One of the things I found most interesting from our RAMs reading about health politics in Iran was the distribution of the reproductive health educational textbooks by the Family Planning Association of the IRI.  These books were aimed at those of reproductive age, meaning girls aged 10-19 and boys aged 15-19 according to Iranian law.  I found this to be particularly interesting given the recent and continuous discussion about sex education in the United States. When to start educating children about sex and reproductive health is a controversial topic in the U.S. How young is too young? In Iran they faced a similar problem. While they were open about reproductive education and were willing to teach children, the definition of what constituted a child left out young girls and boys who were partaking in sexual activities. Although the legal age of marriage for girls was 9 years and 14 years for boys, there was a large population of children marrying much younger; many marriages were only documented if the children were 16 and older. It was not stated if these educational textbooks were distributed to only this age range or to all children in the areas they were given out in. However, if children are marrying before the legal age of marriage, then they will also need education material geared towards them. The Iranian government worked to increase reproductive knowledge to those deemed the appropriate age, but what about those who may be sexually active within and outside of wedlock that are not in the target age ranges?

                Before taking this class, I was not aware of the extent to which midwives and traditional birth attendants  were involved in the healthcare sector. I wasn’t even aware of their role. I have interacted with them in hospitals and clinics but I was sure they did more than check blood pressure or height and weight and assist the doctor with a few things. I was also not aware that birthing centers existed and people could go there to have their children. I did a little research and I found that there are so many roles that midwives birthing attendants, doulas etcetera can play in lieu of a doctor and it is important for these options to remain available. Midwives are also prevalent in countries that have the best “maternal and infant outcomes” (Midwives Alliance of North America). I thought I was the only one who had no clue how involved midwives were.  While having a conversation with some friends about this class, I asked them their take on midwives and midwifery. A lot of them also were not aware the extent to which midwives were utilized. one of them brought up the fact that midwives provide a more personal care. In some of my other classes we have discussed bedside manner and how this plays a significant role in the outcome of the patient. Doctors see a lot of patients each day and as a result do not always have the ability to empathize with their patients. Patience, compassion and understanding are important, especially for pregnant women. I think it is important to continue to promote the training and the  use of midwives, TBAs and other specialists. It is also important to promote the other birthing options. There are probably several other people who are unaware.

http://mana.org/about-midwives/what-is-a-midwife

It is hard to determine how common obstetric violence is because, as we have learned throughout our study of global health, data reporting is not always reliable. Congruent to other forms of violence, victims are not likely to report obstetric violence, and if they do, it is not guaranteed that they will be heard. Additionally, obstetric violence takes many forms, and a patient may not be fully aware that obstetric violence occurred. If she is aware that an act against her autonomy occurred, she may not have the privilege or ability to speak out against it.

Last September, I read an article about traumatic birth titled “In traumatic childbirth, women say healthy baby isn’t the only thing that matters”. The article discussed how women are expected to be joyful about their births when their babies are born healthy and how their feelings about their experiences in birth are downplayed. It also brought a staggering statistic to light; according to the Prevention and Treatment of Traumatic Birth (PATTCh), approximately 30% of births are traumatic, resulting in feelings of helplessness, anxiety, fear, or isolation during labor. Further, one-third of those who describe their birth experience as traumatic will develop post-traumatic stress disorder, an intense, long-lasting psychological syndrome that often consists of anxiety attacks, distressing flashbacks or dreams, and depression. The article discussed the root cause of this staggering statistic to be obstetric violence, specifically in the form of lack of informed consent. The article led me to an organization called Improving Birth’s #breakthesilence campaign, which is a collection of experiences of victims of traumatic birth. As I looked through the submissions to the campaign, it was clear that those who had experienced traumatic birth felt ignored, antagonized, or physically or verbally abused by their caregivers. I’ve included the link the Facebook campaign below, where you can see pictures of people voicing their experiences.

I think the term obstetric violence is appropriate. I like that it includes “obstetric”, indicating that caregivers, likely clinical obstetrics staff, play a role in perpetrating violence against patients. I also like the use of the word “violence”, which carries a lot of weight. I think when analyzing this term it is important to recognize what it stands for beyond the two words. It is important to recognize that obstetric violence is a result of a systematic power structure in obstetric care.  The violence goes beyond physical harm and includes neglect, verbal abuse, refusal of resources, and failure to respect consent. Because many of us in this class are future caretakers or public health workers, we must be aware of the ways systematic violence plays out in a healthcare provider-patient power dynamic.

Sources:

Editorial: “In traumatic childbirth, women say healthy baby isn’t the only thing that matters” – http://www.stltoday.com/lifestyles/health-med-fit/health/trauma-from-childbirth-women-say-healthy-baby-isn-t-only/article_6efe50eb-89e8-517b-bb51-99e12fb06cc9.html

More information about Prevention and Treatment of Traumatic Birth – http://pattch.org

Improving Birth’s #breakthesilence campaign photos – https://www.facebook.com/media/set/?set=a.705655609507930.1073741854.255657527841076&type=3

Another reading on maternal and fetal outcomes as affected by partner violence in Latin America and the Caribbean opened my eyes up to the horrors and prevalence of this issue, which occurs in many nations around the world. According to the study done in Latin America, this issue is most highly associated with unplanned pregnancies. Also uncovered in the study was the overlapping of the issue with the disempowerment of women, which has been shown to increase prevalence of partner violence. Interestingly, whether a woman sought prenatal care was shown to decrease the prevalence of the issue, which may or may not be due to access and affordability of care. The study sought to define the issue in one region of the world, in order to effectively add intervention strategies to decrease the issue and its negative effect on fetal and maternal outcomes. Wanting to know more about the issue, I decided to look into the prevalence of this issue in the USA. As a citizen in this country, I believed there was a small magnitude of this problem. Upon investigation, however, I realized how prevalent the issue truly is. According to the CDC’s report in March of 2003, there are approximately 5.3 million victims of IPV each year. Out of this number 550,000 injuries require medical attention.  I would interested in learning if the results of this study were implemented in a way that greatly decreased the prevalence of this issue. In addition, I am now increasingly more aware of the dangers of IPV both in my own country and others.

Sources:

http://www.cdc.gov/violenceprevention/pdf/ipvbook-a.pdf

http://www.cdc.gov/violenceprevention/pub/ipv_cost.html

This week’s reading on reproductive health in Iran brought me some insight in the intersection of health and religion, which can be a difficult area for many. While blatantly ignoring religion and its importance in many regions and cultures creates problems, I was curious to learn more about how health professions tackle this issue. One source states that over 90% of the population in Iran practice Islam, and as such their religious beliefs and texts are believed to play a large role in their life practices, which include to some extent those of reproductive health. In working with religious officials, health professionals were able to create great change and increase in health in Iran. As such, the nation won the 1998 UN Population Award for successfully reducing population growth with the implementation of the Population and Family Planning Program. I decided to look into whether this award was still being given out, and found that in 2014 it went to Italy, for their development in the category of obstetric care. However, the nation did not accept the redefinition of the family, only including one man and one women joining together, and was not willing to accept and implement sex education for all adolescents and young adults who are not currently getting married. I found the cultural aspects of population growth and its solutions in this nation interesting. For example, at first Iran was not willing to combat its increasing population as a problem, as in previous years a large population was the sign of a strong nation and no problem was detected. Also, a major player in reducing population growth by implementing family planning measures such as contraception was when Islamic clergy members deemed it acceptable. This was notable because they were able to use religious texts and historical evidence to back the acceptance of contraception as a method of family planning. Therefore, I am very intrigued to learn more about the overlapping of religious ideals and modern health practices, as often they can clash but with careful interactions can be successfully done to better the health outcomes of a nation.

Sources:

http://www.religionfacts.com/islam/places/iran.htm

http://www.unfpa.org/public/cache/offonce/home/about/popaward/pid/4641;jsessionid=673ED81B740B0085D3F865E02D581D05.jahia02

RAMS chapter 9 is an interesting discussion of the interaction between policies and local realities, specifically regarding population control in the Islamic Republic of Iran.  It discusses the discord between forces of conservatism rooted in tradition, and policy makers who want to improve life conditions through modernisation. Caught up in the midst of these two sides was the young people themselves in Iran, who reproductive health was the issue at hand.  The question is raised as to why the same authorities who initially agreed to implement a family planning programme, then subtly changed their minds half-way through making restrictions for policy makers.  This case is an example of a clash between the agenda of the religious political elite and that of modernising bureaucrats.  It was seen that top-down policies can provoke reactions which may be passive and indirect, slowly hampering policies.  I think that this case is by no means isolated.  Many, many countries in the world today are facing conflicts between their traditional values and ways of life, and new ‘Western’ or modern ways of thinking and living.  This can extend to all areas of life, including reproductive health.  I think it is essential that policies are not made in a vacuum or simply by the leaders in charge of a nation.  It is important the voices of the people are heard, and on-the-ground research is carried out to see where people are at and what compromises might be found that would achieve a modern goal yet also allow traditions to remain.  But what does this look like in practice and in other related issues such as FGM?

I have noticed that sex education has been a common topic that has arose in class whether we are talking about birth and politics, abortion, or public policy and services. I came across this article written by a journalist, Jemimah Steinfield, who talks about sex education, or the lack there of, in China. Sex discussion and education was strictly forbidden in China until around the time of the cultural revolution when the Ministry of Education allowed some sex education, but mainly to teach children about the differences between men and women. They were to be taught mainly about the anatomical differences only. Even in recent years in China, schools are discussing these same topics and including  nothing about contraception, sexually transmitted diseases, or sexual abuse. The problem is that since no one learns about it, no one grows up to be able to teach about it and the vicious cycle continues. Unfortunately, even though there is no education, this doesn’t mean that people are not engaging in sexual activity. The article states that a survey done in 2012 “showed that 70% of Chinese have engaged in pre-marital sex, up from just 15% of those surveyed in 1989” (Steinfield). So its clear that the population is sexually active and without proper protection and education of risk comes the potential unwanted infections and pregnancies. “Sexually transmitted infections (STIs) are on the ascent and China has particularly high rates of syphilis, while sexual transmission now accounts for 81.7% of all new HIV infections” (Steinfield). As well, the article reports that in 2013, 13 million annual abortions were performed with one patient who reportedly had already had 13 abortions throughout her lifetime.

I found this article especially interesting based on the facts. You’d think figures like this would be making a more profound impact on a population. I found it particularly interesting in comparison to discussions we had had in class and different sexual educations experiences each student has had. The article ends stating that there has been more focus on sexual education in China in the past year, but mostly focused on protection against sexual abuse as the cases of child abuse have drastically rise throughout the past decade.

Steinfield, J. (2014, June). Do Chinese Classrooms Need to Talk About Sex? CNN. Retrieved from CNN website http://www.cnn.com/2014/06/19/world/asia/china-sex-education/index.html?iref=allsearch

I’m not sure how it came up but a few of my friends and I were talking about something and one told us the story of how she was born and I thought it fitting to share with you all.

She writes,”I was born in the beautiful city of Khartoum, Sudan in Soba hospital at 4AM, upside down and with no electricity. There was only one doctor around and he was sleeping. They woke him a little while before it was time for my mother to push. He had to start the generator and others lit candles as there was no electricity.”

She’s almost 21 years old and born in 1994. I compared her birth to what I assume mine was like in Staten Island, New York. I had electricity and my mother received an epidural, but we both made it and so did our mothers. I was amazed by her story not in an, “Oh my goodness how did you make it” kind of way, but in a “the pure power of nature kind of way”.

After multiple presentations on abortion, I became interested in learning more about abortion laws in Georgia. According to the Guttmacher Institute, there are several restrictions on abortion in Georgia that are in effect as of November 1, 2014. These restrictions include:

• A woman must receive state-directed counseling that includes information designed to discourage her from having an abortion and then wait 24 hours before the procedure is provided.
• Health plans that will be offered in the state’s health exchange under the Affordable Care Act can only cover abortion when the woman’s life is endangered or her health is severely compromised.
• Abortion is covered in insurance policies for public employees only in cases of life endangerment.
• The parent of a minor must be notified before an abortion is provided.
• Public funding is available for abortion only in cases of life endangerment, rape or incest.

These restrictions are severely muddled especially the phrase, “counseling that includes information to discourage her from having an abortion.” I am interested in the exact verbiage of this counseling and if the counseling takes into consideration the situation in which the woman became pregnant, e.g. rape. I am also interested why rape is not a reason for abortion under health plans offered by the Affordable Care Act.

Abortions in Georgia as well as in the United States, have been steadily declining since 1991. In 1991, there were 24 legal abortions per 1,000 women aged 15-24. In 2011, there were 16.8 legal abortions per 1,000 women aged 15-24. During this time, there were 28 abortion providers in Georgia, with 19 of those being clinics. Also, 96% of counties in Georgia had no abortion clinic and 58% of Georgia women lived in these counties.

For those of you from other states, I am interested in knowing more about the abortion laws in your states. Please chime in.

References

“State Facts About Abortion: Georgia.” Guttmacher Institute. Web. 13 Nov. 2014. <http://www.guttmacher.org/pubs/sfaa/georgia.html>.