The Social Medicine Portal

Cutting edge Social Medicine 2011: Resident Projects from the RPSM

What is the cutting edge in Social Medicine in 2011, at least in the Bronx?

The 18 social medicine projects completed by the 2011 graduates of Residency Program in  Social Medicine offer one perspective.  These projects cover a wide variety of topics; three were conducted internationally (Quito Ecuador;  Andhra Pradesh, India; and Rwanda). Among the questions addressed were:

1) Are medical schools and residency programs accountable to the broader society?

2) Does the promotion of Zumba dance in the clinic  improve the health of diabetics?

3)  What are the barriers to reproductive health care among homeless adolescents living in shelters?

4) What is a social medicine doctor?

The abstracts published below represent work by residents in Social Pediatrics, Family Medicine, and Social Internal Medicine/Primary Care. The actual presentations were made during Social Medicine Rounds on May 24, May 31 and June 7, 2011.

 The objectives of this study are to obtain information about where teenagers receive their information about sexual health topics, to obtain information about the use of the internet/social networking, and to evaluate adolescent knowledge concerning reproductive health. Male and female adolescents between the ages of 14 and 21 were recruited from two urban clinics in the Bronx. They were asked to complete an anonymous survey which included basic demographic information, internet availability, a knowledge assessment, and questions assessing sources of information and their usefulness. Participants were also asked specifics about websites/social networking resources utilized. Responses to survey questions were tabulated in Excel and descriptive statistics were calculated.

One-hundred and eighty-nine adolescents were surveyed during their clinic visits. The median percent correct on knowledge questions was 64.7%. The most common sources were medical professionals (93%), mothers (85%), friends (86%) and the internet (83%). Information provided by medical professionals was seen as the most useful (92%) followed by mom (81%), boy/girlfriend (79%) and the internet (73%). The most common websites used were Google (74%), Yahoo (26%), and Wikipedia (26%). The top four search terms were sex, condoms, birth control, and HIV.

To assess the potential of group visits in comparison to individual visits, a Centering Parenting Model of group well-child care was implemented at a Federally Qualified Health Center in an urban primary care setting designated as Patient-Centered Medical Home.

Study participants are parent-baby dyads and are established patients at the Family Health Center. Centering Parenting groups consisting of 5-10 pairs meet at predefined routine well-child visits to receive routine well baby care in a group setting.

The purpose of this project is to provide group well child care as an alternative to individual provider care with the hope of improving quality outcomes and parent satisfaction.

 Background: Cervical cancer is a completely preventable disease. Yet 470,000 new cases of cervical cancer are diagnosed each year and 300,000 women die annually worldwide. The overwhelming majority of these cervical cancer cases occur in the developing world. Pap smears are the main screening test for cervical cancer but many developing countries lack the infrastructure to perform pap smears. To address this need for cervical cancer screening in the developing world, the medical organization Prevention International: No Cervical Cancer (PINCC) developed a mobile service which screens for precancerous cervical cells using direct visual inspection of the cervix with acetic acid (VIA) and immediately removes suspected lesions in a single visit using either cryotherapy or LEEP. This study aims to evaluate the effectiveness of PINCC’s mobile cervical cancer screening program in Andhra Pradesh, India.

Methods: For 12 days in August and in December 2009, PINCC went to a different village each day in Andhra Pradesh, India. Mobile cervical screening using VIA was performed on non-pregnant, non-menstruating women between the ages of 23 and 75 who did not have signs of vaginitis. Pap smears were often performed for VIA-negative lesions, or if the squamocolumnar junction (SCJ) was not fully visualized because it extended into the cervical os. Biopsies were taken of VIA-positive lesions. Cryotherapy was performed if VIA-positive lesions covered less than 75% of the cervix and there was adequate visualization of the SCJ. Women with VIA-positive lesions covering >75% of the cervix received LEEP. PINCC referred all women suspected of having cervical cancer to the local hospital, based on the screening VIA results and biopsy. These women did not undergo cryotherapy or LEEP treatment.

Results: PINCC screened 623 women for cervical cancer during the 24 days that they were in Andhra Pradesh, India. Cervical samples from only 543 women were used in this study since there were missing data for 80 screened patients. Of the 543 women screened, 431 were VIA-negative and 112 were VIA positive. The VIA-negative group included 391 completely normal cervical screening after adequate visualization of the SCJ and 40 women who had to undergo pap smears for inadequate visualization of the SCJ. Precancerous cervical cells were found in 3 of 40 pap smears. Of the 112 participants with positive VIA lesions, 21% had cryotherapy, 27% had LEEP, and 45% were biopsied only without treatment due to either a non-functional cryotherapy or LEEP. Squamous cell carcinoma was found in 1.3% of the screened women. Of all the 112 VIA-positive lesions seen, biopsies found cancer or precancerous cells in 53 women, for a positive predictive value of 47%.

Conclusions: In 24 days, PINCC effectively screened 543 women with the low-cost method of VIA and immediately treated them with cryotherapy or LEEP. The PPV of VIA to detect precancerous cells was similar to other studies involving VIA. Further measures need to be taken to reduce the number of samples with missing data and to ensure operational equipment. A mobile “see and treat” model is a feasible method to address the high cervical cancer rates in the developing world.

The Montefiore Transitions Clinic (TC) was established to provide access to primary care, mental health services and social services for recently incarcerated adults. In July, 2009, we established a TC for recently incarcerated adults through partnership with Bronx Parole Board and The Osborne Association, a local prisoner advocacy community based organization (CBO). Initially, referrals to TC were primarily from parole officers and the overall burden of chronic illness was low. Here we report on the impact of a community health worker (CHW) on patient recruitment and disease severity.

To evaluate the impact of the referral source on the disease prevalence seen at TC, we performed a retrospective chart review comparing patients seen before and after the CHW was hired. Data was available for the first 39 TC patients, of whom 38 were referred by the Parole Committee, and the 30 most recent TC patients, 29 of whom were referred by the CBO through the CHW. Our primary measure of interest is prevalence of chronic disease in TC patients, including HIV, hepatitis C, mental illness, opioid dependence and diabetes. Secondary measures include time from correctional facility release to first clinic visit and insurance status.

With the assistance of a CHW, the TC has reached a population of former inmates with a higher burden of chronic illness. Referrals from a CBO, coordinated by a community health worker, identified a population with a high prevalence of chronic diseases including HIV, hepatitis C, mental illness and opioid dependence. system of facilitated referrals, along with access to health centers where barriers to care are minimized, can help bridge gaps in care for the formerly incarcerated population.

Needs and Objectives: Although weight loss can lead to a reduction in diabetes and hypertension and improve health outcomes, only 42% of obese U.S. adults report that their physicians have counseled them about weight loss. Even when weight loss is advised, most physicians do not discuss specific weight loss strategies, indicating that the quality of counseling may be poor. To address this gap, we adapted, implemented, and conducted a pilot evaluation of a previously developed theory-based obesity counseling curriculum for residents using a 5A’s behavioral change model. In this model, residents are trained to assess obesity risk, agree on mutual goals, advise a weight-control program, assist in establishing appropriate intervention, and arrange for follow-up. The objective of our evaluation was to determine the feasibility and impact of a novel obesity counseling curriculum, which incorporates training and practice in obesity counseling skills, on residents’ self-assessed competency in obesity counseling.

Setting and Participants: Our target audience was 28 interns and residents in the Primary Care/Social Internal Medicine Residency Program at Montefiore Medical Center, Bronx, New York.

Description: The curriculum was delivered 4 times over a 6 month period to groups of 5 to 10 residents during ambulatory medicine blocks. One week prior to curriculum participation, residents completed a previously validated survey with 9 items measuring self-assessed obesity counseling competence, based on the 5A’s model. Each question used a 4-point likert scale. The 3-hour 5A’s Obesity Curriculum included a 2-hour didactic and discussion session on the epidemiology of obesity, 5A’s obesity counseling framework and practical tools for its implementation. Case-based discussions of treatment modalities included behavior change, medication, and surgical options for weight loss. The final hour involved reviewing motivational interviewing (MI) and practicing with a standardized patient. Two months after participation, residents completed a post-intervention survey, and gave general feedback. Preliminary analyses compared median scores before and after curriculum participation using the Wilcoxin test.

Evaluation: To date, 16 residents have completed the curriculum and surveys, with another 10 scheduled to participate. Residents reported their counseling competence in: 1) assessing patients’ stage of change, 2) diet and 3) current level of physical activity; 4) agreeing on mutual goals for weight loss; 5) assisting patients in goal setting for weight loss; 6) responding to patients’ questions about behavior change; 7) offering medication and 8 ) surgical weight loss options; and 9) using MI techniques to change behavior. After the curriculum, there was a significant increase in the median scores from 2 to 3 (2=somewhat able to perform, 3=able to perform adequately) in residents’ report of assessing stage of change, assisting in goal setting, discussing treatment options and using MI techniques. There were no differences in the remaining domains. On qualitative questions, residents reported a high degree of satisfaction with the curriculum and requested additional skills practice sessions in MI.

Discussion: We developed and implemented a novel curriculum for residents to address strategies for weight loss using the 5A’s behavior change model, which incorporated obesity counseling skills practice. Preliminary pre and post curricular analyses showed improvements in several areas of residents’ obesity counseling competence. Implementing this three hour curriculum in a residency program was feasible. Post curricular questionnaires indicated that residents were satisfied with the curriculum, and were eager for additional sessions for continued practice and refinement of obesity counseling using MI skills. Further evaluation, with additional learners, and direct observation of counseling skills is needed to fully elucidate the impact of the curriculum in promoting effective obesity counseling skills.

Chronic malnutrition is associated with childhood mortality and affects up to a quarter of children in Ecuador. In southern Quito, lack of knowledge and poor diet diversification are contributing factors. Existing research has shown health education is a critical component in influencing behavioral changes and local collaborators, such as the Ecuadorian Ministry of Health and community physicians, have identified health education as an area that merits further investigation in their patient population. Hence, the objective of our study was to assess the effectiveness of a health education intervention given at a government-run clinic in Quito, Ecuador.

A 20-minute workshop and pictogram handouts were developed to provide education on the effects of protein malnutrition and highlight locally available protein sources. The workshop was offered daily over a 4-week period and the handout was distributed to a subset of patients after the workshop. Oral questionnaires were developed to assess protein nutrition knowledge, confidence in participant’s own knowledge, and protein intake pre- and post-workshop and at home visits three weeks later. A total of 98 participants completed pre- and post-workshop questionnaires and 57 completed home visit questionnaires. We found that knowledge and confidence increased after protein education workshops with retention at home visits. The utilization of pictogram handouts in educational sessions improved protein intake. These findings support continuing to work with Ecuadorian collaborators to further develop one-time, concise educational interventions to improve dietary behavior.

[This presentation won the Daniel Leicht Social Medicine Award and the Chairman's Research Award.]

Purpose: Seen as a public good, graduate medical education (GME) was financed by Medicare 1965, expecting that this responsibility would continue “until the community bears the cost in some other way”. Over 40 years later, Medicare is still bearing the brunt of GME financing, spending $9.5 billion last year. Many have suggested that academic health centers have become dependent on such financing. We sought to better understand the perceived responsibility of GME institutions in addressing the needs of the nation, and the utility of and most likely methods to measure and compare the social impact of GME institutions.

Method: Eighteen informants were interviewed via semi-structured interviews done by phone and in-person. Key informants were chosen from salient national agencies/associations after developing a sampling matrix to ensure appropriate breadth of perspectives. Snowballing technique was employed, and informant interviews were continued until saturation of themes was achieved and confirmed via search for disconfirming data.

Results: Seventeen of eighteen informants noted that GME institutions have a responsibility to be socially accountable. Informants’ definitions of social accountability included: training of future physicians, addressing workforce shortages and providing service to the institution’s community. Multiple informants noted barriers to measuring social accountability, though many informants suggested possible tools for measurement of social accountability.

Conclusions: GME is largely seen as a public good, and multiple informants noted that recipients of GME funding should be responsible to their communities. However, time constraints, financial limitations, and curriculum overload limit GME institutions’ ability to be socially accountable. Financial incentives, accreditation requirements and maintenance of mission values can address GME institutions’ responsibility to medical education, workforce shortages and community service.

Prison release rates in New York City correlate directly with poverty rates, and a disproportionate number of prisoners are returning to the Bronx. Recently released individuals attempting to reintegrate into the community are among the most marginalized of populations and have grave health outcomes. RPSM residents provide care for many of these patients who are directly or indirectly impacted by incarceration. The goal of this project was to develop a longitudinal training program in correctional health for family and internal medicine residents. Methods included reviewing existing correctional health training programs, interviews with medical and academic directors, rotations and site visits to correctional facilities and transitions clinics in San Francisco and New York City.

The proposal for a longitudinal correctional health curriculum is comprised of required clinical and didactic components: Transitions Clinic sessions at FHC and CHCC during elective blocks throughout residency as the foundation; health education workshops, targeted outreach and discharge planning at Rikers Island and VCBC; buprenorphine training and case-based discussions with a substance abuse specialist; and cross-track conferences to discuss syllabus readings. Residents interviewed unanimously support a longitudinal model of learning and this proposed curriculum provides an example of a rigorous training program to meet their educational needs.

Description: During the academic year 2010 – 2011 we initiated an iterative educational process to engage residents in a dialogue about SBP. An anonymous web-based survey was sent to all 19 PGY2 and 3 residents asking them how they would handle four common clinical scenarios that occur when the resident is not in clinic or between patients’ clinic visits: (1) following up of critical lab values; (2) scheduling non-routine follow-up appointments; (3) handling urgent care situations when patients call from home; and (4) titrating medications. Each scenario was derived from our clinical experience and piloted with colleagues prior to survey distribution. Results were analyzed and a set of best practices was created. At a program-wide retreat attended by approximately 25 residents and faculty we moderated a two-hour discussion on the survey results, best practices and other SBP topics identified. A second anonymous survey was sent to the same 19 residents assessing the value of monthly SBP meetings.

Evaluation: Seventy-four percent (14/19) of residents responded to the initial survey, with up to 5 solutions given for each scenario. Responses varied by the skill level of the clinic staff member asked to assist with the task, the number of phone calls, emails, and hand-offs required, and the time needed for task completion. Given the heterogeneity of responses a set of best practices, emphasizing non-physician resources, was created and disseminated. Our second survey used a 5-point Likert scale (5=Quite Valuable, 1=No Value) to quantify the value of monthly SBP discussions. One hundred percent (14/14) of responders reported that sessions would be valuables or quite valuable. We then initiated monthly discussions (60-75 minutes) during ambulatory blocks (4-8 residents/month). To date we have held two sessions. Prior to each session we solicit SBP topics and distribute a resident derived agenda. Afterwards, we email key takeaway points and post updates on our program’s searchable website.

Background: Chlamydia and gonorrhea (GC) screening in specific populations, including substance users, is recommended. Entry into methadone maintenance treatment presents an opportunity to screen a high risk population, yet the prevalence of Chlamydia and GC infection in this population has not been well-defined. To address this gap, we began to routinely offer screening to women admitted to our Bronx methadone maintenance treatment program (MMTP).

Methods: A chart review of consecutively admitted adult female patients from June 1, 2010 is underway. Using a structured chart review instrument, we abstracted sociodemographics (age, race, income), substance type, injection use, trauma and incarceration history; HIV antibody status, syphilis titer, and urine GC and Chlamydia results.

Results: Forty-nine women were entered treatment between June and December 21, 2010. Eleven (22%) self-identified as Black, 32(65%) as Hispanic. Their mean age was 40 All had heroin dependence. Thirty-one (63%) reported cocaine use. Twenty-two (45%) had injected. Eleven (22%) had experienced domestic violence and 30(61%) had been incarcerated. Nine (18%) were HIV positive, and five (10%) had serologic evidence of syphilis infection. None of the 46 (94%) women tested for GC and Chlamydia were positive.

Conclusions: Although women entering MMTP are typically considered at high risk for sexually transmitted diseases, routine testing GC and Chlamydia testing did not identify any infections. The HIV and syphilis infection rates we found warrant routine screening, but the absence of GC and Chlamydia in this population does not thus far support routine screening with drug use as a sole risk factor.

Purpose: It is clear that social conditions contribute to ill health. This was described as early as the 19th century by Rudolf Virchow, generally considered the founder of social medicine. Yet, medical training continues to center on the molecular basis of disease. In efforts to create a different model of physician training, the Residency Program in Social Medicine (RPSM) of Montefiore Hospital was founded in 1970 to train a cadre of socially-minded physicians dedicated to providing care for the underserved. The RPSM is a holistic curriculum that encompasses an understanding of social problems affecting the health of individuals and communities and strategies for addressing these issues, while training in community health centers. This study investigates what encompasses a social medicine physician today, and how their practice differs from other primary care doctors.

Methods: All current residents, faculty and alumni of the Residency Program were eligible to participate in the survey, which was emailed in March 2009. A survey monkey questionnaire was used, and emailed to current department members and an alumni list-serve. The complete survey had seven items that included status (resident, faculty, or alumni); specialty (Family Medicine, Internal Medicine, Pediatrics); questions about the role of social medicine in regards to their practice, how it differs from other primary care doctors, and questions regarding the RPSM curriculum. Demographic data describing the participants was tabulated, and comments were grouped into themes and investigated via textual and qualitative analysis.

Results: The survey was completed by 173 participants. Forty-seven percent were in the field of Family Medicine, 30% in Internal Medicine, and 24% in Pediatrics. Fifty-six percent were alumni, 26% were faculty, and 21% were current residents. There were three main themes that were common to most responses, which were that social medicine doctors 1) have a broad knowledge of the social determinants of health, 2) have the ability to translate this broad knowledge of health into a specific treatment plan, and 3) promote social justice. Within each theme were various sub-themes which provided a richer description of social medicine concepts and its practice contrasted with the practice other primary care physicians.

Conclusions: Social conditions are not separate from medical conditions, an integral concept of social medicine and RPSM. Although this study was limited in that not all potential subjects responded and responses varied greatly in length and description, the concepts of social medicine are clearly central to their practice of medicine. Social medicine is thought to be valuable and essential in the treatment of individuals and communities, and an opportunity for social change. This model of medicine was viewed as fundamentally different from the practice of other primary care physicians. Further research in the practice of social medicine on patient outcomes, and perspectives of patients treated by social medicine doctors could be helpful in substantiating our findings and expanding the number of social medicine residency programs nation-wide.

The Patient Centered Medical Home (PCMH) has received attention as a cost-effective way to address the myriad problems facing the US primary care system. As more practices become PCMH’s, staff must carry out this change, however their perceptions of the PCMH and the change process may not be congruent. We will compare staff opinions of the PCMH transformation at two primary care clinics in the Bronx, NY, using focus groups consisting of providers and support staff, and analyze recorded transcripts for themes. We anticipate the analysis will yield insight into perceptions of the PCMH and the capacities of the clinics to carry out their transformations that will be useful to other practices as they begin their own transformation processes.

 Numerous studies demonstrate the deleterious health outcomes associated with substance abuse and dependence. To intervene early in the course of substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been advocated by many.Few studies have examined the feasibility of or outcomes associated with conducting SBIRT in hospitalized patients. Although data regarding SBIRT for drug use has been sparse, with the rise in opioid use, abuse, and dependence, many advocate for SBIRT specifically for drug use. We sought to test the feasibility of conducting SBIRT for problematic opioid use targeting patients hospitalized on the medical wards of a large urban academic medical center.

We identified adult patients who were admitted floors of the medical wards and administered audio computer-assisted self-interviews assessing theirof problematic opioid use using the WHO ASSISTscreening tool.Patients were categorized as having no opioid use, or low, moderate, or high risk of problematic opioid use. Those who had moderate or high risk problematic opioid use received a brief computer-based intervention. We found that 42 (56.0%) reported no opioid use, 4 (5.3%) low risk, 26 (34.7%) moderate risk, and 3 (4.0%) high risk of problematic opioid use. Of the 29 patients with moderate or high risk, 19 (65.5%) were interested in referral to treatment and 27 (93.1%) reported that the brief computerized intervention was useful. We question whether our model of conducting SBIRT-with a dedicated person outside of the team delivering health care-is feasible. However, this urban inpatient population seems at significant risk thus more research is warranted on how to best use SBIRT to intervene on problematic opioid users in the inpatient setting.

Zumba Bronx is a reproducible and sustainable form of dance exercise that is built on one of the strengths of an underserved community, the passion to dance. Dance aerobic exercise has been shown to improve participants’ s BMI. The 2010 ADA noted that a 5-10% decrease in weight translates into a decrease in HbA1c. The literature review indicated that successful programs for weight loss have consolidated exercise, diet, and behavior modification plans. In addition, studies have illustrated the utilization of pedometers as a useful tool to motivate diabetic patients to increase physical activity and maintain these efforts. The goal of this social medicine project is to promote physical activity for patients with diabetes at the Williamsbridge Family Practice. The study will utilize this culturally appropriate, and cost-effective form of dance exercise, Zumba, coupled with pedometers, and develop patient centered support that can be incorporated into the FHC and CHCC health centers in the future. The objective of this project is to provide diabetic patients with the tools to develop and maintain a healthy lifestyle.

The purpose of this study was to evaluate whether a dedicated immigrant health session within a larger primary care practice can achieve retention in and quality of health care for immigrants. This was a retrospective cohort study with medical record review of all new patients seen at the OPEN-IT clinic at CHCC from October 1, 2007 to September 30, 2009. The primary outcome was retention in care, defined as at least one follow-up visit within one year after the initial visit. Secondary outcomes included rates of age-appropriate cancer screenings and results of specific screening tests as recommended by the CDC for refugee populations, including Hepatitis B surface antigen, tuberculin skin test, complete blood count, and ova and parasites in stool. Results showed that 79% of patients were retained in care, with no detected difference in retention based on age, gender, length of time in US, or presence of chronic illness. Rates of mammography and cervical cancer screening were 82% and 79% respectively, but the rate of age-appropriate colorectal cancer screening was only 24%. We also found that over a quarter of patients screened had evidence of latent tuberculosis, anemia, and intestinal parasites, although our numbers were small. Our results support the need for clear recommendations regarding immigrant-specific screening. Further work needs to be done to improve rates of colorectal cancer screening within our model and to better understand which diseases need to be screened for in the immigrant population.

Medicines have meaning and these meanings affect both their efficacy and their perception of it. Perceptions about efficacy affect adherence to and retention in treatment. Observations by substance abuse clinicians suggest that patients in methadone maintenance treatment(MMT)hold perceptions about methadone and methadone doses that may not reflect current medical understanding about methadone, including about interactions and adverse effects. Literature about the experience of patients in MMT is sparse, and this study aims to understand the experience with and perceptions about methadone among patients in an urban methadone clinic. Individuals in substance abuse treatment are a marginalized population. It is anticipated that a better understanding of their experience in a particularly stigmatized realm of medical treatment will allow clinicians to better understand their needs, their response to treatments with potential for interaction to methadone, and thereby improve the adherence to and retention in methadone treatment.

 Homeless adolescents experience multiple barriers to contraceptive use and they have high rates of unintended pregnancy and poor birth outcomes. The goal is to conduct semi-structured interviews with homeless female adolescents ages 14-18 at family shelters in the Bronx and to have teen educational seminars at a homeless family shelter. Interviews include questions on demographic data and open-ended questions regarding beliefs about contraception, experiences with accessing reproductive healthcare, future plans, and specific barriers to accessing reproductive healthcare as an adolescent living in a family shelter. Teen seminars focus on pregnancy, sex, and STDs. The purpose of our study is to 1) describe the experience of unintended pregnancy, abortion, and contraceptive use; 2) identify barriers to reproductive healthcare access including contraception; and 3) describe preferences for reproductive healthcare access in homeless teens. This data will generate data for targeted changes in services.

 A survey of pregnant Rwandan women’s use of complementary medicine.

Volunteers sought for NYC Doula Project

The New York City Doula Project is seeking volunteers to work as doulas “across the spectrum of pregnancy.” Here is the text of their announcement:

What is a Doula?

The word doula is an ancient Greek term that translates to “caregiver.” A doula provides emotional support, pain management and relaxation techniques, and information to her clients as needed.

Birth – A Birth Doula will provide all of the above throughout a client””s labor and delivery, as well as the immediate postpartum period (about two hours after the baby has been born). The doula meets with clients prenatally to talk about birthing preferences, the creation of a birth plan, and to practice different positions and relaxation techniques for labor. Additionally, a birth doula provides a postpartum visit to review the client’s birth experience and refer them to any resources they may need. Birth doulas are on call for their clients for three weeks.

Abortion- An Abortion Doula will provide all of the above to clients who are choosing to terminate the pregnancy. The doula will stay with the client throughout her procedure, as well as part of the recovery period, and will remain in touch with the client as she desires thereafter.

About The Doula Project:

The Doula Project is a pro-choice New York City-based organization that was started in 2007 to provide free services to lower-income individuals across the spectrum of pregnancy. It was founded by pro-choice doulas and reproductive justice activists, two of whom currently serve as the Project Co-Coordinators. The Project is a volunteer led and run organization that trains and manages its own doula base. We currently have 3 programs that serve the greater NYC area:

1) To provide doula care to people facing abortion, miscarriage, and stillbirth (in partnership with a Manhattan Public Hospital and Planned Parenthood Brooklyn). You do not have to be a birth doula to serve as an abortion doula. We train our own volunteers on this component of care.

2) To provide doula care to people choosing adoption (in partnership with Spence Chapin Adoption Agency). Please be a trained birth doula to apply. We do not require a lot of experience, only a formal training with an established doula certifying program.

3) To provide doula care on a case by case basis to lower-income individuals who are not affiliated with either of our partner organizations. Please be a trained birth doula to apply. We do not require a lot of experience, only a formal training with an established doula certifying program.

We are recruiting doulas for all components of our mission, though priority is given to those who are interested in being both Birth and Abortion Doulas. While you are not required to serve as a doula for all components, you are expected to support the mission and values of the entire project and the work each individual doula engages in. You are also expected to attend all components of our training. We encourage you to apply for all components of our work!

Abortion Doulas:

We are looking for people interested in training as abortion doulas to work with clients in NYC clinics and hospitals. Doulas will be present and provide emotional support to clients before, during and after abortions. We are looking for people who can work at least 2 weekdays a month as well as complete 40 hours of training, provided by The Doula Project, in the summer of 2011. Trained birth doulas are particularly encouraged to apply, though we are excited to bring on reproductive health and justice activists who have no prior doula training.

Job description:

• Report to the assigned hospital/clinic each workday
• Meet with clients in the clinic/hospital before abortion and answer any questions/concerns, help fill out paperwork, and provide pre-abortion counseling
• Provide client with emotional support during abortion (includes 1st and 2nd trimester and laminaria placements). Please note: This means you will be expected to be in the operating room with the client as needed.
• Provide clients with your number to call you anytime to talk after abortion.
• Meet with clients anytime if desired after abortion

Commitment:

• Commit to two 5- 8-hour weekdays per month (Monday – Friday 9-5PM)
• Commit to meeting with the client outside of clinic setting after abortion, if desired
• Provide personal number to client as desired
• Attend monthly abortion doula meetings
• Attend 40 hours of training in the summer of 2011 (includes 25 hours classroom over the course of one week/15hours clinic over the course of three to four weekdays)
• At least one-year commitment to project
• When working in hospital/clinic settings, become hospital/clinic volunteer and go through volunteer training

Adoption and Birth Doulas:

We are looking for previously trained birth doulas to work with birth moms who may be choosing adoption and with clients who cannot otherwise afford doula care. We partner with Spence-Chapin to provide doula support to their clients and support low-income clients who sign up through our website, free of charge. You do not have to have a lot of experience as a doula and will work as part of a two-person doula team. A back-up doula will always be provided for every birth.

Job description:

• Coordinate with your partner doula to ensure that at least one of you will be available at all times during your five-week on-call period.
• Meet with clients, for a minimum of two prenatal visits as desired by the client and as time allows
• Assist client in the creation of a birth plan
• Answer questions and provide resources per client””s request
• Remain in constant contact with client before and during the on-call period, and after, as client desires
• Provide continuous support at the time of the client””s labor and delivery
• Meet with clients for a minimum of one postpartum visit after the birth, as the client desires

Commitments:

• Participate in adoption training with Spence-Chapin (part of larger training we provide)
• Commit to one (1) birth every 6 weeks
• Commit to a minimum of two prenatal visits and two postpartum visits
• Commit to the five-week on-call period with your partner doula. At least one of you must be available at all times during the on-call period.
• Provide personal cell phone or pager number to clients
• At least one-year commitment to the project
• Adhere to Doula Project and Spence-Chapin policies and protocols.

Doula training will take place the weekend of June 18th and 19th (9am-5pm). In order to offset some of the cost of the training workshops, we will be asking each applicant accepted to the Doula Project to pay $25 on the first day of training. We recognize that this may be difficult for some of us; if this is the case for you, please just drop us a line. We will waive the workshop fee, no questions asked.

How to apply:

People with experience in doula work, reproductive health, rights and justice work, abortion counseling or health services are encouraged to apply. People under 30, people of color, queer and trans people and Spanish speakers are strongly desired. People with flexible/free weekdays are ideal. While we are willing to negotiate for the right person, priority will be given to those who can commit to at least two weekdays a month.

Abortion doulas and births doulas who take births through our website will serve in an unpaid volunteer capacity. Adoption doulas will receive small stipends through the adoption agency. We realize this is a big time commitment and will do everything possible to take care of our doulas and work within your schedules.*

You can get our application at www.doulaproject.org.

If you are interested in working with us, we are accepting applications now through April 25th. Please send completed applications at apply@doulaproject.org

Incomplete: How Medical Schools are Failing Doctors and How Doctors are Failing Women

2010 AECOM Student-Run Social Medicine Course

January 6th, 2010 will mark the beginning of the Albert Einstein College of Medicine student-run Social Medicine Course. This course is a unique opportunity for the Einstein students to cover “essentials of medical practice not taught in medical school.”  This year’s list of speakers amply illustrates the connections between clinical practice and social activism.

The opening speaker will be Dr. Joia Mukerjee of Partners in Health who will discuss “Social  Forces in Medicine.”  This event will take place at 5:30 PM at the Riklis Auditorium and will be followed by a reception. Subsequent sessions will take place each Wednesday (with one exception) at the 5th floor Forchheimer Auditorium at 5;30PM. Dinner is provided.  All events in this series will be listed at the top of our blog roll.

At last year’s course several local readers of the Social Medicine Portal dropped by.  Please feel free to come, but write to Ms. Karp (see below) so that we can inform security.

The list of speakers and topics is as follows:
Jan 13 ∙ History of Social Medicine ∙ Matt Anderson, MD, MS.
Jan 20 ∙ LGBT Health and Community Organizing ∙ John-Paul Sanchez, MD, MPH
Jan 27 ∙ Race and Health in the Bronx ∙ Robert Fullilove, EdD
Feb 3 ∙ Harm Reduction in the Bronx: Dealing with the Hepatitis Epidemic among IV Drug Users ∙ Donald Davis
Feb 10 ∙ Motivational Interviewing and Nutrition in the Bronx ∙Yasmin Mossavar-Rahmani, PhD, RD, CDN
Feb 17 ∙ The Impact of Hep B on Pregnancy in the Asian American Community∙Tomoaki Kato, MD; Maya Gambarin-Gelwin, MD
Feb 24 ∙ Abortion Care in NYC∙Marji Gold, MD
Mar 3 ∙ Native American Health ∙ Donna Perry, MD *Price Center Auditorium
Mar 10 ∙ Separate and Unequal: Medical Apartheid ∙ Neil Calman, MD and Nisha Agarwal, JD
Mar 16* ∙ Liberation Medicine ∙Lanny Smith, MD, MPH, DTM&H  *Tuesday at 7:15pm*
Mar 17 ∙ Reentry: Old Fears, New Hopes ∙Meekaelle Joseph
Mar 24 ∙ Street Medicine ∙ Jim Withers, MD
Apr 7 ∙ The History and Practice of Community Psychiatry ∙Thomas Betzler, MD
Apr 14 ∙ Nyaya Health: A Case Study in Developing a Healthcare NGO∙ Ryan Schwarz and Bijay Acharya, MD
Apr 21 ∙ Refugee and Asylee care: Human Rights for Torture Survivors ∙ Nicole Sirotin, MD
Apr 28 ∙ Ayurvedic Medicine ∙Bhaswati Bhattacharya, MD, PhD
May 5 ∙ The War on Women: Criminalization of Reproduction in the United States ∙Robert Roose, MD

For any questions or kosher meal requests, please contact Jessica Karp at jkarp@einstein.yu.edu.

Posted by Matt Anderson, MD

Maternal Mortality, Equity and Allan Rosenfield, advocate for Women's Global Health and Human Rights

In late 2006 I saw Dean Allan Rosenfield for the last time, in his office of the Columbia University School of Public Health, where he had served as dean since 1986. Diagnosed with ALS, he was breathing with supplemental oxygen. His presence—always inspiring to me in its lucidity of what is necessary and possible in the struggle for health and social justice—now showed unmistakably a quality which I realize had been there since long before I met him in 1993: the determination to make every minute alive count positively toward the lives of others.

Maternal Mortality—A Neglected Tragedy: Where is the M in MCH?” he shouted in an article in 1985 The Lancet 2 (8446): 83–85, with Deborah Maine startling and shaming a public health world which had since 1980 been reducing primary care to ever more selective programs targeting children and ignoring others, including those who give children birth and all who rear them, young and old. Alas, the question still stings and will until a comprehensive health approach to all humans, including mothers, comes with health acknowledged, planned and effectively funded globally as a basic human right.

According to Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and The World Bank (http://www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf), the United States has an MMR (Maternal Mortality Rate, i.e. maternal deaths for 100,000 live births) of 11 (11.5 according to the CDC, while for African-American women it is cited as 29.6, see http://www.cdc.gov/od/oc/media/pressrel/r010511.htm), putting the USA at number 41 in the world (the best is Ireland with an MMR of 1). Sierra Leone has an MMR of 2,100, while several other countries in Sub-Saharan Africa have rates above 1000 (examples: Niger 1,800; Angola 1,400; Rwanda 1,300; Burundi 1,100; Malawi 1,100). In short the numbers are atrocious, the realty of pregnancy as a risk for death around the world (even in the USA) evident to anyone who has worked with pregnant women outside the industrialized world and to many who have worked with pregnant women within the USA. The fifth Millennium Development Goal, MDG, is to decrease Maternal Mortality “by 75% by 2015 (starting in 1990).” Alas, even that would leave a terribly high number of women dying preventable deaths. Currently, the lifetime risk of a woman dying in childbirth in Africa is 1:26, with Niger having a lifetime risk of 1:7. (Ireland’s lifetime risk is 1:48,000, a demonstration of what is possible.

It was his characteristic kindness that led Dean Rosenfield to accept my invitation to write the Introduction to Women’s Global Health and Human Rights, WGHHR (http://www.jbpub.com/catalog/9780763756314/), “Global Women’s Health and Human Rights,” together with Caroline Min and Joshua Bardfield. He had always been kind to me, serving at the birth of Doctors for Global Health, DGH on the Advisory Council, and eventually becoming a major donor to DGH through a mechanism that doubled his donations. I have since learned that his kindness as author and co-author spurred many a renowned health professional to publish her or his first paper—one being the Director of the Residency Programs in Primary Care and Social Medicine at Montefiore Medical Center, Dr. Hillary Kunins, co-founder of Medical Students for Choice, MSFC (http://medicalstudentsforchoice.org/), with “Abortion: A Legal and Public Health Perspective” (Annual Review of Public Health, 1991; 12: 361-82).

In a recent lecture (1 June 2009) for the Global Health Course of Montefiore Medical Center and Albert Einstein College of Medicine, Dr. Joia Mukherjee, Medical Director of Partners in Health (www.pih.org) and an author in WGHHR, made the point that any woman who has had a C-section, received antibiotics or gotten blood during delivery or post-partum would likely have died in most parts of the world and consequently should, along with her partner and anyone else who loves her, be fighting for and demanding access to adequate birth-care for women worldwide as a matter of personal to global solidarity

I am certain that Dean Rosenfield would have affirmed that logic of sharing good fortune. His actions, literally to his dying day, embodied and encouraged such solidarity. In addition to his work promoting women’s health, he dedicated much of his professional life to fighting the AIDS epidemic. His vision extended to health equity for all, health in its largest sense of wellbeing including education—especially for women. “People should have access to the same care in a poor country as in a rich country,” he stated in an interview with Charlie Rose in 2006 (http://www.charlierose.com/view/interview/325), also saying: “I think it’s obscene that in our country 15-18% of people are uninsured.”

Dean Rosenfield enhanced Women’s Global Health and Human Rights, the book and the concept, by direct action throughout his professional life. Alas, the health and human rights reality worldwide for women—and thus for all persons–remains abysmal. In terms of global Maternal Mortality we have Ireland’s example as a target–why not? Equity, not just diminished misery, should be our goal—for women, for every human, anywhere in the world. That goal is Dean Rosenfield’s legacy. Making that goal happen is his challenge for all of us, now.

Dr. Siobhan M. Dolan:“Direct to Consumer Genetic Testing: Are We Ready?”

Tuesday February 24th’s Social Medicine Rounds brought Dr. Siobhan Dolan to the Residency Program. Dr. Dolan is double-boarded (Obstetrics and Gynecology, Clinical Genetics) as well as having an MPH. She currently works in the Montefiore/AECOM clinical genetics testing service.

Dr. Dolan began by discussing the difference between traditional clinical genetics and the current field of genomics.  Genetics was originally concerned with single gene defects, usually associated with rare diseases. These mutations were usually of high penetrance (i.e. having the genetic mutation usually caused you to be sick) and caused conditions (like Down’s syndrome) in which environment played a relatively minor role.  Genomics, on the other hand, typically involves multiple (often interacting) genetic variants  that are associated with common conditions. These genetic variants often confer only a modestly increased risk of the disease.  The diseases in question are ones (such as lung cancer) in which the  environment plays a large role.  (For more on this distinction, see the article by Alan E. Guttmacher, M.D., and Francis S. Collins, M.D., Ph.D. in the November 7, 2002 issue of the New England Journal of Medicine entitled: Genomic Medicine: A Primer).

Genomic medicine promised to make genetics relevant to everyone.  In a 1994 article in the American Journal of Human Genetics, Dr. Eric Hoffman predicted “[t]he day of the personal DNA profile provided at birth, complete with calculated risks of various cancers, heart disease, and many other conditions could be actuality by the time that current first-year medical students begin to practice medicine.”   While this prediction proved premature, a few years later genomics entered the mass market with internet-based direct-to-consumer advertising.

Dr. Dolan expressed considerable skepticism regarding the value of many genetic tests.  In order to assess their clinical validity she recommended use of the ACCE criteria developed by the Foundation for Blood Research for the CDC.  These criteria evaluate:

• Analytic validity: Does the test actually measure the genetic variation it is supposed to measure? (“ability to accurately and reliably measure the genotype of interest. “)
• Clinical validity: Is the genetic variation actually predictive to the disorder of interest? (“ability to detect or predict the associated disorder (phenotype)”)
• Clinical utility: What are the risks and benefits of introducing the test into clinical practice?
• Ethical, Legal and Social Consequences of the Test

The ACCE criteria suggest 44 specific questions that should be answered in considering a given genetic test.

Several genetic tests have not lived up to their initial promise. For example, Roche’s AmpliChip CYP450 test was touted as a breakthrough that would allow individualized dosing, particularly of psychiatric medications.  But the clinical utility of the test has been questioned (The Medical Letter, 47(1215/1216), August 15/29, 2005).  In 2007 the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group writing in Genetics in Medicine concluded that: No evidence was available showing that the results of CYP450 testing influenced SSRI choice or dose and improved patient outcomes, or was useful in medical, personal, or public health decision-making.” [SSRI's are a common class of anti-depressant drugs].

Similar concerns have been raised about pharmacogenetic testing for warfarin.   Reviewing commercial tests for CYP450 polymorphisms associated with differences in warfarin metabolism, The Medical Letter concluded in May of 2008 that: “Currently available data are probably insufficient to recommend pharmacogenetic testing just yet for all patients taking warfarin, but these tests may be helpful, especially in selecting an initial dose and in some patients with unexpected therapeutic responses to the drug. Whether they improve clinical outcomes remains to be established.” (The Medical Letter, 50(1286), May 19, 2008)

Regardless of these cautions genomics has now entered the world of direct to consumer advertising and Dr. Dolan reviewed the major categories of this fascinating “brave new world”.  [Please note, we are not endorsing the use of any of these websites.]

1. Determining Paternity.  DNA Lab Centers features a smiling baby on the home page with the caption: “Does he really have your eyes?”   Results can be used to “provide Maternity, Paternity, Immigration, Grandparent and Sibling Testing/Verification.” The use of DNA for immigration cases is, apparently, a growing field.

2. Sites like Ancestry.com offer genetic testing which purport to allow one to investigate ancestry.

3. Dating and Social Networking: Sites like Gene Partner and Scientific Match claim to match people based on genetics.  Gene Partner bases its system on HLA matching and the site provides references to 11 scientific publications. Four of these were non-human studies and three of the studies are listed twice (ouch!).  Of the remaining four studies three relate to female preferences for different male odors and only one associates HLA types with romantic involvement, a study involving 48 couples.  Not a particularly strong evidence base.  Scientific Match seems also to use the HLA types, but the site is less explicit.

4. Sites looking for specific medical disorders: Sites like DNA Direct and 23 and me provide comprehensive genetic testing services include whole genome tests.  Again, the clinical utility of most of these tests has yet to be demonstrated.

It is a shame that the development of genomics in the United States is being left to the marketplace.  The British are rightly proud of their National Institute for Health and Clinical Excellence (NICE) which evaluates new drugs and devices prior to their adoption by the National Health Service.  NICE’s decisions has been controversial at times, but this is to be expected given the nature of the decisions it makes.   The new Federal stimulus bill sets aside $ 1.1 billion dollars for effectiveness research.  This is a welcome move and long overdue.

Concluding thoughts:

Maybe major histocompatibility genes truly explain romance. But in the market, let the buyer beware.

I prefer poetry and will close with the thoughts of Edmund Spenser:

Amoretti XXX: My Love is like to ice, and I to fire

My Love is like to ice, and I to fire:
How comes it then that this her cold so great
Is not dissolved through my so hot desire,
But harder grows the more I her entreat?
Or how comes it that my exceeding heat
Is not allayed by her heart-frozen cold,
But that I burn much more in boiling sweat,
And feel my flames augmented manifold?
What more miraculous thing may be told,
That fire, which all things melts, should harden ice,
And ice, which is congeal’d with senseless cold,
Should kindle fire by wonderful device?
Such is the power of love in gentle mind,
That it can alter all the course of kind.

Posted by: Matt Anderson, MD

Family Centered Maternity Care

Our colleague, Dr. Rebecca Williams, has set up a website exploring Family Centered Maternity Care (FCMC).  Family Centered Maternity Care, as she explains it, is “a philosophical approach to prenatal care and delivery providing care to the pregnant woman in the context of her family. FCMC is prenatal care that considers, includes, and fosters the development of families. Historically, practitioners have also promoted natural childbirth.” While the site is primarily towards the teaching and clinical needs of our Family Practice residents, Dr. Williams updates it on a regular basis, making it a valuable resource.

The movement for Family Centered Maternity Care is several decades old.  Interested readers may want to consult Celeste R. Phillips‘ book  Family-Centered Maternity Care some of which can be read on Google Books. Phillips, a pioneer in the field, defines FCMC as “a way of providing care for women and their families that integrates pregnancy, childbirth, postpartum, and infant care into the continuum of the family life cycle as normal, healthy life events.”  She developed the following 10 principles for FCMC:

Principle No.1: Childbirth is seen as wellness, not illness. Care is directed to maintaining labor, birth, postpartum, and newborn care as a normal life event involving dynamic emotional, social and physical change.

Principle No. 2: Prenatal care is personalized according to the individual psychosocial, educational, physical, spiritual and cultural needs of each woman and her family.

Principle No. 3: A comprehensive program of perinatal education prepares families for active participation throughoutthe evolving process of preconception, pregnancy, childbirth and parenting.

Principle No. 4: The hospital team helps the family make informed choices for their care during pregnancy, labor, birth, postpartum and newborn care, and strives to provide them with the experience they desire.

Principle No. 5: The father and/or other supportive persons of the mother’s choice are actively involved in the educational process, labor, birth, postpartum and newborn care.

Principle No. 6: Whenever the mother wishes, family and friends are encouraged to be present during the entire hospital stay including labor and birth.

Principle No. 7: Each woman’s labor and birth care are provided in the same location unless a Cesarean birth is necessary. When possible, postpartum and newborn care are also given in the same location and by the same caregivers.

Principle No. 8: Mothers are encouraged to keep their babies in their rooms at all times. Nursing care focuses on teaching and role modeling while providing safe, quality care for the mother and baby together.

Principle No. 9: When Mother-Baby care is implemented, the same person cares for the mother and baby couplet as a single-family unit, integrating the whole family into the care.

Principle No. 10: Parents have access to their high-risk newborns at all times and are included in the care of their infants to the extent possible given the newborn’s condition.

Dr. Phillips currently runs a healthcare consulting company, Phillips + Fenwick, which assists hospitals in implemented FCMC programs.  The company website – www.panf.com – has some resources on FCMC, such as a short reading list.  Of particular interest, is her 1999 article Family-Centered Maternity Care: Past, Present, Future which discusses the history and current of FCMC. Readers may also wish to consult the WHO’s document on Care in normal birth, although this document is now 12 years old.

posted by: Matt Anderson, MD

Reproductive and Sexual Health

The Department of Family and Social Medicine hosts a Reproductive Health Fellowship. For information on this fellowship please contact Dr. Marji Gold. This posting, originally published in March of 2005, was prepared by Dr. Louisa Hahn, one the (now former) fellows:

Sexual and reproductive health have been defined in different ways depending on the political and social climate of the times. In the last few decades, most social and international organizations have recognized the merging of health and human rights. This means in part that the state cannot violate people’s rights to sexual health. Governments must also assure that no other organization or person violates those rights and create the conditions in which people are able to fulfill the right to sexual health.

The right to sexual and reproductive health used to be viewed mainly in negative terms (freedom from disease and disfigurement) but is now also viewed in positive terms (freedom to enjoy pleasure and fulfillment). The US Surgeon General, Dr. Satcher, in 2001, sought to establish that “sexual health is not limited to the absence of disease or dysfunction, nor is its importance confined to the reproductive years.” The World Health Organization defines reproductive health as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.

The choice for women of whether or not to go through pregnancy and childbirth is an important reproductive right. Looking through the lens of social justice (PDF), we know that the women most harmed by lack of safe reproductive choices are those without financial means or social connections. Moreover, when women can make their own reproductive choices, it opens up opportunities to them for education and employment. To make these life choices, women must have full access to family planning methods and abortion for unplanned and unwanted pregnancies.

Abortion is a simple, safe medical procedure that saves lives when it is available. The risk of death associated with abortion performed by trained professionals is approximately 0.6 per 100,000 abortions, and the risk of major complications is less than 1 percent. Almost 90 percent of abortions are performed in the first trimester of pregnancy (within the first 12 weeks after the first day of the last menstrual period), and fewer than 2 percent of abortions are performed after 20 weeks. Currently in the United States, there are two safe and effective methods of first trimester abortion: medical abortion and suction abortion. Medical abortion uses pills called mifepristone or RU-486 and misoprostol that essentially induce a miscarriage. Suction abortion is performed with a plastic cannula and hand-held syringe or vacuum. For a description of these procedures and their differences, go to: The Access Project or Brandeis Medical Center.

Women can find themselves with an unwanted pregnancy for many reasons. For many, effective family planning is out of reach. At least 350 million couples worldwide do not have access to information about family planning and the full range of contraceptives options. The contraceptive methods that we have to offer are often not easy to use and sometimes fail even when used perfectly. Between 8 and 30 million pregnancies each year occur because of contraceptive failure. And unfortunately, sexual coercion or rape is common around the world. Between 20% and 50% of all women and girls report sexual abuse, rape or sexual coercion. Women also choose to have abortions due to a variety of social and economic reasons that include: being unmarried, abandoned by their partners, being too young, unstable partnerships, having too many children to support already, and living in poverty.

Of the estimated 45 million pregnancies worldwide that are terminated by abortion every year, about 19 million involve unsafe procedures performed by women themselves, by unskilled providers, or in settings with inadequate medical standards. Approximately 68,000 women die from complications resulting from unsafe abortion and even more suffer from infections, infertility, and long-term damage to their reproductive tract. Unsafe abortion deaths account for 13% of all maternal deaths globally and over 25% in some countries. Evidence from countries where women have full access to safe services shows that these abortion-related deaths and disability can be virtually eliminated with appropriate policies and programs.

But even where it is legal, safe abortion is not always available. In many developing countries, health workers, doctors and nurses do not have adequate training or equipment. Some refuse to refer or perform abortions because they do not understand the laws or because they personally do not support abortion. And when women have complications from an unsafe abortion, adequate medical support is often unavailable, and family planning is not discussed. As one of his first acts as president, George W. Bush re-imposed the global gag rule (or the “Mexico City Policy”) on January 22, 2001. This policy restricts foreign non-governmental organizations from using their own, non-U.S. funds to provide legal abortion services in order to receive U.S. family planning funds. It also prevents them from lobbying their own governments for abortion law reform, and prevents them from providing accurate medical counseling or referrals regarding abortion services.

In the United States, abortion has been a legal right of women since the court case of Roe vs. Wade in 1973. The conclusion held that a woman’s right to an abortion falls within the right to privacy protected by the Fourteenth Amendment. The decision gave women the right to abortion during her entire pregnancy and defined different levels of state interest for regulating abortion in the second and third trimesters. Since then, the number of deaths in the US per 100,000 abortion procedures declined five-fold between 1973 and 1991.

Significant barriers still face a large number of US women seeking this service, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, refusal clauses, anti-choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. Eighty-six percent of US counties have no abortion provider. There has been a steady decline in abortion providers over the past two decades. Only 12 percent of all Obstetrics-Gynecology residency programs require training in first trimester abortion and 91 percent of residents report having no experience with abortion procedures. Currently, almost half the pregnancies in the United States are unintended, and teen pregnancy rates are much higher than other developed countries, and even many developing countries. Women of reproductive age currently spend 68 percent more in out-of-pocket health care costs than men, primarily because of reproductive health-related costs.

The policies of the current administration have strengthened barriers to abortion both at home and abroad. Preserving women’s right to choose in the United States will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals. To eliminate these negative outcomes for women, health care workers and activists need to work to ensure universal access to family planning services, especially for young people and women at risk of sexual abuse, rape and violence. Our communities need to be educated about unsafe abortion, social disparities in reproductive health, and their consequences, and work to reform restrictive laws and policies that deny access to family planning, health and abortion-related services.

For more information about organizations that advocate for reproductive rights and choice, visit these websites:

United States:

• National Abortion Federation
• Planned Parenthood
• Physicians for Reproductive Choice and Health
• Association of Reproductive Health Professionals
• Center for Reproductive Rights
• Abortion Access Project
• National Organization for Women
• American Civil Liberties Union
• Women’s Reproductive Rights Assistance Project
• Feminist Majority Foundation

International:

• International Planned Parenthood Federation
• Marie Stopes International
• Ipas
• International Women’s Health Coalition
• Center for Reproductive Rights Worldwide

See also Martin Donohue’s article Increase in Obstacles to Abortion: The American Perspective in 2004, published in the Journal of the American Medical Women’s Association.

— By Louisa Hann, MD, Family Planning Fellow in Family Medicine