Medical Monday: Breaking News from the World of Obstetrics and Gynecology

POLICY NEWS

As reported last week, many States are starting to push back against the defunding of teen pregnancy prevention programs in their states. The latest such example is Minnesota, where in Hennepin County, HHS (Department of Health and Human Services) terminated a $214 million teen pregnancy prevention program. The grant had originally been obtained to last through 2020 and was cut as of 2018, and the suit filed asks that it be reinstated until 2020 again. Texas’ Teen Pregnancy Prevention Program is called Healthy Futures of Texas, and its Title X funds are slated to be cut. However, This organization and other Texas grant recipients are filing lawsuits to discontinue the termination of their grants. 

Title X is a federal grant program dedicated solely to providing funds for birth control and family planning. The Trump administration governs the awarding of such grant money. Of late, they have shifted their funding criteria to favor those organizations which promote abstinence rather than evidence based birth control. Several chapters of Planned Parenthood and the National Family Planning and Reproductive Health Association have filed suit against the Trump administration alleging that this strategy violates the mission statement of Title X. 

During the recent years of the Trump administration, the number of uninsured Americans rose by 4 million. These are those who slip through the cracks between the Affordable Care Act plans and private insurance, with a single income of $30,000 and a joint family income of about $61,000. The data comes from the Commonwealth Fund who warned that this trend is likely to continue. 

MEDICAL NEWS

We have known for some time now that women have been concerned about contraceptive access ever since Trump was elected. Long acting reversible contraceptives (LARCs) have been the strategy for many women. In one particular study out of UCLA David Geffen School of Medicine, uptake of LARCs nearly doubled in the two weeks following the election. 

All kinds of stereotypes exist about older people. Some have to do with sexual activity. A new study has shown that 40% of people ages 65-80 are sexually active, and of those, 73% are satisfied with their sex lives. In the subgroup of those with spouses or partners, a little over half are sexually active. Caregivers need to continue to bear all this in mind. 

ACOG (American College of Obstetricians and Gynecologists) recently held its annual meeting. One presenter there highlighted the medical benefits of vibrators, and called upon Gynecologists to identify patients who might benefit from them, and initiate discussions which normalize their use. 

ACOG president Dr. Hal Lawrence has termed the current health care climate a “battle” and “ one that is not going to end anytime soon”. They have called it a “fight to protect women’s health care”. The ACOG president has highlight the advocacy efforts of the organization this past year, along with like minded others, the “Gang of Six” consisting of  internists, pediatricians, family doctors, psychiatrists, ob/gyns, and osteopaths. 

Menopause. It is the cessation of ovarian function and all that results from that. We cease to ovulate and become infertile. Then our hormone production quits, and we may have symptoms of estrogen deprivation, like hot flashes and vaginal dryness. The average age of menopause is 51, but the range is considerable and it takes about two years to get completely through. A new study has highlighted a little know fact, that women with a poor diet, i.e. diets high in refined carbohydrates, get menopause much sooner than those with high quality diets, such as those with lots of whole foods and fish. 

The postpartum period or so called fourth trimester, is getting some much needed attention. A new study has illuminated the prevalence of perinatal depression. Turns out it affects 1 in 7 women. Indeed, a related study found that maternal suicide takes more women than hemorrhage and hypertensive disorders combined, and accounts for 1 in 5 postpartum deaths. The study has also shown that only about a fourth of postpartum moms suffering from depression get treatment. Both the US Preventive Services Task Force and ACOG recommend mental health screening during pregnancy. Pregnant moms take note: Your postpartum visit should cover mood, emotions, infant care, sexuality , contraception, sleep, and health maintenance, to name a few. 

The opioid crisis has brought many problems for pregnant women and their children. However, one such problem can go under the radar: Hepatitis C.The opioid epidemic is driving an increase in Hepatitis C among mothers and children and neither the screening protocols for mothers or infants has kept up. Hepatitis C is transmitted by blood, and thus by needles, and infrequently, from mother to child. There is no vaccine, but just recently, there is a fairly good treatment. 

Stay tuned for more news from the intense world of Obstetrics and Gynecology, here, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

POLICY 

In the good news department, the Federal Government is working toward promoting “ interoperability” which means the ability to coordinate health information technology nationally. During the Obama era, the “Meaningful Use “ program helped doctors and hospitals adopt the EMR, or electronic medical record. This new phase is meant to help all those disparate systems to be able to interact with one another. This will make authorized data sharing easier. To this end the ONC, or Office of the National Coordinator for Health Information Technology is working with innovators by giving out APIs (application programming interfaces) to encourage the making of apps which health consumers can use to control the flow of their data. Patients can choose to share their data with consultants or even with researchers who might be able to use it. 

Last week a Federal Judge in Ohio blocked the defunding of Planned Parenthood in that State. This week the same thing has happened in Washington State. Judge Rice in Spokane argued that HHS (Health and Human Services) “ arbitrarily and capriciously” blocked the funding. 

A measure on Maternal Mortality is on the Senate table for a vote in May. The bill would provide for the formation of review committees in each state which would be charged with tracking pregnancy-related deaths and thereafter to help formulate recommendations. The bill would help standardize state efforts in this regard. 

Texas has become infamous for its horrendous and still increasing rates of maternal mortality. Sweeping cuts to the primary health care system for women were made in 2011 including the defunding of Planned Parenthood. However, now that this maternal mortality crisis has come to light, Texas has formulated the Healthy Texas Women program. Usage is increasing from 70k to about 120K clients per year between 2016 and  2017. 

The USPTF, US Preventive Services Task Force, has formally recommended that all caregivers screen patients of reproductive age for abuse. It appears that there is enough evidence to support this whereas a dearth of evidence has kept them from recommending the same for people past their reproductive years. 

MEDICAL NEWS 

ACOG ( American College of Obstetricians and Gynecologists) has come out with a new Committee Opinion Document on postpartum care recommendations for clinicians. It used to be that many clinicians requested on postpartum visit at 6 weeks postpartum. However now, they are calling for at least one early checkup before 3 weeks postpartum, and a second more comprehensive visit by 12 weeks postpartum. Those with complications may need even more. I think this a great step in the right direction since many complications are already brewing within the first week alone. We conduct routine postpartum visits at 2 and 6 weeks for patients with normal clinical courses. ACOG is calling this the “ fourth trimester” and indicates it is a fundamental shift in thinking about postpartum care. Now need to get insurance companies to get on board so that more extensive postpartum care can get covered. 

ACOG has now come out saying that not only should caregivers recommend influenza vaccine to pregnant women, it is recommending that they keep the vaccine in their offices for convenient and expeditious dispensation. 

Population is a tricky thing to understand. Many of our environmental troubles stem from overpopulation. In that light, diminishing birth rates are beneficial. however, negative birth rates adversely affects economies, tooled as they currently are, on infinite growth. New data shows Kansas has reached its lowest birth rate ever. Japan, too is facing similar challenges. Economists and demographic scientists far savvier than me must put all this into context. Suffice it to say the devil is in the details. Whether or not a declining birth rate is good news or bad news depends on where you are, your perspective and your endpoints. As a physician, I know fully half of all pregnancies are unplanned. All of my studies have indicated that with women’s reproductive autonomy comes fewer children, increased educational attainment, increased savings, increased employment and widely increased affluence. But does that affluence need to be as it is in the west, at the expense of the environment? And does our affluence in the west need to stay as it is? Can we keep what’s good of western affluence and get rid of the bad? 

More good news: the number of pre-teen mothers has plunged from 8500 in the year 2000 to 2200 in the year 2016. The largest decline is among African American pre-teens. 

In the common sense department, we have research on depression. A new study published in the Journal Child Development indicates that maternal depression affects the development of children. These changes are apparent through the use of various tests including tests of verbal aptitude. A mother’s depression, in turn, is linked to the level of emotional verbal, and educational support that she has. It really does take a village. Reach out! 

Stay tuned for morebreaking news from teh world of OBstetrics and Gynecology here next week on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy News

This week, and maybe from here forward, policy is becoming more State based. A few blog posts ago, I highlighted the fact that the ACA (Affordable Care Act) is run differently in different States. Some States run it entirely themselves, with money coming from the Fed, while others have the Fed run it. Other States use a hybrid model. Many States are looking at potentially rising health insurance premium rates, which will be necessary to keep programs funded, and are beginning to add State based funds to defray the severity of the increases. In other words, they are providing their own insurance subsidies to their citizens who use the ACA for their health insurance. 

Many States are turning to work requirements for Medicaid Recipients. I believe the idea there is to incentive work and the earning of money , with which ACA or better insurance can be purchased. It is both to reduce the burden of Medicaid patients on a State by causing fewer people to actually need Medicaid, either in the short run or the long run. 

There are currently work requirement proposals in ten States, which could potentially impact 1.7 million. As an Obstetrician Gynecologist, I would advocate for separate work requirement algorithms for pregnant women versus others. 

The judicial branch of our government is starting to weigh in on the Trump administration’s changes on the way health care is being delivered in this country. An Ohio law blocked funding to 28 Planned Parenthood clinics. However, a Federal court has blocked this law, saying that while the State may prefer “ childbirth to abortion” defunding planned Parenthood has little to do with that question since this particular money is not used for the support or performance of abortion. In barring this law, many primary care health services will be safeguarded. 

There are several lawsuit against this administration’s defunding of the Teen Pregnancy Prevention Program. A Federal Judge in Washington DC has declared the termination of the program unlawful and ordered the DHHS, Department of Health and Human Services to move forward again with the application of four such applicants within the program. 

Medical News 

If a pregnant woman is a risk for gestational diabetes, her physician may ask her to improve her diet and be more active. It turns out that those who made the changes have better glucose regulation even one year after baby is born. 

Coming from the other direction, we have the following report from the esteemed Journal Lancet. It seems that the environmentally determined health of both mother and father play greatly into the ongoing health of future not-yet-conceived babies. Each parent’s condition, whether well nourished, stressed, obese or fit, has influence on the cells and the DNA from which future children will be made. This us believed to take place through a process called epigenetics in in which an indivudual’s present day physiologic circumstances feed make and alter the expression of their genes and the genes of their germ cell lines (eggs and sperm). The article goes on to conclude that it points to a whole new level of preconceptual counseling which we must do. 

COPD (chronic obstructive pulmonary disease) usually related to smoking, now kills more women than men in this country. The days of “Virginia Slims” a TV ad brazenly directed toward women, are coming back to haunt us. I try to to remind patients that tobacco related poisons are much harder on women than men, and that smaller people in general get a higher relative dose. 

Many breast cancer patients lose their hair, if not from chemotherapy, then more mild so from anti cancer hormone medications like tamoxifen. New research says Minoxidil can help reverse that. 

Newsflash: the USPSTF - the US Preventive Service Task Force feels there is now enough evidence to recommend exercise to prevent falls in those over 65. And while I jest at the commonsensical nature of this announcement, falls are a major concern for most people over 65 and can lead to serious and life threatening injuries. No matter what age you are now, consult with your caregiver to see how you can attain optimal health and fitness for the present and the future. Whatever it is, whether seated stretching or training for an Ironman, start now. You will not be getting any younger. That is, unless you get more fit. 

A recently reported study shows IUD (Intrauterine Device) use has increased in recent years through 2013. This is believed to have been related to dropping out of pocket prices. I suspect newer studies will show use has increased even further with many women chasing long acting methods for fear of losing affordable birth control coverage. 

US maternal mortality has been increasingly in the news. Despite all the press, maternal mortality continues to rise through the present, and is concentrated in certain areas of the country, most notably Texas. Many correlate the most severe statistics with poverty and discrimination. Of late, many also finger the defunding of primary care clinics, particularly those like Planned Parenthood, which served more real and lower income populations. There are, at present two Bipartisan pills stuck in Committees which would support the formation of state committees to track and prevent the phenomenon. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, next week, on Medical Monday. 

Medical Monday : Two Week Catch Up

Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

Policy News

Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

And now for more of a purple to blue state review:

Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

Medical News: 

Obstetrics: 

Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

Gynecology/General Medical News: 

There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

Stay tuned for more news from the exciting world of Obstetrics an Gynecology, next week, here on Medical Monday ! 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy News

The Trump administration has said that the patients displaced by closures of Planned Parenthood offices can be absorbed by community health centers. However, a new survey out by Kaiser has indicated that fewer than one in five community health center will be able to compensate in this manner. Planned Parenthood may be apt to close if they cannot receive Title X funding through Medicaid on account of including abortion in their counseling or practice. 

A new Ohio law due to take effect later this month would have criminalized abortions done for Down syndrome. However, a Federal Judge has blocked the law, calling unconstitutional. In particular, it has been determined to violate the 14th Amendment due to violations of both liberty and privacy. 

Certain crisis pregnancy centers have no medical credentials whatsoever. Instead, they are merely storefronts for anti-choice or religious advocacy. The Supreme Court will hear arguments this week about the nature of their obligation to disclose their credentials and their agenda. 

The Contraceptive mandate was rolled back in Massachusetts. The state has challenged this but initially has failed to show enough data on adverse effects on the people of the state. The State plans to also argue that the rollback challenges the First Amendment which contains a prohibition against the establishment of religion by the government. 

New fast track legislation for the FDA ( Food and Drug Administration) called “Right to Try” has been under consideration. This would have streamlined/abbreviated the testing and approval process for certain potentially beneficial drugs, thereby getting them to more patients sooner. Proponents cited potential benefit, while opponents cited potential harms of less than completely tested drugs. The House failed to pass the measure failing to meet a 2/3 majority. 

Medical News 

The problem of appalling and increasing Maternal Mortality in the United States is squarely on the table now. Researchers are now focusing on several factors which may have led to this perfect storm. In addition to funding cuts and clinic closures, a shortage of Obstetric providers and rural hospitals providing Obstetric care is now in the mix. 

Stepping back, I'd like to remind readers that Mortality means death. However, for every mother who dies a childbirth associated death, there are 70 others who are near death and critically ill. This is the “ Morbidity” part of the equation. A new study has shown that addressing maternal Morbidity and Mortality in the States would greatly bring down the cost of healthcare. 

I would add that since 50% of all pregnancies are unplanned, that the contraceptive mandate might be worth its weight in gold to decrease maternal Morbidity and Mortality in rural areas and in general. Case in point: Colorado, home of my residency alma mater, the University of Colorado, has made sure safe and effective birth control was available all across the state, rural areas included. As a direct result, rural teen pregnancy rates fell by over half between 2007 and 2014. 

New research on teen pregnancy indicates that childhood bullying and various forms of rejection seems to be a risk factor in teen pregnancy. It is even more so for lesbian and bisexual girls, something caregivers should bear in mind. 

The field of Obstetrics is beginning to grapple with gender issues in the field. In 1970, only 7% of ObGyns were women. Now, 59% are. Furthermore, only 17% of ObGyn residents are men, and residents are the future. What are the ramifications for women’s health? Will men be excluded from the field by patient preference or institutional customs? 

Everyone has hailed the balancing of the field as a good thing. However, is it good if Obstetrics and Gynecology becomes devoid of men? One recent meta-analysis says 8% of patients prefer men Ob/Gyns and 41% have no preference. Here are some factors in the debate: 

• Patients may legally discriminate regarding who sees them. 
• Assuming that a certain gender will be insensitive or unprofessional is unfair. 
• Male medical students going into any specialty may be denied important clinical experience in their training if they are excluded from rooms. 
• Both men and women can and have made significant contributions to Obstetrics and Gynecology. 
• Outside of Obstetrics and Gynecology, men dominate 37 of the 42 other specialties, and fewer than a third of other doctors are women. 
• People want caregivers that are relatable, but their most important priority is to have a good doctor. 
• Women Ob/Gyns are not good Ob/Gyns because of their biology. It is because of learning, skill, and experience. These are gender neutral. 
• How male caregivers are introduced has a great deal to do with how well they are accepted. 
• The healthcare and health status of women is something everyone in society should care about and be able to work on. 

What do you think? Have had both male and female Ob/Gyns and have liked them all. 

Marijuana in pregnancy is again in the news. A recent study presented at the Society for Maternal Fetal Medicine has found an association between MJ use in pregnancy and the following outcomes: increased risk for stillbirth, increased risk of preterm birth, increased incidence of hypertensive disorders in pregnancy. 

Predicting cardiac risk in women is different than predicting it in men. In women, central obesity is a particular concern. Increasing BMI predicts increased cardiovascular risk. However, large waist to hip ratio predicts it even better in women. 

Dr. Barbara Levy, vice president of health policy for ACOG, has stated that labioplasty for purely cosmetic reasons should be cautiously considered since it is the removal of sexually functional tissue. Labioplasty for cosmetic or supposedly performance-related purposes is becoming increasingly popular, even among young women. I would add that it is often a cash up front business that practices use to bolster their income. 

Zika virus infection in pregnancy produces discernible malformations of the brain and eyes 7% of the time, across the board. The rate is higher if the infection is contracted in the first trimester. There is some evidence that the rates of malformation varied by country. 

In the good news department, women who are “ highly fit” in midlife may be less likely to get dementia later in life. This study ran over 44 years on about 1500 women in Sweden. Those only moderately fit saw some delay of dementia as well. 

Also in the good news department is the following: Scott Gottlieb, FDA commissioner, has announced plans to impose new lower limits on nicotine in cigarettes to make them minimally or non-addictive. While certain people will still roll their own, it seems certain that the population as a whole will benefit. 

Stay tuned next week here, for more breaking news from the world of Obstetrics and Gynecology. 

Medical Monday: Delayed Edition

POLICY NEWS 

The Department of Health and Human Services wants to expand funding for “ natural family planning” and “ fertility awareness” which are largely ineffective methods of timing based birth control. In other words, DHHS want Medicaid to begin covering visits where patients are told this is a viable method of contraception. In other words, the DHHS wants to spend your tax dollars on an ineffective, scientifically invalid method of birth control. Meanwhile the rest of the administration is working on dismantling the Contraceptive Mandate, the part of current insurance law which states that insurers must cover, without copay, real effective birth control. Additionally, the DHHS has announced it is moving away from “ comprehensive sexual education” which is evidence based, and instead will be using your tax dollars to teach “ abstinence only” which has been proven not to work. It is beginning to seem like the administration wants women to have more babies. Maybe they see this as stimulating the economy through having more consumers, I don’t know. 

California Judge Haywood Gilliam has stood up to the Feds determined to weaken the contraceptive mandate. He has blocked changes to the ACA in California, saying that he will not allow these changes “ transform contraceptive coverage from an entitlement to a benefit subject to employer discretion.”

Utah is writing law which will require radiologists to specifically notify women of dense breast tissue. In this warning they are to explain that screening is less effective, and that they may be eligible for other screening modalities. 

New Jersey has replaced Republican Governor Chris Christie with Democrat Phil Murphy. Governor Murphy has reversed 8 years of policy by restoring funding to Planned Parenthood and other women’s health organizations. He has also signed a bill expanding coverage for Medicaid coverage of family planning, prenatal care and cancer screening. 

DHHS is working on various plans to reduce the price of prescription drugs to consumers. Sounds good right ? However one of the cost control measures is capping the amount of prescription drug benefit that Medicare Recipients can receive. The other strategies include enabling as many as 5 states to collectively bargain with suppliers over prices. 

The administration is at it again, proposing bargain basement plans for people. In the words of Admiral Akbar, “It’s a trap !”. 

These plans are cheap, and some fear that consumers might not realize their limitations on coverage or pre-existing conditions. These plans which do not comply with the protections and coverage of the ACA ( Affordable Care Act) are a recipe for future disaster. They contribute little to the collective pot and cover little for their purchasers. 

MEDICAL NEWS 

In the important and alarming department, we have cleaning sprays. New research published in the American Journal or Respiratory and Critical Care Medicine has shown that the “regular use of cleaning sprays can have as much impact on health as smoking a pack of cigarettes a day." In this 6000 person study, “ cleaning even once per week was associated with an accelerated lung decline risk”. I will try to find out more about the types of cleaning agents used. 

HPV vaccine is still underused. Fewer than a third get their first dose by age 13, and fewer than half of all children are up to date on all their doses

In other vaccine news, a recent inventory of 400,000 births confirms that both influenza and TDaP vaccines are safe in pregnancy, and confer protection to both mom and baby. 

When we think of a heart attack, we think of an older man with check pain. However, women suffer heart attacks almost as much as men. However in women, particularly women under 55, symptoms may not be recognized since they are different than mens. These patients are more likely to have what is described as indigestion, shortness of breath, palpitations, or jaw pain. 

In related news, women’s heart attacks may have a different mechanism, coronary vasoconstriction, rather than the blockage from plaques that male patients often have. A new study confirms that among women with chest pain, and clean arteries, nearly 8% have scarred areas on the heart confirming that a heart attack occurred. 

About half of all breast cancer patient facing radiation heard “ frightening stories” about it. However after the therapy, only 2% agreed that the stories were true. 

Illinois has targeted maternal morbidity, specifically maternal morbidity due to severe maternal hypertension. A “quality initiative” specifying a “suite of interventions” was implemented. Participants qualified for the study by having BP at or greater than 160/110 (yikes!). Interventions included prompt pharmacologic treatment of maternal hypertension, specifically designed discharge education, and short postpartum follow up intervals. Severe maternal morbidity such as stroke as already decreased by 41%.

Stay tuned for more exciting news from the world of Obstetrics and Gynecology right here, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

MEDICAL POLICY NEWS 

The new budget has blown the top off the old budget, and this, from conservative lawmakers. It exceed prior spending caps, and suspended the debt limit for a year. As part of the package it did refund CHIP (Children’s Health Insurance Program) for four years. 

CMS is the Center for Medicaid Services. According to their actuaries, health spending in the nation will increase by about 5.5%per year to $ 5.5 trillion dollars, nearly a fifth of the economy. The fastest growing sector of health spending is prescription drugs, estimated to grow by over 6% per year in the next decade. Due to the Affordable Care Act, (ACA) personal spending for health care has been at historic lows, though it is projected to increase, even under the ACA, at over 2.2% per year, which is over the cost of inflation which is 1.9%. Whether or not this is good, bad or indifferent, I cannot say. As a mother and as a physician, I feel we undervalue our health care and its costs. We spend on electronics, vehicles and vacations, which are important, but forget that health is at the foundation of it all. 

The Trump Administration is disinclined to regulate drug prices. However, they propose “easing government regulations (read: protections) to “spur innovation” to “lower drug prices”. They also proposed expanding drug coverage and  placing a cap on out of pocket spending for Medicare recipients. While the federal government will not regulate drug prices, it will allow up to five states to band together to negotiate drug prices. 

The ACA has a dependent provision saying that children up through the age of 26 may stay on their parent’s health insurance policies. A study recently published in JAMA, the Journal of the American Medical Association, has revealed that this provision resulted in increased rates of prenatal care, early prenatal care, and reductions in preterm birth. As an Ob/Gyn I can tell you that one of our holy grails is finding a successful approach to preterm birth. Looks like having health insurance might help. 

Maternal Mortality is four times higher for black women than white women in our country. Access to prenatal care is believed to be part of this. A recent New York Times editorial  featured a free Obstetrics clinic in Florida who accepted clients regardless of ability to pay. They were able to document a 40% reduction in preterm labor and low birth weight in this group. 

I reported earlier on the Utah bill which will provide for the use of Medicaid funds to provide family planing services to low income women. Part of the genius of this is that these are not just any poor women. These are women who are below the poverty level, but who are not so poor that they qualify for Medicaid. They are the so called women in the gap. Lawmakers would save everyone money if they gathered data about the lowest income at which one can reasonably afford private insurance, and made that the same level at which one qualifies for the Affordable Care Act. From there, the ACA should cover straight down to incomes which qualify for Medicaid. Then there would be no gaps. Rocket Science. 

Health care is a case of pay now or pay later. By now, everyone including consumers and lawmakers should understand that attending to health and paying for it up front saves both money, productivity and suffering in the long run. This is the single most important message I can tell you. 

Planned Parenthood has been under scrutiny, defunded in parts, and under continuing threat of more defunding. Planned parenthood provides many primary health care services at very low cost, not just family planning services. Their services disproportionately benefit women. Many associate their defunding in certain states like Texas, with increased rates of Maternal Morbidity and Mortality. This last week, leadership of Planned Parenthood announced they will begin a campaign of legislative action in key states. 

West Virginia is attempting to supercede Federal Law. Their Senate has passed the “no constitutional right to abortion” amendment, and it now heads to their House. All this is despite the federal law Roe Versus Wade which guaruntees the right to abortion within various age parameters. One opposing Democratic senator, a physician, simply read ACOG’s (American College of Obstetricians and Gynecologists) statement of opposition to the measure as his response. 

The Trump Administration has developed a “Conscience and Freedom” division of the Department of Health and Human Services. Since when did a Government office dealing with health care need a “ Conscience and Freedom” division ? It sounds very "morality police" to me. Encompassed in this type of approach would be protections for physicians who withheld certain treatments, and punishments for physicians who administered them. This move has also raised concerns in the hallowed halls of academic medicine. Professors from the Bixby Center for Global Reproductive Health and the Department of Obstetrics and Gynecology at UCSF (University of California San Francisco) have written an op ed against the formation of this committee and its enforcers. They have asked the Administration “to stop politicizing medicine and interfering in the judgement of medical professionals.” 

Think all this sounds implausible ? Think again. The Iowa Senate has approved a bill to ban abortion after a heartbeat is detected. We routinely detect heartbeats at 5.5 to 6 weeks after the last menstrual period. The bill includes a provision to charge physicians who do such procedures non-emergently with a Class D felony. Opponents of the measure are many. The University of Iowa would lose it’s accreditation of it’s residency program in Obstetrics and Gynecology if this were to be the case. This is because,to comply with the state law, the Program's policies have to comply with medical science and recommendations. This would worsen the problem of the shortage of Obstetricians and Gynecologists. 

MEDICAL NEWS 

In the recent past, Betamethasone steroids were only given to women expected to deliver before 34 weeks. More recently, the recommendation is to expand the use up through just before 37 weeks., the so-called late preterm period. Steroid given in this way decreases pulmonary (Lung) problems in the premature newborn. New research presented at the Society for Maternal Fetal Medicine has concluded that up to $200 million in savings could be realized by following this new recommendation. 

Increasing evidence shows that ovary cancer starts in the tubes rather than the ovaries. You might know this already if you have recently been counseled about a tubal sterilization procedure. In the past, we performed sterilization by tying, clipping, or cauterizing the tubes. However now we offer patients removal of the tubes to confer additional cancer prevention. 

American “fertility rates” are falling. This could be misconstrued as meaning more American women are infertile. However, this is not what it means. It does mean our birth rate is decreasing. Researchers believe this is explained by later marriage, smaller families, better adoption of birth control and fewer births among the unmarried. Their are varying assessments of this trend. Some people believe economic prosperity is dependent upon ever increasing birth rate, but this is an outdated and flawed analysis. Some believe that decreased birth rate alone will rescue the environment. I wish it were that simple. Data shows that income, educational attainment, and savings all increase with smaller families. 

HPV vaccine rates are still low. They are rising, but are still low. It is effective and has nothing to do with the choice to become sexually active. It prevents cervical cancer and genital warts. The side effects are limited to the side effects of an injection. What’s not to like ? 

Juice is out. Juice has been out for some time but many people seemed to have missed the memo. Many people still think that drinking 100% pure (even organic) fruit juice is a healthy thing to do. It is not. It is too much fruit sugar, in too broken down a form, for people to metabolize without spiking their blood sugar and risking fat deposition. A calorie is not a calorie. The RATE at which sugar enters your bloodstream is key. The rate with juice is just higher than our physiology can handle. It is far better to eat the whole fruit itself. The fruit has structure, even once chewed or blended in a smoothie, and it will enter the bloodstream in a slow release fashion. New research has shown that postmenopausal women who have a single 6 ounce serving of fruit juice per day persistently gain weight over the years. Of course many factors probably go into this, but the juice drinking may be a marker for misconceptions they have about nutrition. 

New research shows that who who meet criteria for and get MRI for breast cancer screening get more “invasive” (meaning with a needle or some other sharp object) biopsies. They say it like its a bad thing. Of course they get more biopsies. We see more detail and raise more concerns. The research goes on… fewer of these biopsies result in a cancer diagnosis”. AGAIN they say this like its a bad thing ! It is good to have no cancer diagnosis. What we are seeing here is a natural expectation of increased sensitivity and decreased specificity in the testing. There are more false positives, which we as a society have decided to accept as the “cost” of earlier diagnosis and better cures. So we as a group trade more pokes with a big needle for many women in exchange for greater years of life for a few. Sounds like a bargain to me ! Read these sensational headlines with care people, and don’t be afraid of needles. Sharp objects are your friend. And by the way, they talk about “invasive biopsies” like there is even such a thing as non-invasive biopsies. Spin the headlines much ? 

It is still meaningful to get your flu vaccine. If it does not prevent flu, it still will decrease the severity. If you don’t want to do it for yourself, do it for the unwell, elderly, children or pregnant women about whom you care. They are especially vulnerable and the death toll nationwide is appalling. Anti-vaxxers, take notice. There is cost to what you say. 

Stay tuned next week for more intense news from the world of Obstetrics and Gynecology. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

I’d like to take a moment to thank readers for their continued attention to this blog and this site. The Women’s March drove home the point of how important it is for all of us to be aware, and for us to make our voices heard. The beginning is simple: learning what is going on. 

Policy

Up to date policy includes one Alex Azar, who will be the new HHS ( Health and Human Services) secretary. As such he will be in charge of health policy in the nation. He has vowed to consider the interests of both parties. 

The legislature is gearing up to vote on a 20 week abortion ban. I’m not sure how much effect this will have since most elective abortions are far earlier than this. Since Roe versus Wade was based 45 years ago, making abortion legal, approximately, twelve hundred restrictive state laws have been passed. 

The Trump administration is crafting a program called “ Conscience Rights” which would allow a health care provide to deny a patient care based on their beliefs. This care would obviously include controversial procedures like abortions and assisted suicide, but would also extend to providing contraception and sterilization. Numerous physician groups including ACOG have raised substantial objections. I would not like to see health care devolve this way. I already know physicians who disapprove of people who get abortions, and physicians who disapprove of people who don’t practice birth control to have large families “ as many as God will give”, or people who drink, or people who smoke, or people who get fat or get sexually transmitted infections. Is there no end to our judgmental mentality ? I though we were in this to teach, comfort and cure. 

Utah is where I went to medical school. It is also the center of governance for the Church of Jesus Christ and the Latter Day Saints, aka the Mormon Church. In general I found the people there an attractive mix of family oriented, strictly religious, and yet interested in and respectful of science and the diverging views of others. So in this progressive atmosphere it comes as no surprise to me that a Republican legislator Representative Ray Ward, has proposed HB 12, which will enable Utah Medicaid to provide birth control, which it currently does not. He is proposing this to save money by decreasing unplanned pregnancies, abortions and reducing all costs associated with those. Brilliant ! 

Texas lost $35 million in federal funds which it voted to exclude Planned Parenthood from the recipients list. It basically lost $35 million worth of care to Texas women. Could this be related to the astounding increase in Texas Maternal Mortality ? Now Texas legislators are trying to get that money back. They are proposing their own program which will still exclude Planned Parenthood; They are calling it Healthy Texas Women. If they get their money back for their new program, there is concern that other states will similarly overhaul how federal money is delivered to women’s health clinics. 

Meanwhile, nationwide, women continue to flock to clinic to obtain long acting IUDs ( intrauterine devices) to give them birth control in case the contraceptive mandate of  Affordable Care Act is revoked. 

The Trump administration is trying to find more ways to “ excuse” people from the mandatory requirement to have health insurance, the so called “ individual Mandate” part of the ACA ( Affordable Care Act).  For all the world, you would think they want fewer people insured. Oh wait ! They do want fewer people using federally sponsored health insurance plans, since those cost the government money which they would prefer to keep for items on their own agenda. They justify this stating consumers should have freedom of choice, meaning the freedom to save for health care expenditures, as if that is common practice, or you could reasonably expect to do it for a large 5 figure expenditure. Last year, there were 3.2 million more people uninsured compared to the year before. Most of this is reckoned to be people who simply chose not to pay for health care. I cannot understand why it is not simply like car insurance. If you are on the road, you must have insurance. If you do not, and something happens, you will cost others a great deal of money and yourself a great deal of trouble. The same is true if people are too irresponsible to obtain health insurance. 

Medical News

Hip fractures among women are on the rise. This new study shows what I have considered inevitable. The women of the Diet Coke, Tab and too much coffee age are upon us. Many were smokers, and few drank milk, let alone ate leafy greens. No wonder bones are breaking. Here in Montana, where winter is 9 months long and there are 3 months of bad sledding, vitamin D deficiency is rampant. Vitamin D is crucial to bone metabolism and is manufactured in the skin by sunlight. Pacific Northwesterners and many of us in the Rocky Mountains inland should consider getting checked and supplemented. 

Breastfeeding may protect against type two diabetes in women. The longer the breastfeeding, the greater the reduction in risk. We have always advised that breastfeeding helps moms lose unwanted weight, and of course that in and of itself lowers risk for diabetes. 

Placental insufficiency is just what it sounds like it is. All placentas are not created equal. Placentas deliver oxygen and nutrients to a growing baby. However, various medical conditions or just bad luck will result in a poorly functioning placenta. Just about any pregnancy complication such as high blood pressure, poor nutrition, or smoking will result a placenta of  poor quality and a higher risk of complications for baby. The worst complication is of course stillbirth. A new study has suggested that nearly a quarter of stillbirths could be preventable. Placental insufficiency is usually the culprit, and with standard prenatal care it is not hard to diagnose. When we identify the problem, we increase the surveillance with monitoring and Ultrasound. Any problems with access to good prenatal care will interfere with identifying and treating complications that lead to stillbirth. 

Texas continues to be in the news as researchers and policy people probe the appalling maternal mortality figures. As of this writing we know that many factors are to blame including access to prenatal care, prevalence of black women in the data set, especially those who are underserved, or who have hypertension. Most interesting to me is the contribution of stress from chronic societal discrimination. 

The spotlight is now on my state, Montana. In the case of 14 child deaths in Montana this year, 3/4 of them took place when an infant slept in the same bed as a mother who was using drugs. Our hospital has addressed this by have an active department of Social Services, an Addiction Specialty service, and the Baby Box program. This is modeled after a common European practice wherein a family with a newborn is sent home with a baby box full of safe supplies. The box itself is made to evidence based standards, having a flat firm mattress , a fitted sheet, and no covers. Baby is kept warm in a sleep sack, a kind of gown in which they cannot get tangled or suffocate. In Finland, for example this has been done for over 75 years with good results. Some say it has helped Finland achieve one of the lowest infant mortality rates in the world. The Baby Box program also includes extensive education about safe separate sleeping practices, but it remains challenging to change people’s behavior of keeping baby with them in the bed. 

http://www.bbc.com/news/magazine-22751415

A County Attorney in Big Horn County, Montana has announced a crackdown on pregnancy women who use drugs or alcohol. That office plan to seek civil restraining orders and even incarceration to meet their goals. ACOG has come out against this, indicating it basically keeps high risk women away from prenatal care. Handmaid’s Tale, much ? 

When medicine and policy collide: More women received indicated mammograms when Obamacare, aka the Affordable Care Act, banned copays. If that does not tell you copays are a barrier to screening, I don’t know what does. 

Women skip mammograms for money. But, a new study says women skip paps for embarrassment. Young women in particular could identify embarrassment due to body shape, shape of vulva, or smell. We need to do more to help women and girls feel comfortable in their own bodies. 

A new study reveals that increased long use of oral contraceptive pills confers better and better protection agains endometrial (uterine) and ovary cancer. It also confirms that long term use does not seem to affect risk of colon or breast cancer. You may have in the past heard other studies which have contradicted this. The good news is that our methodologies improve and computing power increases every year, making the quality of our data better and better as time goes by. 

Not-so-fun-fact: New research incites that a women's risk of dying from childbirth is 14 times higher than her risk of dying from an abortion. 

Finishing today in the SUPER COOL department, we have two entries. 

First, those Scandinavians are once again on the forefront of progressive perinatal care, this time using the power of probiotics. A new study shows probiotics consumed in pregnancy lowers the risk of preeclampsia and preterm birth. These Scandinavian countries provide comprehensive prenatal care and keep thorough databases on all patients, enabling them to glean meaningful information of good quality. More research is needed on how to implement this finding. 

Lastly, Apple has roiled out a new feature in the Health App enabling users, meaning patients, to control and transfer their own medical records. Twelve large medical institutions have begun beta testing. This is great for patient empowerment. It is also partakes of the open data movement, which says that in an ideal world, data should be fully shared, without fear of discrimination. When patient and research data can be shared, we can expect a great acceleration of medical progress on the topics which matter most. 

Stay tuned until next week, for more breaking news from the world of Obstetrics and Gynecology.

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The Graham-Cassidy Bill leads the policy news this week. This is the GOP's last ditch attempt to repeal the ACA (Affordable Care Act). It has been simplified down to one key point : redistributing Federal funds for Medicaid expansion and insurance subsidies as State block grants. The bill was introduced by two GOP Senators, Lindsey Graham of South Carolina, and Bill Cassidy of Louisiana, and with support from others. 

During the week that the Graham Cassidy bill has been around, it has been scrutinized. The Kaiser Foundation has determined that the redistribution of funds in those plan would be quite unequal between States. Consider that different States expanded Medicaid more than others, and some did not expand it at all. What States would stand to have taken away would therefore vary. Overall Federal spending on health care would drop by more than 100 billion dollars between 2020-2026 under this plan. Many physician groups have also criticized the plan. Most notably, ACOG (the American College of Obstetricians and Gynecologists). Eleven Governors including some from the GOP have come out against the bill as well. 

It is unclear if there will be enough votes to pass this bill. More than 50 are needed. Toward the end of the week Senator John McCain has stated he will not support it, and that alone may doom it. Remember that Senator McCain was recently diagnosed with brain cancer this last year, and is therefore deeply involved in the health care world. 

The deadline to pass this bill is September 30th. But it will only be brought to the floor if it is determined beforehand that it will pass. This deadline is needed in part because insurance companies and insurance commissioners need to settle on rates which the commissioners will approve and that will keep the insurers solvent. 

The Iowa legislature voted to forego Federal Funding just so they could deny funding to Planned Parenthood. Now the Iowa Department of Health and Human Services is beginning a collection of data about the effects that this is having. They are trying to determine if defunding Planned Parenthood has reduced access to reproductive health services for Iowans. Seems bass ackward to me. 

In a interesting and positive turn, State Senator Ray Ward, a Republican out of Bountiful, Utah  has proposed a bill that would allow Utah Medicaid recipients to have a postpartum IUD placed while they are still at the hospital. This would bring the red state in line with all but 6 other states which lack this law. 

On to the medical news. 

How bad is the opioid crisis ? It is so bad that death from opioid overdoses is skewing our life expectancy gains statistics. 

Women and opioids are a special case. It turns out opioid addiction and sexual violence are closely linked. In these cases, police are seldom called due to the presence of the drugs and fear or retaliation. 

Speaking of drugs, ACOG has come out with a new Committee Opinion. In this latest document, they have stated clearly that pregnant and breastfeeding women should not use marijuana. 

In the this-makes-perfect-sense department, a new study out of Harvard has shown that adequate sleep and adequate support protect against postpartum depression. That said, even those with high levels of support can get postpartum depression. For example, Ivanka Trump has recently shared her story of postpartum depression. 

An insulin pump may give better control to pregnant diabetics than conventional prick and inject methods.We currently use insulin pumps in non-pregnant diabetics, but have not until now, seen evidence about their use in pregnancy. 

There was a recent Apple event with new product announcements. In it, mention was made of the Apple watch, and the app called Health Kit, and their potential for ultimately helping patients like diabetics. Fast forward only a few days later when I attended Stanford MedX conference. We heard from a young diabetic woman who solved her own problem. Using small cheap components and a little home built computer set up called raspberry pi, she combined a blood glucose sensor with some dosing software and an insulin pump to create her own “ artificial pancreas”. We heard her presentation as an example of what an empowered patient could do. Empowerment plays a huge role in healing. 

The opposite of empowerment is psychological trauma, with resultant PTSD. It turns out that this sort of thing significantly increases one’s risk of being diagnosed with lupus. Lupus is a serious autoimmune disorder characterized by inflammation of the joints and many other tissues. According to a study published in the Journal Arthritis and Rheumatology, trauma even without PTSD are than doubles the risk of getting the disease. Those with PTSD are three times more likely than their peers to get lupus. Nearly 55,000 women’s questionnaires were examined over a 24 year period. This news reinforces the already widespread advice that stress management is important. 

Stay tuned for more exciting news from the world of Obstetrics and Gynecology, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obsterics and Gynecology

As expected, the Trump administration is planning to roll back the contraceptive mandate. The contraceptive mandate requires that insurers cover costs for contraception without copay. The proposed change in regulation would allow employers to refuse to cover contraception because of religious or moral objections. This change will not go unchallenged, Numerous lawsuits will likely be initiated if this change takes place. 

Those objecting to the contraceptive mandate often cite their objection to certain birth control methods which prevent implantation. However, mainstream authorities focus on the fact that increased contraceptive availability is associated with plummeting incidence of abortion and unplanned pregnacy. 

In other policy news Texas plans to continue funding their task force to determine the causes of their alarming rate of maternal mortality. It is really a shame that Texan’s don’t just save their money and acknowledge the obvious: that increased maternal mortality is directly related to their gutting of health care services to women. At this time, one quarter of Texas women lack health insurance. Data from many quarters tells us that this is a sure fire way to ensure poverty and high maternal mortality for many generations to come. 

Arkansas is racing to the bottom as well. A Federal Appellate court in St. Louis has ruled that Arkansas can block Medicaid funding to Planned Parenthood. 

Winning the race to the bottom, is of course the the Trump administration, who has resolved to cut Teen Pregnancy Prevention program funding. The American College of Obstetricians and Gynecologists (ACOG) came out with a swift condemnation of this plan. The current administration supports abstinence only programs, and yet asserts they favor “ evidence based” programs. Sling that medical jargon. 

Lawmakers have prevailed upon the Trump administration to make the Federal Government insurance subsidy payment for August. In fact, it is Republican members of Congress together with Democrats who have convinced the administration to continue payments, fearing a collapse of insurance markets. They believe this will buy time for a bipartisan solution to stabilize the markets. The CBO (Congressional Budget Office ) continues to warn that ending subsidies with cause premiums to rise by 20% by 2018. 

In encouraging news, Oregon has passed law budgeting half a million dollars to expand comprehensive reproductive health care coverage for all its citizens. The law also requires insurers to cover such services with no out of pocket cost. Available evidence tells us that, as a direct result, they should expect decreased rates of unplanned pregnancy and abortion, with increased levels of educational attainment among women, decreasing unemployment statewide, and increased standards of living. 

https://www.cdc.gov/obesity/data/prevalence-maps.html

On to the medical news. 

It is time for us to start thinking about obesity in more sophisticated ways. Obesity is a devastating and widespread medical problem. It is also very personal and for that reason it is challenging to discuss and treat. We are now beginning to understand that the causes of obesity include but are not limited to individual habits. For example, poverty and its many causes factor in strongly. We can graph the incidence of obesity on maps and thus understand obesity is part of culture as culture spreads across geography. New research out of the National Institute of Health has revealed that the “ origins of obesity lie as much in early childhood - even prenatally and intergenerational- as it does in an individual’s current behavior. “ Obesity is closely tied to many forms of human suffering and disease, from heart disease and diabetes, hypertension and cancer, to poor self esteem and depression. Further research is necessary, by all means. However to effectively address this serious problem, both patients and physicians are going to have to do better at mustering their courage and talk about obesity in frank and accurate terms. 

You might have noticed my mention of obesity as having a role in increasing cancer risk. Maybe you were not aware of this, since there is not an obvious connection. However, we have always know that obesity is associated with many types of cancers. However, new research from the Journal of the Academy of Nutrition and Dietetics sheds more light on the subject. It turns out that “ women who eat a lot of high calorie foods may face a slightly higher risk of obesity related cancers - even if they remain thin” The study went on to elaborate that “ women who favored low nutrient high calorie foods had a 10% higher risk of cancer linked to obesity. “ Cancers related to obesity include cancer of breast, colon, ovary, kidney, and endometrium (uterine lining). 

A new study from the Canadian Medical Association has shown that oral cancers related to the HPV are on the rise. Between 2000 and 2012 it is believed that the incidence of such cancers has risen by 50 %. 

Smoking in pregnancy is still a big problem. It turns out that depression in pregnancy makes smoking more likely. This tendency of smoking during depression in pregnancy is on the rise, according to new research published online in the October issue of Drug and Alcohol Dependence. 

HPV and smoking are a bad combination. Did you know smoking greatly accelerates the progress of HPV related disease ? 

HPV has an effective vaccine against it. However, new research indicates that less than half of girls and a quarter of boys are vaccinated. HPV ( Human papilloma virus ) has a vaccine. Humans papilloma virus causes genital warts, precancerous and cancerous lesions of the genitalia and mouth. Vaccines are available for young people from the ages of 9-26 years of age. They have little in the way of known side effects. 

In other virus news, there have been no locally transmitted cases of Zika viruses in Florida yet this year. The same encouraging trend has also been seen in Latin America and the Caribbean. Authorities now believe that those infected develop immunity to reinfection. However, authorities are also concerned that Zika may now be getting transmitted sexually. Work on a Zika vaccine is underway. 

Again, I encourage you all to contact your elected officials about your views on women’s health. Tell them the American people are willing to shoulder their collective responsibility for people's health care and the good of the future. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In policy news we find more of the same. Texas again figures prominently, so much so that I have decided to create a new category: Texas news. Texas is an unmitigated perinatal disaster and is an embarrassment to this country, particularly to its medical establishment. But make no mistake, if current trends in law and politics are any indication, women's healthcare in every state will be like Texas.

To wit: a new study through the Commonwealth Fund has shown that one quarter of working age Texas women still lack insurance of any kind. A significant percentage of those who are insured struggle to pay medical bills and admit to having skipped needed care because of cost. Texas did chose not to expand its Medicaid, and this is believed to be one of the causes for these phenomena.

Also in Texas, ordinary standard insurance does not cover abortion. A new bill passing the Texas House will require women to buy supplemental insurance coverage for this procedure. It also increases reporting on complications after abortion and on the incidence of minors receiving the procedure. 

Finally in the Texas news, the Texas physician Dr. Brett Giroir, a Pediatrician, has been nominated for assistant Secretary of Health at the Department of Health and Human Services. However, Democratic Senators have delayed his confirmation on concerns that he would not support women's health programs. And they wonder why Texas is in the state it's in.

The Trump administration has cut funding for the Texas Teen Pregnancy and Prevention Program. Now it proposes eliminating funding for all such programs across the country. Moreover the fundamental research for the Teen Pregnancy Prevention Project is situated at Texas A&M University and theses researchers have recently been notified that their funding has been cut.

In Texas, Planned Parenthood has been barred from receiving Medicaid reimbursement. As a result the number of comments coming in to the Center for Medicaid Services (CMS) have doubled from 9,000 per week to 18,000 per week. According to the Center for Public Policy Priorities this will remove healthcare access from 45,000 people.

In the good news department, a bipartisan group of high ranking Senators are trying to strengthen existing law regarding health care. They are recommending that the Federal government continue paying subsidies, and that all Americans enroll in coverage. They also recommend renewal of the Children’s Health Insurance Program. Even Senate Majority Leader Mitch McConnell has said that he would consider such a bipartisan effort to shore up subsidy payments to insurers to stabilize current insurance markets.

In the medical news, one is seven women experience anxiety or depression in the first year after giving birth. This remains vastly under-diagnosed untreated with only 15% of those affected seeking help. Obstetricians have been alerted to increase screening for these debilitating conditions. 

In other concerning news, the team suicide rate among girls has reached a 40 year high. This is according to a new report from the Centers for Disease Control and Prevention published this last week in the Morbidity and Mortality Weekly Report. As of 2015 it sits at about 5 per 100,000. 

Preterm birth has continued to be a significant perinatal problem and one that has been resistant to explanation and treatment. However, new research published in Obstetrics and Gynecology has indicated that sleep disorders may play a role in some cases. Data from over three million birth was studied, with conditions like apnea and insomnia being tied to preterm birth. 

New research indicates that risk of stroke is decreasing for men but not women. Stroke risk is related to the incidence of several medical conditions, including obesity, smoking, high blood pressure, diabetes, and high cholesterol. These conditions are on the rise among women. 

Physicians and patients, listen up: Physicians are doing a BAD Job at educating patients about marijuana use in pregnancy. Increasing State legalization has led many to believe marijuana is entirely safe under varied conditions. (Since when do we believe what politicians have to say about science and medical care ? ) This has not been substantiated. According to researchers at the University of Colorado in Denver, the data available is limited, and sometimes flawed. However, there is “ moderate evidence that the use of marijuana in pregnancy is associated with increased risk of reduced fetal growth, lower IQ scores in young children, adverse effects on a child's cognitive functioning and academic ability, an increase in attention problems” There may also be associations with low birth weight and preterm birth. Patients need to be honest with their caregivers, and caregivers have to help patients to meet their needs some other way than to use marijuana.

Stay tuned form more fascinating and important news from the word of Obstetrics and Gynecology, next week, on Medical Monday. 

Medical Mondays: Breaking News from the World of Obstetrics and Gynecology

Forty prominent groups concerned with women’s health have written a letter of complaint to the new administration. The recipients include President Trump, the Secretary of the Department of Health and Human Services Tom Price, White House aide Ivanka Trump. The letter has criticized each of the major changes that the present administration has either enacted or proposed, for example replacing Obamacare, cutting funds to Medicaid, reducing access to women's healthcare by shutting down Planned Parenthood as well as the "global gag rule”, also known as the “ Mexico City policy”  which prevents international organizations who offer abortion as part of their services from receiving any US funds. The letter further alleges that women's healthcare needs have been traded for political benefit. The letter went out during Women's Health Week to call attention to the issues. In order to begin addressing these concerns, Ivanka Trump has begun meeting with various groups concerned with women’s health, including female Democratic leaders. 

Imposition of the global gag rule may cut off millions in funding to combat other conditions like HIV/AIDS and malaria, leading to a global health crisis. 

In a move long opposed by Republicans, the Trump administration’s budget proposal will include 6 weeks of paid family leave for both mothers and fathers. 

Texas is still trying deal with having shot itself in the foot. Texas took a stand against abortion and removed Planned Parenthood from their Federal Funding recipients. By doing so under the Obama administration, they lost their Federal funding for the Texas Medicaid Women’s Health Program. Texas has the highest maternal mortality rate of all the States, and a very high percentage of uninsured people. They want their Federal funds back. 

Health insurance is not just about a single subscriber, or even a single family. It is a funding pool that we agree to make together, that lets us all have predictable manageable health expenses, even if something really bad and expensive should happen. It also is a way for everyone in society to help safeguard the future, by contributing to the care of the next generation. This is done by contributing to a pool that pays for the care of women and children. This elementary and beneficial concept behind health insurance seems to have escaped Republican Rod Blum from Iowa who believes men do not need to contribute to an insurance pool which covers pregnancy. He was jeered off the stage in a town hall meeting. 

And now for a piece of news that cinches the connection between policy and health care. Research presented at the annual meeting of ACOG (The American College of Obstetricians and Gynecologists) has shown that the Affordable Care Act (ACA) under Obama led many pregnant women to get prenatal care earlier and that led to better perinatal outcomes. Of course this is in jeopardy now. 

Researchers with the American Cancer Society have presenting new findings indicating that increased access to care under the ACA led to early detection of some cancers. These included breast, colon and lung cancers. Early diagnosis leads to more cures and longer survival. The biggest changes occurred in states with significant Medicaid expansions. These gains too are in jeopardy. 

A recent study has shown that women under fifty doubled their survival time in recent years. I suspect mammograms played a role in this. There is controversy on when mammograms should start: 40 versus 50. ACOG recommends 40. So do breast cancer survivors under 50. Cancer patients over 50 also saw increased survivals, but not quite so dramatic. 

The World Heath Organization has presented the shocking news that pregnancy complications are the leading cause of death for teenage girls worldwide. The biggest causes were hemorrhage, complications  from abortion, and obstructed labor. 

Lancet, one of the world’s premier medical journals produced research on “ Amenable Mortality”. “Amenable Mortality means deaths that could’ve been avoided through timely or effective medical care. American scores 80 on the heal care quality index (HAQ) and that is at the bottom on the second decile, on a par with Estonia and Montenegro. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The health care policy package proposed by the new administration must pass through several committees before actually passing to the House and the Senate. One of these is the Budget Committee. This last week House Republicans brought the American Health Care Act (ACHA)  through this committee by vote of nineteen to seventeen. However three GOP lawmakers voted against it, showing a house divided. Centrist Republicans who approved the bill did so providing the tax credit system change to better benefit the working poor. Nonetheless it is the working poor and older workers who will experience a disproportionate rise in premiums. This is because of the substitution of tax credits for subsidies. Those who have low wages have low taxes and tax credits mean little to nothing to them. As previously reported, tax credits help those with substantial tax burdens, i.e., those with higher incomes.  

Analysts believe premiums will likely rise for a number of reasons. Principally the lack of the individual mandate will keep a lot of money from entering the pool, and this needs to made up somewhere. The premiums from 24 million consumers are likely to come out of the pool,as 24 million are likely to lose insurance with the repeal of the ACA.  This alone is believed to account for what is expected to be a 15-20 % hike in premiums. Those of us who obtain health insurance coverage will make up that staggering shortfall. Moreover, when the uninsured hit the hospital, we will also pay for them in rising medical costs, since the care providers will be left holding the bag. 

Despite all this Health and Human Services Secretary Tom Price still says that the ACHA is “ intended to make health insurance feasible for every single American.” He and others in the new administration insists no one will lose coverage with with transition from the ACA to the AHCA. 

The Department of Health and Human Services budget will be cut by 15 billion, 18 percent. And yet, there will be sizable block grants for the opioid crisis and a “ Federal Emergency Response Fund.” The President’s new budget will cut funding to the NIH by 5.8 billion dollars. 

President Trump wants to give the States ability to alter their own Medicaid. On the table are copays, work requirements an premiums. 

Readers will recall from last week that Representative John Shimkus cited a “War on Men” and decried the mandate that men must purchase insurance which covers prenatal care. He does not believe that men should have to contribute to a general insurance pool if it includes funds for the prenatal care of women who also purchase that insurance. He is the same man who has sponsored anti- abortion bills out of his concern for the well being of fetuses. Connect the dots much ? 

That place where the federal government buck always stops is the Congressional Budget Office or CBO. According to the CBO, defunding Planned Parenthood would increase the number of Medicaid births, decrease overall Medicaid spending, but increase unplanned pregnancies. As unplanned pregnancy rates rise, so do abortions. 

And now for the highlights in medical news. 

Gardisil, the vaccine against Human Papilloma virus, is effective. It turns out that two doses are affected as the currently recommended three, good news for everyone including those kids who failed to get their third dose. 

When I was in training there were no limitations on length of our shifts. We routinely worked 36 hours at a stretch, and in my big training center, most of the time, we have no sleep at all. Shortly after I finished residency in 1994, an 80 hour per week working standard was set. Additionally the limitation of 18 hours per shift was instituted. However now concerns about continuity of care have caused the number to swing back to 24 hour shifts. However, The 80 hour week per limit for residents at all levels remains in place.

Preterm birth remains a serious problem in this country. We've developed various methods to try to predict its likelihood including cervical length ultrasound and fetal fibronectin testing. It does have some utility, together with the clinical judgment. However, it turns out that, according to a recently published study in the Journal of the American Medical Association, they have limited utility in first-time mothers.

Over 400,000 physicians from various disciplines compose the Medical Society Consortium on Climate and Health. Associations who participate include the American College of Physicians, the American Academy of Allergy, Asthma, and Immunology, the American Academy of Family Physicians and American College of Obstetricians and Gynecologists. The group has identified eight threats whose increase is related to climate change which will doubtless have serious effects on human health. They are, extreme heat, extreme weather, air pollution, ticks and mosquitoes, contaminated water, contaminated food, mental-health, and nutrition.

On that sobering note, I would encourage you to get more active in political, social and environmental activities which concern you. Your elected officials are truly easy to reach by phone or email. 

Stay tuned for more important news from the world of Obstetrics and Gynecology next week on Medical Mondays. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology.

On last Monday , President Trump signed an executive order “ granting relief” from the stipulations of the ACA (Affordable Care Act). Among other things, this means the Department of Health and Human Services (DHHS) may reduce what insurers are obligated to cover for patient’s care. 

Planned Parenthood reports that the number of women trying to get IUDs in their clinics has gone up 900% since early November, i.e. the election. IUDs are a very reliable long acting contraceptive.  They are obtaining these IUDs under the contraceptive benefit under the ACA, which they fear will be repealed under the current administration. 

The Democratic Governor’s Association has urged Congress not to overturn the Medicaid Expansion or to convert to block grants. They stand to lose a great deal of coverage and funding for their constituents. 

Two moderate Republicans, Senator Susan Collins of Massachusetts, and Senator Bill Cassidy of Louisiana, a physician, have indicated a partial replacement for the ACA, which would allow states to continue to operate under it if they chose. Under this proposal, states who opted out of the ACA could get a block payment to administer on their own. The authors have emphasized that the bill is a work in progress. 

At the recent GOP policy repeat, a plan was made to have a replacement for the ACA  to the House floor by the end of March. The House Speaker, Paul Ryan indicated that they intend to get these replacement laws made in 2017. 

The US has frozen funding to health care providers in poor countries who discuss abortion as an option. This policy is called “ The Mexico City Policy” and it is been enforced and revoked back and forth through the administrations of Clinton, Bush, Obama, and now Trump. 

The CDC (Centers for Disease Control) reports that consumption of sugar drinks is still “ well above” the recommended limit. Consumption of these drinks has decreased steadily for the last ten years but now seems to have plateaued. 

The South has higher cancer mortality rates that the rest of the country. These are areas of the country where poverty, smoking and obesity are more prevalent, and these factors are believed to be the reasons. Overall, the US health rate from cancer has decreased 20% in the last ten years. 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology.

For the first time in many months, there is nothing new to report about the Zika virus. I am going to take this is as a good thing and report on the rest of the news. 

With the end of 2016 approaching, ACA (Affordable Care Act) signups have reached a new high. At the same time many fear loss of their contraceptive method if the ACA is repealed. The ACA as it currently stands, pays 100% for contraceptives. 

The ACA seems to have enabled more people to keep up on preventive care. Also according to a new study, the number of adults who skipped recommended medical care fell about 20 % between 2013 and 2015. Similarly, a new Vanderbilt study showed that patients accessed emergency department care more quickly since cost was not a consideration in choice of hospital.  

Texas has noticed all Planned Parenthood Clinics that it is removing them from the Medicaid Program. This means that no Medicaid recipients may be seen at Planned Parenthood, which normally serves predominantly the Medicaid population. I’m wondering if this will have unintended consequences. For example, perhaps Planned Parenthood will have to start filing their clinics with well insured women, while the private and hospital owned clinics uptown will start to fill with medicaid patients ? It will be interesting to see how this will play out. It almost certainly will mean less access to care and a shift in who sees whom. Planned Parenthood is appealing the Texas Health and Human Services Division. 

ACOG (American College of Obstetricians and Gynecologist) has officially endorsed 30-60 seconds of delayed cord clamping. This procedure allow baby to get more blood from the umbilical cord. This is especially beneficial for smaller, early babies, but can be good for term babies as well. It results in higher blood hemoglobin counts, but also, understandably more jaundice, since jaundice comes from the breakdown products of blood cells. As an obstetrician, I can tell you that this works out most of the time. However, if baby is not breathing well, I get them to the nursery staff right away. Also, if there is excess maternal bleeding, we cut this procedure short, and move to get the placenta delivered. 

On a personal note to readers, I have appreciated all the attention to my posts. However, I plan to curtail my blogging to once a week come January 1st, 2017. I will continue Medical Monday since I believe this information to be very important to you. Additionally, I do plan to put out an occasional digest of existing website pages and posts on selected topics, which I think will be high value. However, based on my numbers of readers and subscribers, it seems clear to me that I need to get my information out in more accessible forms, such as in books or apps. There is so much material on the site now, that most topics are really well fleshed out, though the material is deep in the pages. I will need some time to pull this content out and organize it. At the same time, you are of course welcome and encouraged to access the website anytime via the menu, the search page, or the blog tags on the right of the home page on your own and free of charge. My website will be there free for all as an up to date medical resource.