Monday, March 06, 2006

Fertility

She fit the profile. She was in her late thirties, it was her ninth pregnancy, she hadn't had much prenatal care, and sure enough, her urine drug screen showed she had cocaine in her system. Her newborn baby had it too.

Most of our mothers who use cocaine tend to be older, at least older as far as mothers of newborns go. It's not surprising, too, that they often don't get much prenatal care, given their chaotic lives. But the part that puzzled me was why they so often had so many pregnancies. I know that some of these women will earn money for drugs by prostitution, either overt prostitution or by attaching themselves to a man who provides for them even though they don't really care for him. You would think, though, that it would be to their advantage to use birth control or even get their tubes tied, that they would do better in prostitution in a non-pregnant state. Then one day an obstetrician who has worked for years in our urban area explained to me that a woman's value on the street was higher if she was fertile, was lessened if she could not get pregnant.

I don't know if that's true or not. It has the ring of urban myth. Maybe it's just their chaotic lifestyles that also explains their frequent pregnancies. But truth can be stranger than fiction, so it could very well be true or at least partly be based in fact.

I've written before in a post that some people get angry at mothers who use drugs during pregnancy, but that doesn't do any good, except for letting the miffed health care worker blow off some steam. Instead, we should recognize that the birth of a baby can be a time when a mother might have incentive to change her life, to make things better for her baby, and we should capitalize on that by trying to get her into rehab. It seems like a small step compared to the problem of women who remain fertile to increase their value, but hey, it's at least something.

15 Comments:

Blogger La Lubu said...

"Older"? Is that why I was tested for drugs when I was admitted with premature labor (I was 32, which is considered "ancient" in the midwest---sorta like having your first child at 50 elsewhere)? I was angry when I found out about it; hell, I'm a lifelong nonsmoker, gym rat, healthy eater---and have always been very anti-drug. It pissed me off that I could be tarred with the brush of "suspected drug-user" for going into premature labor. I viewed it as an insult, like assuming that I was a liar and a thief also, until I could prove otherwise.

And that "proving otherwise" is something that I found to be a big part of the preemie parent experience---that I had to work extra-hard to prove that I was a good parent, because the fact I gave birth to a preemie was damning somehow---that I must have "done something wrong" to have a preemie.

Is this your experience from the other side? Are preemie parents given extra scrutiny, or just the single mothers? Honestly---I'm curious.

1:49 PM  
Anonymous armchair ethicist said...

Yes, people can change for the better and birth of baby is just as good a time as any. As cynical as we often are, it is good to read the end of your post.

La Lubu, there is a saying, "Trust, but verify". Probably the "verifying" feels just as bad as not being trusted, but it's fundamentally different. I have been made to feel stupid and incompetent by NICU nurses, the kind of accusation a blood test can't prove wrong. I sympathize with you, but at some level, I just decided to accept the temporary unpleasantness, chalking it up to they have a job to do and it's all "nothing personal".

4:00 PM  
Blogger Flea said...

Doc,

How many of her kids are still with her? In my state (MA) the children would be absconded with. So mom wouldn't have the chance to use the new baby to clean up her act. She'd have to clean up her act then get back the baby/babies.

best,

Flea

5:00 PM  
Anonymous maribeth, CNM said...

I have doubts about fertility increasing the street value of female sex workers. Simply -- how would men even know? Unless we're talking about fetishists here, or possibly the effect of pheromones?? The latter is interesting to consider.

From my experience working with prostitutes and drug addicted childbearing women in urban Seattle, I'd say it's definitely because of the chaotic lifestyle. Heck, even for educated, privileged women, control of fertility takes attention, dedication, and resources.

Most such women get pregnancy and delivery care only through medicaid. And in every state I've worked, medicaid requires a month-long waiting period from surgical consent to operation for tubals. It's no surprise that these women are not good about obtaining postpartum or women's health / reproductive care.

As far as ethical quandries go, here's one: I've seen - several times - OBs tie tubes without consent, during an emergency c/section (usually for a crack induced abruption). What do you think of this?

8:29 PM  
Blogger Dream Mom said...

Your posts are always wonderful because they provide so much to think about.

I love the idea that giving birth might raise the idea that a woman would change her life however I doubt she would have the tools or the financial resources to do it.

You also raise the thought as to why a woman wouldn't consider getting her tubes tied. Being a prostitute would probably indicate that her already chaotic life is in the "survival" mode where she can only be concerned with how to get food, clothing and shelter. If that were the case, she will never be able to think or dream about tomorrow when her she is engrossed with how to make ends meet and make it through the day.

9:28 PM  
Blogger neonataldoc said...

Thanks, all. So many comments, so little time!

La luba, I don't think we blame mothers of premies for the premature birth. I was surprised to hear you say that. Mothers of premies often feel guilty about it, though, even though in their head they know they did nothing wrong.

Flea, this mom claimed she had all her babies, although the number of babies she said she had didn't match her OB record. We're waiting to hear from Protective Services. Sometimes they tell a different story than mother. As you suggest, in many - but not all - of these cases the kids are removed from mother's custody.

Maribeth, I have never seen an OB do a tubal ligation without consent, although I'm usually gone from the delivery room by the time they get to the tubal. In my experience, the OB's are so worried about being sued that they wouldn't do anything without consent.

8:06 PM  
Anonymous Anonymous said...

Love your blog.

You didn't mention the patient's (or her customer's) demographics, but in my experience, if she is of any type of Hispanic descent, there is a strong feeling in many Hispanic men against having sex with an "infertile" woman. My best friend, an RN from Columbia, was divorced by her (very American educated Hispanic)husband after her emergency hysterectomy--it somehow would have made him less macho to have sex with her. And I have had Hispanic patients who have declined contraception/tubal ligation because of their religion--even if they don't go to church EVER--or because of the perceived male disapproval of the infertile woman.

Haven't encountered this in most of my other clients; the druggies and prostitutes just can't plan that far ahead to agree to have a tubal ligation; they are worried about getting through today--maybe tomorrow.

La Lubu--sorry that you were insulted by the drug testing. In the facilities where I worked, every woman who comes in in premature labor--no matter who, what type of prenatal care, anything--is tested for drugs. I don't necessarily agree with it but we have been burned too many times by a "classy" mom who has drugs in her system. The concern isn't you--it's the baby (who would go through withdrawal and usually will require special handling.) I always informed my patients of the screen and the reason. Yes, many women got insulted, and I apologized, but unfortunately, many of the women who really were insulted were positive for drugs. (I found the non-drug user moms were initially insulted, but understood the rationale and cooperated much better than the drug users--THEY knew they had nothing to hide). You sound like a great mom. Sometimes premies, like shit, just happen. He/she is still your baby, and you love them just the same.

(I usually blog comment with my name, but my friend mentioned above requests that I do it anonomously this time because she doesn't want to risk recognition--she approves of my mentioning her situation--she's reading over my shoulder as I type this--but doesn't want the world to know the reason for her divorce.)

7:27 AM  
Anonymous Alice said...

Maribeth - I'm surprised to hear about OBs tying tubes without consent. A week ago I was at a stat Csection for placental abruption. It was the woman's ninth baby, she had been begging in clinic to have her tubes tied, she had signed all the papers, and she had a lung condition which actually makes it very hazardous for her to be pregnant. However, because she was semiconscious when she came in, and could not affirm that, right now, she wanted her tubes tied, they didn't do it.

8:02 AM  
Anonymous Anonymous said...

Not being a drug user myself, I can can only guess that these women wish for and plan to get their lives together and therefore many times don't want their tubes tied; they think the good life is around the corner, whenever they can get off drugs. Their intentions are probably good. They don't NOT want children but probably both enjoy and try to deal with the children as they come unexpectedly, and probably resolve to get off drugs but have a hard time doing so.

I don't know about men consciously choosing to prefer a fertile woman over a non-fertile one, but someone mentioned pheremones. Tube-tying would not interfere with those, but it's a fact that a woman who is not ovulating (because of hysterectomy or menopause or hormonal birth control methods) is not nearly as interested in sex and therefore, a pool of such women would be less sexually active. Women can have sex any time of the month but are far more driven to do so around ovulation (testosterone, I believe, being the driving force. Works for men, works for women, too. No or low testosterone = more interest in snacking, shoe shopping, or reading a good book than in sex.) And I do believe that men know, on a subconscious level, which women are in that phase of their cycle. I think the attraction is probably intense. Hey, if dogs and cats can "smell" an ovulating female from a mile away, why can't humans do the same? I think it's been proven that they can.

As for the psychological aspect of consciously preferring a fertile partner, I believe that could be true. It's just part of our baser reptilian brains (that most of us overcome with reason due to necessity and being unable to raise an unlimited number of children) but , (apologies in advance to anyone who might be offended) I, specifically, in all honesty, would feel sad if my husband became surgically infertile (vasectomy) - sorry, but it would make him seem in my eyes to be like a sad once-was-a-man. Maybe I'd get over it and move on. I'm not sure if he admits to the same in reverse about me but I do think he'd get over it and even be ultimately happy if I underwent surgical sterilization. (Although I struggle with it because I ENJOY feeling like a fertile woman, even if I don't think I'd get around to having more children, potential unplanned pregnancies aside. The decision on his end is done - in principal, it makes sense, but he honestly does not want anyone cutting his nether region and I don't want him to go through that. The decision on my end is up in the air as of now. My mother, who is 79 and boldly candid, gave me the shocking (in this P.C. day and age) information that it's somewhat common knowledge that marriages can suffer to a small or large degree sex-wise and then in general after male sterilization.) Sorry to be un-P.C. and I'm sure individual experiences can differ dramatically. I just wanted to give a little perspective on why some people don't rush to get sterilized, even with a large-ish (and sometimes outright very large, over time) family. Sometimes people enjoy having families that others would consider large, anyway. All members of the family are loved and valued.

10:13 AM  
Blogger Judy said...

I don't know about overt prostitutes, but based on a conversation I had with a mom of 6, I'd say that it's not urban myth about women who are living with men for the money, rather than for love.

She'd been married once. 3 of the kids were her husband's. He died. The father of #4 wanted her to have his baby and promised the moon. He left before the baby was born. #5 & #6 were twins. Their father made the same promises as the father of her fourth child. She had a tubal after the twins were born, but planned to keep that a secret from any future lovers. She figured the man would stick around as long as he thought there was a chance of impregnating her. After all, her fertility was pretty thoroughly proven.....

11:28 PM  
Anonymous Anonymous said...

I have no pity for these jerks. and of course, all those drugs and they have normal babies, and then me with my first pregnancy and doing everything right, and my daughter has CP...it sucks. It's not fair...where is the justice?
Vanessa

10:04 PM  
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