The Institute of Medicine issued a report this week that added eight preventive services for women to the provisions that will be provided free of charge under the Patient Protection and Affordable Care Act.
One noteworthy recommendation calls for free contraception and counseling on how to prevent unintended pregnancy.
In addition, pregnant women would be screened for gestational diabetes and new mothers would receive counseling and equipment to support them in efforts to breastfeed their babies.
The report "provides a road map for improving the health and well-being of women," said committee chair Linda Rosenstock, dean of the School of Public Health at the University of California at Los Angeles. Each of the eight services "stands on a foundation of evidence supporting its effectiveness," she said.
The recommendations would fill "gaps" in care that bedevil women in the present system, the report said.
The seven additional recommendations are these:
contraceptive methods and counseling to prevent unintended pregnancies
screening for gestational diabetes
cervical cancer screening, including human papillomavirus testing, for women over 30
counseling on sexually transmitted infections
counseling and screening for HIVAIDS
lactation counseling and equipment to promote breast-feeding
screening and counseling to detect and prevent interpersonal and domestic violence
yearly well-woman preventive care visits to obtain recommended preventive services
My daughter Nora lives in Los Angeles, Cal., so I am aware that Angelenos are so dreading the shutdown of 10 miles of the I-405 expressway there for road work this weekend they have dubbed the event "Carmageddon."
Nora is going to walk or take buses as much as she can this weekend, and being from Chicago, she is comfortable with those activities. But many Angelenos are famously more car-bound than she is.
But Jenny Benjamin, writing in The Stir today, brings up an interesting and, to her and other expectant moms, urgent point: What happens if your baby decides to be born in L.A. this weekend?
Pregnant with twins, less than two weeks shy of her due date, a 30-minute drive away ("without traffic") from the hospital she carefully chose for its neonatal intensive care unit, Benjamin considers the possibility of an early labor and aks, "For the love of all things good and holy, what am I going to do?!?!"
Will her husband wind up delivering the twins (one of whom is in a transverse position) on the side of the road? Should she call an ambulance? "Ambulances aren't hovercrafts -- they're going to get stuck in the same traffic!" Benjamin notes.
Her doctor lives close to the hospital. "Good to know at least one of us will be able to get there," she writes.
"Aargh, it's times like this that I really wish that Segways had caught on!" Benjamin frets.
The best solution, she notes, is not to have the babies this weekend. "I have about as much control over that as I do the traffic," Benjamin writes. "Maybe I should see how much my husband knows about home birthing."
Everybody knows that obstetricians are one of the most-sued medical specialties, but nailing down the details on that truism can be difficult.
CRICO Strategies, an international firm that provides risk-management software to hospitals and insurances companies, last month released a "benchmarking report" on malpractice risks in obstetrics that helps fill out that sketchy picture.
The report looked at 800 obstetrics-related medical-liability suits filed between 2005 and 2009.
Families dealing with the death of a mother or child, a severely damaged infant, or some other effect of a childbirth gone awry most commonly charged "communication failures, judgment lapses, and faulty technique as the reasons behind their injuries and their malpractice cases," the report states.
Sixty-five percent of cases involved "high-severity injuries."
Across the board, about one in 1,000 births involves a "preventable adverse outcome," the report noted.
While those can occur throughout pregnancy and birth, most suits in the study concerned allegations that birth assistants had mismanaged labor and delivery, particularly the second stage of labor — the actual birth.
"Substandard clinical judgment" was the top complaint in the suits, accounting for 77 percent of claims. Most of the suits named an attending physician.
The most common reason for suing was "birth asphyxia," a potentially injurious lack of oxygen, which accounted for 27 percent of the suits, and the most common allegation was that of a "delay in treatment of fetal distress" (25 percent of claims involving small hospitals, 19 percent involving large ones).
If you think this is dangerous, try giving birth in poor countries without a midwife, hospital or medicine. This flashmob is one of a series happening in Paris, Berlin, Utrecht and across Canada to highlight the scandal that millions of women in poor countries and around the world aren't getting the healthcare they need for a safe and healthy pregnancy.
(And just to put your minds a rest - the dancing expectant mums in this video aren't pregnant, they were professional dancers wearing pregnancy suits!)
Tina Fey, Emmy-winning creator/writer/producer/star of the television comedy 30 Rock, has kicked the ambivalence she was wrestling about having another baby.
Fey, a former standout member of the Saturday Night Live ensemble, will announce on The Oprah Winfrey Show on April 12 that she is five months pregnant with her second child, People magazine reported on its website this week.
Celebrities are often reticent about the details of their pregnancies, but Fey has let her anxieties hang out on the topic in her new book, Bossypants,and in a recent, related New Yorker article, "Confessions of a Juggler."
Tina Fey
It is unsettling to be a woman of 40, in her "last five minutes" both of fertility and decent movie offers, Fey writes, and she weaves wacky scenarios as she considers having another baby vs. concentrating on her career.
"Why not do both, like everybody else in the history of the earth?" she asks.
The math is impossible, Fey writes.
"No matter how you add up the months, it means derailing the TV show where 200 people depend on me for their income, and I take that stuff seriously. Like everyone from Tom Shales to Jeff Zucker, I thought 30 Rock would be canceled by now."
But 30 Rock is still going, and now Fey is pregnant. It's going to be interesting to see what happens.
In my opinion, Fey has made the right decision, because it is the decision she has made. (Her husband, she writes, just wanted her to get off the dime.) And that goes for any woman. She who controls her own fertility has at least a shot at controlling her life.
(Or, Fey may have gone through years of hand-wringing and then just discovered she was pregnant. That whole control thing is hard to pull off.)
In any event, the gynecologist who tells Fey during her paroxysms of indecision, "Either way, everything will be fine," was probably right.
Fey is in for a wild ride, balancing a hugely demanding job and two children. She is sure to get a lot of the question she says is the rudest you can ask a woman: "How do you juggle it all?"
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-oldthalidomide 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.
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 Timesarticle 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."
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.
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.
Every pregnancy begins with a 3 percent chance that the resulting baby will have birth defects, and that is before individual genetic and environmental histories come into play. Some birth defects cannot be prevented or fixed. Medicine cannot work miracles.
That's the message in "The perils of the imperfect expectation of the perfect baby," an article in this month's American Journal of Obstetrics and Gynecology. Prospective parents need to understand that "perfection in pregnancy is not attainable now or even in the foreseeable future," according to the article's authors.
Doctors too can get drawn into "expecting more from medicine than its limited diagnostic and therapeutic capacities justify," say the article's authors, led by Frank A. Chervenak MD. Not only that, but "many pregnant patients are optimistic about the advances in medicine and are confident that their physicians will solve all problems that could occur with their pregnancy."
In fact, everyone needs to get in touch with "the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them," the article states.
The expectation that a perfect baby can eventually be taken away from every pregnancy "assumes powers of medicine to control human reproduction that medicine does not possess," the article states.
September is Be Kind to Writers and Editors Month, and as both writer and editor here at Birth Story, I intend to take advantage of this important event. I've been writing some long posts, but I'm hoping to keep them a bit shorter this month.
Jane E. Brody's Personal Health column in the New York Times Science section today, for example, suggests that moms should adopt a healthy regimen, and maintain a lean frame, even before they get pregnant, if they want to help their children avoid becoming overweight themselves.
Brody's piece is a survey of the present understandings of how a mother's weight while pregnant affects the health of her fetus.
Her chief reference is a recent Lancet article that sought to tease apart the influence of genetics from the effects of more-than-adequate weight gain during pregnancy.
A separate study in Circulation "found that a woman’s weight before pregnancy was even more important than excessive weight gain during pregnancy in predicting a number of risks for the baby" that included childhood obesity," Brody writes.
"The new findings suggest that Americans are now caught in a vicious cycle of increasing fatness, with prospective mothers starting out fatter, gaining more weight during pregnancy and giving birth to babies who are destined to become overweight adults," Brody writes.
The latest recommendations from the Institute of Medicine, a subsidiary of the National Academy of Sciences, call for these weight gains during pregnancy:
¶28 to 40 pounds for thin women, with a B.M.I. of 18.5 or lower.
¶25 to 35 pounds for normal-weight women, with a body mass index of 18.6 to 24.9.
¶15 to 25 pounds for overweight women, with a body mass index of 25 to 29.9.
¶11 to 20 pounds for obese women, with a body mass index of 30 or higher.
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