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

Brenna’s presentation on HIV make me think of this article I read a while back about why women don’t take HIV medication, even when it is provided to them for free. The article talks about a study in South Africa where 5,000 women were given either HIV gel or a pill to prevent the transmission of HIV during intercourse. However, the study was interrupted when it was discovered that women were not taking the medication even though they claimed to take it every day. The article states, “more than 90 percent of the women claimed to be complying. But blood samples told a different story: Just 24 percent were using the gel, and only 30 percent were taking the pills.” The article then progresses to talk about the reasons why the women chose not to take the medication. I wanted to see what you all think about the article and if you all think that the reasons the women report not using the medication would be the same in different cultures?

http://www.npr.org/blogs/goatsandsoda/2014/11/13/363595295/yes-doctor-i-took-my-anti-hiv-meds-but-really-i-didnt

When I read the new proposed guidelines the CDC posted on circumcision, I knew that I wanted to blog about it for Birth and Global Health. Men are largely ignored when it comes to reproductive health; however, they are 50-percent of the equation. Being a self-described hippie, I have always said that if I had male children that I would not circumcise them as it was unnecessary. However, the CDC says that there is strong evidence that male circumcision can:

1. Cut a man’s risk of getting HIV from an infected female partner by 50 to 60 percent.
2. Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more.
3. Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

All of this evidence sounds extremely promising, but I am interested in how many men will opt to get a circumcision now that they are older adults, especially since the CDC has recommended that doctors counsel parents of baby boys and teenagers, as well as men, on the benefits and risks of circumcision.

References

http://abcnews.go.com/Health/wireStory/cdc-circumcision-benefits-outweigh-risks-27301210?page=2

http://www.npr.org/blogs/health/2014/12/03/368008742/cdc-considers-counseling-males-of-all-ages-on-circumcision

One of the most saddening topics we discussed in class was obstetric violence. The Han article we read was about intimate partner violence during pregnancy (IVP-P) in Latin America. While re-reading it in preparation for the exam last week, I thought about how fixing IPV-P seems almost like a lost cause. I wondered how screening for it could even be helpful, when many of the women included in the study were from low-income, underprivileged areas and probably did not have access to adequate counseling or protective services, and lacked the resources to leave their partner. In the paper, Han cited an “intervention study”, specific to LAC. I decided to read it to see if it included anything to be optimistic about.

The article is called “Intimate Partner Violence During Pregnancy: A Pilot Intervention Program in Lima, Peru”, by Cripe et al. In their study, they looked at the effectiveness of standard care and empowerment care for pregnant women who were abused. Standard care included receiving a card listing resources and other information to assist them in help seeking, and empowerment care included both a card and a therapy session (those in the standard care group received a therapy session after the post-interview). The researchers looked for differences in safety behaviors, health-related quality of life, and use of community resources by these women by comparing pre and post interviews (before and after birth). They conducted the study at the Instituto Nacional Materno Perinatal in Lima, Peru, which is operated by the Peruvian government and provides services to low-income and high risk women.

Ultimately, their results were not statistically significant, but they found a general trend showing an increase of safety behaviors, health-related quality of life ratings, and use of community resources in women in the empowerment group. While there were a couple of limitations and obstacles in the study, the overarching point is valuable; simply screening for IVP-P is important and should be a regular procedure in prenatal appointments. Even if the consulting physician, researcher, or other health personnel can’t force a woman to seek help or leave her partner immediately, planting the seed in her mind is important and may encourage her to begin thinking about her situation and what she can do to increase her safety and well-being. The authors stress that IPV is a huge problem in Peru, and abolishing it all together is a daunting task. However, it is important that steps be taken to fix this problem. In addition to evaluating existing legal policies and resources for abused women, small interventions in other spheres (in this case, the medical sphere) can help as well. To quote the authors:

“Based on our experiences working with abused women in Lima, Peru, we expect that a combination of intervention methods that include screening, counseling, and advocacy by both health care professionals and community outreach workers may empower abused women to seek help and, subsequently, reduce IPV in Peru.”

I read this hoping to see results for one intervention that worked for everyone and could be realistically employed. I knew that was an unrealistic hope, but I felt these studies mustn’t be useful unless they saw substantial results. I was wrong though – these things must start small.  The benefit of simply asking a woman about her situation, looking for suspicious markers that may indicate IPV, an delving deeper into her personal life and hardships she might be going through can really make a difference.

Citation: Cripe, Swee May, et al. “Intimate Partner Violence During Pregnancy: A Pilot Intervention Program in Lima, Peru. Journal of Interpersonal Violence, 2010 25: 2054. February 9 2010.

The idea of attempting to change potential harmful maternal social norms in developing countries has come up multiple times in class discussion. How effective and, in a way, how ethical is it to try and change a social norm or local custom that may lead to poorer maternal health outcomes?

An article I have read recently discussed the role of educational campaigns with a focus on human rights and empowerment on changing potentially harmful social norms. One such custom that was mentioned was from Senegal, where women believed that working harder than normal during pregnancy would lead to a brighter future for their child. As has been mentioned in class, overworking mothers during their pregnancy can have detrimental health outcomes for themselves and their unborn child. Changing this norm appeared to be imperative to bettering maternal health outcomes in the community.

But westerners can’t just go in and tell pregnant mothers that their customs are wrong and hope that they will change their ways. Mothers should be provided with better information through educational campaigns so they can make the best decision for themselves. In this way, mothers may feel more empowered and wouldn’t feel as if foreigners are telling them how to live their life.

Source: http://www.huffingtonpost.com/molly-melching/jnj-tostan-maternal-health-social-norms_b_3390216.html

I have recently read an article discussing the importance of patient confidentiality in the context of HIV status for South African women receiving antenatal care.

It is clear that women receiving antenatal care should inform a doctor of their HIV status in order to receive proper information and learn about preventative measures to ensure that their child does not become infected with HIV. However, this conversation between doctor and patient should be held entirely in confidence. If a woman’s HIV status is disclosed to the community, she may faced a large amount of stigma against her and her family. Especially in a located like South Africa where the adult HIV prevalence rate is 19.1% (http://www.unaids.org/en /regionscountries/countries/southafrica), releasing that type of information could have detrimental social repercussions for the patient. It is gravely important that doctor patient confidentiality agreements are upheld especially with disease like HIV, which has a lot of stigma surrounding it.

Source: http://www.theguardian.com/global-development/2014/oct/09/hiv-stigma-maternal-deaths-south-africa-amnesty

During one of the class presentations, I remember our class getting into an important discussion about breastfeeding and the factors that can influence a woman’s decision to breastfeed a child or not.  After coming across an article on the same topic, “Inviting African-American Mothers to Sell Their Breast Milk, and Profiting,” I had a few thoughts regarding this program to increase breastfeeding amongst African American women in Detroit, and I was curious to see if any of our classmates had any other thoughts to contribute.

While this program has a noble-sounding cause of increasing breastfeeding amongst a group with historically low rates of breastfeeding, the author makes the argument that this program is ethically questionable in how it is profiting from the program.  Medolac, the Oregon-based company working with the Clinton Global Initiative, claims to “seek to increase breast-feeding rates among urban African-American women” and promote “healthy behavior and prolonged breast-feeding within their communities” by starting a local campaign to grow members of the Mothers Milk Cooperative, the only milk bank owned and operated by nursing mothers.  The milk bank pays approved members (screened and blood tested) $1 an ounce for their milk.  The cooperative has an agreement with Medolac, which processes the milk into a commercially sterile, shelf-stable product and sells it to hospitals for about $7 an ounce (a 600% markup).

At 40%, Detroit has one of the lowest breast-feeding rates for black women in the country.  Medolac’s goals of more breast-feeding and economic empowerment sound promising, but the author argues that the economic and racial elements of the Medolac plan “make it look more like a modern-day breast milk marketing scheme than a public benefit.”  While Medolac officials argue that paying women for their breast milk will increase the likelihood that they will breast-feed their own babies, there is no research behind this claim.  Additionally, the author argues that selling breast milk will likely take the priority over breastfeeding children for these women: “Rare is the mother who will produce enough excess milk, at $1 an ounce to affect her family’s economic situation significantly…the average mother produces 200 ounces of oversupply every two months.”

When thinking about the types of Safe Motherhood interventions we have studied this semester, many have had unintended negative consequences.  With the involvement of a for-profit company, the likelihood of maternal health being the primary motivation seems significantly smaller.  I’m curious to hear what other students think – is this program taking advantage of women in vulnerable financial situations or will this incentivize women who might not otherwise breastfeed to do so?  What would be a better way to incentivize breastfeeding in communities that may not have a strong history of breastfeeding?

I came across an article in The New York Times yesterday about Britain’s national health service encouraging women with low-risk pregnancies to have their birth experiences at home-that it was actually safer to do so than in a hospital or birthing center!  This echoes our discussion earlier this semester about the politics around birth location and the small, but active movement of home births in nations that are so accustomed to traditional hospital births.  This article claims that “giving birth in a traditional maternity ward increase(s) the chances of surgical intervention and therefore infection.”  Although we have already discussed the benefits and risks of having a home birth, the article is notable because it is comes from a national source and not a minority voice.  This could have tremendous impact on the way women in Britain think about their deliveries, where normally 9/10 women give births in hospitals.  Still, there are opponents to the recommendations, citing a trend that could be misinterpreted by women who are not low-risk.

What are your thoughts about this?  Do you think it’s ethical of an announcement as influential as the national health service (albeit of Britain, not the U.S.) to be broadcasted?  How do we establish a balance between preventing unnecessary hospital interventions and having as safe a birth as possible at home?

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.