pregnancy

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Having A Baby? Big Differences In Hospital Quality Across Massachusetts

If you’re one of the roughly 70,000 women who will give birth in Massachusetts this year, you may be planning to deliver at a hospital close to home or where your OB practices. But what you might not realize is that when it comes to childbirth, there are big differences in hospital quality across the state.

For example:

  • Your chance of having a Cesarean section is almost three times higher at some hospitals
  • While some hospitals allow you to schedule an early delivery even when it’s not medically necessary, other hospitals have stopped this practice because a baby’s brain, lungs and liver need the full 39 weeks to develop
  • Your chance of having an episiotomy — a surgical cut to enlarge the vaginal opening — ranges from 0 to 31 percent
  • Trying for a natural delivery after having had a C-section is encouraged at some hospitals but not offered at others
  • Three times as many women breastfeed their babies at some hospitals as compared to others

“The door you walk in will have a big impact” on what happens during and after childbirth, says Carol Sakala, director of programs at the nonprofit maternity quality group Childbirth Connection.

The hospital where women choose to deliver “absolutely matters,” says Dr. Neel Shah, an assistant professor of obstetrics at Harvard Medical School. Take C-section rates, Shah says. “In many ways, which hospital you go to is a bigger predictor of whether or not you’re going to get a C-section than your own risk or your own preferences.”

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Differing Views On Antidepressants During Pregnancy

The question of taking antidepressants during pregnancy is extremely intimate and complicated. Research studies evaluating the risks and benefits are mixed. There are documented harms, like an elevated risk of pre-term birth. But there are also the documented harms of untreated depression. In other words, it’s a deeply personal health decision that requires judgement based on a body of data that offers no easy answers.

The latest on this fraught debate comes from Andrew Solomon who wrote a long piece published in last Sunday’s New York Times Magazine, “The Secret Sadness,” with this basic message: “Pregnant women who are depressed often fear taking the medication they rely on. But not treating their depression can be just as dangerous.”

Solomon, whose own depression is well documented in his powerful book, “The Noonday Demon: An Atlas of Depression,” (The Times piece will be added as a new chapter in the book) begins the magazine article with an anecdote about Mary Guest, “a lively, accomplished 37-year-old woman” who “fell in love, became pregnant and married after a short courtship.”

Struggling with depression for much of her life, Mary took various antidepressant and anti-anxiety drugs, Solomon writes, but decided to discontinue the meds during pregnancy. But Mary’s mood and behavior “spiraled downward” so, “near the end of her fifth month of pregnancy, she finally, reluctantly, resumed taking an antidepressant,” he writes.

Then, at six-and-a-half months pregnant, and convinced that something was wrong with her fetus, Mary “went to the 16th floor of the building where her parents lived and jumped to her death.” Solomon quotes Mary’s mother saying: “We feel, rightly or wrongly, that if Mary had stayed on her medications, or even gone back on them sooner, it’s possible she would have survived.”

It’s an intense, moving story.

But Dr. Adam Urato, an assistant professor at Tufts University School of Medicine in Boston and a maternal-fetal medicine physician at Tufts Medical Center and MetroWest Medical Center in Framingham, says he’s got an important story to tell too: that antidepressants can also cause harm. Urato writes and lectures on this topic frequently, and says he feels that Solomon’s piece didn’t offer the complete picture. (Here’s Urato’s full rebuttal to Solomon’s article on the website Mad In America, published by journalist Robert Whitaker.

Solomon quotes Urato in the Times story (in fact, some of the quotes come from a post Urato wrote for CommonHealth). But Urato says his views weren’t fully reflected. Here, edited are a few of Urato’s points:

1. Anecdotes Have Limitations

No one wants a pregnant woman to kill herself. An article in which pregnant women stop their medications and kill themselves while others continue on their meds and have happy outcomes is sure to push readers in an obvious direction. However, such anecdotes are limited.

For example, the author could have told stories of women who stayed on their medications, weren’t counseled regarding the risks, and had severely impaired babies. Continue reading

Medicated (And Unmedicated) Women Are Talking

By Alicair Peltonen
Guest Contributor

I think a crucial step in decreasing the stigma surrounding mental illness is talking about it openly. And it seems readers want to talk.

My post, “The Medicated Woman: A Pill To Feel Better, Not Squelch Feelings,” on mental health and medication, was shared on Facebook more than 15,000 times and now has over 200 comments, so I thought it was worth a follow-up.

One thing readers wanted to discuss is the safety of antidepressants during pregnancy, a complicated topic which has been covered here and here on CommonHealth. Safety studies are mixed in many cases so women should consult their doctors. Here’s what it says on the Mayo Clinic website:

A decision to use antidepressants during pregnancy is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Still, few medications have been proved safe without question during pregnancy, and some types of antidepressants have been associated with health problems in babies.

Other comments underscored that stigma still exists but may be slowly diminishing.

(Flickr Creative Commons)

(Flickr Creative Commons)

Jackie wrote: “It took me until I was in my 50’s to accept that medication wasn’t the ‘weak”‘ way. I now see how much I lost and am living through a tremendously stressful life without those urges to accelerate into other cars or cement walls.”

“It’s in our family, but I was the first to seek help, and was probably the worst off. It was a secret that my grandfather had committed suicide,” wrote lilycarol.

And here’s a comment from helentroy4: “My mother was much like me. But to her dying day she never acknowledged that her behaviors were anything but ‘perfect mothering.’ I think had she been able to take advantage of this medication (or others of its kind), she would have been able to have the calming of her heart and soul that I have been blessed to have.”

There were many who suggested that lifestyle changes, including more exercise and sleep, meditation or yoga might be safer and more beneficial than medication. Continue reading

Painkillers? Prozac? Brazilian Blowout? Hotline Counsels Pregnant Women On Risks

(Tatiana VdB/Flickr/Creative Commons)

(Tatiana VdB/Flickr/Creative Commons)

Joy Shapiro of Framingham, Mass., was the sort of hyper-cautious expectant mother who doesn’t just cut out alcohol and caffeine. She worried about the ingredients in everything she consumed or put on her body, from fitness drinks to sunscreen.

But thanks to a referral from her obstetrician, she had a secret weapon against her anxiety: Patricia Cole, the program coordinator for MotherToBaby Massachusetts — also known as the Pregnancy Exposure Infoline — whom she “bombarded” with queries.

“At one point, I emailed her like 20 ingredients that were in my face cream to say, ‘Are any of these going to be a detriment to my pregnancy?’” Shapiro says. “You’re essentially living for two, and you want to make sure you’re not doing anything that could harm your child.”

Cole helped Shapiro navigate not just food and cosmetics but medications — prescription steroids, acid reflux, nasal sprays. The sorts of decisions that have become commonplace, nearly universal, in a country where 9 out of 10 pregnant women take at least one medication during pregnancy, and 7 out of 10 take a prescription drug.

“Less than 10 percent of approved medications have enough data to show what, if any, concerns there are for fetal effects.”

– Dr. Cheryl Broussard, CDC

Many of the old concerns about risky exposures during pregnancy — leaded paint, thalidomide — have faded, but in this nation of prescription-fillers, meds have become a major worry.

Last year, the CDC launched its Treating for Two Website, part of a national initiative aimed at making medication use during pregnancy safer. It seeks better research on the effects of meds during pregnancy, and better guidance for expectant mothers and their doctors. The agency warned just last month about the potential risks of opioid painkillers — such as codeine or oxycodone — for pregnant women.

“Really, the problem is that we just don’t know a lot of information,” says Dr. Cheryl Broussard, a CDC expert on medication use during pregnancy. “We know that up to 9 out of 10 pregnant women take at least one medication during pregnancy, but less than 10 percent of approved medications have enough data to show what, if any, concerns there are for fetal effects.”

Clinical trials on drugs seeking approval generally do not include pregnant women, or drop women if they become pregnant. Continue reading

CDC: Risks Loom As Many Women Of Child-Bearing Age Are Prescribed Painkillers

Source: CDC

Source: CDC

The U.S. Centers For Disease Control and Prevention reports that many women of child-bearing age (notably, women on Medicaid) are taking opioid pain medications and that these drugs taken during pregnancy can increase the risk of birth defects.

According to the agency’s latest Morbidity and Mortality Weekly Report:

During 2008–2012, more than one fourth of privately insured and more than one third of Medicaid enrolled reproductive-aged women (15–44 years) filled a prescription for an opioid from an outpatient pharmacy each year. Prescription rates were consistently higher among Medicaid-enrolled compared with privately insured women.

The most frequently prescribed opioids, says the CDC, were hydrocodone, codeine and oxycodone.

The report details why early exposure is particularly risky:

“The development of birth defects often results from exposures during the first few weeks of pregnancy, which is a critical period for organ formation. Given that many pregnancies are not recognized until well after the first few weeks and half of all U.S. pregnancies are unplanned, all women who might become pregnant are at risk.”

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Culture Clash: U.K. Embraces Homebirth As Best For Some Women

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

Sarah Parente shortly after the homebirth of her daughter Fiona (Courtesy of Leilani Rogers)

By Jessica Alpert

Sarah Parente, an Austin, Texas-based doula and mother of four, gave birth to her first child in the hospital with no complications. But then she decided to make a shift: Parente delivered her next three babies at home. “For women with low-risk pregnancies, home birth can be a great choice,” she says. “You have less stress because you are in your own home surrounded by a birth team of your choosing.”

Though home birth has recently gained cache in the U.S. — with some celebrities trumpeting the benefits of having their babies at home  — the practice remains uncommon and the majority of pregnant women give birth in a hospital setting. Still, Parente may be getting a little more company, albeit slowly. Data released by the Centers for Disease Control (CDC) earlier this year shows the rate of homebirths in the U.S. has increased to 0.92 percent in 2013 and the rate of out-of-hospital births (including home) has increased 55 percent since 2004.

Experts in the United Kingdom are saying that’s a good thing.

The London-based National Institute for Health and Care Excellence (Nice) recently released recommendations that homebirths and midwife-led centers are better for mothers and often just as safe for babies as hospital settings, the BBC reports. Of the 700,000 babies born in England and Wales each year, nine out of 10 are born in obstetric-led units in hospitals. Continue reading

Opinion: New Pregnancy Drug Guidelines A Mixed Bag For Consumers

pumicehead/flickr

pumicehead/flickr

By Dr. Adam Urato
Guest Contributor

Last week the Food and Drug Administration published a final rule that will change how drug companies present information on the risks of medications during pregnancy. This is considered a very important step as there are approximately 6 million pregnancies in the U.S. every year and the average pregnant woman takes between three and five prescription drugs during the course of a pregnancy.

For decades, the public has relied on the FDA’s Letter Category system in which a Category A drug was considered safe, Category D unsafe, with B and C falling in between, and Category X meaning contraindicated in pregnancy.

This past week the FDA announced that it is scrapping that letter system and replacing it with a new system that will offer descriptions about the effects of the drug during pregnancy and lactation. A third section (the “Females and Males of Reproductive Potential” subsection) will include information about pregnancy testing, contraception and about infertility as it relates to the drug.

So what exactly does all this mean for consumers?

As a Maternal-Fetal Medicine specialist, here’s my read on the changes:

What this means is that men and women are going to have to actually go to the drug information label and read it. No longer will a pregnant woman simply be able to look up a drug and find out that it’s a Category D in pregnancy, for instance, and then avoid it.

And this is a major problem that I see with the new system: many patients and physicians do not take the time to read through the label prior to using a medication. A description-based system risks losing the benefit of warning that the current Letter System provides when the drug is simply listed as Category D or X.

Also, it seems that the drug companies themselves are going to be asked to write these pregnancy sections on the label. This strikes me as absurd. Continue reading

Study: Pregnant Women Hungry For Better Info Earlier On

Pregnancy test (Wikimedia Commons)

Pregnancy test (Wikimedia Commons)

The “+” sign pops up on your pregnancy test. You call the office of the obstetrician you’ve chosen for just this eventuality, and the receptionist congratulates you and sets you an appointment four or six or eight weeks away.  “But,” you think, “I have so many questions now!” The books aren’t enough. So you turn, of course, to Google, and navigate the thickets of information alone.

If this was your pregnancy experience and it struck you as odd or off or wrong, you’re not alone, according to a recent small study that likely reflects a far broader opinion. Writes one pregnant friend: “My docs are wonderful and insanely knowledgeable, and I call them for the big stuff. However, there’s so much little stuff when you’re pregnant, especially for the first time. It’s constant googling, is this normal? Everything from symptoms, food, exercise routines, massages, whether to dye your hair – it’s endless.”

And some things you need to know early, she notes. “I did have the books – I found the Mayo Clinic guide to a healthy pregnancy to be quite good. But, not so easily searchable, especially when you’re at dinner and you’re like, ‘Can I eat xyz?’ My husband downloaded a few apps right away that allow you to search what you can eat, what to avoid. Some are obvious: alcohol, sushi, some way less so – um, lunch meat?”

From the study’s press release:

Pregnant women are using the Internet to seek answers to their medical questions more often than they would like, say Penn State researchers.

“We found that first-time moms were upset that their first prenatal visit did not occur until eight weeks into pregnancy,” said Jennifer L. Kraschnewski, assistant professor of medicine and public health sciences, Penn State College of Medicine. “These women reported using Google and other search engines because they had a lot of questions at the beginning of pregnancy, before their first doctor’s appointment.” Continue reading

Pregnancy Woes: Why Did The Price Of My Progesterone Skyrocket?

(Photo: Rekha Murthy)

(Photo: Rekha Murthy)

By Rekha Murthy
Guest Contributor

Update: KV Pharmaceutical changed its name to Lumara Health, two days after this post was published.

I’m 34 weeks pregnant and working hard to keep this baby inside me for as long as possible. As with my last pregnancy, there’s a real risk that the baby could come too early. But we’re both holding on so far, thanks to a combination of luck, modified bed rest and medical science.

The science is my biggest concern right now. I will spare you much of it because, man or woman, you will instinctively cringe and close your legs. However, one critical medical intervention that has been proven to work for countless women and babies is again under threat, and I must speak up.

Every week, my husband injects me with 250 mg (1 ml) of 17 alpha-hydroxyprogesterone caproate (“progesterone” for short). Leaving aside what this does to an otherwise tender and loving marriage, these injections have been found to significantly lower the risk of preterm birth.

Two weeks ago, my insurance co-pay for progesterone went from $5.50 per dose to $70 per dose. Just like that. For those without insurance (or with a deductible), the medication went from $32.50 per dose, according to my local compounding pharmacy, to…wait for it…$833 per dose, according to the new pharmacy my insurer is now requiring me to use.

$833. Per. Dose.

Pricing varies somewhat across pharmacies and insurers, but not enough to make this price change any less breathtaking. In fact, the drug’s list price is $690 per dose.

The 12-fold leap in my co-pay sent an epic shock through my (natural and synthetic) hormone-laden system. I immediately called both pharmacies, my insurer, and my doctor, and started digging around online. I soon learned that the price increase came from a new requirement to buy expensive brand-name progesterone, instead of the affordable compounded version I had been getting. A disturbing picture came into focus. Continue reading