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keever's journal
13 July 2009 @ 12:00 am
12 July 2009 @ 11:33 pm
Stories: 1) Facebook Ads A Big, Fat Wrinkle For Some Users 2) Farming On Facebook And Other Web Trends
13 July 2009 @ 12:00 am
Rising unemployment has cut across all groups, but economists said they were uncertain why the racial difference was so much starker in New York City.
13 July 2009 @ 12:00 pm
My mom turns sixty-nine this fall, and she recently asked if I could turn my communications expertise to a more familial project: updating her personal profile on a popular dating site. As she gears up to meet men for Coke dates in the mall, I geared up for how to have "the talk" that I never got from her. How do I cover the basics, like condom use and STI prevention that I wished I'd heard from her as a teen-and how do I cover topics like vaginal dryness, communication, and pleasure (topics I would have liked, but maybe not from mom)? I wish to be as bold as masturbation guru Betty Dodson, who, the story goes, once asked her mother, How are your orgasms?
From birth to death, we are
all sexual beings. We have a hard enough time acknowledging this when
it comes to children, but when it comes to aging adults, the silence
is deafening. And deadly: 60 percent of unmarried women ages fifty-eight
to ninety-three report that they didn't use a condom the last time they
had sex, and the CDC reports that 15 percent of new HIV cases are among
people over fifty. The number of adults sixty-five and older will reach
seventy-two million by 2030-and, according to current statistics,
about 46 percent of them won't be married; 7 to 10 percent will identify
as LGBT. That's a lot of people. More importantly, that's a lot
of people having sex: Stacey Lindau's groundbreaking research on sexuality
and aging showed that 53 percent of those aged sixty-five to seventy-four
are sexually active. My mom is going to have a lot of Coke dates.
Scary statistics aside, sexuality
has a lot more to offer elders than risk: healthy sexuality contributes
to quality of life, and aging adults can see real health benefits from
sexual enjoyment - whether that happens alone or with a partner. Regular
sex is believed to stimulate the immune system, lower stress, and improve
sleep. According to a Scottish study, folks having regular sex look
seven to twelve years younger than their peers. And it's a lot cheaper
(with less recovery time) than plastic surgery or Botox.
Aging adults also have special needs when it comes to sexuality. Erection concerns and vaginal dryness are common among elders, and a penetration-focused sexual discourse leaves many potential avenues for sexual fulfillment unexplored. Assisted living facilities are not always supportive of sexual expression amongst residents. Dementia, as well as cognitive and physical impairment, can pose real barriers to issues such as consent, healthy decision-making, and sexual desire. Stigma and shame from family, caregivers and doctors, who get "grossed out" by the idea of older adults having sex, leave the concerns of aging adults invisible and untended. Separation and death of a partner leave boomer-plus adults willing - but ill-prepared - to enter a new world of dating and relationships. LGBT elders face special concerns of isolation and oppression as they grow older. For all these reasons, aging adults are left with few resources, little information, and a paucity of supportive healthcare.
As part of our mission to promote lifelong healthy sexuality, the National Sexuality Resource Center has made sexuality and aging a priority issue: We are currently conducting an assessment of the sexuality needs of aging adults in assisted living facilities, leading presentations on sexuality and aging at national conferences including AARP, and working to include the special concerns of LGBT elders in sexuality dialogues.
Over the next weeks the National
Sexuality Resource Center will co-produce a series on sexuality and
aging, in partnership with RH Reality Check. In our efforts to promote
positive, healthy sexuality - not just disease prevention or risk avoidance - you
will find articles that discuss sexuality in all its complexity. Relationship
coach Katherine
Forsythe covers
singles, dating, and relationship issues; Clitoral
Truth author Rebecca
Chalker offers sexual health tips. Lara Riscol will take a look at the
problems posed by Alzheimer's and sexuality, and sexuality pioneer
Peggy Brick will introduce her groundbreaking work on sex education
for elders. To finish things off, Meika Loe takes a look at how Viagra
puts extra pressure on men's sexual performance.
13 July 2009 @ 12:00 pm
Birth is a big part of Melissa Cheyney’s life – especially right now. As a new mother, having given birth in May of this year to a beautiful girl, as well as a practicing midwife and homebirth advocate, Cheyney has devoted much of her life to bringing new life into this world. In fact, the weekend after we conducted this email interview, Cheyney attended her first birth as a midwife since her daughter’s arrival. But it is her work as a professor of medical anthropology and reproductive biology at Oregon State University that recently caught my eye.
In this capacity, Cheyney and her research partner, doctoral student Courtney Evans, explored the effect of midwife-attended homebirths on elevated rates of prematurity and low birth weight in babies born in a particular county in Oregon between 1998- 2003. And though their research disproved the notion that homebirth yields poorer birth outcomes (in fact, just the opposite was true - all of the homebirths studied resulted in successful health outcomes for the newborns), they did uncover something else in the process. When results of their study hit both the hospital provider and homebirth/midwifery communities, “antagonism was…considerably amplified” [this quote is from a pdf of an article published in a journal – I’ll need to get the link] between the two; leading Cheyney and Evans to examine the ways in which the hospital/ homebirth provider relationship could be improved.
It is no surprise to Direct Entry Midwives (also known as DEMs) or homebirth advocates that many in the hospital-based birth practitioner community believe homebirth to be unsafe and inferior to in-hospital birth. Both ACOG and the AMA have issued statements proclaiming as much. But Cheyney and Evans discovered a “deep mistrust” between the two communities that led Cheyney to want to do something to ameliorate some of the hostility in the relationship. Cheyney worked with her own back-up physician, obstetrician Dr. Paul Qualtere-Burcher, to create a pioneering protocol guiding the midwife/doctor relationship with the goal of creating optimal experiences for both providers and patients alike. The document, “Proposal for Increased Collaboration between Direct-Entry Midwives (DEMs) and Obstetricans for Homebirth Clients,” is grounded in a series of foundational ideas: homebirth is a viable alternative to a hospital birth particularly when facilitated by a skilled DEM with a physician back-up; research supports the idea that homebirth is a safe option for low risk pregnant women; obstetricians and hospital care represent a “safety net,” as Cheyney and Qualtere-Burcher propose, that can contribute to healthier birth outcomes for both mother and baby if complications arise during a homebirth.
Professor Cheney graciously agreed to answer some of my questions about her groundbreaking protocol, her research into the hostility between both home and hospital-based birth practitioners and why it’s critical to women’s health that these issues are addressed.
1) Do you know if there are there similar protocols being developed in other parts of the country between DEMs and physicians (in those states where midwifery is legal!)? If not, would you like to see this replicated?
To my knowledge, this is really the first of its kind, at least one that is being formally implemented and studied. However, in areas where midwifery is legal, these kinds of arrangements exist more informally between individual midwives and physicians that have developed relationships usually over years of working together. I would love to see these protocols replicated and modified to meet the specific needs and goals of the given area. We know that homebirth is safest when it is planned, a trained midwife is present and medical back up is available if needed. It’s really that third criterion that needs streamlining and strengthening in our country.
2) Oregon seems to have progressive rules and regulations regarding DEMs - unlicensed midwives are able to practice. Has this been supported by physicians? Has there been resistance, active or otherwise, by OB/GYNs to Oregon's policy?
Most OB/GYNs in the state of Oregon are unaware of the distinction between unlicensed and licensed midwives. Many refer to us all as “lay midwives” – a term that most DEMs find insulting because it suggests very little or no education. Voluntary licensure is thus, rarely an issue for obstetricians. Place of delivery is much more contentious. Many obstetricians are opposed to homebirth regardless of the practitioner type. However, in my capacity as the state legislative liaison for the Oregon Midwifery Council this year, I did find a few legislators that are concerned about voluntary licensure and they have called for a study session this summer to explore the feasibility of mandatory licensure. I will have a lot to say about that. In addition, a small group of labor and delivery nurses at Oregon Health Sciences University recently addressed the health licensing agency’s board of direct-entry midwifery which I serve on, requesting that the protocols that govern the practice of LDEMs be tightened to exclude breech, twins and VBACs. They are also advocating for mandatory licensure. With these exceptions, I would say that the vast majority of practitioners remain unaware of voluntary licensure status and just oppose homebirth in general.
3) What has your experience as a practicing midwife been like as you've developed relationships with physicians? Have you experienced the "deep mistrust?" In other words, were you surprised at your findings that there was antagonism, distrust and conflict between doctors and DEMs?
The vast majority of my personal experiences have been positive, largely because I was fortunate early on to establish a relationship with several local obstetricians through my work as a researcher. For the most part, I feel like I have been treated with respect and as a colleague whenever I have transferred the care of one of my clients. However, about a year and a half ago, I did experience a negative transport that was the result of deep mistrust. I had been caring for a low-risk woman who had a straightforward labor, but experienced a severe complication at birth known as a shoulder dystocia. This is where the head is born, and the shoulders become impacted behind the pubic bone. I responded quickly and was able to extract the baby and perform a successful resuscitation. However, this baby suffered a broken arm, which is the second most common complication from a shoulder dystocia. When we transported to the hospital, the pediatrician in the ER threatened me with child abuse and arrest. His attack on me and subsequently the parents who felt judged during their care made a bad situation even worse. The parents still recount the most difficult part of that day being the interaction with this pediatrician. Later when mom and baby were moved to the postpartum ward, we received nothing but support and compassion from the labor and delivery staff who had recently lost a baby to a shoulder dystocia. Thankfully, this baby made a full recovery and ultimately solidified my relationship with this hospital. My quick action at his birth helped to overturn the misconception that direct-entry midwives are untrained. So while most of my experiences have been extraordinarily positive, my one negative transport experience stands out in my memory and made me well aware of what I might find with this study.
4) In your proposal, crafted by you and your back-up physician, you write that "Obstetricians acknowledge that there are twenty-nine studies that now clearly indicate homebirth as a safe and viable option for low-risk women." But with the ACOG and AMA both stating, essentially, that the safest setting for birth is in a hospital, do you find it difficult to "convince" OBs that homebirth is a “safe and viable” option?
In the community where the proposal is now being implemented and studied, half of the practices in the county were represented at the proposal meeting. All of the obstetricians present were willing to concede that homebirth for low-risk women was a viable option. The bone of contention lies with how to define low-risk. As addressed in Cheyney and Everson 2009 (see attached), midwives tend to have a broader definition of risk that includes psychosocial, emotional and social risk, where physicians are more likely to see risk as simply clinical risk. As a result, a woman may choose a homebirth even when at higher risk for a complication because of a past traumatic experience in the hospital. This can be hard for obstetricians to understand during a transport when they are filled with fear about having to attend a higher risk woman that they do not know well. Dialogue around whether a higher risk woman should still have the right to choose a homebirth tends to be very difficult and heated. One bad experience may also bias a doctor against all home deliveries.
In addition, in my experience, there is often a divide between theory and practice for obstetricians. In theory, they know that their professional organization opposes homebirth. In practice, they are called in with some regularity to assist in homebirth transports. They are also well aware that homebirth, water birth and births with doulas are on the rise. This means that physicians cannot simply ignore homebirthers and continue to vocalize their mistrust of Direct-entry midwives. We are forced, out of necessity, to interact. As physicians come to know the midwives in their community, a grudging respect has the potential to emerge, making it difficult to remain adamantly opposed in some cases.
5) How can providers who are already open and amenable to working with midwives help foster a more supportive culture among colleagues, as you suggest in the proposal?
One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff. Conversely, hospital births where a woman feels too many interventions were used can be constructed as abusive or traumatizing to the woman after numerous retellings. These stories effectively maintain the home/hospital divide. Physicians and midwives can work to overturn that divide by refusing to participate in “telephone,” by being committed to accuracy and professionalism; sharing only the stories they have first-hand knowledge of. Midwives and physicians who have positive experiences working with one another also need to speak up regarding those positive interactions.
6) What are some of the stereotypes or judgments held by midwives about OBs/physicians?
Let me begin with this caveat, midwives often hold fewer misconceptions about obstetricians because we actually get to see hospital deliveries when we transport. We have first-hand knowledge of the model of care that we often critique. However, very few physicians ever attend a home delivery, and yet feel very comfortable critiquing that option. That said, because midwives often hear stories of hospital births from clients who are unhappy with the experience and are now seeking an alternative, many maintain an outdated view of hospital deliveries as inhumane and impersonal. The vast majority of women, about 70% in the United States, leave the hospital feeling it was a positive experience. Only about 30% leave with regrets or frustrations about their experience and treatment. We as midwives disproportionately serve that 30%. This can prevent us from seeing the work that obstetricians are doing to humanize and individualize birth in the hospital. Finally, while obstetricians can envision a world without midwives, midwives cannot envision a world without obstetricians. Thus, midwives have a larger incentive to work towards positive relationships with back-up physicians.
7) What if a pregnant woman faced with a VBAC or twins does not want to consult with an OB? Is this protocol suggested or mandated?
It is suggested. Oregon law prevents any clinician from forcing a woman to engage in any intervention or procedure against her will. Midwives can strongly encourage it, and because they have a close relationship with their clients, their suggestion is likely to be followed. Midwives who have agreed to participate in this experimental protocol will have to document in their charts that the physician consult protocol was encouraged.
8) What happens/occurs now with a transport where the midwife and physician have not previously spoken? Do they get a chance to confer? Is the midwife even allowed in the room or does that depend on the doctor?
Before the protocol, non-emergent transports were highly variable and dependent upon the physician on call for undoctored patient. During emergency transports, there is little time for consultation and that will remain the same with this protocol. However, since the vast majority of transports are non-emergent (more than 95%), there is at least the theoretical potential for midwife and physician to meet in the hall and to discuss the case before entering the room together to propose an agreed upon course of action to the mother. The extent to which this happens in practice varies considerably by facility and by physician. The point of our protocol was to help standardize interactions and to help physicians and midwives to create a culture of interaction and collaboration built on mutual trust and respect. See also our discussion of this in Cheyney and Everson 2009.
9) You write in the proposal: “Opportunities are made available for physicians to observe homebirths and for DEMs to observe low-risk hospital deliveries.” This is a fantastic idea and I'm surprised that this doesn't already happen. Are there any classes or opportunities available in medical school, for those who chose to pursue an OB/GYN track, to learn about midwifery and for midwives in training to observe hospital births?
Currently, there are no opportunities for obstetricians to observe home deliveries during their medical training in the U.S. However, this is an option for physicians in the Netherlands; in fact, it is a requirement for all Dutch obstetricians who wish to attend low-risk deliveries. Obstetricians often have exposure to hospital deliveries with Certified Nurse Midwives, however. Because many Direct-entry midwives have been doulas at some point in their lives and because they accompany women who transfer care due to a complication, there is a general understanding among midwives about what happens in a “low-risk” hospital delivery. Further, most transports are for non-emergent cases with low-risk women, allowing them to see many low-risk deliveries in the hospital. The reverse simply cannot be claimed for physician knowledge of homebirth practice.
10) On a personal note, you had a baby recently. As a practicing midwife, a researcher of this issue and a mother, do you have any advice for women who are pregnant or looking to have a baby soon and who plan on working with a DEM, about how best to ensure the most comprehensive care for themselves during childbirth? Should they ask their midwife if she has a back-up physician with whom she has an amiable relationship?
Very few DEMs in the United States have formal relationships with particular back-up physicians. As such, if women asks this question, the answer will very likely be no. It may be more helpful to ask what transports are typically like. Because the vast majority of midwives who go into labor intending to deliver at home do so successfully, I would never advise a woman to make a decision about whether a homebirth is right for her based simply on what a transport may be like. It is most important that the woman’s philosophy of care matches that of her midwives. There is a spectrum of homebirth midwifery, from very hands off to more medicalized. Some will do breech births and twins, some will not. Some have antagonistic feelings toward the medical model; others see the relationship as collaborative. It is important for women to take the time to interview the homebirth providers in their area, and when possible, to choose a midwife with a similar perspective.
In this capacity, Cheyney and her research partner, doctoral student Courtney Evans, explored the effect of midwife-attended homebirths on elevated rates of prematurity and low birth weight in babies born in a particular county in Oregon between 1998- 2003. And though their research disproved the notion that homebirth yields poorer birth outcomes (in fact, just the opposite was true - all of the homebirths studied resulted in successful health outcomes for the newborns), they did uncover something else in the process. When results of their study hit both the hospital provider and homebirth/midwifery communities, “antagonism was…considerably amplified” [this quote is from a pdf of an article published in a journal – I’ll need to get the link] between the two; leading Cheyney and Evans to examine the ways in which the hospital/ homebirth provider relationship could be improved.
It is no surprise to Direct Entry Midwives (also known as DEMs) or homebirth advocates that many in the hospital-based birth practitioner community believe homebirth to be unsafe and inferior to in-hospital birth. Both ACOG and the AMA have issued statements proclaiming as much. But Cheyney and Evans discovered a “deep mistrust” between the two communities that led Cheyney to want to do something to ameliorate some of the hostility in the relationship. Cheyney worked with her own back-up physician, obstetrician Dr. Paul Qualtere-Burcher, to create a pioneering protocol guiding the midwife/doctor relationship with the goal of creating optimal experiences for both providers and patients alike. The document, “Proposal for Increased Collaboration between Direct-Entry Midwives (DEMs) and Obstetricans for Homebirth Clients,” is grounded in a series of foundational ideas: homebirth is a viable alternative to a hospital birth particularly when facilitated by a skilled DEM with a physician back-up; research supports the idea that homebirth is a safe option for low risk pregnant women; obstetricians and hospital care represent a “safety net,” as Cheyney and Qualtere-Burcher propose, that can contribute to healthier birth outcomes for both mother and baby if complications arise during a homebirth.
Professor Cheney graciously agreed to answer some of my questions about her groundbreaking protocol, her research into the hostility between both home and hospital-based birth practitioners and why it’s critical to women’s health that these issues are addressed.
1) Do you know if there are there similar protocols being developed in other parts of the country between DEMs and physicians (in those states where midwifery is legal!)? If not, would you like to see this replicated?
To my knowledge, this is really the first of its kind, at least one that is being formally implemented and studied. However, in areas where midwifery is legal, these kinds of arrangements exist more informally between individual midwives and physicians that have developed relationships usually over years of working together. I would love to see these protocols replicated and modified to meet the specific needs and goals of the given area. We know that homebirth is safest when it is planned, a trained midwife is present and medical back up is available if needed. It’s really that third criterion that needs streamlining and strengthening in our country.
2) Oregon seems to have progressive rules and regulations regarding DEMs - unlicensed midwives are able to practice. Has this been supported by physicians? Has there been resistance, active or otherwise, by OB/GYNs to Oregon's policy?
Most OB/GYNs in the state of Oregon are unaware of the distinction between unlicensed and licensed midwives. Many refer to us all as “lay midwives” – a term that most DEMs find insulting because it suggests very little or no education. Voluntary licensure is thus, rarely an issue for obstetricians. Place of delivery is much more contentious. Many obstetricians are opposed to homebirth regardless of the practitioner type. However, in my capacity as the state legislative liaison for the Oregon Midwifery Council this year, I did find a few legislators that are concerned about voluntary licensure and they have called for a study session this summer to explore the feasibility of mandatory licensure. I will have a lot to say about that. In addition, a small group of labor and delivery nurses at Oregon Health Sciences University recently addressed the health licensing agency’s board of direct-entry midwifery which I serve on, requesting that the protocols that govern the practice of LDEMs be tightened to exclude breech, twins and VBACs. They are also advocating for mandatory licensure. With these exceptions, I would say that the vast majority of practitioners remain unaware of voluntary licensure status and just oppose homebirth in general.
3) What has your experience as a practicing midwife been like as you've developed relationships with physicians? Have you experienced the "deep mistrust?" In other words, were you surprised at your findings that there was antagonism, distrust and conflict between doctors and DEMs?
The vast majority of my personal experiences have been positive, largely because I was fortunate early on to establish a relationship with several local obstetricians through my work as a researcher. For the most part, I feel like I have been treated with respect and as a colleague whenever I have transferred the care of one of my clients. However, about a year and a half ago, I did experience a negative transport that was the result of deep mistrust. I had been caring for a low-risk woman who had a straightforward labor, but experienced a severe complication at birth known as a shoulder dystocia. This is where the head is born, and the shoulders become impacted behind the pubic bone. I responded quickly and was able to extract the baby and perform a successful resuscitation. However, this baby suffered a broken arm, which is the second most common complication from a shoulder dystocia. When we transported to the hospital, the pediatrician in the ER threatened me with child abuse and arrest. His attack on me and subsequently the parents who felt judged during their care made a bad situation even worse. The parents still recount the most difficult part of that day being the interaction with this pediatrician. Later when mom and baby were moved to the postpartum ward, we received nothing but support and compassion from the labor and delivery staff who had recently lost a baby to a shoulder dystocia. Thankfully, this baby made a full recovery and ultimately solidified my relationship with this hospital. My quick action at his birth helped to overturn the misconception that direct-entry midwives are untrained. So while most of my experiences have been extraordinarily positive, my one negative transport experience stands out in my memory and made me well aware of what I might find with this study.
4) In your proposal, crafted by you and your back-up physician, you write that "Obstetricians acknowledge that there are twenty-nine studies that now clearly indicate homebirth as a safe and viable option for low-risk women." But with the ACOG and AMA both stating, essentially, that the safest setting for birth is in a hospital, do you find it difficult to "convince" OBs that homebirth is a “safe and viable” option?
In the community where the proposal is now being implemented and studied, half of the practices in the county were represented at the proposal meeting. All of the obstetricians present were willing to concede that homebirth for low-risk women was a viable option. The bone of contention lies with how to define low-risk. As addressed in Cheyney and Everson 2009 (see attached), midwives tend to have a broader definition of risk that includes psychosocial, emotional and social risk, where physicians are more likely to see risk as simply clinical risk. As a result, a woman may choose a homebirth even when at higher risk for a complication because of a past traumatic experience in the hospital. This can be hard for obstetricians to understand during a transport when they are filled with fear about having to attend a higher risk woman that they do not know well. Dialogue around whether a higher risk woman should still have the right to choose a homebirth tends to be very difficult and heated. One bad experience may also bias a doctor against all home deliveries.
In addition, in my experience, there is often a divide between theory and practice for obstetricians. In theory, they know that their professional organization opposes homebirth. In practice, they are called in with some regularity to assist in homebirth transports. They are also well aware that homebirth, water birth and births with doulas are on the rise. This means that physicians cannot simply ignore homebirthers and continue to vocalize their mistrust of Direct-entry midwives. We are forced, out of necessity, to interact. As physicians come to know the midwives in their community, a grudging respect has the potential to emerge, making it difficult to remain adamantly opposed in some cases.
5) How can providers who are already open and amenable to working with midwives help foster a more supportive culture among colleagues, as you suggest in the proposal?
One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff. Conversely, hospital births where a woman feels too many interventions were used can be constructed as abusive or traumatizing to the woman after numerous retellings. These stories effectively maintain the home/hospital divide. Physicians and midwives can work to overturn that divide by refusing to participate in “telephone,” by being committed to accuracy and professionalism; sharing only the stories they have first-hand knowledge of. Midwives and physicians who have positive experiences working with one another also need to speak up regarding those positive interactions.
6) What are some of the stereotypes or judgments held by midwives about OBs/physicians?
Let me begin with this caveat, midwives often hold fewer misconceptions about obstetricians because we actually get to see hospital deliveries when we transport. We have first-hand knowledge of the model of care that we often critique. However, very few physicians ever attend a home delivery, and yet feel very comfortable critiquing that option. That said, because midwives often hear stories of hospital births from clients who are unhappy with the experience and are now seeking an alternative, many maintain an outdated view of hospital deliveries as inhumane and impersonal. The vast majority of women, about 70% in the United States, leave the hospital feeling it was a positive experience. Only about 30% leave with regrets or frustrations about their experience and treatment. We as midwives disproportionately serve that 30%. This can prevent us from seeing the work that obstetricians are doing to humanize and individualize birth in the hospital. Finally, while obstetricians can envision a world without midwives, midwives cannot envision a world without obstetricians. Thus, midwives have a larger incentive to work towards positive relationships with back-up physicians.
7) What if a pregnant woman faced with a VBAC or twins does not want to consult with an OB? Is this protocol suggested or mandated?
It is suggested. Oregon law prevents any clinician from forcing a woman to engage in any intervention or procedure against her will. Midwives can strongly encourage it, and because they have a close relationship with their clients, their suggestion is likely to be followed. Midwives who have agreed to participate in this experimental protocol will have to document in their charts that the physician consult protocol was encouraged.
8) What happens/occurs now with a transport where the midwife and physician have not previously spoken? Do they get a chance to confer? Is the midwife even allowed in the room or does that depend on the doctor?
Before the protocol, non-emergent transports were highly variable and dependent upon the physician on call for undoctored patient. During emergency transports, there is little time for consultation and that will remain the same with this protocol. However, since the vast majority of transports are non-emergent (more than 95%), there is at least the theoretical potential for midwife and physician to meet in the hall and to discuss the case before entering the room together to propose an agreed upon course of action to the mother. The extent to which this happens in practice varies considerably by facility and by physician. The point of our protocol was to help standardize interactions and to help physicians and midwives to create a culture of interaction and collaboration built on mutual trust and respect. See also our discussion of this in Cheyney and Everson 2009.
9) You write in the proposal: “Opportunities are made available for physicians to observe homebirths and for DEMs to observe low-risk hospital deliveries.” This is a fantastic idea and I'm surprised that this doesn't already happen. Are there any classes or opportunities available in medical school, for those who chose to pursue an OB/GYN track, to learn about midwifery and for midwives in training to observe hospital births?
Currently, there are no opportunities for obstetricians to observe home deliveries during their medical training in the U.S. However, this is an option for physicians in the Netherlands; in fact, it is a requirement for all Dutch obstetricians who wish to attend low-risk deliveries. Obstetricians often have exposure to hospital deliveries with Certified Nurse Midwives, however. Because many Direct-entry midwives have been doulas at some point in their lives and because they accompany women who transfer care due to a complication, there is a general understanding among midwives about what happens in a “low-risk” hospital delivery. Further, most transports are for non-emergent cases with low-risk women, allowing them to see many low-risk deliveries in the hospital. The reverse simply cannot be claimed for physician knowledge of homebirth practice.
10) On a personal note, you had a baby recently. As a practicing midwife, a researcher of this issue and a mother, do you have any advice for women who are pregnant or looking to have a baby soon and who plan on working with a DEM, about how best to ensure the most comprehensive care for themselves during childbirth? Should they ask their midwife if she has a back-up physician with whom she has an amiable relationship?
Very few DEMs in the United States have formal relationships with particular back-up physicians. As such, if women asks this question, the answer will very likely be no. It may be more helpful to ask what transports are typically like. Because the vast majority of midwives who go into labor intending to deliver at home do so successfully, I would never advise a woman to make a decision about whether a homebirth is right for her based simply on what a transport may be like. It is most important that the woman’s philosophy of care matches that of her midwives. There is a spectrum of homebirth midwifery, from very hands off to more medicalized. Some will do breech births and twins, some will not. Some have antagonistic feelings toward the medical model; others see the relationship as collaborative. It is important for women to take the time to interview the homebirth providers in their area, and when possible, to choose a midwife with a similar perspective.
13 July 2009 @ 12:00 pm
Sonia Sotomayor's confirmation hearings begin today, and Republican senators reportedly "intend to focus on what they see as Judge Sotomayor's willingness to bring a personal agenda to the court, especially when it comes to issues of race." At issue is Sotomayor's work as a board member with the Puerto Rican Legal Defense Fund, and her decision in Ricci v. DeStefano. Sotomayor sat on the board of PRLDEF, and was not a litigator for them; somehow, though, she's being held responsible for their litigation strategy -- which isn't even that radical to begin with. In Ricci, Sotomayor's Second Circuit Court of Appeals panel affirmed a District Court's ruling that a Connecticut fire department did not violate the law when it decided to scrap exam results and promoted no one in an effort to make promotions more racially balanced.
I don't doubt that Republicans will harp on the race issue during the confirmation hearings -- as much as they love to accuse liberals of "playing the race card," they are the true masters of assigning an insidious agenda to anyone who isn't white and dares discuss race (or, heaven forbid, evaluates laws against discrimination). Sotomayor's color apparently makes her "biased" towards parties who share similar, less-than-privileged backgrounds, while the white skin worn by most of the sitting Supreme Court justices is assumed to play no role, and certainly not to bias them towards, say, white firefighters who feel like they were victims of affirmative action.
In a sane political system, Sotomayor's opinion in Ricci and even the Supreme Court's departure from it would be a non-issue. Affirming a lower court's ruling is about the most un-activist thing a judge can do, and the district court decision in Ricci was affirmed unanimously by the Second Circuit panel. Sotomayor's panel initially didn't even issue an opinion; when one finally was written on request of another judge, it was eight sentences long. Her role in Ricci was hardly the Angry Latina Woman of Limbaugh lore. The United States Supreme Court overturned the Second Circuit's decision, but by a narrow margin -- and Justice Ruth Bader Ginsberg felt so strongly about the Court's decision that she read her dissent from the bench.
In other words, it was a tough call -- one that divided the highest court in the country.
There is certainly good reason for the divisiveness. The Ricci decision struck a blow to disparate impact theory, making it easier to maintain laws and employment practices that are racially unbiased on their face but that in practice result in discriminatory outcomes. Sotomayor's position -- not that the fire department had to scrap the test results, but that they were legally permitted to -- was hardly revolutionary or far-left. One more left-leaning moderate judge on the Supreme Court and that position would have been affirmed.
The Supreme Court justices who evaluated Ricci are not raceless; most of them are white. And yet no one suggests that perhaps their whiteness influences their views on racial inequality, or that they aren't unbiased simply by virtue of belonging to the American cultural majority. Sotomayor, though, is branded a "racist" because she voted to uphold a lower court decision based on well-established legal theory.
Luckily, it's only a few conservative blowhards who are pulling the racist card. Republicans will undoubtedly bring up Sotomayor's views on affirmative action and race, but no one expects dramatics at the confirmation hearings. Despite right-wing whining about her "temperament" and the predictable problems with her not being a white male, it would be a surprise if the hearings did not go smoothly. The American Bar Association gave her their highest rating, and she is by all reputable accounts a highly-qualified, intelligent and moderate jurist. And with a ranking Republican member of the Senate Judiciary Committee having his own race issues, one would hope that the GOP would tread lightly with the racism accusations.
Of course, a lot can happen in a few days, and with all the focus on Ricci and race, there's been surprisingly little effort made to push Sotomayor to publicly state her position on Roe and reproductive rights. There has been even less talk about Sotomayor's views on gay rights, an underdeveloped legal area that is almost certain to make its way up to the Court in the next decade. And from the left, scant attention has been paid to Sotomayor's extreme deference to law enforcement agents, even when they encroach on citizens' privacy rights. So who knows -- maybe if the GOP lets go of its race fixation, a bomb will drop and we'll all find out that Sotomayor would vote to extend the rights guaranteed by Roe, or that she thinks there's no legitimate reason why a marriage between Adam and Eve is more valid than one between Adam and Steve (hey, here's hoping).
But with an experienced, pedigreed and thoroughly moderate judge
like Sotomayor, and with Democrats outnumbering Republicans on the
Judiciary Committee, I wouldn't hold my breath. More likely than not,
these will be the most boring hearings yet. And that is probably best
for all involved -- especially since it will open the door for Obama to
nominate a more progressive legal theorist in the future. Those will
be some fireworks worth watching.
13 July 2009 @ 03:29 am
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Links in this episode:
Domestic violence during a recession
Domestic violence during a recession 2
Domestic violence during a recession 3
Domestic violence during a recession 4
On this episode of Reality Cast, I'll be interviewing Candace Walsh about her new anthology exploring the positive side of divorce. Also, I'll look at the intersection of the recession and domestic violence, and ask some more questions about the questionable new blog Sex, Really.
A small but important victory looks like it's about to be won.
- hiv ban *
The HIV travel and immigration ban has broken up families and separated friends for two decades now, but the HHS has started the process of lifting the ban. It's been a long time coming.
***********
Stories about the intersection of economic tough times and the issues we cover at RH Reality Check keep coming up. I've been interested to note that the Public News Service has devoted a lot of its resources to tracking the problems of domestic violence in economic tough times.
- dv 1*
There's a number of important things about a recession that exacerbate the problem of domestic violence. The most obvious connection, of course, is the way that stress in general shortens the tempers of abusers, making them more likely to lash out more often. I'd add that many abusers actually cast around looking for excuses to abuse and intimidate, excuses that will allow their victims to say that the abuser couldn't help himself. In this case, being stressed out by finances can create a situation where an abuser beats his partner, and during the period afterwards, when he's apologizing and making excuses, he says that the financial circumstances were the cause. This will give some victims a reason to forgive the abuse, or at least be guilt-tripped into forgiving it.
Representative Loretta Sanchez spoke with Women's eNews a few months ago about this problem, and why it means that funding for domestic violence programs needs to stay in place.
- dv 2*
As Public News Service has discovered, though, the problem is way more complicated than just simply stating that stress makes the problem of domestic violence worse. Economic hard times actually give abusers many tools they need to accomplish the main mission of abuse, which is to control their victims, break their will, and keep them from escaping.
- dv 3*
Listening to these reports, what I found interesting was how much domestic violence can really be understood as something like a hostage situation. People think of it as hitting, mostly, and while that's a big part of it, to really understand domestic violence, you have to realize that it's part of a larger pattern of intimidation and control. It's sickening, but it's clear from the interviews with advocates that Public News Service did around the country that abusers can be extremely creative in finding ways to use economic strategies to trap their victims in the relationship.
- dv 4 *
Even in flush times, abusive strategies like forbidding your partner from working and racking up debt that they'll be stuck with if they try to leave are awful, but now that we're in dire economic straits, these strategies are likely even more effective. The odds are never good for a woman with holes in her resume and a pile of debt, if she's trying to get a job and a measure of economic independence that allows her to leave an abusive husband, but now there's even fewer jobs out there for these women to take. To make it worse, the economic stimulus package that was supposed to create all these jobs hasn't done near the job it was supposed to, and so I don't see how women in this situation can even come close to getting the help they need.
One thing that I got out of this coverage was that financial control is the sort of thing that people should look out for, if they want to help women trapped in abusive relationships. You may not be able to see him hit her or scream degrading abuse at her, but you might be clued into a woman's situation if she seems to have financial problems that stem back to her husband's unwillingness to allow her a measure of financial independence. For people who are in a position to help women out in abusive relationships, it's definitely something to look for as a red flag.
**********
insert interview
**********
It may seem a little soon to come back to the new sex blog run by prude and scold Laura Sessions Stepp called Sex, Really, but there are just so many mysteries to uncover and so much silliness to mock. Sex Really is funded by the National Campaign to Prevent Teen Pregnancy, which opens up a whole host of questions. First of all, since it's the National Campaign to Prevent Teen Pregnancy, then why do they have a blog that appears to be aimed squarely at women in their early 20s? I'm not saying women in their early 20s will pay attention, because reading this website is like getting sex advice from someone who only does it missionary style in the dark twice a year, but that's the intended audience.
But assuming that it's good to prevent unintended pregnancy in women in their 20s, which it is, I have to ask, why then does Sessions Stepp worry more about who you're sleeping with and when rather than whether or not you're protecting yourself? You're just as likely to get pregnant if you sleep with a guy on the first date or the 15th if you're not using condoms. And on the 2nd episode, we get to hear that women are sleeping with the wrong guys, because apparently Sessions Stepp thinks the main operating principle is that whatever young women are doing, it's wrong.
- nice guys 1 *
Really? They're going with the hoariest of stereotypes, that women are so stupid or masochistic that we'll pick a guy who beats us over someone who buys us flowers every time? Never mind that most abusers are actually the nicest of nice guys up front, coming on heavy with the charm and favors. No, what's stupidest about this is the reference to "Forgetting Sarah Marshall". I actually saw that movie, and it was crystal clear that the main character was NOT a nice guy, and that Sarah was smart to dump him, because he was neglectful and self-absorbed. But because he's kind of douchey, suddenly he's a nice guy?
The problem with the myth that women only like bad boys is that there's category confusion. It's true that confident men who make their intentions clear to women do better than guys who lurk around, afraid to speak up and only pretending to be your friend. But confidence doesn't automatically make someone bad and being shy doesn't make you nice. In fact, it's distinctly un-nice to just pretend to be someone's friend in order to get her to sleep with you. It's passive aggressive and mean.
But Sessions Stepp has scientific proof!
- nice guys 2 *
Except that's not what the article said at all. There was no reason to think that such men are more attractive to women, or that women are just so stupid and hateful. Tatiana at Jezebel pointed out that narcissistic young men in college claimed to get laid more. That's it. They may exaggerate their conquests, or they may sleep with more women because racking up points is important to them. But that doesn't mean they get the girl. And if so-called Nice Guys are angry that they have to settle for stable relationships with actual girlfriends, then they aren't so nice, are they?
But Sessions Stepp has a testimony from a young woman who found that a guy she was attracted to initially turned out to be not such a great guy!
- nice guys 3 *
And then she dumped him because he was a bad boy who didn't have a job. So much for the idea that women will always stick by the bad boy.
The problem here is selection bias. Sessions Stepp is ignoring that shy men can be bad boyfriends that neglect, cheat, or even hit their girlfriends. Sessions Stepp is also ignoring all the men out there with swagger who are respectful and gracious to their girlfriends. If it doesn't confirm the theory, it's ignored.
And what about the so-called nice guys who fall for girls that are obviously bad news? Nice guys are defined by the fact that they moon after women who don't want them, who tease them, and who often have personally chaotic lives. Why don't we scold nice guys and tell them to date nice girls who are quietly hiding in the shadows themselves? I guess Sessions Stepp thinks men are entitled to like who they want, but women are obligated to put aside what we want and dole out our bodies as rewards to men who prove that they're supposedly nice by being passive aggressive and whiny.
***********
And now for the Wisdom of Wingnuts, the oh not Sarah Palin edition. As in, I can't believe that Sarah Palin of all people was the target of this wingnuttery from Rick Sanchez at Fox News.
- sanchez *
As in, he actually suggested that Sarah Palin resigned because she's pregnant. I wasn't aware that they cloistered their pregnant women in Alaska. They are different up there! Just kidding. Just another example of how out of touch the male-dominated conservative punditry really is, that they don't realize that pregnant women are perfectly capable of doing their jobs, because after all, you aren't incubating the fetus in your brain.
12 July 2009 @ 08:21 pm
A&E is working on a reality project with the Jackson family which could gain newfound viewer interest in the wake of the King of Pop's death.
13 July 2009 @ 02:29 am
Blond or brunette? Cold and calculating, or proper and polite? Walking dead or, uh…walking dead? Watching True Blood's Eric and Bill verbally spar in a Dallas hotel bar tonight got us thinking—which one of these guys is a hotter vampire?...
13 July 2009 @ 03:15 am
by Roger Ebert
The climactic scene in "Harry Potter and the Half-Blood Prince" takes place in one of those underground caverns with a lake and an ominous gondola as the means of transportation, popularized by "The Phantom of the Opera." At first I thought -- no gondola! But then, one appeared, dripping and hulking. In another movie I might have grinned, but you know what? By that point, I actually cared.
The climactic scene in "Harry Potter and the Half-Blood Prince" takes place in one of those underground caverns with a lake and an ominous gondola as the means of transportation, popularized by "The Phantom of the Opera." At first I thought -- no gondola! But then, one appeared, dripping and hulking. In another movie I might have grinned, but you know what? By that point, I actually cared.
12 July 2009 @ 12:00 pm
12 July 2009 @ 10:48 pm
Look, art is not a democracy.
In fact, all stories start alone. And I say this as someone who writes collaboratively a lot. But all stories start alone. One voice, and then another and another - -whether these be the writers or the chracters of both. And then the story grows. But all stories start as an impulse that needs expression more than the silence and the dark.
When we play in fandom, we too are adding to the story. But stories are not a democracy, rather they are trees as well as shards and fragments. The idea that the fans should have a say in the creation of an original story someone or some team is creating sincerely appalls me. Because art is not a democracy and stories demand their space from the dark.
You don't have to like the stories that come forth. Don't have to play with them. Should be a critic and can completely toss out any canon you want. But those are your stories speaking out, and they don't have to be and shouldn't be anyone else's.
In fencing I learned all sorts of things, like that idea that everyone dies alone and everyone fights alone and everyone lives alone. It sounds bleak at first, but it's not. It's power. It's fact. It's simplicity. I learned the simplest thing is the hardest thing is the best thing. I learned that stories come to us alone.
I'm not saying you have to have liked the many turns CoE took, hell you can loathe it. I really do not care. But never, ever say that people don't have a right to tell their stories and never ever seek or threaten to silence those stories.
I am sad and I'm appalled and because I MAKE STUFF TOO, I do find this personally problematic.
If you haven't seen James Moran's most recent blog post, you should: http://jamesmoran.blogspot.com/2009/0
12 July 2009 @ 10:00 pm
Gay guy: Hey look, the Union Square sign is broken. It says "Squarf." "Squarf" sounds like a verb.
Female friend: I got squarfed until I bled last night.
--Union Square
Overheard by: David
12 July 2009 @ 10:30 pm
Quick thoughts on the second episode of "Hung" coming up just as soon as I give you my list of do's and don't's... "I'm a normal guy. I do normal things. Why don't you market me that way?" -RayHaving spent the pilot showing us why Ray's life is pathetic enough that he'd consider a career as a hooker, episode two of "Hung" spends more time on the pimp half of the equation, exploring Tanya's own sad existence as a failed poet and unfulfilled temp. By the end, it's very clear why she might think being a "happiness consultant" is her best option right now -- and that, while she and Ray have as steep a learning curve at their new career as Walter White did as a drug lord, she's not as ill-equipped as you might think. Hooking up with Lenore the personal shopper is actually a damned clever idea, especially given the kind of guy Ray wants to sell himself as.
"What's normal?" -Tanya
While Thomas Jane is the main reason I'm watching, Jane Adams is a whole lot of fun in this episode, particularly in the moment where we see Tanya so excited by the possibilities of her plan that she literally skips through the chain restaurant's parking lot.
Overall, "'Great Sausage'" is quite a bit funnier than the pilot, which I know some people dismissed as being too dark and depressing. The addition of Rebecca Creskoff as the epically hateful Lenore is a strong step in a more comic direction, as we see both Ray and Tanya struggle mightily with how to deal with this forceful, nasty but not uncharismatic piece of work.
The half-hour length (which will be standard from here on out) also suits the show better, I think, than the 45 minutes or so of the pilot. (Feel free to make all the "Hung" length jokes you want, folks; I've been telling them for a few weeks now.) There are still some bumps ahead -- even with her minimal appearances so far, Anne Heche/Jess is really annoying -- but I was glad I watched this one back-to-back with the pilot, as it gave me a much better sense of what "Hung" could be like.
What did everybody else think?
12 July 2009 @ 10:30 pm
So apparently Matt Long is gonna be on my TV again next season! The show is called "The Deep End" and it also stars Tina Majorino, whom I've already decided to ship him with cause that's how I roll. (See?) But they will probably pair him with Rachelle Lefevre, the spunky redhead, cause that's how the network rolls. Anyway, the show is about first-year lawyers at a prestigious law firm. You know what that means? Wacky hijinks! Norbert Leo Butz is also on the show, as is Billy Zane, LOL.
There's a preview for it on ABC.com: Hi Matt Long and your cute little face. (Also on YouTube for my international friends) And here's a clip from the first episode which has a cute enough Matt/Tina moment to give me hope! :)
Try not to cancel this one, ABC!
(The preview also includes exciting appearances by Tom Amandes and Meredith Monroe, if you care to know that.)
There's a preview for it on ABC.com: Hi Matt Long and your cute little face. (Also on YouTube for my international friends) And here's a clip from the first episode which has a cute enough Matt/Tina moment to give me hope! :)
Try not to cancel this one, ABC!
(The preview also includes exciting appearances by Tom Amandes and Meredith Monroe, if you care to know that.)
13 July 2009 @ 02:12 am
Seen from the Promenade, the topsail schooner Clipper City, under auxiliary power, passes Pier 3 on her way back to her berth at Pier 17, South Street Seaport.
13 July 2009 @ 01:37 am
A series about vampires appears to be pulling the channel out of a dry spell that began when several hit shows like “The Sopranos” ended.
12 July 2009 @ 05:46 pm
Only a few days left until "Harry Potter and the Half-Blood Prince" hits theaters at midnight Wednesday (one minute after 11:59 p.m. Tuesday, people!). Many may be dusting off their Ravenclaw scarves and watching movie marathons to get hyped up, but the specter of the swine flu could have made the film's launch a much more somber event. Emma Watson and Rupert Grint had filmed their kissing scene for "Deathly Hallows" prior to the announcement, but neither seems particularly shaken up by the incident when discussing it in this video. Yeah, they say that now ...
-- Keeping the spirit alive until the last moments, Hero Complex's Geoff Boucher will be having a chat with "Potter" producer David Heyman at the Apple Store (1248 Third Street Promenade) in Santa Monica on Monday night at 7. If you stop by, say "Hi!"
-- A few weeks later, more Potter fun can be had even after the film's release -- in the magical realm of San Diego at Comic-Con International. There are a couple of panels of note to spotlight, and both seem to basically ask: What's next for Harry Potter fans?
Thursday (July 23) at 3:30 p.m. is the Evolution of Fantasy panel in Room 3. The group will talk about the next "big thing" since Harry Potter and Twilight, etc., are over in book form. Panelists Jacqueline Carey (Naamah's Kiss), Lynn Flewelling (Shadows Return), Patrick Rothfuss (The Name Of The Wind), Thomas Sniegoski (The Fallen), Greg Van Eekhout (Norse Code), and Cindy Pon (Silver Phoenix: Beyond the Kingdom of Xia) answer questions posed by moderator Lev Grossman (The Magicians).
Then Sunday (July 26) at 2 p.m. is the Muggles, Wizards, Tentpoles, and Fans in the World of "Harry Potter" panel in Room 32AB. Panel members Leslie Combemale (ArtInsights Gallery, official/exclusive HP art supplier), Henry Jenkins (USC, author of Convergence Culture), Melissa Anelli (webmaster, The Leaky Cauldron, author of Harry: A History), Gwendolyn Grace (president emeritus, HP Educational Fanon), Lev Grossman (Time magazine book reviewer, author of The Magicians), and Heidi Tandy (webmaster, Fiction Alley) will get into the latest Harry Potter issues. The session will be moderated by Potter Headmaster (their words, not mine!) Eric Bowling.
-- Jevon Phillips
Jessica Cave spills about smooching with Rupert Grint
Rupert Grint gets swine flu -- will he miss premiere?
VOTE: Who deserves Oscar: "Up," "Trek" or "Potter"?
Dan Radcliffe on the art of acting
Emma Watson talks about her e-mail pal, J.K. Rowling
Getting to know the real-life Weasley boys
12 July 2009 @ 08:56 pm
Scorenotes has a brand new interview with composer Nicholas Hooper on this score for Harry Potter and the Half-Blood Prince. Of interest are new comments on a discarded piece for choir set in Latin, writing the romantic themes for scenes such as the Harry/Ginny Kiss, writing for the Inferi in the Cave scene and much more. To listen click here (SPOILER caution). The soundtrack for Harry Potter ...
12 July 2009 @ 08:55 pm
A new interview featuring actor Rupert Grint (Ron Weasley) in The Observer is now online, featuring a new photo of the young actor which can be seen right here. In this interview, Mr. Grint chiefly discusses his love of music, particularly the punk genre which he likes due to the "madness behind it. The craziness, the passion. And the whole anarchist thing is quite cool." Expressing his knowl...
12 July 2009 @ 07:55 pm
You may have asked yourself, "How the hell would I ever find Misha Collins if he were in a whole group of people dressed as Santa Claus? HOW?"
Look for the guy wearing a tree skirt, of course.
Ah, Misha. You are one of a kind, always.
Look for the guy wearing a tree skirt, of course.
Ah, Misha. You are one of a kind, always.
12 July 2009 @ 05:00 pm
Plz to open door. Not that I sure I wants to go out, I wants to stand in open doorway and thinks about whether I wants to go out. It’s a kitteh thing. You wouldn’t understand.
grass iz awlwayz greener on teh udder side.
Picture by: dunno source. Caption by: Puddy_tat via Advanced Lol Builder
