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Sunday, September 30, 2012

Birth by the Numbers

I just realized that I've never posted this fabulous video on my blog before! It's not a new one, but it is classic. I refer to this all the time, and it was also shown in one of my MCH courses.


Epidemiologist Eugene Declerq examines Birth by the Numbers. First he discusses the neonatal, perinatal, and maternal mortality rates and how the United States continually ranks low compared to other countries. Then he moves onto Cesarean section rates compared to other nations and in what situations it is life-saving, and what situations it is actually harmful. 

Then he focuses on the U.S.'s c-section rate. I love this video because he addresses the falsity that the rising cesarean rate is attributable to upper-middle class white mothers choosing elective cesarean sections. These exist, but it's a very small percentage, and is not driving the increase in c-sections. 

It's also not the case that U.S. mothers are more high risk than other mothers. 


The video is about 22 minutes long, but it's worth a viewing. 


So what is the reason for the increasing cesarean rates? Provider practice changes.

Truth be told, mothers are feeling pressured to have a cesarean by their care provider. They're scheduling more women for inductions, which increase risk for surgery. Providers are lowering their threshold for "medically indicated" c-sections. They fear the tiny percent possibility of something going wrong, and the possibility of a lawsuit. C-sections are more convenient for doctors who want to make it home in time for dinner. 

Don't believe me? Listen to the data, and watch the video above!
 
 

Thursday, September 27, 2012

Anthropological Perspectives on Health Care Professional Training

So grad school is kicking my butt this semester, and I have not had as much time as I would like to blog! I feel sad that it has fallen by the wayside.

I'm taking a really great anthropology class this semester on health systems and medical systems. One of our first class sessions we read and discussed articles on the topic of medical provider training, and the making of the modern health care professional, from an anthropological perspective. I find this topic really interesting in its own right (especially because of Robbie Davis-Floyd's analysis of the way OB/Gyns are trained in Birth as an American Rite of Passage), but also because I know two people in medical school right now. So as I read these articles I imagine them being shaped and molded into new kinds of people.



Readings covered the education and creation of the modern health care professional, or the formation of the individual undergoing biomedical training, and aspects of training that contribute to their subjectivation. A lot of really great discussion points came out of these articles (see below for bibliography), such as the socialization of medical students, how students come to patient-blame and ignore social context, the perpetuation of inequalities, and the issue of the market-driven health care system.

Most interesting was the way health care professionals are socialized in their training, learning how to fit in as a clinician. Students learn things like "detached concern," and how to appropriately "present" patients. Unfortunately, these students often come to engage in victim-blaming, blaming the patients for their poor health rather than larger forces like power inequalities, poverty, racism, social status, etc. Because medical students are often taught how to standardize and be objective, they fail to take into account the unique, situated experiences of each individual patient. In fact, these future health care providers repeatedly come to preserve social inequality and reproduce power inequalities created by biomedicine instead of working to solve the broader political and economic issues that contribute to poor health.

Anthropological study of the way in which clinicians and physicians become modern health care professionals enables us to understand “what kinds of people are formed” through medical training. This is a topic I find particularly fascinating because of the enormous effect that health care professionals have on all our lives. I found it interesting to read the ways that clinical training affects the not only the kind of doctors these students become, but also the kinds of people they become. Moreover, these readings illuminated the important ways in which their biomedical training preserves the production the biomedical model, power differentials, and the widening health disparities in our health care system.

I would have liked to have learned more about what these researchers and authors feel would make medical training more efficient at teaching these future health care providers to recognize and address social and power inequalities, rather than perpetuating them. If medical training continues produce health care professionals who ignore the social context of each patient’s health and suffering, what is a better way to train them? These are not issues that will be easily solved. 


Articles:

Adams, V. and S. R. Kaufman 2011 Ethnography and the Making of Modern Health Professionals. Culture, Medicine and Psychiatry 35(2):313-320.

Holmes, S. M., A. C. Jenks and S. Stonington 2011 Clinical Subjectivation: Anthropologies of Contemporary Biomedical Training. Culture, Medicine and Psychiatry 35(2):105-112.

Holmes SM and Ponte M. 2011 En-case-ing the Patient: Disciplining Uncertainty in Medical Student Patient Presentations. Culture, Medicine and Psychiatry. 35(2):163-82.

Jaye, C., T. Egan, and K. Smith-Han 2010 Communities of Clinical Practice and Normalising Technologies of Self: Learning to Fit In on the Surgical Ward. Anthropology & Medicine 17 (1): 59-73.

Rivkin-Fish, M. 2011 Learning the Moral Economy of Commodified Health Care: ‘‘Community Education,’’ Failed Consumers, and the Shaping of Ethical Clinician-Citizens Cult Med Psychiatry (2011) 35:183-208.

Thursday, September 20, 2012

Formula Ads in Pediatrician Offices

Donna at Banned from Baby Showers wrote a post about how she tried to get her pediatricians office to remove the free formula coupons from their check-out desk. She very bravely spoke up about it being a problem, but found the receptionists didn't think it was a problem and didn't have anything to say. Then she links to the American Academy of Pediatrics statement on the distribution and display of formula materials in pediatrician offices.



I'm going to break this statement down for you. It states
The Centers for Disease Control and Prevention and the US Surgeon General have stated strongly and clearly that patients must be protected from commercial infant formula marketing; and Whereas the Federal Government Accountability Office (GAO) as well as American College of Obstetricians and Gynecologists (ACOG), American Public Health Association (APHA), and the AAP all identify distribution of formula company packs as “inappropriate in medical environments and recommend against it.
If you're a pediatrician, receptionist in a pediatricians office, nurse, obstetrician, and NURSING MOTHER, it is important to know that
research has demonstrated that the free distribution of commercial materials such as formula samples, diaper bags, formula coupons, or other gifts via commercial infant formula marketing implicitly endorses formula feeding and creates the impression that clinicians favor formula feeding over breastfeeding, and research demonstrates that this activity decreases exclusivity and duration of breastfeeding.
So if you TRULY support breastfeeding, or want to breastfeed yourself, it doesn't make sense to have the freebies there.
The Academy advise pediatricians not to provide formula 43 company gift bags, coupons, and industry-authored handouts to the 44 parents of newborns and infants in office and clinic settings.

But Pediatrician offices and hospitals will hand them out anyway, because the companies provide them with money and incentives.And don't think that your doctor, who says he/she is pro-breastfeeding, won't take those incentives.

This actively violates the World Health Organiation's International Code of Marketing Breast Milk Substitutes, a position statement which is in accordance with evidence-based research recognized by the American College of Obstetricians and Gynecologists, the American Public Health Association, the American Academy of Pediatrics, the World Health Organization, and others (USBC statement).

Many parents will say that they were legitimately unable to breastfeed and the free coupons are a godsend for them to be able to buy the formula that they needed to. But would they have not formula-fed without the coupons? I highly doubt it. But the presence of these things have been proven by numerous research studies to actively hinder breastfeeding. Here are just two:
  • Advertising of infant formula in obstetricians’ offices lowers the rate of breastfeeding among women who visit those offices prenatally (Howard et al. 2000)
  • Formula samples provided in health care settings present the appearance that health care providers sanction and encourage the use of formula for all mothers. This practice undermines the entire health care system and weakens the credibility of health care providers. (Hartman & Desjardins 2007)
So it's like weighing a few dollars off coupons vs. the health and medical costs of a nation.

Perhaps if pediatricians insist that the coupons are there for people who truly cannot breastfeed and benefit from them, than they should either have them when a woman presents saying she can't or does not want to breastfeed. Or they could have them side by side with coupons for free breastfeeding assistance!

What do you think a possible solution could be? 



Tuesday, September 11, 2012

Postpartum Reading

I've decided that once I have time in my life to read things unrelated to grad school, I want to enhance my postpartum knowledge. I don't want to pay for a postpartum doula training, because I don't think I need to add that certification, but I will read the books!

Here is the list that DONA International suggests:

Section One: Becoming a Mother (choose one) 
The New Mother: Eagan, Mothering the New Mother: Placksin, Misconceptions: Wolf, The Year After Childbirth: Kitzinger, Ourselves as Mothers: Kitzinger

Section Two: The Newborn (choose one)
Your Amazing Newborn: Klaus and Klaus, Touchpoints: Brazelton, The Mind of Your Newborn Baby: Chamberlain, The Vital Touch: Heller, Infancy: Field The Baby Book: Sears, The Year After Childbirth: Kitzinger
 

 Section Three: Breastfeeding (choose one)
The Ultimate Breastfeeding Book of Answers: Newman, The Breastfeeding Answer Book: La Leche League, Dr. Jack Newman’s Guide to Breastfeeding (Canada), Breastfeeding Made Simple: Morbacher and Kendall-Tackett
 

Section Four: Family Building, Touch and Attachment (choose one)
Bonding: Kennell and Klaus, Becoming a Father: Sears, The Vital Touch: Heller, The Baby Book: Sears, The Family Bed: Thevin, Fathering Right From the Start: Heinowitz
 

Section Five: Infant Care (choose one)
The Baby Book: Sears, Pregnancy, Childbirth, and the Newborn: Simkin, The Mother of All Baby Books: Douglas
 

Section Six: Postpartum Mood Disorders (choose one)
Overcoming Postpartum Depression and Anxiety: Sebastian, The Postpartum Husband: Kleiman, This Isn’t What I Expected: Kleiman, I’m Listening: Honikman, Depression in New Mothers: Kendall-Tackett
 

Section Seven: Birth (choose one)
The Complete Book of Pregnancy and Childbirth: Kitzinger, The Birth Book: Sears, The Birth Partner: Simkin, Pregnancy, Childbirth, and the Newborn: Simkin


Section Seven: Birth (choose one)
The Complete Book of Pregnancy and Childbirth: Kitzinger, The Birth Book: Sears, The Birth Partner: Simkin, Pregnancy, Childbirth, and the Newborn: Simkin


Section Eight: Multiples (choose one)
Having Twins and More: Noble, The Art of Parenting Twins: Malstrom, Multiple Blessings: Rothbart, Mothering Multiples: Kerkhoff Gromada


Section Nine: The Mother’s Changing Body (choose one)
Essential Exercises for the Childbearing Year: Noble, The Year After Childbirth: Kitzinger, Pregnancy, Childbirth and the Newborn: Simkin


Section Ten: The Work of the Postpartum Doula (choose one)
Nurturing The Family:The Guide For Postpartum Doulas: Kelleher, Nurturing Beginnings: Pascali-Bonaro



Seems like a lot! Doesn't it? Whew. That's 10 books, minus the categories from which I've actually already read (i.e. breastfeeding, birth).

Any mothers, postpartum doulas, doulas, childbirth educators, etc have any suggestions on which books I should choose to read? Or not read? Let me know! 

I appreciate the help, and I'm sure other mothers and birth professionals do as well.



Sunday, September 9, 2012

Breastfeeding and the Working Mom

I recently attended an occupational health presentation entitled "Breastfeeding and the Working Mom: The Impact of Perceived Breastfeeding Support at Work on the Well-Being and Job Attitudes of Women"

This was a presentation on a study from an occupational health and psychology perspective. The presenter, Dr. Bruk-Lee, explained that much of the research on women pumping at work focuses on evaluating lactation programs and their effectiveness, and the work-family conflict interventions/policies. The purpose of her particular study was to investigate the impact of perceived breastfeeding support at work on the job attitudes and psychological well-being of women who express milk at work.

Psychological 'well-being' encompassed burnout, postnatal depression, work family conflict, and job satisfaction. 'Job attitudes' related to performance, turnover, commitment, counterproductive behaviors, and organizational citizenship. Breastfeeding support came either from the organization (policies, physical accommodations, etc), or from supervisors and co-workers.

Interestingly, 82% felt they could often or always express all of the milk the baby required during the workday. 62% reported no company designated place for women to breastfeed or pump (and these were women in a variety of professions and settings). Reasons they stopped expressing breast milk (on average when babies were 33 weeks old): 54% personal choice; 26% employer; 14% supervisor; 6% health care provider.

Organizational policies affect more than breastfeeding duration, i.e. psychosocial work environment and performance. What the study concluded overall was that co-workers/supervisor support was more important for levels of well-being and good job attitude than the organizational support (like physical spaces to pump). Breastfeeding support offered by supervisors and coworkers was a stronger predictor of outcomes than other forms of support.

Much of the focus on improving breastfeeding support for working moms is targeted at adding reasonable break time for moms to express milk and the provision of a private non-bathroom space in which to do so. This is important, but this study shows that this organizational support is not as effective at improving mom's psychosocial well-being, work performance, turnover rates, etc as coworkers and supervisor social support.

So what can be done? What should we be doing to improve this aspect of work support? Giving workshops on lactation? That might never happen in most work environments.
The presenter had no solutions. The answer is basically that it will take cultural change, which takes time. But we clearly can't remain focused solely on the physical space. Perhaps, though, having a space, and breaks times, etc, will make it more the norm, which will contribute to changing attitudes about expressing milk at work.

What are your thoughts?

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