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Norplant became available in 1991 in the United States and within a year, had cornered 12% of the U.S. contraceptive market. Written in 1992, this report recognizes the potential for social control present in the method of delivery of Norplant and attempts to differentiate for the reader, the issues of reproductive choice and population control. It includes a background of the drug and a summary of concerns, such as the lack of information available that pertains directly to Native Americans and their limited access to Norplant removals. Although Norplant is extremely effective compared to other hormonal contraceptives, several side effects, such as decreased efficacy in women of greater weights and prolonged menstrual cycles, make it an inappropriate choice for many women. Add to this the fact that the drug is downright dangerous for women with diabetes and blood pressure problems, and it becomes a particular threat to Native American women, among whom the above-mentioned illnesses are relatively common. Pamphlets included with Norplant packages fail to emphasize the gravity of the situation. Patients are given little counseling and are told to watch a one-sided video provided by the manufacturing company to assuage their fears. Further, there have been no long-term studies on the effects of Norplant, particularly on selective sections of the population, such as teenagers, whose bodies may react differently to an extended use of the drug. Several foreign research studies have been conducted but seem inconsistent and untrustworthy due to a lack of regulation and controlled environment. Indian Health Services (IHS) still has no formal policy regarding Norplant; welfare policy permits financial aid for Norplant insertion but not for early removal unless the reason is a serious medical reaction to the product. The report goes on to discuss involuntary use of long-term contraceptives for parents accused of drug or child abuse; it is an intrusive punishment as well as a violation of a person’s right to procreate and to refuse medical treatment. A conclusion and recommendations for developing an effective IHS policy for Norplant and for restructuring of Title 19 welfare policy to include removal costs within initial fees follows.
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This report discusses several important aspects of the use of Norplant and Depo-Provera contraceptive devices by the Indian Health Services (IHS). The topics covered include the policy and procedures of IHS, counseling of patients, and the lack of information made available to them. The drugs’ failings and effects of lifestyle are also mentioned, as well as the issue of informed consent prior to procedure and the lack of a standardized protocol with a tracking system for patients with Norplant inserts. The report delves into the potential for misusing both drugs for purposes of social control rather than as contraceptives chosen for and by a woman. It cites, as proof, past testing of the drug in an unethical and ineffective manner on women of lower socio-economical means as exemplified by the studies done in Brazil and India. Overviews of both foreign studies are included in the appendix. The report briefly describes the background, basic facts, and chemical processes of the drug, and discusses drawbacks, particularly culturally specific problems such as diabetes, obesity, and the interference of prolonged menstrual cycles with religious ceremonies. It goes on to convey the enormity of the 1970’s sterilization abuse by IHS, where 25,000 Native American women were coerced into sterilization though uninformed consent in 1975 alone. More recently, Depo-Provera has been used on severely retarded Native American women with the intention of eliminating their menstrual bleeding altogether for the convenience of their caretakers; the fact that the drug eliminates bleeding completely in only a fraction of the cases remains ignored. Further concerns with IHS treatment of Norplant include its decentralized structure where implant services must be contracted to traveling physicians, leading to limited availability of doctors licensed to remove the insert. High rates of physician turnovers and patient mobility also ensure a lack of consistency at IHS service units. The report also questions the applicability and absolute trustworthiness of a FDS approval.
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Written two years after the 1993 Depo-Provera report, this document studies the drug in more detail than the previous. The information presented in the report was gathered through interviews and questionnaires, a copy of which is included in the appendix; forty-two women were consulted, 88% were Native American and 12% Caucasian. Results are graphed in statistical percentages; graphs tabulate the entire medical process, the information received by the women, and their understanding of the drug and its side effects. The report was conducted due to concerns about such side effects f Depo-Provera and its irreversible, provider-controlled distribution. The side effects include an increased risk of breast cancer with prolonged use, genital abnormalities in cases of fetal and infant exposure, blood clots and higher cholesterol levels, and reduced glucose tolerance. With a history of diabetes in Native American populations, some of these side effects can be debilitating. The survey found that many users were young teenagers at the time of their first injection. Women who start using Depo-Provera at an early age face the added risk of developing advanced osteoporosis by the time they reach their thirties, as well as dealing with irregular periods and a lack of protection from STDs. A brief history mentions past unethical uses of the drug and the potential for coercive practices regarding social control. The report discusses on whom the responsibility for a patient’s health ultimately falls and the extent of a physician’s role in decisions made by the woman concerning long-term birth control. Recommendations in the conclusion encourage further study on the long-term effects of the drug, particularly on over-weight women, and the development of a culturally sensitive and consistent protocol on part of the IHS.
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Traditional Native American custom left the issue of abortion in the hands of the woman facing the choice; the decision was hers alone and was not, as it is today, imposed upon by impersonal governmental policy. Although illegal abortions can be extremely dangerous due to the lack of proper and sterilized equipment, they were not legalized in the United States until 1973. At the time, a federal account was specified in order to fund abortions for women on Medicaid or those who received health care through IHS. In 1976, the Hyde Amendment was established, and limited federal funding to abortions where a woman’s life was threatened physically. A 1997 revision to the Hyde Amendment allowed financial aid in cases where rape or incest caused the pregnancy. The report goes on to discuss individual states’ ability to determine Medicaid policies and thus, the ability to expand or restrict funding for abortions. Regardless of whether a state is able to expand its Medicare policy, Native American women are still constrained by the Hyde Amendment. Given their rights under the Hyde Act, however, IHS abortion policy in practice is yet more limiting. A survey conducted by Native American Women's Health Education Resource Center found that 85% of the IHS units surveyed were “noncompliant with official IHS abortion policy” and 62% stated that they do not provide abortions even in the case of life endangerment. Although IHS Chief Medical Officer permits the use of Mifeprex (RU-486, the abortion pill), not one of the units surveyed carried the drug in stock. The report includes a brief description of RU-486 and ends with a plea to IHS and other organizations to at least provide the health care guaranteed to women by the constitution and the Hyde Amendment.
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The state of South Dakota has been known to be conservative, and it is extremely difficult for a woman to obtain abortion services here. In fact, only one private abortion clinic, located in Sioux Falls, exists in the entire state. Indian Health Service, under the directive of the Department of Health and Human Services, is required to follow federal abortion policy that permits federal financial aide in cases of rape, incest, or life endangerment; they have failed to provide these guaranteed services in the past. Since 1981, a mere twenty-five abortions have been performed by the 352 IHS units established nationwide, a figure that is hugely disproportionate to the number of rapes reported by Native American populations. The issues covered in this report include the massive turnover rates of physicians at IHS, a phenomenon that results in a sexist, cultural, and religious bias. These traveling doctors have few connections with the communities in which they work, and their impersonal outlook helps muddle the question of whether a patient’s case fulfils the requirement of rape, incest, or life endangerment needed to obtain the necessary abortion. The report includes recommendations for involving the Native American community in actions for change and ways to work specifically with, as well as potential challenges in working with, Native American populations. An outline guides the reader through the group’s strategy for approaching individual IHS units, and finally, moving on to an international scale.
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This focus group study featured eight women, between ages 18-37, from six different Lakota and Dakota nations, who used IHS as their primary health care providers. The purpose of the study was “to bring awareness to IHS’s present delivery of services to Native American women,” to examine IHS policy and protocol, and to see if women who receive care there felt well informed of their condition, medication, and capable of administering to themselves afterwards. A study such as this also helps initiate formal dialogue between IHS and their patients. The report includes a brief history of IHS, funding, and echoes their mission statement. Statistics comparing the health of Native Americans with all other races indicates a much lower health status. Many women questioned mentioned the lack of information presented to them during their hospital visit. The physicians seem to have no interest in educating their patients about short-long term effects of various RTIs or prevention methods, and this type of attitude leads to women making uninformed decisions about the birth control device appropriate for them. Instead, they often report feeling pressured to use certain kinds of contraceptives, particularly long-term types. Even more shocking is the fact that the men and women these patients see are sometimes not physicians at all but practicing PAs or fraudulent doctors not in good standing with their certification board. IHS also has a history of severely violating their oath of confidentiality, to the point that pregnant women delay seeking prenatal care in order to delay informing the public of the news of their pregnancy. The report includes a review of IHS health care practices and a discussion of the implications of the focus group’s dialogue.
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Written between June-July in 1999, this report examines the level to which young Native American women in the Aberdeen area have been educated on the topic of common reproductive tract infections. The Resource Center has been concerned by the high incidence of RTIs reported in the communities, and, in the process of this report, conducted a focus group discussion with twenty-seven young women between the ages of 14-19 years from seven different Lakota and Dakota nations. The intent of the discussion was to empower the girls’ voices through publication, thus allowing their words to reach school officials, counselors, and policy makers, as well as directly affecting the direction of the Resource Center’s educational programs’ curriculum. The report includes a brief explanation of RTIs and a paragraph on the history of sexual education policy at the area schools. The listed questions were put to the girls in a near survey style, and their responses are reported as quotes. The study found that there was little clarity about the terms RTIs, STDs, and even HIV/AIDS due to the lack of effective or consistent sex-education in schools. Group leaders also recorded the girls’ primary sources of information and their suggestions for improving sex-education curricula. The discussion placed a clear emphasis on culturally specific and appropriate health education, and recommendations include proposals for involving the community and schools in future programs.