We have been studying women’s health at school the past few weeks. It has been a great way to wrap up the semester for me. I could be writing volumes about it, if I had the time. As Indigo Montoya says, “Let me explain. No, there is no time. Let me sum up.”
I went and talked to our pharm professor about induction for macrosomia (big baby) for a while, and pointed out that our textbook says that ACOG does not recommend it, that ultrasounds are notoriously nonpredictive and outcomes do not improve with induction. She said during class that macrosomia was an indication for induction, and it would be done at 37, 38 weeks. I went to a lecture on a successful maternal mortality and morbidity intervention program at a big hospital, and they had a policy that any induction before 39 weeks needed approval of the director of obstetrics. A read int he New York Times that some insurance companies are refusing to cover inductions before 38 weeks. I sent that article a family member. She got induced (for suspected fetal macrosomia, natch). her induction was unsuccessful, and her delivery was highly complicated. She spent 13 weeks in the hospital. Typical? No. Preventable? Maybe.
My pharm teacher also said how her own 9 pound baby was too big for her hips, but my textbook defined macrosomia at 4,500 or 5,000 g, depending on diabetes (I would have to go back and read that part to get it right…) Anyway, that’s over 9 pounds. She was very cool about it, and said her daughter, with whom she had a failed induction at 37 weeks or so, had multiple infections and lung problems and had to be in NICU a lot.
We have a visiting professor who has been pretty good about a lot of stuff. I made a commitment to only go up and discuss topics if it was evidence based. He did the lecture on external fetal monitoring, and did a good job of presenting the lack of evidence on its superiority to intermittent monitoring, and gave a good list of risks (many) and benefits (few) of internal fetal monitoring.
But, the next day, he steamed through intrapartum care. He went off on a rant about La Leche League. He stated that there benefits and disadvantages to both breastfeeding and formula feeding. He said his wife watched a La Leche League video which listed the benefits of breastfeeding, and then said, “If you have chosen to formula feed, that is OK, too.” His wife was apparently devastated by this comment. He was still angry. “Can you imagine saying that?” Yes, yes I can. He called La Leche League a bunch of extremists.
(By the way, professors in obstetrics are very funny about how they will complain about how everyone tells pregnant women horror stories, which is true, and then will proceed to give their own horror story example and extrapolate that into what they think should be standards of care. I have seen that 3 times in this system alone, at least.)
Now, I can’t vouch for each and every gorup leader or member. I have had someone tell me that one local group leader was discouraging someone from supplementing at all, even when her baby was clearly failing to thrive to the point that its developmental milestones could be affected. There are ways, with supplemental lactation systems and pumps, that mothers can still try to establish a successful breastfeeding relationship and still make sure the baby is getting adequate nutrition. I know some moms cannot breastfeed for a variety of reasons, and no one should ignore very real health issues on the maternal or neonatal side when considering breastfeeding.
Then he said the killer statement that always gets me: “It is a lifestyle decision.”
No dude, no it’s not. It’s a health decision. It’s not a lifestyle decision. I pumped at work for two babies. I know residents who have managed to pump. No one’s lifestyle precludes her from breastfeeding. Are there socioeconomic factors that influence a mother’s success in breastfeeding? Absolutely. Just like there are lifestyle and socioeconomic factors that influence compliance with many health decisions that involve ongoing behavior, like HAART in AIDS treatment, liver dialysis, low glycemic diets for diabetics, etc. That does not make these lifestyle decisions.
Just like any other health decision, there are many issues to consider when discussing breastfeeding with a prospective mother. Any pregnant person who can consider breastfeeding because it is not completely contraindicated for her and the baby (which is rare, but happens, such as in cases of HIV+ moms, certain drug regimens, etc.) should be told a list of the health benefits of breastfeeding for the baby and mother. They are facts. These lists do not exist to make moms who cannot / do not breastfeed feel guilty. Just like lists of the benefits of exercise do not exist to make couch potatoes like me feel guilty. Yes, some people can’t exercise due to health reasons. Some people have little time or opportunity to exercise due to lifestyle and socioeconomic reasons. Does that make the decision to exercise or not a lifestyle decision? Of course not, it is a health decision with many valid options. Does that mean doctors and their teams should not have a nuanced discussion with their patients about the benefits of exercise, with obvious attention to the personal medical history of the individual, as a component of true informed consent and patient education? Just in case someone like me feels guilty that I don’t try harder to make time? Or someone with advanced rheumatoid arthritis or some other condition may not even be able to exercise much if at all?
Healthy People 2010 has tracked the abysmal breastfeeding rates. We don’t need people teaching the practitioners of the future to tell future doctors that breastfeeding is a lifestyle decision and any promotion otherwise is extremism.
Oh, and I am a finalist for the research fellowship. More vibes, please!