Thursday, July 2, 2015

New Ricki Lake & Abby Epstein Documentary on Birth Control

Ricki Lake and Abby Epstein, the duo who brought us the ever popular Business of Being Born, are back together. They are planning a new documentary called Sweetening the Pill (based on a book of the same name) which aims to open our eyes the way that BoBB did, but this time, about birth control.

BoBB questioned the "one size fits all" and over-medicalized approach to childbirth, showing women that there are more options out there for birth. Sweetening the Pill hopes to do exactly the same thing, questioning the ubiquity of hormonal contraceptives (including the pill and hormonal IUDs, rings, implants).

They are probably assuming that the same audience who cheered at their questioning of the assumption that hospital birth or cesareans are right for everyone would also cheer at their questioning of the assumption that hormonal birth control is right for everyone.

I find the concept of this film fascinating from a medical anthropology perspective. Reproductive anthropologists examine phenomena like menstruation, menopause, and birth control from a cross-cultural and biological perspective, often finding that ideas we hold true are not always universal.

If you look at a the history of medicine, you find that men's bodies were considered the ideal, while women's bodies were thought to be defective machines. Men's bodies were the basis for a normal, healthy functioning body, without the confusing aspects of menstruation, pregnancy, and menopause. Female bodies were seen as problems that needed to be solved.

Controlling our bodies' menstrual cycles allows the female body to be more like a man's, as we can control our "out-of-whack" hormones, keep from getting pregnant at any unknown time, and even cease bleeding. It created a freedom for women who were somewhat enslaved by their bodies making decisions for them, consequences that kept some from living a life they wanted or working outside of the home.

These days, the white Western body is seen as the norm, while women of color or women from other nations are to us what women used to be to men. Hormonal birth control was developed based on what would be appropriate for the European/American body, not for the Asian, African, or Latina body. Standard hormone dosages, or any hormones at all, may not be right in all bodies, similar to how not everyone's body can process lactose.

Many women find they have side effects from taking The Pill that they do not like, like feeling sick or uncomfortable, and often stop taking the pill. There has been some research on biological side effects, and we know that the pill does increase your risk of blood clots. Unfortunately, so does being pregnant! Other serious issues are rare, and it is up to women to make the right choice for themselves. Many think that choosing when to be pregnant (or never being pregnant) is the right choice for them, so taking the pill is worth the small medical risks.

There is research that has found that hormonal birth control can affect sexual desire. We know that it affects hormones, and studies have found that it might affect who we find attractive. Women might wonder "Would I be different if I wasn't on this birth control?" It is a valid question to ask.

Sweetening the Pill doesn't say that hormonal birth control isn't great, they just wonder why its the only one that is usually recommended to women when they talk to their doctors about birth control. Are there other options? What's right for me? Maybe a lot of women don't even know there are non-hormonal birth control options, other than condoms. Maybe their doctors don't even tell them the side effects.

I think that this is a valid perspective. I think that women deserve to know that there are non-hormonal options, such as the diaphragm and a non-hormonal copper IUD (Paragard).  Other examples include cervical caps, spermicide and sponges, the pull-out method (withdrawal), and natural family planning (also called fertility awareness).

The main method that the film seems to focus in on is Fertility Awareness (Natural Family Planning). They argue that though we felt empowered by The Pill, being aware of your own body's processes is even more empowering. You don't need a medication or "unnatural" hormones messing up your own natural processes, you just need to get in tune with your body.

Fertility Awareness Method: a mathematical calculation of a woman’s cycle in order to determine periods of fertility and is only effective if a woman has regular 28-day periods. Fertility Awareness requires that the woman daily monitor cervical fluid, temperature and other factors to determine fertile days. In either case, either abstinence or use of a barrier method during fertile times is required in order to prevent pregnancy. 

Fertility Awareness is a great thing to learn to do, especially if you're trying to get pregnant, but it is not a highly reliable form of birth control if you are really super trying NOT to get pregnant. If people used it perfectly, it would be as effective as people perfectly using the pill or the patch, but people don't use these things perfectly. In typical use, you take the pill at different times each day, and you might mess up or forget your tracking.

Typical use of Fertility Awareness methods (including cervical mucus methods, body temperature, methods and periodic abstinence) has a 24% "failure rate," which means it is about 76% effective. That is quite close to the effectiveness of Withdrawal (pulling out), which people often refer to as a ridiculous method to use to prevent pregnancy. The success rate for withdrawal is 78% (surprisingly effective, all things considered)! I've seen other website cite Fertility Awareness as 80% effective and pulling out as 73% effective, but I trust the data from the Guttmacher Institute, a highly respected reproductive health research organization:

So, the public health side of me thinks that it is not wise for Sweetening the Pill to get too many people moving away from their hormonal birth control, which has quite a few benefits for women, especially low income women and marginalized women and women of color. Birth control that is highly effective, like the pill (91% effective with typical use) and the hormonal IUD (99% effective), is not something we should step away from lightly. It allows women control over their lives, it helps women who truly shouldn't (medical reasons, youth, or otherwise) get pregnant, and it avoids abortions. The Natural Family Planning method really doesn't have the efficacy that these methods do.

I'm not vehemently against starting the conversation that this documentary is starting, the way some articles on the internet have been -- see the infamous Amy Tuteur's post on and's articles to hear some outrageously unbalanced reviews. I think that this is a valuable conversation to have. I recognize that I am of a class privileged enough to be able to afford all types of birth control and have the time to track fertility, if we want to. Not everyone actually has the financial and temporal freedom to actually choose what is right for them, so we need true open and honest information on all of the options.

You can find more information on the film Sweetening the Pill at the Kickstarter site (which has been fully backed).

I think a great part of this conversation, from an academic viewpoint, is whether the Pill or Natural Family Planning is more empowering, more feminist. The film's preview implies that though the Pill was the ultimate female empowerment 55 years ago, being one with your body's processes and not relying on pharmaceuticals is more empowering. Others might think that by rejecting the pill, we are undoing the work that was done to become less enslaved by our biology.

 Best Daily's post quotes Ricki Lake/Abby Epstein:
"The progression of mainstream feminism is founded in part on women overcoming and controlling their biology", they explained. "This is because for a long time women's biology or difference has been used against us as justification for our mistreatment and oppression. Women have come to feel that they must overcome their biology in order to have equality and freedom."
To enjoy the same privileges as men, do we feel we must we be more like them, not just in our attitudes, but in our biology? Lake and Epstein think so: "The male body is held up as the "ideal" in the medical industry and the female body is seen as inherently faulty and problematic. Women have had to make sacrifices to be allowed to work alongside men in a patriarchal society. The fear is that if we stop making those sacrifices we will lose that ground."
I don't think Ricki Lake and Abby Epstein are "anti-choice" or "anti-feminist" as the Time and Slate articles call them, but I do hope that they present their information in a balanced way. I do hope they talk about the pros of hormonal birth control for so many women, and the potential cons of fertility awareness methods. I hope they talk about other methods that aren't usually talked about in the mainstream.

We will have to wait for its release to find out!

Monday, June 1, 2015

Officially a Lamaze Certified Childbirth Educator

It is official - I passed my Lamaze exam and am now a certified childbirth educator!

I wrote a couple of months ago about why I did my training in Lamaze, before I had completed my requirements. Because I had to wait from my training course in October to my exam in April (the exam is only offered twice a year), the process took me exactly that length of time (plus waiting for exam results)! I was able to teach a childbirth education course to be "signed" off on and register and take the exam in the time in between. If you are interested in becoming an LCCE and are already in the birth world, I think you could also do it in this time frame. I will point out, however, that if you do not "keep up" with at least the last couple of years' worth of birth/breastfeeding research and recommendations, you might have trouble. 

The Exam

To prepare for the exam I read the enormous study guide, which I did not think was a very user-friendly review source. It spends much of the time referring you to outside sources. This is great as far as providing resources goes, but when I want to sit down and study for something, I don't want to have to go searching all around. I appreciated that each section had a "Review Questions" page, which I think actually helped me understand the Lamaze thought-process better than reading the study guide. I like the articles that were actually included in the study guide document, but skipped most of them unless they were Lamaze-specific and I wanted to get an idea for what their angle was. This turned out to be a good idea, because most of the questions on the exam asked extremely vague questions (e.g. "choose the best answer") rather than clear-cut fact-based questions. It is a good idea to get a feel for how Lamaze would like you to answer.

One of the up-sides, or down-sides, of Lamaze is that I get to create my own curriculum. I do not have to follow a particular work book or a set of rules. I am encouraged to base the curriculum on the 6 healthy birth practices, which I would do anyway (because they are great!), but other than that, I can choose my own books, worksheets, posters, and other teaching tools/resources. This is a pro because I am not limited, but a con because that means I have to come up with what I want to use! I am still experimenting, and haven't fully decided on what tools I think most essential. I am doing it on the cheap, at the moment, before I decide to invest in expensive DVDs, posters, pelvises, dolls, etc. Any recommendations or product reviews would be greatly appreciated!

Lamaze does offer the purchase of a pre-made slide set, but I don't see myself teaching with slides, and I know that it is a product I could probably make on my own (minus some shiny photos). For someone who is starting from scratch, though, I bet this would be a really useful tool. 

I am excited to join the a community that I feel is respected, focused on evidence-based medicine, and well-known. 

Wednesday, April 15, 2015

Notes from the Field: Learning with Indigenous Midwives in Chiapas, Mexico

Mounia during the Day of the Dead fiesta
November 2014
Today's post is a guest article from anthropologist Mounia El Kotni. Mounia's "Notes from the Field" appeared in the most recent Council on Anthropology and Reproduction newsletter, and she has kindly allowed its reproduction here. In this post, she describes her participant-observation experience with midwives in Chiapas.

Learning with Indigenous Midwives in Chiapas, Mexico

“Oh, I see, so you want to be a partera (midwife)” is the typical response I hear after explaining the purpose of my visit; that I am doing dissertation research to document how midwives live and work. Although I try to explain my research goal in terms of “helping raise awareness on the difficulties parteras are facing,” I am always met with this same response “so you want to learn how to become a midwife?” And as I have gotten to meet parteras and aspiring midwives, I must admit that there is not always a clear difference between what I do and how I act and what they do and how they act: asking questions about pregnancy care, sitting in on prenatal consults, taking notes on almost everything the partera says... There is a thin line between participant-observation and midwives’ apprenticeship model. And indeed, I have been learning a lot about how parteras work and live, but also a hell of a lot about plants given in pregnancy care and massage techniques.

Since October 2014, I have been in San Cristóbal de Las Casas, Chiapas, conducting dissertation fieldwork and volunteering for the Women and Midwives’ Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). As a volunteer, my work consists mainly of two tasks: administrative tasks (aka looking for funding) and logistical support during events and workshops. Since 1985, OMIECH has been strengthening Mayan medical knowledge and organizing health workshops in indigenous Tseltal and Tsotsil communities of Chiapas. Even though I am in Chiapas, some of my notes echo those of Kara E. Miller (Fall 2014 Newsletter). Here too, the parteras - who are referred to as Traditional Birth Attendants in international documents - are frustrated with the lack of possibilities to transfer their skills to the next generation. This is why the Women and Midwives’ section organizes workshops focused on reproductive health, and care during pregnancy, birth, and postpartum. These workshops are open to all members of the community where they take place, and aim to perpetuate botanical and medical knowledge by transmitting it to younger generations.

Micaela giving a workshop at the meeting of OMIECH parteras
February 2014. credit: OMIECH
The loss of knowledge is accelerated by various factors: young people’s migration, midwifery not being an attractive profession economically, and also the increasing medicalization of birth. The push to send women to birth in hospitals comes with a delegitimation of indigenous parteras’ knowledge as “not-modern”. Through conditional cash-transfer programs (documented by Vania Smith-Oka in the state of Veracruz), women are pushed to have their prenatal visits and give birth in hospitals. Parteras, on their end, have to attend trainings given by the Health Secretary. These trainings emerged in the 1980s, and intensified in Chiapas under the pressure of reducing maternal mortality rate to comply with the Millennium Development Goal (Chiapas has one of the highest maternal mortality rates in Mexico). Indigenous traditional midwives either have to follow the trainings or stop practicing. This can have dramatic consequences in places where they are often the only health care provider in their communities.

Micaela during a community workshop with parteras.
May 2014. credit:Alice Bafoin
As I jot down notes during an interview or observation within these different settings, I feel a thrill of delight when their words echo one another. But then I realize this means that these state policies are really achieving great changes for parteras. And like Sisyphus, tirelessly, my colleagues at OMIECH reweave what is being unwoven: traditional medical knowledge, but also, and as important, pride in it and trust within the community.

While “in the field”, my notes are scribbly at times, crystal clear at others, but rarely absent. I try to type them regularly, as a good apprentice-anthropologist, but have stopped feeling guilty when I could not do so. It took me a few months to be able to “let go” and admit there will always be an event I will miss, a trip I cannot make... At my mid-point in the field (already), I have just started to take drawing classes, which helps me expand the range of my notes, when words fail to describe a hand gesture, or when I do not know the terminology for this exact point on the belly that needs to be massaged. These classes have made the familiar look different, and made me look at people in a new way, which in turns adds more depth to my notes. Life in the field intertwines professional, political and personal spheres. The friendships I have built through this research promise to impact both my career and personal life. As we were searching for plants in the garden of the organization for an upcoming booklet publication, my colleague Micaela corrected me as I got the name of the plant wrong, once again. I could sense, for the first time, an impatient tone in her voice. I pause and I suddenly realized that although I am not studying to become a midwife, every one of the parteras I have met has been a teacher to me, training me a little bit, sharing their story, their tortilla and their endless knowledge. I am looking forward to learning a lot more in the next five months I will be spending with them and I hope my dissertation will bring them knowledge they can use in their struggle.

Mounia El Kotni is a French-Moroccan doctoral candidate at the State University of New York at Albany. Her dissertation documents the impact of Mexican health laws on the practice of indigenous midwives. She is currently conducting fieldwork with the Women and Midwives Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). Since 2012, Mounia is also a member of the French organization Association Mâ, which promotes respected childbirth. She can be reached at
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