I am so sorry for my rushed presentation last week. It didn’t want to hold too many people up after class since we all had finals coming up soon. I will use this forum here to explain some parts of the presentation that I didn’t have a chance to do earlier.

My original plan was to open the presentation up in another language, Cantonese. I wanted people to experience the feeling of not understanding anything at all. I choose breastfeeding because it is a topic that is easy to understand. Yet, as you may guess, without any pictures or diagrams, you would not have been able to understand what I was trying to convey to you. Once I would should the diagrams of how to breastfeed and when to breast feed, you would immediately know exactly what I was trying to say. (Here is a link to some really great pictorials:  http://www.spring-nutrition.org/publications/training-materials/nigeria-community-and-facility-infant-and-young-child-feeding)

My point in doing this small experiment in the beginning is to show how effective pictures are. It seems that we lack the use of pictures for many health related issues. See the

pamphlet above. It is suppose to be informative but lack diagrams and pictures for people who are illiterate and non-English speakers to understand. If you recall the health literacy study that I brought up in class. This study provided a survey for adults with various backgrounds, including individuals in prisons. The survey assess 3 domains, clinical domain, prevention domain, and navigation of healthcare system. The clinical domain involved ability to fill out a patient information form correctly, understanding dosage of medication, and following a healthcare provider’s recommendation. The prevention domain refers to activities involving prevention of disease and managing health such as addressing signs and symptoms of health problems. Understanding of how eating and exercise can influence health. The last domain is understanding of how the healthcare system works such as your rights as a patient, what health insurance will and will not pay for.  From this survey, “58% of Black and 66% of Hispanic adults exhibited “basic” or “below basic” health literacy, compared to only 28% of White adults.” This is a staggering number. Although there are many influences over health literary such as education level, but I feel that this is more reason for why we need more pictorial health materials so that more people can understand the health information that is being told to them.

In addition, the Delp and Jones study showed that pictorials enhanced the ability to recall and understand information as well as increasing adherence to the methods shown in the pictorials. This study gave 234 emergency room patients were either given instructions without pictures for managing lacerations or instructions with pictures. The study showed that not only were the instructions with pictures more likely to be read but also found that those with the instructions with pictures were more likely to do what what recommended in the instructions, about 77% compared to 54% respectively.

I am citing these studies to show just how effective pictorials can be to understanding health matters. This class is about birth and global health so I continued to see how this can be expanded broader, into the context of our class.

In Myanmar, an NGO initiated a community based safe motherhood initiative. They handed out pictorial handbook, similar to the one we saw from Dr. Sibily’s presentation, that addressed common signs and symptoms during pregnancies as well as antenatal care. The healthcare volunteers also held 3 day weekly sessions for 6 months and taught with the pictorial handbook. Overall, they saw an increase in health communication as well as health knowledge. Each cohort was given a pictorial kit that included the 5 dangers of pregnancies (ante partum hemorrhage, pre-eclamptic toxemia, prolonged labor, mal-presentation, and post partum hemorrhage). During the prenatal visits, the mothers were asked to bring this pictorial kit with them and the nurse would ask the mothers to explain each card to them. When the nurse would notice a misunderstanding, the nurse would correct the mistake before moving on to the next pictorial. This resulted in an increase from 8.9% to 34.2% between the first and 2nd antenatal visit as well as a 13% increase in delivery in a facility.

The health policies surround breastfeeding leaves much of a loophole for companies to climb though to avoid providing a facility for women to pump With the ACA, it required “employers to provide reasonable break time” and a facility (not bathroom) for mothers to pump. This law is known as “Break Time for Nursing Mothers”. This law only applies to companies with at least 50 employees. However this law does not describe how much time is “reasonable” and what this “facility” is nor what the “facility” would include.

Certainly, we are all aware of the benefits of breastfeeding but having to go back to work makes it nearly impossible to breastfeed. If we first address the “facility”, the law is very vague on what this could possibly entail. It only requires the company to provide a facility. So say we are talking about a woman who works for a big company, hundreds of employees. The company could decide to select a small unused room at the other end of the building as this designated area. Since the law only covers pumping breast milk rather than breastfeeding, the facility should include a way for mothers to store the breast milk, but the law does not include this aspect. Also, the employer is not “required to compensate an employee receiving reasonable break time for any work time spent for such purpose”. So not only can the facility be far away from the mother but the time that the mother is gone could put her work at risk. As an employee, you certainly do not have the leisure to get up and leave for any amount of time whenever you want. If you fear your job being in jeopardy, you might be less inclined to breastfeed.

Many many studies show the potential positive effects breastfeeding has on the mother and child but yet these laws are not supportive of this view. This law, “Break Time for Nursing Mothers” appears to allow for more mothers to breastfeed while working but the law is too broad and not specific enough. It leaves much of the details for the individual companies to interpret. I personally think that more effort should be put to make the laws more rigid and make the companies more accountable so that women can breastfeed during work. I see it with the same as allowing time for people to take breaks to smoke. If the company can allow for this to happen, then certainly they can provide a convenient facility for women to breastfeed and/or pump.

What are your thoughts about this law?

What do you think should be done policy wise to make it easier for mothers to breastfeed/pump while at work?

Information about the law:

http://www.dol.gov/whd/nursingmothers/

http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx

Information about breastfeeding:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020209/

I came across an interesting article written last year regarding to maternal mortality rates and the cause of such a high rate in the US specifically. The article does not blame what we have normally attributed causing maternal mortality, in fact it shifts the blame to the one person we entrust with most of our medical decisions-doctors, specifically in hospitals. It blames how the new medical technology is constantly putting the mothers and their children at risk of dying.

This is an interesting aspect that I would have never considered. Doctors are the ones that we tend to entrust with our lives and we rely on them to provide us the best care there is. I certainly do believe in that over use of technology and how the high prevalence of infection is in hospitals that could potentially affect the rates of maternal mortality. But I would have never blamed the medical technology as the reason for the higher rates of maternal mortality. I have always thought of medical technology being a good aspect and one that helps the United States stand apart from the rest of the world’s healthcare system. However, this article seem to argue that there is such thing as too much technology with birth. It does seem to be true to a certain extent. I mean, birth has been occurring for so many thousands of years without one piece of equipment that we have hooked up everywhere in hospitals. Births in third world countries lack these modern day equipment and they still fare well.

What are your thoughts on medical technology for births? Do you think it does more harm than good?

http://www.slate.com/articles/health_and_science/science_of_longevity/2013/09/death_in_childbirth_doctors_increased_maternal_mortality_in_the_20th_century.2.html

After reading Chapter 9 in the RAMS book, I find it interesting that the issue brought up about policy making is just as relevant to the United States as it is to Iran. Certainly, the US is not dealing with early marriages of girls at the age of 9, or even younger. However, we are constantly battling sex education policy. The push for sex education started around 1892 when the National Education Association passed a resolution for “moral education in the schools”. The city of Chicago was the first to implement sex education in 1913 for high schools but this did not last long as the Catholic Church fought against this type of education resulting in Ella Flagg, the superintendent of schools, to resign. Congress took action with sex education after the end World War I when rates of STDs rose drastically. Congress passed the Chamberlain-Kahn Act, which provided money for educating soldiers about syphilis and gonorrhea. This Act raised awareness about STDs and made Americans view sex education as a public-health issue. However, controversy arose in the 60s when religious groups felt that sex education should not be taught in schools but rather at home. They felt that this topic should be left for parents to discuss with their children and that teaching it in schools will result in more kids having sex.

Similar to the situation in Iran with controlling the population growth, the US had a joined effort to educate students regarding to sex education but differences grew when it came to the details of how to educate the students. It is a nationwide consensus that the younger generation needs to be educated but there is much controversy as to whom should educate the younger generation, the school or their parents? Both groups think they have the best interest of the students with each of their ways to educate but neither consults the student of which way would work best. I personally think student views are not incorporated since during this time frame (from middle school through high school), the students are still seen as children. I do not think it will ever be possible that the voice of the student will be involved in the policy making of sex education.

For me personally, I am from South Carolina. I remember that we had little to no sex education. In my freshmen year, we had a class called “Freshmen Success”, which incorporated sex ed into it. We talked a lot about studying skills and getting to know ourselves for the semester. Our sex education took about 2 classes out of the entire school year. We watched a movie called “The Miracle of Life” and that was just about it. There was no discussion before or after and my teacher seemed uncomfortable about the subject in its entirety. Before high school, my gym teacher taught sex education and took out about a week of class (essentially 3 class days in total) and we talked mainly about abstinence and how we should wait until marriage.

It is interesting to note thought, that despite all of the drastic differences with the teachings of sex education, the rate of teen pregnancies has dropped from one-third of teenagers (between ages 13-19) will become pregnant as teenagers in 2006 less than one in four teenagers in 2010. It seems that even with the conservative way of teaching, teen pregnancy rates are falling nationwide.

What were your experiences with sex education, if any at all, in school?

What ideas do you think will help influence the laws of the teachings of sexual education?

http://www.newsweek.com/brief-history-sex-ed-america-81001

http://www.bbc.com/news/magazine-30275449

I just wanted to make a comment about the medicalization of diseases in other countries such as depression. In a recent book I read, Crazy Like Us by Ethan Watters, the author sets out to analyze globalization of American psychiatry. There was a consistent theme across all of the case studies presented dealing with different types of disorders (anorexia nervosa, schizophrenia, PTSD, and depression)-that the DSM is not culturally sensitive and therefore cannot apply towards other societies. For instance, the DSM refers to depression having x, y, and z symptoms but in another country, these symptoms (x, y, and z) may just be the cultural norm and depression, in that society, actually has symptoms of a, b, and c. As in with Japan, introversion is a prized characteristic and well respected whereas in the US, introversion is not a prized personality trait. Yet in the DSM for depression, introversion is one of the symptoms listed. Therefore, taking the DSM criteria to diagnosis depression in Japan might lead to misdiagnosis of individuals.

This caution is to say that we cannot be quick to judge other society’s rates of post partum depression. These rates assume that the symptoms listed in the DSM are universal when there is heavy evidence this is not the case. This affects the way that post partum depression is treated in each of the society. With the misconception that the disorder is experienced the same way, individuals with post partum depression will never get treated properly since their actual symptoms were not recognized correctly in the first place. I think more attention needs to be placed for diagnosis of psychiatric disorders and put it in the context of society rather than having an universal system. This will help address the correct symptoms and signs of the disorder. However, as stated in Hannah’s presentation, there seems to be an importance of support systems with being a pregnant mother. This seems to be universal as the support system allows the mother to connect with other mothers with their issues.

Source: Crazy Like Us by Ethan Waters