I was recently listening to a segment on NPR that addressed the fact that many obstetricians are reluctant to speak to their patients about the potential danger of toxic substances in their environment. Though it is well documented that exposure to heavy metals and solvents can cause miscarriage, birth defects, and developmental problems, less than 20 percent of obstetricians ask their patients about their exposure to environmental hazards. They withheld the information because they felt that they would create fear and anxiety in their patients and as a result their patients would raise questions that the doctor’s felt they did not know how to answer.

Current research has shown that pesticides and air pollutants are linked to birth defects, but it is not clear whether the exposure people experience in a normal daily life is enough to cause these issues. For this reasons doctors feel that they cannot offer solutions to their patients on ways to prevent exposure and they would send their patients into unnecessary fear spiral. The Center for Environment Research and Children’s Health at Berkeley has recommendations for simple and inexpensive steps to help pregnant women reduce their exposure in their home, but doctors often neglect to tell their patients about these.

Is it ethical for doctors to withhold this information that affects the health of their baby?

I understand the concern that they may not be able to offer many solutions, but I feel that mothers have a right to know that these hazards exist. I don’t think it will send women into an unnecessary spiral of panic. At least informing mother’s of exposure risks from things they have control over such as cleaning products, food containers, or food products would allow the mothers to make safer choices instead of unknowingly exposing their babies to dangerous chemicals.

Few Doctors Warn Expectant Mothers About Environmental Hazards http://www.npr.org/blogs/health/2014/06/25/324940705/few-doctors-warn-expectant-mothers-about-environmental-toxins

There was recently a segment on the Daily Show satirizing the explosion of pink breast cancer awareness products on the market today, with the latest being a pink oil drill bit and a $50,000 donation from a multibillion dollar oil company that releases chemicals directly responsible for breast cancer every single day. Similar to Lydia’s and Elizabeth’s posts on promoting awareness and being ready to partner with certain organizations, this made me think about the role of advocacy in promoting health programs and what true advocacy actually looks like. Is slapping a pink or white ribbon on a backpack, going to a run to support the cause, or celebrating an awareness day once a year truly advocacy?

It is obviously incredibly important to promote awareness of Safe Motherhood and maternal and child health initiatives, but maybe because it is still in the growing stages of promoting wider awareness, we could take a different approach to promoting awareness. We need to capitalize on commitment. Instead of handing out pins to put on backpacks and making Motherhood themed products or having awareness runs, maybe there should be letter writing days and campaigns to ask for political commitment and policy changes. A true advocate should also inform themselves so they can have educated conversations with people informing them about the issues and what they can do to help. True advocates can rally and require that leading organizations in maternal and child health such as UNICEF, USAID use awareness days to bring donors and shareholders together to assess the state of Safe Motherhood and create concrete plans for action.

Having a colored ribbon or a symbol for people to relate to and recognize can be important for gaining recognition for Safe Motherhood and maternal health, but for real change to be made we as true advocates must demand more. We talked in class that it is hard to get traction around this campaign because there is no one easy solution. This is true, but there are hundreds of inexpensive, empirically proven, and practical solutions that can and should be implemented now! Campaigns should be created that attach faces to stories of preventable deaths followed by the simple solution that could have saved a life. This will make the issue a reality for people and the mothers can become the rallying point to create a call for action.

I’m reading a very interesting/shocking book called Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men, written by Mara Hvistendahl. Just as the title says, the book focuses on how sex selection abortions came to be, and the effect they have on populations and the societies that are affected by an overabundance of boys. A team of French demographers place gender imbalance on par with the HIV/AIDS epidemic. In 2008 it was estimated that AIDS had claimed 25 million lives in the history of its epidemic. This is a fraction of the estimated 100-160 million girls that have been lost to sex selective abortion practices. As the first generation touched by sex ratios imbalance grows up, the silent biological discrimination that is sex selection has been exacerbated by visible threats to women, including sex trafficking, bride buying, and forced marriages. This only exacerbates the problem, and only further impedes progress in reproductive health for women.

From the 1950’s through the 1970’s UNFPA, The Rockefeller Foundation, The Ford Foundation, and The World Bank sent $1.5 billion in aid to India to support implementation of “any necessary population control measures: including abortion, sterilization, and birth control. Quite interestingly, many of the main players pushing for the implementation of these programs in India, China, and a few other Asian countries were fighting extension of the same rights in the US. The argument was that over population in these areas was impeding development. Chinese officials felt that boosting per capita GDP was a long and difficult process that would take many years to accomplish. With the support of these aforementioned western organizations, China implemented the one-child policy in 1980. Cutting the birth rate and reducing the number of people who would share in the wealth (or lack there of) in the nation seemed a quick and attainable way to push development. Economic development, along with the urbanization, education, and new job opportunities has been shown to lead to lower birth rates in families. But because development is accompanied by plummeting birth rates, it raises the stakes for each birth, increasing the chances parents will abort a female fetus, creating an alarming triangle of development, falling fertility, and sex selection.

In 1982, two years after the one child policy was enacted in China, ultrasounds were widely distributed. Though sex determination was technically illegal in China, there was little incentive to crack down on it, so a small bribe could go a long way. The fine for sex selection was also ten times less than the fine for having a second child. This drove many parents to choose to “beat the odds” and ensure that they had a son on the first try.  I thought this was a striking example of the different effect that certain technologies can have in culturally distinct environments. In the political and cultural climate of China and India at the time, ultrasound technologies served as an inexpensive gateway for working the system and helping families to ensure that they had a boy, at the expense of unborn girls.

Reading this book has made me stop and think about how the implementation of certain technologies often has dangerous and unintended results. I don’t think technology should be withheld, but the implementation has to be careful and sensitive to the political and social climates they are being introduced to. So what can be done? How do you check that what is supposed to be a helpful technology is not promoting gender inequality and obstructing maternal health? As sex selection cannot happen without abortion, this issue obviously opens up conversation on access to abortions and what should be done in that respect.

In light of the fact that the US has the highest rates of STDs and teen pregnancy or any industrialized country, the debate surrounding sexual education in schools is incredibly important. My home state of NM has no requirement for teaching sex ed in schools, and when it is taught, there are no requirements on what should be included. NM also has the second highest teen pregnancy rate in the US. My high school did not teach sex ed, and teen pregnancy was common place with a daycare on school grounds to help moms who wanted to continue going to school. Growing up in this climate it became obvious to me that simply not talking about sex did not stop kids from having sex. For this reason I adamantly support comprehensive sexual education in public middle schools and high schools. Education is power, and teaching young adults about their bodies and safe ways to express their sexuality is important and will help protect against unwanted pregnancies and the transmission of disease.

My high school was also 85% Hispanic with 50% of those students being first generation Americans and 15% newly immigrated. This is important in this conversation because sex was a taboo subject in within this group. Strong catholic families celebrated when their daughters became pregnant, but shamefully swept the action that caused the pregnancy under the rug never to be talked about. Breaching the subject of sex in this community was uncomfortable and considered highly inappropriate especially in school. These cultural differences are incredibly important to consider when approaching the subject of teaching sex ed in public schools. The US has an incredibly diverse cultural heritage, and for many people, talking about sex is incredibly uncomfortable and for some can be terrifying. When discussing the implementation of sex ed in schools, we have to be sensitive to these needs. I work at an HIV/STD clinic in Atlanta and I have seen in support groups we have with HIV positive women from many different backgrounds that forcing someone who is uncomfortable talking about sex because of cultural or religious beliefs doesn’t work. They shut off and are not receptive to the information. The conversation has to become relevant to them, and be presented way that is respectful and approachable to them. In our support groups we have found that breaking women up into smaller groups with a peer navigator that understands cultural or religious hesitations helps to create a more comfortable and relaxed environment where the women feel safe to open up. Once this is established they usually become very engage and ask a lot of questions. I think something similar could be applied to schools. Small culturally sensitive groups could maybe be used to help students feel safer in discussion, and help mediate the cultural barriers between families.

Does this solution seem like it would be feasible?

We all know that educating students about their bodies and sex is important for future health outcomes, so what other solutions are there that still provide the necessary information but make the environment safer and sensitive to cultural differences?

The viewpoints offered in  Born in the USA  and A Walk to Beautiful are important to understanding the underlying factors that contribute to health outcomes for women and their children in different settings. Perhaps the starkest contrast in these films is access to medical care available to the mothers. The young mother’s in Ethiopia had to travel many hours to reach a hospital. It is likely that most women in these areas are not receiving any type of prenatal care, and have probably not received much medical care for most of their lives. This compounded with the fact that many of these girls are stunted due to lack of access to necessary nutrition, and the young age of many of the mothers the first time they give birth creates a perfect storm of risk factors. A study conducted in 2010 found that the major contributing factor to maternal death in rural southwest Ethiopia was a lack of referral care for mother’s in distress during pregnancy. This was due to the fact that families often did not understand the severity of certain situations because conditions such as fever, dizziness, and pain are considered normal during pregnancy.. Of the 94.4% of births that occur in the home in Ethiopia, 67.5% are attended by untrained neighbors, 20.5% untrained relatives, and 4.7% traditional birth attendants (Deribe et al, 2010). On a policy level, many of these issues could be addressed through the extension and improvement of the capacity of frontline health workers and midwifes. These individuals could attend to women and provide prenatal care, catching warning signs in early stages when they can hopefully be attended to without the amenities of a large hospital. They would also be present to help the mother’s during birth, better equipped to respond to difficulties in labor than an untrained neighbor or family member may be. They could also lead educational efforts focused on maternal and newborn health care. If mother’s and communities have a deeper knowledge of their bodies and their needs during pregnancy they will hopefully be empowered to have a healthier pregnancy. Extension of education on newborn care would hopefully promote better nutrition for newborns which could help to prevent stunting and lead to better health in the future.

The U.S. seems to be confronting the opposite end of the spectrum, over medicalization of the process of child birth. Opposite to what I expected when I first learned about infant and maternal mortality rates in the U.S., the over emphasis on medical care has not led to better outcomes. Despite spending more on medical care than any other country in the world, the U.S. ranks 50^th in maternal mortality and the rates have increased 25% since 1998 (Amnesty International, 2010). According to a report released by the Foundation for the Advancement of Midwifery, many women in the U.S. do not understand the options available to them when giving birth. A hospital is seen as the safest place other options are not explored. Many American women are taught to be afraid of the natural pain that accompanies childbirth. Epidurals to treat pain slow labor, leading to the use of pitocin to push the labor along (Foundation for the Advancement of Midwifery, 2013). These conflicting events push many women to expensive and invasive cesareans that may not be necessary. The high cost associated with child birth in the U.S. has another affect. African American women are four times more likely to die in child birth than any other race. A study done by Amnesty International showed that many African American women cannot afford the care they need during pregnancy and childbirth. Insurance companies turn these women away, and many doctors don’t take Medicaid (Amnesty International, 2010). The first and what I believe the most important policy that needs to be implemented are programs like the Affordable Care Act that will ensure that women have guaranteed lifelong access to quality health care. Policies that support the advancement of the visibility of midwifes could help alleviate many of the problems that are faced. Extending midwifes would cut down on hospitalization, the use of unnecessary cesareans, and provide excellent care at a fraction of the price.

Amnesty International. (2010) Deadly Delivery: The Maternal Health Care Crisis in the USA. http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf

Kebede Deribe, Sibhatu Biadgilign, Alemayehu Amberbir, Tefera Belachew, Kifle Woldemichael. The Road to Maternal Death In Rural Southwest Ethiopia. Ethiopa J Health Sci. 2010 March; 20(1): 71–74.

Foundation for the Advancement of Midwifery. (2013). The Pregnant Elephant in the Room:The U.S. Maternity Care Crisis.  http://www.gih.org/files/FileDownloads/US_Maternity_Care_Crisis_FAM_October_2013.pdf