Category Archives: Politics

Breastfeeding (Part 3) and Obesity: A state-by-state review

Okay… I’m about to break my single-post personal record for number crunching and hotlinks. Please bear with me!

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(Photo by sebribeiro)

Obesity is a complicated health issue. A bewildering array of factors— everything from the culture we live in, to the foods we eat, genetics, politics, and the exercise we get (or, usually, don’t)–come into play in determining whether today’s average-sized newborn will become tomorrow’s obese adult.

Breastfeeding helps prevent obesity, as demonstrated here and here and many other places. The association between low breastfeeding rates and child obesity doesn’t get any stronger than this:

The eight states with the highest rates of teen obesity (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Ohio, Oklahoma, and West Virginia) are also America’s eight lowest in exclusive breastfeeding at 6 months of age.

Also:

Of the eight states with the lowest rates of teen obesity (CO, MT, ID, UT, MA, VT, SD, WI), five are in the Top 10 in terms of exclusive breastfeeding at 6 months.

The obesity-breastfeeding association pans out across all age ranges, too:

The 10 states with the leanest overall populations average 21.2% exclusive breastfeeding at 6 months. The 10 most overweight/obese states average 11.5%.

Of course, it’s hard to successfully breastfeed if the support isn’t there:

Now, as I said, there’s more to obesity than whether or not a baby is breastfed. The more obese states tend to have significantly higher rates of poverty than the “leaner” states do, to cite one obvious example. And an association between two variables doesn’t prove one is the cause of the other.

Still… what more evidence do you need to support breastfeeding for all mothers in all situations? In an ever more obese nation, why not give kids the healthiest start we can?

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*(US average is 3.24 IBCLC’s per 1,000 births; the bottom 8 states average 2.49; the 5 states with the highest breastfeeding rates [CO, OR, UT, NH and VT] average 22.8).

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Filed under Breastfeeding, Obesity, Politics

“Optimal Care in Childbirth,” by Henci Goer and Amy Romano: A review

I’m a pediatrician. My interest in childbirth, from the time I finished my obstetrics rotation in medical school until I began writing my book, Birth Day, in the mid-2000s, was focused on what I needed to know in the course of preparing for the arrival of a sick newborn. What’s the gestational age? Any maternal illnesses? How’s the fetal heart tracing? Then I’d set out my tools and watch and wait until my new patient emerged from his mother.

I confess I did not give much thought to what was being done to the mother in the course of her giving birth, whether it was an induction, an episiotomy, or as happened more and more frequently over the years, a cesarean. Babies were my business; I was only peripherally aware of any obstetrical controversies smoldering behind the scenes.

My research for Birth Day was a crash course in the science and politics—especially the politics—of childbirth. I was introduced to the deep divide between what I’ve come to think of as the right and left wings of American maternity care.

At the extremes I saw a clash of incompatible cultures: the “all technology, all the time” (right-wing) camp–which viewed childbirth as a potentially lethal affair and managed laboring women accordingly–versus the solo, unassisted (lefty) birthers whose only desire was to be ignored by doctors and their interventions as nature took its wise, benign course. From many of the the emails I received from Birth Day readers, there really didn’t seem to be much in between.

The research literature of childbirth is the battlefield on which these “baby wars” have long been fought, a landscape littered with studies–some excellent, some awful–that support just about any conclusion an observer might want to make. Take a hot-wire topic like cesarean section. Depending on the biases and prejudices of the author, the same operation can be an unqualified boon to mankind or the devil’s own handiwork. Separating the research wheat from the chaff, the solid evidence from the cherry-picked, can be a daunting task.

So where can a maternity care provider turn for reasonable and reasoned advice? In their new book, Optimal Care in Childbirth: The Case for a Physiologic Approach (Classic Day Publishing), Henci Goer and Amy Romano seek to be that go-to resource—and they succeed.

Professional life has not been easy for Goer and Romano. In the introductory chapters of Optimal Care they describe the conflict between the birth-as-pathology-oriented medical management (MM) model of care so prevalent in the U.S. (the obstetric right wing, in my mental construct), and the low-intervention physiologic care (PC) model that emphasizes birth as a normal event and a major life milestone marking

Henci Goer

the transition to parenthood. Despite the authors’ declaration that “every group that has ever set out to design a healthy maternity care system has articulated the principles and practices” of the PC model, change in the American way of birth has been slow and incremental.

“The [PC model] wheel has been reinvented repeatedly, yet somehow we cannot get it rolling. The obvious question then becomes, Why not?”

Goer and Romano then line up the suspects, usual and not, for the maddeningly unmovable status quo. There’s money, of course—the perverse economic incentives that support hospital maternity wards and the expensive technologies that come with them—and the inertia of entrenched habits and practices. Too, there is the belief held by many women, often reinforced by their maternity care providers, that their bodies are not competent for the task of giving birth.

Interestingly, Goer and Romano also cite the rise of “evidence-based decision-making” in medicine (or, as the late Canadian obstetrician Phil Hall described it, “decision-based evidence making”) as a self-reinforcer of conventional obstetric care. When an evidence-gathering framework designed to evaluate the treatment of  illness is instead applied to a normal physiologic process, the result is an increasingly narrow definition of “normal” and a much broader one of “pathology.”  Of such thinking, the authors conclude, comes the likes of early labor induction, routine episiotomies, and skyrocketing cesarean rates—and the incredibly difficult task of trying to change an obstetric culture so committed to the MM model that the benefits of all births being cesareans is actually considered a legitimate topic of discussion.

“By now you may be thinking that the situation is hopeless; resistance is futile.”

Well, yes, that thought does cross a reader’s mind. The research deck does seem to be stacked in favor of medical management. So, given decades of crying in the childbirth wilderness, what keeps Goer and Romano going? Why haven’t they surrendered to the inexorable march of techno-birthing? How have they not gone completely nuts?

“It is not [hopeless],” Goer and Romano insist, “but those wanting to reform maternity care need a solid foundation in what the obstetric evidence does, does not, or only seems to support, as well as an

Amy Romano

understanding of the impediments to change…”

In other words, you have to fight “science” with science, and that is what Goer and Romano do so well in this fine book.

Optimal Care is a hefty volume–nearly 600 pages—and not every reader will want to plow through it from start to finish. There’s really no need to, though—the book’s structure invites focused reading. Each of its eight sections is divided into chapters that hone in on specific aspects of a more general topic. A reader interested in the subject of episiotomies, say, need read only the twenty pages of Chapter 15 to learn why episiotomies are rarely necessary, and why, despite that evidence, they are still commonly performed. Meanwhile, those who wish to read about a more complicated topic like cesarean section will find an in-depth discussion of the science and politics of that surgery spread over the three chapters of Section II, “The Cesarean Epidemic.”

I found two features of Optimal Care in Childbirth particularly helpful for busy clinicians. At the end of each chapter are concise, bulleted “Strategies for Optimal Care” designed to promote physiologic birth in a variety of settings.  Following that are “Mini-Reviews”—summaries of topic-related research which include, notably, the authors’ reasons for including and excluding certain studies. Goer and Romano are refreshingly upfront about their PC model biases—literally from page one—an honest and rare thing to see in the highly polarized world of modern maternity care.

Optimal Care in Childbirth is a welcome addition to the ever-expanding library of maternity care books. By using science in the service of physiologic birth, Henci Goer and Amy Romano offer a welcome push-back to the all too common view of uncomplicated childbirth as a disaster just waiting to happen.

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Filed under Book review, Cesareans, Maternal-child health, Natural childbirth, Politics

Why ‘Obamacare’ is important for American children

Good news for kids.

“You cannot educate an unhealthy child, and you cannot keep an uneducated child healthy.” Jocelyn Elders M.D., former U.S. Surgeon General

I was one of millions of happy people following Thursday’s Supreme Court ruling that upheld the Affordable Care Act. The ACA greatly expands access to care, benefits, and coverage for millions of children, and if there’s any hope for the future of this country it has to start with healthy children.

It’s difficult for people with health insurance to truly understand what it’s like for those who don’t have it. Or for those who had it and then lost it in the recent economic downturn. And it’s easy to overlook the toll this can take on a child’s chances of success in life.

Here’s one example from my practice:

I took care of a family I’ll call the Swensons for several years. Greg and Connie have three kids, ages 6, 7,and 10. Greg is a welder and his wife Connie was a receptionist at the construction firm where Greg worked. Both lost their jobs about a year ago, and with it went their health insurance. They moved to a neighboring state to live with family and search for work in a more construction-friendly region.

Stephen, their ten year-old, is a very bright boy who suffers from asthma. When they had health insurance and jobs, Greg and Connie were able to keep Stephen healthy, but not without inhalers, allergy medications, and clinic visits.

When Greg and Connie lost their incomes and insurance, though, medications and regular doctor visits quickly ate up what money the Swensons had saved. Stephen got sicker. He wound up in  emergency rooms three times, and then was hospitalized for a few days when his asthma got out of control. He missed about three weeks of school due to his illness, and he was fatigued for a few weeks after that.  It took him the rest of the school year to catch up to his new classmates on the work he’d missed when he was sick.

None of that had to happen. In most other industrialized countries Greg and Connie could have simply taken Stephen to a pediatrician or family doctor in their new home town and stayed on top of his asthma care. Money would still have been tight, but they wouldn’t have had to go deep into debt to keep Stephen healthy and doing well in school.

The American Academy of Pediatrics has a nice summary the ACA’s benefits for children  (see the fact sheets for more details). Take a look–it’ll give you some hope for the future. How anyone can equate that to the second coming of 9/11 is beyond my powers of comprehension.

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Filed under Asthma, Politics

Jailing addicted new moms: A slippery slope?

Two troubling articles about pregnant women, addiction, and the law came out this week.

1) The first, in the most recent New York Times Magazine, describes how Alabama is increasingly handing out long jail sentences to drug-addicted new mothers. The charge? “Chemical endangerment of a child,” a Class A felony in Alabama that carries a mandatory 10-year sentence.

Emma Ketteringham, the director of legal advocacy at the National Advocates for Pregnant Women (NAPW), is particularly rankled by the use of the “chemical endangerment” statute to prosecute addicted women. The law was originally drawn up to protect children from the dangers of parental meth labs and the like; it was never intended to be used against pregnant women struggling with the disease of addiction. From the Times article:

[Ketteringham] argues that applying Alabama’s chemical-endangerment law to pregnant women “violates constitutional guarantees of liberty, privacy, equality, due process and freedom from cruel and unusual punishment.” In effect, she says, under Alabama’s chemical-endangerment law, pregnant women have become “a special class of people that should be treated differently from every other citizen.” And, she says, the law violates pregnant women’s constitutional rights to equal protection under the law.

It also makes it much less likely that an addicted woman will seek help during her pregnancy, thus putting her child in even greater danger–a point which seems to have been lost on the state’s legislators.

The push to prosecute drug-addicted pregnant women is actually part of the larger effort to pass “fetal personhood” laws (which have been introduced as initiatives and measures in 22 states to date), which declare that a fully constitutional-rights-endowed person is created the moment sperm meets egg.  A major problem with this view, according to Lynn Paltrow, executive director of NAPW, is that:

“… there is no way to treat fertilized eggs, embryos and fetuses as separate constitutional persons without subtracting pregnant women from the community of constitutional persons.”

In other words, from the moment of conception a woman’s rights would be superseded by those of her fertilized egg.

2) Okay, so getting jailed on a PWA (pregnant-while-addicted) charge may seem like a distant concern for most Americans–the vast majority of pregnant women in the U.S. are not drug-addicted, after all.

But hold on a moment. As the second article (from the Washington Post) points out, the number of pregnant women addicted to prescription painkillers has tripled in the last decade, including many women who are being treated for very legitimate pain issues–not the “typical” drug addict so often reviled in the media.

The Alabama law makes no distinction between “medical” addiction to painkillers (prescribed after a car accident, say), and “recreational” addiction to heroin or crack, and in a way, they’ve got a point. From a baby’s standpoint it doesn’t matter why mom’s addicted, so why not prosecute them all? There hasn’t been a legal stampede to throw the book at moms on Vicodin as yet, but it shouldn’t take a politically ambitious Alabama attorney too long to figure that one out.

Spending a decade in jail for the “crime” of having a baby while addicted to a doctor-prescribed treatment may seem like a stretch today, but today’s stretch is often tomorrow’s norm. As Rush Limbaugh-esque politicians steadily chip away at women’s reproductive rights, it doesn’t sound so far-fetched to me.

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Filed under Maternal-child health, Newborns, Politics

Home birth geography quiz!

Quick! Name the country where:

  • Maternity care is provided in hospitals by obstetricians, and at home by medically-trained midwives and traditional midwives.
  • Obstetricians don’t trust midwives.
  • Midwifery groups don’t trust each other, and none of them trust obstetricians.
  • Midwives feel obstetricians are often insulting and disrespectful to them.
  • Obstetricians, in fact, are often insulting and disrespectful to midwives.
  • Timely transfer from home to hospital during labor is often hampered by delays in deciding to seek care, by slow transport to the hospital, and by delays in receiving care on arrival.
  • Women seeking home births are afraid of hospitals, which they see as cesarean mills.
  • Obstetricians are viewed primarily as surgeons, their motives mainly financial.
  • Economic and ethnic disparities are rife; those with money get care when and where they want it.
  • Despite years of progress, maternal mortality rates remain stubbornly high.

I know what you’re thinking: Hey! I live there, right?

Wrong. It’s Iran.

Specifically, it’s Zahedan, the capital of Sistan and Baluchestan province in eastern Iran, home to 600,000 people on the border with Pakistan.

A recent study of maternity care in Zahedan revealed a very fractured, and fractious, obstetrical world. What with battles over where and when midwives can legally practice, how best to deal with a flood of undocumented and uninsured immigrants, layers of professional suspicion, accusation, intrigue and infighting…you start to get the idea that maternity care is a mess the whole world ’round.

Granted, there are differences between Zahedan and the U.S. It’s unlikely, for example, that an American woman would have to have her eclamptic seizures exorcised by a faith healer before her family would allow her to go to the hospital (a not-uncommon practice in Zahedan). Too, an American family would probably not be required to drive their very angry midwife home before heading to the local maternity ward. And an Iranian midwife’s trump card–the threat to “go outside the home and shout and bring disgrace” on a woman and her family for seeking hospital care–probably doesn’t strike a lot of fear in American hearts.

Still…

Hospitals in Zahedan have begun a two-pronged outreach effort of sorts, aimed at convincing mothers and their relatives that a) traditional midwives may be lacking the kind of training needed in real emergencies, and b) hospitals aren’t simply scary cash-machines for doctors:

“Women who choose to give birth at home accept the risk that complications may arise. Training midwives and persuading mothers and significant others who make decisions about the value of referring women to hospitals at the onset of life-threatening complications are central factors to increasing the use of available hospitals. The hospitals must be safe, comfortable and attractive environments for parturition and should give appropriate consideration to the ethical and cultural concerns of the women.”

Maybe we have more in common with Iran than we thought…

 

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Filed under Home birth, Politics

OBOS at our house

We had the pleasure of hosting a house party for Judy Norsigian at our home this week. The party was to celebrate the  40th anniversary of the publication of Our Bodies, Ourselves and to learn more about the ongoing efforts of Our Bodies Ourselves (aka OBOS), the nonprofit health education and advocacy organization that  Judy co-founded as the Boston Women’s Health Book Collective in 1969.

How important is Our Bodies, Ourselves? How about this as an indicator: Time  magazine named it one of the 100 most influential nonfiction books written since 1923. And it remains a trusted resource—Library Journal selected it as one of the eight best consumer health books of 2011. What can I say? As a writer, I’m jealous!

My wife and I have different recollections of the early editions of Our Bodies, Ourselves. Elisabeth has a special place in her heart for the book – like many, many women she learned a great deal about her own body and the larger world of women’s health on those pages.

Me? I was one of the very few people at the party who hadn’t read a single page of Our Bodies, Ourselves in my twenties. That’s not to say it didn’t influence my life. Nearly every woman I knew back then had a copy on her bookshelf, but I kept a respectful distance. Our Bodies, Ourselves was a mysterious woman-thing, all about their bodies and themselves. (I kept waiting for somebody to publish an equivalent guy-book—maybe Hey, Man! It’s Your Body!—but they never did.)

I first met Judy Norsigian in 2009, when I was on the Portland stop of my Birth Day book tour. We were introduced by a mutual friend (the indomitable Judith Rooks) and Judy very kindly agreed to introduce me at my Powell’s Books reading. I still have the sneaking suspicion that the audience was there for Judy, not me…

Judy Norsigian

We reconnected at the Home Birth Consensus Summit in Virginia last October, where Judy was the Summit’s go-to person for her wisdom and her well-grounded-in-reality common sense. She mentioned to me that she would be coming to Berkeley in April, and since we live just an hour away, we decided to do the house party.

It was a remarkable evening. Twenty-five women (and three men) listened as Judy spoke eloquently and passionately of OBOS’s ongoing advocacy efforts, which included a few topics that would have been straight out of a science fiction novel in 1969:

  • Calling for policies that preserve or expand access to sexual and reproductive services—a white-hot topic in the current political climate.
  • Advocating for improved maternity care policies, especially expanded access to midwifery care, the promotion of VBACs, and a reduction in unnecessary labor inductions.
  • Urging better FDA oversight of siliocne breast implants.
  • Serving on the Steering Committee for this summer’s  third Tarrytown Meeting, where prominent health advocates and academics will work for more responsible governance of new human genetic technologies.
  • Establishing better informed consent for women seeking assisted reproductive technology.
  • Serving as co-plaintiff in an ACLU lawsuit regarding the patenting of human genes.

As soon as the party ended Judy was hard at work, answering emails and preparing for the rest of her northern California trip. We dropped her off in Berkeley the next morning, after an enjoyable ride that included a thorough hashing of the public health challenges facing California (that’s Elisabeth’s turf, as director of Maternal, Child and Adolescent Health for Sonoma County—I played the role of driver/active listener).

Rough economic times are particularly rough on nonprofit organizations. I hope you’ll be inspired to contribute to OBOS here (not to put too fine of a point on it, but DONATE HERE!!) We need OBOS more now than ever!

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Filed under Maternal-child health, Politics

Breastfeed and go broke?

Must be all that breastfeeding...

Much ado is being made of a study in the The American Sociological Review which showed that women pay a steep economic price for breasfeeding their babies.

That’s kind of a “well, duh!” statement, I realize. It’s no surprise—early motherhood is rarely an economic boom-time for any woman, particularly for those women who have to quit work to have a baby, or who don’t receive some kind of paid maternity leave. All that bonding comes at a cost.

The study found that breastfeeding doesn’t penalize all nursing mothers equally, though. “Short-duration” breastfeeders (ie, less than 6 months) and formula-feeding moms had similar loss of income over the five-year period. It was the “long-duration” breastfeeding women (greater than 6 months) who really took it in the pocketbook:

 “By contrast, women who breast-fed for longer durations experienced a much steeper decline in earned income over the first five years of their children’s lives.”

The study has some problems. The researchers don’t say anything about the women they studied, or about what other factors might have had an impact on length of nursing and income. Were the “long-duration” moms better off financially, and so better able to afford the drop in income? Did other potential “long-duration” breastfeeding moms end up in the “short-duration” category because of the financial need to quickly return to a workplaces hostile to breastfeeding? In other words, would the income differences be so stark if employers really embraced their breastfeeding employees?

You can read this study as evidence that breast feeding is financially bad for mothers and, ultimately, their children, as the loss of income makes life more difficult for families. Or you can see it as an indictment of how corporations (and by extension, American society) view breastfeeding—like paid vacation and sick leave, it’s just one more thing that gets in the way of a productivity. (All that icky workplace pumping! What a waste of widget-assembling time!)

So, bring on the formula, right?

Wrong. The American Academy of Pediatrics recommends that women breast-feed for 12 months or more. There’s sound scientific evidence to back up that recommendation. Unfortunately we live in a time and place where scientific evidence often takes a back seat to political expediency and corporate pressure. In short-term-profit-driven America, the health of the next generation of workers doesn’t count for much.

Still, there’s plenty you can do to help. The American Academy of Pediatrics has an excellent breastfeeding Advocacy Resource Guide. Do you have an advocacy group you’d like to mention? Pass it on!

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Filed under Breastfeeding, Politics

On, Wisconsin! “Obamacare” and children’s health

Healthier little Badgers...

As the Patient Protection and Affordable Care Act (aka “Obamacare”) celebrates its second anniversary and prepares for a Supreme Court test, it’s good to pause and remind ourselves of the health benefits it has already brought about.

Take Wisconsin, for one example: 281,000 kids (21% of the state’s children) are now receiving additional preventive health care benefits because of the Affordable Care Act.

"First, free shots for kids...then world domination!"

I’m sure the people who equate health care reform with Hitler, etc., can find something wrong with that, but I can’t.

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More on home birth risks

From the recent comments file:

While I abhor the tone taken by many comments on the blog I’m asking you to look at, this doctor has some disturbing statistics on neonatal mortality at homebirths. Could you please discuss your thoughts on this post?http://skepticalob.blogspot.com/2012/01/curious-silence-on-rising-rate-of.html
Thank you! Catherine Taylor

Catherine – thanks for your comment! I appreciate it.

Home birth neonatal mortality, by provider type

The chart (left) from the blog you referenced says more about the way home births are handled in the U.S. than it does about home birth itself. As I’ve mentioned before, the Birthplace in England study, as well safety data from Canada and Europe, show that in selected circumstances home birth can be as safe as hospital birth in terms of maternal or neonatal deaths–if home birth is integrated into the larger maternity care system, which in the U.S. it is most definitely not.

Here in America we have a patchwork of state laws that in many cases increase the risk of home birth for mother and child. We also lack the kind of nationally recognized licensure and regulation of home birth midwives that most other western countries have, which can lead to women being cared for by poorly qualified, “underground”  birth attendants and to the kind of tragic outomes that the chart highlights.

The first step in addressing these issues can be found in the Home Birth Consensus Summit’s Common Ground Statements:

“It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should:

  • allow for independent practice
  • facilitate communication between providers and across care settings
  • encourage professional responsibility and accountability, and
  • include mechanisms for risk assessment.”

With few exceptions the regulatory, institutional, and medical systems in the U.S. don’t support home birth. Yet women are increasingly seeking home births, and no matter what the blogging doctor Catherine cited might fervently prefer, they can’t be forced to do otherwise. Speaking as a physician, unless you’re part of the effort to make home birth a safer alternative for those women who want one (and their babies), you’re part of the reason for those bad statistics.

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Filed under Home birth, Politics

Poor parents diluting formula: A sign of the times?

On the political chopping block?

This is a very worrisome item if you care about children and the future of this country.

Researchers at Cincinnati Children’s Hospital found that 27% of families enrolled in the federal Special Supplemental Program for Women, Infants and Children program (better known as WIC) reported running out of their babies’ WIC-supplied formula at the end of most months, and watering down the formula to get by.

That’s a very bad thing to do to a developing brain. There is ample evidence from all over the world that malnourished infants and toddlers can end up permanently damaged. Preventing that from happening is why WIC was founded in the first place.  

This doesn’t seem to trouble the members of Congress, particularly the Tea Party Republicans. The recent Congressional budget fight, which is far from over, included Republican-led proposals that could drop 700,000 women and children from the WIC program. The nutritional toll this would take on American children is appalling.

Keep that in mind next time you hear politicans babble on about poor people getting a free ride.

(P.S.: WIC is very much pro-breastfeeding. They provide formula to women who decide not to nurse their babies.)

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Filed under Nutrition, Politics