Remembering Ruth

This morning I began the day with a cup of tea, drinking out of one of my favorite mugs with a quote on it from an inspirational woman: Women belong in all places where decisions are being made. I am reading this quote on the morning of one week after the passing of Ruth Bader Ginsburg, originator of this quote, trailblazer and consistent champion for reproductive rights and gender equality. Stories of her life and memory have flooded news outlets, being laid bare for us to get the chance to say thank you for her work and acknowledge where we must all pick up and continue the fight for gender equality.

I wanted to reflect on some of the ways that her civil rights work has made life more equitable for women and girls. Even before she joined the Supreme Court in 1993 and established important precedents and decisions regarding reproductive rights, she co-founded the Women’s Rights Project at the ACLU, an initiative that was devoted entirely to gender equality. She fought fiercely to make sure women’s rights were seen as an essential part of human rights. She may not have gone into law school intending to fight gender discrimination, but her experiences as one of only nine women at Harvard Law School in 1956, being turned down for law jobs despite graduating tied for first place in her class from Columbia Law, and facing unequal pay for equal work while serving as faculty at Rutgers Law School in 1963 set the stage for laws she would help create and cases she would bring to justice.

During her time on the Women’s Rights Project with the ACLU, Ginsburg pushed to have pregnancy discrimination recognized as a form of sex discrimination, fighting against an Air Force policy in 1972 that automatically discharged pregnant officers unless they terminated their pregnancy. Ruth Bader Ginsburg believed that, "The decision whether or not to bear a child is central to a woman's life, to her well-being and dignity. It is a decision she must make for herself. When the government controls that decision for her, she is being treated as less than a full adult human responsible for her own choices." In cases such as Whole Woman’s Health v Hellerstedt (2016) and June Medical Services v Russo (2020) she reinforced the essential nature of abortion and reproductive care as part of healthcare and protective of women’s bodily autonomy and equal status as citizens in this country. She expressed in multiple dissents the need for separation of church and state with regard to contraception coverage, a logical response since numerous studies show decreases in STIs, teen pregnancy, and abortions with comprehensive sexual health education and access to contraception over abstinence only education and restrictions placed on access to contraception and abortion. Ginsburg paved the way for women to obtain financial independence through the Equal Credit Opportunity Act passed in 1974, having downstream effects of everything from decreasing their risk for being trapped in abusive relationships to realizing their talents and dreams. Finally, she helped the world see that sex discrimination is damaging for both men and women through representing Charles Moritz in 1968, ultimately proving that men are entitled to the same caregiving and social security rights as women.

Ruth Bader Ginsburg made space for women to be in all places where decisions are being made building on the work of other trailblazing women before her, and I am grateful for all the ways that she has shaped my ability to be in my final year of medical school irrespective of my sex. In medical school, we learn about social determinants of health and how they affect our patient’s wellbeing and overall physical and mental health. Societies inequalities, gender based discrimination included, have many implications on health and I am happy to continue working toward gender equality alongside the generations of feminists Ruth Bader Ginsburg has inspired.

Anna Braginskaya M.D. Candidate, Class of 2021 Drexel University College of Medicine

IBD and Pregnancy

The intersection of women’s health and gastroenterology gives way to an interesting discussion of sexual, reproductive, and mental health. Most inflammatory bowel disease (IBD) is diagnosed between 15-26 years of age or later in life between 50-80 years.  The first peak of onset comes at a critical time for women’s sexual and reproductive health. For example, 1306 women with IBD enrolled in the Crohn’s and Colitis Foundation of America, were surveyed about vulvovaginal symptoms including vaginal itch, burn, discharge, dryness and pain (Ona et. al, 2017). Women with constant or frequently active IBD have increased odds for vaginal discomfort (OR 2.01, 95% CI 1.46, 2.78), vulvovaginal discomfort, decreased interest in sex for 55% of women, or ability to have sex in 47% of women surveyed (Ona et. al, 2017). From an early age, gastrointestinal health can significantly impact quality of life for many individuals. 

There is a spectrum of considerations when it comes to discussion of IBD in pregnancy, specifically. A study conducted at Icahn School of Medicine at Mount Sinai found that mothers with IBD often have gut dysbiosis during pregnancy that is reflected in the offspring’s gut microbiome (Torres et. al, 2020). Specifically, they often have lower alpha diversity during the first and second trimester of pregnancy and different beta diversity during each trimester compared to mothers without IBD. Offspring of these mothers presented with reduced bacterial diversity that persisted from the first week of life through 3 months; this includes a reduction in Bifidobacterium which usually aids in maturation of the immune system and protection from colitis (Torres et. al, 2020). The infant microbiome profile varied with infant exposure to antibiotics, feeding and delivery method. Interestingly, Caesarean section and exposure to antibiotics during pregnancy and early life have been shown to increase the risk of IBD. On the other hand, breastfeeding is shown to be protective against IBD (Torres et. al, 2020). This data lends itself to investigating how to promote gut microbiome diversity in mothers with IBD and indirectly offspring.  

Research shows that mothers with IBD are at a small but significantly increased risk of new-onset psychiatric diagnosis during the postpartum period — specifically mood/anxiety disorders and substance-related disorders — when compared to their non-IBD counterparts (Vigod et. al, 2019). Furthermore, mothers with Crohn’s are at higher risk than those with ulcerative colitis (Vigod et. al, 2019). This information is consistent with the American Gastroenterological Association’s ‘Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway’ that calls for a multidisciplinary model to include MFM physicians, IBD specialized gastroenterologists, family planning and behavioral specialists who address the increased risk of psychiatric illness in mothers with IBD. This collaborative approach helps the expectant mother navigate IBD-specific items, including finding therapies safe in conception, pregnancy or lactation, as well as the higher risk of miscarriage, small-for-gestational-age infant, premature delivery, poor maternal weight gain, and complications of labor and delivery in IBD.  

Roshni Singh   DUCOM 2020

Mahadevan, U., Robinson, C., Bernasko, N., Boland, B., Chambers, C., Dubinsky, M., Friedman, S., Manthey, J. , Sauberan, J., Stone, J., Jain, R. (2019). Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD Parenthood Project working group. Gastroenterology, 156(5), 1508 – 1524. 

Ona, S., James, K., Long, M., Martin, C., Chen, W., Mitchell, C. (2017). Prevalence of vulvovaginal discomfort in a cohort of women with inflammatory bowel disease. American Journal of Obstetrics and Gynecology, 217(6), 740.  

Torres, J., Hu, J., Eisele, C., Nair, N., Huang, R., Tarassishin, L., Jharap, B., Cote-Daigneault, J., Mao, Q., Britton, G., Uzzan, M. Chen, C., George, J., Lrgnani, P., Maser, E., Loudon, H., Stone, J., Dubinsky, M., Faith, J., Clemente, J., Mehandru, S., Colombel, J., Peter, I. (2020). Infants born to mothers with IBD present with altered gut microbiome that transfers abnormalities of the adaptive immune system to germ-free mice. Gut, 69(1), 42-51. 

Vigod, S., Kurdyak, P., Brown, H., Nguyen, G., Targownik, L., Seow, C., Kuenzig, M., Benchimol, E. (2019). Inflammatory bowel disease and new-onset psychiatric disorders in pregnancy and post partum: a population-based cohort study. Gut, 68(9), 1597-1605.