The Epidemiology of Abortion: A Primer

A few days ago I posted about the proposed ban here in Wisconsin on abortion after 20 weeks’ gestation–and about how honestly, we’d rather not talk about it. Today’s post involves not one but two things most people would rather not discuss: abortion and statistics. Wait, wait, don’t go! Here, have a calming manatee.

CalmingManatee

I wasn’t especially interested in the issue of abortion until I went to graduate school for my Master’s in Public Health. In my time there I came to appreciate the control of fertility as a public health issue. But it was really the training in epidemiologic methods that got me interested in the issue.

Research findings are a big part of the public discourse around abortion, specifically of the argument that undergoing an abortion is bad for your health. The safety of legal abortion is just one piece of a much larger debate, but it is an important piece. Unfortunately since most people are unfamiliar with the methodological issues involved, we have to rely on experts. Each side of any debate inevitably has its own experts, all wielding citations to published articles, so the lay public may be left with no clear idea of the state of the evidence, and could understandably conclude that this debate is just more divisive ideology with a scientific facade.

I think we can do better, though. As one of my statistics professors at Berkeley was fond of saying, “Why be a slave to some little number cruncher?” I happen to believe most people can understand the science around this issue just fine. This post is an attempt to provide a basic understanding of how people go about trying to prove or disprove a connection between abortion and subsequent health problems, and some tools to help you evaluate research claims for yourselves.

My intent is that this will be useful no matter what your perspective on the legality or accessibility of abortion. I don’t think a pretense of neutrality contributes constructively to the public conversation, and I make no attempt to hide the conclusions I myself have drawn. These issues have become so intertwined with social identity that it is rare to have a productive conversation about abortion among people with very different positions, but I’ve had such conversations and I want to have more of them. I’m not oblivious to the state of U.S. politics right now, but I continue to believe it’s possible to move the public debate away from “What side are you on?” and toward “What works?”

Ralph_Hedley_(follower)_An_argument_from_opposite_premises

“Well I read it on HuffPo so shut your cake hole, Phyllis!”

The skills that allow a critical reading of scientific evidence are relevant to anyone who has or would like to have an opinion on the ethics of abortion. As I said in my last post, we have enough consensus to start a conversation as long as we agree on the precept that good ethics begin with good facts. If you disagree with that crucial premise, however, this is not the post for you. Perhaps you would like to pass the time on this excellent site instead.

Time for some Epidemiology 101. In order to keep this simple, I’m going to focus on just one hypothesis: that abortion causes depression. It’s plausible; having an abortion is often a difficult experience, accompanied by feelings of sadness and stress. Dozens of studies have examined the question. However the principles below apply equally well to other outcomes.

Let’s say that you know a person–we are going to call this imaginary person Veronica–who had an abortion at ten weeks of pregnancy, and six months later was diagnosed with depression. You suspect Veronica’s depression was caused by the abortion. However, you already know about Rooster Syndrome (just because the rooster crowed and then the sun came up doesn’t mean the rooster made the sun rise), so you know that just because Veronica had first an abortion and then an episode of depression doesn’t mean the two events are related. So how could you prove or disprove your suspicions?

What you really want to know is this: if Veronica had not had an abortion, would she still have depression now? The only way you could actually prove such a thing is with time travel. Since you have observed what happened to Veronica after having an abortion, you could get in your time machine, travel back to the moment before, and intervene so that in this version of history she never gets the abortion. You then stay in this alternate universe to observe her for six months and compare the two Veronicas. Did she still get depression? If she did, then you know that her abortion did not cause it. If she did not get depression in the alternate universe, then you know that in the real universe her abortion set into motion a chain of events that led to her depression.

You may recall that this alternate universe is what is known in theoretical circles as the counterfactual scenario (thanks, David Hume!). Obviously, it is not real–boy I hope that’s obvious. But I bring it up because I think it helps to understand how studies are designed. A useful way to think about critiquing a study is to ask how close or far it gets us to the counterfactual scenario, given our ongoing shortage of time machines.

Even before we leave the alternate universe, though, we already have some methodological issues. You can’t simply erase Veronica’s abortion; if she doesn’t have an abortion she has some other experience instead. You are always comparing the results of the abortion to the results of something else. So how did you intervene to prevent the abortion? Did you go yet further back in time and provide her with a condom at the appropriate moment so that she never got pregnant at all? Did you get her take her to a pub crawl before she ever missed her first period, causing a miscarriage through heavy drinking? Did you provide support for her during her pregnancy in exchange for agreeing to adopt the child? Did you remove some of the barriers to giving birth, allowing her to choose to raise a child herself right now (you can probably come up with $245,000 considering you came up with a time machine)?

We can’t know without testing them what the outcome of any of these scenarios would be, but it seems plausible that they could make Veronica less vulnerable to depression. But on the other hand…

Did you make her an appointment at a Crisis Pregnancy Center where she was misinformed about how far along she was in her pregnancy so that she couldn’t schedule the abortion until past the time when the clinics in her area could perform it? Did you call up a group of  your friends to stand in front of the clinic shouting and thrusting pictures of mutilated children at her, until Veronica was too afraid to enter the clinic?  Did you close the only clinic she could get to, by lobbying your state legislators to pass laws requiring abortion providers have hospital admitting privileges? Did you kill the only abortion provider in the area? Did you get the US Supreme Court to overturn Roe v. Wade so that Veronica would–let’s say she lives here in Wisconsin–face three years in prison for getting an abortion, while her doctor would face ten?

Personally, I find it much harder to believe that these experiences would be less traumatic and less likely to cause depression than choosing an abortion. Plenty of people would disagree with me, though. But I’m an empiricist by nature and training–we can’t actually know what works by reasoning it out in our heads. The point is that none of these interventions are equivalent to each other, and none carries an equivalent risk of depression. You’re going to have to get in your time machine and go back at least nine times in order to conduct this counterfactual experiment. At least you will if you want to know if any of these strategies would actually have made Veronica healthier than she is here in the universe in which she got an abortion.

We can’t actually observe the counterfactual, so what’s the next best thing? The next best thing would be to observe two identical people, one of whom has an abortion and one of whom doesn’t. I’m not talking twins here, cause as Orphan Black teaches us, genetics do not make a person. I mean two people who are actually the same people. So we’ll get a big tub of programmable flesh, make ten pregnant doppelgängers of Veronica and…

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Okay, okay. Enough about time machines and programmable flesh; let’s take this back to reality. When it comes to abortion, you can’t observe the same person under two conditions, and you can’t observe two copies of the same person. What you can do is compare two groups. The people in the groups are not the same, but the groups are the same on average. In particular they are the same with respect to everything that predicts depression–same number of people of each race and ethnicity, same number of people at each age, same number of people with children, same number of married people, same number of people living in poverty, same number of people with a prior history of mental illness, etc. If in fact your hypothesis is correct and abortion causes depression, that doesn’t mean that you would expect to find that everyone in the abortion group has depression, or that zero people in the comparison group have it, because lots of other factors cause depression in some people and protect against it in others. But if there is a causal connection, you would expect to see meaningfully (how meaningful? ymmv) more cases of depression in the abortion group.

In real studies, investigators attempt to make groups that are the same on average by randomly assigning subjects to one group or the other. Obviously no one will be conducting a study in which every pregnant person who enters the the study is randomly assigned to Group A or Group B, and then the Principal Investigator assigns Group A to give birth and Group B to have an abortion. Boy I hope that’s obvious, cause if it’s not I hope none of you are conducting any experiments. So when it comes to studying the effect of abortion, that study design is out, too. Abortion is hard to study.

Given that there will be no randomized groups, which groups can you compare? Now at last we arrive at real-world research. Here are a few strategies researchers have employed to try to study the effects of abortion.

Skip the comparison group. One strategy is to study only people who have had abortions, and draw conclusions from just one group (example here, admittedly an old one) . But you already know what is wrong with this reasoning. This is Rooster Syndrome again. Without a comparison group of people who did not have an abortion, there is nothing to suggest that the abortions are responsible for the prevalence of depression in this group. This is the weakest kind of evidence.

Compare people to themselves. An alternative strategy is to measure the same people twice (example here), before and after the abortion, and compare how much they’ve changed. That’s more convincing, but it doesn’t help with Rooster Syndrome.

Compare pregnancies ending in abortions to wanted pregnancies or miscarriages. Most studies on this topic have compared a group of people who chose to end unwanted pregnancies to a group of people who chose to continue planned or wanted pregnancies (example here). This type of study is limited by the fact that it is impossible to know how much of the differences between the two groups result from abortions and how much result from the higher proportion of unwanted pregnancies among people who choose abortions. An unwanted or mistimed pregnancy is an extremely stressful experience, no matter how the pregnancy ends, and could explain different amounts of depression in the two groups. In epidemiologic terms, this type of bias is called confounding. The relationship of abortion to depression is likely to be confounded by the “wantedness” of the pregnancies in studies using this type of comparison group.

Compare pregnancies ending in abortions to unwanted pregnancies carried to term. Other studies have compared a group of people who had abortions to a group of people who chose to continue unintended pregnancies (example here). That removes the issue of confounding by “wantedness,” but there are still important sources of bias here.

One of the most important issues is that people who have had depression in the past are more likely than people who have never had it to have another depressive episode–no surprise there. So one important predictor of depression after an abortion is depression before the abortion. Since ones current and past mental health can factor in to how capable one feels of continuing a pregnancy, failure to account for mental health history can lead to what is known as an indication bias. In this case the perceived need for an abortion (the indication) is associated both with the probability of choosing an abortion and with subsequent depression–potentially creating a spurious association.

There are other sources of indication bias, as well. In this study, some of the reasons people in the U.S. cited for choosing an abortion included “Can’t afford the basic needs of life,” “Not enough support from husband or partner,” “Physical problem with my health,” and “Became pregnant as a result of incest.” These are things that can contribute to depression no matter how the pregnancy ends.

How close do you think those two groups of people are to being the same on average at the start of the study? If people who continue their pregnancies are more likely on average to have supportive partners, adequate financial resources, good physical health, and good mental health, they are less likely to have depression. You may find more depression in the abortion group, but it is impossible to know whether that is a result of their having had abortions or of the preexisting issues that led to them feeling they needed abortions.

Statistically adjust or “control” for sources of bias. Any of the above methods that use a control group can use statistical methods to reduce confounding bias by measured effects. This is a complex topic that I’ll have to cover another day, but I’ll just give a brief overview. You know that people living in poverty are more likely to have abortions, and more likely to have depression, so you think socioeconomic status could be biasing your estimate of the relationship between abortion and depression. So you use statistical techniques to adjust your estimate for socioeconomic status, so that the estimated association between abortion and depression can be interpreted as independent of class. At least you can try. How well you can adjust for potential confounders depends on how well you can measure them (socioeconomic status is challenging to characterize well). But most importantly, you can’t measure every kind of confounder. There will always be some patterning in who gets and abortion and who gets a different pregnancy outcome, and some of that patterning will lead to distortion. It’s an inherent limitation of observational epidemiologic studies.

Given all these different approaches, there has been a lot of conflicting evidence about the relationship of abortion to depression. These three influential systematic reviews found that there was no evidence of an association between abortion and depression and that most of the research on the topic was fundamentally flawed, but the author of a fourth review disagreed, and by choosing a different set of studies to review found evidence that people who had abortions did have more depression.

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Right about now you might be asking me what was the point of telling you all this if there’s no clear answer, and it all just depends on who you ask. But we’re not done yet, because someone came up with an extremely elegant solution to the limitations of the methods described above.

Compare people who chose abortions and obtained them to people who chose abortions but were denied them. Now we arrive at the highest quality evidence available. In comparing two groups of people that both sought out abortions, you solve the problems of confounding by “wantedness” and confounding by indication. When people are recruited at the same clinics you remove many other sources of confounding by socioeconomic and demographic characteristics, and you remove some of the influence of selection bias (when people who had abortions and have depression are more likely to join or stay in your study than people who don’t). You also get an assessment that is more relevant to the question of whether abortion should be legal and/or accessible.

There is only one study that has ever used this design. It is called the Turnaway Study, and you should remember that name because it is very important. Importantly, the subjects in this study were all at very similar stages of pregnancy, but some were just over the limit of when abortions could be performed at their clinic. Subjects did not self-select into the two groups. This is about as close to random assignment as an observational study can get, and thus the best approximation of the counterfactual scenario. Incidentally, the Turnaway Study findings suggest that having an abortion was associated with similar or even lower risk of depression as carrying an unwanted pregnancy to term.

Clearly I can’t cover all of epidemiology in one blog post, or even all of the methodological issues involved in studies of the effects of abortion. But I hope this has given you an action plan:

1. When you read an article claiming a study says “abortion causes ______” or “abortion is associated with ______,” you ask “Compared to what?”  Likewise, when a study says “women who had abortions have more/less ______,” you ask, “Compared to whom?”

2. When you read study results, think critically about how much the observed differences between comparison groups are telling you about abortion, as opposed to other things correlated with abortion like socioeconomic status, past mental health history, lack of access to contraception, lack of health literacy, etc.

3. Read a lot about the Turnaway Study. They are publishing a lot of results, all of them interesting. Right now this is the best kind of evidence we have.

Class dismissed.


Image: An Argument from Opposite Premises, Follower of Ralph Hedley [Public domain], via Wikimedia Commons

Wisconsin’s Abortion Ban is a Bad Idea–No Matter How you Feel about Abortion

We need to talk about the abortion ban that is well on its way to becoming Wisconsin law. People who believe abortion is never justified need to talk about it. People who believe abortion is morally neutral need to talk about it. Most people’s take on abortion is more complex than either of the above, and they most of all need to talk about it. The ethics of abortion are hard, and I respect that different people will give these issues years of careful thought and still come to different conclusions. If we all endorse the adage that good ethics begin with good facts, then we have enough consensus to start a conversation, so let’s begin. If you disagree, then this is probably not the post (or the blog) for you. Perhaps you would like to pass the time instead by reading this heartbreaking classic by the great American poet Lucille Clifton. Clifton knew better than anyone that it would be easier not to talk about abortion. But that’s not good enough. So this is what I have to say.

There is no evidence that banning abortion late in pregnancy leads to fewer abortions. Other states have tried it, and there is no evidence that it worked. For one thing, very few such abortions are performed–as you probably know, they are only about one percent of all abortions in the U.S. As you also probably know, these are mostly abortions performed in response to a medical diagnosis, maternal, fetal, or both. One doctor has publicly speculated that the ban may lead to more abortions as families may not have time to wait to get all the information, and may wind up ending a pregnancy that could have led to a live birth.

These are the stories no one wants to think about. It’s easier to pretend that if you want a baby, and you take the greatest possible care trying to bring your baby into the world, if you believe in the sanctity of life, and try to be a good person and a good mother, that you and your baby will thrive. We could all pretend that no pregnant woman is diagnosed with cancer, that all fetuses develop kidneys and brains, that live-born children with Trisomy 18 don’t suffer in the 48 hours during which 95% of them will die. We could also pretend that these things only happen to people who did something wrong, or who are in some way different from us. Compassion is much harder. What if a few moments’ witness to the pain of a family having to lose the baby they wanted is just too much, and it breaks us?

Some of the figures involved in Wisconsin politics right now are claiming that pregnancy never kills. It’s an easy enough lie to tell, because these scenarios are rare. Most people don’t know anyone who had to end a pregnancy to save their own life, so it’s easy for them to dismiss such stories as abstractions. Not, however, for doctors. Doctors meet the people who are living this nightmare. They have to deliver the news no one ever wants to hear. That’s one of the reasons so many doctors oppose this kind of legislation. It’s one of the reasons why the Wisconsin Medical Society and the American College of Obstetricians and Gynecologists, neither of them known for their fringe political stances, have opposed this bill in Wisconsin. As of this writing the proposed law still contains an exception for cases when carrying a pregnancy to term would kill someone–at least I think it does. The language is pretty vague, and I’m no lawyer.

But the truth is, this is all beside the point. You may think parents should not have the right to make these decisions for any reason, but we can agree to disagree. Likewise you may feel persuaded by the argument that any amount of uncertainty over whether later abortions cause fetal pain means those abortions should not happen, even if the weight of the evidence is against it. That is also beside the point. It’s all beside the point as far as this law goes, because abortion bans don’t work.

What is the purpose of this bill? It pretty clearly won’t end abortions, late or otherwise. Wisconsin women will have to obtain them in other states. To quote this econometrics paper, “The demand for abortion is quite inelastic.” That could never be more true than in the case of late abortions. It should not surprise anyone that the consequences of having to travel for an abortion can be devastating for families living in poverty. As was the case before Roe and now, restrictions on abortion do not apply equally. Money could always get you an abortion, probably even a safe one.

The real purpose of this bill is probably to provoke a ruling in the U.S. Supreme Court. Then the conversation about abortion will change. Most of that conversation will surround the ethics of abortion. And it will be a waste of time. Not because the ethics aren’t important–they are–but because they are moot. Making abortion illegal doesn’t make abortion go away. These attempts tend to backfire. Looking at aggregate data, countries in which abortion is illegal actually have more abortions. The demand for abortion is inelastic. Abortion need not even be illegal to prove that point. Even within my time in medical school, a doctor here in Madison told me about a patient who was flown in from a rural area after she nearly died attempting to give herself an abortion with a knitting needle.

I still believe that it is possible to achieve consensus on abortion in the U.S. No one actually has to change their mind or compromise any ethics in order to achieve this consensus; all we need to do is embrace the practice of evidence-based policy. Cause the evidence suggests making abortion a crime is not going to reduce abortions.  Are you bothered by how many abortions are performed in the U.S. right now? Guess what, me too. Let’s get cracking on preventing unwanted pregnancies. Are you bothered by the idea that someone might feel like they couldn’t continue a wanted pregnancy because of a diagnosis of Down Syndrome? Guess what, me too. How about we get some legislation going that supports families of children with special needs, and makes the deck a tiny fraction less stacked against people living with cognitive disabilities. I would so much rather be working on either of those issues, wouldn’t you?

And let’s not do a few other things. Let’s not make women choose between watching their child suffer and going to prison. Let’s not force women to risk their lives by continuing a pregnancy because they could not prove there was a zero percent chance of survival without an abortion. Let’s not create an underground economy for abortions because they are no longer performed legally by doctors.

On this blog I usually try to make my points with a dose of humor, but I can’t on this one. The truth is I’m profoundly depressed about the state of politics in Wisconsin, and the general unwillingness of the politicians who control all three branches of government right now to use evidence. I’m not utterly clueless. I have a pretty shrewd idea of what’s going to happen with this law. I sure hope it doesn’t lead to more abortions. But it probably will.

Let’s Talk About Intentional Weight Loss and Evidence-Based Medicine

You are a doctor. You are trying to get through a busy clinic day when there is a knock at your office door. It is a pharmaceutical rep. Before you can say anything, he lets himself in, saying, “I’ll only take up a minute of your time, but I just have to tell you about this exciting new weight loss drug. It’s 95% effective at treating obesity in adults.” Sounds good right? Oo, he’s giving away a free pocket knife with the drug’s logo on it. Maybe you do have a minute to spare. You know you have some questions about the study that got this new drug approved.

Pixton_Comic_Pharmaceutical_Rep_Visit_by_Epiphenomena
You start by asking how much weight the study participants lost on average. Turns out it’s about 10% of their body weight in the first year. So women weighing 250 pounds at the start of the study weighed, on average, 225 pounds after a year.

Well ok, so it’s not a cure for obesity, but it still sounds useful. Everyone’s always telling you how small weight loss can have a dramatic effect on health. And besides if you took the drug for five years you could lose 50% of your body weight, right?

Well…the rep tugs at his collar…not exactly. By the end of the second year, people in the study had started to regain the weight. At the end of the study subjects taking the drug weighed, on average, about six pounds less than the control group. In fact, by the end of year five, less than half the subjects had sustained their modest weight loss. Somewhere between 20-80% of subjects (depending on who you counted and how long they stayed in the study) had gained even more weight than they lost.

Ouch. So in the long run this drug could actually hurt more people than it helps? That can’t be right, can it? Still, that’s still a lot of people who are able to sustain weight loss in the long term. Given the terrible consequences of obesity, maybe a small chance at weight loss is worth the risk. Well, actually, now that you think of it, what are the other risks? That is, what are the side effects?

The rep clears his throat and begins to mumble a list. Depression, worsened self-esteem, difficulty concentrating, constant hunger, obsession with food, increased risk of eating disorders. Also bone loss.

But the side effects were rare, right? Was the drug well tolerated? The rep scratches the back of his neck. Actually not so rare. Actually about half of people assigned to take the drug dropped out of the study and no one’s sure what happened to them.

Whoa. That doesn’t sound harmless at all. Still, if it’s a choice between depression and obesity, you know most of your patients will choose depression. So which of your patients might be good candidates for this new drug?  It’s a new treatment, so maybe all of your patients should try it, just in case it works.

But then the rep starts shuffling his feet. He mutters something and you realize that this supposedly new drug is just a reformulation of a drug that has been around for a long, long time. In fact, it’s been around so long that people accept it as dogma that it works, despite its lack of evidence base. It’s extremely popular. In fact, now that you think about it, you don’t have very many obese patients who haven’t tried this drug in one form or another, on and off for most of their lives. Does it really makes sense to make them try the same drug that has failed them so many times?

But you’re not ready to give up yet. What about the control group in this drug study? What about the poor souls who did not even get to try the drug, who were just abandoned to their disease? I mean, whatever the drug’s effects, it can’t be worse than just continuing to live with obesity, can it?

The rep is ready for this. There was a control group in this trial, he is excited to tell you. He is excited, because it turns out the numerous prior studies of this drug rarely have a well-chosen control group, they just compare different formulations of the same drug if they even have a comparison group. But this control group was given no weight loss intervention at all! Instead of being encouraged to lose weight, they were just counseled on their “health” (the rep uses air quotes for this word, as though people like that could even have health). They were given mental health interventions, including learning how to read their body’s cues for hunger and satiety, and support for body image issues. They were encouraged and supported in physical activity, and taught to find ways to move their body that felt good and were sustainable. The rep is giggling now.

So it sounds like the control group must have gained a lot more weight? He stops giggling. Actually no. And how did the two groups compare in terms of other metabolic outcomes like blood pressure and cholesterol? The control group did better. And mental health outcomes? The control group did way better (though the rep whispers But who cares, it’s not like mental health is really health.) And did half of this group drop out too? No, they mostly stayed.

You politely escort the pharmaceutical rep out, thanking him for the pocket knife and accepting his card. He has given you a lot to think about.

Will you recommend the new drug? To anyone? Only to the few people that have never tried it before? How many times should you require your patients to try and fail with this drug before you recommend they stop?

Well friends, by now you see where I’m going with this: the drug in this story is not really a drug invented by some sleazy big pharma boogeyman. It is every weight loss intervention there is. It is Weight Watchers, Jenny Craig, Nutrisystem, the Atkins Diet, the Paleo Diet, the Blood Type Diet, the French Woman’s Diet, the Aerobic Housecleaning Lifestyle, the Grapefruit Diet, the Sugar-Free Diet, the Ice Cream Diet, a sensible low fat diet, and MyPyramid. It is Orlistat (slower regain but more fecal incontinence) and all the other weight loss drugs. It is gastric bypass surgery and lap bands (those probably produce slower regain, but no one really knows because the quality of the evidence is so poor, though it clearly involves greater risk of being hospitalized for things that happen when someone surgically remodels your stomach). The diets, the pills, the surgeries, they all work the same–for the vast majority there will be temporary weight loss followed by weight regain, often at serious cost to mental and physical health.

Please remember this when some recommendation comes out suggesting “treat the weight first” and that all other health problems will have to take a back seat. Remember this when academics are slap-fighting about whether BMI is linked to mortality. None of it actually matters at all to the patients you have today, because existing weight loss interventions don’t work. Even with outcomes for which weight loss could be beneficial, the benefit will be temporary if and when the weight comes back. Quickly or slowly it will come back for all but a very few. The best most people can expect for their pain and suffering is to be about five to ten pounds lighter, and those are the minority for whom the treatment succeeds. It doesn’t matter how big a problem you think obesity is, and it doesn’t matter whether or not you’re right about it, because we do not have any tool that will make obesity go away.

Like the villain in this story, there are a lot of people and a lot of companies who make money off of the promise of weight loss. It’s a great business model; the more the intervention fails, the more money people pour into it. These people and companies have a vested interest in perpetuating the lie that anyone can and should become thin. But medicine doesn’t have to be a part of it.


To any reader who would like an overview of these issues in scientific language rather than in the form of a short story, I highly recommend this review article by Linda Bacon.

Update 1/24/2015: It’s been great to see how much interest this post has generated, and I hope that it will start a lot of productive conversations. Hello and welcome to everyone that’s new here. Out of more than 1,000 visitors that have stopped by in the past 24 hours, only one person has felt the need to leave hostile comments, which I have since deleted. However in the interest of keeping the dialogue constructive I don’t think I can continue to leave comments unmoderated, and since I can’t commit to moderating them in a timely manner I have disabled comments. Thank you to everyone who is contributing to a civil discourse around these complex issues.

In Praise of C-Sections

You know who makes a really macho crowd? Biological mothers. I have watched people who for most of their lives have espoused a mainstream, less-is-better approach to pain suddenly bragging about it as though the involuntary firing of their nociceptors were an achievement. People who are completely pleasant as a rule will hear the word “epidural” and SHOONK they are transformed into The Uterus Gladiators! With savage glee they race into a totally imaginary arena, to compete with other savagely gleeful person-hatchers, in an epic fight to decide once and for all who had the most pain in childbirth, and–importantly–who sought the least relief for that pain.

Whee! This is fun! Pay no attention to that octopus.

Whee! This is fun! Pay no attention to that octopus.

You’ve probably guessed I have limited patience for this brand of one-upmanship. There are women in my life whom I deeply respect that have chosen home birth (okay only one woman but I respect the living daylights out of her judgment), and lots more that have chosen to forgo pain relief in a hospital delivery. That is a totally awesome choice if it is a thing that you want to do, and I’m glad that activists over the years have succeeded in making these options available to everyone. But if that is not your thing, oy gevult don’t feel ashamed of yourself. Like any kind of treatment there are costs and benefits to pain relief in childbirth, but that doesn’t make it bad. I’m hereby giving you permission: you do not and should not have to justify the decision to relieve your pain.

The Uterus Gladiators, however, are nothing compared to the Vagina Valkyries. You know who I mean. The women who have experienced a vaginal delivery and now feel lifetime superiority over the women who required or–gasp!–chose a surgical delivery.  “I had a baby with no medical intervention,” I hear one of them bragging before yoga class, shortly before sprouting wings and flying off to adjudicate some Norse battle deaths. You’d really think from the sound of it that medical intervention was a vice.

C-sections are often not a matter of choice, but a life and/or death situation. Sometimes they are a measure of last resort after the first, second, and third choices have been exhausted. Some c-sections are elective, but the term “elective” is loaded. Are the consequences of not electing this procedure acceptable? That’s subjective. And that’s what bothers me about the push to shame patients out of seeking medical care by convincing them that they are less–less strong, less brave, less womanly, less maternal, less natural, less smart, less aware, less educated, less thorough, less fierce in standing up for their rights, less resistant to domination by medical practitioners. My husband refers to this movement as “the crunchy granola arm of the patriarchy.” I call it rudeness personified.

Maybe it’s time for c-section veterans to start bragging. “Yeah, boyyyyy, I had a major abdominal surgery, and they took a baby out of me. And then I HEALED. And didn’t have any INCONTINENCE. And my vagina has not lost any TONE. Yeah! Yeah! Wooa wooa!”

This might be the time to warn you there’s a picture of a baby being born via c-section at the bottom of this post. If you’re not so good with such pictures, you may want to scroll slowly.

There is a real public health issue at play here. Per the WHO, ideally 10-15% of all deliveries should be c-sections. Fewer than that constitutes “underuse,” which is common in developing countries, and more constitutes “overuse,” which is common in developed countries. Where I live the rate is close to 30%.  So is this a problem, and if so how big? It’s an area of heated debate. Almost all of the evidence comparing c-sections to vaginal deliveries is observational, meaning it comes from studies that compared outcomes from women who wound up with c-sections to outcomes from women who wound up with vaginal deliveries. Obviously, women don’t wind up in these categories at random, so some factors will predict both choice of a c-section and risk to mother and baby, creating spurious associations. I’m personally skeptical that all such factors can be measured and controlled-for in an observational study.

I’d really like to see some randomized trials to help guide decision making, but to date there are almost none. The evidence base, in short, is lacking. Do remember this when everyone starts shouting. However, be comforted by the fact that one reason there isn’t a huge rush to conduct such a randomized trial is that both methods of childbirth are quite low risk. Even if one does turn out to be safer than the other when all the evidence is in (someday, I hope, sigh), this is still a choice between good and better.

I totally hear the historical argument about how birth has been medicalized, and I’m right there with anybody who wants to argue that pregnancy and birth are normal and should not be treated like diseases. But birth also involves things that are the rightful province of medicine–pain, organ damage, morbidity, mortality. No one should be required to make their decisions about these things differently than they would in another context because they are choosing it for a birth. And they are also not required to justify their choices (I said it again). Every birth is different, and you really don’t know what you would have chosen if you had had someone else’s birth experience–this goes double for cis men.

This is not just another I’m-okay-you’re-okay everybody’s-choice-is-great post for the feminine blogosphere. This is a post in praise of c-sections. I am so glad that this surgery exists. I am so glad that we have come far enough that not being able to expel a baby from your body in the traditional way does not mean that it has or you have to die. Cesarean sections save lives. Sometimes they are awesome. So how about we dismiss the Vagina Valkyries with the eyerolls they have earned, and turn our attention to making this life-saving surgery available to every woman around the world that needs it. Or wants it.

This is objectively awesome.

This is objectively awesome.

Photo Credits
Vaginal birth art: Lynn Friedman via photopin cc
C-section photo: emergencydoc via photopin cc

Talk is Cheap, Teen Pregnancy is Expensive

Which of the following arguments do you find persuasive?

A. Sex ed for teenagers should only teach abstinence, because teaching about other aspects of sexuality and sexual health implies that schools expect teenagers to have sex. Thus it stands to reason that more teenagers will have sex, leading to more unintended pregnancies and more STIs.

B. Sex ed for teenagers should be comprehensive, including the full range of options for contraception, because teenagers will have sex no matter what is happening in their classrooms. Thus it stands to reason that teenagers who are only taught about abstinence will be less likely to use protection when they do have sex, leading to more unintended pregnancies and more STIs.

C. Neither of the above.

I choose option C.

Sex ed is back in the headlines here in Wisconsin. We lost over 12,000 jobs this past month, but the Governor’s special legislative jobs session has so far been focused, as the Capital Times editorial succinctly put it, on Deer, Fertilizer, and Sex Ed, (oh and a few other things), but not so much on jobs.

I testified in support of the Healthy Youth Act, which is now on the chopping block, in 2009 when the State Senate held public hearings, and my testimony may be found below. It is not my best work, but the premise is sound, and it is this: empirical evidence is available of the comparative effectiveness of abstinence-only and comprehensive sex ed curricula. That means that we don’t need to debate and debate in a seemingly endless effort to reason out a priori which type of curriculum must work best. We can look at the research which tells us which type of curriculum DOES work best.

At the time the Healthy Youth Act was passed, the balance of research favored comprehensive sex ed, both for reducing unintended pregnancies and STIs and for increasing abstinence. I freely admit that I have not tried to stay on top of new studies in the field since that time, but my point is not so much the state of the evidence, it is how we use the evidence–or more often fail to use it.

Is all research correct in its conclusions? Obviously not. But if you think that the studies supporting comprehensive sex ed have methodologic flaws that call their results into question, that is a reason to demand bigger, better studies. It is not a reason to trash the entire principle of basing policy decisions on what works. Limited evidence makes a better guide than pure conjecture, which is what option A and option B above both are.

We can have a meaningful debate around sex ed on the issues of the value of abstinence, the value of education, the meaning of childhood, the right of a society to dictate sexual practices, and so on. These are moral issues, and important ones. But most people understand that most other people have firmly held beliefs on these issues which are not going to change because of a well-reasoned argument from someone of the opposite view. Instead we debate effectiveness, because that makes our argument sound objective and rational. The problem is that effectiveness can’t actually be proven or disproven by debate.

My 2009 testimony appears below the jump: Continue reading

How do you Know if Your Bullet is Magic?

This cluster of attractive scientists is highly significant.

Against all odds I actually managed to see a movie the other night, and that movie was Contagion. It’s a solid flick, and I do recommend it. Even if you know kind of a lot about viruses, you will not be annoyed. They get almost everything right, and the Infectious Disease 101 exposition is not too disruptive. But they got one very important thing wrong, namely the point of human subjects research. Spoilers are about to commence below the jump. Continue reading