Human Trafficking in the US is Real! Here’s How Nurses Can Help

by, Leith Merrow Mullaly, RN, MSN, IBCLC

Sex trafficking is a form of modern slavery that exists in our own backyard. Traffickers resort to violence, threats, lies and other forms of intimidation to force both adults and children to take part in sexual acts against their will. Sex trafficking can occur anywhere, even in your very own community.

In 2016, the National Center for Missing & Exploited Children estimated that 1 in 6 endangered runaways reported to their Center were likely sex trafficking victims.  The Urban Institute estimated that the underground sex economy ranged from $39.9 million in Denver, Colorado, to $290 million in Atlanta, Georgia.  Prostitutes are victims of these crimes.

Yet, sadly, since 2007 the National Human Trafficking Resource Center Hotline has received only 145,764 calls*  (1-888-373-7888).  Why is this? Many of the victims of sex trafficking have no knowledge that such a resource even exists.  To make a phone call to get help is not possible for most victims as communication is strictly controlled and monitored by the pimp who has all the power.  Perhaps, we nurses should have this phone number posted in areas where women in your care can see it.  Nurses should also be aware of the warning signs associated with trafficking, and  when we suspect our patient/client may be such a victim, we should hand them a phone!

Commercially exploited children in our country have almost universally been sexually abused and enter prostitution with a history of complex trauma.  Their families have been absent or dysfunctional.  Several young women with whom I work were identified by teachers as abused (eg, a 7 year old who wouldn’t change gym clothes because of bruises all over her body).  There  were mixed reaction from teachers.  Some did follow up with local child protective services.  Some called parents.  One young woman told me “My teacher was concerned but my mother denied any sexual abuse but then said ‘well, she is so suggestive around my husband’; I was 6 years old!”  Many girls tried to tell an adult but many were afraid.  Some shared “I have told people and nobody believed me”.  Some were placed in foster homes, and believe it or not, they were molested and recruited by their pimps from the foster care system.

What can nurses do?  This may seem so much bigger than what we can do as individuals. But we can develop a more acute awareness about the realities of human sex trafficking right in our own environment.   When you hear or suspect human sex trafficking may be occurring to the patient sitting before you, believe them!  They very frequently display a fearful, distrusting affect because many times they have tried to tell and NOT been believed.  Offer them your belief.   Former President Jimmy Carter wrote an editorial in the Washington Post (May 31, 2016) entitled: “Curb prostitution, punish those who buy sex rather than those who sell it”.  I recommend reading this. Carter describes the “Nordic Model” which is a system that treats purchasing and profiting from sex as major serious crimes.  That might be something for which nurses in small or large groups, such as an AWHONN  Chapter or Section, can advocate for at their own local or state level.  Just imagine the impact it could have if the men in your community who are purchasing sex were prosecuted and exposed in public as the criminals they actually are.  We have heard “but he is a pastor” and “but he is on city council” and “ their reputations would be destroyed”.  Women and children who are sold for sex face more than ruined reputations, they face ruined lives!

As health care providers and patient advocates we must begin to work vigorously with our own elected officials to change the unacceptable and shocking status quo.  Did you know that trafficked children are treated as criminals in many jurisdictions even though under Federal law those under 18 years old are classified as victims?

My state, the Commonwealth of Virginia, was the last state in the country to pass a stand-alone human sex trafficking law (2015).  Now, anyone assisting, or working to traffic, sell or purchase prostitution can be arrested and charged.  This law came about because of the incredible tenacity and diligent work of a very few advocates working with their local legislators.  They provided both Representatives and their constituents with education on this issue.

Health education has always been a strong focus for nurses.  The public looks to us to educate them and the public trusts nurses to provide solid, honest information.  My “own public” sat in disbelief when we first started talking about sex trafficking right here where we live and work.  I heard comments like “No way, this is a lovely community.  Not here!”  As they learned the realities they were initially horrified, but now are very energized to help in any number of ways.  We also can’t  forget to educate parents.  They need to know that when young teens, girls and boys, meet other “youth” on the internet they are often opening themselves to traffickers.  When middle and high school kids sext and post photos they can and do become easy prey to predators.

If your community doubts the very idea of sex trafficking in your town, send them to a website called “Backpage”.  It is a trafficking website that lists ads for prostitution.  In my small size city there are more than 20 ads a day!  “Plenty of Fish” is another site that purports to be a dating site. We have had some of our trafficked victims “hooked up” on this site with “clients” purchasing sex.  If a nearly naked woman is advertising to come to a hotel room to provide a “massage”, read between the lines.  If the face is blurred, it most likely means the girl is a young minor.  If you look…unfortunately you will find human sex trafficking right in your own backyard.

Overwhelmingly the young women with whom I work had dreams of growing up to be moms or lawyers or teachers or doctors or nurses.  One girl had seriously and sincerely wanted to be an astronaut.  No one ever dreamed of growing up to be a prostitute!  They were brought into the “life style” as young minors.    They did not choose the life and do NOT benefit financially (a common misconception).  Once used, these victims are humiliated, shamed, embarrassed and trapped in a system they despise but have no idea how to escape.  Many seem to know of a girl who tried to escape who either “disappeared” or who was re-captured with her photo posted on line with her head shaved and tattooed by  her pimp.

NURSES CAN MAKE A HUGE DIFFERENCE if we just start working together to: 

  • Learn the facts about Human Sex Trafficking in our own communities
  • Work more closely with local and state law enforcement
  • Provide vitally-needed education to our peers, friends, organizations and parent groups
  • Advocate with legislators to enforce the law and explore alternatives such as the “Nordic Model” which is now used in Canada, France and Sweden
  • Believe a patient who trusts you enough to share their situation
  • Post the National Human Trafficking Resource Center Hotline – 1-888-373-7888—in a visible location in your setting
  • Be hyper-alert to telltale signs such as :
    • Tattoos or branding
    • Very unclear past history and no stable address
    • STD’s, especially repeated episodes
    • Wearing scanty clothes – often 2 sizes too small
    • Presence of cotton or debris in vagina and/ or rectum
    • Problems with jaw or neck
    • Inability to keep appointments
    • No identification
    • Accompanied by a person who does not allow the patient to speak or does not want to leave them alone during interview and/or care
    • Inconsistent stories (conflicting stories or misinformation)
    • Lack of documentation of age- appropriate immunizations and health care encounters

There are 3 million nurses in our country.  I believe that together we have the power to change hearts and minds so that our local communities and our nation understand the realities of human sex trafficking.  I serve on the Foundation Board of a home for victims. Our motto is: “Changing one life at a time and changing the world for future generations”.  I have seen the first goal come true with individual young women.  Won’t you join me in meeting both goals?

AWHONN believes Nurses are ideally positioned to screen, identify, care for, provide referral services for, and support victims of human trafficking. Therefore, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) supports improved education and awareness for nurses regarding human trafficking. Learn more about AWHONN’s position on this critical topic.

Resources:


References

*Number of calls reported to the Human Trafficking Hotline as of December 2016 for more information visit https://humantraffickinghotline.org/

Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities

National Center for Missing & Exploited Children

Urban Institute


leithLeith Merrow Mullaly, RN, MSN, IBCLC
Leith Mullaly is a past president of AWHONN and has served at all levels of the organization. Leith has a passion for both nursing and the specialty of Women’s Health and Newborn care. Her focus within AWHONN has always been to mentor future leaders and encourage nurses’ participation in their professional association. She has experience as a Staff Nurse, Staff Educator, MCH Director, Clinical Faculty Member, Certified Lactation Consultant and Author. She is a nationally ranked speaker on topics such as Postpartum Depression, Breastfeeding, the Image of Nursing, Service Excellence, Perinatal Loss and Bereavement, Mature Primiparas. Her interest in care for Victims of Human Sex Trafficking has been a major focus for the past several years.

Lessening the Risk of Birth Trauma

By Karin Beschen, LMHC

 “I was at a routine dental office visit a few weeks after my daughter was born. I remember being reclined in the chair, the bright overhead light and the scent of latex.  Images of surgical masks whipped through my mind.  Fear rushed through my body and I shook uncontrollably.  My body felt hollow and numb but also heavy and out of control.  In that moment I truly believed I was having another emergency c-section.”

This quote is from a woman who experienced a traumatic birth.  She is the mother of a beautiful baby and has had many moments of joy and connection, but also times of panic and fear.  “Mini movies” of her daughter’s birth play in her mind throughout the day.  She deleted the photos of her daughter in the NICU and she wants to disappear when her friends talk about pregnancy.  The birth didn’t end when her baby was born; it followed her from the hospital and it has interfered with many aspects of her life.

Research reveals that between 33-45% of women perceive their births to be traumatic. (Beck, 2013).  Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant.  The birthing woman experiences intense fear, helplessness, loss of control and horror.”  (Beck, 2004a, p. 28).

Approximately 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:

  • Prolapsed cord
  • Unplanned cesarean
  • Use of vacuum extractor or forceps to deliver the baby
  • Baby going to NICU
  • Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
  • Women who have experienced previous trauma, such as rape or sexual abuse
  • Women who have experienced a severe complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3rd or 4th degree tear), or cardiac disease

My therapy work with mothers is typically after a traumatic birth.  The more I learn about the mother’s labor and birth experience, the more I can understand what care and education could have better supported her during  birth.

The “3 E’s” – explain, encourage and empathize – can be a useful framework for obstetrical staff in lessening the risk of a traumatic birth.  

Explain  

When explaining a process, options or a procedure, always include the woman in the discussion of her own care.  There is a distinct difference in hearing a discussion and being a part of one.  If plans change, explain what is happening and what is needed to correct the situation.

Encourage

The connection a mother has with those caring for her during childbirth is deep — you are present during one of the most emotional, unpredictable times in her life.  Encouragement is empowering and can offer the mother a sense of control.  Encourage questions.   If plans change, discuss possible alternatives.   Using “we” in conversations shows alignment and rallying together.

Empathize 

Women in labor yearn for companionship, support and empathy.

Phrases such as “I know,”  “I’m here,” and “Yes” are phrases that connect staff with a woman’s experience when she feels pain, fear, disappointment or frustration.

I’ve heard many birth stories over the years; devastating stories of physical compromise, intense fear and loss of the baby’s life.  How the mother is cared for, is what she remembers.  The tone of your voice.  The gentleness.  The validation of feelings.  One of my clients was unaware she was being rushed for an emergency cesarean.  She said in all of the chaos and in a knee-chest position, she extended her arm and a nurse held her hand.  Beauty within terror.   It was a simple gesture and it has been the most powerful, healing memory for her.   Even in the midst of an emergency, someone saw her need.  Someone saw her.

Obstetric staff has great influence on how a mother remembers her birth experience.  Expressing empathy and explaining and encouraging a laboring and postpartum mom can influence her health and well-being.  New mothers who receive the “3 Es” can better transition to home, experience less anxiety, have more positive feelings about themselves and improved bonding with their babies.


Karin Beschen is a Licensed Mental Health Counselor specializing in reproductive and maternal mental health.  She also serves as a volunteer co-coordinator for Iowa for Postpartum Support International.

 

 

Additional Resources

Postpartum Support International 

PaTTCh (Prevention and Treatment of Traumatic Birth)

Improving Birth

References

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic Childbirth New York, NY: Routledge.

 

 

 

We May Have Different Religions

By Evgeniya Larionova

“We may have different religions, different languages, different colored skin, but we all belong to one human race”. –Kofi Annan (Ghanian Diplomat, 7th UN Secretary-General, 2001 Nobel Peace Prize winner)

What is exactly childbirth? Some people compare it to a miracle, a heroic act, or a surge of love accompanied by strenuous and intense hours of labor. It’s absolutely one the most unique experiences that can happen to a woman’s body. The time when she is particularly vulnerable and in need of much support and care.

For me, a nurse practitioner student on labor and delivery floor at Massachusetts General Hospital, witnessing childbirth was something that I would never forget. Thrown into the action on a first clinical day, I had mixed feelings of joy, excitement and a slight nervousness. I felt extremely privileged and grateful to witness a natural delivery and I was hoping to help a future-to-be mom during the process.

From the morning report I found out that the woman I was assigned to follow was a recent immigrant from Guatemala who belongs to the indigenous Mayan population. Mayan was the patient’s native language but she was also able to understand Spanish. Her husband had been residing in the United States for 5 years. She moved here a year ago and the family has finally reunited.

My patient was accompanied by a traditional nurse midwife known as comadrona. Comadronas are trusted women leaders in their communities who accepted a spiritual calling. They usually don’t receive any formal training but have years of experience delivering babies. Comadronas regard birth as a natural process and rely heavily on God and prayers. The nurses established a plan of care recognizing my patient’s spirituality and personal support system. The Mayan midwife was present during labor and helped with comfort measures. The nurses also invited a qualified interpreter.

When I entered the room, a nurse and a midwife, along with the comadrona, surrounded the tiny woman. One of the nurses was checking her vital signs and the nurse-midwife was encouraging the woman to take slow deep breaths and relax. The comadrona, wearing a traditional colorful embroidered dress, was gently massaging her back. The room was dimly lit and the scent of fresh lavender floated in the air. My patient’s contractions were increasing steadily and were becoming more regular. This was active labor –she was ready to give birth.

The whole atmosphere struck me. There was no other language present in the room but the language of trust, respect and compassion between these women. I immediately wanted to become connected with what was happening- just by holding this woman’s hand and talking to her.

Reflecting back on this experience, I understood that nurses not only created the environment that made this woman feel comfortable and that was respectful of her spirituality but that the environment also had a significant impact on the labor and birth process. Although childbirth is unique and at the same time a unifying biological event for any woman; providing therapeutic communication, physical, emotional, spiritual care and comfort during the labor process is crucial.

The comadrona shared her knowledge and experience with the American nurses. It was important for my patient to have a traditional midwife near the bedside who comforted and prayed with her. There was interplay between modern and traditional medicine that contributed to the positive outcome. Nurses in this particular case were not only culturally sensitive and able to understand cultural values, beliefs and attitudes of clinicians and patients, but also culturally competent and had knowledge, capacity and skills to provide high-quality care (Jernigan et al, 2016).

It’s essential for any nurse in such a unique, heterogeneous country like the United States to be cognizant and open-minded of cultural diversity and the patient’s cultural perspectives. I will take this amazing experience to my future nursing practice and strive to always treat my patients with dignity, respect and compassion. I also hope to continue to integrate a holistic model and culturally sensitive care into our modern childbirth practices.

This woman gave birth to a beautiful baby daughter whom she named after a nurse taking care of her during her labor and birth.

Additional Resources & References
http://prontointernational.org/
https://he-he.org/en/
http://www.mayamidwifery.org/
http://midwivesformidwives.org/guatemala/
http://www.birth-institute.com/study-abroad-guatemala/
http://www.acog.org/
Jernigan, V. B. B., Hearod, J. B., Tran, K., Norris, K. C., & Buchwald, D. (2016). An Examination of Cultural Competence Training in US Medical Education Guided by the Tool for Assessing Cultural Competence Training.Journal of Health Disparities Research and Practice, 9(3), 150–167.


evgeniya-headshotEvgeniya Larionova received her Bachelors of Science in Nursing from MGH Institute of Health Professions. She is a founder and an Artistic Director of AMGITS Drama&Poetry Club at the Boston Living Center. She is a member of the student Leadership Committee of the Harvard Medical School Center for Primary Care. Evgeniya is passionate about infectious diseases, community health and integrating holistic care in modern practices.  In her spare time she plays in the Russian theater, enjoy reading, playing the guitar and hiking.

What You Need to Know About Light Bladder Leakage

By Susan A Peck, RNC, MSN-APN

What do a 30 year old pregnant woman, a 67 year old who has 3 children – all delivered vaginally- and a 45 year who has never been pregnant have in common?  They are all experiencing light bladder leakage and each of them feels embarrassed to discuss it.  Bladder leakage is very common and can occur in any woman, of any age, and of any pregnancy status!

Light bladder leakage also known as urinary incontinence, is an involuntary loss of urine.  It is estimated to occur in up to 1 in 4 women.  The two most common types of incontinence include stress incontinence and urge incontinence, but some women can have a combination of both types.

  • Stress incontinence is the loss of urine (small or large amounts) from activities that cause pressure on your bladder such as coughing, running, jumping, or sneezing. It happens when the pelvic floor muscles- that support the bladder- weaken.  The weakened muscles can be caused by pregnancy, previous vaginal births, obesity or being overweight or chronic urinary tract infections.  Sometimes, incontinence may occur without any of these risk factors.
  • Urge incontinence is the frequent sudden need to urinate that often causes bladder contractions and the loss of small or moderate amounts of urine. It happens from bladder irritants such as caffeine or alcohol, excessive hydration, use of certain medications such as diuretics (water pills), or neurological conditions.  In some women, this may be called an overactive bladder.

As a Women’s Health Nurse Practitioner, I ask my patients about bladder leakage and incontinence- because most of the time they will not mention it to me first. Here are two stories which are very similar to real life cases I see every day.    The first was a 55 year old fitness instructor who has 3 children, all delivered vaginally.  She sees me once a year for her annual well woman exam and this year when I asked her if she had any bladder leakage, she said yes, that it just started about 6 months prior.  She was quite surprised by this because she teaches Pilates as well as Zumba and thought she had a pretty “strong core”.  But lately, in Zumba class she would feel dribbles of urine coming out.  She was embarrassed someone would see it on her pants, so she’s started to wear a pad to class, but hated exercising while wearing one. Patient B is 30 years old, a mother to a 2 year old son born via cesarean section and working full time.  When I asked her about incontinence, she told me that since her son was born, she leaks urine each time she coughs or sneezes and notices that it happens more when she drinks coffee – the caffeine she needs because of her busy life!  She was also quite surprised that the leakage is happening because “she is young and did not have a vaginal birth”.

Both of these women were surprised to know how common bladder leakage is, but very happy to know they are not alone.  During their pelvic examinations, I asked them to each perform a Kegel exercise- by contracting the pelvic floor- so that I could assess their pelvic floor tone.  The Patient A did the Kegel correctly, but had poor tone.  Patient B did not perform the Kegel correctly – instead she was bearing down/pushing out.  I routinely test my patients for their pelvic floor tone and at least 50% of the time, tone is poor, or the exercise is not performed correctly.

Below are some tips to help maintain good pelvic floor muscle tone, which is is critical to prevent or improve bladder leakage.

  • Kegel exercises are the easiest way to strengthen these muscles, as well as pilates exercises which focus on strengthening the core. Here is a link from the Mayo Clinic to assure you’re practicing them correctly.
  • Weight loss is very important in the management of bladder leakage. Even just a 5-10 lb loss can relieve some abdominal pressure against the bladder.
  • Try to reduce exposure to bladder irritants such as caffeine and alcohol and to not let your bladder get too full – even during busy days!
  • For some women, referral to a physical therapist that specializes in pelvic floor physical therapy can also be very helpful. Yes, there are physical therapists that specialize in this important muscle group!  In situations where these conservative measures do not help sufficiently, there are urogynecologist physicians – who are gynecologists who have a sub-specialty in pelvic floor medicine- who may offer other treatments including surgery.

Light bladder leakage is a common complaint among women of all ages.  If you are experiencing this, please mention it to your nurse or health care provider, if they don’t ask about it first.  Many women believe it is a normal part of ageing or a normal consequence of pregnancies or childbirth – but there are ways to help, so do not feel embarrassed or uncomfortable bringing up the subject and asking for help.


RRWJMS20150428

Susan A. Peck, RNC, MSN, APN is a practicing Women’s Health Nurse Practitioner. For 20 years, Ms. Peck’s career has focused on women’s health care, first as a labor and delivery staff nurse and for the last 16 years as an Advanced Practice Nurse. She currently works in the Department of Obstetrics & Gynecology within Summit Medical Group, a large multi-specialty practice group in Northern New Jersey.

Ms. Peck’s areas of expertise include contraception, osteoporosis, general gynecology and prenatal care. She has spoken at several national and state conferences including the AWHONN National Convention.

The Benefits of Prenatal Yoga

by, Lori Boggan, RN

The popularity of yoga has grown exponentially over the last many years in the western world. More and more studies are proving the benefits of a regular yoga practice. So how can yoga benefit the expectant mother? A 2015 study from Brown University suggests that yoga can be an effective alternative treatment for women suffering from depression during pregnancy. Another study from The University of California, Irvine, showed decreased cortisol levels and higher affect on the days the pregnant yoga group practiced. While most women can safely practice prenatal yoga during pregnancy, there are some conditions that may preclude yoga so women should always ask their midwife or doctor before starting. Conditions such as increased risk for preterm birth, placenta previa, premature rupture of membranes, or preeclampsia are other likely contra-indications. The following are just a few of the many benefits of prenatal yoga.

Connection to Breath

Prenatal yoga teaches the mom-to-be how to connect deeply to the breath, a breath that taps into the parasympathetic nervous system. In this state of deep relaxation, the baby benefits as well. The breath is the earliest bond that connects mom and baby on the deepest level. Also, the deep breathing that is practiced in prenatal yoga can relieve stress and anxiety and improve sleep. The breath learned and practiced week after week in prenatal yoga class can be used as a tool to guide her through the labor process.

Increased Flexibility

Gentle stretching and opening of the hips and pelvic floor muscles prepare the body months in advance to yield for the baby’s passage. Regular modified squatting as practiced in prenatal yoga can open the pelvic outlet by as much as 30 percent. The mom-to-be learns positions in class that can be used in labor to ease baby’s passage and possibly shorten labor.

Mental Preparation & Increased Strength

I tell my prenatal students to imagine they were about to run a marathon and had not prepared physically or mentally in any way. While they would of course make the finish line, had they prepared they will have been more apt and conditioned to face the challenges along the way. Prenatal students are guided through poses that test their strength and breath in preparation for their journey through labor. The added benefit of these exercises is strong legs for pushing and strong arms for baby holding.

Connection to Baby

Showing up every week to yoga class allows the expectant mom an hour of uninterrupted connection with her baby. Prenatal yoga allows her to connect to the living, growing being in her womb. It is a sweet meditation between mom and baby in anticipation of their first encounter.

Alleviation of Pregnancy Aches

Depending on the ailment of the day, there is almost guaranteed a yoga pose that can in some way alleviate it. Prenatal class allows a woman to practice in a safe environment guided by a teacher with knowledge of the common aches and complaints of pregnancy. From headaches to heartburn, carpel tunnel, constipation, low back pain, and/or achy feet, the yoga instructor guides the students through poses that can help relieve and soothe some of their complaints.

Creation of Community

Prenatal yoga brings women together during the most exciting, challenging and, rewarding days of their lives. Friendships are made out of the sheer desire to know that the mamas truly are not alone in this journey. These friendships and their support continue to grow long after their babies arrive.

While more research will likely prove the benefits, it is easy to witness in a class full of focused, happy mamas. Childbirth educator and Prenatal Yoga Teacher/Director of Mama Tree in San Francisco, Jane Austin, sums it up perfectly. “It is very common that when a woman gets pregnant, she looks outside of herself and her own experience for answers. Yoga gives women the opportunity to look within, to pay attention to how she is feeling not only physically but mentally and emotionally as well. When a mama tunes into her own experience and really pays attention, it often amazes her what she discovers. She has a wealth of wisdom and an inner knowing that can surface if she creates the space to listen. Yoga helps create that space.” Stay tuned for my interview with Jane on the benefits of postnatal yoga.

img006Lori is a neonatal nurse that has made her way to Sweden. She is also a Yoga Alliance Certified Yoga Teacher and Certified Prenatal/Postnatal Yoga Teacher. Follow her adventures working and traveling through Europe in her blog, Neonurse, or on Instagram.

References

Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes.
The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms.
Potential for prenatal yoga to serve as an intervention to treat depression during pregnancy.

https://www.ncbi.nlm.nih.gov/pubmed/24767955
https://www.ncbi.nlm.nih.gov/pubmed/25747520

Human Trafficking in Our Own Backyards

by, Leith Merrow Mullaly, RN, MSN, IBCLC

Learn more about AWHONN’s position on this critical topic.

Slim and obese, tall and short, strikingly beautiful and very plain, black, Asian and white…literally the girls who live next door.  These are the young women I support and with whom I work.  They are all victims of sex trafficking right here in the “good ole U.S.A.”

Most of us think of sex trafficking as something that occurs in Africa, Southeast Asia, the Middle East, Russia or South America.  Unfortunately it is estimated that there are almost 300,000 women, children and even men who are trafficked for sexual purposes in our own country.  I have been told by multiple young women that there is not a single hotel or motel in the United States where a prostitute cannot be obtained!  This includes the most expensive and elegant big city hotel to the most humble rural establishment.

Prostitution is much more lucrative than drug dealing.  A single pimp can earn more than $1.5 million every six months with 6 women or children in their “stable”.  The chances of being apprehended are fairly small and there is often no one to testify against the pimp.  I have worked closely with a young woman who finally agreed to testify against her pimp only when the F.B.I. put her into hiding.  Two previous potential witnesses had “disappeared” and are assumed to have been killed.  (It is most distressing to learn that this pimp is a husband and father with children in an elite private school.  He is a highly respected businessman who owns several companies and is known for his charitable giving!)

My husband and I serve on one of the few Foundation Boards in our nation that is providing real hands-on help to these young women.  This sheltered home, provided by  the county and located in a small city,  offers not only a safe escape away from their dangerous traffickers/pimps but most importantly, individual and group trauma-based counseling  because many of our residents are suffering from PTSD, dissociative and other personality disorders.  Most of our residents were on the street by age 14!   Many of our young women are pretty badly damaged and not easy to handle initially. They are combative and angry and extremely defensive.  They cannot TRUST!  They express profound shame and state “I feel so dirty”. We take them to free clinics to treat their STDs and obtain medications for their anxiety disorders, which are often severe.  We help them finish their GED certification and work closely with our community college on educational opportunities.  We offer classes on body image.  We try to introduce them to what a healthy male-female relationship should be via “Pizza Night”. One or two married couples, who really care, bring pizza and spend the evening eating and visiting.  Sadly, for some of our young women, this is a totally new experience. Things that you and I accept as common and expected, these women have never known.  We held the very first birthday party for a twenty year old!

One day a young woman decided she really wanted to move forward.  She asked if we thought there was a “thrift shop for prostitutes” where she could donate all her clothes “because some of these outfits were very expensive”! Instead, we had a big bon fire!  Today she is in college, hoping to become a nurse.  As nurses, we have seen and experienced so many facets of life.  We know about child sexual abuse.  Yet, have we really considered what happens to them long term?  Certainly many children receive help, counseling and appropriate adult love and support.   I must confess that I had not consciously made the direct connection between abused children and victims of sex trafficking.  Men in prison have bragged that they can spot a vulnerable young person in less than 2 minutes!  I was truly ignorant about the scope and size of sex trafficking…right here in our own backyard.  This is the impact and outcome for many victims of childhood physical and sexual abuse.  I sincerely hope that I may open your eyes and hearts so that when you see a prostitute, you see a victim and not a criminal.

When you see a young woman “on the street” or in your clinic, L&D or E.D. be alert to signs and indicators of possible human trafficking.  While not all signs prove human sexual trafficking, some of the following should be “red flags”:

  • No stable address & no family, community connections
  • Very unclear past history
  • An overbearing male companion
  • A “beaten-up” body, often with healing scars
  • A number tattoo (pimp’ s ID)
  • Emaciated, starved appearance
  • STD (almost 100%)
  • Scanty clothes (often 2 sizes too small & often animal prints)

When you encounter these kinds of signs we need to at least think “sex traffic victim”.  Yes, victim!  Most, if not all young women and to a lesser degree, young men, end up on the street because they are victims of repeated child sexual abuse at home.  Pimps brag that they can spot a “vulnerable prospect” in 2 to 10 minutes!

As nurses we need to grasp the pervasive nature of this problem…NOT in some far off country, but rather, right here at home…in our own backyards.  I was naïve about all this until I became involved with one of the very few homes in the United States offering a safe haven for these young women.  We work with the state police, the F.B.I. and Homeland Security to get sex- trafficked women off the street.  It is estimated that there are only 100 beds nationally for sex trafficked women over the age of 18 and only another 100 beds for those less than 18 years old.

I’ll be writing more about this topic and what we can all do to help these victims in upcoming AWHONN Connections blogs.

_______

AWHONN believes Nurses are ideally positioned to screen, identify, care for, provide referral services for, and support victims of human trafficking. Therefore, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) supports improved education and awareness for nurses regarding human trafficking. Learn more about AWHONN’s position on this critical topic.

leithLeith Merrow Mullaly, RN, MSN, IBCLC
Leith Mullaly is a past president of AWHONN and has served at all levels of the organization. Leith has a passion for both nursing and the specialty of Women’s Health and Newborn care. Her focus within AWHONN has always been to mentor future leaders and encourage nurses’ participation in their professional association. She has experience as a Staff Nurse, Staff Educator, MCH Director, Clinical Faculty Member, Certified Lactation Consultant and Author. She is a nationally ranked speaker on topics such as Postpartum Depression, Breastfeeding, the Image of Nursing, Service Excellence, Perinatal Loss and Bereavement, Mature Primiparas. Her interest in care for Victims of Human Sex Trafficking has been a major focus for the past several years.

Ladies on a Mission

Guatemala

by, Lori Boggan, RN

When we enter the medical profession, we make a lifetime commitment to the service of others.  As nurses, we serve our patients, our community, our friends, and our family.  No other profession has such a deep connection to and is so trusted by society.  We are the ones at the bedside day and night.  We are the ones that our patients trust with their privacy, their secrets, and their lives.

Volunteer nursing is no foreign concept for American nurses.  In fact, the earliest “nurses” were nuns, or family members of those active in the Civil War.  They were in the trenches before any formal nursing education or organization existed.

For most, nursing is a calling.  Nurses are innate caregivers.  What is it about a nurse that is willing to use her own money, travel to an unfamiliar place sometimes lacking basic accommodations, and work long hours without pay?  It is the drive to care for those in need.

The following interview is with one of AWHONN’s own that goes above and beyond.  Nancy Stephani Zicker, a labor and delivery nurse from Central Florida has journeyed to Guatemala yearly since 2014 to help less fortunate women in need of gynecological surgery.  She journeys with her friend and obstetrician, Dr. Cecille Tapia-Santiago, of Volusia ObGyn Daytona Beach.  In addition to gynecological surgeries each year, Dr. Tapia sees patients in the mission’s clinic and educates Guatemalan midwives.  I interviewed both ladies in hope to inspire others to join mission work.

How long have you been going on missions?

Nancy:  I have been going on yearly medical mission trips every March since 2014.

Cecille:  I have been doing 1-3 mission trips a year since 2000.


Where has your mission work taken you?

Both: Guatemala


Why Guatemala?  Is there any particular need there with regard to women and infant’s health?

Cecille:  Absolutely. When we go there we provide contraceptive care, well woman care, and manage surgical conditions (uterine fibroids, large ovarian cysts, and pelvic prolapse being the most common).


Describe a typical day in the life of a volunteer nurse.

Nancy:  Each year that I have gone, I have been assigned to work as a circulating nurse (and sometimes scrub in to tech or assist) in the OR. There are clinic nurses, OR nurses, PACU nurses and ward (floor) nurses.

FullSizeRender-100We go in to a completely bare room and make it a functioning OR.

As an OR nurse, we first have to unpack and sort all of our supplies, as well as set up the operating rooms. We arrive on a Saturday late afternoon and get right to work. Sometimes we set up in community centers and sometimes we set up in an actual hospital. This usually takes Saturday evening and all day Sunday to accomplish.

Monday morning, the surgeries begin. Depending on the number of cases scheduled, we usually are in the OR from 8am-5pm. Once all surgeries are done at the end of the week, we have to break down the ORs to leave the space as we found it and inventory all supplies so we can order more for next year.  We all have had to improvise and be creative with available equipment and supplies. It’s quite the challenge, but the entire team comes together and we make it work.z


20140306_102410Cecille, describe your work educating midwives in Guatemala

It’s THE BEST PART. Midwives in Guatemala are mostly lay (no formal training at all). Guatemala has one of the highest infant mortality rates in the world. We do 1-2 day seminars and teach basic infant resuscitation as well as basic management of labor, delivery and postpartum complications. The midwives have to deal with a lot of prejudice from the physician community and often won’t get paid for their service if the patient has to be transferred to a hospital.  So anything they can do to show their critics that they are furthering their education and are doing right by a patient is helpful.

Is there any one particular patient story that you can share that stands out in your mind where you felt you really made a difference in that patient’s life? 

Cecille:  One of the midwives came back to a refresher course and told us that she gave CPR to a baby with apnea. Initially the family was resistant and thought the baby was dead. The midwife pulled out her certificate from the seminar and showed the family. She told the family to let her try and do CPR. She successfully performed mouth to mouth and chest compressions and the baby was fine!  We also had a young lady with an enormous pelvic mass that was compressing her entire abdomen and pelvis. She had been turned down by everyone and when we saw her, she was cachectic and probably a few weeks away from dying. We removed an enormous yet benign ovarian cyst. It was over 50cm in diameter and weighed 25 pounds.

How has mission work changed your practice?

Nancy:  It has made me a better nurse. Seeing and working with the patients I see on my mission trips has renewed my love of nursing and my compassion for people in general. The patients I see on these trips are so profoundly grateful for the care they receive.  It helps to renew one’s zest for nursing.

Cecille:  It hasn’t really changed how I practice at home, but you have to be a particular type of person to do well on these trips. In order to do this type of work you have to be patient, flexible, meticulous, and creative. You can’t go to these trips if you’re going to expect U.S. standards of equipment, timeliness and availability of things you have every day at home (for example blood, cautery, suction, light).  I have seen time and time again physicians, nurses and staff struggle because they have unrealistic expectations of what it’s like to operate in third world conditions. And by the same token seen plenty (like Nancy) that just sail, adapt and just sail.

How has mission work changed you as an individual?

Nancy:  Personally it has made me realize that as humans we all want the same things- we want our children healthy, we want access to quality healthcare, we want to be able to be happy in our daily lives, and we want a peaceful existence.

Cecille:  It refreshes my choice and faith in my profession. Medicine has changed so much. The physician/patient relationship many times is not what it used to be. We live in a defensive medicine environment that often plays in to how we practice here. Over there, patients and families trust and believe that, just like at home, I do my very best to provide the very best care my skill set allows, and that I will never go above that skill set and take unnecessary risks. That trust factor makes any responsibility tolerable.

Guatemala

What advice would you give a nurse contemplating mission work?

Nancy:  It’s important to choose the right organization to join, one that interests you. Each one has a different application process and requirements, as well as when and where they go on their trips. They all differ with their missions and what they offer. I have gone on 3 trips so far, and have applied for my 4th with the same group. It’s called Cascade Medical Team, whose parent organization is Helps International. I have friends that have used various other organizations. It’s important to choose one that fits your interests and your budget, as well as the dates you’re available to go. Also, for me on my first trip, it really helped that I went with someone I knew and who had experience with volunteering for medical mission trips. Not only was she able to give me a heads up on what to expect, but it is just amazing to be able to share the experience with someone you know- someone who understands why you would want to, or should want to, volunteer for such a trip
.

How can a nurse prepare for his/her first mission?

Nancy:  Be open-minded. Prepare to go out of your comfort zone and learn new things, both in the nursing/medical field and also culturally.

FullSizeRender-101Where to next?

Nancy:  To date, I have only been to Guatemala. At this point in time, I only volunteer for one mission trip each year and I have found that I really enjoy helping the people there and so have concentrated my trips to Guatemala.

Thanks for sharing, Nancy and Cecille!  And thank you for your service!  For more information on their work with Cascade Medical Team, visit www.cascademedicalteam.org.

Lori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/ or on Instagram.

Sexual Intimacy During Menopause

by, Susan A Peck, RNC, MSN-APN

Adrienne felt fortunate and happy in so many ways.  Since becoming “empty nesters” she and her husband Paul are really enjoying their new-found time together.  Whether they take vacations, head to the movies, or just spend time at home, their friendship and love have flourished. In the past, no matter what stressors life sent their way, Adrienne and Paul would always cherish their alone time as a way to reconnect and maintain their intimacy.

Compared to her friends, Adrienne also felt pretty lucky with her menopause experience.  She only felt hot flushes from time to time and wasn’t too bothered by insomnia.  All in all, life was good….until she began to feel uncomfortable…down there.  Was it a yeast infection?  Why did she feel itchy and irritated, especially after her morning walks?  And then, one weekend, when she and Paul became intimate, things just didn’t feel the same.  She loved Paul and wanted to be intimate with him, but it seemed like her body was taking a long time to catch up to her mind and heart.  This had never happened before – pleasure with Paul was never an issue.  Continue reading

The Color of Endometriosis

by, Ashley Hodges, PhD, CRNP, WHNP-BC

As a teenager I would hear friends talk about the severity of their menstrual cramps, confident endometriosis was the culprit. I am fairly certain I understood nothing about endometriosis, but soon questioned whether I too was suffering from this disease. It took nursing school for me to realize that I had been blindly following the musings of these young women and likely sounded ridiculous in my own conclusions. It was graduate school and my work as a Woman’s Health Nurse Practitioner where I learned fact from fiction and became well versed in diagnosis and treatment options.

Despite my formal education, it was not until a dear friend; we will call her Lisa, was diagnosed with endometriosis and later labeled infertile that I began to truly see all colors of the disease. My use of the word color is intentional. Read on and you will see why.


What Is Endometriosis?

Endometriosis is a chronic disease of estrogen-dependent lesions of endometrial glands and stroma found outside the uterus (Rogers, 2013).  Endometriosis is most commonly found on the ovaries, the fallopian tubes, the bowel, and the areas in front, in back, and to the sides of the uterus. Endometriosis affects approximately 5 million women in the United States. (American College of Obstetricians and Gynecologists , 2010). However, the actual numbers are unknown since endometriosis is often goes undiagnosed due to lack of symptoms and difficulty or delay in diagnosis.


Misconceptions about Endometriosis

  1. Endometriosis is fast and easy to diagnose.

FALSE. It has been estimated that the time between the onset of symptoms and surgical diagnosis of endometriosis is 6.7 years.

  1. Endometriosis is always painful.

FALSE. Not all patients with endometriosis experience pain. When women do experience pain, timing may be before, during, or between periods. Some women experience pain during or after intercourse. Others may experience pain with bowel movements, especially during the menstrual cycle.

  1. Hormonal treatments cure endometriosis.

FALSE.. There is no cure for endometriosis. Hormonal suppressive therapy does improve pain symptoms. However, recurrence rates are high after the medication is discontinued (American College of Obstetricians and Gynecologists, 2010).

  1. Women with endometriosis are infertile.

FALSE. This is not necessarily the case although up to 50% of women with endometriosis have difficulty conceiving naturally (American Society for Reproductive Medicine, 2012).


Lisa’s Story

At the age of 24 Lisa knew something was not right. Being a nurse she could only justify so much about her heavy, frequent and painful periods. Sex was painful, but maybe it was her state of mind or the bad relationship. She had moved to a new town only 2 years before, far from her less- than- thrilled parents. She was working long hard hours in the Neuro ICU and had little time for a social life. Lisa and Brian had been dating for over a year and his anger over her long hours and lack of attention to intimacy was worsening. This, she thought, was why her health was so poor.  Today, 22 years later, Lisa admits she knew something else was wrong, but denial was the easiest path at the time.

By the age of 28, Lisa’s symptoms were worsening, missed days from work putting her job at risk. She and Brian married that year. Her symptoms worsened over the next year with sex becoming unbearable. One afternoon at work she noticed blood in her stool following a painful bowel movement, but wrote it off to hemorrhoids, being on her feet all day as a nurse. That evening Lisa spoke to her mother, listing off her most recent symptoms of back and leg pain, abdominal pain, and nausea. Lisa decided it was time to see her provider and discuss her recent and recurrent symptoms. That night. Lisa woke in the middle of the night with severe lower abdominal pain which led her to seek care in the emergency department.

Lisa was taken to the OR and a right ovarian cyst the size of a softball was removed. Upon waking from surgery, Lisa was told of the ovarian cyst diagnosis. It was not until the next morning she was informed of the other findings. Lisa had severe endometriosis on her uterus, fallopian tubes, ovaries, ureters, bowel and bladder.

Lisa was told the chance of her conceiving naturally was likely nonexistent and that assisted reproduction was the only hope. Lisa underwent surgery to remove large areas of endometrial lesions and received six months of Leuprolide. She tried to conceive without any other medical intervention for three months without success. Fearful of worsening endometriosis she elected to take three months of ovulation induction medication, again without success. Lisa was given the option of moving forward with other reproductive assistance, but due to the cost, elected to wait and save money. Unfortunately, Lisa was back in the OR just six months later for additional surgery including a hysterectomy.

Today Lisa continues to struggle with complications from scarring and recurrent endometrial lesion implants. Lisa and Brian elected to adopt a child who is now 2 years old and are hoping to adopt again soon. Unfortunately Lisa’s story is not unique. More options are available for women today in the treatment of endometriosis but the struggle continues.

What is the reason behind the word “color” in this post’s title? Lisa saw many providers and sought support and guidance through more nontraditional methods. At one visit to an alternative methods provider, she was told to give a color to the endometriosis and then to not own anything of that color. She later told me that she gave endometriosis the color brown… because endometriosis was one big (beep).

Learn more about this topic at: http://endometriosisfoundation.org/

HodgesADr. Ashley Hodges is an Associate Professor and Assistant Dean for Graduate Clinical Programs at the University of Alabama at Birmingham School of Nursing. She is certified as a Women’s Health Nurse Practitioner and has over 25 years of experience in maternal child nursing, administration and nursing education. She was recently named in the Top 20 Outstanding Professors of Women’s Health Nursing by Nurse Practitioner Schools. Dr. Hodges served a two-year term as Board Member for AWHONN beginning in 2014 and was the 2015 Chair of the Public Policy Committee. She is currently a member of the editorial advisory board for the journal Nursing for Women’s Health. 

RESOURCES

American College of Obstetricians and Gynecologists. (2010). Management of endometriosis (Practice Bulletin No. 114). Obstetrics & Gynecology, 116(1), 223-236

American Society for Reproductive Medicine. (2012). Endometriosis and infertility: a committee opinion. Fertility and Sterility, 98, 591-598.

Rogers, P. A., D’Hooghe, T. M.,  Fazleabas, A., Giudice, L. C., Montgomery, G. W., Petraglia, F., & Taylor, R. N. (2013) Defining future directions for endometriosis research. Reproductive Sciences, 20(5),  483-499.

Cardiovascular Disease In Pregnancy & Peripartum Cardiomyopathy

by, Julie Vasher, DNP, RNC-OB, CNS, C-EFM
Clinical Implementation Lead at the California Maternity Quality Care Collaborative at Stanford University

Janine is a 27-year-old African American woman who gave birth to her second baby without complications ten days ago. She came into the emergency room with complaints of cough and extreme tiredness. She attributes the fatigue to her new baby’s sleep schedule. She spoke in bursts because she appeared to be short of breath. Her vital signs are: blood pressure 120/60; heart rate 112 bpm; afebrile; respiratory rate 28 with an oxygen saturation of 94%; and she is considered obese (BMI 36). She has continued swelling in her feet. She is given antibiotics, steroids and breathing treatments. She feels better and is discharged home. A week later she returns to her physician with continued and worsening symptoms. The physician changes her antibiotic for an upper respiratory infection and suggests future testing for asthma.  A few days later, the patient experiences cardiac arrest at home and resuscitative attempts are not successful. Autopsy findings indicate she died from cardiomyopathy. (A composite case study representative of several PPCM cases found online)

Women are entering pregnancy with more chronic disease like hypertension, diabetes, and obesity. (CDC). Cardiovascular disease (CVD) is the leading cause of death for women during pregnancy and the postpartum period (Hameed, Lawton, McCain et al., 2015). Peripartum cardiomyopathy (PPCM) is an unusual disorder occurring in pregnancy that causes the heart to dilate and weaken, leading to symptoms of heart failure. Continue reading