A nursing student in our cohort posted this article to our class Facebook page this week and I found it very interested and wanted to share with you all. The article begins by discussing the Healthy People 2020 goal to decrease the number of infant deaths to 6/1000 and tells how currently the US is at 6.1/1000. However, as we have discussed in class, the U.S. infant death rate is still relatively high compared to other developed countries such as Austria whose has a rate of 3.8, Finland who has a rate of 2.3, and Monaco who has a rate of 1.8 (the lowest in the world.) However, the article brings up an important concept that we have only briefly touched upon in class… how these data/stats are collected. The article states that there is often a discrepancy in the definition of a live birth and claims that the US rate may actually be lower (around 4.2). U.S. statistics include babies born before 24 weeks (even though chance of survival is very low for babies born before 23wks) while other countries may classify extremely low birth weight babies as a stillbirth/miscarriage; thus, if the ELBW babies die they are not included in the infant death rate.

While this in itself is interesting to think about, and can spark conversation about policies that perhaps need to be in place to insure more accurate data collection and parameters defining how we calculate infant death rate, the article goes even further to discuss an issue I find even more intriguing.

The article claims that the majority of infant deaths in the U.S. actually do not occur in the neonatal period (first 28 days) while the babies are still in the hospital, but over time after they are home. Furthermore, they examined how this is particularly true with babies born to women of lower socioeconomic status. While we have discussed how socioeconomic status contributes to birth outcomes across the globe, I found it interesting that the article claims that in comparing outcomes between the U.S., Austria, and Finland that children born to poor minority women in the U.S. “were more likely to die within the first year than children born to similar mothers in other countries.” So, I am wondering what you all think may play in to this. What makes infants (and women) of lower socioeconomic status in the U.S. more vulnerable than women of lower socioeconomic status in other developed nations?

Here is the link to the article:

Romm, C. (2014, October 1). Why American Babies Die. Retrieved November 18, 2014, from http://www.theatlantic.com/health/archive/2014/10/why-american-babies-die/381008/

After our brief discussion at the end of class, I found myself searching for recent news about obstetric violence, and came across this article in XXXX written on October 1^st, 2014. It discusses how there are several cases of women speaking out because they were either forced into c-sections or received episiotomies without being asked. Shocking as it is that this would occur, it presents the idea of who are we really treating during birth. Is the focus the fetus—to make it out in the best condition possible—so the decision is made by the medical provider? Or is the focus the mother—to honor her preferences—and risk some fetal factors to satisfy her desires/needs for birth? Do we really have to choose?

I think many times when women give birth in the US, the relationship between provider and patient is established and decisions have already been clear in case things progressed to certain situations. But what if they have not? It is my understanding that it is the provider’s responsibility to ensure a healthy state for both parties. What if their lives aren’t at risk, but some things would just “make it easier?” Who do you make it “easier” for?

The article also refers to an Australian organization Birthtalk, which describes traumatic birth as, “A birth that you can’t let alone. It stays with you…It might not look ‘that bad’ to an outsider. It might not look ‘that bad’ to your partner…It could have been a caesarean or a natural birth. It might have taken 30 hours or 3 hours. A bad birth is defined by the way you feel not just the events that occurred.” How do you set standards and give suggestions for this situation if birth is not to be based on any one person’s interpretation of an already very difficult process? Is this the approach to have? One could argue….isn’t the mother healthy and leaving with a happy, healthy baby?

I also was interested to keep the discussion going about culture and how one’s understanding of their own culture might affect their perception of other cultures. The article mentioned above continues “our cultural view of pregnancy and birth, it seems, stems from a patriarchal attitude that feminism seeks to dismantle: that women must be submissive, passive, and let the experts who know better do the work.”

So where do we go from here? How do we advocate for women in their birthing experience, but empower them to trust the medical team?

Lock, K. (2014, October). We Need to Talk About Obstetric Violence. Daily Life.  Retrieved from http://www.dailylife.com.au/news-and-views/dl-opinion/we-need-to-talk-about-obstetric-violence-20140930-3gydt.html

After my initial research and the class discussion for my presentation last week, I wanted to delve further into the prevalence of female genital mutilation (FGM) in the United States.  The collective shock of our class that the practice exists in the United States hugely echoed my own surprise.  Looking into statistics of FGM brought me to the website of Equality Now, an international human rights organization “dedicated to action for the civil, political, economic, and social rights of girls and women.”  Their report on FGM was further eye opening for me on this subject.

In 1997, the U.S. Department of Health and Human Services (HHS) estimated that over 168,000 girls and women living in the U.S. have either been, or are at risk of being, subjected to FGM.  However, there is little information known on how many of these procedures have actually occurred on American soil.  In fact, even the HHS estimate is from speculations based on populations from FGM affected communities in the U.S.  There have only been a couple of reported cases of FGM in Georgia, one in 2003 and another in 2010.  The cutting can happen when girls are on vacation in their parents’ countries of origin or when circumcisers are brought into the country to cut girls, but some reports also indicate that a few doctors may be performing FGM on girls in hospitals in the U.S.  Unfortunately, the silence surrounding the issue makes it extremely difficult for girls and women who oppose the practice within communities to speak out openly against it.

The video, which unfortunately did not work in class, was a reflection of an effort to create an awareness campaign on FGM in the U.S.  The hope of such campaigns is that increased awareness and understanding will lead to greater openness on the discourse of FGM, and as a result could lead to better prevention and education regarding the practice.  The video is included in the links below if anyone is still interested in watching it!

http://www.equalitynow.org/sites/default/files/EN_FAQ_FGM_in_US.pdf

http://www.theguardian.com/society/video/2014/may/13/fgm-us-girls-american-female-genital-mutilation-video

In another one of my classes, we talked about adoption and it occurred to me that it’s quite relevant to our class. In this instance I am speaking of giving a child up for adoption right after birth. In many states, the mother is not allowed to consent to adoption for up to 72 hours. Meaning that even if a mother wants to give her child up for adoption right after birth, she cannot legally do so until three days after the baby is born. I think this is very interesting because the mother would either have to care for the child for three days and then give it up or have the child be taken care of by the state until the timer is up.

I saw this kind of like the abortion debate. Clearly different, but still a woman is being coerced by the government to take care of and keep a child she does not want. Even if a woman is sure she does not want to, or cannot afford to keep the child, caring for the child for three days could be very confusing. I’ve included a link that lists each state and when the birth mother can consent to adoption. Do you all think this is a way for the state to convince a mother to keep a child or if having a time frame is ok?

http://www.adoptionbirthmothers.com/adoption-truth/adoption-facts-faqs/adoption-laws-by-state/

One of the things I found most interesting from our RAMs reading about health politics in Iran was the distribution of the reproductive health educational textbooks by the Family Planning Association of the IRI.  These books were aimed at those of reproductive age, meaning girls aged 10-19 and boys aged 15-19 according to Iranian law.  I found this to be particularly interesting given the recent and continuous discussion about sex education in the United States. When to start educating children about sex and reproductive health is a controversial topic in the U.S. How young is too young? In Iran they faced a similar problem. While they were open about reproductive education and were willing to teach children, the definition of what constituted a child left out young girls and boys who were partaking in sexual activities. Although the legal age of marriage for girls was 9 years and 14 years for boys, there was a large population of children marrying much younger; many marriages were only documented if the children were 16 and older. It was not stated if these educational textbooks were distributed to only this age range or to all children in the areas they were given out in. However, if children are marrying before the legal age of marriage, then they will also need education material geared towards them. The Iranian government worked to increase reproductive knowledge to those deemed the appropriate age, but what about those who may be sexually active within and outside of wedlock that are not in the target age ranges?

                Before taking this class, I was not aware of the extent to which midwives and traditional birth attendants  were involved in the healthcare sector. I wasn’t even aware of their role. I have interacted with them in hospitals and clinics but I was sure they did more than check blood pressure or height and weight and assist the doctor with a few things. I was also not aware that birthing centers existed and people could go there to have their children. I did a little research and I found that there are so many roles that midwives birthing attendants, doulas etcetera can play in lieu of a doctor and it is important for these options to remain available. Midwives are also prevalent in countries that have the best “maternal and infant outcomes” (Midwives Alliance of North America). I thought I was the only one who had no clue how involved midwives were.  While having a conversation with some friends about this class, I asked them their take on midwives and midwifery. A lot of them also were not aware the extent to which midwives were utilized. one of them brought up the fact that midwives provide a more personal care. In some of my other classes we have discussed bedside manner and how this plays a significant role in the outcome of the patient. Doctors see a lot of patients each day and as a result do not always have the ability to empathize with their patients. Patience, compassion and understanding are important, especially for pregnant women. I think it is important to continue to promote the training and the  use of midwives, TBAs and other specialists. It is also important to promote the other birthing options. There are probably several other people who are unaware.

http://mana.org/about-midwives/what-is-a-midwife

It is hard to determine how common obstetric violence is because, as we have learned throughout our study of global health, data reporting is not always reliable. Congruent to other forms of violence, victims are not likely to report obstetric violence, and if they do, it is not guaranteed that they will be heard. Additionally, obstetric violence takes many forms, and a patient may not be fully aware that obstetric violence occurred. If she is aware that an act against her autonomy occurred, she may not have the privilege or ability to speak out against it.

Last September, I read an article about traumatic birth titled “In traumatic childbirth, women say healthy baby isn’t the only thing that matters”. The article discussed how women are expected to be joyful about their births when their babies are born healthy and how their feelings about their experiences in birth are downplayed. It also brought a staggering statistic to light; according to the Prevention and Treatment of Traumatic Birth (PATTCh), approximately 30% of births are traumatic, resulting in feelings of helplessness, anxiety, fear, or isolation during labor. Further, one-third of those who describe their birth experience as traumatic will develop post-traumatic stress disorder, an intense, long-lasting psychological syndrome that often consists of anxiety attacks, distressing flashbacks or dreams, and depression. The article discussed the root cause of this staggering statistic to be obstetric violence, specifically in the form of lack of informed consent. The article led me to an organization called Improving Birth’s #breakthesilence campaign, which is a collection of experiences of victims of traumatic birth. As I looked through the submissions to the campaign, it was clear that those who had experienced traumatic birth felt ignored, antagonized, or physically or verbally abused by their caregivers. I’ve included the link the Facebook campaign below, where you can see pictures of people voicing their experiences.

I think the term obstetric violence is appropriate. I like that it includes “obstetric”, indicating that caregivers, likely clinical obstetrics staff, play a role in perpetrating violence against patients. I also like the use of the word “violence”, which carries a lot of weight. I think when analyzing this term it is important to recognize what it stands for beyond the two words. It is important to recognize that obstetric violence is a result of a systematic power structure in obstetric care.  The violence goes beyond physical harm and includes neglect, verbal abuse, refusal of resources, and failure to respect consent. Because many of us in this class are future caretakers or public health workers, we must be aware of the ways systematic violence plays out in a healthcare provider-patient power dynamic.

Sources:

Editorial: “In traumatic childbirth, women say healthy baby isn’t the only thing that matters” – http://www.stltoday.com/lifestyles/health-med-fit/health/trauma-from-childbirth-women-say-healthy-baby-isn-t-only/article_6efe50eb-89e8-517b-bb51-99e12fb06cc9.html

More information about Prevention and Treatment of Traumatic Birth – http://pattch.org

Improving Birth’s #breakthesilence campaign photos – https://www.facebook.com/media/set/?set=a.705655609507930.1073741854.255657527841076&type=3

Another reading on maternal and fetal outcomes as affected by partner violence in Latin America and the Caribbean opened my eyes up to the horrors and prevalence of this issue, which occurs in many nations around the world. According to the study done in Latin America, this issue is most highly associated with unplanned pregnancies. Also uncovered in the study was the overlapping of the issue with the disempowerment of women, which has been shown to increase prevalence of partner violence. Interestingly, whether a woman sought prenatal care was shown to decrease the prevalence of the issue, which may or may not be due to access and affordability of care. The study sought to define the issue in one region of the world, in order to effectively add intervention strategies to decrease the issue and its negative effect on fetal and maternal outcomes. Wanting to know more about the issue, I decided to look into the prevalence of this issue in the USA. As a citizen in this country, I believed there was a small magnitude of this problem. Upon investigation, however, I realized how prevalent the issue truly is. According to the CDC’s report in March of 2003, there are approximately 5.3 million victims of IPV each year. Out of this number 550,000 injuries require medical attention.  I would interested in learning if the results of this study were implemented in a way that greatly decreased the prevalence of this issue. In addition, I am now increasingly more aware of the dangers of IPV both in my own country and others.

Sources:

http://www.cdc.gov/violenceprevention/pdf/ipvbook-a.pdf

http://www.cdc.gov/violenceprevention/pub/ipv_cost.html

This week’s reading on reproductive health in Iran brought me some insight in the intersection of health and religion, which can be a difficult area for many. While blatantly ignoring religion and its importance in many regions and cultures creates problems, I was curious to learn more about how health professions tackle this issue. One source states that over 90% of the population in Iran practice Islam, and as such their religious beliefs and texts are believed to play a large role in their life practices, which include to some extent those of reproductive health. In working with religious officials, health professionals were able to create great change and increase in health in Iran. As such, the nation won the 1998 UN Population Award for successfully reducing population growth with the implementation of the Population and Family Planning Program. I decided to look into whether this award was still being given out, and found that in 2014 it went to Italy, for their development in the category of obstetric care. However, the nation did not accept the redefinition of the family, only including one man and one women joining together, and was not willing to accept and implement sex education for all adolescents and young adults who are not currently getting married. I found the cultural aspects of population growth and its solutions in this nation interesting. For example, at first Iran was not willing to combat its increasing population as a problem, as in previous years a large population was the sign of a strong nation and no problem was detected. Also, a major player in reducing population growth by implementing family planning measures such as contraception was when Islamic clergy members deemed it acceptable. This was notable because they were able to use religious texts and historical evidence to back the acceptance of contraception as a method of family planning. Therefore, I am very intrigued to learn more about the overlapping of religious ideals and modern health practices, as often they can clash but with careful interactions can be successfully done to better the health outcomes of a nation.

Sources:

http://www.religionfacts.com/islam/places/iran.htm

http://www.unfpa.org/public/cache/offonce/home/about/popaward/pid/4641;jsessionid=673ED81B740B0085D3F865E02D581D05.jahia02

RAMS chapter 9 is an interesting discussion of the interaction between policies and local realities, specifically regarding population control in the Islamic Republic of Iran.  It discusses the discord between forces of conservatism rooted in tradition, and policy makers who want to improve life conditions through modernisation. Caught up in the midst of these two sides was the young people themselves in Iran, who reproductive health was the issue at hand.  The question is raised as to why the same authorities who initially agreed to implement a family planning programme, then subtly changed their minds half-way through making restrictions for policy makers.  This case is an example of a clash between the agenda of the religious political elite and that of modernising bureaucrats.  It was seen that top-down policies can provoke reactions which may be passive and indirect, slowly hampering policies.  I think that this case is by no means isolated.  Many, many countries in the world today are facing conflicts between their traditional values and ways of life, and new ‘Western’ or modern ways of thinking and living.  This can extend to all areas of life, including reproductive health.  I think it is essential that policies are not made in a vacuum or simply by the leaders in charge of a nation.  It is important the voices of the people are heard, and on-the-ground research is carried out to see where people are at and what compromises might be found that would achieve a modern goal yet also allow traditions to remain.  But what does this look like in practice and in other related issues such as FGM?