First World Business over Breast

This disturbing article from the New York Times has appeared in my inbox and Facebook page at least 20 times this week. It details the power of large corporations, ie formula manufacturers, to influence not only our government but also international policy in order to increase their bottom line. Simply put, US government officials present at the United Nations-affiliated World Health Assembly this spring tried to pressure developing world countries to place less emphasis on breast-feeding and allow the promotion of alternative feeding methods, namely formula. This is at a time when US hospitals are competing for patients by hiring lactation consultants, providing free breast-feeding classes and training all of the maternity staff in best practices for nursing. We will not allow a formula manufacturer to advertise in American hospitals or clinics, but we are ok with the promotion of formula products in the developing world. Two empiric situations should make clear why this policy will increase childhood mortality.breastfeeding-mother

  1. An American woman is planning to nurse her child but her husband has misgivings about this as he is concerned that he will not be allowed to feed the newborn. Following an uncomplicated delivery, the newborn had difficulty latching to her breast but was finally successful due to the assistance of an experienced lactation nurse and the benefit of a breast pump and breast shields. She was able to exclusively nurse for the first few months of her child’s life and her husband managed diaper changes and the occasional bottle containing breast milk, allowing him to feel more involved in his child’s care. When she returned to work three months after delivery, her insurance provided her with a breast pump and her employer allowed her to take additional 20 minute breaks twice a day to pump breast milk and store the milk bottles in a small refrigerator. The mother introduced solid food when her child was 6 months but continued to supply her child with breast milk until a year of age. 12. A Haitian women delivers one month prematurely due to pre-eclampsia, a common condition in Haiti. Her infant is smaller than average and unable to nurse for more than a few minutes at a time. The woman’s grandmother is helping to care for her in the hospital and believes that the early milk, colostrum, is bad for baby and tries to finger feed the child water. Because the child is not nursing well, the mother does not produce enough milk. After one week, the infant is lethargic and dehydrated. A local mission group shows up distributing medications and has some extra formula that was donated. The grandmother hears about this while she is getting her free blood pressure medications and takes the formula home for the infant. Within days the baby is much more responsive and greedily sucking on the bottle that was donated with the formula. However, the mother’s milk has now completely dried up so the grandmother returns to the site of the medical mission clinic to get more formula. The medical team is gone but has left a message that they will return in 3 months. The grandmother is able to purchase a small amount of formula in town. In order to make it last longer, the mother mixes it half strength with the drinking water they get from the river. Soon the infant develops diarrhea and becomes lethargic again and won’t take even the diluted formula. The family doesn’t seek medical care again as it is too expensive and their extra money was spent on formula. The infant dies a few days later. Since the mother only breast feed for the first few weeks of her infant’s life, ovulation returns within a few months and she becomes pregnant when her child would have been six months of age. Her mind and body have not recovered from her first pregnancy and due to poor nutrition she again delivers a premature infant. The story is likely to repeat.

Breast feeding provides maternal advantages as well as being the perfect, age adjusted food for children. Mothers who breast-feed reduce their long-term risk of breast cancer, uterine and ovarian cancer. Exclusive breast-feeding is a means of contraception for the first six to twelve months after childbirth, allowing for better spacing of pregnancies when more effective means of birth control are not available. When women in the developing world don’t have access to a safe drinking water supply, it provides their young children with immunity to diarrhea causing illnesses, the #1 cause of death for these children after childbirth.

Formula has its place in infant care but business interests of large US corporations should not take higher precedence over the lives of children. This article in the Atlantic gives a history, both past and present, as to the lengths these companies have gone to promote their products. Email, tweet or phone these companies ( Nestle and Similac) and let them know how you feel about their policies.

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Families are changing… and so should their Physicians

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As an ob/gyn in practice for 27 years, I have been present for the creation of thousands of families. In the beginning of my career, the vast majority of those families involved a mom, dad and their biological children. However, over the years family structure has been changing and I have had to change my understanding of family in order to support my patients both during pregnancy and after childbirth. This change became very evident over the past few months as I had the privilege to be present at the beginning of some unique families.

Many of our patients are first generation immigrants with their extended family living abroad. I have had to understand the visa process so that I am able to complete paperwork allowing grandparents to share in the joy of a new grandchild.  Frequently, these grandparents extend their stay for the first year of a child’s life while the mother returns to her job. The stress of living and working in a foreign country can often be exacerbated by the lack of extended family for support.

A patient that we had cared for during her last two pregnancies chose to become a surrogate for a gay couple that resided outside of the US. Each of the men donated sperm that was used to fertilize a donors eggs (not our patient) and the fertilized embryos placed within her uterus to grow into a boy and girl. Seeing the smiles and tears on the fathers faces as they were each handed a baby was a reminder that love is found in many places. Their ongoing concern for the woman who had carried their babies, allowing her to hold and visit the babies during the next months as the paperwork was completed to allow them to take their children home, was a testament to humanity. My patients post-partum visit involved a conversation about loss as well as gratitude for her help in creating a new family.

Pregnancy is not always a risk-free venture. Two years ago one of our patients had an uncomplicated pregnancy followed by a severe post-partum hemorrhage that resulted in a hysterectomy in order to save her life. She and her husband wanted a second child to complete their family and were matched with a local woman to carry their biologic child. The surrogate also happened to be our patient and antepartum visits are scheduled so that both of the women can be there. It was a full house at the time of the 20 week ultrasound appointment when both husbands were also present. The plan is for the surrogate, her husband and their children to remain as extended family after the child is born.

At the time of her annual exam last year, one of my long-term patients that I had seen during the birth of her child 5 years earlier and a subsequent divorce, lamented the fact that her son would not have a sibling and her vision of a family with two children was quickly fading as she approached the age of 40. We discussed other ways to create the family that she wanted and one year later she delivered a healthy daughter that was created with artificial insemination using donor sperm. Along the way she had extended her “village” of support to include men who would provide nurturing to both of her children.

A same-sex female couple also chose artificial insemination with donor sperm but found the selection process for the donor more difficult as the couple wanted the donor to reflect their mixed race relationship. Their beautiful olive-skinned child will be born at the end of the summer.

I always enjoy visiting with my patients at their annual exams, especially when I have a special bond having delivered their children many years earlier. A bittersweet moment happened a few weeks ago as a patient in her late 50’s broke down in tears describing the mental health issues of her son that I had delivered early in my career. Those tears ended in smiles as she showed me pictures of his 3-year-old son that she and her husband are adopting and will raise with the help of their son. Instead of retirement plans, she is making plans for kindergarten.
The unique structure of my own family enables me to understand that the social structure of our patient’s families affect their physical and mental health. After giving birth to three sons, my husband and I adopted two daughters from Korea and China. When a friend experienced premature ovarian failure, I offered to donate eggs so that she and her husband could create a family. Raising children of color in a predominately white society requires discussions about racism and intentional relationships with other cultures. We have developed a “cousin” relationship with my egg donor children that has both challenges and rewards. All of these struggles have enriched our family, but not without the need for some difficult conversations. Part of our job as a physician is to recognize these same familial relationships with our patients so that we can better understand their health care needs.

What Ireland understands that Iowa has forgotten

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Maternal death was a reality for Savita Halappanavar, a 31-year-old Indian dentist living in Ireland who was refused a termination of pregnancy in 2012 when she started to miscarry her 17 week fetus who still had a heartbeat. She died 4 days later from sepsis. Her death ignited the growing social movement in Ireland that resulted in an overwhelming vote this week to legalize abortion. Those Irish working abroad took the time to return home so that they could vote, having worked and lived in more socially liberal European countries and being witness to the advantages of legalized abortion.

Compare this vote to what is currently happening in Iowa. A recent “heartbeat law” will make abortion illegal once a heartbeat can be seen on ultrasound, approximately 6 weeks of pregnancy. That same Irish woman would not have fared better in Iowa.

Abortion has been legal in the US since 1973. We have been spared details of botched illegal abortions, infection due to an incomplete miscarriage or lack of choice with an unplanned pregnancy. If the rest of the US joins Iowa in enacting strict abortion laws and making it impossible for Planned Parenthood to operate throughout the country, stories like this will start to be seen and heard. Because when abortion is outlawed, it will not go away … it will simply go underground and become more dangerous.

Irish women understand this as they have been traveling to England for years to obtain the abortions they can’t receive in their home country. That option is only available for those with the monetary resources to afford a plane ticket and time off work. The US is already a country where your choices as a woman are determined by the state in which you live. Are we willing to make this even more polarizing?

Ireland is separating its government policies from the dictates of the Catholic church. They passed a same-sex marriage law only a few years ago and currently have a prime minister who is openly gay and the son of an Indian immigrant.  We in America seem to be letting conservative Christian policy dictate our government with more restrictive laws on immigration, LGBTQ rights and abortion. Ireland is able to look back on their history of more restrictive human rights and is witness to the stories that have resulted. History is the greatest teacher – are we willing to pay attention and learn?

Mothers Day Immigrant Style

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 I have written a previous blog about two mothers in Korea and China who I will never know but yet I honor each year on Mother’s Day.  This blog  post is about those moms from throughout the world who moved to America and have raised their children in a world where their family looks different, may dress differently and are caught between two very different cultures. While most of us will celebrate our mothers this weekend for providing us with guidance, car rides, food and love, immigrant mothers in this country have done even more to make sure that their children have a better life than they did. They have left their country of birth, their extended families and all that they have known, to move to America and start over so that their children would have more opportunities. I recently had the wonderful opportunity to sit down with four of these women and asked them to share their stories.

Mona was 15 when she moved to the US with her parents and three siblings from Somalia. Both of her parents learned English and held more liberal views, but still believed that girls needed to be more submissive in their behavior than boys. Mona often needed to stand up to her parents in order to gain much of the same independence that was granted to her older brother and friends. Because of the ongoing conflict in Somalia, her mother has not had an opportunity to return to her home to reconnect with her siblings and parents. If she had remained in Somalia, childcare would have been shared between relatives as well as cooking and socializing. Raising her family in America left her much more isolated and without a support system when her independent daughter brought home a Caucasian boyfriend who she would later marry.

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Hieu entered the US from Vietnam at age one, accompanied by her parents and two older brothers. Their family was sponsored by a church in Hinckley. Unlike Mona, who grew up in a diverse metro high school, Hieu and her family were the only Asians in a rural community. Although Hieu never thought of herself as different from her classmates, she remembers her mother struggling to assimilate as she had a difficult time learning the language and mourned the lack of a community of women and the comfort foods of Vietnam.  A monthly trip was made to Minneapolis to purchase some of the ingredients for homemade Vietnamese food. This move to America had been Hieu’s dads plan and her mother went along with the idea as she believed her children would have greater opportunities in America rather than in Vietnam, which was just starting to rebuild after the war.  Although she has had a few opportunities to return to Vietnam, the memories and lost connection with family makes the trip emotionally difficult.

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Jackie came to the US from Kenya at age 19 on an academic scholarship to attend college. Her parents had saved and worked 2 and 3 jobs in order to put her and her 8 siblings through boarding schools and college. As each child graduated from college and got a job, they were expected to give their paycheck back to their parents in order to help the next child in their education. The expectation was even higher for Jackie as she had the opportunity for a well-paying job in America and could send larger funds back to Africa to provide for education for nieces and nephews.

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Jackie’s mom

Gladys won the green card lottery at age 36 due to the medical needs of her son with sickle-cell. The medical care that he could receive in the US far surpassed what was available in Kenya.  Gladys had worked as an RN in Kenya and soon found a job in the US but had to move here 3 months before her husband and children could follow.  Once her family arrived she noted that the big difference in this country was that she was not able to afford a maid or in-home childcare provider, as she had done in Kenya. Like many working moms in America, she was faced with a second full-time job when she returned home from her paying job as a nurse.

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Gladys’s mom

Despite coming from different parts of the world and at different ages, all of these women shared with me many of the same stories. Feeling responsible for family members that remain in the home country – whether that be paying for the education of a niece or being asked to help fund the purchase of a house by a cousin you have never met. Trying to keep parts of the home culture alive in your children while also allowing them to feel fully American. Sharing stories of the struggles you had to overcome to make a life in this country in order to combat the entitlement that can be a pervasive part of teen life in America. Creating a middle ground in your nuclear family between the opposing pull of the individualistic American culture and the community culture back home.

Observing a woman become a mother is something I see happen every day in my work as an ob/gyn physician. Giving birth is not what makes a mother. That task is accomplished in the sacrifices mothers make for their children and the love they bestow on them. Immigrant mothers have often made one of the largest sacrifices imaginable – leaving all that they know to try to create a better life for their children in a foreign land with a foreign language. I often wonder if I would have the strength to do the same.

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Left to right: Gladys, Jackie, Hieu and Mona

 

Mothering in the 21st Century

Sen. Tammy Duckworth Brings New Baby To Work After New Senate Law Passes

History was made this week when Senator Tammy Duckworth brought her 10 day old daughter to work with her on the Senate floor so that she could vote. It is 2018 and well into the 21st century but Senator Amy Klobuchar had to author a rule change that was voted on by the entire Senate before the above momentous occasion could come into being. And she had to reassure Senators that no breast-feeding or diaper changes would happen while the baby was on the Senate floor. Because we all know that infants don’t need a diaper change or food at a moments notice and sometimes without warning. Some Senators wanted Senator Duckworth to vote from the adjoining coat closet – to keep the baby off the Senate floor and out of sight. However, Senator Duckworth is a double amputee and in a wheelchair and the coat closet does not have handicap access. This amazing woman gave birth to her second child at age 50 as a double amputee and as the first Senator to be pregnant while in office. Instead of honoring these accomplishments, the Senate (predominately male and average age of 63) sought to keep her from voting while she was recovering from childbirth and caring for her newborn daughter and toddler.

We have developed a warped view of mothering in this country. We encourage women to return to work, but don’t legislate paid maternity leave. We encourage mothers to breast feed for the first year of their child’s life, providing them with reams of information on the benefits of breast milk. But our society sends a different message when it concerns infant care.  Most of us don’t have Senator Klobuchar writing rule changes for us at work or in public. We need to negotiate with our bosses when we return to work about length of maternity leave,  time off during the day to pump and to find a location to both pump and store our milk.

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If you choose to breast feed in public, the message is that you should be discreet and cover up or go into a closed room.  A variation of the above product  is on almost every pregnant woman’s wish list. You can see your baby but no one else can see what you are doing behind the volumes of material. You receive 2 awards – one for nursing your infant and the second for not demonstrating how that happens.

The primary function of a breast is to feed a child. Society has turned breasts into sexual objects and make woman feel embarrassed about the original function but want us to flaunt them for the second purpose. We are more comfortable with this picture:

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Than we are with this view.

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The post-childbirth changes we hide from you.

Last week my daughter goaded me into attending a yoga sculpt class with her as part of her recovery from knee surgery. I participate in hot yoga once a week but had never been lured into the high energy, loud music of the class next door. I knew I was headed for trouble when they instructed me to pick up hand weights before rolling out my mat. Shortly thereafter, the throbbing music started and we were swinging our arms with weights attached. I was managing to keep up, with only a few short breaks for a gulp of water, when the instructor started us doing the dreaded jumping jacks.

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I have birthed three children. I exercise regularly. I am not overweight, don’t smoke and used the bathroom before class. It DOESN’T matter. I can’t do more than a few of those jumps before I start leaking urine. This is probably the reason they make patterned and dark-colored yoga pants. Many of my patients report the same experiences;  Jumping jacks and jumping on a trampoline provoke urinary leakage. Childbearing did this to us….and those changes extend far beyond urinary leakage. Following is only a partial list of what to expect post-childbirth.

  1. Weight – most women retain 5-10 lbs after each pregnancy.
  2. Jelly belly – flat abs of our teen years are a distant memory
  3. Saggy breasts – breast-feeding for a full year is great for your child but does a number on the aging of breast tissue
  4. Emotions – I watched Sophie’s Choice before I was a mom and loved it. Can’t ever go back and watch it again post childbirth. Same for Saving Private Ryan.
  5. Sex – not only the physical changes but also the inability to relax while worrying about the children sleeping in the next room or what time you need to get up in the morning.
  6. Multi-tasking – It seems that we need to always be doing two things at once if we are to get all accomplished. Folding clothes while helping with homework or cooking and making a grocery list.

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But no fear – I have found a cure for all that ails us as women. Steaming your vagina is puported to detoxify and clense your vagina, strengthen and tone your entire reproductive sytem (no more leaking of urine or saggy breasts!), speed healing after childbirth, alleviate pain during intercourse (but the kids will still be next door), balance hormones to reduce PMS and allows one to better cope with unresolved emotional baggage (maybe that is why I can’t read Sophie’s Choice). I didn’t make this up as it is word for word from the website. And all of this for only $399 that includes the wooden seat and the customized potpourri mix. Maybe this technique will even allow me to have another child in my post-menopausal years so that I can try again to get the parenting gig correct.

 

 

Female Body Parts 101: The cervix – Soon to be #1 Cancer Threat to Women Worldwide

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I have previously written about the uterus and menstruation, but have been lax in finishing the reproductive system. Two patient stories reminded me of how neglected the cervix can be.  As I was interviewing a new patient, age 24, I noted that she had not received a Gardasil vaccination in her teen years. I informed her of the benefits of the vaccine, preventing Human Papilloma Virus (HPV) infection of the cervix, thus markedly reducing her long term risk of cervical cancer. The vast majority of cervical cancer is caused by HPV, with strains 16 and 18 accounting for 70% of cervical cancer. The vaccine can be administered from ages 12-26 in both boys and girls and is covered by insurance. Following our discussion, she declined the vaccine stating “My family doesn’t believe in vaccines”.

Later in the week, I was called to the ER to see a 65 year old woman who presented with vaginal bleeding after menopause. She had not seen a physician since her last child was born in her late 30’s. A large tumor had completely replaced her cervix and was extending into her uterus. Her survival chances are around 60% – after radiation, chemo and extensive surgery. Due to age this woman did not have the option of a Gardasil vaccine, but the cancer could have been detected in a pre-cancerous state by a pap smear and easily removed via an office procedure.

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Obtaining cells for a pap smear

The cervix is a muscular structure that is located at the top of the vagina and encompasses the lower third of the uterus. It is the gateway that allows blood to leave the uterus during a period and remains closed to keep the developing fetus inside the uterus until labor ensues. It responds to uterine contractions by slowly dilating to allow for passage of the infant.

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Pap smears were developed to screen for pre-cancerous changes on the cervix that could be treated before they developed into cervical cancer. We have only recently discovered that HPV is the virus that causes cervical cancer and now screen for HPV when we do pap smears. HPV is a virus that is passed back and forth between men and women during intercourse. It is a silent infection in men – no symptoms, no testing available, no treatment and no long term health consequences. Completely sexist but so are many health problems – ie breast cancer, pregnancy, uterine and ovarian cancer.  So it only follows that vaccinating young men to prevent them from transmitting the virus will help to reduce the burden on women.

Pap smears should be performed every 3-5 years, depending on age, and don’t need to be performed after age 65 if you have not had an abnormal pap in the past 10 years. A common misconception is that pap smears are performed whenever a speculum is placed in the vagina – NOT!  Pap smears are never done in the ER or urgent care, even if a speculum is placed or pelvic exam done. You just need to believe me on this fact.

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By 2020, cervical cancer is expected to exceed deaths during childbirth as the number one killer of women during their reproductive years. Currently, 70% of cervical cancer is diagnosed in the developing world due to lack of screening for pre-cancerous abnormalities. In 2011 Rwanda initiated a school based vaccination program for both boys and girls and thus far has a 93% coverage of eligible youth. The current rate in the US is 60%, with many states less than 50%. Rwanda, still recovering from a horrific genocide and 70% of it’s population rural, beats the US in vaccination rates by a great distance. We are the richest country in the world with the most expensive health care system. Treatment for the 65 year old patient described above will cost hundreds of thousands of dollars. Where are we willing to spend our dollars?

Cervical cancer is one of the few cancers that is well understood and has a single cause; HPV.  We have the ability to eradicate this cancer in the near future via robust vaccination programs and regular screening. Former president Jimmy Carter had a vision to rid the world of Guinea Worm, a parasitic infection in tropical countries. It will soon be the second disease eradicated in the world, after smallpox. Cervical cancer can be #3 and the first cancer.