We start first this week with a correction. The error was late in last week’s section on policy. In it I reported that ProPublica reported that the “ US is the most dangerous country in which to give birth”. That should have read, “the US is the most dangerous affluent country in which to give birth”. That’s still an awful distinction and one of the reasons why I write.
Title X funding has been denied to clinics in Nebraska who proved abortions. No surprise there. However, what is more noteworthy is that the new law restricts the speech of the caregivers in clinic. In particular, caregivers, when behind closed doors and under patient confidentiality, are prohibited to “ counsel in favor of or refer patients to abortion services”. Does it make anyone else nervous that a state government is attempting to restrict what is said in a private medical visit ?
Enrollment in the ACA this year in 2018 did not plummet as was expected. Enrollment dipped slightly by 400,000 to 11.8 million Americans, which represents a drop of a little more than 3%. This was despite the fact that advertising and the time frame for enrollment were slashed. This drop was noted primarily in the 39 States who’s ACA is run but the Fed. The remaining 11 States manage their own ACA programs, and they did not see this drop in enrollment. Of note, among all enrollees, 27% were new enrollees. The average pre credit premium did go ip in 2018 compared to 2017, at $621 versus $476.
In the latest turn of events regarding detained pregnant teen immigrants, a Federal Judge has ruled that HHS ( The Department of Health and Human Services) must allow pregnant detainees the right to obtain an abortion. The current policy of the the HHS Department of Refugee Resettlement has sought to block their right to do so. Under the Obama administration, such patients had the right to obtain elective abortion at their own expense, though they were able to get it paid for if it had been as a result of rape or incest or if was a threat to life.
Huffington Post interviewed physicians on the subject of hair dyeing during pregnancy. The panel’s conclusion was that “ there is just not enough conclusive evidence or research to suggest they dyeing …hair while pregnant will cause fetal harm”. While this statement is true, it bears examination. Insufficient evidence of harm does not constitute sufficient guarantee of safety. Insufficient evidence of harm does not even rule out the possibility of harm. It does not even rule out the probability of harm. It simply means that there is not enough evidence to say one way or another. The article goes on to says that there is a general consensus that it safe. While this too, is true, it is a weakly based consensus. It is based on the notion that a large number of pregnant women dye their hair and that no one has noticed any disturbing patterns emerging among their offspring. And yet, our notice has not been particularly attentive, since no one has bothered to do even an population based study of pregnant women who dye their hair complete with meaningful follow up of their offspring. I belabor this point to hone the readers' understanding of what the statements they read actually mean.
Apparently younger patients typically like to pick younger doctors. This makes some sense to me in that the patient has someone to whom she can relate. However, there is also a shortage of Obstetricians and Gynecologists in many places in the country, especially rural areas. The older Ob/Gyns are still in place, with ever increasing work loads, especially in the underserved areas, while the younger docs want to be in the city with more partners, city lifestyle and higher pay. Services are strained in the areas least likely to bear it, and this may be impacting maternal mortality rates.
Every generation thinks teens are worse than they were. Turns out they are wrong. By several metrics, todays teens are quantifiably different than the teens of yesteryear. The incidence of many high risk behaviors among teens have dropped considerably. For example, cigarette use and alcohol have dropped sharply compared to past generations. Teen pregnancy rate are at an all time low. Teens are delaying sex more and even teen driving fatalities are down. It is interesting to note that while most authorities are reassured by these changes, others point out that teens may be less mature, age for age, than their predecessors. In other words, perhaps teens are more immature than they used to be. I was initially dismayed by this assessment. But I suspect they do not mean immature in the sense of irresponsible or silly. I suspect they mean more dependent on parents and more risk averse. This observation which point to kids behaving “younger” longer, may go along with what some have noted to be a modern extension of adolescence. In the “olden days” perhaps even 75 years ago, a 19 year old male was expected to have a job and a career direction. He could be thinking about marrying once he was settled. Certainly a 19 year old girl, which in those days was in fact, a young woman, would typically be thinking about marriage and independence from family. These days most families are concerned about thier 19 year olds continuing their education or training, for at least another 4 years.
The extension of adolescence is a critical topic right now, and I am scarcely qualified to address it. However I am the mother of three grown children including two sons and have shepherded countless women into motherhood. That and the formal literature I have read indicates extended adolescence is real in biologically, developmentally and sociologically measurable terms. We may begin adolescence sooner in terms of menstruation and puberty, but our brains are remaining plastic much longer. Our health and nutrition are better. As implausible as it sounds, society is actually safer, our parenting is actually better, and children are kept from harsher stresses compared to the past. We are more affluent than before. The age of information has made its debut. There is far more novelty in our environment and with our added relative affluence we can extend education until the mid twenties and afford children the opportunity to travel, all of which keeps the brain in a far more plastic and youthful state. This brain “metaplasticity” is based in neurons and their activity and can be measured. As a side note, a new post mortem study published in Cell Stem Cell has confirmed that neurogenesis (the making of neurons) continues in older people, even through the 70s. However in most older folks, they tend to be more poorly vascularized.
Extended adolescence can go wrong. It has been credited with the hapless directionless young adult, deadbeat dads, kids who drop out of college, the 40 year old gaming in his mom’s basement, etc. Some say this is related to changes in our economy with a shift more to information based work than labor based work. With extractive industries and jobs with manual labor on the wane, men are less likely to get a job not requiring years of higher education. Acknowledging the breadth of these factors can help us understand why the blame game is fruitless. The bottom line is that older adolescents need parental support which they tell me is a foundation of unconditional love combined with a clear set of reasonable expectations and consequences.
All of this bears very much into the work of Obstetricians and Gynecologists as we help women through the phases of their lives. We counsel women on risks to their health everyday. We support them through pregnancies where they may be on their own or poorly supported. We encourage them to move forward with their lives even after their children are born. We support women as they struggle with parenting their own adolescents.
Here is some more reading for those of you who are interested.
Whole genome DNA sequencing has become popular for adults. Antenatal genetic screening has become standard prenatal care. Now the two can be combined though amniocentesis and whole genome sequencing. I wonder how long it will be before this can be done with a single maternal blood draw.
Mayo Clnic is studying a streamlined form of home based prenatal care. A pilot group of patients is using home monitoring for baby and vital signs. They also have 8 actual clinic visits which is fewer than standard. Motivation for this study is to determine a valid protocol for women in remote areas.
Last week I reported that boys were receiving Gardisil vaccine against HPV at a fraction of the rate of girls. Good news this week: that these rates of vaccination for boys are increasing rapidly. from 8 to 26% between 2011 and 2016. Girls’ rates went from 38 to 46 percent in the same time interval.
ACOG has created a document called a Committee Opinion and thereby formalized something that most of us have always done. Ob/Gyns play a role in ensuring that women are protected from workplace discrimination. They do so by writing notes for work as documentation for specific health related work restrictions. They can help enforce sick leave, postpartum leave or parental leave for fathers. They can also help patients identify workplace abuses and refer them to the correct authorities. This behooves all providers to familiarize themselves about local laws and local labor offices. Workplace stress is a real health hazard and it is part of the Obstetrician Gynecologists responsibility to help deal with it.
Many PCO (polycystic ovary) patients need to take Metformin to get pregnant. They are also advised to stay on it or related medications to prevent gestational diabetes. However, some are concerned about taking it in pregnancy. The available evidence indicates it is safe. Newer research has shown it reduces miscarriage and preterm labor.
Vices taxes work. The Lancet has reported that taxing known harmful substances like cigarettes alcohol and soda steers consumers toward healthier choices. This study was a meta-analysis of 5 internal national studies from around the world. Concerns have been raised that these taxes disproportionate burden the poor, but this study examined this question and found that there was no disproportionate harm to this group. Larry Summers, a former Treasury Secretary and emeritus professional at Harvard wrote an analysis for the study, confirming that “ taxes are an underused instrument for the prevention of premature death and disease….” and “ consistently raise prices, reduce consumption, and save lives, while generating additional revenue to support public services.
Vegetables work too. A new study confirms that lots of vegetables help older women keep blood vessels healthy. Of note, the ones that worked the best were the cruciferous vegetables, aka the brassica family which include cabbage, brussels spouts, cauliflower, cabbage, kale and the like. On that note, for northerners, I will recommend purchasing and planting spring seed. Those of you in the southern hemisphere can cultivate and plant now for a prompt spring germination.
Stay tuned for more breaking news from the world of Obstetrics and Gynecology, next week, here on Medical Monday.