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Monday, February 23, 2015

You should be worried about pharmaceutical ethics: except when it comes to vaccines

In just a few short days the panic of measles has died down to barely a murmur in the news. The baby named Gryffin, who mother incited mass panic with her social media rant (and whose grandfather Alan Hibben is apparently a Canadian pharmaceuticals bigwig, oh well) has tested negative, predictably, and is presumably doing fine. Other infected individuals have apparently gone off into the sunset to convalesce uneventfully, since we haven't heard a damned thing about how they've fared since then; it's as if no one cares anymore (unless they die, of course).

Meanwhile, a few other interesting articles have surfaced (some old, some new) that haven't been getting the attention they should in light of the heated arguments and loss of friendships over whether to vaccinate or not. One such article was posted by Huffington Post Canada, who seems to be drinking less KoolAid over the vaccine debate than their American counterpart: "Merck has some explaining to do over its MMR vaccine claims."  Yes, yes they do have some "explaining" to do: but will they?

The article, originally published in September, leaves me wondering: has anyone followed up on this situation and whistle blower claims - which state that:

"It [Merck] "failed to disclose that its mumps vaccine was not as effective as Merck represented, (ii) used improper testing techniques, (iii) manipulated testing methodology, (iv) abandoned undesirable test results, (v) falsified test data, (vi) failed to adequately investigate and report the diminished efficacy of its mumps vaccine, (vii) falsely verified that each manufacturing lot of mumps vaccine would be as effective as identified in the labeling, (viii) falsely certified the accuracy of applications filed with the FDA, (ix) falsely certified compliance with the terms of the CDC purchase contract, (x) engaged in the fraud and concealment describe herein for the purpose of illegally monopolizing the U.S. market for mumps vaccine, (xi) mislabeled, misbranded, and falsely certified its mumps vaccine, and (xii) engaged in the other acts described herein to conceal the diminished efficacy of the vaccine the government was purchasing."

In an additional lawsuit, Merck came under fire for not only monopolizing the market on their mumps vaccine, but selling an overpriced product that was ineffective as well. The suit contends that Merck predicted a mumps outbreak would occur - and it did - especially in highly vaccinated populations both in 2006 and in 2009-2010.

And only what, five years later, we're hearing about this. After assuming "I'm sure they've all been vaccinated, you need to get vaccinated!" over and over again. Well, what if they were? "Oh, sometimes that happens, they're not 100 percent guaranteed." I'm sure it's never because the manufacturer knew they were selling a defective product, right? "Oh, you're such a conspiracy theorist!"

I find it pretty crappy that American news outlets didn't pick this up and trounce it all over the place. There is a virtual treasure trove of articles about ethics violations and conflict of interest between drug makers and studies, all from perfectly reputable sources that are trusted by most Americans, and yet, here we are. Still calling non-vaccinating parents "stupid" and expecting them to actually trust the same companies and regulatory bodies that are fudging numbers, touting flawed or seriously questionable studies when it comes to other medicines on the market. But that study that proved vaccines cause autism? Yeah, that one was debunked. So get over it.

For the record, I vaccinated my kids. I think one of them still needs another dose of varicella (whoops! eye roll) and if it were up to me or I had the energy to fight it, I'd probably say screw it and we'd proceed as normal. I am increasingly skeptical of vaccines, though; not because of autism, or Jenny McCarthy (gag) but because of stuff like this: that I'm supposed to question and be afraid of the ethics violations of drug companies and the FDA, just as long as it doesn't come to vaccines. Okay, that makes perfect sense.

It seems that when parents genuinely do have concerns about these companies or the far reach of the FDA when it comes to vaccinations, they're belittled, criticized, sworn at, and practically threatened with death or jail: they should die, their kids should die, they should be jailed, blah blah blah. I've heard it all. What they don't realize during their foaming-at-the-mouth rant is that they sound as bad as people who claim vaccines killed the dinosaurs (or whatever ridiculously implausible anti-vaccine rant you can think of). Besides, all that's been done before: during the American smallpox epidemic, refusers were often vaccinated at gun point or jailed because of their beliefs. And even then, they realized that duh, we can't really send a government-employed official out to hunt you down and vaccinate you against your will, so they stopped doing it by force (at least if you're a civilian). (Although there are some reports that claim people in Malawi were recently held at gunpoint during vaccination campaigns, but I can't corroborate that yet.)

Forbes Magazine - whose articles on vaccines often read like paid propaganda, in my opinion - warns us all to be wary of the FDA and the recall of generic Wellbutrin's 300 mg dosage, a drug primarily used for depression and smoking cessation. It was found that increasing numbers of patients were reporting drug ineffectiveness with the 300 mg dosage, and patient advocacy groups were ignored when they gathered hundreds of complaints from the get go. The FDA's response was essentially to blame the patient, since they do have mental illness after all, and claim that they had "faith" the drug was working as it should.

We should be scared to death
about the FDA ignoring
complaints about a generic drug -
but not about anything else?
Photo: Egahen/freeimages.com
Instead of conducting their own studies, the FDA then asked the manufacturer to look into the claims that the generic drug was not truly equivalent to the name brand. Even after they were forced to look into it themselves, they were slow to admit there was, in fact, a difference. Not only that, but they had to admit they only studied the 150 mg dosage, and didn't study the efficacy of the increased dosage at all, only assuming that it would work the same way. What was equally shocking: they received countless complaints and knew there were problems, but did absolutely nothing about it until they were forced to and could not contain the "problem" any longer.

This is, however, not the only case of bioequivalents not really being equivalent. The same is true of Synthroid and levothyroxine, used to treat thyroid disease, and some patients complain of a return of symptoms when being put on the generic drug. Most are told "it's all in your head" and insurance companies refuse to pay for the name brand preferred, even when it's clear the generic doesn't work for that particular patient. (If you want, you can read more here, but it's complicated.)

In this case, thousands of patients can be under treated for thyroid disease - which can lead to a host of other autoimmune diseases if not treated properly - not only keeping them feeling miserable, but eventually driving up healthcare costs in the long term. In the case of generic Wellbutrin, the author of the Forbes article rightly points out the toll is probably great: the number of people who, despite having mental illness, are perfectly capable of advocating for themselves and understanding their medicine isn't working; the number of patients who aren't able to advocate for themselves who are just further medicated into oblivion; and the patients who may have likely committed suicide because they were being inadequately treated. No doubt when that comes to light, there will be lawsuits, as there should be: and there are billions of dollars paid out to injured parties because of medication problems and recalls.

But why not vaccines? While there is the Vaccine Injury Compensation program, it seems like much is done to discredit and remove any possible link between vaccines and injury of any kind, autism or not. I personally don't know that I'd call it autism, per se, but in some children, no matter how "rare!" it is, there are still adverse reactions, some quite profound. You cannot expect parents to inject their children with a drug - and yes, it is a drug, with the possibility of creating side effects like any other drug - and poo poo their questions or concerns over it just because it doesn't happen to the majority of children. When you look at kids who are exhibiting marked, profoundly different behaviors shortly after vaccination that they never did before, you cannot simply dismiss them and encourage parents to remove their tinfoil hats of disbelief and forge full speed ahead into the most aggressive vaccine schedule this country has had to date.

Nor can you dismiss them from questioning the motives of "Big Pharma" and the FDA when it comes to vaccine efficacy and safety - because after all, this is the same entity that declared generic Wellbutrin 300 mg (and a laundry list of other drugs over the years) perfectly effective and "safe."

More reading:
Patients vindicated! Generic Wellbutrin withdrawn - The People's Pharmacy

Wednesday, January 21, 2015

When the media totally gets it wrong

When the media starts talking about a topic you are acutely aware of or one that's personal to you, you are more aware of when they get it wrong. In my case, birth advocacy and thyroid disease awareness are two subjects that are close to my heart and something I know a lot about.

So it's utterly depressing and maddening when you come across an article that is just so bad and misleading that you want to scream at the top of your lungs.

When the news does a terrible job covering a topic you're
intimately familiar with, it makes you wonder how
they handle all the other stuff.
Photo credit: jayofboy/freeimages
This one - The Daily Mail's "Australian woman gives herself a Cesarean section" - is pretty horrendous. You immediately conjure up images of serious peril; something has gone horribly wrong and she's in dire straits with no sign of help anywhere, right? Wrong!

Apparently, this is an article about a maternal-assisted cesarean (definitely not the same as performing the surgery on yourself, as the Mail implies), something that is verrrrrry slowwwwwwly catching on in the birth community. By slowly I mean probably at a snail's pace, because we still don't hear very much about it. The woman, disappointed over the fact that she could not have a VBAC with the twins she was carrying, decided that she wanted more of an active role in the birth and presented her case to her OB, who - not surprisingly - flatly refused. Apparently after he did more research, (gasp!) he changed his mind. (double gasp!)

"'(The doctor) was quite willing once he realized the risk of infection wasn't as high as he perhaps first thought,' Mrs. Wolffe said.'"

Amazing. An OB that listened the patient, while still yielding to necessary medical intervention, and they both had a positive outcome. I am speechless.

However, that's not the problem. Further down in the article, a video accompanies it captioned 'Live Cesarean: graphic 2013 video of birth broadcast on Twitter." Okay… except that's not the Australian woman's birth they're showing. In fact, it's from a hospital in Texas, something the Mail doesn't exactly explain beforehand and most people from their UK readership didn't pick up on (including, apparently, all the American accents in the room).

How this had anything to do with this woman's birth is beyond me, but it sure makes for great fodder for readers to totally attack her - everything from her looks, to her birthing practices, to a "DIY birth" (which it obviously was not). Some even criticized the weight of the babies, for whatever reason. At any rate, it did nothing to advocate for alternative choices in birth and only made the mother look like a total freak (if you trust the people commenting).

Thanks for totally misleading your readership, Daily Mail. Not that that's anything new, apparently…

Dr. Samadi's commentary on Fox left a lot to be desired,
namely the idea that there is more than one way of
treating thyroid disease - not to mention that many
doctors are neither well-versed in or willing to treat more
complicated cases.
January is Thyroid (Un)Awareness Month
Like bajillions of other Americans, I have thyroid disease, and it's a topic I've written about a lot. I've also basically forced myself to get educated on it in order to understand what was happening to my body, because I found that my doctors were not always that knowledgable. Apparently these guys are no exception.

Dr. David Samadi is apparently one of Fox News' resident doctor experts, which in and of itself isn't bad - except he's a urologist commenting on thyroid disease. Since the two aren't obviously related, I was puzzled why he was weighing in on the subject. While I realize they have time constraints on the broadcast, they really do reflect a serious problem with misinformation and an overall lack of education on the subject, which can often leave patients untreated or improperly medicated.

While I do give him points for mentioning more than just the TSH, it's important to know what to do with the results. Just this week I heard a patient say how enthusiastic their doctor was about ordering tests, even though she'd admitted there were some she had never heard of, but then also admitted she had no idea what to do with the results of the bloodwork. That doesn't help you very much as a patient, but at least she was being honest.

Another expert, NYU Medical School internist Dr. Mark Siegel, gives a very watered-down, extremely over-simplified and perhaps even dismissive explanation. His commentary also left a lot to be desired, and outraged a number of people in the comments who have firsthand experience with the disease.
"Here's the good news…[this] is so treatable… if you have low thyroid, I can give you something called levothyroxine. [It] just replaces the thyroid and you're back to normal. It's a great, great medication." 

Yes. Well. If you do well on levo, that's your business. Not everyone does, and while some prefer the name brand equivalent, Synthroid, some would rather choose neither and use Armour Thyroid instead - but you usually won't catch a single mainstream physician mentioning that in an article about hypothyroidism. Whether it's intentional or not, Synthroid is usually the only drug mentioned, which misleads patients into thinking Armour has been pulled from the market or simply doesn't exist anymore.

And wouldn't it be great if it were "just" that easy! Just pop a pill and you'll feel like a million bucks in no time. For some, it works great and they're on their way, but for others, it's a constant battle to get a physician to treat them adequately and even take them seriously.

When you catch them screwing up on a topic you're familiar with, it almost makes you wonder what they're telling you about all the other stuff.


Saturday, October 11, 2014

Pinkwashing the breastfeeding and breast cancer studies

It's October, the time of year where you're likely to see a proliferation of those pink ribbons on every item imaginable. You may see pink washing in a number of obvious places, and then in some not so obvious ones.

I saw this meme on FaceBook the other day. Wow, those figures are pretty convincing, aren't they? Or are they? I don't think I would've even noticed had I not just read an article - from a reputable source - that presented very different numbers.



I think I can safely say for all of us that breast cancer is pretty much every woman's worst nightmare. And while it is true, that some studies have found a correlation between reduced risk and duration of total nursing time as well as number of children breastfed, it is not conclusive. Despite everything - the money poured into awareness campaigns and research, "not much research has looked at links between breastfeeding and a lower risk of particular types of breast cancer in particular women."

That also doesn't mean it's an absolute that you won't get breast cancer if you breastfed, long-term or otherwise. I still remember a college professor of mine detecting her cancer literally while she was nursing her baby (who I believe was two at the time). In fact, one of the women commenting on the thread where this was originally shared said she'd been diagnosed with it while nursing her fourth child.

One thing that bugs me a lot about this meme is the complete lack of sources. Where is this information from? The first rule of thumb we learn in any basic composition class is "Always site your sources." When pressed for further data or information, the moderator of the page where this was shared kind of shrugged it off and figured the American Cancer Society would have more information. While I don't think she was the creator of this graphic, she was passing along incomplete information and didn't even realize it.

In fact, the American Cancer Society has something very different to say:
"For every 12 months of breastfeeding (either with only 1 child, or as the total period of a time for several children), the risk of breast cancer decreased by 4.3%, compared to women who did not breastfeed. Risk decreased by 3.4% for each child breastfed, compared to women who did not breastfeed.  This lower risk did not differ by women's age, race, numbers of births, age at birth of first child, family history, or country of residence." - American Cancer Society Expert Voices (click here for full article text)  
Something this meme doesn't address are the types of breast cancer impacted, which can be important - because some studies show that breastfeeding can offer protection from certain types of cancer more than others. As the article suggests, the studies are inconclusive, but so far seem to show more risk reduction for hormone receptor-negative cancers, which are more aggressive. While there is some evidence that breastfeeding can impact rates of hormone receptor-positive cancers, (which are the most common and are 'fueled' by estrogen), in my own reading I found it difficult to determine statistically how much protection was offered, and was concerned that advocacy groups and the general public are simply lumping the two together as one.

It took me awhile, but I was finally able to find the source for this meme's data, a study done in Sri Lanka on a very small group of women (100 cases with cancer, 203 controls). (It's also interesting to note that this study found a correlation between past abortion and cancer rates, but we won't even go there.) Unless you're from Sri Lanka, this could give women a very false sense of confidence.

That's not to say that there isn't some very promising, important data to consider, like these studies:

Delaying childbirth may reduce the risk of an aggressive form of breast cancer - from December 2012. Studies have shown that delaying the age of your first birth by at least 15 years after your first menstrual period could reduce the risk of rare but aggressive triple-negative breast cancer, by as much as 60 percent. While uncommon, it does not depend on estrogen to feed it, and is therefore unresponsive to conventional drugs like Tamoxifen. It accounts for roughly 10-20 percent of breast cancers.

Breastfeeding can reduce the risk of certain types of breast cancers. Recent studies have shown that breastfeeding can reduce the risk for estrogen receptor-negative and progesterone receptor-negative cancers, in women who had three or more children and did breastfeed. Risk was elevated in multiparous women who did not breastfeed. This type of cancer often strikes younger women and has a poor outlook. (The study also showed that in women who never had children, their risk decreased by 40% for hormone receptor-negative cancers, but went up by the same amount for hormone receptor-positive cancer.)

Race can also be a factor in hormone receptor-negative cancers: African-American women who had four or more children but never breastfed are 68% more likely to get this type of cancer, compared to women who had only one child but did breastfeed. Studies showed that with each child breastfed, the risk declined. The study also showed that among African-American women who had given birth four or more times, there was slight protection against hormone receptor-positive cancers, regardless of whether they breastfed or not. The same was found for white women.

"The higher incidence of ER-/PR- breast cancer in African American women may be explained in part by their higher parity and lower prevalence of breastfeeding relative to white women." - Julie Palmer, ScD, MPH, senior epidemiologist at the Slone Epidemiology Center and professor of epidemiology at Boston University School of Public Health 

• A Canadian study showed promise for those with a family history of breast cancer - specifically those with the BRCA1 gene (which is more often hormone receptor-negative), stating that breastfeeding for a year could reduce their chance of cancer by 32%, and with "each year of breastfeeding, it reduced their risk by 19%. "With two or more years of breastfeeding, that risk was nearly cut in half. Researchers "calculated that just five women with the BRCA1 gene needed to breastfeed for a year to prevent one developing cancer." It's important to note, however, that these benefits were not observed with women carrying the BRCA2 gene (which is more frequently hormone receptor-positive).  

An earlier US study found, however, that among women with a family history of breast cancer, there was a 59% reduction in risk of getting premenopausal breast cancer, but did not specify which type. (Most likely it is hormone receptor-negative.) The study also noted the duration of breastfeeding did not seem to make a significant impact, and noted "the reduction in risk was similar whether women breastfed for a lifetime total of three months or more than three years." Nor was there a difference noted among women with no family history.

Personally, I think it's important to look at several things when presented with statistics: first, what is their source? Is the study old, and have newer, more accurate studies come out since then? What population did they study? What factors did they include, or exclude?

For instance, an interesting study was conducted by a Chinese researcher at Yale University, which was entirely comprised of Chinese women, mainly because he claimed they have substantially longer breastfeeding rates than the United States. His research (which was published in 2001) looked at three studies conducted in the 1980's, not long after China adopted their infamous one-child policy. Given what we now know about cancer rates and multiparous women and their breastfeeding habits, it is a wonder he could find any woman who had managed to give birth more than once to even do the study. (The one-child policy applies to roughly a third of the population, but the overall parity rate of Chinese women as of 2013 is about 1.5 children, suggesting it has become a cultural standard to have lower birth rates overall.)

While he found a "50 percent reduction in breast cancer risk among those women who breastfed for more than 24 months per child, compared to women who breastfed their children for less than 12 months," it's interesting to note that according to this article, China's breastfeeding rates have "plummeted since the 1970's" when infant formula was introduced. In the 1980's, when these studies were conducted, breastfeeding rates in China were at their lowest.

While this might be good news for Chinese women, it is hard to tell if it correlates to Western women for a number of reasons. Dietary and lifestyle differences can also impact cancer rates, and vary widely between East and West populations. And while this study was published in 2001, as of now roughly 58% of Chinese women exclusively breastfeed their newborns, whereas it drops sharply to around 14% by five months, making it on par with the United States. (And by month six, it nosedives to an alarming 2%.) As of 2013, it was declared that China's breastfeeding rates were "among the world's lowest."

The researcher claimed, "In Chinese society, it is socially acceptable to breastfeed for a long time." Could it really have changed that much in a little more than a decade?

Either way, we need to be careful not only in how we share the data, but how we interpret it. When reading these kinds of statistics, pay close attention to what sources, if any, are listed. Likewise, realize that there could be flaws, unanswered questions or stipulations in those numbers that are not reflected in a meme that merely spews out numbers without proof, leaving the reader with a false sense of confidence and security about a very serious topic. It's important to not take the data as a personal attack as long as it's shared appropriately or dismiss the benefits of breastfeeding for both mom and baby. Likewise, studies should be shared without judgment or hostility. Whether in sharing or interpreting this data, it's so important to get the facts straight and understand the caveats that could seriously impact our understanding of our own level of risk.

_____________
Sources:

The Chinese government really, really wants babies to breastfeed - Quartz.com (a good piece that is particularly damning of the heavy influence of infant formula in the Chinese market) 

Friday, September 26, 2014

A glimpse into 1950s parenting: The A-ha Moment

When we think of typical 1950s parenting, we picture dad coming home from work, belt in hand; mom is perfectly made up and ready for bridge club, remote, distant, and oblivious. But when I came across an article from 1957
in an old magazine I bought at an antique store, it made me smile to think there were parents even then who "got it."

"I wish I had stopped a little oftener to think, "Does this really matter? Is it more
important to them than to me?"
There were the Dr. Spocks and other experts who warned you about the dangers of spoiling your babies, how to introduce solids by four weeks and all kinds of other "advice" that is truly horrifying to think of today. Sometimes you wonder if these "experts" even had children themselves. Even Dr. Spock, in his twilight years, regretted the advice he dispensed and backpedaled on his own message. It's sad that for some, it took a lifetime to realize; for others, like the author of this article, thankfully we stopped to realize a bit sooner that maybe there is more to life than spanking, yelling and rigid, unbending schedules. Hopefully we can all find a happy medium.




Thursday, September 18, 2014

Reply turned post: The Beauty of OB

You often see posts like "Confessions of a Labor Nurse," or "Why You Need Pitocin in Labor" (I think poor Nurse Jenna removed that post a long time ago) and they're supposed to be touchy-feely, feel good pieces that make you come away with a renewed sense that childbirth is such a special time, that your care provider really does care about you and your child and they only want the best for you. Which sometimes comes at a high price, we know. Sometimes an induction, a cesarean, difficult labor and delivery - they all can happen and are often a rite of passage before entry into motherhood. 

It's hard for me not to be cynical about it. But to cut to the chase, sometimes I think the true beauty of OB is that women still want, and manage, to give birth at all after being subjected to the institutional abuses and misuses that are so typical of modern obstetrics. 

That isn't to say I'm critical of lifesaving measures, or that I'm saying, "All cesareans are unnecessary!" I'm more critical of abuse of care and intervention that is misconstrued as good care, when really, it's excessive and sometimes pointless, sometimes causing the problem you're trying to prevent in the first place. 

But I feel like all these posts have an overtone that says, "You should be thankful. Now shut. up."

The author of this article over at Huffington Post is an L&D nurse. I'm not, and I'm not trying to compare my experiences with hers. But as I see so often in these posts, they really don't get to the heart of the matter. They sort of gloss over, or completely miss, whole areas that are often untouched in our culture of women. The idea that women often come home without a baby, or sometimes never come home themselves, is incredibly tragic. No one is arguing with that. Modern obstetrics has saved many lives, both mothers and babies, and yet the place we are in today is proof of how its overuse can taint our perception of things so much we can't see what's really going on. 

Often the women who are missing, shattered or empty, as the writer mentions, are not only the ones who never survive childbirth or come home to an empty crib. They are often women who look normal and whole on the outside, with perfectly healthy children. We cannot discount their experiences and just assume that everything is perfectly normal and right because we can't see anything broken, or lost. If a woman is subjected to horrible treatment in labor, sometimes resulting in physical injury, how many times does an attorney refuse to handle her case if she seeks prosecution? Because she and her baby both appear healthy and happy on the outside? If no one is physically maimed or dead, they don't even want to talk to you. 

The author mentions staying healthy in pregnancy and waiting for active labor as ways to have a healthy delivery, avoiding induction unless for a medical reason. But unless you know what some valid medical reasons are (and more importantly, aren't) anything that comes out of your doctor's mouth is therefore a 'medical reason' and before you know it, the Pitocin is flowing. Staying healthy is relative, unless you're an illicit drug or alcohol user, and even the healthiest, most informed women can still be subjected to dubious care at times. Oftentimes it never seems to be enough. And often has nothing to do with you and everything to do with an impatient, overbearing care provider who is set in his/her ways and refuses to change. 

She mentions the case of a teenage mother who was induced, with no success, and then sectioned. As a result, she hemorrhaged and her uterus was removed. They lamented, rightfully so, over the fact that she would never have any more children. Do they ever lament over how some teen mothers are degraded and insulted because they're young and often unmarried? Or do they consider for a moment that this young mother's complications were caused in part because of the induction, which carries a risk of postpartum hemorrhage? Why do these happy sunshine articles never, ever candidly discuss what goes on behind closed doors, the whispered conversations or blatant remarks when they don't think a patient is listening - or when they don't care if they are? 

Yes, it's great to do all the "right" things in your pregnancy to encourage the best outcome possible. And sometimes, those things happen despite your best efforts. But when you look at these figures, it's hard to see the "beauty" in OB, only the ugly side that makes it seem like the deck is stacked against you. 

For the original graph and accompanying post, click here
Source: Evidencebasedbirth.com,  Rebecca Dekker, PhD, RN, APRN 


Thursday, May 22, 2014

Birth History: Death in Childbirth


In the days of our great-grandmothers and beyond, childbirth was often a dreaded, formidable time. Hospitals were usually avoided as places where only sick people went, usually never to return. The possibility of death while giving birth loomed over a woman as she came closer to her due date, overshadowing any joy of her upcoming arrival.

Among the greatest risks to a woman in childbirth were childbed fever, toxemia and postpartum hemorrhage; the last two of which are still a major cause of maternal deaths worldwide today.

Childbed fever, or puerperal fever, is an infection of the female reproductive organs and was one of the most common causes of death in childbirth prior to the early 20th century. It frequently took the mother's life within days of giving birth and was extremely painful. And it was almost entirely caused by the hygiene practices of the birth attendant - which included midwives and physicians.

It's important to make this distinction, because many times people tend to think of midwives of that time period as uneducated, inept, or practicing witchcraft in an unsanitary, ramshackle house. While there were some that did, there were many who were very capable, some even experiencing fewer deaths than their physician counterparts.

A Lysol ad from 1937, referencing
infection control both in hospital births
and those that take place at home. 
It is also worthy of noting that, unlike with neonatal mortality rates, maternal deaths were more likely to happen among women in higher socioeconomic classes: likely because they were more apt to go to hospitals to give birth or have the finances to pay for a private physician.

Dr. Ignaz Semmelweis is often credited with understanding how childbed fever was transmitted: he theorized, correctly, that midwives and physicians were spreading the streptococcus pyogenes bacteria through improper hand washing from patient to patient. He proposed that physicians wash their hands in a chlorine solution prior to delivering a child, an idea that offended fellow doctors. Despite his repeated attempts to educate healthcare workers on proper hygiene, they often ignored his requests and refused to believe they were, in fact, contributing to the problem - even as maternal deaths were decreasing among those who practiced Semmelweis' hand washing guidelines.

When he first introduced the protocols in a Vienna obstetrical clinic in 1847, the rate of childbed fever deaths in the doctors' wards was three times higher than that of the midwives' wards.

Decades before Semmelweis' work, physician Alexander Gordon made similar observations as early as 1790. His ideas were not well-received and he was essentially run out of practice. Later, physician Oliver Wendell Holmes came to the same conclusions, only to be equally rebuffed and ignored.

It literally took decades - roughly half a century - before physicians started admitting that perhaps they were indeed the cause of infection and deaths in so many women. And even then, it wasn't until around the 1930s when cases finally started to become scarce, due in part to better hygiene practices, more sanitary birthing conditions and the introduction of antibiotics and sulfa drugs. During Semmelweis' work in Austrian maternity wards, handwashing alone led to a dramatic lowering of maternal deaths.

It was 1925 when my great-grandmother delivered her last babies, a set of twins, at home. The doctor was called in - who I later discovered had questionable hygiene practices. Even then, after much was known about controlling the spread of infection, obviously some continued to disregard it. In my opinion, it's not enough to say "Women died in childbirth before modern obstetrics. You should be thankful your physician does X, Y, Z to make sure you and your baby is safe." Most of us know that maternal deaths were far more common, but do we understand why? One birth blogger who spent an unusual amount of time criticizing the natural birth movement wrote about 'those headstones in a graveyard of all those mothers and infants who had died because of natural childbirth.' (Paraphrasing a bit here, as it's been a few years ago since I read that. But still, that was the gist of the message.) One thing I have noticed: when discussing maternal deaths, many sources will completely gloss over the cause, as if it was just an unfortunate problem that happened for no reason.

Today:
Puerperal fever is still a risk of childbirth today, but in many cases we have different names for it. Although rare, it does still claim the lives of women. No longer known as 'childbed fever,' it is not unusual for women to develop fevers during labor, which are usually treated with imminent delivery, cesarean section (which alone can increase risk of infection) and antibiotics at the first sign of a problem. Chorioamnionitis, an inflammation of the fetal membranes, is caused by a bacterial infection that tends to occur in longer labors. Among the risk factors are repeated vaginal exams and internal fetal monitoring.

It is true that in many ways, modern obstetrics has saved countless lives of both mothers and babies. But you have to have some perspective on the reasons why many women died -  reasons that were primarily iatrogenic in nature - death brought about by the very people who were supposed to save them.

Links:
Childbirth in Early America - Digital History
British maternal mortality in the 19th and 20th centuries - National Center for Biotechnology Information
The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory: National Center for Biotechnology Information

Saturday, May 17, 2014

Birth History: A Dysfunctional Culture




May is Pregnancy Awareness Month, and while I've covered some of these topics before, I've been planning to put them together in more of a series for quite some time now. There is so much to learn while pregnant, and it can get quite overwhelming when you're faced with decisions that range from the mundane to the life-changing. So much of how our medical community views pregnancy, however, is still deeply rooted in old traditions and practices, some of which were, and continue to be, groundbreaking in the field of obstetrics. Some, on the other hand, not so much.

I once heard someone say how hard can it be? You go to the hospital and push out a baby. If only it were that easy. And if you go behind the scenes much, it's probably never been that easy, for reasons that are often not clear to us until we experience childbirth ourselves. Even then, without some historical perspective, we may not realize just how dysfunctional maternity care in this country still remains, probably a century later.

Many maternity care practices were nothing short of barbaric and humiliating, yet were seen as standard practice and therefore somehow acceptable. Whether it's having your hands tied down in labor, being given pain medication that you feel you don't want or need (as we see in Peggy Vincent's Baby Catcher) or given prophylactic episiotomies and forceps births (we'll get to that later), it's all been considered status quo in "modern" obstetrics. And yet, as we see with new guidelines on episiotomy, VBAC and other protocols, it can be painfully slow to implement these changes.

You can't begin to understand the 'typical' mindset towards birth today unless you understand its history. It is a bright spot in some places, in others very dark and tarnished.

You might want to read:

Birth: The Surprising History of How We Are Born