maternal health

By now, the enormity of America’s opioid abuse and overdose epidemic is common knowledge. With 78 Americans dying every day from an opioid overdose and with enough painkillers prescribed to give just about every U.S. adult their own bottle of pills, there’s hardly a community that’s gone untouched by the deadly problem. And a new study reminds us that we’ll be dealing with the aftermath far into the future.

The study, published in the form of a “research letter” in JAMA Pediatrics, examined rates of neonatal abstinence syndrome (NAS), a condition that occurs when babies are exposed to drugs in the womb and is most often caused by opioid use. Babies with NAS are more likely to be born with low birth weights, birth defects, and breathing and feeding problems, among other issues. Treating NAS can take months, and the long-term effects are not entirely known. The new study aimed to describe current trends in NAS in the U.S. as well as in the rural state of Kentucky, where overdose deaths reached a record high in 2015.

In examining inpatient data nationally and from Kentucky, researchers found that the national rate of NAS has more than doubled, from 3.6 cases per 1,000 births in 2009 to 7.3 per 1,000 births in 2013. In Kentucky, which like many rural states has been hit particularly hard by opioid abuse, the NAS rate rose from 6.6 per 1,000 births in 2009 to 15.1 in 2013, peaking at 23.4 per 1,000 births in the last quarter of 2014. Between 2011 and 2013, Kentucky’s NAS rates were more than double the national rate.

The study notes that while state and federal efforts seem to be slowing down rates of opioid abuse and overdose, there’s been little impact on rates of NAS. Authors Joshua Brown, Pratik Doshi, Nathan Pauly and Jeffrey Talbert write:

The Protect Our Infants Act of 2015 is a federal, bipartisan law introduced specifically to combat the NAS epidemic. This law, along with several others currently being considered by Congress and covered by national media stories, has succeeded in bringing national attention to NAS. However, it fails to offer any tangible short-term solutions to the rapidly growing problem. Meanwhile, rural states, such as Kentucky, that are disproportionately affected by the opioid abuse epidemic must continue to enforce and supplement policies related to surveillance programs along with coverage for addiction services through state services. Because of the tremendous burden of NAS and the potential for lifelong complications for the neonate, tailoring of interventions to pregnant women or women of childbearing age should be a priority of national and state drug abuse efforts.

In July, President Obama signed the Comprehensive Addiction and Recovery Act of 2016 (CARA), a wide-ranging law designed to confront the opioid crisis by expanding education and prevention efforts, strengthening treatment options and widening access to overdose medications, among other measures. Still, the law needs enough funding to make a sustained difference. The White House has already directed millions to overdose prevention and addiction treatment, but Congress has yet to fully fund CARA.

In signing CARA, Obama said: “My administration has been doing everything we can to increase access to treatment, and I’m going to continue fighting to secure the funding families desperately need. In recent days, the law enforcement community, advocates, physicians, and elected officials from both sides of the aisle have also joined in this call. Now, it’s up to Republicans to finish the job and provide adequate funding to deal with this public health crisis. That’s what the American people deserve.”

To request a full copy of the new NAS study, visit JAMA Pediatrics.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Tue, 10/04/2016 - 13:18

More than 1 million mothers gain health insurance, thanks to the Affordable Care Act

kkrisberg — Thu, 05 May 2016 15:25:57 +0000

More than 1 million mothers gain health insurance, thanks to the Affordable Care Act

Just in time for Mother’s Day comes more good news from the Affordable Care Act: the rate of uninsured moms caring for kids younger than 19 has dropped to its lowest rate in nearly 20 years.

According to a new analysis from the Urban Institute released this month, the rate of uninsured moms fell 3.8 percentage points between 2013 and 2014 — that’s a decline about three times as large as any of the previous year-to-year changes observed since 1997. In sheer numbers, that means about 1.6 million moms gained health insurance. To give you even more perspective, consider that uninsurance rates among mothers had increased by more than 2 percentage points from 1997 to 2013, at which point nearly one in every five of America’s moms was living without health insurance.

This not only matters to the health of mothers — who remain the primary caregivers of their families — but to the health of their children too. Beyond the more obvious fact that access to health care is critical to healthy pregnancies, safe childbirth and infant survival, there’s also some evidence that when a mother enjoys good health and well-being, it has positive trickle-down effects for her child’s health and development. For instance, children of mothers who struggle with depression are at higher risk of developing depression themselves. Certain health-related behaviors such as nutritious eating and not smoking — both of which can be influenced by access to medical care — also have a multitude of benefits for kids, not the least of which is reducing exposure to secondhand smoke. And insurance gains among parents are often linked with greater access to care for their children. (Of course, many of the health challenges that mothers face are linked to social determinants — lack of paid sick leave, no maternity leave, wage inequities — and, unfortunately, those won’t be solved with a new health insurance card.)

To conduct the new Urban Institute analysis, researchers examined data on thousands of U.S. moms from the National Health Interview Survey between 1997 and 2014. In addition to the overall decline in uninsured moms, they found that uninsurance among low-income moms fell from 39.4 percent in 1997 to 37.5 percent in 2013 — then it dropped by an additional 6.2 percentage points between 2013 and 2014. (The first ACA open enrollment period was October 2013 to April 2014.) Previous to ACA implementation, mothers in moderate-income families had been experiencing a rise in uninsurance rates between 1997 and 2013, from about 15 percent to 19 percent. However, it dropped to 14 percent in 2014. Among higher-income moms, the uninsurance rate remained stable throughout the study period at less than 4 percent.

Not surprisingly, the analysis found that moms living in states that expanded Medicaid eligibility experienced greater uninsurance declines than those living in nonexpansion states. More specifically, uninsurance rates fell 8.1 percentage points among moms in expansion states and with incomes at or below 138 percent of the federal poverty level. In contrast, that rate fell only 4.9 percentage points in nonexpansion states. Among the mothers who remained uninsured as of 2014, about half were Hispanic and almost half were not working, though only about one-fifth lived in families in which no one was employed. More than 40 percent of uninsured moms in 2014 attributed the lack of coverage to high costs. The next most cited reason was that their coverage stopped after pregnancy.

Overall and despite all the gains, low-income moms are still twice as likely to go without health insurance as moderate-income moms and nearly 15 times as likely to be without insurance as higher-income moms, the analysis reported.

In a Health Affairs blog post by analysis co-authors Michael Karpman, Jason Gates, Genevieve Kenney and Stacy McMorrow, they write: “Together, these findings suggest that by expanding coverage and improving the health and financial stability of mothers and their families, the ACA may be contributing to a healthier, happier Mother’s Day. Perhaps when we toast moms on their special day in 2017, there will be even greater coverage gains to celebrate.”

To download a full copy of the analysis, visit the Urban Institute.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Thu, 05/05/2016 - 11:25

Tags

Affordable Care Act

government

healthcare

Public Health - General

“Previous to ACA implementation, mothers in moderate-income families had been experiencing a rise in uninsurance rates between 1997 and 2013, from about 15 percent to 19 percent. However, it dropped to 14 percent in 2014.”

That drop may be an anomaly and due only to insurance companies not setting premiums high enough to cover ACA mandates.

From today’s WSJ:
“Insurers have begun to propose big premium increases for coverage next year under the 2010 health law, as some struggle to make money in a market where their costs have soared…
Providence Health Plan, currently the largest insurer for people buying coverage through the Oregon health exchange, is seeking an average increase of 29.6%...
In Oregon, regulators’ filings show Moda Health Plan Inc., once the largest insurer on the exchange, saying it needs to hike premiums there by an average of 32.3%. That is coming on the heels of an increase of around 25% last year; the insurer also said it would stop selling individual plans in Alaska.”

Also, from the data in the posted article, I understand that over 31% of low income moms are still uninsured.
Wasn’t the purpose of the ACA to provide health insurance for everybody, or at least to force everyone to have health insurance?
Why don’t almost a third of these moms have insurance?
Is it too expensive?
If so, just think how expensive health insurance will be under the ACA if *everyone*, including these moms, actually *is*
forced to have health insurance!

Hi See Noevo,

According to the data, low- and moderate-income mothers experienced the largest gains in insurance coverage under the ACA --- and it's precisely these types of populations at which much of the law was targeted, as such income groups faced higher risks of being uninsured pre-ACA.

In terms of low-income moms still being uninsured, much of that is related to the refusal of some states to expand Medicaid eligibility --- a transition that is entirely paid for by the federal government. (As I'm sure you know, the ACA was designed under the assumption that all states would expand Medicaid. But the Supreme Court ruling making expansion optional means that millions of Americans now fall in a coverage gap in which they don't qualify for Medicaid and don't quality for marketplace subsidies.) So, yes, for many of these moms, insurance is probably still too expensive to purchase without any assistance. However, that was also the problem before the ACA, which is exactly why the feds upped their Medicaid financing.

And yes, some premiums for some plans in some states have gone up. In other places, premiums went down. But keep in mind that within the marketplace, big rate hikes now have to be reviewed by federal officials and in some states, insurers have to negotiate pricing with state health commissioners. While this certainly isn't perfect, it means that people buying insurance in the market, as opposed to getting it through an employer, now have an authority advocating for affordability and quality on their behalf. Before, consumers in the individual, private marketplace had NO leverage and were entirely at the mercy of profit-driven insurers. Before the ACA, an individual didn't buy insurance, they applied for insurance and just had to cross their fingers that they'd gain affordable and regular access to medical care. The ACA has dramatically shifted that paradigm and that's a good thing, especially if we measure the success of a health care system in actual health outcomes and not in insurance profit margins.

No one said fixing our health care system would be cheap or quick. But I'd argue that the expense (or investment) is certainly worth it.

Thanks for reading!

New study: Ubiquitous chemicals known as phthalates linked to childhood asthma risk

kkrisberg — Fri, 19 Sep 2014 15:00:21 +0000

New study: Ubiquitous chemicals known as phthalates linked to childhood asthma risk

About one in every 10 U.S. children is living with asthma — that’s closing in on 7 million kids. And while we have a good handle on what triggers asthma attacks and exacerbates respiratory symptoms, exactly what causes asthma in the first place is still somewhat of a mystery. However, new research points to some possible new culprits that are difficult, if not nearly impossible, to avoid.

Those culprits are phthalates, ubiquitous chemicals found in just about everything, from food packaging to shower curtains to vinyl flooring to personal care products such as fragrances and shampoos. (Phthalates are a group of chemicals that make plastics flexible and hard to break and are also used to help cosmetic products cling to the skin.) Just this week, researchers from the Columbia Center for Children’s Environmental Health at the Mailman School of Public Health published findings that children born to mothers who experienced high levels of exposure to two particular phthalates during pregnancy had a significantly higher risk of developing asthma. Specifically, they found that high maternal exposure to butylbenzyl phthalate (BBzP) and di-n-butyl phthalate (DnBP) resulted in a 72 percent and 78 percent increase, respectively, in the risk of a child developing asthma between ages 5 and 11 years old when compared to mothers with lower levels of exposure.

“Everyone from parents to policymakers is concerned by the steep rise in the number of children who develop asthma,” Robin Whyatt, study co-author and co-deputy director of the Columbia Center for Children’s Environmental Health, said in a news release. “Our goal is to try and uncover causes of this epidemic so we can better protect young children from this debilitating condition. Our study presents evidence that these two phthalates are among a range of known risk factors for asthma.”

To conduct the study, which is the first of its kind, Whyatt and her colleagues followed a group of 300 pregnant women and their children in New York City. All of the women were either African American or Dominican. Researchers measured the exposure to four different phthalates via urine samples taken during the woman’s third trimester and when the children were ages 3, 5 and 7. To control for confounding variables, the study excluded women if they used tobacco or illicit drugs or were living with diabetes, hypertension or HIV.

Phthalates were detected in 100 percent of maternal prenatal urine samples. Among the children, 154 had a history of reporting asthma-like symptoms and 94 were diagnosed with asthma. Since pretty much everyone tests positive for phthalates exposure, researchers compared women with the highest levels to those with lower levels. They found a significant association between concentrations of BBzP and DnBP metabolites during the third trimester of pregnancy and an asthma diagnosis among children ages 5 to 11 years old. However, the researchers reported their results with caution. Authors Whyatt, Matthew Perzanowski, Allan Just, Andrew Rundle, Kathleen Donohue, Antonia Calafat, Lori Hoepner, Frederica Perera and Rachel Miller write:

These findings may imply that prenatal exposure to some phthalates has effects on transient wheeze and/or nonspecific airway hyper-responsiveness. It is possible that the respiratory consequences of prenatal exposure to phthalates mimic what has been observed following prenatal exposure to cigarette smoke, where several large cohort studies have essentially established its role in recurrent wheeze in very young children. Alternatively, prenatal phthalates exposure may induce a nonspecific airway hyper-responsiveness, manifested as report of wheeze, use of asthma medication, cough or other breathing problems, that develops into clinical asthma during childhood only in a subset of children. The development of airway hyper-responsiveness is believed to have an environmental component, and develops at a very early age. Further prospective studies are needed to resolve these important clinical questions.

On the preventive side, avoiding phthalates is quite difficult, both because the chemicals are pretty much everywhere and because they’re rarely listed as an ingredient in the products we buy. The news release announcing the study results notes that several phthalates, including BBzP and DnBP, have been banned from many children’s products, but steps haven’t been taken to warn pregnant women about the possible health risks to their fetuses. This newest study builds on the researchers’ previous findings that child and prenatal exposure to certain phthalates is associated with a higher risk of asthma-related airway inflammation and childhood eczema. Like many environmental exposure risks, limiting exposure to phthalates in an effective way will likely take action from policy-makers and regulators.

“While it is incumbent on mothers to do everything they can to protect their child, they are virtually helpless when it comes to phthalates like BBzP and DnBP that are unavoidable,” said study co-author Rachel Miller, co-deputy director of the Columbia Center for Children’s Environmental Health. “If we want to protect children, we have to protect pregnant women.”

According to the American Lung Association, asthma is the third leading cause of hospitalization among children younger than 15 years old. Every year, the chronic respiratory disease results in about $50.1 billion in direct health care costs.

To read the full study, which was published this week in Environmental Health Perspectives, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 09/19/2014 - 11:00

Thank you for sharing! This is extremely significant as children are 39 percent more likely to have an attack than children. I am curious to see if there is any crucial variation in the results in different races or if it remains the same. In addition the response could be different depending on the location as climate and the surrounding environment are factors that affect how aggravated the condition is.
http://www.niantic.com/story/Best-Climates-for-Asthma/589341
http://www.cdc.gov/nchs/data/databriefs/db94.htm
http://www.buffalonews.com/life-arts/family-matters/asthma-action-plan-…

New study finds the greener the neighborhood, the healthier the baby

kkrisberg — Fri, 05 Sep 2014 12:01:25 +0000

New study finds the greener the neighborhood, the healthier the baby

Forget pink or blue. It turns out that the best color for baby may be green.

In a study recently published in Environmental Health Perspectives, researchers found that mothers living in neighborhoods with plenty of greenness — grass, trees and other types of lush vegetation — were more likely to carry their pregnancies to full term and deliver babies at healthier weights. Specifically, the study found that very pre-term births were 20 percent lower and moderate pre-term births were 13 percent lower among mothers living in greener neighborhoods. Also, babies from greener neighborhoods were less likely to be classified as “small” for their gestational age than babies in less green neighborhoods. And the association between greenness and better birth outcomes stood up even after researchers adjusted for factors such as income, noise, neighborhood walkability and poor air quality.

“This was a surprise,” said study lead author Perry Hystad, an environmental epidemiologist in Oregon State University’s College of Public Health and Human Services, in a news release. “We expected the association between greenness and birth outcomes to disappear once we accounted for other environmental exposures such as air pollution and noise. The research really suggests that greenness affects birth outcomes in other ways, such as psychologically or socially.”

To conduct the study, researchers used satellite-derived data on vegetation and compared it with birth outcomes among 64,705 births in Vancouver, British Columbia. They noted in the study that with half of the world’s population living in urban areas — and with that number expected to grow — it’s important to understand the characteristics of urban environments that contribute to positive health outcomes. They found that birthweight was 20.6 grams higher on average with each 0.1 increase in greenness, with babies in the greenest neighborhoods weighing 45 grams more at birth than infants with moms living in the least green neighborhoods. In the news release, Hystad noted that even though the birthweight differences seem small on an individual basis, “those are substantial differences that would have a significant impact on the health of infants in a community.”

Why is this important? According to the Centers for Disease Control and Prevention, low birthweight is the “single most important factor” in newborn mortality and those babies who do survive can experience serious, long-term health problems. Overall, the study concluded that living within 100 meters of increased greenness was linked to healthier birthweights and a lower likelihood of preterm birth. Study authors Hystad, Hugh Davies, Lawrence Frank, Josh Van Loon, Ulrike Gehring, Lillian Tamburic and Michael Brauer write:

The fact that residential greenness exposure remained associated with birth outcomes after adjusting for a number of hypothesized environmental exposures suggests that alternative pathways may link greenness exposure to birth outcomes. Two well-hypothesized pathways that were not examined in this study include psychosocial and psychological influences. Greenness may facilitate positive psychosocial influences by providing shared spaces for interactions. For example, exposure to greenness has been associated with social support and increased social ties and community belonging. …While we were unable to examine these pathways, our findings of a persistent greenness association with birth outcomes that was independent of previously observed associations with noise and air pollution suggests more research is required that includes all potential pathways potentially linking greenness to birth outcomes.

The study authors noted that it’s unclear just how much green space and what type of greenery is of greatest benefit to newborns, but they did say that one or two potted plants won’t make a difference. And that’s the next step for researchers — examining exactly why greenness seems to make a difference and determining how much greenness it takes to impact newborn health. The answer could lead to one of the more low-cost and enjoyable ways to promote child health — planting more trees.

“We know that green space is good,” Hystad said. “How do we maximize that benefit to improve health outcomes? The answer could have significant implications for land use planning and development.”

To download a full copy of the study, visit Environmental Health Perspectives. And check out this article we published last month on the life-saving nature of trees.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 09/05/2014 - 08:01

Tags

Environmental health

healthcare

Public Health - General

I agree 100% but it is not ' evidence based medicine' so there is little to no interest. Sorry nature, even though you provide so many answers to life and disease, us humans have lost all common sense and driven by economies and political swindle that we have moved on. Our mobile phones, patenting drugs etc are more important now than the water we drink, the air we breathe, and the trees that balance the planet's health. And even though people recover quicker in hospitals who have access to 'some greenery', unfortunately this is not evidence based medicine, but considered ' woo' or something like that.
And even though Japanese scientists have discovered ' forest bathing' as an important part of health and vitality, sadly, this also regarded apparently as ' non scientific nonsense'.
My deepest apologies that we have departed from our own natural health and that of the planets health as well. My deepest apologies also go to the Natives of the land worldwide who have lost their land, spirit and their pride.

The very fact that no one has written here compared to other articles on this science blog site explains everything.

Maternal health and fracking: Is there a link?

lborkowski — Mon, 02 Jun 2014 08:38:01 +0000

Maternal health and fracking: Is there a link?

by V. Tinney, J. Paulson, and E. Webb

In recent months, spikes in birth defects, and stillborn and neonatal deaths in drilling-dense regions of Colorado and Utah has raised the attention of local communities, researchers, and public health officials. There is still much to be studied to be able to determine if there is in fact a causal link between hydraulic fracturing and adverse outcomes for infants and children. However, preliminary research is starting to suggest that there very well could be a connection. Researchers McKenzie et al. in a recent study released in February 2014, observed an association between proximity to natural gas wells within a 10-mile radius of maternal residence and a prevalence of congenital heart defects and possibly neural tube defects (an opening in the spinal cord or brain that occurs in early development) in an area of Denver, Colorado. These findings strongly suggest that rapid and thorough further investigation is warranted.

Chemicals used in the extraction, processing, distribution, transport, and waste disposal of tight oil and shale gas reservoirs can pollute the surrounding air and water. One particular phase in the tight oil and shale gas life cycle is known as high-volume horizontal fracturing (fracking). In this process, high volumes of water, sand, and chemicals are pumped under pressure into gas wells to fracture subterranean shale and force natural gas to the surface for capture and distribution. Shale gas production in the United States is projected to increase by 113% between 2011 and 2040. Pennsylvania experienced a quadruple increase in gas extraction with hydraulic fracturing between 2009 and 2011.

So what are the possible connections here and what do we know to be true concerning children’s susceptibility to toxic chemicals? There are a number of ways that unconventional natural gas extraction can impact the health of children. Children have vulnerable periods of development, both in terms of in utero exposures as well as exposures that occur after they are born. Children’s unique physiology during development makes them more susceptible to health problems. Infants and children face increased exposures, greater absorption due to a rapid metabolism, and the reduced ability to detoxify many compounds, compared to adults, making them particularly vulnerable to adverse environmental exposures.

Infants and children are also exposed to more toxic chemicals in their surrounding environment than adults. They eat more, drink more, and breathe more per unit of body weight than adults do. Studies suggest that children aged one through five years, eat approximately three to four times more food per kilogram than adults do, and that the air intake of a resting infant is twice that of an adult. Furthermore, children frequently put their hands in their mouth, which increases their ingestion of toxins in dust and soil, and they play close to the ground. This means that children will receive a higher dose of the contaminant than an adult would. Children’s detoxifying mechanisms are also developing and therefore may not protect them as well as an adult’s detoxifying mechanisms would. Kids also live longer than adults do. Should an exposure a child receives at a young age cause adverse health outcome 40 years after the exposure, it is likely the child will be alive to experience the adverse health outcome, whereas an adult exposed at age 50 may not live to see the onset of the disease.

Neural tube defects, including spina bifida (incomplete closing of the embryonic neural tube), can develop as result of chemical exposure during prenatal development of the nervous system. A well-known quartet of chemicals, usually abbreviated as BTEX, is used in millions of gallons of fracking fluids every year, and the levels in groundwater contamination spills at drilling sites studied in Colorado exceeded the National Drinking Water Standards. A study by Lupo et al found that mothers living in areas with high levels of benzene (“B” in BTEX), were more likely to have an offspring with spina bifida than were women living in areas with the lowest levels. Slama et al. reported that maternal exposure to benzene was linked with decreased fetal birth weight and decreased head circumference, both during pregnancy and at birth. Benzene acts on the skin and mucous membranes, and after absorption it can have systemic effect on the central nervous system, leading to interactions on at the systemic level.

Adults also need to be protected from environmental exposures throughout the life course as preconception exposures can influence child development. For men, environmental exposures that damage sperm can affect the health of their future offspring. For women, all the eggs a woman has during her lifetime are formed while she is still in her mother’s uterus. If an in utero exposure damages the developing fetus’ eggs, then the health of the child that fetus conceives 20 to 30 years later can be affected. Fetuses can be exposed to chemicals even inside the mother’s womb. During embryonic and fetal development, damage can occur when chemicals pass the placenta and/or blood-brain barrier. In utero exposures also impact the health outcomes of the developing fetus and with 50% of pregnancies unplanned, exposures a women experiences before she even knows she is pregnant may impact the health of her child.

Much of the conversation on the potential health effects of unconventional gas has focused on the health impacts associated with increased air pollution; either from the increased truck traffic, flaring, containment ponds and misters, etc., or from water pollution; such as from flow-back water containing naturally occurring radioactive materials, heavy metals, or the many chemicals injected into wells that may contaminate ground water. The Center for Environmental Health has more information on its website and last year issued an in-depth report on the health effects of unconventional gas extraction, specifically for pregnant women and children.

But what about other concerns, such as noise and stress, that are also quite harmful for maternal and child health? Beyond chemical exposures, there are a number of other ways that fracking can affect the health of families. For example, increased traffic volume can increase the likelihood of injuries and fatalities in a community. Other aspects of the fracking process, such as increased levels of noise from traffic and equipment can cause stress, difficulty sleeping, and psychological problems that can exacerbate physical outcomes or existing health conditions. Health outcomes related to noise pollution include hypertension, sleep disturbance, cardiovascular disease, stroke, increased aggression, depression, and cognitive impairment (such as problems with attention and recognition). Noise from road traffic has been linked with a higher risk for heart attack and heart disease.

A woman’s stress levels during pregnancy can affect the health outcomes of her child. Several studies from the University of California Irvine have looked at the effects of maternal psychosocial stress and health outcomes and have found an association between maternal stress and preterm birth, low birth weight, higher body mass index and percentage body fat, primary insulin resistance, and decreased memory performance in female children. Within communities where there is unconventional gas extraction, views on whether unconventional gas extraction is beneficial for a community or not are often very polarized, creating disputes and stress among neighbors.

No one experiences environmental exposures in isolation. What are the combined effects of multiple environmental exposures? For example, we know that air pollution effects lung development and exacerbates asthma. Now if we add stress to a person’s exposure to air pollution, it has been shown that paternal stress may have a synergistic effect in that stress amplifies the effects of traffic related air pollution on asthma. A study by Islam et al found that there is a possible common biologic pathway of stress and air pollution, and children whose parents reported a stress had children who experienced a greater detrimental effect of air pollution on their lung function volume. Unfortunately, government regulations do not require safety testing of chemicals used in fracking, nor do they require assessments of the potential impacts of multiple chemical and environmental exposures. Further, gas extraction activities are exempt from federal legislation that would otherwise regulate pollutants created by gas extraction activities including the Safe Drinking Water Act and the Clean Air Act.

There is an overall lack of systematically collected, peer-reviewed research on the health effects. of unconventional gas extraction activities. However, we do know that there are multiple toxins involved with unconventional gas extraction processes and multiple pathways of exposure to humans. Without robust research, we do not know what the long-term consequences of rapid expansion of unconventional gas extraction in the US will be on the health of women and future populations. Policy and regulation decisions are highly dependent on evidence-based information. Studies show that regulatory reforms have significantly reduced adverse health outcomes for infants and children. For example, the Clean Air Act (CAA) of 1979, resulted in air improvement standards that resulted in a 0.5% reduction in infant mortality. Legislators and regulators need to make science and health research an integral part of the development of efficient, cleaner and safer energy resources and practices.

Veronica Tinney, MPH and Jerome Paulson, MD, FAAP are with the Mid-Atlantic Center for Children’s Health and the Environment (the Pediatric Environmental Health Specialty Unit (PEHSU) for Federal Region 3: Pennsylvania, Maryland, Virginia, Delaware, West Virginia and the District of Columbia). Ellen Webb, MPH is with the Center for Environmental Health. These organizations can help citizens, health professionals, and parents navigate the potential health impacts of unconventional gas extraction in their communities and provide resources and education to community members and health professionals on the potential health impacts of unconventional gas extraction.

lborkowski Mon, 06/02/2014 - 04:38

Tags

Investing in children's health: Home visit programs

lborkowski — Mon, 27 Jan 2014 08:54:11 +0000

Investing in children's health: Home visit programs

I wrote last week about the Prevention and Public Health Fund, which the Affordable Care Act (ACA) created to invest in improving overall population health – with the hope that improved health will help slow the growth of healthcare costs. Another provision of the ACA that aims to reduce future healthcare costs is “Maternal, Infant, and Early Childhood Home Visiting Programs” (Section 2951). Three studies published in the latest supplemental issue of the American Journal of Public Health address this type of program.

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs send trained professionals to the homes of parents of infants and young children to promote child health and development and reduce child abuse, neglect, and injuries. The Nurse-Family Partnership is probably the most widely known and extensively researched home-visit model; it enrolls vulnerable (generally, low-income and teenaged) first-time mothers while they’re pregnant and links them with public-health nurses who visit them during their pregnancies and the first two years of their children’s lives. The nurses provide “guidance for the emotional, social, and physical challenges these first-time moms face.” In the stories on the Nurse-Family Partnership website, that guidance ranges from teaching 17-year-old Shanice relaxation techniques and how to interpret her baby’s cries to equipping 19-year-old Amanda with self-confidence and an action plan to leave an abusive boyfriend. (For an even more in-depth story, read Katherine Boo’s fascinating 2006 New Yorker piece “Swamp Nurse.”)

Professor David Olds and his colleagues developed the nurse-family partnership model and conducted the first randomized trial of it in Elmira, New York. Followup studies conducted after the children reached age 15 found that the children whose mothers received visits had 48% fewer verified incidents of child abuse or neglect and were 58% less likely to have been convicted of a crime, while visited women had spent 20% less time on welfare.

Reductions in child abuse, criminal convictions, and time on welfare translate into public savings, as well as harder-to-quantify improvements in quality of life. A Washington State Institute for Public Policy analysis of a nurse-family partnership program for low-income families calculated that a program investment of $10,291 per participant yielded $22,781 in savings due to reduced crime, child abuse, disruptive behavior, substance abuse, and need for public assistance, as well as children’s greater likelihood of graduating high school and securing employment. That’s a net savings of $13,181 per participant, as well as a big reduction in suffering.

Birth spacing and enrollment factors
In a study just published in the American Journal of Public Health (AJPH), Katherine Yun and colleagues examined the impact of the Pennsylvania Nurse-Family Partnership on birth spacing for first-time Latina mothers. Short intervals between pregnancies are associated with higher risks for preterm births and low-birthweight babies, and the national 2020 Healthy People goals include reducing the number of pregnancies that occur within 18 months of a previous birth.

In this study, Yun et al used client data from 23 Pennsylvania NFP programs, welfare eligibility files, and birth certificate files to compare birth spacing in two groups: Latina women who were enrolled in an NFP program for their first child’s birth and who had received some form of welfare assistance in the previous year (the enrollee group) and demographically similar Latina women who had received some form of welfare but were not enrolled in an NFP program (the non-enrollee group). The study sample included women who delivered first-born babies in Pennsylvania between 2003 and 2007, with followup through the end of 2009 to identify subsequent births to the same mothers.

The researchers found a decrease in the risk of short interpregnancy intervals (18 months or fewer) for Latinas enrolled in the program compared to the nonenrollees. When considering all age groups in the sample, 22.9% of enrollees and 25.8% of non-enrollees had conceived second children within 18 months. When considering only those age 18 and under at first birth, the difference was greater: 24.3% compared to 28.9%. (Findings for both analyses were statistically significant.) The authors note that these effects “were smaller than those seen in an NFP randomized controlled trial that included a large cohort of Latina women,” but that the difference “might reflect expected changes in program effects after wide-scale implementation outside of the experimental setting … [or] secular trends, such as declines in the US adolescent birth rate over the past 2 decades.”

In discussing the study limitations, the authors note that although they used propensity score models to create a matched sample of non-enrollees, there might be unmeasured differences between the women who enrolled in the program and those who didn’t, which could bias the results. Factors influencing at-risk first-time mothers’ enrollment in a home visitation program are the subject of another study appearing in the same issue of the AJPH.

Neera K. Goyal and colleagues studied enrollment in the Hamilton County, Ohio Every Child Succeeds program, which sends visitors to at-risk mothers’ homes during pregnancy and the first year of the child’s life. The model emphasizes “early prevention during pregnancy, education in child development and health, parenting skills, and maternal economic self-sufficiency.” Women are eligible if they are unmarried, younger than 18, or low-income. Using vital statistics records and census data as well as referral and enrollment information, the researchers identified factors associated with referral and enrollment in the home-visitation program. They found:

Results demonstrated that referral was more likely among those with lower education and in women living in communities with higher levels of social deprivation. However, once women were referred to home visiting, enrollment was paradoxically less likely for those with lower education and higher community levels of social deprivation. This suggested that despite appropriate referrals among the target, eligible population, there was lack of engagement among women at highest risk who were perhaps most in need of home visiting.

Getting public-health services to those who can benefit from them most is often a challenge. In another study published in the same AJPH issue, researchers look at a program that takes a different approach: It seeks broad enrollment, and then targets more-intensive interventions to those most in need, rather than seeking to enroll only high-need participants.

Casting a wide net in Durham
Kenneth A. Dodge and colleagues examined emergency care episodes in a child’s first six months of life, comparing families randomly assigned to the Durham Connects program to those who were not. Unlike the more narrowly targeted home-visit programs, Durham Connects is available to families regardless of income (or other maternal characteristics) and whether or not the birth is a first birth. During the 18-month study period (July 1, 2009 – December 31, 2010), the families of babies born on even-numbered days were assigned to the program, and those with odd-numbered birth dates were not.

Durham Connects begins in the hospital when the mother gives birth and a staff member explains the program and asks for enrollment consent. Parents who agree to participate receive one to three home visits during the baby’s first 3-12 weeks and a staff member followup (by phone or in person) one month later. During their visits, nurses evaluate health and psychosocial risks in four areas known to affect child wellbeing: “(1) parenting and child care (child care plans, parent–infant relationship, and management of infant crying); (2) family violence and safety (material supports, family violence, and past maltreatment); (3) parent mental health and well-being (depression and anxiety, substance abuse, and emotional support); and (4) health care (parent health, infant health, and health care plan).” The nurses also provide up to 20 brief “teaching moments,” offer extended education on specific topics (crying, breastfeeding, etc.) as needed, and help connect families to relevant community resources.

Subsequent interventions vary depending on risk scores, with low-risk families receiving little further contact and those with higher scores receiving referrals to community services and followup communications. Those whose scores show imminent risk receive emergency interventions; only 1% of the families completing the program fell into this category.

The researchers obtained records from the two hospitals at which the participant births occurred and tallied the number of emergency department visits and overnight hospital stays the infants had in the six months following their initial release from the hospital. Their analysis found that Durham Connects infants had 59% fewer emergency medical care episodes in their first six months of life than did infants in the control group. Based on the costs of those episodes, they calculated that every dollar spent on the program saved $3.02 per infant in emergency-care costs in the first six months of life. “For a community the size of Durham with an average of 3187 resident births per year and a Durham Connects intervention cost of $700 per birth, a community annual investment of $2 230 900 in the Durham Connects program would yield a community-wide emergency health care cost savings of $6 737 318 in the first 6 months of life,” Dodge et al conclude.

The Durham Connects program, the authors note, was designed to be implemented at the population level, not just offered to a group of high-risk families. This universal delivery can reduce the stigma that can otherwise reduce enrollment in programs for low-income or otherwise at-risk mothers. Dodge et al also report that while home-visiting programs are promising, none has yet scaled up successfully. As scale-up occurs, penetration and retention can decline, while quality and fidelity can degrade. And, they point out, scaled-up programs rely on communities having sufficient resources to provide the services to which home visitors might connect eligible families. In contrast, they write, Durham Connects “was delivered universally in a mid-sized community with a high rate of poverty.”

Durham Connects is a nonprofit founded with support from Duke University, the Durham County Health Department, hospitals, the Department of Social Services, and the nonprofit Center for Child and Family Health; The Duke Endowment funded its multi-year pilot. In addition to Durham Connects, which is available to all local families, the county offers other programs for higher-need families, and Durham Connects nurses often help assure that eligible families obtain these additional services.

Uncertain outlook for federal funding
The Department of Health and Human Services (HHS) has been distributing the ACA-appropriated MIECHV money to state entities “that have implemented high-quality, evidence based home visiting programs.” Most recently, 13 states received a total of $69.7 million. Because the ACA requires that entities serving high-risk populations get priority when grants are awarded, programs like Durham Connects are unlikely to receive money from this funding stream. As research on the impacts of different home-visit models accumulates, communities may decide to seek other sources of funding for programs like Durham Connects that serve larger populations with lower per-participant costs.

The Affordable Care Act only appropriated funding for MIECHV programs through fiscal year 2014. Grantees are required to report to HHS by the end of 2015 on their improvements in benchmark areas, including improvements in maternal and newborn health; prevention of child injuries, abuse, and neglect; improvement in school readiness and achievement; and reduction in crime or domestic violence.

Maternal and child health advocates will be advocating for Congressional reauthorization of MIECHV program funding. Brent Ewig of the Association of Maternal and Child Health Programs notes that funding the program at existing levels for another five years would cost $2 billion, and still only reach a small portion of the eligible population.

As studies continue to demonstrate the long-term benefits of home-visit programs, local and state officials probably recognize that supporting these programs makes financial sense. However, with all states except Vermont having legal requirements for balanced budgets, it can be hard for states to make expenditures now for savings that will show up in future budget years. Although politics can make it hard for Congress to increase spending on public programs like MIECHV, there are no legal constraints on its ability to invest in children’s health today in order to reduce future unemployment and Medicaid spending. For lawmakers seeking to improve children's lives, supporting home-visit programs is one evidence-based way to do so.

lborkowski Mon, 01/27/2014 - 03:54

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Affordable Care Act

Study: Job conditions linked to preterm birth risk among Hispanic workers

kkrisberg — Fri, 17 Jan 2014 15:23:47 +0000

Study: Job conditions linked to preterm birth risk among Hispanic workers

“There’s a lot we don’t know about preterm birth and we know even less about the disparities in those births.”

Those are words from Ondine von Ehrenstein, an assistant professor in the Department of Community Health Sciences at the UCLA Fielding School of Public Health, who recently examined the links between occupational exposures and preterm birth rates among Hispanic women. Perhaps not surprisingly to those in the public health world, von Ehrenstein and her research colleagues did find that Hispanic women are at particular risk for preterm birth associated with certain occupational conditions. However, what may be more surprising — and what could be critical to an effective intervention — was that the effect of occupational exposure on preterm birth risk varied by nativity, or whether a woman was U.S.-born or foreign-born.

“We found higher risks related to physically demanding and shift work, especially among U.S.-born Latina women,” von Ehrenstein told me. “Why is there such a difference? We’ll need further research to really understand.”

However, Ehrenstein and fellow researchers have begun to lay the groundwork. To conduct the study, which was published in the February issue of the American Journal of Public Health, researchers examined a case-control study nested within a cohort of more than 58,300 births in Los Angeles County in 2003 and used the U.S. Census Occupation Codes and Classification System to characterize the mothers’ occupations during pregnancy. The study noted that while previous U.S.-based studies have been conducted on preterm birth and occupational exposures (which is defined as both working conditions, such as daily working hours, and environmental exposures, such as indoor air quality), they have not teased out the relationship of the mother’s place of birth.

Authors also note that rates of preterm birth are higher in the U.S. than in many peer nations. (A recent March of Dimes report found that the U.S. preterm birth rate dropped to 11.5 percent in 2012 — a 15-year low — but it’s still the highest rate among industrialized nations.) Study authors von Ehrenstein, Michelle Wilhelm, Anthony Wang and Beate Ritz write:

The prevalence of preterm birth in the United States increased over the past decades with persistent racial/ethnic disparities, and it remains the main cause of infant mortality. Hispanic women have on average a higher prevalence of preterm birth than non-Hispanic White women, and risks tend to vary by nativity (US-born vs. foreign-born). These disparities remain poorly understood and have not to date been explained by social or demographic factors. …Occupational exposure may increase risks for preterm birth by interrupting the prenatal neuroendocrine balance, thereby promoting premature parturition (birth), and these adverse occupational influences may possibly affect Hispanic populations in the United States disproportionally and may possibly also be modified by nativity.

The study found that among all women who worked during pregnancy, there was a suggestion of increased risk of preterm birth among health care practitioners and technical occupations, building and grounds cleaning and maintenance, and food preparation and serving jobs. Risks were also associated with physically demanding work as well as shift work. When zeroing in on Hispanic women who worked while pregnant, the risk was higher among health care practitioners and technical occupations.

The risk of preterm birth also increased among Hispanic women doing shift work and physically demanding jobs — however, that risk only increased among Hispanic women who were born in the U.S. and not among foreign-born Hispanic women. The elevated odds ratio for preterm birth was statistically significant for foreign-born Hispanic women working in building and grounds cleaning and maintenance (though von Ehrenstein said it’s important to note that this group of Hispanic women also represented the vast majority of such workers). Still, foreign-born Hispanic women working in such maintenance jobs faced a preterm birth risk two-and-a-half times larger than women working in the office and administrative support sector.

“These ethnic disparities indicate that there is room for prevention,” von Ehrenstein said.

Researchers hypothesized a number of reasons for the differences. For example, the pronounced risk among Hispanic health care workers might indicate that such workers are “doing especially heavy physical work, although we currently have no evidence for this,” the study stated. Authors also noted that “lower acculturation has been reported for foreign-born compared with US-born Hispanics, and it has been associated with better support networks, healthier nutrition, and lower rates of smoking and alcohol consumption, reflecting healthier practices among women in the country of origin.” However, Ehrenstein pointed out that some of the biggest factors influencing pregnancy outcomes may be exposures that occur early in life — what she called the life course perspective — which could help explain the differences by nativity.

von Ehrenstein said the findings on nativity could be especially helpful when developing interventions. She also said that working to improve birth outcomes and infant health today — whether through policy or program — can reverberate throughout the lifespan.

“Early health risks may have lifelong implications,” von Ehrenstein said. “So if we want to reduce health costs and the implications for public health, a prime venue for prevention is really in promoting healthy pregnancies.”

To access the full study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 01/17/2014 - 10:23

Obstetric fistula as a neglected tropical disease

tsmith — Tue, 28 Aug 2012 19:09:08 +0000

Obstetric fistula as a neglected tropical disease

Mahabouba*, age 14, was sold into a marriage as a second wife to a man 50 almost years her senior. Raped and beaten repeatedly, she ended up pregnant, finally succeeding in running away 7 months into her pregnancy. Fleeing to the nearby town, she found that the people there threatened to return her to her husband, so she ran back to her native village in Ethiopia. However, her immediate family no longer lived there. An uncle eventually took pity on her and provided her with housing. When Mahabouba went into labor, lacking resources, she tried to deliver her baby herself. Her pelvis was still too small for the baby's head to pass through, and she ended up in obstructed labor for 7 days before a birth attendant was finally called in to assist. By this point, the tissue of between the baby's head and Mahabouba's pelvis had become necrotic due to lack of blood flow. The baby was stillborn and Mahabouba had developed a fistula--a hole had formed between the tissue in her vagina and her rectum. She had no control of her waste elimination, and couldn't even stand up due to damage to her nerves.

Her uncle wanted to help her, but the common belief was that women who experienced such tragedies were cursed by God. She was moved to a hut at the edge of the village and left to fend for herself against circling hyenas. Eventually, still unable to use her legs, she crawled to another village searching for help. Found by a missionary, she was taken to the Addis Ababa fistula hospital. The damage to her body was too severe to completely fix, but she received a colostomy which allowed her to at least live in society, and eventually she became a nurse's aide at the hospital.

Mahabouba's story, on the grand scale of things, is a success story. It's estimated that up to 3.5 million women currently suffer from fistulas, with somewhere from 50,000 to 130,000 new cases each year--and most of them go untreated. Because many of these happen in rural areas lacking health care providers, it's difficult to get at exact numbers, and there is little push to obtain them. A woman quoted in Kristof and WuDunn's "Half the Sky," an Australian gynecologist who has worked in Ethiopia for more than 30 years, notes that women with fistulas "are the women most to be pitied in the world...They're alone in the world, ashamed of their injuries. For lepers, or AIDS victims, there are organizations that help. But nobody knows about these women or helps them."

A new paper aims to change that. Out today in PLoS Neglected Tropical Diseases, Dr. L. Lewis Wall of Washington University in St. Louis argues that obstetric fistula should be included among the neglected tropical diseases (NTDs), which currently include a variety of infectious conditions. NTDs typically are present in warmer climates, and they disproportionately affect the "bottom billion" of the world's population--the poorest of the poor. They also lack attention from the research community, particularly when it comes to funding priorities.

Though obstetric fistula isn't an infectious disease, it certainly fits the other parameters for a NTD. "The emphasis on infectious diseases has meant that other important forms of morbidity and mortality have been neglected," explained Wall via email. "Surgical services are not high on the list of most public health interventions and infectious disease specialists and public health workers are, in general, ill-equipped to deal with surgical issues or obstetric issues. This would mean focusing attention on a huge category of human need that is also neglected as are the traditonal NTDs and could mean a significant uptick in funding for programs to deal with maternal health generally, and obstructed labor/obstetric fistula particularly."

Indeed, history has shown that obstetric fistulas are fairly easy to prevent and treat, given the proper medical personnel and training. Once common in the United States (the Waldorf-Astoria hotel in Manhattan sits on the site of the first fistula hospital in the U.S.), Wall points out that they are now rare enough here that they merit case reports in the medical literature. Why are they so uncommon? Primarily, very few women in the U.S. are so unattended in childbirth that they would go days in labor without intervention. Rather, most would have a Cesarean section to remove the baby and thus the fistula wouldn't develop in the first place. Access to this intervention is severely lacking in women in developing countries. "The Cesarean rate in the United States is over 30% (for various reasons) but in many African countries, the rate is less than 1%; well below the 6% needed to meet minimal maternal health needs," points out Wall.

For women who do develop fistulas, surgical treatment has a high success rate--and is cheap. One of the tragedies of obstetric fistula is that the surgery to treat the injury in many cases costs only around $420--for less than the cost of a fancy TV, you could give a woman back her life. Still, that's far above what most women in developing countries can afford to pay. Furthermore, even if every woman could afford treatment, "the surgical capacity to treat current fistula cases is woefully inadequate; probably only 10,000 cases per year, with 3-10 times that many new cases," says Wall.

Unfortunately, there are painfully few treatment centers in developing counties. In addition to the facility in Ethiopia, Dr. Wall is also one of the founders of the Danja fistula center in Niger, which opened its doors earlier this year. There are others scattered throughout continent, but given the rarity of surgical expertise and the frequency of obstetric fistula, the need far outpaces the personnel available. Nevertheless, early attention and surgical intervention are both needed. Wall notes, "The most important thing is identifying prolonged labor and intervening before a fistula develops. There are pilot studies using village health workers to identify women who do not delivery in a timely fashion and to route them to centers for more advanced obstetric care, but these are few and far between. There are programs to train emergency medical technicians who can perform Cesarean sections without being fully qualified doctors; there has been some success with this. With rare exceptions, however, fistula surgery requires surgical skill, long training and experience, so healthcare systems must develop the capacity to perform this kind of work, even when patients are not popular or wealthy enough to 'pay' for services."

While obstetric fistula mirrors many other NTDs, there is one way it is also unique--it affects women solely, and particularly very young women (age 12-14) whose bodies have not developed enough to safely bear children. Maternal health is already a sorely underfunded area of research. Every day, even in 2012, 800 women die from causes related to pregnancy and childbirth, and 99% of those are in developing countries, particularly in rural areas. A midwife working in Ethiopia and quoted in "Half the Sky" lamented, "If this happened to men, we would have foundations and supplies coming in from all over the world." The inclusion of obstetric fistula into the umbrella of NTDs could open up new funding streams and awareness, and bring us one step closer to this goal.

_____________________
*Mahabouba's story is told in "Half the Sky" by Nicholas Kristof and Sheryl WuDunn, pages 93-97, as well as in this New York Times article. Other women's stories can be found at this site.

Works cited and further reading

Wall, LL (2012). Obstetric Fistula Is a "Neglected Tropical Disease" PLoS Neglected Tropical Diseases, 6 (8) Link

Kruk et al. (2007) Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique. BJOG.

White et al. (1987) Emergency obstetric surgery performed by nurses in Zaïre. Lancet.

Wilson et al. (2011) A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ.

Kristof and DuWunn (2009). Half the Sky: Turning Oppression into Opportunity for Women Worldwide. Knopf, New York.

tsmith Tue, 08/28/2012 - 15:09

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