Childbed fever

"There is not a corner in Britain where this formidable disease has not made many mourners,”  John Mackintosh, an Edinburgh, Scotland "man-midwife" wrote of puerperal or "childbed" fever in the 1820s.

This bacterial disease of the upper genital tract typically began within the first three days after childbirth with abdominal pain, fever and respiratory difficulty, and very often ended with the new mother's death.

Medical writers had been remarking on childbed fever at least since Hippocrates, but in the early modern era, it began to attract attention for a number of reasons. For one, it began to appear in epidemics, with very high mortality rates. For another, accounts of outbreaks were written about and published. And at least some of the new, scientific man-midwives themselves were spreading the disease by going straight from autopsies to the birth chambers of homes and especially of hospitals, without cleaning up at all in between.

There were terrible epidemics of puerperal fever in the German city of Leipzig  in 1652 and 1665, at the Hôtel Dieu in Paris, France, in 1745 and 1746, and at the British Lying-In Hospital in London, England, in 1760. It is possible that these were the first ever epidemics of childbed fever.

Easy to be hard

Birth is the most common reason for a person to be hospitalized in the United States, a major point of intersection for a healthy population with the health-care system.

But while birth may be common, it isn't cheap. The average cost of maternity care in the United States in 2004 was $8,800, according to a report by the March of Dimes, and that figure can take off for the stratosphere — into the tens and even hundreds of thousands of dollars — in the event of complications.Pregnant Graffiti

With the national mid-term elections just a few weeks away, many politicians are drumming up votes by weighing in on the health-care reform legislation Congress passed earlier this year, and on government programs that subsidize health-care services like maternity care for low-income people.

Rand Paul, an ophthamologist who is the Republican candidate for the Senate in Kentucky, remarked last week that half the state's 57,000 yearly births are paid for by Medicaid. “Half of the people in Kentucky are not poor. We’ve made it too easy,” Paul said.

You could say Paul is right. A woman doesn't have to be officially poor in Kentucky to have her baby's birth paid for by Medicaid.  Kentucky allows Medicaid coverage for a woman whose income is 185 percent of the official federal poverty level of $18,310 for a family of three. That is, her family of three can make just under $34,000 and still qualify.

But remember, the average birth experience will cost her almost $9,000.

The March of Dimes analysis found that consumer costs for a birth averaged just under $500, but that pre-supposes that the mother has health insurance that covers childbirth and maternity care.

Analysts for The Guttmacher Institute, which concerns itself with sexual and reproductive health both in the United States and globally, working with recent figures from the U.S. Census Bureau, figure that 2.3 million women of reproductive age lost health insurance in the year between 2008 and 2009 alone.

The National Women's Law Center has found that individual insurance plans, which are exempt from the Pregnancy Discrimination Act of 1978, tend not to offer maternity care. The NWLC found that just 12 percent of the plans it examined offered maternity care, and that the provisions they offered were often limited.

"That’s why having insurance coverage is so critical. Employer-based group plans usually have good maternity care coverage, but most low-income women don’t get insurance through the workplace," the Guttmacher Institute states on its website today.

So looked at from that aspect, Paul is wrong. We're not making things too easy at all. The way thing are set up now, we're making it too hard for women to obtain coverage for maternity care.

Pregnant Graffiti by Petteri Sulonen, courtesy of Wikimedia Commons

Booties on the ground

In his excellent review of Annie Murphy Paul's new book, Origins: How the Nine Months Before Birth Shape the Rest of Our Lives in the New York Times Book Review on Sunday, physician/author Dr. Jerome Groopman wrote:

Of necessity, research on fetal development involves observing pregnant women in their daily lives; no one would purposefully have one group eat in a possibly risky way or be exposed to a potentially dangerous substance, and compare outcomes with an unperturbed control group. We have, at best, only correlations between a mother’s lifestyle and her child’s future health, not clear causation.

And, in "The Case Against Breast-Feeding," Hanna Rosin's 2009 article in The Atlantic, she wrote, "An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies."

Really? Why not? Both Groopman and Rosin are writing about how vulnerable observational studies are to being tainted by hidden variables. Controlled trials are a better system for testing what works and what doesn't.

But if I am reading their statements correctly, Groopman and Rosin are saying that we cannot even think about practicing actual, rigorous science if babies and fetuses are involved.

Building up a body of "evidence-based medicine" around a segment of the population that is exempted from clinical trials — depending entirely on observational research, that is — seems unwise to me. We don't need to wonder what a worst-case scenario involving babies would look like;  we have the 50-year-old thalidomide catastrophe as a demonstration. Thousands of children around the world were born with deformed limbs after their mothers took the drug.

Subjecting drugs and behaviors that can affect unborn children to standard scientific trials that include pregnant women might save the population from potentially massive damage from those behaviors, and from the drugs once they are put on the market. This is especially true now that we suspect the experience in the womb has a huge influence on the course of an individual's life — the subject of Paul's book, Origins.

Now I understand why the medical ethicist Ruth Macklin, writing in The Lancet last winter, called for the inclusion of pregnant women in drug trials, and retaining women who get pregnant in such trials. Conventional wisdom seems to have rendered the concept so unthinkable that a call for change is necessary.

What do you think about including pregnant women in clinical trials? I would love to read your comments.

Making birth possible for millions

For the first time ever, the Nobel Prize committee has awarded one of its coveted medals — and $1-million-plus in prize money — to a scientist who worked in the area of reproduction.

The British biologist Robert G. Edwards won the Nobel Prize in "physiology or medicine" today for pioneering in vitro fertilization with a colleague, Patrick Steptoe, a gynecologist and medical researcher who died in 1988. The pair's efforts led to the birth of the first "test tube baby," Louise Brown, on July 25, 1978.

Since then, four million babies have been born with the assistance of IVF, in which sperm and egg are united outside the mother's body and then transferred to the womb.

The Nobel Committee waited more than 30 years to make the award. Edwards, who spent most of his career at Cambridge University, is 85 years old and "not in a position to understand the honor he has received today,” a colleague, Dr. Michael Macnamee, was quoted as saying in a New York Times article by Nicholas Wade.

Edwards and Steptoe unlocked many of the secrets of the human reproductive system on their way to success with IVF. They tried 40 embryo transfers before they achieved a pregnancy, which turned out to be ectopic. The second try led to the birth of a daughter to Leslie and Gilbert Brown of Oldham, in Greater Manchester, England.

Like virtually all medical visionaries, Edwards and Steptoe were subjected to vitriolic attacks. The British medical establishment withheld all manner of support from them, even after Louise Brown's birth.

But the joy of millions of families all over the world who were able to hold their own babies as a result of IVF technology eventually quelled the critics.

Louise Brown, herself the mother of a three-year-old boy, said of the award today: "It's fantastic news; me and Mum are so glad that one of the pioneers of IVF has been given the recognition he deserves. We hold Bob in great affection and are delighted to send our personal congratulations to him and his family at this time."