The IUD Crusade

“Belgium would like to acknowledge the comment made by Malaysia, and moves to second for the record.”

“The chair recognizes Belgium, and the record shall reflect Belgium’s endorsement of Malaysia’s comment. The chair recognizes the vice chair. Vice chair?”
“The Vice Chair would like to remind country participants to please state for the record if this is a comment, question or a point of personal privilege.”

“So noted.”

I yawned, and glanced at my empty coffee cup longingly. I am well aware that working for the United Nations sounds terrifically glamorous and important. It is. About 5% of the time. The remaining time is spent desk bound, filing forms in triplicate and attending meetings that are so mind numbingly dull, neurons snooze and synapses stagger to a halt.

The flood of acronyms and bureaucratic procedure have a way of making even the most interesting of topics profoundly dull and positively indecipherable. I was pretty sure we were talking about gender and human rights, but New Zealand was reading his speech in the most mono of monotones, and the ear revolted at listening for longer than five seconds.

A gentle snore erupted from Swaziland in the row ahead of me. Ghana was busily engaged in constructing an elaborate chain of paperclips. Now if only Kurgistan was gchatting Uzbekistan while Georgia played Farmville, this would be exactly like my MPH classes at Berkeley.

I was briefly diverted by imagining how it would be to conduct my life in UN speak.
“Oregon would like to recognize New York. New York, for the record: is this a question, comment or point of personal privilege?”

“New York requests tabling of dinner plans and motions that New York, Oregon and Australia have another round.”

I snickered.





Thirty six hours previously I’d been sipping an ice cold Corona, listening to Sweet Child of Mine, and enjoying the best enchiladas I’d had since the Mission District.
I was in Amman, Jordan on a mission for the World Health Organization, Iraq.

Three weeks ago, after eighteen months of bureaucratic and political delays, the Iraqi Ministry of Health's formal request to WHO for a reproductive health training finally got processed. The Iraqi health system, along with a lot of the country's infrastructure, has been decimated by years of war and strife.


By the time the paperwork got processed, we had less than a month to prepare for a "training of trainers" workshop. Iraqi physicians would come to Amman for a week long conference organized and led by yours truly, one other American obgyn and a well meaning epidemiologist. The Iraqis wanted an update in every contraceptive method available as well as clinical training (IUD and implant insertion, sterilization, counseling techniques).

I sent out pleading emails to obgyn friends for any and all grand rounds they'd given on contraception, and quickly started putting together our curriculum.
This was my first time doing this indepth of a training, and my first trip to the Middle east. I wasn't at all sure what to expect.

What was the current state of reproductive health in Iraq? What kind of contraceptive methods were available? Who was coming to the conference (doctors, midwives, nurses, family practice doctors or obgyns?)? Could I mention abortion? And most importantly, what on earth should I wear?




For security reasons, the conference was going to be held in Jordan. This was super exciting! Jordan, for those who haven't seen Indiana Jones, is where Petra, the lost city is. Archaeology, was right up there on the list of things I wanted to be when I grew up, somewhere after Gynecologist and Secret Agent, but well before Astronaut.

I immediately bought a Lonely Planet and downloaded the Lost Crusade. After my trip to Ethiopia for work, I'd learned my lesson. Schedule a couple vacay days around the trip or you'll never leave the hotel. I was not flying all the way to Jordan without seeing Petra, the Dead Sea, and hopefully Wadi Rum. In true obgyn fashion, I just planned to stay awake for a couple days to fit it all in.





Petra needs to be added to your To Do list. Stat.
An entire city carved into rose red cliffs preserved for centuries. I'm a gynecologist, not a geologist, so I can't bore you with too many facts about Petra. Our guide provided a range of info from historical details on lost civilizations to how to train a camel, but I was too busy staring, mouth agape, to take much of it in.

I did learn that telling a woman she resembles a camel is a Bedouin compliment.

Waves of red, black, green and white, undulated through the face of the cliffs that lined our path as we hiked into the city. The shapes were no less amazing; both the man made buildings that had been carved into the rock, enduring for centuries, but also the smooth surfaces that had been shaped by wind, flash floods and aeons of harsh sun.

Ater a quick shower and lunch, we clambered back into the Jeep, and headed south to Wadi Rum. An hour and a half south, and we were in a different world entirely. I felt as if I'd stepped into a Ray Bradbury short story. Intensely blue skies contrasted with fiery red sand to the horizon. Cliffs molded by wind and sun provided shade for occasional clusters of camels. The landscape was Martian.

We drove to a camp site and watched the sun set. I clambered to the top of one of the dunes, and as I watched the fading light I was really glad I decided to go to medical school.

Later, sitting by the fire, I was romantically entertaining thoughts of spending a while in the desert. I'd wander around red sand dunes, write, take photos, drink turkish coffee and think meaningful thoughts. Then a scorpion the size of Detroit lazily ambled past my foot, and I quickly realized the Bedouin lifestyle is not for moi.



We woke at dawn to have a brief stop at the Dead Sea (yes, you really do float) before arriving in Amman in just enough time to clean the mud from between our toes, throw on frumpy, professional attire, and meet with Ministry of Health representatives from Jordan and Iraq.

Forty physicians would arrive for the start of the conference tomorrow. In our organizational meeting we reviewed the conference agenda and got answers to some of the questions we'd been trying to figure out.

The doctors were all obgyns working in both the public and private sector. All but two were women.



Contraceptive supplies are highly limited in Iraq, especially in the public sector, which is where health care is provided for free, or minimal cost. What they have to offer women depends on the month. Some months they have depo provera (a long acting injectable form of birth control) and copper intrauterine devices. Most months they have one type of pill and male condoms they can offer women.

To have your tubes tied, government permission is needed. A woman must have had a minimum of FIVE children and be at least FORTY years old before she can request permission from the state to be sterilized. It goes without saying that she needs her husband's permission for a tubal ligation or any other form of contraception.

The average woman in Iraq gives birth to five children. Decisions about family planning are typically made before a woman arrives at the doctor's office. A woman's value is highly dependent on the number of children, and sons, that she has. Input on whether she uses contraception, and what kind, is based on the guidance of her inlaws, mother, and religious leaders.

Given the lack of access to basic medicines, and religious restrictions, the public health focus is on delaying marriage and promoting breastfeeding (to try and encourage birth spacing, or time between pregnancies).

Vasectomy is practically unheard of in Iraq where usage of male condoms is less than 2%. In a related note, a brief hooray for the enlightened men of the United Kingdom, New Zealand, and Iran who have the highest rates globally of both vasectomy and condom use. Yay.

Newer methods of sterilization (hysteroscopic) are unavailable. Implants (like Implanon) not available. The levonorgestrel IUD, (the Cadillac of Contraception), is available, but only in the private sector for the staggering sum of 20$. This is beaucoup expensive for Iraq, but having paid 800$ for mine, I was kind of underwhelmed. I was however, aghast to learn that a woman can only have one if she has a concurrent medical condition (hyperplasia, annovulatory bleeding etc).




For the next four days I barely left the Hotel Kempinski.
The Iraqi contingent arrived full of enthusiasm, questions and information about life in Iraq. The other ob and I gave lecture after lecture and were bombarded with questions. It was inspiring, fascinating and absolutely exhausting.

I learned that it is 60 degrees CELSIUS (140 Fahrenheit) in Baghdad in the summer. I hadn't realized that the temp scale went that high. Did I mention they have rolling blackouts and that AC is non existent?

This was the first trip out of Iraq for most of the group, even though Amman is only a few hours away by car or plane.

The majority of the doctors wore headscarves and loose clothing that covered them from their neck to their toes. The outfits were colorful, matched and were accessorized with heavy gold bracelets, rings and knock off Vuitton handbags.

Medical school text books in Iraq list the mechanism of action of an IUD as causing an abortion. It's not how the IUD works of course, but this limits the acceptability of one of the few effective methods of contraception available.

Animated conversations in bursts of Arabic and English punctuated our lectures. The physicians were passionate about improving the health and lives of women and families in Iraq. They talked about the importance of delaying marriage for teenage girls, because once married, it was imperative that a woman (or girl) have children to establish her worth to her new in-laws. They spoke respectfully about the difficulty of caring for women when the majority of their decisions were made for them, by their husband, families or religious communities.

I worry about getting sued as an Ob-Gyn. Most of us will in the US, on average, seven times in a career. It's the litigious culture we live in, and it breeds defensive medicine and many complaints.

I wondered why so many of the Iraqi doctors seemed risk averse and highly conservative. It came across as paternalistic and a little condescending, but I knew from our group conversations about consent and counselling (not to mention the personal sacrifices these doctors were making to provide care) that they cared deeply about promoting women's health.

On the last day, one of the doctors, pulled me aside during the training I was leading in how to insert an IUD. She again asked me if I was sure that an IUD didnt cause an abortion. For the umpteenth time I reassured her it did not.

She then confided that in her community, any bad medical outcome, whether the fault of the doctor or not, was settled not by a lawsuit, but by retribution. An unexplained stillbirth or death of a patient, even if no one was at fault? The doctors feared for their lives, and those of their families.

"It's the law of the jungle," she earnestly related. Jesus. I doubt I was able to conceal my shock, because she continued to explain. "It's just since the war. There is no law." My admiration for these physicians, and the work they do, under the most demanding of situations increased exponentially.