Navelgazing

Lots of navelgazing lately about what I'm about regarding childbirth.

I would say right now I am mostly trying to hash out a spot somewhere between three angles on the topic:

One. The fact that many or even most aspects of modern American birth are not optimal for healthy mothers and babies, aka the public health angle.

Two. The severe lack of information, choice, and agency most women face in their childbirth experiences, aka the feminist angle.

Three. The devious little inner know-it-all birth nerd that thinks everyone should have a non-interventive birth and breastfeed as long as possible, aka the asshole angle.

Woops! I let that one come out of my virtual mouth. You know, I'm working on this, and I'll be frank and say that I haven't whooped it yet. I can talk big about how both One and Two are problems on a population/society level, not an individual level, but talk to me about a pregnant woman and the asshole wheels start spinning, true story.

In my head, this is wrapped up with a few other issues, which I hope to write about in the short term future:

A. The question of what actions my convictions about these issues compel me to.

B. Issues I seem to have with advocacy. And you know it's true because I once had to get told by a certain BU professor interested in childbirth that "Advocacy is real, you know." Doy!

Reading - Quick Hit

I think this might be the book that blows my mind a thousand times this summer. Last summer it was Birth as an American Rite of Passage. So this would be kind of appropriate. I got the recommendation from Molly at First the Egg.

This selection is not actually very related to all that, but it struck me, so here it is.

"Oppression is not the mother of virtue; oppression can warp, undermine, turn us into haters of ourselves. But it can also turn us into realists, who neither hate ourselves nor assume we are merely innocent and unaccountable victims."

- Adrienne Rich, from the 1986 introduction to Of Woman Born: Motherhood as Experience and Institution

Twitter Questions

I always get a little excited when I find myself wondering something that's not easily googleable. I like asking these things on twitter, but despite its awesomeness*, I have not found it to be a great question-answering forum. Here are some answerable questions I've posted on twitter that have gone unanswered - and that I am still wondering about. Virtual gluten-free vegan coffee cake for anyone who comes up with answers!

"What are best predictors of c-section? (I know previous CS - what else?) looking for demographics to maternal health to hosp procedures." (13 April)

"Educate me - what does it mean if an NP works in obstetrics "in ambulatory"? Who does she treat and for what?" (6 April)

"so the oft-quoted '60% of women do not meet their breastfeeding goals', supposedly a CDC study ... anyone know what study?" (3 April)

"Of those not breastfeeding, are there more who want to but couldn't, or who didn't want to start? Very diff problems - which to target?" (3 April - and followed by "Regretting words 'problems' & 'target' in last tweet. Try again: very diff strategies to up rates in those 2 cases.")

"What's the history/rationale for the divisions perinatal/neonatal/post-neonatal/infant/child (in the context of mortality)?" (31 March)

"When a tweet stops in the middle of a sentence with an ellipsis at the end, does the rest exist somewhere? Or a link ending w/ an ellipsis?" (24 March - my newest theory on this baffler - cross-posted from facebook or tumblr and just gets truncated?)

"Has anyone written about benefits of midwifery care for preterm or low birthweight babies? Anyone got links?" (21 March)

"anyone have a rec for textbook type reading on women's studies/feminism? think undergrad intro class - i want it light but contentful." (11 March)

""Hospitals...have to report metrics such as...how many women get episiotomies during childbirth." http://huff.to/aNmqi. Anyone know where?" (1 March)

"still don't know the answer to this question - how do we define "preventable" when talking about morbidity or mortality?" and "I'm interested in thoughts on balancing risk of mortality w/ risk of morbidities, esp where conflict arises in practice. blog/twit rec.s?" (15 February)

"Is there a word meaning offspring that is 1)non-gendered + 2)relational like parents(cf child: does not imply 'belonging' like 'parents')" (9 Feb)

"[asking people how healthy they feel =good proxy for measurable health.] [asking about patient satisfx w/ HC =?good proxy for HC quality?]" (31 Jan)

"Does anyone have any general research articles on diet as a confounder in studies that show associations btw obesity and morbidities?" (26 Jan)

"Ok brilliant people: someone point me to a solid bit of reading on W*stboro B*ptist. Not what they do, but why. Socio/anthro/etc answers." (9 Dec)

*I sort of want to post about how awesome twitter has been for me, but it seems silly to ode a social networking site.

Casual lunch conversation about VBAC and government intrusion

I had a casual conversation with my boss the other day about my class and interests in public health and childbirth. (For any readers who don't know me personally, I do not currently work in an area related in the least to public health.) Well, we got talking and before I knew it I was letting loose all my favorite appalling statistics about childbirth in the US. Yes, I said the word "vaginal" to my very male, very straight-laced boss, and the heavens did not come crashing down. I was proud of myself. I'm always nervous that if I start talking about this stuff I am going to weird people out. He did ask the source of my interest, and when I said "I'm not pregnant" we both laughed - three other co-workers just returned from their maternity leaves, so it is baby season at my office. He also told me his sister used to work at Yale in their Nurse-Midwifery program! How cool is that?

I also talked about the basic idea that we tend to think of individuals as being responsible for or capable of controlling their own health outcomes, though research shows that this often isn't the case. He objected strongly to the claim that the government has a place in issues of say, childhood obesity - for him, it is solely the parents' job to deal with their children's health. He is devoutly Libertarian. I had to admit to myself after the conversation that I have not spent enough time thinking about the idea that it is a political belief that government should care for its citizens in the way that public health often advocates. Is it possible to be on the right-wing, less-government side of things and be an advocate for public health? I feel like my thinking on this issue is so simplistic as to be laughable. I guess it will have to come with time and a better understanding of what roles the US government does and does not actually play on public health issues.

When we were talking about childhood obesity, I pointed out that lower-income neighborhoods often have a paucity of accessible supermarkets with reasonably-priced and appealing produce sections. He argued that the market would take care of that, and if it were the case that people would buy the produce, the stores would have it. That seemed all wrong, but I didn't have a rebuttal until the next week, when attending the kick-off breakfast for the annual Project Bread Walk for Hunger. One of the speakers was Lauren A. Smith, who is the Medical Director of the Massachusetts Department of Public Health. She was explaining how hunger and obesity often go hand-in-hand in communities. I don't have the exact quote, but she said that fast food is the economically smart choice for people who are struggling with hunger. Fast food is often extremely calorie-dense - a lot of calories not only per gram, but per dollar. When your first priority is eating at all, it only makes sense to get as many calories per dollar as you can - and an apple does not fit that bill.

I leave you with two awesome links:
Maybe this is part of the problem/solution?
And as much as I roll my eyes about not eating "weird chemicals that should never be in food zomg?!?!?", this is disturbing.

Populations and Individuals

One of the hallmarks of public health is that unlike medicine, you're thinking at the level of a population, not an individual.  This is one of the first things I learned about public health, but I feel like I still don't have a sophisticated understanding of how to think about the relationship between the two.


There are two aspects of this split that I'm thinking about: 1. how to intervene, how to avoid just telling collections of individuals the same thing a doctor would tell an individual (e.g. "eat less salt"); and 2. how to understand population level outcome measurements, how to make those statistics more meaningful than "you have an x% chance (based on data about other people like you and what happened to them) of getting this disease."

The NYT ran an article this week about salt reduction.  The inspiration for the article is a NEJM article which I have not read yet on the same topic, specifically with reference to the reduction of cardiovascular disease.
This sentence from the NYT article caught my attention:

"If everyone consumed half a teaspoon less salt per day, there would be between 54,000 and 99,000 fewer heart attacks each year and between 44,000 and 92,000 fewer deaths..."

This made me laugh because it reminded me of some sort of motivational group effort, like, if only we each did our part, now Get It Together, People!.  But half a teaspoon less salt per day is a LOT less salt.  Depending on gender, that would be a 30-40% reduction for the average American adult.  Small wonder that you'd see such big results.  I can totally believe that for a given individual, that reduction in salt could have dramatic effects on his or her health.


Now suppose it claimed, instead (not suggesting this is equivalent or true! thought experiment in progress): "If everyone consumed one pinch less salt per day, there would be between 540 and 990 fewer heart attacks each year and between 440 and 920 fewer deaths."


In that scenario, it seems less plausible that the good benefits are because any given individual who was eating x amount of salt is now eating (x - 1 pinch) of salt.  That is, it seems harder to interpret the sentence as being strictly true.  Put another way, if we had a laboratory of humans who were all fed exactly x grams of salt per day, and then we cut their salt intake to (x - 1 pinch) per day, would you see the results above?


Or: does the sentence really mean the following: some number of people (perhaps those who were eating way too much salt) suddenly dropped their salt intake dramatically (and the rest of us didn't make any changes), so that the average came out to each person eating 1 pinch less per day.  Then, those people who dramatically reduced their intake made up the group who didn't get heart attacks or die after all.


There are probably things I should already know that address this question.  For example, more than the averages are important, and standard deviations will address the question of variance in individual levels.  Furthermore, the basic split between longitudinal and cross-sectional studies addresses these concerns (hey, I learned something in my speech-language pathology class!).  I know there are aspects of cross-sectional study methodologies that try to overcome the effect of all the averages (average of day-to-day salt intake per individual, average of individuals' salt intake to give population level estimates).  Maybe after I read the actual study I'll have a better idea of how it works, and whether the NYT quote above is a misrepresentation or not.


Final notes on the NYT article.  Kudos for:


1. acknowledging that action beyond the level of the individual might be appropriate
2. quoting someone on the idea that when we legislate these kinds of things, we must be very wary of unintended consequences
3. mentioning some subpopulations that would particularly benefit (would have gotten extra points for mentioning health disparities more broadly)
4. quoting the study author on the population-individual issue


Boos for:


1. being wishy-washy about where the bulk of the sodium intake is from. As far as I know, the research clearly points to processed and restaurant foods
2. having a kind of pointless quotation about how instead we should be working on anti-smoking efforts because they'd make a bigger difference.  Who said we should put all our energies toward one single problem? This just seemed irrelevant, like the reporter simply wanted one more dissenting opinion