Tag Archives: Take Action

VBAC Summit

As long promised, here is my wrap up of the VBAC Summit, hosted by the illustrious Birthgirlz, aka Miriam Pearson-Martinez and Michelle Fonte. I was one of many speakers at this year’s summit. I was part of an impressive line up including Miriam Pearson-Martinez, Laureen Hudson, R. Zachary Pearson-Martinez, Jill Arnold from The Unnecesarean, Tamara Taitt, Dr Christ-Ann Magloire, and Nancy Wainer.

I had a fantastic time at the summit. Here are a few pictures from the summit, including a not very flattering one of me starting off my presentation with a grin. Jill Arnold and I spent the weekend together and caused all sorts of trouble and were very silly. All of the speakers were wonderful.

Here is a link to my presentation, “ACOG, VBAC and other four letter words,” a history of ACOG’s position on VBAC.

I was promised audio of my presentation, so I am hoping that shows up in my email inbox sometime soon. In the meantime, I am wrapping up my Geriatrics rotation and really looking forward to finally starting ob/gyn next month!

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Invasive abortion law is vetoed!

(Trigger warning, description of forced medical procedures)

Governor Charlie Crist of Florida vetoed Florida HB 1143, which would require transvaginal ultrasound (also known as the affectionately as the “dildocam”) for women seeking abortion in Florida, above and beyond what was medically necessary (which would be more likely a much less invasive transabdominal ultrasound if needed for dating purposes). In fact, many women consider being forced to have a vaginal procedure against their will as medical rape.

Gov. Crist said:

“This bill places an inappropriate burden on women seeking to terminate a pregnancy. Individuals hold strong personal views on the issue of life, as do I. However, personal views should not result in laws that unwisely expand the role of government and coerce people to obtain medical tests or procedures that are not medically necessary. In this case, such action would violate a woman’s right to privacy.”

I was one of the many Florida voters who emailed and called to urge for this bill to be vetoed.

Charlie Crist was elected to governor as a Republican. I have been a fan of his since his election. He has continuously been a moderate who is highly practical and responsive to the state’s will and needs. He is running for Senate now, but will be running as an Independent, due to a far right tea party challenger.

I hope this veto helps him with the moderate and liberal vote. I will be voting for him. Sorry, Kendrick Meek, but Crist continues to deliver.

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Exciting things a-brewin’

I am going to be in a production of Eve Ensler’s The Vagina Monologues tomorrow night. This is my third year being involved with our medical school V Day production. I was the narrator for the past two years. This year I am performing the poem at the end, a poem about birth called “I Was There in the Room”. It ends with:

The heart is capable of sacrifice
So is the vagina
The heart can forgive and repair
It can change its shape to let us in
It can expand to let us out
So can the vagina
It can ache for us and stretch for us, die for us
And bleed and bleed us into this difficult, wondrous world
I was there in the room
I remember

I also was selected to be a delegation coordinator for Amnesty International’s lobbying effort to bring attention to maternal mortality, including lack of prenatal care and racial disparities.

So, I know I am supposed to write up my cousin Susan’s birth story (which will probably be my first non guest post at Mothers in Medicine), and talk about the whole NIH VBAC conference thing, and recruit more doctors for my survey, but I’m a little busy right now. I’ll get to them soon, I swear.

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Update on the Tebow ad

Since I posted about the Tim Tebow anti-choice Scrutinize Your Focus on the Family ad that is scheduled to air during the Super Bowl, I have found out some more disturbing information.

Mrs. Tebow claims that she was told to get an abortion while pregnant in the Philippines, where she and her husband do missionary work. In fact, they run an orphanage there. But, abortion is and has been illegal in the Philippines. Making abortion illegal does not reduce abortions. It just makes them more deadly.

According to this UN Humanitarian Affairs report:

there are an estimated 560,000 cases of induced abortions per year, resulting in some 90,000 women being hospitalised for post-abortion care; and about 1,000 deaths a year in the island nation.

Most of these women are already mothers. Their children are much more likely to die before the age of 12 without a mother. It also makes them more likely to need to go to an orphanage. Like the one the Tebows run, out of the kindness of their Christian hearts.

But, it is the Christian religion* that is contributing to the orphan problem in the Philippines. According to this 2006 Guttmacher report (pdf) on Unintended Pregnancy and Induced Abortion in the Philippines:

At the same time, weak government support for modern contraception and the insistence of the Catholic Church on natural family planning methods contribute to low levels of modern contraceptive use and persistent reliance on less effective methods. Many women use no family planning method at all.

I am all about the middle ground on this issue. I don’t have a problem, like some reproductive rights activists do, with saying I want abortion to be rare. I know it’s hard to discuss something with nuance, but that doesn’t necessarily say it’s because it’s an evil procedure. Unintended pregnancy is the problem. No one wants to be in that situation. The only way to prevent it, experts say in so many places I won’t even bother to link it, is by increasing the autonomy of the women in the community: access to affordable effective contraception and abortion without shame, education, microloans, and the like.

Making abortion illegal and letting them die, bleeding in the hallways of hospitals or in their beds, surrounding by their surviving children, is not pro-life. How can members of the same party who houses Lt. Gov. Andre Bauer, also align themselves with groups like Focus on the Family? The supporters of this ad, Focus on the Family and their socially conservative hardline choir, think talking about the poor as breeding stray animals who don’t know any better with unconcealed contempt is compatible with calling the birth control and the IUD “a chemical assault and destruction of some unborn?”.

Let’s reduce abortions, spontaneous or medical. Let’s reduce death. Let’s reduce the number of orphaned children. Let’s prevent unintended and intended pregnancy losses. Effective, affordable contraception is the best way to do this.

*I am not anti Christianity, nor anti all Christians. My family is all quite religious, most of them practicing that religion as pro-life, socially conservative Presbyterians. We don’t see eye to eye on this issue. I was tipped off about the disconnect between Mrs. Tebow’s claims and the reality of reproductive care and maternal mortality by someone who went to Catholic school with my husband. I am off to a celebration of a Catholic christening today of a boy at whose birth I was the doula.

Religion, to me, is personal. That is why I support conscience clauses for health care practitioners, and (edited to correct major typo!) STRONGLY OPPOSE one-child only laws, and forced abortions or forced sterilizations. But, when it comes to maternal mortality and public health, I don’t think religion has a place in the discussion. Any group that would worship a god that thinks maternal mortality isn’t a higher priority than their rules about sex and reproduction isn’t someone I want at the table. They can preach to their choir all they want, and people can choose to observe in the way that is right between them and their deity(ies) of choice, or lack thereof.

TAKE ACTION:

Go to Emily’s List and sign their petition. This is what I wrote in the comment section:

1000 women died in the Philippines (where Tim Tebow was born, and his family does missionary work) in 2008 alone due to the unavailability of safe, legal abortion.

How many of the orphans at the Tebow’s orphanage had moms who died from the lack of contraception and legal, safe abortion there?

This is not something worth breaking your non controversy Super Bowl ad over.

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Blog for Choice

I missed Blog for Choice day this year. Rachel has a great round up at Women’s Health News. The research team I am doing my fellowship had a grant application due today. I rocked the references. We had some long days, and it finally was finished yesterday afternoon.

On to the choice stuff. I am of course extremely annoyed about this Tim Tebow Focus on the Family Super Bowl commercial nonsense. NPR reports that CBS has made an announcement in defense of accepting the ad, which, based on an anecdote about Tebow’s mother refusing a medically recommended abortion when she had amoebic dysentary and ending up with a Heisman trophy winner, encourages people to ignore medical advice during pregnancy when they take teratogenic medications. Or is just about a mom lovin’ her son, depending on who is telling you about the ad.

CBS has refused to take Super Bowl ads they have deemed too controversial in the past from the likes of MoveOn.org, PETA, and the United Church of Christ, who were simply stating that they were inclusive to everyone. Now that the Tebow Focus on the Family ad is causing an uproar, CBS has announced oh, by the way, did we mention we have changed that policy? Coincidentally, right before FOTF approached them, I suppose.

I took the Redhead’s advice (hat tip to SharkFu) and made a donation to Planned Parenthood. I also threw some money at Medical Students for Choice, a group of which I am a proud member. Please join me as part of the backlash to this nonsense.

I trust women. I trust Tim Tebow’s mother to make her own choice about her pregnancy, and I trust all women to have that choice, too. Even if they come to a different decision than she would. I also hate that this anti-choice advocacy totally ignores all of the women (and mothers! and their children!) who die every year due to illegal abortion. Here is my blog for choice day post from last year if you mistakenly believe that anti-choice laws don’t kill mothers and their children, or other myths about abortion.

If you can’t afford to give money, consider installing the GoodSearch toolbar on your browser, and your searches will earn money for Medical Students for Choice.

I am having a Beatles Rock Band party during the Super Bowl. My hubby will have the game on in the living room, but I will be in the back room doing the Beatles thing. And making and serving food. I hope to miss the Tebow commercial. And any commercial with farting horses.

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Personhood bill in Florida

The radical anti-choice lobby has brought a so-called “Personhood” Bill to Florida. This would try to extend human rights to conceptus “at the beginning of biological development”.

If the physiology of pregnancy (like, there is no biological test for conception, and the vast majority of fertilized eggs do not implant, and no major medical organization defines that as the beginning of life) and the major ethical concerns with this don’t already sway you to sign this petition against the Personhood amendment in Florida, maybe this will:

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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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My conscience clause comment

My comment to the Department of Health regarding the proposed rescission of the Bush era conscience rule. For information on making your own comment, please visit Rachel at Women’s Health News.

This comment is in regards to the rescission proposal.
I am a medical student, a future ob/gyn, a mother, and a concerned citizen. I think there was no current need for the new conscience clause ruling. The former HHS secretary, Mike Leavitt, purposefully mischaracterized the state of licensing for ob/gyns in order to forward a political ideology. The American Board of Obstetrics and Gynecology publicly demanded that the HHS show even one case of discrimination against a practitioner who exercised his or her right to refuse to participate in an abortion, and Secretary Leavitt was unable to produce even a single example.

The Obama administration states that it is committed to changing the unfortunate recent history of overlooking science and truth in order to advance political ideology in health policy. In fact, most of these decisions have been based on opinions that only represent a minority ideological belief of the citizenry. The rescission of this ruling is imperative to reestablish faith in our national health policy.

The current conscience legislation is already too overreaching. I am concerned that requiring health care entities to pre-certify that they do not discriminate in hiring, specific to conscience refusal, will hamper the ability of certain organizations to fulfill their mission statements. For example, in my high risk area, South Florida, the Department of Health has family planning clinics established and funded for the sole purpose of providing birth control to the underserved. With the climate encouraged by this recent legislation, it is entirely plausible that these facilities would be forced to hire employees that are opposed to birth control.

In fact, some sections of the rule do not refer to abortion at all, and could be construed to apply to any practice that a potential employee finds unethical. Birth control is not abortion according to medical definitions of pregnancy and the methods of action of birth control, but many extremists see forms of birth control as abortion, and the law caters to such a worldview. How long until observant Christian Scientists are applying for jobs at surgery centers with the intent of obstructing surgical procedures? It seems like this rule is likely to increase costly lawsuits. It also seems like health care entities will be almost forced to hire employees that will expressly NOT fulfill their job duties in order to avoid such lawsuits. Where is the pressing need to increase such lawsuits? In actuality, there is a pressing need for more abortion providers and more contraception access, not less. There is a pressing need to reduce health costs, not increase them. There is a need to increase common ground, not accentuate difference and encourage uncooperation when there is already more than adequate provisions protecting conscientious objection in health care.

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Don’t cave, Obama!!

I was disappointed to hear on NPR this morning, on Shakesville, and in my email inbox from the National Family Planning and Reproductive Health Association (NFPRHA), that Obama has caved to Republican pressure and has personally called Henry Waxman to remove provisions from the bailout that would increase funding for birth control for low income women.

First of all, there is no argument that this would increase jobs, both at clinics and at pharmacies. Secondly, it would DECREASE ABORTIONS. 40% of unplanned pregnancies end in elective terminations. Low income women are MUCH more likely to get pregnant and to choose abortion than higher income women. Third, it would decrease unplanned pregnancies that are carried to term by women who are on public insurance and other social welfare services. More pregnant low income means more government on WIC, welfare and Medicaid. A lot of that is state money. States are really strapped right now.

I cannot believe Obama is caving on this issue. Women’s reproductive issues have already been the red headed stepchild of this administration, when they buried ending the Gag Rule in some effort to make it seem less controversial. We need to stop letting the minority define this position. Also, I don’t believe for one second that taking that provision out will increase Republican support for the bailout. I think it’s pretty clear that the main Republican strategy for rejuvenating its base after this last catastrophe of an election is to oppose the bailout. Throwing poor women’s uteri under the bus is not going to change that one bit.

If anyone wants to take action, check out the action alert at the NFPRHA site.

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Health Care Community Discussion

I participated in a Health Care Community Discussion at a local freestanding birth center last night. I volunteered to be the note taker and put it together. Here is what I just turned in:

Background research:
Declerq, E , Norsigian, J. Troubling data on infant deaths. Boston Globe, Nov. 11, 2008. http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/11/17/troubling_data_on_infant_deaths/. Accessed online Dec. 30, 2008.

“Advocates of health reform who focus exclusively on access presume that the United States provides effective but expensive healthcare, and that the only real problem is lack of access to this care. The reality is more complex when we examine those mortality figures… [T]he United States ranks last in infant mortality, third to last in perinatal mortality (deaths in the first seven days and fetal deaths), and last in maternal mortality… While the US infant mortality rate improved marginally – 3 percent – since 2000, the 15 comparison countries, which already had much better rates, improved by 21 percent in the same period. Put in concrete terms – if the US infant mortality rate merely equaled the current average rate of the other 15 industrialized countries, there would be more than 11,000 fewer infant deaths every year in the United States.

The biggest recent shift in maternity care has been a 50 percent rise in the cesarean rate since 1996 to 31.1 percent (third highest among the 16 countries) in 2006. This is testimony to the US belief that more medical intervention, regardless of cost, is better – even when the evidence doesn’t support such a claim. A blind acceptance of medical interventions is a systems problem that won’t be solved by expanding health insurance coverage.

The first step in improving outcomes is recognizing that our problems go beyond access to care. Our poor showing can’t be shrugged off as a function of some subgroup – the uninsured, minorities, immigrants (some generic “them”) having health problems that undermine otherwise solid outcomes. This is not just about who gets care, but about how they’re cared for. Expanding access to a system that doesn’t work won’t change these embarrassing rankings.”

Block, J. Midwives Deliver. Los Angeles Times, Dec. 24, 2008. http://www.latimes.com/news/opinion/la-oe-block24-2008dec24,0,2046506.story. Accessed online Dec. 30, 2008.

Not only is childbirth the most common reason for a hospital stay — more than 4 million American women give birth each year — it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation’s maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison… The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices… The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better… The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Washington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%.

Introductory discussion: This discussion group will be primarily focusing on maternal and pediatric health. Not only is that the vocations, areas of expertise and interest of our participants, but it is a critical area of importance and area in which a great impact can be made in outcomes and in costs.

Informed choice, informed consent is key. Patients cannot make true informed choices without adequate, non biased information and access to all of their options in care. This includes alternative birthing options, such as freestanding birth centers, and the ability to refuse or delay treatment, such as vaccines in children with autoimmune disorders.

Practitioners at the meeting have seen midwifery care integrated into hospital systems seamlessly in other countries with better infant and maternal mortality and morbidity rates than the United States: Ireland is an example. One pediatrician at the meeting trained for a year in Ireland and saw the majority of low risk births delivered by midwives with excellent outcomes. (Ireland ranked lowest in the world in maternal mortality rates, 1 in 100,000 live births, while the United States had 11 in 100,000, WHO Maternal Mortality in 2005, http://www.who.int/whosis/mme_2005.pdf, Accessed Dec. 30, 2008)

Simply improving access isn’t enough. Leading a horse to water isn’t enough if it’s bad water. Practitioners are not practicing evidence based medicine. Standard of care is not based on evidence based medicine. Malpractice suit outcomes and testimony are not based on evidence medicine. This is leading to expensive interventions, worse outcomes for mothers and their children, and tension between different types of practitioners.

There are also problems in the current system – practitioners are not getting paid. Midwife centers are not getting paid, ERs are not getting paid, and major hospitals are closing their doors. With all of the money we are spending, people are not getting good care, and practitioners are not getting reimbursed. The birth center sponsoring the meeting estimates that they are not reimbursed for 25% of their health services delivered, and Florida law is more progressive than some states in supporting coverage of midwives by insurance, including Medicaid.

Questions:
1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?
• Not every state has legalized midwifery or legalized homebirth. We need consistent access and consistent licensing. This should apply to nurse midwives and lay (certified professional midwives) midwives. Midwives should have access to medicines and licensing and insurance to cover treatment of minor complications of low-risk, normal births within the scope of their training.
• Women are not informed about their health choices, such as choosing an alternate practitioner or location for birth. For example, at one Ob/gyn practice, a member of the group observed a pamphlet entitled “Birthing options” included only cesarean section or vaginal birth, with or without an epidural, at a hospital.
• There is a serious problem with the definition of standard of care. If practitioners in the local geographical area do not support midwives, do not support low intervention birth, do not support evidence based practices such as birth in freestanding birth centers, allowing trial of labor for attempted vaginal deliver after cesarean delivery (VBAC), intermittent fetal monitoring, food and drinking during labor, continuous labor support, avoidance of episiotomy, freedom of movement in labor and delivery, etc, then these practices can be vulnerable to malpractice cases and ostracization in the local medical community, including a lack of reimbursement and hospital privileges. This hostile environment discourages practices that save money, provide patient choice and satisfaction, and save lives of mothers and children. The cesarean rate in South Florida is rapidly approaching an astonishing 50%, and that should not be an appropriate standard of care for ob/gyns to defend in malpractice cases.
• In pediatrics, locally there is a lack of continuity of care. Pediatricians are not following contemporary recommendations by professional health organizations. This is especially a problem with nutrition and breastfeeding.
• There is a problem with overtreatment and overmedicalization in pediatrics, also. The pediatrician and the midwives have noticed a tendency for many practitioners to lumbar puncture every child that presents with a minor fever. Doctors are prescribing medicines, such as albuterol, that they know don’t work. Doctors need to keep up with continuing education and evidence based recommendations for practice.
• Is there anything that holds pediatricians to evidence based standard of care? If the American Academy of Pediatrics recommends one practice as a standard of care, but the doctors in the community are making other recommendations contrary to the recommendations, what recourse do consumers have? Even the most educated consumers have problems discerning good medical information on the internet, and many practitioners are not open to patients who advocate for their own care, especially if their information is contrary to the advice of the practitioner. One midwife in the meeting described being “fired” by her children’s pediatricians for bringing in information supporting extended breastfeeding. In regards to informed consent, the only recourse right now for consumers to inform themselves.
• One member of the group suggested public service messages that advertise phone numbers and websites that give out individualized health advice and that complete, unbiased health options (access to other practitioners, like midwives should be available from these sites.)
• Start educating children in health classes in school, or sex ed, making people aware of their options for out of hospital birth.
• Career days are a good option for alternative practitioners like midwives at all levels of education, starting in elementary school.
• Insurance companies should talk about midwives and out of hospital birth as options.
• Maternity care should always be covered by all insurance plans. One member of the group had an experience in which she was insured, but wanted to add maternity coverage. The insurance company refused to allow her to add maternity coverage unless she took a series of negative pregnancy tests. Pregnancy should never be a preexisting condition, especially if a woman has received no prenatal care yet. Early and consistent prenatal care is so important; no one should have to forego prenatal care based on insurance bureaucracy.

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

• People usually get references from educated consumers or references from friends in the field.
• Most people in the room go to who is covered by insurance, but there is little information from the companies about the nature of the practice.
• Interviewing the practitioner is important.
• Check how the office staff responds to you.
• People would have improved options with universal single payer coverage.
• Doctors who make home visits would be nice.
• See answers to question #1 regarding public health information websites and phone lines, and standards of care based on evidence based medicine, not local practitioners.

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?

• Yes, many people have had problems paying bills.
• Single payer universal program would solve this problem.
• No one should go bankrupt to pay hospital bills. No one should choose between medicine and food. No one should choose between her current children’s day care and prenatal visits.
• Insurance companies and employers have saving accounts to pay health bills. We could pay taxes to make these savings accounts.
• Health care costs could be decreased by preventative programs (fitness, nutrition).

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

• Some people don’t have employers to cover them. This system fails small business owners and the self employed.
• Public system preferred by all. People can buy supplemental insurance or pay for elective procedures if they wish.
• Single payer universal plan preferred by all.

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

• Employers and individuals pay way too much for inadequate health plans.
• Employers can pay taxes and stop having to pay for the insurance and stop having to pay salaries to human resource personnel who handle negotiating complicated insurance plans.
• They can play a role in preventative care and dispersing information. They can provide time for exercise, provide healthy food, sponsor groups like Weight Watchers.
• Small businesses struggle with being able to provide special perks and extra flexibility. It would be better if they had more support, tax breaks, and financial incentives.

6. Have you gotten the prevention you should have?

• Birth control is essential to preventative medicine. Women spend 5 years trying to get pregnant, and about 25 trying not to. 98% of women in the United States use birth control at some point in their lives, and about 50% of pregnancies are unplanned. About half of these unplanned births end in abortion.
• All insurance should provide birth control. All pharmacies should provide birth control and emergency contraception. All hospitals should offer emergency contraception.
• As for preventative care of all kinds, don’t just note how many people didn’t receive it, note how many weren’t offered the preventative care. But, allow people to decline. People need informed consent.
• Some people don’t notice people not knowing about flu shots and mammography. We live in a dense, urban area, however.
• Universal dental care, especially for children.
• Universal mammography and new technologies such as MRI for breast cancer screening should be supported.
• Optometry and hearing care for children should be provided through schools, including hearing aids and glasses. If children get screened, there should be follow through and access to care and devices.
• Parents need to know how to work the system. People should not have to work so hard to access care.
• Longer maternity leave!!!!
• More sick days.
• Women sit in clinics for 7 hours to get a 15 minute prenatal visit at a public clinic. They avoid prenatal care and have higher complication rates. This is why women show up in labor without adequate prenatal care.
• High schools should have good information and access to adequate sex education, access to birth control, access to prenatal care and access to daycare and health services for children of teenage mothers.

7. How could public policy promote healthier lifestyles?

• We need to retrain health care professionals. They are too centered on drugs and overmedicalization.
• Mandating PE and recess programs need to be enforced in schools. More indoor facilities for PE.
• Treat healthy patients like healthy patients. Don’t overmedicalize patients in labor.
• Accountability! For practitioners to practice evidence based medicine.
• Good food and nutrition in schools.
• Public schools with gardens. Public gardens in cities.
• Access to healthy food in all neighborhoods and areas.
• Less environmental pollution and pesticide use, more local growing of foods.
More funding of alternative medicine, more promotion of these alternative methods. Expand federal funding of alternative and complementary medicine, and cooperate with other countries to learn from their successful integra

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