Maternal Age; Always Too Young Until You’re Too Old

Danielle’s presentation sparked my interest, especially the comparative age of African American mothers due to stress and the disparity of maternal age in characterizing black Americans versus other populations in our country. Though African Americans see better birth outcomes at younger ages due to this, young teenage mothers in general within the U. S. (13-17 years old) see a much higher rate of low birth weight babies, premature deliveries, and infants who are small for their gestational age, when the mother’s living situation and education level as well as prenatal care were controlled for. This results in longer NICU visits, more instances of diminished lung development and growth deficits, and higher infant mortality.

Though these differences were less extreme in the 17-20 and 20-24 age populations, it was increased compared to those born to mothers older than 24. This may in part be related to these studies being conducted on the babies being born, unable to control a population and select candidates to get pregnant; most women in American and almost all women of higher education in America are choosing to wait longer for marriage and children than ever before, which brings us to the other end of the spectrum.

The number of first births per 1000 women 35 to 39 years of age increased by 36 percent between 1991 and 2001, and the rate among women 40 to 44 years of age leaped by a remarkable 70 percent. Regardless, the relatively stable spontaneous abortion rate among mothers (10%) doubles in mothers 35-39 (20%) and continues to 50% in the early 40’s and 90% in the late 40’s, with points to an increase in congenital abnormalities that cause this or uterine insufficiency, the inability to form a placenta that can adequately feed and foster the child’s growth. The rate of pregnancy related hypertensive issues also increases in older mothers. Additionally, once born, the risk of Down’s syndrome goes from 1/1000 in mothers age 30 to 1/400 at 35, and 1/100 at 40, and other congenital abnormalities show a similar if not so drastic incline.
In professional journals to lectures by the successful that we see so frequently at Emory, it is often said that the late 20’s (post-graduate school) and early 30’s are the years to lay groundwork and establish the path of your career, highly necessary for later success and higher earning, but in the U. S. today, we have little protection for working mothers. With no guaranteed return employment or paid maternal leave, it has become a financially inadvisable decision to become pregnant during the times when it is most healthy to do so, and many economists point to this as yet another reason and solid barrier creating the 23 cent gap and keeping women from high powered careers like CEOs.
Other than providing nationally mandated access to maternal leave (as we’ve discussed, and I’m sure mostly agree upon) how do you think we could make children less devastating to women’s careers? Were you born to a mother over 35 or under 24? Have you considered when in your life to have children, should you choose to do so, and what qualifiers are most important to you in determining the “right” time?

Anderson, A. N., Wohlfahrt, J., Christens, P., Olsen, J., & Melbye, M. (2000). Maternal age and fetal loss: population based register linkage study. The British Medical Journal, 320. 1708.

Fraser, A. M., Brockert, J. E., & Ward, R. H. (1995). Association of young maternal age with adverse reproductive outcomes, 332. 1113-8.

Geronimus, A. T. (1996). Black/white differences in the relationship of maternal age to birthweight: A population-based test of the weathering hypothesis. Social Science & Medicine, 42(4). 589-97.

Heffner, L. J. (2004). Advanced maternal age – how old is too old? New England Journal of Medicine, 351(19). 1927-9.

Fresh Eggs or Frozen: Beyond the Grocery Aisle

While discussing pregnancy and birth, it only seems right to discuss infertility and our new technological ways of circumventing it. As science advances, so has birth, and infertility is no longer considered an untreatable problem. In vitro fertilization (IVF), the process of placing fertilized eggs within a woman’s uterus for implantation, and intrauterine insemination (IUI), inserting washed sperm into the uterus, better known as artificial insemination, are allowing women that previously could not bear children to do so. However, they are far from perfect.
The biggest barrier in IVT use is cost, ranging from $8,000 to $15,000, often not covered by insurance. Though it does not solve many of the problems IVT does, the average artificial insemination treatment is much less expensive at an average of $895, but still wildly more expensive than the typical manner of getting pregnant, and beyond what many couples are able to easilyafford. The constraint of price becomes even clearer with the caveat of success; these are prices per treatment, with no guaranteed success.  With fertility treatments, IVF succeeds 45% of the time with mothers under 35 and IUI succeeds in a viable pregnancy 8-17% (also variable with maternal age.) The few insurances that do offer these procedures only pay for one treatment, so a positive outcome is a coin toss at best, for those that can afford it.
There are problems with the method itself as well. Anecdotally, having worked in the Emory Midtown NICU, the nurses told me every baby to stay there over 20 days was IVF, or at least most were, and scientifically, there is data to back this up; the freezing process used on IVF embryos results in hypomethylation, meaning genetically, there are fewer markers turning genes off, and leaving excessive genes active can lead to numerous problems, from autism to schizophrenia to higher cancer rates. Very few longitudinal studies have been conducted to discover how frequently or severely this presents, but any significant change in the DNA as such is worth noting.
Additionally, from fertility treatments come multiple fertilizations, and though the mother can choose to opt for having a one-child pregnancy, or keeping three or more, in the majority of cases mother’s choose to keep two. Twins, most often, are born pre-term, already more likely to have an extended stay in the NICU due to incomplete lung development, and suffer more frequent childhood illnesses and growth deficits. With mothers already in advanced maternal age, as is often the case, this pregnancy is especially difficult and is more commonly lost, in which case, the effort has all been for naught.
Clearly, we have a long way to go in these pregnancy methods, but despite this panoply of difficulties, since its 1978 conception there are now five million IVF babies (many adults) in the world today, a testament to its success. How would you improve access to these treatments, and/or delivery of them? If you or your partner were infertile, would you choose to use one of these methods? How can we better advocate for all mothers struggling to get pregnant?
Bolnick, J. M., Bolnick, A. D., Estill, M. S., & Diamond, M. P. (2014). Epigenetics: are babies healthier conceived through IUI compared with fresh or frozen IVF cycles? Fertility and Sterility, 102(3). 85.
Eden, A., Gaudet, F., Waghmare, A., & Jaenisch, R. (2003). Chromosomal instability and tumors promoted by DNA hypomethylation. Science, 300. 455.
Evans, J., Hannan, N. J., Edgell, T. A., Vollenhoven, B. J., Lutjen, P. J., Osianlis, T., Salamonsen, L. A., & Rombauts, L. J. F. (2014). Fresh versus frozen embryo transfer: backing clinical decisions with scientific and clinical evidence. Human Reproduction Update, 20(6). 808-21.

Talk With Me Baby

Talk With Me Baby is a program that aims to transform parents and caregivers into conversational partners, providing early language exposure to babies in order to nourish critical brain development required for higher learning. It integrates language nutrition coaching as a core competency across large-scale workforces of nurses, WIC nutritionists, and early education professionals, thus systematically training nurses to educate parents about the importance of early language exposure.  The program is a collaborative effort between the Georgia Department of Public Health and Department of Education, Emory University’s School of Nursing and Department of Pediatrics, the Marcus Autism Center at Children’s Healthcare of Atlanta, the Atlanta Speech School’s Rollins Center for Language and Literacy, and Get Georgia Reading – Georgia’s Campaign for Grade Level Reading.

Research has shown that the first year of a baby’s life, when the brain is developing and maturing, is the most intensive period for acquiring speech and language skills. Those skills are easiest to develop when a baby is consistently exposed to language from even their first hours of life. The regular practice of talking to a baby lays a solid foundation for the child’s future educational achievements. It has been suggested that babies that are born into low-income families are exposed to fewer words than their peers. By the age of 3, these children hear 30 million fewer words than a child that comes from a professional family. Talk With Me Baby aims to solve this problem.



Pictorial Teachings

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:

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 theBreast feeding pamphlet

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.

In the last study that I was going to present on, they studied the use of pictorials to teach the birth attendants. The study was held in Nigeria to train community birth attendants. Majority of the women were illiterate and so they used pictorial cards to teach them the information. Again, an increase in health knowledge was seen and the trained birth attendants used the pictorials over and over while helping other mothers. I found this study particularly interesting since the study noted how the pictorials created a baseline of information across all birth attendants. Similar to having a textbook at hand for reference. This lowered the variability of information from one birth attendant to another so that all mothers can get about the same care.
Through these studies, it shows how effective pictorials can be to enhance health understanding. In a global context, pictorials can reduce the language barrier between those who are training the birth attendants. It also allows for an increase in health knowledge for mothers as well. They become more aware of what is happening to them and can recognize the signs and symptoms of common ailments during pregnancy. In the US, more pictorials should be utilized so that more information can get across those who are illiterate as well as non-English speakers. I hope everyone enjoyed this presentation, despite it being rushed. I also included my presentation into this post, if anyone is interested. I hope everyone has a great break!.



Pictorial Teachings



Allen J. and Hector D. “Benefits of breastfeeding.” NSW Public Health Bulletin, 16.3 (2005): 42-26. Web. 3 December 2014.     

Holtby, Mike. Ethnic Groups. 2013. Myanmar 2013. Web. 3 December 2014.

Houts, P., Doak C., Doak  L., and Loscalzo M. “The Role of Pictures in Improving Health Communication: A Review of Research on Attention, Comprehension, Recall, and Adherence.” Patient Education and Counseling, 61.2 (2006): 173-90. Web. 4 December 2014.

Kutner M., Greenberg E., Jin Y., and Paulsen C. “The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).” U.S. Department of Education. Washington, DC: National Center for Education Statistics. (2006). Web. 4 December 2014.

Matthews M., Walley R., Ward A., Akpaidem M., Williams P, and Umoh A. “Training traditional birth attendants in Nigeria-the pictorial method.” World Health Forum, 16.1 (1995): 409-414. Web. 4 December 2014.

Rahman A. and Anwar I. “Behavior Change Communications during Antenatal Visits Using Pictorial Cards Improves Institutional Delivery Rates: Evidence from Mathlab, Bangladesh.” International Journal of Tropical Disease & Health, 3.3 (2013): 242-256. Web. 4 December 2014.

Soe, Htoo H. and Somrongthong, R. “The effect of community based safe motherhood pictorial handbook health education intervention in Pa-Oh ethnic group, Myanmar.” Journal of Medicine and Medical Sciences, 2.10 (2011): 1171-1179. Web. 4 December 2014.

The Baby Friendly Initiative for all babies. UNICEF UK. Web. 3 December 2014.

SPRING (Strengthening Partnerships, Results, and Innovations in Nutrition Globally). USAID. Web. 3 December 2014.




Community mobilization for improved maternal and newborn health

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After taking this class and traveling to Guatemala to work with community health workers, I realize how important and influential community mobilization is toward a necessary change.  I found a really great guide published by USAID that details how communities can be mobilized specifically toward improved maternal and newborn health.  It details the problems that mothers and unborn children face at birth, all of which we’ve outlined throughout the semester (i.e.-the three delays).  It talks about common complications, potential illnesses, and their appropriate interventions.  Yet it also highlights the importance of including the community as drivers for change and the ways in which this can be accomplished.  The document explains this necessity:

“Any approach to improve essential maternal and newborn care services must address the issues of the community and the health system together, systematically, and in close collaboration among all stakeholders if it is to be successful.”

It includes the use of the “Community Action Cycle” as pictured above.  This involves different phases such as organization of community stake-holders, planning outcomes and interventions, and preparing to mobilize.  However, the cycle doesn’t start or end at a designated point because all communities operate differently.  The important part of community mobilization is identifying appropriate stakeholders (mothers, health workers, community leaders, government leaders, etc) and having them establish strategies for issues that the entire community is affected by.  Finally, in order for change to be sustainable, mobilization has to continue and consistently be reinforced within the community.  I think this is a great tool to use for individuals or groups who are considering using this method whether it be for infant and maternal health or for any other public health issue.

USAID & ACCESS.  (2009).  How to Mobilize Communities for Improved Maternal and Newborn Health. Retrieved from


And a Baby Makes Three; Gay Parenting and a Gender-Neutral Society

(Not even going to lie; I was really, really excited to see a presentation in our class about lesbian mothers. This is my little add-on.)

The Atlantic published and article recently stating, according to the data of nations that have had gay marriage a few more years than us, they are longer lived than straight marriages, as far as we can tell. The author attributed this to going into the relationship without assumptions about roles and responsibilities, but hashing everything out and fostering communication; there are no boxes to force this couple to fit into, while the dead goose of 50’s stereotypes hangs over straight couples from the moment they walk down the aisle (Mundy, 2013). Though two lesbians may both be effeminate, that doesn’t determine the way their home life is run, but men, some of the most unacknowledged victims of gender stereotyping, still feel inherent shame if, say, their wife makes more money than them and they are not “the provider”. The Atlantic suggests those roles be redefined, considering the harm, and this follows the trend of society today.

Gender-neutral is coming in vogue as we lose stereotypes right and left; at Emory, we have a women’s rugby team, and this week on TV began the seventh season of RuPaul’s Drag Race. College campuses are instituting gender neutral housing, and 2013 was dubbed the Year of Gender Neutral Names, such as Riley, Peyton, or Rowan. Facebook has more than 50 new gender categories (Jayson, 2014). This can in no way be neatly separated from an acceptance of gay culture and integration into the fold of new value sets, but then again, that begets a chicken and egg argument. So this begs the question, how does this affect parenting?

Well, from extensive survey work, it’s been shown that the only difference between gay parents and heterosexuals is that gay parents are more likely to adopt ‘less conventional parenting standards,’ into which ‘gender-neutral’ fits neatly. In this practice, “walk it off”, “be a man”, and “boys will be boys” are no longer acceptable ways to approach raising a son, and “bossy” is no longer a word to put down girls with, but even less radical parents are coming over to this mindset. In fact, the trans community urges parents to consider that though parents may believe they are raising a son or a daughter, they may be wrong about which they think their child is, as biological sex deviates from gender.

Research tells us raising children in a gender-neutral way, listening to their desires as opposed to what you might expect them to be, results in children that exhibit less anxiety, aggression, and depression. Considering the resentment fostered by role strain in traditional relationships and the pressure society puts on heterosexuals to fit those boxes, it makes you wonder if adult life is suffering those consequences, too.

How has gender affected your life and relationships? How do you think it impacts health settings, family life, or the raising of a child? How would you raise a boy differently from a girl, if you would? What good things do you think are lost if we let go of heteronormativity and what is gained?

Jayson, S. (2/7/2014). Gender loses its impact with the young. USA Today

Martin, K. A. (2005). William wants a doll. Can he have one? Feminists, child care advisors, and gender-neutral child rearing. Gender & Society, 19(4). 456-79.

Mundy, L. (22/5/2013). The gay guide to wedded bliss: Research finds that same-sex unions are happier than heterosexual marriages. What can gay and lesbian couples teach straight ones about living in harmony? The Atlantic.

Japan, America, and The Right To Be Fat

After the presentation given on Japan and the quarantine period after birth and the very strict traditions regarding feeding and bathing, I was inspired to look further into Japanese health practices and found many other things were strict and different.

Firstly, due to the impetus of a significant other toward settling and having babies, rather than fewer women marrying, as you see in the U. S., there are much fewer young people in Japan dating or having sex (Haworth, 2013). The combination of conservative culture, preventing casual relationships, and marriage being, as they put it, the “death” of a woman’s career there, the population is gradually decreasing to the point that it concerns the government, and they are providing incentives. Personally, if I knew my mom would want to shut me indoors and tell me not to shower if I had a baby, I would be deterred too.

But speaking of incentives, it seems the Japanese government has no qualms about being involved in the health of its citizens and their life choices rather personally. 2008 heralded the institution of The Metabo Law to fight metabolic syndrome by regulating waistlines, with mandatory checks and counseling, treatment, therapy, and later monitoring for men with waistlines more than 33.5 inches and women more than 35.4 inches.

My first response to this was concern; it seems a bit totalitarian and unaccepting of various body types. However, recognizing the relative homogeneity of Japan in racial and ethnic backgrounds and thereby, likely, fewer deviations from the typical body structure, it made more sense than it would here. And additionally, isn’t our First Lady always telling us the American weight is out of control? As a healthcare provider, I have come to see this first hand. The estimated annual health care costs of obesity-related illness are a staggering $190.2 billion or nearly 21% of annual medical spending in the United States (Cawley & Meyerhoefer, 2012), so it makes sense for the government to be invested. With regard to birth, the complications of obesity in a pregnant woman present as subfertility, miscarriage, thrombo-embolism, hypertensive disorders, metabolic syndrome, preterm delivery and higher frequency of cesarean section, and complications for the baby include intrauterine death, congenital anomalies and macrosomia (Sirimi & Goulis, 2010). (For the non-nursing students, those are all very bad.)

Somehow, as an American, I just take for granted that it’s a right to be fat, just as it is a right to smoke, even if it is unhealthy and unwise. We talk a great deal in our culture about not fat-shaming and loving and accepting all bodies, though on top of the hypertension, diabetes, and other bone and organ problems caused by obesity, obese people are the most depressed and misdiagnosed in the country, so it’s not just moderately unwise but can actually be an immediate risk. How much excess weight goes past choice and aesthetic to health? People, especially fit people, debate the validity of BMIs. But by having a measured cut-off, it prevents rather than treats, and we know it is easier to not gain weight than to shed it; could this theoretically stop people before their weight is dangerous? Regardless, however successful this measure proved to be in Japan (and it was very successful), due to the different relationship with the government here, I think, however wise, it would clash culturally with Americans.

What are your thoughts? Is it moral, to save people from themselves, or immoral to take away choice? Is their government over-reaching? Is ours not fighting obesity hard enough? Let me know. (And good luck with finals.)

Cawley, J., & Meyerhoefer, C. (2012). The medical care costs of obesity: an instrumental variables approach. Journal of Health Economics, 31(1). 219-30.

Haworth, A. (20/10/2013). Why have young people in Japan stopped having sex? The Guardian.

Jayarajan, N. (25/5/2011). The Fat’s on Fire: Curbing Obesity in Japan. The Boston University School of Public Health, The Movement.

Sirimi, N., & Goulis, D. (2010). Obesity in pregnancy. Hormones, 9(4). 299-306.

Nurses in policy

The presentation by the nursing students about the importance of nurses with higher education and nurses in policy was incredibly interesting. If anybody knows about what goes on in hospitals and health care settings, and how patients are faring with the current health care system, it is nurses.

I read a couple of articles online, and found that there are 6 nurses in congress! I’m a little unfamiliar with politics (unfortunately), so I didn’t know this and thought it was really cool.

One Congresswoman nurse who has done influential work is Congresswoman Lois Capps.  (D-CA). On her website, she says “once a nurse, always a nurse”, and discusses how she is always using her nursing background when dealing with health care issues and policy. She is a supporter of the Affordable Care Act, and believes it is a crucial step in fixing the broken health care system in the United States. Some of her main priorities related to healthcare include heart disease, maternal, child and infant health (!!), cancer, and work-force issues. She a founding member of the Congressional Nursing Caucus, which provides a forum for congress to discuss issues affecting the nursing community. In addition, she is a strong ally of the LGBT community.

She is currently sponsoring legislation concerned with domestic violence survivors, health education in schools, and medicare, among tons of other issues. Check out her website to learn more!

Lois Capps:

Congressional Nursing Caucus:

Costs Associated With Domestic Violence

This is another “fill in the gap” post! I didn’t go into costs for domestic violence a lot in my presentation due to time, but domestic violence is very costly. The costs of domestic violence in 1995 exceeded $5.8 billion, which breaks down into $4.1 billion in direct medical and mental health care costs and nearly $1.8 billion in indirect costs of lost productivity. In 2003, the costs exceeded $8.1 billion, a sum which consisted of $460 million for rape, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in the value of lost lives. However, all of these numbers can be considered underestimates because the costs of the criminal justice system are not factored in. On the same token, a study that surveyed 3,333 randomly selected women aged 18 to 64 found that the total adjusted health care costs for women who disclosed physical abuse were 42% higher than for women who had never experienced abuse. Furthermore, women who had disclosed non-physical types of abuse had total annual healthcare costs that were 33% higher than woman who had not experienced any type of abuse. So, yes. Domestic violence is very costly, whether you’re treating visible symptoms of abuse or non-visible symptoms of abuse. This alone should spark more collective effort for screening and treatment, but I suppose it’s just such a sensitive issue that people are still hesitant regardless of the facts.

Centers For Disease Control and Prevention. (2014). Intimate partner violence. Retrieved from

De Boinville, M. (2013). Screening for domestic violence in healthcare settings. Retrieved from

Domestic Violence & Child Maltreatment

I left a lot out of my powerpoint in the interest of time (although we still had a lengthy discussion afterwards lol), so I didn’t mention child maltreatment very much. But someone inquired about the relationship between domestic violence and child maltreatment. These two issues, unfortunately, overlap very strongly. Children who are exposed to domestic violence, even a little bit, are at a very high risk of exhibiting negative emotional and psychological behaviors. There is also evidence to suggest that abused children grow up to become abusers themselves, which compounds the problem. But specific to child maltreatment, mothers who are abused suffer numerous consequences that will affect the mother/child relationship. Mothers may become depressed, anti-social, have attachment problems, etc. This makes them unable to adequately care for their children. In addition, abusers who abuse their partners/spouses are also more than likely abusing the children. This results in a very ugly and dangerous family situation. To me, domestic violence is very much it’s own detrimental cycle. The abuse itself, in addition to the consequences of abuse, are also risk factors for abuse once again. It’s like it never ends, but it can with serious attention and effort.

Centers For Disease Control and Prevention. (2014). Intimate partner violence. Retrieved from

Lien, H. (2003). Child protection in families experiencing domestic violence. Retrieved from