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What To Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)

Screen shot 2015-03-20 at 9.07.11 AM

By Ananda Lowe
Guest Contributor

The term “homebirth cesarean” didn’t exist before 2011, when Oregon mother and student midwife Courtney Jarecki coined it. But now, a Google search returns almost 2,000 entries on the topic.

The term refers to a small but emerging community of mothers who have experienced the extremes of birth: They’d planned to have their babies at home, but ended up in a hospital, most often in the operating room having a cesarean section, major abdominal surgery. Needless to say, the effect of such a dramatic course change takes a toll, and can often be overwhelming.

(“Homebirth cesarean” can also refer to births that were planned to occur at a freestanding birth center outside of a hospital, but eventually were transferred to the hospital for a cesarean.)

How often does this happen?

Home births, though a small fraction of the approximately 3.9 million births a year in the U.S., are on the rise. Based on the most recent birth data from the National Center for Health Statistics, “the 36,080 home births in 2013 accounted for 0.92% of all U.S. births that year, an increase of 55% from the 2004 total.”

Eugene Declercq, a professor of community health sciences at Boston University School of Public Health, studies national birth trends. He said in an email that while there are no nationwide numbers on homebirth transfers to the hospital, “the studies that have been done usually report about a 12% intrapartum transfer rate.”

But beyond the numbers, what happens emotionally when your warm and fuzzy image of natural childbirth in the comfort of home suddenly morphs into the hard reality of a surgical birth under fluorescent lights?

A woman who'd planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

A woman who’d planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

Jarecki founded the homebirth cesarean movement to figure that out. She connected women who, like herself, shared the experience of giving birth through full surgical intervention, despite their original plans of having their babies at home or outside of the established medical system.

In Jarecki’s case, she labored at home for 50 hours until her midwives detected a rare complication known as a constriction ring, or a thickened band of tissue in her uterus that was impeding progress. Shortly after this, meconium appeared, and Jarecki knew it was time to go to the hospital. Her emotional response to the intensity of the situation, however irrational, was one of anger, shame and failure at her ability to give birth normally. A cesarean followed.

Over the next several years, Jarecki began helping other homebirth cesarean mothers emerge from the silence and shame they felt confronting their unexpected surgeries. Some of these women also report that their postpartum recovery was tougher because their unique needs were not adequately addressed by their home birth midwives or their hospitals.

Jarecki started by launching a (now busy) Facebook page as a support group for these mothers and their health care providers.

Childbirth Expectations vs. Reality

Rule number one in childbirth is that it rarely unfolds as you expect. Continue reading

Dementia As A Global Public Health ‘Tidal Wave’

We often think of dementia as a private, intimate hell. A mother no longer recognizes her daughter’s voice. A father rages incoherently at a family dinner.

But it’s worth remembering the global scope of dementia; it’s a looming, worldwide public health disaster, a ‘tidal wave,” as the head of the World Health Organization recently put it, that’s growing worse each year.

This week, the World Health Organization held the first-ever ministerial conference calling for global action against dementia, saying, essentially, enough already, this is something we really need to deal with now.

The WHO’s Director General, Dr. Margaret Chan, offered some sobering perspective in her opening remarks and noted that there are three specific reasons to act now: “Dementia has a large human cost. Dementia has a large financial cost. Both of these costs are increasing.”

According to remarks distributed by the WHO, Chan spoke of dementia, including Alzheimer’s, in dire terms:

“The world has plans for dealing with a nuclear accident, cleaning up chemical spills, managing natural disasters, responding to an influenza pandemic, and combatting antimicrobial resistance. But we do not have a comprehensive and affordable plan for coping with the tidal wave of dementia that is coming our way.”

And the numbers are staggering:

–Dementia currently affects more than 47 million people worldwide, with more than 75 million people estimated to be living with dementia by 2030. The number is expected to triple by 2050.

–Dementia leads to increased long-term care costs for governments, communities, families and individuals, and to productivity loss for economies. The global cost of dementia care in 2010 was estimated to be U.S. $604 billion – 1.0% of global gross domestic product. By 2030, the cost of caring for people with dementia worldwide could be an estimated US $1.2 trillion or more, which could undermine social and economic development throughout the world.

–Nearly 60% of people with dementia live in low- and middle-income countries, and this proportion is expected to increase rapidly during the next decade, which may contribute to increasing inequalities between countries and populations.

Continue reading

Conflicts Abound In Research Studies On Food, Nutrition, Expert Notes

Marion Nestle, a professor in the Department of Nutrition, Food Studies, and Public Health at New York University, has been called one of the most powerful foodies in America. (Michael Pollan deemed her No. 2, right after Michelle Obama.)  Ranking aside, Nestle (no relation) knows her Big Food.

(david_pics/Flickr)

(david_pics/Flickr)

In a recent post on her blog Food Politics, Nestle makes a clear case that food and nutrition “research” is riddled with conflicts of interests — chocolate makers sponsoring a study on the cognitive benefits of cocoa, for instance.

Nestle notes that some studies paid for by food companies or trade groups “almost invariably promote the financial interests of the sponsor.” Here are just a few examples she collected in a week or so: Continue reading

One Doctor Asks: Why Are We Arguing About Measles Vaccines In 2015?

By Dr. Rebecca Weintraub
Guest Contributor

This week, as I juggled work, family and shoveling, I prepared a lecture on promoting equity in health delivery. My first slide is a picture of the Ebola virus, and as of this morning, my last slide is a map of the ongoing measles outbreak. That’s because this week, we’ve heard a clear public health message from both President Obama and Surgeon General Vivek Murthy: Vaccines are safe and effective.

Why is this message being repeated in 2015?

As a mother and physician, I am dismayed that all Americans are not practicing this guidance based on evidence from 40 years ago. Vaccines are safe and effective. There is no link between vaccines and autism.

In 1757, Dr. Francis Home proved the infectious nature of measles and detected the virus in blood. The highly contagious virus spreads via droplets and replicates within the newly infected person for 14 days. The symptoms include high fever, red eyes, runny nose and cough. A few days after the onset of these symptoms, “Koplick’s” spots—bluish markings on the inside of the cheek—appear. Then, a rash starts at the head and travels to the feet. The infected person is contagious for four days before and after the onset of the rash. We test suspected cases for antibodies against the virus. After confirmation, the treatment is supportive, including rehydration, nutritional support, medicines to reduce fever, antibiotics for superimposed infections, and Vitamin A supplementation. Once the measles infection has taken hold, there is no cure.

We’ve made tremendous strides in the discovery and development of new vaccines. In 2000, the Centers for Disease Control and Prevention declared the measles virus eliminated. But now, there are over 100 confirmed cases of measles across 14 states. Our most vulnerable populations are at risk of contracting an entirely preventable disease. This is not only an issue of choice, but an issue of health equity and our role as global citizens.

So now we can, and must, eradicate measles… again. We can learn from Mississippi and West Virginia, which have been at the forefront of new vaccination efforts. Continue reading

Why The Current, Post-Eradication Measles Outbreak Is So Infuriating

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

Back of female with measles/ Wellcome Library, London. Wellcome Images/flickr

That certain parents refuse to get their kids vaccinated isn’t new. But suddenly, it’s news. And it’s troubling. I’m a big supporter of “crunchy” parenting, but not when it puts other people’s children (and mine) at risk. The current measles outbreak has infuriated many parents and medical professionals who, fuming, wonder why we are arguing about a virus that was already eliminated here in the U.S. 15 years ago.

So, here’s one such parental rant on the topic by Alicair Peltonen, an administrative assistant at the Harvard School of Public Health and a journalism student at the Harvard Extension School.

By Alicair Peltonen
Guest Contributor

When I was in elementary school, one of my favorite books was called “The Value of Believing In Yourself,” by Spencer Johnson, MD. It was part of a children’s book series meant to teach lessons through the life stories of historical figures. The Value of Believing In Yourself was about Louis Pasteur and his quest to develop the rabies vaccine.

That book still stands as my most cherished source for the science of immunity. Even with a bachelor’s degree in biology, a career spent working in scientific and medical research and a current job in the immunology department of a prestigious graduate school, I still picture all viruses as scruffy black blobs with scary pink faces and foaming fangs. And vaccines are the steadfast soldiers in uniform with huge mustaches and bayonets that are sent in to get the bad guys. How on earth could anyone be more scared of the soldiers than the black blobs?

I have kids. I know all about fear. Those first days with my oldest daughter were magic, but it was a dark magic. It came with visions of this tiny creature I was now in charge of falling off my lap as I breast-fed or rolling face-first into a crib bumper. I imagined a hundred ways she could be injured or worse — and I imagined all the ways it would be my fault.

I went straight to my local Isis Maternity (a wonderful organization that no longer exists) and signed up for new mommy classes. Those classes were an education for me, not in what to do as a new parent, but what not to do. All the women I sat criss-cross applesauce with were lovely, caring, engaged moms who were genuinely searching for the best way to rear happy, healthy child. And every single one of them was irrationally afraid of one thing. And those “things” were all different. Continue reading

Frostbite, Hypothermia And Other Fun Facts To Remember On Blizzard Day

It’s going to be a long, long day. If you’re like us, you’ve already cooked some kind of elaborate breakfast, chosen the morning movie lineup, and set up the “Let’s Dance” Wii. And it’s not even 8 a.m.

When you’re ready to venture outside and “play,” remember it’s freezing, with ferocious winds. No doubt you’re familiar with this kind of extreme weather, but there are a few health tips worth repeating. Here’s the Boston Public Health Commission with a cute video reminder:

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.”

Continue reading

White Coats For Black Lives: Toward Racial Equality In Health Care

Kaitlyn Veto/flickr

Kaitlyn Veto/flickr

Acknowledging the public health impact of racism and deep disparities in the quality and accessibility of medical care for patients of color, a national organization, White Coats for Black Lives, says it’s launching a new effort today, in celebration of Martin Luther King, Jr.

Dorothy Charles, one of the group’s organizers and a first year medical student at the University of Pennsylvania’s Perelman School of Medicine, offers some context in an email:

Racism profoundly impacts people of color: the black-white mortality gap in 2002, for example, accounted for 83,570 excess deaths. As future physicians, we are responsible for addressing the perpetuation of racism by medical institutions and seek policy change to eliminate disparities in outcomes.

Here’s a statement from the White Coats for Black Lives National Steering Committee:

Upon matriculating in medical school, students recite the Hippocratic Oath, declaring their commitment to promoting the health and well-being of their communities. On December 10, 2014, students from over 80 medical schools across the United States acted in the spirit of that oath as we participated in a “die in” to protest racism and police brutality. In our action, we called attention to grim facts about the public health consequences of racism, acknowledged the complicity of the medical profession in sustaining racial inequality, and challenged a system of medical care that denies necessary treatment to patients unable to pay for it, disproportionately patients of color.

Today, in celebration of the legacy of Dr. Martin Luther King Jr., we announce the founding of a national medical student organization, White Coats for Black Lives. This organization brings together medical students from across the country to pursue three primary goals:


1. To eliminate racism as a public health hazard

Racism has a devastating impact on the health and well-being of people of color. Tremendous disparities in housing, education, and job opportunities cut short the average Black life by four years. Physicians, physician organizations, and medical institutions must therefore publicly recognize and fight against the significant adverse effects of racism on public health. We additionally advocate for increased funding and promotion of research on the health effects of racism.

2. To end racial discrimination in medical care

We recognize that insurance status serves in our healthcare system as a “colorblind” means of racial discrimination. While it is illegal to turn patients away from a hospital or practice because of their race, patients across the country are frequently denied care because they have public insurance or lack health insurance. We support the creation of a single payer national health insurance system that would give all Americans equal access to the healthcare they need. Such a system would create a payment structure that reflects the fact that “Black lives matter.” Moreover, ample evidence suggests that patients of color receive inferior care even when they are able to see a doctor or nurse; we therefore advocate for the allocation of funding for research on unconscious bias and racism in the delivery of medical care. Continue reading

Why You Really Need A Flu Shot (Even Though The Vaccine Isn’t Great)

(WFIU Public Radio/Flickr)

(WFIU Public Radio/Flickr)

By Richard Knox

This flu season is shaping up to be a bad one. And this year’s vaccine doesn’t work very well against the most common flu virus going around. So should you even bother getting a flu shot?

Yes. Putting it a different way: My wife, my daughters and I will. And the evidence says you’d be somewhere between slightly foolish and dangerously blasé if you don’t — depending on your personal risk factors.

I know there are naysayers — the Internet is full of them. “I recommend that my patients of all ages not take these incessantly promoted immunizations, primarily because of their lack of effectiveness,” writes blogger Dr. John McDougall. He says he’s not one of those across-the-board vaccine deniers but just doesn’t think flu vaccines (of any given year) are worth taking.

To understand why I think he’s wrong — even this year, when vaccine effectiveness is expected to be even lower than usual — you need to know something about the situation we’re all in.

Several viruses circulate during any given flu season. And flu viruses are always changing — sometimes not so much from year to year; sometimes in a bunch of little ways (a phenomenon called genetic “drift”); and sometimes in a big, sudden way, called a “shift,” which touches off pandemics.

Drifts Or Shifts?

Public health researchers constantly monitor flu virus mutations. But even the smartest flu dudes can’t know in advance when they’ll happen, or whether mutations will be drifts or shifts.

This year, one of the flu viruses outwitted them. Or, since viruses can’t have intentions, it’s better to say that random genetic drift in that viral strain, called H3N2, happened in late March. That’s a bad time in the annual cycle of vaccine production.

Just a few weeks earlier, leading flu specialists gathered at the World Health Organization in Geneva and decided that this season’s vaccine (for the Northern Hemisphere) should contain the same viruses as last year’s — two type-A viruses (an H1N1 that caused the pandemic of 2009 and has stuck around since, and an H3N2 that first appeared in Texas two years ago) and two type-B flu viruses.

Late-Breaking Mutant

Making each year’s flu vaccine is a complicated business that waits on no virus. The recipe has to be decided in February to get the chosen viruses growing in hundreds of millions of special chicken eggs, the first step in vaccine production. Continue reading

Viewpoint: Consider Tough Penalties To Boost Disabled Patients’ Access To Care

We already know that patients with disabilities face major obstacles when trying to access basic medical care. Now, a team of researchers are proposing some novel strategies to help fix the system, including withholding payments to health care organizations and making accreditation contingent on compliance with disability law.

The researchers, Dr. Tara Lagu and colleagues at Baystate Medical Center, Tufts University School of Medicine, and a Massachusetts not-for-profit organization, the Disability Law Center, suggest that this is the first time these types of strategies have been proposed.

“The goal of this paper was to start the conversation,” says Dr. Lagu via email.

Dr. Tara Lagu, M.D., MPH (Courtesy)

Dr. Tara Lagu, M.D., MPH (Courtesy)

Lagu’s groundbreaking earlier study on access to care for people with disabilities found that even in the current high-tech health care environment, many elements of routine medical care — like getting a patient on to an exam table — remain elusive.

The latest article, published in JAMA Internal Medicine, describes the range of barriers, including:

“…physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities.

And here, Lagu offers some possible solutions:

As our study last year reported, patients with disabilities face real difficulties when they try to access health care. This suggested that our current strategy for enforcement, lawsuits, have fallen short. In part, this is because patients don’t want to bring lawsuits against doctors with whom they have an existing relationship and because lawsuits are extremely unpopular with physicians. More importantly, lawsuits have failed to initiate system-wide change: it is not clear that, in recent years, there have substantial improvements in access to care for patients with disabilities.

For these reasons, we believe that novel strategies are needed. As we considered what such strategies might look like, we considered other mechanisms of enforcement that have been successful at motivating change in health care settings, and we came to four possibilities: withholding payment, making accreditation contingent on compliance, regulation, and lawsuits at the state or national level aimed at initiating large-scale policy change. Continue reading