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Family Planning Healthcare Women's Care

Midwife360 and the Scoop on IUDs

Many of my clients ask about birth control options that do not have hormones. There are a few, mostly they are the barrier methods like condoms (male and female), diaphragms, and cervical caps, or surgery. But the copper IUD is the only one that is long term and reversible and does not have any hormones. Since the copper IUD is not the only long term, reversible contraceptive, I wanted to break it down here for you.

What is an IUD?

IUD stands for IntraUterine Device. There are 2 types of IUDs, those with hormones and those without. Both of them are T-shaped plastic rods that are about 1.3 inches long with a string attached to the leg. The ones with hormones contain progesterone impregnated plastic, while those without have some copper wrapped around the arms and/or leg. 

Progesterone IUDs

The hormonal IUDs are called Mirena, Liletta, Kyleena, and Skyla. They are approved to last from 3 to 5 years and the Mirena and Liletta can be effective up to 7 years. The Skyla (3 year device) is a bit smaller than the others and is marketed towards young women who havenʼt had babies yet. The hormones effectively thin the lining of the uterus causing the wearer to have a super light or no period. Women usually still feel that they are cycling, as they can still get bloating or other pre-menstrual symptoms, but without the bleeding. Sometimes the IUD can cause an increase in period bleeding, but this is usually short-lived and will slow down or stop completely within a few months. This can make it more difficult to get pregnant once the IUD is removed as it can be 6 months or longer before the period returns to normal. 

Copper IUDs

The copper IUD that is approved for use in the US is called Paragard. There is another brand that is used in other parts of the world called Nova-T that is the exact same thing as the Paragard – a plastic T-shaped device with 380mm2 surface area of exposed copper. The Paragard is approved for 10 years and effective for at least 12. The Nova-T package insert says itʼs approved for 5 years. 

Pros and cons

The benefit of using an IUD is that it is placed once and then you donʼt have to think about it. You donʼt have to remember to take a daily pill, switch out your patch every week, do a monthly vaginal ring swap, or get a shot every 3 months. They are very effective, partly for this very reason – everyone is a perfect user. They are considered 99% effective in preventing pregnancy.

However, if you do get pregnant, especially with a hormonal IUD, you have a greater chance of having an ectopic pregnancy (when the fertilized egg doesnʼt make it past the tube into the uterus). As mentioned above, the hormonal IUDs can lighten or stop the period which is beneficial for those with super heavy cycles or super painful cramping – such as with endometriosis (a condition where the uterine lining or endometrium grows in places outside the uterus – when she has her period these places also bleed causing extreme cramping).

Another con with the hormonal IUDs is the tendency for those with them to be unable to lose weight or gain unwanted pounds over time.

An advantage of the copper IUDs is that one gets very effective birth control without using hormones. This means that it doesnʼt affect your cycle or your ability to get pregnant once it is removed. The only other birth control that doesnʼt use hormones are the barrier devices (make and female condoms, diaphragms and cervical caps). However if one has a copper allergy, it can cause multiple systemic symptoms and even affect the efficiency of the immune system. 

Placement

When you go to have your IUD placed, you should be on your period. This helps reduce the risk of infection as you have a flow that will carry any unwanted accidentally introduced bacteria out of the uterus. It also means that your cervix is softer and more open. You will be counseled regarding the risks of perforation and infection – which are the more common risks of placement. Your provider may also mention that expulsion of the device is also possible. Perforation would be pushing the inserter through the wall of the uterus and placing the IUD outside of the uterus. 

The provider should use sterile technique and clean inside your vaginal vault with betadine or hibicleanse prior to inserting the IUD. Some providers will numb the cervix with lidocaine, which makes the insertion much less uncomfortable. The uterus should be at least 6 cm deep, which is noted during the insertion as the inserter has cm markings on it. Once the IUD is properly placed the provider will make sure to cauterize any active bleeding with silver nitrate sticks.

Then you should be given a prescription to get an ultrasound to check placement and cautioned to refrain from intercourse for one week. Having an ultrasound assures that the IUD was placed properly in case there are questions about that in the future. It also reassures everyone that there was no perforation at the time of insertion. You can feel the strings which should be about 2-3 cm long hanging out of your cervix. These strings will be used to remove the IUD when you are ready to have it taken out. 

Removal

Getting the IUD removed is typically much easier than placing it. Sometimes the strings are no longer visible in which case an instrument is used to capture them and draw them out where they can be grasped with an instrument and the IUD removed with one swift tug. It does not hurt and I donʼt think Iʼve ever removed one where the client didnʼt say “Thatʼs it? Youʼre done?” It is important to wait a couple of cycles before trying to conceive as the risk of miscarriage is higher in the first 2 cycles of stopping any type of birth control. 

Support your local Nurse Midwife!

You can see an OB/GYN or CNM to get counseled regarding which birth control option is right for you, or if an IUD is a good option for its effectiveness in treating heavy menstrual bleeding and painful periods even if you donʼt need birth control. As always – do your research, know your body, ask questions, expect respect – make sure you are satisfied with the results! 

Categories
Healthcare Pregnancy

Call to Action

My name is Fadwah Halaby and I am a certified nurse midwife serving families in Palm Beach and Broward counties. I offer well-woman care with a holistic touch as well as pregnancy and birth services with birth in the clients home. This is a choice that any woman can make and a viable option for all low risk, healthy clients and even with some that have a more complex physiologic pregnancy – such as previous cesarean, twins, or breech.

Pregnant people have human rights too!

The bottom line is that we all agree that everyone should have certain rights by virtue of being human – we call them human rights. And these rights are repeatedly denied to many pregnant women because her care provider has decided:

  • that he or she is not comfortable with a given situation
  • has decided on a particular course of action
  • is determined to force the client to comply

This has gone so far in some cases as getting a judge to order a forced cesarean surgery by deeming the client incompetent to make decisions for her own body and that of her baby. It is ludicrous to imagine that a person who has conceived and grown a baby in their womb for 40 weeks does not have the best interests of that baby in mind when making decisions regarding the birth of the baby. No one has more of a vested interest in that baby than that pregnant person. And no one has more of a vested interest in the woman’s body than the woman herself. We have a right to choose to birth at home, in a birth center, in the hospital or anywhere else a person would choose to birth. This is a basic human right and is upheld in the laws and rules of our state.

What is not supported by our laws and rules is the right of that pregnant person to have the trained and licensed provider of their choice attend to them in any of these settings.

Nurse Midwives are trained to practice independently

As a certified nurse midwife (CNM), I am trained and licensed to attend to women in any of these settings. I have maintained hospital privileges without any negative incidents for more than 8 years and over 1600 births. Yet now that I am attending to women in their homes, I am not allowed to continue to care for them should they require a transfer to the hospital either before or during labor. ACOG (American Congress of Obstetricians and Gynecologists, the OB/GYN national organization) recognizes women’s right to choose their place of birth and makes a recommendation that if a woman wants to birth at home she should be a healthy, low-risk candidate, choose a CNM to attend her, and birth in an integrated environment. [ACOG Committee Opinion on Home Birth] And this, my friends, is the missing piece of the puzzle. The lack of integration makes out of hospital birth less safe for everyone.

Transferring from home to hospital is fraught with anxiety for both clients and home birth care providers

How many times have you heard stories of “train wrecks” – home birth transfers to the hospital when things have gone far past the point of being OK? Midwives dropping clients off at the door or not participating in the transfer at all are tales that are told by hospital personnel about home birth transfers. It is true that the out of hospital provider is bound by duty to shift location to the hospital once they feel that it is no longer safe to be at home and if it is for an emergent reason, then the 911 system should be employed to make the transfer. If it is for a non-emergent reason (as 90% of home to hospital transfers are), then the transfer can happen by private vehicle. In both cases, the hospital should be alerted and records sent ahead to facilitate care for the client and to give the receiving provider as much advance information as possible. The provider should accompany the client and be prepared to give a concise report of the relevant details and reasons for the transfer. This is considered a hand-off and according to JCHAO [Joint Commission for Hospital Accreditation] is where most critical incidents happen.

One solution

Giving APRNs (Advanced Practice RNs or Nurse Practitioners) the ability to practice to the extent of their training (why are we being restricted from that in the first place?!) would make this situation much safer. By allowing the clients chosen provider to be a member of the team once the transfer to the hospital becomes necessary. I have not been able to maintain hospital privileges, not due to any malpractice or incidents. This is purely due to not having an obstetrician who doesn’t have a financial stake in me or my practice being willing to “take responsibility” for my actions. Really, why should anyone else take responsibility for my actions?

I am trained to work to the extent of my scope of practice like any other healthcare provider. To make decisions, prescribe medications and tests and to interpret those results and determine when consultation, co-management, or referral is necessary. LIKE ANY OTHER HEALTHCARE PROVIDER. There is no worry that OBs will start trying to treat people for heart failure – they would refer to a cardiologist. If they try to work outside their scope of practice, then they are appropriately reprimanded or relieved of their license to practice. We understand that we would be held to the same standards. However, to require me to find a doctor willing to take responsibility for my work and to require that they sign my application for hospital privileges places an undue burden on me and is effectively restraint of trade. This has to stop now.

Please support Senate Bill 972 and HB 871 to increase the number of health care providers and contribute to reducing the costs of health care. Reach out to your Senator and Legislator with a postcard, email, and/or phone call today! Click here or below to find your elected official now.

Categories
Healthcare

The Health Insurance Rant

Health Insurance A Lose:Lose Situation for Consumers and Providers

How did we come to this juncture where we are supporting the lumbering giant that is the insurance industry particularly as it relates to healthcare? I am an NPR person; I listen to NPR when I’m driving in my car and I heard a piece yesterday that really got me upset! They were talking about the rising cost of healthcare insurance. All of the big companies were planning on raising their rates next year and  Humana was going to be raising their rates higher than everyone else – like by 40%! It is predicted that for someone earning around 27K, their premium would be about $150/m. I remember when I earned less than 30K per year and paying out $150/m for health insurance would have been extremely difficult. So that’s one thing. The other, more important thing that really concerns me – and this, my friends, is the elephant in the room – is how the heck did we get to this place where we support this industry that has absolutely nothing to do with our health?

Difficult Contracting

I have been running my own small healthcare practice for 2 ½ years now. I have been struggling for recognition and compensation from these insurance companies from day 1. Achieving in-network status was the first thing. Cigna updated my new tax ID with my NPI (National Provider Identifier – a national registry that lets them know that the person is legit and bestows a unique identifying number) and we were good to go right away. I thought that all the other companies would do that. However, I found out that even though I’d been providing care for their members for nearly a decade. All of the other companies required me to apply for a contract, and most of the big guys denied me initially. Aetna came around after my national body (ACNM – American College of Nurse-Midwives) wrote a letter for me. Humana is just starting to consider a contract – after multiple Humana members applied for a gap exception for coverage for my care. Blue CrossBlue Sheild won’t even talk to me, doesn’t contract with non-MDs and is extremely difficult to deal with – even for their members. The rest of the companies fell somewhere in-between and eventually granted the in-network status.

Difficult Reimbursement

The next insult is the rates that I am bound to accept now that I have achieved the holy grail of in-network status. My clients pay their premiums and want to use their insurance plan. However, they are subject to their deductibles and co-insurance amounts which require a certain amount of investigation to discover and interpret. The industry standard requires those of us providing maternity care to refrain from billing any services until after the baby is born. This puts all maternity providers in a precarious position because everyone knows that most people are not as keen to pay for a service once the job has been completed. So the trick is to estimate what the insurance company is going to say that the client owes (the deductible and co-insurance up to the amount that is in the insurance contract for the service) and make payment arrangements for this to be paid off prior to their due date. This is irrespective of my charge for the service. If we overestimate, then we have to refund money to the client. If we underestimate, then we have to try to collect for the services that have already been performed.

The Game of Claims and Coding

Submitting forms and getting paid is the other side of this game. The act of submitting a claim is like a ritual or a game – literally. They will deny payment if the coding isn’t correct, but they won’t tell you what’s wrong with it. Most providers pay someone to do this for them and they have to subscribe to a billing platform that electronically submits the claim through one of several national clearinghouses that pass it along to the insurance company. If a paper claim is submitted, it has to be on a particular form that is printed in red ink – if the ink isn’t red, then they won’t accept the claim. All while the status of the claim is communicated to the provider through many forms that are generated, printed, and mailed. So much paper! So many people involved who are making an hourly wage!

Keep the Money Between Consumers and Providers

The bottom line is that all of this detracts from the relationship between me and my clients. The longer I participate intimately with this system, the more I am confused as to the purpose of the insurance industry in health care. Instead of paying out large sums of money for insurance premiums to people whose only job is to move paper around (accept or deny claims and issue checks or take-back letters) we could be using that money to pay for health care. Obviously, the industry is making money – record gains even – and that is off the backs of their members and their providers. I think those folks ought to find another career and we should move away from this cumbersome system.

#getridofhealthinsurance #protectsmallhealthcarebusiness #dontgetbetweenmeandmymidwife