The osteopathic medical student who writes Mom’s Tinfoil Hat is obsessed with the process of birth and thinks that you should be, too. In dispensing advice on choosing an OB provider, she doesn’t even mention the most important characteristic, the skill level and professional reputation of the provider. Instead she concentrates on the atmospherics.

Step 1 for choosing a provider:

Episiotomy: Do you employ them? Routinely? Under what circumstances?

It is up to you, but this would be my main litmus test.

The main litmus test?

Let’s step back a minute and consider why you choose any obstetric provider. As I have written many times in the past, anyone can deliver a baby if there are not going to be complications. All you have to do is hold out your hands and make sure the baby doesn’t hit the floor. Dads, policemen and taxi drivers do it on a regular basis.

The reason to choose a professional provider is because childbirth is inherently dangerous and many complications do not announce themselves until they occur during the process of birth. You choose a provider to prevent, diagnose and manage complications, limiting the possibility of severe injury or death of the baby or mother. So the last thing that you should care about is whether the provider promises not to cut an episiotomy. The chief priority ought to be the baby’s and mother’s lives, not the mother’s perineum.

What other factors might you use to judge a provider. The blog author suggests among others:

During labor, can I eat and/or drink? Can I have access to a tub for labor, or a shower, or walking, or a birth ball, or my own clothing, or (fill in the blank)? Can I bring a doula to my labor? How many support people can I have, and what are the visitation rules in general? Can my support person spend the night with me in labor and after the baby is born? Do you require an I.V.?

What do all these factors have in common? They are all about atmosphere. They make about as much sense as choosing a provider because of the color of the office walls or the type of magazines in the waiting room. Sure they might make you feel more comfortable, but they will do nothing to protect you in the event of an emergency.

Of course, “natural” childbirth advocates like to pretend that they will not have complications, and as long as you are pretending, you might as well pretend that wearing your own clothes is more important than the skill level of the provider.

This is a classic example of the “natural” childbirth obsession with process over outcome. Most obstetric providers (obstetricians and CNMs) are obsessed with outcome. The goal is the birth of a healthy baby to a healthy mother. All efforts are governed by that goal.

In contrast, “natural” childbirth advocates are obsessed with the “birth experience” and not just any birth experience, either. It must be the pre-approved, highly stylized experience that they have idealized. No pain relief, a birth ball, and, as the blog author emphasizes above all else, a perineum untouched by the provider, except, of course to sew up the lacerations that occurred spontaneously.

How should women who care about the outcome choose a provider? The first step is to make sure the provider is qualified. What is her training? How long has she been in practice? How many deliveries has she done (this is especially critical in choosing a CPM since they usually have paltry clinical experience)? Has the provider been disciplined by the relevant professional board? Has the provider been found guilty of malpractice or paid out a settlement? All obstetricians will be sued once or twice and insurance companies often force settlements. However, alarm bells should ring if the provider has been sued six times and paid out multiple claims.

It is also important to find out about the hospital, if you are choosing a hospital. Does the hospital have a level three nursery? Is there a pediatrician or neonatologist available around the clock in case the baby is born with a problem like difficulty breathing? Has the hospital been downgraded by JACHO, the hospital accreditation board? Have there been any maternal deaths at the hospital and under what circumstances did they occur? This can often be difficult to find out because hospitals usually insist that patients and families cannot discuss a legal settlement if a case is settled.

In other words, the most important factor is safety. What level of safety can the provider and hospital be counted on to provide? Only after that has been ascertained can the atmospherics be considered.

Like many “natural” childbirth advocates, the blog author displays an astounding amount of denial about the risks of childbirth and complete indifference to what training is required to be a good, safe provider. She asserts in the comment section:

I mean, if I was going to get a complicated and rarely performed procedure done, I would probably want to ask my surgeon about his experience and skill level – how many of these procedures have you done, and what were the outcomes? But, with a relatively common, non technical event, like a physiologically normal vaginal delivery, I think practice patterns for common interventions, informed consent, and basic practical questions (can my partner spend the night in the post partum room?) make much more sense…

No ob/gyn can finish a residency without doing a serious number of deliveries, vaginal and cesarean. I don’t think skill level is a big issue there.

First there is the assumption that complications will not occur. Second there is the assumption that skill means merely technical skill. Sure any obstetrician can do a vaginal delivery or C-section, but the skill that counts far more is clinical judgment, knowing how to prevent, diagnose and manage complications. All obstetricians are essentially equal when it comes to most clinical skills, but they are not equal when it comes to judgment.

I’m not suggesting that the atmospherics are irrelevant. They can make a big difference to the mother’s comfort level and certainly deserve consideration. However, they take a back seat to safety concerns. Once you have found competent providers, you can choose between them based on the atmospherics. Dwelling on your intact perineum is cold comfort if your baby dies of a preventable cause.

Unassisted birth advocate Rixa Freeze ponders how different women can view epidurals very differently:

Epidural + empowerment are two words that don’t always get put together in the same sentence, even among women who gladly choose epidurals for pain relief. For me–huge caveat that I’m speaking about my own thought processes here, not generalizing myself onto all women–an epidural is the opposite of empowerment. Not just emotionally or psychologically, but in the literal sense, too, because an epidural causes full or partial paralysis from the waist down. The thought of losing sensation, of literally being unable to walk or move, isn’t something I would look forward to in labor. To me, labor = movement. I cannot imagine having a contraction without moving in response to it.

She views epidurals as disempowering because they limit movement and sensation, yet there are many women who find them empowering because they eliminate pain. Dr JaneMaree Maher of the Centre for Women’s Studies & Gender Research at Monash University in Australia,offers a very different way of conceptualizing pain and empowerment, one that resonates with the majority of women. In her article The painful truth about childbirth: contemporary discourses of Caesareans, risk and the realities of pain , she observes:

… Pain will potentially push birthing women into a non-rational space where we become other; ‘screaming, yelling, self-centered and demanding drugs’. The fear being articulated is two-fold; that birth will hurt a lot and that birth will somehow undo us as subjects. I consider this fear of pain and loss of subjectivity are vitally important factors in the discussions about risks, choices and decisions that subtend … reproductive debates, but they are little acknowledged. This is due, in part, to our inability to understand and talk about pain.

As she explains:

… [W]hen we are in pain, we are not selves who can approximate rationality and control; we are other and untidy and fragmented. When women give birth, they are physically distant from the sense of control over the body that Western discourses of selfhood make central; they are very distant from the discourses of choice that frame the caesarean rates debate. I am not suggesting here that women become irrational in childbirth … I am however suggesting that we continue to frame birthing experiences and decisions as if that model of subjectivity were the relevant one and in so doing, we move further away from articulating the realities of birthing, of pain and of the ways in which women engage.

So epidurals, as the most effective form of pain relief, give women control over their own bodies and control over the way in which they behave. This allows women to represent themselves to others in the ways in which they wish to be seen, instead of pushing them into a “non-rational” space.

While women like Rixa value the ability to move above all else, and therefore consider forgoing an epidural empowering, most women value the ability to control their own bodies and control the way that they behave. For them, pain is disempowering because it robs them of the control they value, and robs them of the ability to articulate other desires or even speak.

The bottom line is that there is nothing inherently empowering about pain or pain relief. It depends on what each individual woman values and wishes to control. Wanting to move in labor is no more or less important than wanting to be comfortable in labor. Women who choose epidurals find them very empowering.

“Natural” childbirth advocate like to declare to all that they are “educated” about childbirth. However, the only way to be truly educated is to read the scientific literature. Therefore, I highly recommend two posts about reading scientific papers that I found in a rather surprising place.

Consider the following quotes:

Start with the abstract, a short summary of what the article contains. The abstract will give you a brief overview of the article and its contents. Keep in mind that abstracts are not comprehensive, and are written by the study authors. They are in a sense similar to theatrical trailers. You can often get the basic gist of what the article is about from the abstract, but just like a well-done movie trailer can make a bad movie look good, you can’t gauge the quality of an article by the abstract alone. Read the whole thing! (emphasis in the original)

And:

… The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked….

… I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

It sounds like I could have written either of them, but I didn’t. They come from Andrea Lythgoe and Amy Romano writing on the Lamaze website Science and Sensbility. Bravo to them for acknowledging that being educated starts with reading the scientific literature.

Just when I think I’ve heard it all, along comes a new wacky theory of disease causation. The claim is that bras cause breast cancer. I can see the appeal. The claim unites a number of axioms of alternative health: cancer is caused by toxins; cancer is preventable by simple things you can do at home; anything “unnatural” is bad for you.

How are these axioms combined to create the claim that bras cause breast cancer? According to the alternative health website Health & Beyond:

“Bras cause breast cancer. It’s open and shut,” says medical researcher Syd Singer…

The Singers became breast cancer sleuths in 1991 [when] Soma discovered a lump in her breast …

Could bras be constricting breast tissue, Syd wondered, hampering lymph drainage and causing degeneration?

Amazingly enough, the Singers figure it out without doing ANY research! Aren’t they smart?

The World Health Organization calls chemical toxins the primary cause of cancer. But poisons accumulating in breast tissue are normally flushed by clear lymph fluid into large clusters of lymph nodes nestling in the armpits and upper chest. The Singers found that “because lymphatic vessels are very thin, they are extremely sensitive to pressure and are easily compressed.” Chronic minimal pressure on the breasts can cause lymph valves and vessels to close.

“Less oxygen and fewer nutrients are delivered to the cells, while waste products are not flushed away,” the Singers noted. After 15 or 20 years of bra-constricted lymph drainage, cancer can result.

The Singers rushed to share their insights with major organizations, but they were ignored! Why? Could it have been because their theory is stupid, lacking proof, and in conflict with what we know about lymphatic drainage? Not according to the Singers. It’s a conspiracy!!!

Well aware that their findings were “explosive,” the Singers sent their survey results to the heads of America’s most prestigious cancer organizations and institutes. None responded. Like the cancer business, the bra business is huge. Multiply how many worldwide women buy several $25 bras every year and you end up with a multiple of the $6 billion-a-year US bra business.

Big Bra is hiding information to protect their sales! Who knew?

Of course, the Singers theory is nonsensical. When lymph drainage is impeded, the area swells up, often quite dramatically. For example, women who have had lymph nodes removed as part of breast cancer treatment often experience marked painful swelling in the arm on that side. No woman wears a bra that is tight enough to cause her breasts to swell markedly (although some would surely choose to do so if there were such a bra). There is no evidence that “toxins” accumulate in the breasts or that “toxins” are drained by way of the lymphatic system. And there’s no scientific evidence that anyone who experiences lymphedema (the medical term for swelling caused by impaired lymph drainage) in any part of the body has an increased risk of cancer in that body part.

The Singers are not bothered by such details. They’ve proven the theory to their own satisfaction. After discovering a breast lump, Soma stopped wearing her bra:

“Going bra-less for all occasions, Soma began dressing to de-emphasize her breasts. She also began regular breast massage and bicycle riding, vitamin and herbal supplementation, and drinking only purified water.

Two months later, her lump disappeared.”

Well, if that isn’t proof, what is?

Of course, the vast majority of breast lumps are not cancer, many are cysts, and a large proportion disappear spontaneously in three months, just like in Soma’s case. So what? The Singers “know” that Big Bra is concealing more than breasts. They “know” that bras cause breast cancer, and they know that Big Bra is engaged in a cover up of this important information.

What should you do? The Singers believe that you should not wear a bra, but they have kindly offered this helpful information for women who continue to trap “toxins” in their breasts:

Don’t wear this disastrous device to sleep. Take it off at home. Massage your breasts every time you remove your bra. Sing your lymphatics into health — or at least breathe deeply.

Words to live by!

“Natural” childbirth advocates have presented episiotomies as exhibit A in their case against modern obstetrics. They argued for years that episiotomies are unnecessary, or even harmful. Research done in the 1990s seemed to confirm their view by showing a correlation between episiotomies and third and fourth degree perineal lacerations. Third degree lacerations involve disruption of the anal sphincter and fourth degree lacerations extend into the tissue of the rectum itself. Both types of lacerations can have long term consequences including bowel incontinence and recto-vaginal fistula.

Based on the correlation of episiotomies and severe lacerations, obstetrics made an about face on episiotomies. Episiotomies are now discouraged, except in specific instances. The assumption was that a decline in episiotomy rates would lead to a decline in rates of serious perineal lacerations. That has not happened.

Episiotomy in the United States: has anything changed? by Frankman et. al reviews trends in episiotomy and severe lacerations over 25 years, from 1979-2004. Although the episiotomy rate has declined dramatically, the rate of third and fourth degree lacerations has remained unchanged.

Rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004…

With the use of linear regression, the rate of episiotomy with vaginal delivery
decreased by 1.4% per year from an intercept rate in 1979 of 60.9% between 1979 and 2004…

Overall AARs [age adjusted rates] of anal sphincter laceration did not change between 1979 and 2004 (4.5-5.0%).

The authors broke down the statistic into episiotomies associated with spontaneous vaginal delivery and episiotomies associated with operative vaginal delivery (forceps or vacuum).

… Episiotomy with spontaneous vaginal delivery decreased, whereas episiotomy with operative vaginal delivery remained high. Episiotomy with forceps-assisted vaginal delivery declined (83.2% in 1979 to 11.7% in 2004), whereas episiotomy with vacuum-assisted vaginal delivery increased (0.7% in 1979 to 38.1% in 2004). These changes were associated with a shift in obstetric practices favoring vacuum-assisted over forceps-assisted vaginal delivery. The overall rate of forceps-assisted vaginal delivery decreased from 8.2 per 1000 women in 1979 to 0.8 per 1000 women in 2004. The rate of vacuum-assisted vaginal deliveries increased from 0.1 per 1000 women in 1979 to 3.7 per 1000 women in 2004.

… When episiotomy with spontaneous vaginal delivery was analyzed separately, episiotomy rates decreased by 1.4% per year from a rate of 53.4% in 1979 over
the study interval. Similarly, an analysis of episiotomy rates with operative vaginal
delivery demonstrated an annual increase of 1.2% from a rate in 1979 of 84.0% between 1979 and 2004.

… When the AAR of anal sphincter laceration was evaluated by vaginal delivery type, the rates were highest among women undergoing operative vaginal delivery. The AAR for anal sphincter laceration for operative vaginal delivery increased from 7.7% in 1979 to 20.5% in 1996, followed by a decrease to 15.3% in 2004. For spontaneous vaginal delivery, the rate of anal sphincter laceration increased from 5% in 1979 to
a peak of 8.9% in 1987 and then steadily decreased to 3.5% in 2004.

In other words, for spontaneous vaginal delivery as the episiotomy rate declined by 63%, the rate of severe lacerations declined by only 30%. For operative vaginal delivery, as the rate of episiotomy declined by 40%, the rate of severe lacerations increased by 100%.

The graph below illustrates these trends. It was adapted from the paper. It shows rates of episiotomy by delivery type (solid lines) and rates of severe lacerations by delivery type (dotted lines).

The authors, staunch opponents of episiotomy insist:

Decreasing rates of episiotomy have corresponded with decreasing age-adjusted rates of anal sphincter laceration. However, rates of episiotomy and anal sphincter laceration remain high for operative vaginal delivery (50.1% and 15.3% in 2004, respectively). Episiotomy and operative vaginal delivery are well known risk factors for anal sphincter laceration.The high rates of anal sphincter laceration associated with forceps- and vacuum-assisted vaginal delivery are probably the direct result of continued use of episiotomy with these procedures

That’s not how I read the graph. The steep decline in episiotomy rates for spontaneous vaginal delivery resulted in a much more modest decline in severe lacerations. The steep decline in episiotomy rates for operative vaginal delivery resulted in an increase in severe lacerations.

The evidence does not indicate that episiotomy is associated with the persistently high rate of severe lacerations in operative vaginal deliveries. It indicates that the rate of severe lacerations seems to be independent of the episiotomy rate. In the case of spontaneous vaginal delivery, the decrease in episiotomy does not lead to a decrease of comparable magnitude in severe lacerations.

These findings suggest that there are other factors involved in the rate of severe lacerations besides episiotomy. It’s not argument for brinding back routine use of episiotomy, but it does suggest that the “dangers” of episiotomy have been exaggerated.

What’s going on in California? Why has the maternal mortality rate risen so sharply?

Nathanael Johnson, of California Watch, broke the story yesterday:

The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.

For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

Unfortunately, it is impossible to figure out what is going on because the state of California is withholding information on the deaths. We don’t know the causes of death, the demographics of the mothers, or the level of care they received.

Although the state of California refuses to release the case by case accounting of the deaths, we can find some information. The California Maternal Mortality Care Collaborative (the same entity that is withholding the complete report) has some startling graphs on its website.

The graph above reveals several interesting findings. First, the maternal mortality rates have been rising in the US as a whole, but have been rising faster in California. Second, the large increase after 2002 reflects the change in the way that maternal mortality is reported. It had been suspected for some time that maternal mortality in the US was being substantially underestimated. New data collection forms confirmed this undercounting; hence part of the rise in maternal mortality reflects better data gathering. Third, rates of maternal mortality are so low that a few deaths can dramatically change the rates, hence the sawtooth nature of the graphs. Fourth, although the rates fluctuate from year to year, the overall trend is upwards.

The graph displaying racial differences in California maternal mortality is truly mind boggling.

Maternal mortality among Asian and Hispanic women is lower than or equal to the rates for white women. The maternal mortality rate for black women is astoundingly high, topping out at an extraordinary 54.9/100,000. That number is more than triple the rate for women of other races, and is consistent with overall US data from 2006 (white maternal mortality of 9.5/100,000 compared to black maternal mortality of 32.7/100,000). African Americans make up only 6% of the population of California, less than half the nationwide percentage, so the high rate of black maternal mortality cannot be blamed for the increase in California maternal mortality.

What is the reason for the high and rising rate of maternal mortality in California? Without patient level data, it is impossible to know. However, there are three possibilities: changing characteristics of pregnant women, changing level of care provided, and change in the type of care, specifically the rising C-section rate.

Does the increase in maternal mortality reflect an increase in obesity, age or fertility treatment in pregnant women? We don’t have access to the data that will tell us. Is the increase in maternal mortality related to California’s worsening fiscal status and associated cutbacks in services? We don’t know that either. We do know that the C-section rate has been rising dramatically all across the US. The C-section rate in California in 2006 was 31.3% almost exactly the same as the overall US rate. This is an increase from the US rate in 2003 of 27.5%, representing an increase of 13.8%.

Is the rising C-section rate responsible for the rising maternal mortality rate? Without patient level data we cannot know, but it certainly is a possibility. I have written in the past about the diminishing returns of an ever increasing C-section rate and predicted that there would be a point at which the risks to mothers would outweigh the benefits to infants. I await the release of the California report to find out if we have reached that point.

Evidently for lactivists there is no problem so great that it can’t be solved by throwing breast milk at it. Looking at the horrific recent earthquake in Haiti you and I might see death, injury, homelessness and the threat of disease. Lactivists saw a breastfeeding problem. They embarked on not one, but two separate inane campaigns to promote their favorite cause instead of focusing on the real needs of children in Haiti. It is difficult to imagine how people can be so self absorbed.

Haiti is in desperate need of baby formula, but the lactivists actually mounted a campaign to stop shipment of formula to Haiti. Salon’s Broadsheet ran a piece entitled Formula for disaster; do donations of artificial milk help or hurt Haiti’s babies? As the piece reported “RadicalLactivist” Cassaundra Blyth embarked on a Twitter based campaign:

PLEASE! don’t send formula to Haiti! The women & children shouldn’t be victimised twice! Breastfeeding during emergencies is VITAL to health.

That’s right folks; in the midst of the greatest natural disaster in decades, lactivists are concerned that aid workers will use their precious time and even more precious formula to convince breastfeeding mothers to switch to formula. Are these people insane? Haven’t they heard that 150,000 died and hundreds of thousands more are injured. Hasn’t it occurred to them that among the dead and severely injured there are likely to be thousands if not tens of thousands of breastfeeding mothers? How are those infants to be fed?

Breastfeeding is no longer an option for these babies. The ONLY option is formula feeding. Yes, powdered formula can cause harm if mixed with contaminated water. Yes, it would be safer to give those babies pre-mixed formula. But at the moment babies are starving for lack of milk of any kind. Far more babies can be fed with shipments of powdered formula than with pre-mixed formula. Time is of the essence if starvation is to be avoided, and a group of grown women is trying to stand in the way of feeding these babies.

But the inanity does not end there. Lactivists began calling for donations of breast milk:

When lactation consultant Faith Ploude heard that babies in Haiti might need donated breast milk, she made sure to get the word out to her classes at Mercy Hospital in Miami — and her database of more than 1,000 nursing moms.

The La Leche League and the Human Milk Banking Association of North America made similar pleas.

Let’s leave aside the issue that breast milk donations would be pathetically inadequate; one thousand donations of breast milk would feed one thousand infants only once. Consider that buildings from the meanest shack to the Presidential Palace have crumbled and are uninhabitable. People are living in tents if they are lucky or in the open air if they are not. Where are the refrigerators to store the milk? Obviously there are none, and breast milk will spoil immediately if it is not refrigerated, becoming undrinkable and potential dangerous in a matter of hours.

And how is the breast milk to get to Haiti? It has been a nightmare shipping in even the most basic supplies. Breast milk that must be frozen if it is to survive until it reaches the babies.

Red Cross workers are appalled:

“Tell them not to send it,” said Eric Porterfield, a spokesman for the American Red Cross, “I’m 100 percent sure we didn’t ask for that.”

The international Emergency Nutrition Network has asked one group, the Human Milk Banking Association of North America, to retract a press release this week that issued an “urgent call” for breast milk for orphaned and premature infants in Haiti, saying the donations contradict best practices for babies in emergencies.

Such donations pose problems of transportation, screening, supply and storage and create an “unfeasible and unsafe intervention,” according to a statement from the Office of U.S. Foreign Disaster Assistance, or OFDA.

Lactivists embarked on a campaign to interfere with delivery of formula to Haiti and to send breast milk to people who couldn’t possibly use it. Was this well meaning naivite? That certainly played a role, but the lactivists were never thinking about what the infants of Haiti actually needed; they were thinking of themselves and their personal obsession with breastfeeding. They viewed this as another opportunity to self actualize by promoting their pet cause. The human tragedy of the devastation in Haiti was just another venue to showcase their belief that every child must be breastfed. The actual needs of Haitian babies were never considered.

Lactivists need to get a grip. A horrific natural disaster is not an opportunity to highlight the benefits of breastfeeding. It is a tragedy that obligates us to send the people of Haiti what they need, not simply what we’d like to give.

I am eagerly awaiting the new “right to life” campaign aimed at high school girls, tentative slogan: “Sleep with your boyfriend, get pregnant, stop breast cancer!””

Well, truth be told, I don’t really know if that’s going to be their next campaign but it would be the next logical step in their pious crusade to protect the health of women. To hear the “right to life” folks tell it, an ongoing conspiracy has prevented women from learning about the association of breast cancer to abortion. Indeed the Coalition on Abortion Breast Cancer (ABC) was formed for no other purpose than to disseminate this momentous news.

Of course, the consensus among cancer experts, epidemiologists and public health officials is that abortion does not cause breast cancer, but no matter. ABC has embarked on a campaign to highlight this putative link. Not surprisingly self identified antiabortion physicians and scientists have been enthusiastic participants.

Joel Brind, PhD, professor of biology at Baruch College has thoughtfully provided the ABC folks with an analysis of a “bombshell” paper by Jessica Dolle (Risk Factors for Triple-Negative Breast Cancer in Women Under the Age of 45 Years) published in the April 2009 issue of Cancer Epidemiology. As Prof. Brind explains:

The Dolle study is based on a population of 897 cancer patients diagnosed under age 45 and 1,569 controls with a similar age distribution, all from the greater Seattle, WA area. The subjects were all subjects of earlier studies published by the Daling group during the 1990’s … for whom breast tumor tissue specimens were still available to do complete analyses for 3 prognostic tumor markers, namely, estrogen receptors (ER), progesterone receptors (PR) and HER2 receptors. The present study divides the patients thus examined into two groups: Triple negative breast cancer (TNBC), i.e., those negative for all 3 markers (187 cases) and all other combinations (710 cases; referred to as non-TNBC).

The study was specifically designed to look at the association between breast cancer and use of oral contraceptives. As part of the study, though, the authors looked at confounding factors that might impact the incidence of breast cancer. What excited the antiabortion crowd was the following table.

The bottom entry in the table looks at the impact of abortion history on subsequent development of breast cancer. The relative risk is 1.4 meaning that women who had had an abortion were 40% more likely to develop breast cancer than those who had never had an abortion.

The results were not statistically significant, but no matter. The “right to life” folks are not bothered by such trivial details. Because of their profound commitment to the health of women they want to do everything possible to prevent death from the scourge of breast cancer.

But wait! There’s more information in the table, and it is statistically significant. The best way to lower your risk of breast cancer is to have a baby before age 20. Another equally sound strategy is to have 4 or more children. Just imagine how far a girl could lower her breast cancer risk if she had 4 children before age 20!

This is important news. And since they are so concerned about preventing breast cancer, surely the folks at ABC will soon be embarking on a campaign to promote teen pregnancy. Not only should teens get pregnant, they should get pregnant over and over again. That’s the best way to reduce the risk of developing breast cancer in the future and the folks at ABC feel that preventing breast cancer is their most important priority.

But wait! I can find no mention on the ABC website, or on any antiabortion website of the protective effect of teen pregnancy on developing breast cancer. What could that mean? Could it be that their pious concern for the health of women is nothing more than a bald faced and cynical attempt to prevent women from having abortions? Could it be that they really don’t care about the future health of women at all? It could be, and that would force us to a very sad realization. Indeed, there’s really no way to avoid the conclusion that the antiabortion folks who promote a link between abortion and breast cancer are nothing more than hypocrites, who don’t care about breast cancer (since they don’t mention the protective effect of teen pregnancy).

In fact, we may be forced to conclude that they don’t care about the health of women at all. They never mention at all the most important health effect of abortion: even if it were true that abortion raised a woman’s risk of breast cancer by 40%, it doesn’t change the fact that carrying a pregnancy to term raises her risk of death by 1500%!

Surprise! It’s Alaska, home of that stalwart supporter of abstinence only education, Sarah Palin, and her daughter Bristol, a teen who became pregnant outside of marriage. That startling bit of information is was included in CDC statistics that formed the basis for a new review calling attention to a worrisome development. After years of dropping steadily, the teen pregnancy rate has plateaued and begun to rise.

According to a report from the Guttmacher Institute, U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity:

In 2005, the U.S. teenage pregnancy rate reached its lowest point in more than 30 years (69.5), down 41% since its peak in 1990 (116.9). However, in 2006, the rate increased for the first time in more than a decade, rising 3%…

… [F]or the first time since the early 1990s, overall rates of pregnancy and birth—and, to a lesser extent, rates of abortion—among teenagers and young women increased from 2005 to 2006. It is too soon to tell whether this reversal is simply a short-term fluctuation, a more lasting stabilization or the beginning of a longer-term increase. Preliminary data on births for 2007 show a further increase in the birthrate among all women, including teenagers …

Twenty-eight states had statistically significant changes in teen pregnancy rates, 22 states had increases in teen pregnancy rates, while 4 had decreases. Alaska had the largest increase, the teen pregnancy rate rising a startling 19%. It holds the dubious distinction of beating out traditional leader Mississippi, which experienced an increased rate of teen pregnancy of 13%.

Opponents of abstinence only education were quick to suggest that such programs are to blame:

“One of the nation’s shining success stories of the past two decades is in danger of unraveling,” said Sarah Brown of the National Campaign to Prevent Teen and Unplanned Pregnancy. “Clearly, the nation’s collective efforts to convince teens to postpone childbearing must be more creative and more intense, and they must begin today.”

But the increase is hardly an endorsement of values neutral, fact based sex education. Even, Heather Boonstra, Guttmacher’s senior public policy associate, acknowledges that:

… the reasons for the increase are probably complex and multifold. “We’ve been seeing declines in contraceptive use,” she says, probably at least in part because of complacency about the HIV virus that fueled a rise in condom use among teens in the 1990s. She also says teen pregnancy seems to be more acceptable in many American towns and cities as teens flock to blockbuster movies like Juno (which positively portrays a pregnant teen) and see pregnant peers in their classes, something that was rare several decades ago.

The data indicate that both intended and unintended teen pregnancies rose:

The teenage birthrate in 2006 was 41.9 births per 1,000 women. This was 32% lower than the peak rate of 61.8, reached in 1991, but 4% higher than in 2005.

The 2006 teenage abortion rate was 19.3 abortions per 1,000 women. This figure was 56% lower than its peak in 1988, but 1% higher than the 2005 rate.

From 1986 to 2006, the proportion of teenage pregnancies ending in abortion declined almost one-third, from 46% to 32% of pregnancies among 15–19-year-olds.

The data suggest that teen pregnancy is not a matter of sex education, but rather a lifestyle choice. In that sense, it does reflect the abject failure of abstinence only education. Abstinence only education has had no impact on rates of teen sexual activity, and now rates of both unintended and intended teen pregnancy are rising once again.

But fact based sex education does not appear to be the answer, either. Teens are choosing to get pregnant and choosing to carry pregnancies to term, putting in doubt one of the fundamental assumptions of fact based sex education, that teens who know more will take more precautions to avoid pregnancy.

If we intend to decrease the rate of teen pregnancy, the answer will not lie in either type of sex education alone.

The Sunday edition of The New York Times featured a disturbing expose of serious medical errors associated with the newest forms of high tech radiation treatment,Radiation Offers New Cures, and Ways to Do Harm. The piece is an example of excellent medical journalism, compelling stories of two individuals who sustained truly horrifying injuries as the result of treatment errors framed a detailed investigation of similar errors that have occurred in New York State.

One of the most notable features of the medical errors highlighted by the article received only short shrift, however. That is unfortunate because it is an increasing source of medical error and is rarely included in public discussion of medical errors. Of the 1264 specific mistakes identified in the article, only a small proportion were made by doctors. The vast majority of errors were made by other people: physicists and programmers who ran the machines, ancillary medical professionals who positioned the patients during actual treatment, and support staff who brought the wrong patients for treatment.

Medical errors are a very serious problem and we should be engaged in an all out effort to reduce them to zero if possible. When people think about medical errors, they tend to imagine them as physician errors that could be corrected by greater diligence. Yet many medical errors are cause by people other than doctors, including people who are not medical professionals. These errors fall into three broad categories: errors introduced by complex monitoring and treatment machinery, errors caused by ancillary medical personnel, and clerical errors.

Consider the errors attributable to machinery. Extraordinarily complex machinery is involved in many aspects of medical care. In this case, the injuries and deaths were caused by a highly specialized and sophisticated form of radiation delivery, a linear accelerator with a multi-leaf collimator. The article explains:

… [A] linear accelerator with 120 computer-controlled metal leaves, called a multileaf collimator, … could more precisely shape and modulate the radiation beam. This treatment is called Intensity Modulated Radiation Therapy, or I.M.R.T. The unit St. Vincent’s had was made by Varian Medical Systems, a leading supplier of radiation equipment.

“The technique is so precise, we can treat areas that would have been considered much too risky before I.M.R.T., too close to important critical structures,” Dr. Anthony M. Berson, St. Vincent’s chief radiation oncologist, said in a 2001 news release.

Sophisticated machinery is run by computers and computers must be programmed. The case of Scott Jerome-Parks who was severely injured by excess radiation and subsequently died illustrates how serious errors can be made:

Tasked with carrying out [the treatment] plan was Nina Kalach, a medical physicist. In the world of radiotherapy, medical physicists play a vital role in patient safety — checking the calibration of machines, ensuring that the computer delivers the correct dose to the proper location, as well as assuming other safety tasks…

On the morning of March 14, Ms. Kalach revised Mr. Jerome-Parks’s treatment plan using Varian software. Then, with the patient waiting in the wings, a problem arose, state records show.

Shortly after 11 a.m., as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message. The hospital would later say that similar system crashes “are not uncommon with the Varian software, and these issues have been communicated to Varian on numerous occasions.”

An error message asked Ms. Kalach if she wanted to save her changes before the program aborted. She answered yes.

Ms. Kalach did not know that the computer had not saved the treatment instructions that she had programmed. As a result, Mr. Jerome-Parks received a massive overdose of radiation:

The investigation into what happened to Mr. Jerome-Parks quickly turned to the Varian software that powered the linear accelerator…

When the computer kept crashing, Ms. Kalach, the medical physicist, did not realize that her instructions for the collimator had not been saved, state records show. She proceeded as though the problem had been fixed.

“We were just stunned that a company could make technology that could administer that amount of radiation — that extreme amount of radiation — without some fail-safe mechanism,” said Ms. Weir-Bryan, Ms. Jerome-Parks’s friend from Toronto. “It’s always something we keep harkening back to: How could this happen? What accountability do these companies have to create something safe?”

The software malfunction was one among many similar highly technical errors. Indeed more than half of the identified medical errors were related to programming the linear accelerator. Yet at the other end of the spectrum of sophistication, there were disturbingly large numbers of errors as well. In 174 instances, the wrong location was treated or even the wrong patient was treated. In 66 instances, staffing shortages or miscommunications resulted in treatment errors.

In total, at least 621 patients were harmed by medical errors, but ultimately only 6% of the errors were attributable to the physicians caring for the patients. The New York Times article on radiation treatment errors sounds an alarm not merely about a specific, highly technical form of treatment. It also raises serious questions about errors caused by ancillary medical personnel and even support staff. Such errors are inexcusable, and will require a different approach than conventional medical errors, an approach we must start working on immediately.