expects from a nominee, but there were some standout moments—like when she mentioned disability rights, which she did repeatedly.

Clinton integrated disability into her discussion of her record, talking about her work to ensure that disabled children have the right to go to school and bringing up the health-care needs of disabled youth. Her commentary reinforced the fact that she has always cared about disability issues, particularly in the context of children’s rights.

But she did more than that. She referenced shortages of mental health beds. She explicitly called out disability rights as necessary to defend. And at one point, she did not mention disability, which in itself was radical. When she outlined her plans for gun reform and clearly stated that she wanted to keep guns out of the hands of people who shouldn’t have them, she referenced people with criminal histories and terrorists, but not mentally ill people, who have been fighting a surge in stigma thanks to perennial (and wildly incorrect) assertions that mental illness causes violence. That omission was clearly deliberate, given the meticulous level of crafting that goes into writing one of the most important speeches of a presidential candidate’s career.

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The nominee’s speech would have been remarkable on its own, but what made it truly outstanding is that it was far from the first appearance of disability at this year’s Democratic National Convention (DNC). The convention included disabled people every evening as part of a larger inclusive policy that made 2016 a banner year for disability rights activists, who are used to being invisible. These kinds of appearances normalized disability, presenting it as a part of some people’s lives and a source of pride, not shame or misery.

On Monday, for example, disability rights activist Anastasia Somoza rolled out to give a sharp, compelling speech that didn’t cast disability in a tragic or exceptional light. She wasn’t the only wheelchair user to appear on the DNC stage—Paralympic athlete Mallory Weggemann led the pledge of allegiance on a different evening. Dynah Haubert, an attorney for Disability Rights Pennsylvania, took the stage on Tuesday. Nor were wheelchair users the only disabled people represented. Ryan Moore, a longtime friend of Clinton’s, spoke about health care and his experiences as a man with spondyloepiphyseal dysplasia congenital syndrome, a form of dwarfism. Connecticut Gov. Dannel Malloy talked about his learning disabilities. Musician Demi Lovato, who has bipolar disorder, took on mental health.

Former Iowa Democratic Sen. Tom Harkin, a nondisabled man who played an instrumental role in the push to pass the Americans with Disabilities Act (ADA) in 1990, taught the crowd sign language during a lively speech about the fight for disability rights on Tuesday, the 26th anniversary of the landmark legislation.

On Wednesday night, former Rep. Gabby Giffords (D-AZ) strode out onto the DNC stage in Philadelphia, smiling and waving at the crowd, to make a few short remarks. “Speaking is difficult for me,” she concluded, “but come January 2017 I want to say these two words: ‘Madam President.'” Her speech was about gun violence—a subject with which she’s intimately familiar after being shot in the head in 2011.

This level of representation is unprecedented. Some speakers, like Somoza, explicitly talked about disability rights, putting the subject in the spotlight in a way it’s never been at previous conventions. Others, like Giffords, came up on stage to talk about something else entirely—and happened to represent disability while they were at it. Similarly, Rep. Tammy Duckworth (D-IL), a decorated combat veteran and double amputee, talked about military policy.

This is a striking contrast from the treatment of disability at previous Democratic National Conventions: When disabled people have appeared, it’s often been in the form of a lackluster performance that objectifies disability, rather than celebrating it, as in 1996 when former actor Christopher Reeve framed disability as a medical tragedy.

Disability rights activists have spent decades fighting for this kind of representation. In 1992, two years after the passage of the ADA, the platform included just three mentions of disability. This year, the subject comes up in 36 instances, woven throughout the platform for an integrated approach to disability as a part of society, rather than as something that needs to be walled off into a tiny section of the platform, tokenized, and then dismissed.

In the intervening years, disabled people in the United States have fought for the enforcement of the ADA, and taken the right to independent living to court in 1999’s Olmsted v. L.C., which was namechecked in the 2000 platform and then forgotten. Disabled people advocated to have their rights in school codified with the Individuals with Disabilities Education Act (IDEA) in 2004, pushed for inclusion in 2010’s Affordable Care Act, and are fighting to pass the Community Choice Act and Disability Integration Act (DIA). Disability rights in the United States has come a long way since 1990’s infamous Capitol Crawl, in which disability rights activists dragged themselves up the steps of the U.S. Capitol, pleading with Congress to pass the ADA.

And as activists have pushed for progress in the courts and in Congress, disability rights have slowly become more prominent in the Democratic party platform. The ADA has been a consistent theme, appearing in every platform since 1992 alongside brief references to civil rights; historically, however, the focus has been on disability as a medical issue. The 1996 platform introduced Medicare, and health care in general, as issues important to the disability community, a refrain that was reiterated in years to come. In numerous years, Democrats addressed concerns about long-term care, in some cases positioning disabled people as objects of care rather than independent people. Disabled veterans have also played a recurring role in the platform’s discussion of military issues. But beyond these topics—again, often approached from a dehumanizing angle—and the occasional lip service to concerns about discrimination and equal rights, until the 2000s, education was the only really consistent disability issue.

In 2000, however, the Democrats went big, building on eight years under President Bill Clinton, and the influence of his then-first lady. For the first time, disability wasn’t simply lumped under “civil rights.” The platform explicitly called out the need for protection from disability hate crimes, but it also began to introduce the idea that there were other issues of relevance to the disability with a discussion of the digital divide and the obstacles that held disabled people back. Almost 30 years after the passage of the Rehabilitation Act of 1973, which barred disability discrimination by government agencies and contractors, the Democrats were starting to embrace issues like accessibility and independent living, which also played a prominent role in 2000.

It was a hint that the party was starting to think about disability issues in a serious way, especially when in 2008, the Democrats discussed the shameful delay on ratification of the United Nations’ Convention of the Rights of Persons with Disabilities, took on the Community Choice Act, talked about the need to enforce IDEA, and, again for the first time, explicitly addressed voting rights issues. By 2012, they were also calling out discriminatory voter ID laws and their disproportionate effect on the disabled community.

That’s tremendous, though incremental, progress.

And this week, the efforts of a generation of disability rights activists are on display everywhere in Philadelphia, where Daily News columnist Ronnie Polaneczky observed that accessibility is a top priority across the city. The DNC is providing expanded accessible seating, wheelchair charging stations, service dog relief areas, Braille materials, closed captioning, American Sign Language interpreters, medication refrigerators, and more. That’s radical inclusion at work, and the result of incredible efforts by disability rights organizers—including the 400 delegates who disclosed disabilities.

Those same organizers have been hounding the presidential candidates, holding them accountable on disability over and over again. They’ve brought up concerns about independent living, wage disparities, education, access to services, accessibility, hate crimes, reproductive rights, the “marriage penalty” and government benefits, and casual disablism in campaign rhetoric and practices. Advocates leaned on the Clinton campaign until it began captioning its content, for example. RespectAbility sent journalists out on the trail, #CriptheVote organized Twitter, and Rev Up encouraged people to register to vote and get involved. The disability community may be more explicitly politically active this year than ever before, and the DNC has been responding accordingly.

Clearly in consultation with disability rights activists, the Democrats have brought a host of new issues into this year’s platform, acknowledging that disabled people are part of U.S. society. Some of the many issues unique to this year’s platform include: abolition of the subminimum wage, concerns about economic opportunities with an explicitly intersectional discussion of the racial wealth gap, affordable housing, accessibility at the polls, the role of disability in the school-to-prison pipeline, and the need for more accurate Census data.

Notably, in a platform that has loudly called for a Hyde Amendment repeal and pushed for other abortion rights, the Democrats have also reinforced the need for access to reproductive health for disabled people, a revolutionary clause that’s gone virtually unnoticed.

This is a platform—and convention—of aggressive inclusion, and it reflects a victory for disabled people in the United States. It does still lack some components the disability community would like to see, like a shoutout to the DIA, which Clinton supports. This is, however, the start of what looks like a robust and real relationship between the Democrats and the disability rights community.

Culture & Conversation Maternity and Birthing

On ‘Commonsense Childbirth’: A Q&A With Midwife Jennie Joseph

Elizabeth Dawes Gay

Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Jennie Joseph’s philosophy is simple: Treat patients like the people they are. The British native has found this goes a long way when it comes to her midwifery practice and the health of Black mothers and babies.

In the United States, Black women are disproportionately affected by poor maternal and infant health outcomes. Black women are more likely to experience maternal and infant death, pregnancy-related illness, premature birth, low birth weight, and stillbirth. Beyond the data, personal accounts of Black women’s birthing experiences detail discrimination, mistreatment, and violation of basic human rights. Media like the new film, The American Dream, share the maternity experiences of Black women in their own voices.

A new generation of activists, advocates, and concerned medical professionals have mobilized across the country to improve Black maternal and infant health, including through the birth justice and reproductive justice movements.

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Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

At her clinics, which are located in central Florida, a welcoming smile and a conversation mark the start of each patient visit. Having a dialogue with patients about their unique needs, desires, and circumstances is a practice Joseph said has contributed to her patients having “chunky,” healthy, full-term babies. Dialogue and care that centers the patient costs nothing, Joseph told Rewire in an interview earlier this summer.

Joseph also offers training to midwives, doulas, community health workers, and other professionals in culturally competent, patient-centered care through her Commonsense Childbirth School of Midwifery, which launched in 2009. And in 2015, Joseph launched the National Perinatal Task Force, a network of perinatal health-care and service providers who are committed to working in underserved communities in order to transform maternal health outcomes in the United States.

Rewire spoke with Joseph about her tireless work to improve maternal and perinatal health in the Black community.

Rewire: What motivates and drives you each day?

Jennie Joseph: I moved to the United States in 1989 [from the United Kingdom], and each year it becomes more and more apparent that to address the issues I care deeply about, I have to put action behind all the talk.

I’m particularly concerned about maternal and infant morbidity and mortality that plague communities of color and specifically African Americans. Most people don’t know that three to four times as many Black women die during pregnancy and childbirth in the United States than their white counterparts.

When I arrived in the United States, I had to start a home birth practice to be able to practice at all, and it was during that time that I realized very few people of color were accessing care that way. I learned about the disparities in maternal health around the same time, and I felt compelled to do something about it.

My motivation is based on the fact that what we do [at my clinic] works so well it’s almost unconscionable not to continue doing it. I feel driven and personally responsible because I’ve figured out that there are some very simple things that anyone can do to make an impact. It’s such a win-win. Everybody wins: patients, staff, communities, health-care agencies.

There are only a few of us attacking this aggressively, with few resources and without support. I’ve experienced so much frustration, anger, and resignation about the situation because I feel like this is not something that people in the field don’t know about. I know there have been some efforts, but with little results. There are simple and cost-effective things that can be done. Even small interventions can make such a tremendous a difference, and I don’t understand why we can’t have more support and more interest in moving the needle in a more effective way.

I give up sometimes. I get so frustrated. Emotions vie for time and energy, but those very same emotions force me to keep going. I feel a constant drive to be in action and to be practical in achieving and getting results.

Rewire: In your opinion, what are some barriers to progress on maternal health and how can they be overcome?

JJ: The solutions that have been generated are the same, year in and year out, but are not really solutions. [Health-care professionals and the industry] keep pushing money into a broken system, without recognizing where there are gaps and barriers, and we keep doing the same thing.

One solution that has not worked is the approach of hiring practitioners without a thought to whether the practitioner is really a match for the community that they are looking to serve. Additionally, there is the fact that the practitioner alone is not going to be able make much difference. There has to be a concerted effort to have the entire health-care team be willing to support the work. If the front desk and access points are not in tune with why we need to address this issue in a specific way, what happens typically is that people do not necessarily feel welcomed or supported or respected.

The world’s best practitioner could be sitting down the hall, but never actually see the patient because the patient leaves before they get assistance or before they even get to make an appointment. People get tired of being looked down upon, shamed, ignored, or perhaps not treated well. And people know which hospitals and practitioners provide competent care and which practices are culturally safe.

I would like to convince people to try something different, for real. One of those things is an open-door triage at all OB-GYN facilities, similar to an emergency room, so that all patients seeking maternity care are seen for a first visit no matter what.

Another thing would be for practitioners to provide patient-centered care for all patients regardless of their ability to pay.  You don’t have to have cultural competency training, you just have to listen and believe what the patients are telling you—period.

Practitioners also have a role in dismantling the institutionalized racism that is causing such harm. You don’t have to speak a specific language to be kind. You just have to think a little bit and put yourself in that person’s shoes. You have to understand she might be in fear for her baby’s health or her own health. You can smile. You can touch respectfully. You can make eye contact. You can find a real translator. You can do things if you choose to. Or you can stay in place in a system you know is broken, doing business as usual, and continue to feel bad doing the work you once loved.

Rewire: You emphasize patient-centered care. Why aren’t other providers doing the same, and how can they be convinced to provide this type of care?

JJ: I think that is the crux of the matter: the convincing part. One, it’s a shame that I have to go around convincing anyone about the benefits of patient-centered care. And two, the typical response from medical staff is “Yeah, but the cost. It’s expensive. The bureaucracy, the system …” There is no disagreement that this should be the gold standard of care but providers say their setup doesn’t allow for it or that it really wouldn’t work. Keep in mind that patient-centered care also means equitable care—the kind of care we all want for ourselves and our families.

One of the things we do at my practice (and that providers have the most resistance to) is that we see everyone for that initial visit. We’ve created a triage entry point to medical care but also to social support, financial triage, actual emotional support, and recognition and understanding for the patient that yes, you have a problem, but we are here to work with you to solve it.

All of those things get to happen because we offer the first visit, regardless of their ability to pay. In the absence of that opportunity, the barrier to quality care itself is so detrimental: It’s literally a matter of life and death.

Rewire: How do you cover the cost of the first visit if someone cannot pay?

JJ: If we have a grant, we use those funds to help us pay our overhead. If we don’t, we wait until we have the women on Medicaid and try to do back-billing on those visits. If the patient doesn’t have Medicaid, we use the funds we earn from delivering babies of mothers who do have insurance and can pay the full price.

Rewire: You’ve talked about ensuring that expecting mothers have accessible, patient-centered maternity care. How exactly are you working to achieve that?

JJ: I want to empower community-based perinatal health workers (such as nurse practitioners) who are interested in providing care to communities in need, and encourage them to become entrepreneurial. As long as people have the credentials or license to provide prenatal, post-partum, and women’s health care and are interested in independent practice, then my vision is that they build a private practice for themselves. Based on the concept that to get real change in maternal health outcomes in the United States, women need access to specific kinds of health care—not just any old health care, but the kind that is humane, patient-centered, woman-centered, family-centered, and culturally-safe, and where providers believe that the patients matter. That kind of care will transform outcomes instantly.

I coined the phrase “Easy Access Clinics” to describe retail women’s health clinics like a CVS MinuteClinic that serve as a first entry point to care in a community, rather than in a big health-care system. At the Orlando Easy Access Clinic, women receive their first appointment regardless of their ability to pay. People find out about us via word of mouth; they know what we do before they get here.

We are at the point where even the local government agencies send patients to us. They know that even while someone’s Medicaid application is in pending status, we will still see them and start their care, as well as help them access their Medicaid benefits as part of our commitment to their overall well-being.

Others are already replicating this model across the country and we are doing research as we go along. We have created a system that becomes sustainable because of the trust and loyalty of the patients and their willingness to support us in supporting them.

Photo Credit: Filmmaker Paolo Patruno

Joseph speaking with a family at her central Florida clinic. (Credit: Filmmaker Paolo Patruno)

RewireWhat are your thoughts on the decision in Florida not to expand Medicaid at this time?

JJ: I consider health care a human right. That’s what I know. That’s how I was trained. That’s what I lived all the years I was in Europe. And to be here and see this wanton disregard for health and humanity breaks my heart.

Not expanding Medicaid has such deep repercussions on patients and providers. We hold on by a very thin thread. We can’t get our claims paid. We have all kinds of hoops and confusion. There is a lack of interest and accountability from insurance payers, and we are struggling so badly. I also have a Change.org petition right now to ask for Medicaid coverage for pregnant women.

Health care is a human right: It can’t be anything else.

Rewire: You launched the National Perinatal Task Force in 2015. What do you hope to accomplish through that effort?

JJ: The main goal of the National Perinatal Task Force is to connect perinatal service providers, lift each other up, and establish community recognition of sites committed to a certain standard of care.

The facilities of task force members are identified as Perinatal Safe Spots. A Perinatal Safe Spot could be an educational or social site, a moms’ group, a breastfeeding circle, a local doula practice, or a community center. It could be anywhere, but it has got to be in a community with what I call a “materno-toxic” area—an area where you know without any doubt that mothers are in jeopardy. It is an area where social determinants of health are affecting mom’s and baby’s chances of being strong and whole and hearty. Therein, we need to put a safe spot right in the heart of that materno-toxic area so she has a better chance for survival.

The task force is a group of maternity service providers and concerned community members willing to be a safe spot for that area. Members also recognize each other across the nation; we support each other and learn from each others’ best practices.

People who are working in their communities to improve maternal and infant health come forward all the time as they are feeling alone, quietly doing the best they can for their community, with little or nothing. Don’t be discouraged. You can get a lot done with pure willpower and determination.

RewireDo you have funding to run the National Perinatal Task Force?

JJ: Not yet. We have got the task force up and running as best we can under my nonprofit Commonsense Childbirth. I have not asked for funding or donations because I wanted to see if I could get the task force off the ground first.

There are 30 Perinatal Safe Spots across the United States that are listed on the website currently. The current goal is to house and support the supporters, recognize those people working on the ground, and share information with the public. The next step will be to strengthen the task force and bring funding for stability and growth.

RewireYou’re featured in the new film The American Dream. How did that happen and what are you planning to do next?

JJ: The Italian filmmaker Paolo Patruno got on a plane on his own dime and brought his cameras to Florida. We were planning to talk about Black midwifery. Once we started filming, women were sharing so authentically that we said this is about women’s voices being heard. I would love to tease that dialogue forward and I am planning to go to four or five cities where I can show the film and host a town hall, gathering to capture what the community has to say about maternal health. I want to hear their voices. So far, the film has been screened publicly in Oakland and Kansas City, and the full documentary is already available on YouTube.

RewireThe Black Mamas Matter Toolkit was published this past June by the Center for Reproductive Rights to support human-rights based policy advocacy on maternal health. What about the toolkit or other resources do you find helpful for thinking about solutions to poor maternal health in the Black community?

JJ: The toolkit is the most succinct and comprehensive thing I’ve seen since I’ve been doing this work. It felt like, “At last!”

One of the most exciting things for me is that the toolkit seems to have covered every angle of this problem. It tells the truth about what’s happening for Black women and actually all women everywhere as far as maternity care is concerned.

There is a need for us to recognize how the system has taken agency and power away from women and placed it in the hands of large health systems where institutionalized racism is causing much harm. The toolkit, for the first time in my opinion, really addresses all of these ills and posits some very clear thoughts and solutions around them. I think it is going to go a long way to begin the change we need to see in maternal and child health in the United States.

RewireWhat do you count as one of your success stories?

JJ: One of my earlier patients was a single mom who had a lot going on and became pregnant by accident. She was very connected to us when she came to clinic. She became so empowered and wanted a home birth. But she was anemic at the end of her pregnancy and we recommended a hospital birth. She was empowered through the birth, breastfed her baby, and started a journey toward nursing. She is now about to get her master’s degree in nursing, and she wants to come back to work with me. She’s determined to come back and serve and give back. She’s not the only one. It happens over and over again.

This interview has been edited for length and clarity.