(I’ve been mulling this post for a while, so the background for those who missed it in the news: The US Preventive Services Task Force has recommended a decrease in screening for breast cancer, with routine mammography not recommended until 50 years of age, and only every two years thereafter rather than annually. They have also determined that breast self-exams and routine clinical exams are not as crucial as we’ve thought. While policy changes are not happening immediately, I wouldn’t be surprised if the scope of routine screening is eventually scaled back, as has been happening for Pap smears and prostate cancer screening.)
Watching the discussion on the recent recommendation for a decreased breast cancer screening regimen, I’ve been struck by the fact that a regimen of less intervention in women’s health is being taken seriously, and I couldn’t help but wonder why we aren’t having the same public conversations about birth practices in America.
Normally, I have an impulse to blame the patriarchy (or more generally, the kyriarchy) for the state of birth practices but here with breast cancer we have a major women’s health issue and people are actually willing to talk about the risks of screening and intervention. Officialdom is actually encouraging women to talk with their doctors about the risks and benefits of the current screening recommendations – Kathleen Sibelius, head of HHS, in urging women to continue with the old recommendations even said:
Keep doing what you have been doing for years – talk to your doctor about your individual history, ask questions, and make the decision that is right for you.
Can you even imagine this message being promulgated about induction for postdates? Or cesarean for breech? Why are women encouraged to question and individualize their breast cancer screening, but not their births? Are older women more politically powerful and respected than women in their fertile years?
Or is birth exceptional because of the involvement of another life? Can we trace this back to liability? If a malignant tumor is missed due to these new recommendations a most likely middle-aged woman may die of breast cancer, sad, but accepted as the course of nature, especially if the victim is not deemed too young. But if a problem with a birth arises, a baby may die or be seriously injured – sad, and so abhorrent to our society that doctors may feel they need to do things at all costs to prevent that outcome.
Or is it the timescale involved? With breast cancer, there is time to deliberate options, seek second opinions, time for some watchful waiting. In birth, even when discussion of options happens before the onset of labor, such as elective induction, the timescale is no more than weeks long, and typically much, much less. We are urged to place our trust in providers with expertise to make decisions on the spot.
As the recommendation has sunk in, I’ve also been struck by women’s reactions. Women do not know whom to trust: their doctors who have been advising those mammograms, and monthly breast self-exams for the past 20 years, or the panel claiming that these efforts at detection do not pay off. The screening regimen has been promoted as almost an empowerment tool for knowing your body and achieving early detection, yet it leads many women into unnecessary biopsies and even overtreatment, and exposes women to risks from the x-ray radiation and breast compression of the mammogram itself.
A typical reaction against the panel’s recommendations came from Rep. Debbie Wasserman-Schultz, D-Florida . She is concerned that the new recommendations are “patronizing” and she said
It’s pretty outrageous to suggest that women couldn’t handle more information.
But this is not mere information – the screening by mammography itself is a procedure can carry risks, and the treatment that may follow carries risks. Isn’t it patronizing that women have been asked to uncomplainingly submit to a heavy regimen of screening based on very little evidence of benefit?
Back to birth – how many women even know that many obstetric practices are more cultural than evidence-based? How many women get an honest discussion with their providers about the risks to common interventions in birth? Perhaps a good comparison with breast cancer screening is electronic fetal monitoring – in select cases, the outcomes can be improved with the screening, but in routine situations there’s precious little evidence of benefit, and high risk of overtreatment. And yet the practice is so unquestioned that the use of EFM is hospital policy in many places, and women who are able to question and customize other birth options are not allowed any alternatives with EFM.
For those who are working to change birth practices in America – does this foretell what women’s reactions may be as practices are proposed to be changed based on evidence from research? Will women be attached to the highly cautious approach and see recommendations to ease up as patronizing? Or will women wonder why they have been sold a bill of goods and start to question other prescriptions around birth?