Monthly Archives: April 2009

Call to action on breastfeeding

The HHS has a call to action on breastfeeding that is currently open for comments. (h/t to Our Bodies, Our Blog.)

I commented on Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care, and Paid Maternity Leave so far, but could easily comment on all of the topics. I hope they get lots of good feedback. Please comment!

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Look, but don’t touch

According to Motherlode, a Connecticut middle school is banning hugs and high fives between students.

So, in other words, it is Ok to strip search a middle schooler and make her shake out her bra and underwear, but the kids can’t high five or hug each other?

These aren’t the priorities I want to instill in my kids.

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Good things a brewin

I haven’t had time to post recently. But, good things have been brewing, so I wanted to throw up some links.

First, a study finds homebirth as safe as hospital birth. Of course, this occurred in the Netherlands. I would love to practice there one day. An American DO needs to pave the way, since our licensing is ambiguous in that country. Note the complication rate was 7 per 1000. That includes NICU admission or any neonatal mortality.

Note that in the United States, our infant mortality rate alone is 7 in 1000.

Hillary Clinton gave a rousing defense of comprehensive international reproductive medicine. I still get misty when I hear our administration advocating for evidence based, women centered medicine that will save more lives of women and children.

Also good stuff, the FDA is going to be extending over the counter, non prescription status for plan B to 17 yr olds. It is safer than a pregnancy for all ages, children who can’t talk to their parents about it are high risk and should have more access. Unfortunately, proving your age requires ID. I think the requirement should be lifted because privacy outweighs the negligible risk. If a young woman is in a small town, she will be forced to show her license in order to get Plan B. We need mroe progress on this issue. Plan B needs to be available without a prescription, end of story.

The New England Journal of Medicine published a study on using PCR, a cheap DNA analysis is better than a pap smear when screening for cervical cancer. Very interesting. I may be doing some research on PCR testing for HPV during my research fellowship.

And, finally, Shakesville has been cracking me the hell up.

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Vaccinations – dipping my toes in the waters

I have wanted to talk about vaccinations for a while, but I have been afraid to broach the subject. I am definitely at a clash between two cultures when it comes to vaccinations. I know how ugly the language can get coming from both sides of the issue. I want to discuss some nuance here. Let’s see if it works.

I got an email from a faculty member at my medical school asking us to make phone calls against Florida SB 242 relating to immunizations, which is on the agenda of the Policy and Steering Committee on Ways and Means April 21st. I am not taking a stand on whether this sort of email is appropriate. I do encourage political discourse. I wish the email had a link to the full text (pdf) of the bill (which is actually hard to pin down. I think there are a lot of proposed amendments, too) or used the original language of the bill. I would like to exercise my same freedom to discuss the issue that my faculty member took, and examine some aspects of the proposed legislation.

The proposal wants to start a registry of vaccines by lot number. Why is this a problem? I know many people swear there is no link between autism and vaccines. Vaccine reactions are supposed to be rare. Why can’t we support this by tracking lot numbers? Autism was not under any form of surveillance in Florida when I wanted to research it five years ago in an epidemiology class. There are supposed pockets of autism here. What’s wrong with a little old fashioned public health research here? Nothing wrong with data. The lot number is an easy enough thing to note. When I administer an HIV screen I note the lot number (with a sticker) in no less than eight places. Parents can refuse to be part of the registry. So, this doesn’t have to be a burden if parents are resistant to having that sort of information recorded. I am a big fan of opt out options. (Although I tend to think there will be some overlap between the parents who don’t want their kids’ vaccines tracked by big brother and the parents who don’t want to vaccinate, period.)

The second recommendation (one of the links above) is to prohibit:

The sale, purchase, manufacture, delivery, importation, administration, or distribution of any human vaccine used for children under age 6 or pregnant women which contains any organic or inorganic mercury compound in excess of 0.1 microgram per milliliter.

There is an exception made for epidemics. I always hear vaccine advocates saying that thimerosal is no longer an issue, it has been removed from virtually all vaccines. So, again, what is the problem. Why defend the mercury? I know some people say dental types who want to defend the mercury in silver fillings are just trying to prevent lawsuits. Is this the same sort of issue? Mercury was in most vaccines up until very recently, and is still present in some, namely the flu vaccine.

Finally, it allows for a modified schedule for vaccine administration. Again, what is the problem? Why the utter inflexibility? It does not say it allows for any new exemptions. Some diseases do not cause outbreaks generally (bacterial meningitis, hepatitis B), at least not in young children. I can still see how a pediatrician can inform the parents, allay fears, and try to set up a schedule that works for everyone. Is the child not going to be in daycare (which may not accept the adjusted schedule) and not exposed to many people? What’s wrong with waiting on a few?

I think my professor is afraid that making accommodations about vaccines in any way gives credence to vaccine critics. I think the opposite. Making sure vaccines are as toxin free as possible and allowing for some parent autonomy, within reason, actually takes fuel away from the extreme anti vaccine crowd.

OK, have at it. Try to be civil or you may get a square on the bingo card.

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Some navel gazing

I am done with classes. I took my last exam for my last medical school class on Tuesday. I went to a party Tuesday night, and slept it off most of Wednesday (after getting the kids to school). Ran errands and saw some friends Thursday, and here I am.

I am really thankful for having people there for me in what has been a really amazing and strange and transformative experience.

It was pretty anticlimactic, actually. And, it’s weird in a few ways. It’s weird because I am becoming a fellow, so I am not really with my class anymore. I have made a lot of friends in my class. More than I thought I would, and closer ones than I thought I would. I am friends with everyone who will be a fellow, so we will have a sort of camaraderie. And, I have some friends in the upcoming class that I will be joining on rotations.

Things are a little weird, also, because it is a little scary to me how depressive, lethargic and lost I get when I am not on a strict, high paced schedule. I am going to be self directed for a while now. All I want to do is veg out, watch TV, nap and eat mac and cheese on the couch. I need to study for boards, prepare lectures for an embryology class I am teaching for the midwifery school, and just pick up all the loose ends I let accumulate when I was in school. Oh, and be in my brother’s wedding (along with both of my sons…isn’t there some sort of quota of one generation only being in a wedding party?), and be a mother and wife, including arranging activities and supervision for the kids for summer vacation.

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Did I mention that they’re brown?

Shakesville tipped me to yet another article about single mothers that handles the race and ethnicity issue badly. The CNN article shows a beautiful picture of a pretty-enough-to-be-an-actress white woman with her dream wedding (which included her 10 month old child – gasp!) in the same idyllic intro with two of the mass media’s favorite single moms: Angelina Jolie and Bristol Palin. If you bother to click through to the second photo, you see a much less flattering picture of a black mother and her baby, whose boyfriend of five years and the father of the child is nowhere to be seen, although he is still involved, according to the article.

Experts wring their hands over the loss of stigma associated with so called “out-of-wedlock” birth. Brown, of the The National Campaign to Prevent Teen and Unplanned Pregnancy, says “I wish people spent as much time planning when to get pregnant, with whom, under what circumstances as they do planning their next vacation.” Yes, 50% of pregnancies in the United States are unplanned, regardless of the marital status of the participants. Is there any mention of what planning a pregnancy would entail? No, of course not.

Then, the article links to a breakdown of births to single mothers based on race and age. On the one hand, this information is significant when looking at the big picture of single parenting, since certain groups don’t seem to have a stigma associated with single parenting. The article horribly mishandles the statistics on these groups, saying, “While 28 percent of white women gave birth out of wedlock in 2007, nearly 72 percent of black women and more than 51 percent of Latinas did.”

Umm, no. Nearly 72% of black women weren’t even pregnant in 2007. This may seem like a minor detail to the author, but her denominator is wrong. Nearly 72% of women who GAVE BIRTH in the United States in 2007 who were identified as black were also identified as unmarried. Big difference than all black women. Anyone who is writing for CNN on epidemiological issues should know the importance of the correct denominator, which is key to discussing public health numbers.

My biggest question is, why is there so much focus on the racial and ethnic breakdown of the mothers in this particular article? Why is there no mention of contraception? If there was some analysis that was pertinent to the current statistics that had something to do with race or ethnicity, I would be interested. However, as the preliminary data from the National Center for Health Statistics suggests, the latest increases occurred over all racial and ethnic groups. So, while it is true that black women are much more likely in general to become single mothers, it has absolutely nothing to do with the most recent increase. A 20% increase in the ratio of births attributed to the unmarried in the past five or so years is a big deal, statistically. It apparently crosses all racial and ethnic lines, and is independent of age. So, why does this article, and others on similar topics, spend so much time (with interactive graphs!) on the racial and ethnic breakdown of the single mothers? It seems to be easier to point at the brown people than to wonder what is changing with everybody, regardless of brown-ness.

So, any discussion of abstinence only education, increasing contraception costs, loss of employer-paid insurance, refusal of insurance to cover contraception, the stigmatization of contraception by the religious right, decreased availability of abortion, increasing obstacles for minors to have access to abortion or other factors which may have actually had an influence on these new record breaking numbers are completely swept under the rug. The graphs and a few paragraphs tell us what we apparently already know – for generations, black culture in America has not emphasized the importance of marriage in parenting – and that racial disparity becomes the scapegoat of an article on the latest increase in single parenting, when it is nothing new and hardly relevant to the increase.

Any discussion of why children of single parents have higher rates of poverty or high school drop out rates is absent. Is it because their parents are unmarried? Or, as I am going to assume, are the 40% of babies born to single mothers more likely to face hardships if the single mother in question has darker skin, less income, less resources, and is younger? Where is this racial and ethnic analysis or the poor outcomes? Maybe the single parenting issue is simply a confounder of a greater societal problem. Maybe poor, brown, and ethnically disadvantaged children do worse, period. I don’t think Bristol Palin’s child is going to face the same problems as a child born to a teenager who isn’t white, rich, and the daughter of a governor.

The beautiful woman at the top of the page who had her dream wedding with her white now-husband and white child probably won’t have as bad outcomes as some of the teen mothers in the same article. Why was she chosen as the poster child for this article? Was it, as it seems to me, that her wedding photo was a stark contrast to the photo of the proud single black mother? If 72% of black women who gave birth last year were single and that is such an important point, why isn’t a black woman at the top of this article as the main photo? Is this white woman’s wedding on an organic farm 10 months after the birth of her first child really news worthy? Or is it just easier to gossip about her, Bristol and Angelina and how we wished a stronger stigma made them more shameful, lest they end up like those browner women who already just don’t seem to care if they are married?

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I love a good point

Dr. Russell Turk, M.D., wrote a column celebrating the FDA decision to expand Plan B over-the-counter availability to 17 year olds. (H/t RH Reality Check)

I agree with this board certified ob/gyn on many of the same points I have made myself: that it is better than the alternative, that pregnancy occurs at those ages, so all options should be available, and that delaying or impeding reproductive care for minors who can become pregnant is never a good thing.

Then he throws out this piece of brilliance:

The irony is that once a girl is pregnant, she’s legally considered an “emancipated minor” — which means she can make medical decisions of a much more serious nature without adult supervision. And yet we can’t trust her to make a decision that will keep her from getting pregnant?

Of course! This not only addresses why Plan B should be available over the counter for minors, but also supports why birth control and comprehensive sex ed should be available to minors. And, it also provides yet another reason why parental notification and consent laws directed at minors seeking abortions are hogwash. I knew about parenthood being emancipatory, but I never did the second level thinking that links preventing pregnancy as being an equally important mature right of minors.

Thanks, Dr. Turk!

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