We’ll get back to exercise in pregnancy (and postpartum), but not today. Today we go deep in other pools. I have described to some how my initial career intentions – become a physical therapist; be good at it – were somewhat naively based upon the dual premises that I wanted to help people and to understand our physical bodies in order to provide that help. Naïve not to knock the satisfaction to be found in fulfilling both of those original intentions; naïve in that I had no idea I would find myself so fully committed to female pelvic and obstetric health, or that I would be gob-smacked (Dear @GussieGrips, I have been loving ‘gob-smacked’ ever since your introduction!) by how my physical therapy practice intersects with domestic and global issues of gender, human rights, and social justice. Practically-speaking, these have become completely entwined for me, existing on a continuum that factors in the role/value/rights of women in relationship to their health (overall, pelvic and obstetric) and further to the health (in all senses) of their families, communities and cultures. One illustrative and far-from-isolated anecdote – an upper middle class American woman comments about my work in global maternal health, most specifically in obstetric fistula, praising me and offering up “Those poor, poor women. So awful.” Yup. It is awful. Despite rising awareness and action, obscene numbers of women and girls in the developing world continue to lack adequate family planning and obstetric care. But ‘poor them’? How about ‘poor us’? More directly to my patient – Poor You.
You – educated woman, living in metro Boston, MA, in the resource-rich USA, home of medical care renowned to be the best in the world – you were embarrassed to talk to your doctor about your incontinence and pelvic organ prolapse for years and once you did you were summarily told it was a consequence of pregnancy and childbirth and the meaning of these issues to you were dismissed. Five years and three other providers later you finally have a physician (and now a physical therapist) on your team, validating the importance of your health, and working with you to make things better. A generation of years passed from first symptoms to appropriate care. Poor You.
Poor Them/Poor You/Poor Us – no pity; find clarity, empathy, understanding, and change. It is all of this that makes today’s post so timely. It comes from Dr. Meredith Reiches, instructor of the Human Evolutionary Biology Dept. class, Birth, at Harvard University, and she leads in with a reference to The Vagina Monologues. A play that was among my early influencers in developing this ‘continuum’ way of thought and in whose playbill my good-hearted boss allowed me to advertise our newly minted pelvic and obstetric physical therapy program. I don’t think anyone came to me for PT as a result of that playbill, but perhaps I was just ahead of my time.
Out with the poor,
“There is a moment at the end of Eve Ensler’s landmark play, The Vagina Monologues, in which a journalist, asked about the relationship between vaginas and birth, says: “What’s the connection?”
This was the magnitude of omission I felt I’d made when I realized that I taught a semester-long college class about human birth—the evolution of a pelvis that lets us walk upright and a fetal head that must turn to pass through that pelvis, the chemical signals that cause labor to start, the coordination of motor neurons in the uterus that lead to contractions—with barely a mention of the pelvic floor muscles, which are crucial to balance, birth, and urogenital function. The pelvic floor is a particularly important topic in a class focused on evidence-based investigation of contemporary American medical birth practices. Which widespread protocols, rituals, or traditions support pelvic floor health, and which need to be reevaluated?
The importance of the pelvic floor to birth would have escaped me altogether had it not been for a friend whose midwife, at a postpartum checkup, noted that giving birth had weakened the muscles in my friend’s pelvic floor. The midwife advised my friend to get a referral for physical therapy, a process that proved easier said than done: insurance required that the referral originate with a physician, and more than one physician had never heard of the service and described my friend’s condition as the inevitable outcome of vaginal birth. Undeterred, she persevered until she found a urogynecologist who said “What the heck?” and gave her the referral. The resulting therapy improved her pelvic floor function in an experience so dramatic that she began recommending postpartum—and prenatal—consultations with physical therapists widely, even as she started to ask why such consultations were not standard in the US, as they are in other countries including France.
Through my friend, I had the good fortune to meet Jessica McKinney, founder of the pelvic floor practice at Marathon Physical Therapy and of the Share May Flowers movement. Jessica gave an illuminating lecture in my college course on birth, beginning to rectify the knowledge gap in a group of young people who will, I hope, be able to make informed choices about their own pelvic floor health in the future.
It is worth noting that Eve Ensler’s Vagina Monologues use the vagina as a symbol for the entire women. The aim in this activist theater piece is not to reduce women to a single component of their shared anatomy—it’s not the equivalent of using slang terms for body parts to call some one an unkind name—but rather to think of the treatment of vaginas as a litmus test: if vaginas are considered shameful, then something inherent in women is considered shameful. If a culture tolerates callous handling and violation of vaginas, then it is a culture that tolerates callous handling and violation of women.
Like the vagina, the pelvic floor is integral to giving birth, the perpetuation of human life. How remarkable that such an essential anatomical system should be functionally invisible! How outrageous that the people whose bodies labor to give life should be told to expect anything but the most thoughtful, thorough, sensitive care. When full pelvic floor function is within reach, when a modest investment in education and non-invasive therapy could improve quality of life and reduce the human and financial costs of surgery, there is no reasonable justification for withholding knowledge and services.”
Dr. Meredith Reiches, PhD Dr. Reiches is an instructor in the Human Evolutionary Biology Dept. at Harvard University and leads the class, Birth. Her research interests include The Gambia, Human reproductive ecology and endocrinology, ecological variation in puberty, growth and reproductive function in adolescence.