The art and science of women’s health

The Women's Health Initiative, a series of randomized controlled trials begun in 1991, was supposed to be definitive in terms of the role hormone-replacement theory would play in managing the health of post-menopausal women. However, the WHI has yielded unexpected and sometimes apparently inconsistent results.

The medical establishment expected the WHI to show that HRT, which had been popular for years, helped prevent cancer, heart disease and osteoporosis in older women.

L'Arlesienne / Vincent van Gogh
"Sheesh"

Instead, in 2002 researchers announced in the Journal of the American Medical Association that they had stopped the trials, which involved more than 160,000 women, because participants receiving estrogen combined with progesterone were developing invasive breast cancer at substantially higher rates than were women receiving a placebo, and their rates of heart disease were also high.

HRT, which to that point had been prescribed liberally for post-menopausal women, virtually disappeared as a therapy, in spite of the fact that it did seem to be helping women avoid hip fractures and colon cancer.

Just last week, though, again in JAMA, a group of WHI researchers reported that a smaller study of women who have had a hysterectomy, who were treated with estrogen alone for a median of 10.7 years, showed a decreased breast cancer risk with the treatment, with no significant increase in heart disease.

Well, that's disconcerting. Should post-menopausal women be asking their doctors about HRT after all? Probably not most of them.

“Women are different — it’s relevant to almost every medication and almost every intervention,” Joann E. Manson MD told Tara Parker-Pope in a story in last Sunday's New York Times.

“With this study, in many ways, science worked the way it’s supposed to work. It’s a little like watching sausage being made. It may seem on the surface that the study was a real problem and had many, many flaws, but in reality, it ended up giving invaluable information,” said Dr. Manson, a WHI investigator who is also chief of preventive medicine at Brigham and Women’s Hospital in Boston.

Adds Pope, "The most compelling lesson of the research should be that science is always worth the wait. Consumers should insist that doctors make recommendations based on scientific evidence, say investigators, rather than allowing drug companies or marketing hype to dictate patients’ health care choices."

That's true for middle-aged women, pregnant women, men and parents as well.

Image: Vincent Van Gogh's "L'Arlesienne"

Birth news

Yipes! That was a long hiatus! So sorry. Hope not to do that again.

I am back on Birth Story with huge new respect for teachers, after serving winter quarter as an undergraduate lab instructor at Northwestern University's Medill School of Journalism. What teachers do in the classroom, I discovered, is the tip of the iceberg of the job.

I am back. Yes! So back to our topic, sort of. Well, a tangent, actually.

Nearly every time I Google "birth news" looking for, you know, something to blog about — my topic is birth — I come up with some permutation on the "birther" flap calling for President Obama to produce (on a daily basis, as far as I can tell) his birth certificate. Otherwise, critics will assume he was born in Kenya, his father's country of origin.

Barack Obama

Is he? Or isn't he?

Donald Trump and Whoopi Goldberg got into a dustup on "The View" last week about Obama's alleged reluctance to produce his birth certificate. (Just Google "birth news.")

The next day, "The View" ladies showed what they said was a copy of Obama's birth certificate.

Ben Smith at Politico wrote yesterday that the document Trump claimed was his own birth certificate, produced to needle the President, is not in fact Trump's official birth certificate. (But then Trump did come up with the right one.)

All of which just tells you that you can't go wrong, publicity-wise, getting a corner of this issue, or non-issue, as the case may be. Maybe I'll get a lot more hits today than I do ordinarily, writing about boring old childbirth.

The Arizona legislature is considering legislation that would require the state to sign off on proof of U.S. birth from presidential candidates. (They wouldn't let me teach at Medill until I produced proof of U.S. birth. Surely presidential candidates don't get a pass on that.)

The House version of the Arizona bill calls for evidence that that baby dropped onto U.S. soil, while the Senate version of the bill includes a definition of a "natural" U.S. birth as one to individuals who were U.S. citizens at the time.

I think both those elements have to be there, actually. That is, proof of either of those things ought to be enough, and I think maybe we need some laws to clarify that.

Even though some people go to great lengths to manipulate the law to convey U.S. citizenship to their infants like, allegedly, the Chinese women Jennifer Medina writes about in the New York Times today, it is important for anyone born in the United States to be an "automatic" citizen. Anything else is a total repudiation of what the United States has been, and stood for, for more than two centuries.

At the same time, we live in a small world. Pregnant U.S. citizens travel all the time for work and pleasure, and probably some other reasons, too, and they shouldn't be terrified about losing their children's full rights of citizenship if they happen to be abroad when their water breaks.

The Administration and numerous officials of the state of Hawaii, where Obama was by all accounts born on Aug. 4, 1961, have repeatedly confirmed the President's birth to a U.S. citizen on U.S. soil. Two for two. (So that's settled, right?)

And whatever you think of Barack Obama, he is a stellar example of the promise the United States has made to its residents, going even beyond its citizens — that if you work hard, the sky is the limit on what you can achieve.

Well, that's my two cents for today. It's nice to be back, although like teaching, blogging is a whole lot more time-consuming than I thought it would be before I actually tried it.

Happy spring, dear reader!

No pressure, Mom!

Annie Murphy Paul's new book, Origins: How the Nine Months Before Birth Shape the Rest of Our Lives, is getting the star treatment. It is the subject of a Time magazine cover story (written by Paul), and an article by the New York Times' Motherlode blogger, Lisa Belkin.

And why not? Paul has written what looks to be a fascinating exploration of the explosion of research on the effects of the environment human beings encounter while developing in their mothers' wombs.Origins by Annie Murphy Paul

In a guest post for Motherlode (the link is above), Paul writes, "Startling as it may seem, qualities ranging from our intelligence to our temperament to our health, and our susceptibility to diseases as varied as cancer, asthma, obesity, diabetes and mental illness, are affected by our experiences as fetuses decades ago."

We have already considered one aspect of this research here at Birth Story, how a mother's weight gain during pregnancy can influence her infant's lifetime chances of being able to maintain a healthy weight. But Paul covers the waterfront in this "new chapter in the long-running nature-nurture debate," as she calls it.

In her Motherlode guest post, Paul raises and then downplays the likelihood that mothers will be blamed for anything that goes awry with their children, given the new understandings of the importance of what goes on in the womb.

Love Paul's optimism! And, I'm impressed she researched this book while she was pregnant. I'm looking forward to reading it.

We dream for our children

My children are 10 years apart in age, and one thing that has struck me since Maeve's birth almost 13 years ago is how much more complicated the world grows as they get older.

When children are small, you can see clearly how their perfect lives will roll out. You can see them graduating from Harvard — or perhaps Yale; you devote serious time to considering which would be better — going into law or medicine, gliding along until they finish up as President of the United States. Along the way, of course, there will be sports trophies, prom dresses, all the trimmings.

Reality sets in gradually. It turns out the kids have learning disabilities, or strange hair, or no interest in sports — whatever, and likely in multiples. Ten years or so after spinning all those perfect dreams, you might find yourself praying they'll finish high school. Or even, please, God, let them stay alive through high school.

When Maeve was in preschool, I remember sitting in a group listening to moms in the Harvard vs. Yale stage, while my mind was on the then-exotic sensation some teen-aged boys in Nora's vast social network had created by sending nude pictures of girls they had probably known since kindergarten out across the Internet. I remember thinking that perhaps I had seen some of those boys, and those girls, on swings in the park or at a library reading hour when they too were small.

What I mean to say is that many of the things that seem critical when children are little get put firmly in perspective as they grow.

Poking around Lisa Belkin's Motherlode blog on the New York Times website this week, I landed on a post called "A Breast-Feeding Guru Who Uses Formula," which attracted me because I have been writing about breast-feeding. Through Belkin, I discovered Katie Allison Granju and her mamapundit blog. (I know, where have I been?)

Granju is a writer and digital-media expert who has become an authority on breast-feeding. Nevertheless, she found with her fifth child, Georgia, now seven weeks old, that she was unable to breast-feed. "I did have colostrum for the first week or two, but I never got the full enchilada," she writes in a post on Babble.com.

She tried "pumping, herbs, supplemental nursing system, plenty of skin to skin with baby, nursing on demand, nipple shields," all to no avail.

She is "resigned" now to the fact that Georgia is a bottle-fed baby, and she does what she can to inject warmth and meaning into an experience she never expected a child of hers to have.

But Granju believes that a horrific recent event in her life has contributed to her inability to breast-feed.

"I suspect that the biggest factor in my inability to produce milk at the moment is that my oldest child died in my arms only a few weeks before G was born. God only knows what the shock of that experience did to my body and its normal functioning," she wrote.

The death of Granju's son Henry from a drug overdose is about as terrible as this world gets. We dream for our children but they live the lives we give them. My heart goes out to the Granjus.

Putting motherhood on the clock

One of Hanna Rosin's grievances against breast-feeding in "The Case Against Breast-Feeding," her article last year in The Atlantic, is that it prevents women from doing work that would be more productive, or at least more lucrative.

"It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way," she wrote.

Hello? This week alone, as the mother of a 12-year-old at the end of summer vacation, I have spent a morning at the beach, an entire day at a water park, and an afternoon turning Gatorade bottles into papier mache fish. Need I say that no one gave me one shiny dime for any of this activity?

To the extent that women do it themselves, motherhood is a career-wrecker. Six months or so of exclusive breast-feeding at the front end seems hardly worth mentioning.

I have not worked more than 30 hours a week (most years much less) since my older daughter, Nora, was born almost 23 years ago. It was my choice, but I paid a price in diminished salary and less prestigious assignments — in opportunities.

Even so, I would do it again if I got a do-over.

Why is that? Because I can't think of anything I would rather have than time and relationships with my husband and my children. That was true when the girls were little, and it's true now.

Nora has moved 2,000 miles away this summer. When she calls me, I drop everything to talk with her. And even though, if I added up our phone/Skype sessions, the total would probably look like a serious time commitment, I don't ever worry about how much valuable time I'm losing.

(For a twist on this perspective, see "Putting a Price on Motherhood" in today's New York Times.)