November 7, 2011
A recent article about the shameful infant mortality rate in the U.S. caught my attention. Certainly the statistics quoted are nothing new but still remains alarming. However, the Op Ed by CNN contributor Deborah Klein Walker gave the subject matter a new spin. Walker wrote “This is one of the greatest injustices in our country: that a baby’s chance of having a healthy life is largely dependent on where he or she is born. States and local communities vary widely in what care their leaders choose to provide to women and children.” If Dr. Walker were present, I’d give her a great big hug for her courage to say what no one else dared. A baby can die based on a hospital zip code.
Every pregnant mother needs to take a mini course in hospital politics because they are directly affected. A hospital is no longer a place of healing. It is a business and at times, ruthless. I have witnessed a colleague forced out of business because she said no when a hospital wanted to buy her practice so they withdrew her admitting privileges instead. I recall bitter battles with my former employer because I would not encourage my patients to deliver at a hospital that was notorious for being under staffed, overworked and a haven for medical errors, simply because of a business relationship that my employer had with thatehospital.
I commend our federal government for initiating programs such as Healthy Start and the new home visiting program, but dependence on government assistance alone cannot guarantee a healthy baby. A pregnant mom must do her due diligence. She must investigate the credentials of the provider and hospital where she intends to give birth. What should a pregnant mom do if she lives in a community or state that has a high infant mortality rate? Give birth at a teaching hospital that’s affiliated with a university or medical school. Most of these institutions receive federal and state financial support and are obligated to provide care to patients.
Can a baby die based on the zip code where it’s born? Unfortunately, yes unless the mother is willing to do her homework and take the necessary precautions to avoid that from happening. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
March 16, 2011
To everything there is a season and mine comes to an end today. For 760 weeks I attempted to give quality care to my patients. The task was not always easy especially when most of my patients held the unenviable position of having a high risk pregnancy and receiving Medicaid or being uninsured. Babies have a right to be born healthy regardless of their mothers’ income or insurance status.
The memories of my tenure at the county health department are indelible. I remember the woman who paid to be taken across the border only to be abandoned and walked from San Salvador to Texas. And the obese patient who rode a bicycle to the clinic with a blood pressure of 221/110. Of course she refused to go to the hospital because she alleged that they treated her “like dirt.” I begged, pleaded, and personally drove up the street to fill her blood pressure medication prescription to avoid her having a stroke or seizure in my exam room. My nurse found an ambulance company that was willing to take her to the high risk specialty hospital where she delivered prematurely in order to save her life and that of her baby’s.
And then there was dear Priscilla* (name changed) who had a bipolar breakdown and was about to be inappropriately discharged from the labor room triage until I advocated from my home around midnight and found her a hospital bed in my county where she was appropriately admitted, treated and subsequently delivered. There was also Katy* (name changed) who was sent home inappropriately with low fluid and subsequently went “on vacation.” I tracked her down in another state, told her to go to the nearest hospital where she was emergently admitted and delivered via c/s. My advocacy, diagnostic saves and battles with hospital clerks (who practice medicine without a license) continued for almost 15 years. It was difficult, stressful and at times frustrating, especially when the administration’s emphasis was on patient volume and money as opposed to quality patient care.
As this chapter of my life closes, I’d like to think that I’ve made a small but unique difference in the lives of others. I will indeed miss my patients, but I will not miss the stress. Service is the price we pay for being here. I hope I have served humanity well.
September 15, 2010
Whenever a pregnant woman lists “no pain medication” in her birth plan, I cringe and then urge her not to be stoic. Women who are not in pain tend to progress better in labor, contrary to myths and fabrications. According to medical studies, labor can cause pain similar to an amputated finger. The American Congress of Obstetrician-Gynecologists states that it is unacceptable for “an individual to experience untreated severe pain” that can be corrected with anesthesia while under the treatment of a physician. As long as there are no medical reasons prohibiting medication, pregnant women should ask and receive pain relief while in labor.
Untreated labor pain has been associated with the development of post-traumatic stress disorder. Post partum depression is more common in women who did not receive pain relief during labor and men are also affected when their laboring partners are in pain. A discussion of pain relief should be done by OB care providers prior to the patient’s hospital admission including whether the anesthesia services will be covered by her insurance plan, including Medicaid.
Not all pregnant women need to receive an epidural although it should definitely be an option. There are many options for pain relief in early labor including IV medications, acupuncture, assistance from a doula, and water therapy in showers or whirlpool baths. As the labor progresses, an epidural may be requested.
An anesthesia evaluation should be done by an anesthetist or anesthesiologist prior to the placement of an epidural, including informed consent for the procedure. Information such as bleeding disorders, low blood pressure and the use of blood thinners should always be obtained. The most common side effect of an epidural is low blood pressure which can be corrected provided that emergency equipment is readily available. Fetal monitoring should be continuous while the patient is receiving an epidural as well as monitoring of her blood pressure. Many hospitals now offer a patient-controlled epidural pump that allows the patient to sit up or walk while in labor.
Contrary to popular belief, epidural anesthesia does not increase the rate of cesarean sections but it can increase the second stage (time that the patient is pushing) by 15 to 30 minutes as well as the use of forceps or a vacuum extractor. It’s equally important to make certain that the anesthesia has not eliminated the patient’s ability to feel the urge to push.
Giving birth is one of the most pivotal moments in a women’s life. Please do everything in your power to make it enjoyable.
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
July 12, 2010
Every time I want to retreat from medicine, stories Like Angela Burgin Logan’s give me reasons to press on. Angela almost died having a baby because her physician was too careless to listen. Stories like Angela’s is what inspired me to write The Smart Mother’s Guide to a Better Pregnancy. I saw too many “near-miss” and “near-death” occurrences among pregnant women and decided to do something about it because most of them are preventable.
Angela is a 30-something year old African American alumnus of Syracuse University who has extensive business experience as a marketing executive for celebrities and is also married to one. She had an uneventful pregnancy up until her late second trimester when she developed signs and symptoms that any trained obstetrician would have immediately recognized as impending pre-eclampsia. She gained five pounds a week and developed swelling. She could only sleep propped up on a pillow because she couldn’t breathe pillow. She complained of shortness of breath and difficulty walking. All of her complaints were disregarded by her physician and staff in a condescending manner. It was only after she gained 15 pounds in one week did her physician reluctantly order lab tests based on her insistence.
On the night of her delivery, she went to the hospital because she could not breathe. Her blood pressure was extremely high, her platelets were low and she had significant protein in the urine. Angela had a lethal variant of pre-eclampsia called the HELLP Syndrome. Against Angela’s wishes, she was forced to lie on her back for a nursing procedure and fluid seeped into her lungs. She lapsed into a coma. An emergency C. Section was performed and it was discovered that she had an enlarged heart. Her infant daughter was born in distress and there was an 80 percent chance that Angela would die. Thank God she didn’t. Angela is now on a mission to warn pregnant moms about pre-eclampsia and urges them to “trust their instincts.” I totally agree.
Arrogance and condescension have no place in a patient-physician relationship and is a sure-fire way to end up in court. I urge all pregnant women to become proactive regarding their prenatal care and above all, trust your instincts. The days of the passive patient are gone. A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 26, 2010
Insomnia or difficulty falling asleep can affect pregnant women and is usually seen during the last four weeks of pregnancy. It usually occurs because hormone levels mimic menopause and resolves after the baby is born. In extreme cases, some healthcare practitioners will prescribe sleep aids such as Ambien® or its generic form, Zolpidem on a short term basis.
Recently, I interviewed a third-trimester patient who had transferred from another state. Towards the end of the interview, she asked me if I would prescribe Zolpidem which she had been taking since fourteen weeks. I found this highly unusual because pregnant women do not usually experience insomnia that early in their pregnancy. Because I do not prescribe sleeping pills in my practice, I consulted with a high-risk specialist for his expert opinion and received a rude awakening. He informed me that women who take Zolpidem are at high risk for committing suicide and there is probably a mental health issue that needs to be addressed. When I asked the patient whether she was depressed, she admitted that she has been “under stress” during her pregnancy, her husband was previously incarcerated and that she would be amenable to going to a mental health professional for a depression screening and possible medication. I was both relieved and annoyed. Upon investigating the medication further, I discovered that
- Zolpidem or Ambien° should never be prescribed without first determining the reason for the sleep disturbance
- It is only to be used on a SHORT TERM basis
- It is often used as a drug of choice for suicide attempts, can worsen depression
- Stopping it abruptly could lead to withdrawal symptoms
- It is a Category C med meaning it can be taken during pregnancy but there are risks
Pregnant women should not take sleeping pills on a long-term basis. If insomnia lasts for more than two weeks, insist that further tests be done.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 12, 2010
If it appears that the number of ob-gyn physicians in private practice is shrinking, it’s not a figment of your imagination; it’s real. There are a burgeoning number of obstetricians who can no longer pay for malpractice insurance but they’re too embarrassed to tell you. Shrinking reimbursements (or payments) from insurance companies coupled with higher medical practice premiums have changed the landscape of obstetrics dramatically.
Some Ob physicians have stopped delivering babies, others have retired from private practice and many have become hospital employees called hospitalists. Hospitalists will take care of you in the hospital while your ob provider sees patients in the office; in some cases, a LOT more patients, but more on that in a minute.
Contrary to popular belief, the days of milk and honey for most physicians are gone. Money previously spent on vacation homes, boats, luxury cars and exotic vacations is now used to pay for billing code specialists, and triple the number of their original office staff in order to fulfill insurance demands. False denials of payments by insurance companies mean additional paperwork and manpower. Delay of payments is the order of the day and higher patient co-pays certainly don’t help. Many physicians can’t provide health insurance for their office staff because of prohibitive costs.
It’s not a coincidence that gyn-“spas” are on the rise and your gynecologist is now doing liposuction, facials and selling vitamins. Some obstetricians opt to see more patients as a way to compensate for their losses and that becomes a dilemma. As the number of patients increases, the quality of their care decreases.
There is also the danger of monopolies forming when hospital systems purchase physician practices which could drive up the cost of healthcare even more and limit your physician’s autonomy. So, what is a patient to do? Empower yourself with information. Ask how many patients your physician sees per day before making an appointment. If your insurance company is delaying payment for your procedure, file an official complaint with your State Commissioner of Insurance or to the Center for Medicare and Medicaid if it’s a self-insured plan. If your OB is honest enough to admit their concerns, ask how you can help.
Small changes CAN make big differences.
March 10, 2010
Electronic fetal monitoring was first used at Yale University in the 1950s and is a great asset in terms of checking fetal well being. Unless a woman delivers at home, most pregnant women will have fetal monitoring during the time that they’re in labor. The fetal monitor measures both the baby’s heart rate and the mother’s uterine contractions. Why is this important? Because the vein in the baby’s umbilical cord receives oxygen which is necessary for growth and development, especially in the brain. When the uterus contracts, the blood flow to the baby is reduced, then increases once the contraction is over. The fetal monitor essentially tells us two important things: (1) whether the baby is tolerating labor and (2) whether it’s receiving enough oxygen.
Of four million babies born in the US each year, approximately 875,000 will experience birth injuries. What is a birth injury? It’s any type of injury suffered by an infant as a result of the birthing process. Most birth injuries can be avoided if someone is paying attention. Babies can’t tell us when they’re in trouble with their mouths, but they can certainly do so with their hearts. The signs of normal and abnormal fetal heart tracings are included in The Smart Mother’s Guide to a Better Pregnancy. Fetal tracings are either reassuring (meaning good) or nonreassuring (not good). If the fetal tracing is nonreassuring, then the baby needs to be delivered as quickly as possible.
Despite our current healthcare challenges, babies will continue to be born. I therefore encourage all pregnant women, childbirth educators and doulas to take these bold new steps:
- Become familiar with fetal tracings and the distinction between reassuring and nonreassuring traces (pages 201 and 202 of The Smart Mothers Guide®)
- Doulas should become Labor Room Advocates who can be another set of eyes and ears that can address any issues during labor and make certain that appropriate communication of hospital staff (including the status of the fetal tracing) is known during a shift change
- Become familiar with a high-risk specialist who can offer a second opinion in case there is a disagreement regarding labor room management
When your baby’s fetal monitor attempts to “talk” to you, everyone should understand what it’s saying.
September 7, 2009
Did you know that nearly seven babies will die before their first birthday for every thousand who are born in the U.S. and the rate for African American, Hispanic and Native American women, are even higher? Premature births occurring before thirty-seven weeks and low-weight babies, weighing less than five pounds account for the highest number of deaths in the U.S.
In recognition of September as the National Infant Mortality Awareness Month, I’d like to share some SMART tips to pregnant women:
S = Seek prenatal care early. Problems in pregnancy cannot be fixed at the last minute. Tests for genetic problems can only be detected in the early first and second trimesters. A first trimester ultrasound is also the MOST accurate in terms of a due date.
M = Mention all high-risk factors such as family history of diabetes, high blood pressure or bleeding. Do not omit information such as smoking or “recreational” drugs. It will come back to haunt you.
A= Ask to have your cervix measured during your ultrasound if there is a previous history of premature contractions or delivery. A cervical length of 2.5 centimeters or less is a risk factor for preterm labor.
R= Research your hospital and prospective physician or midwife carefully. Is the physician or midwife skilled in managing high-risk conditions? Will they continue to see you even if you lose your insurance? Has the hospital had any recent outbreaks of antibiotic-resistant – infections in the newborn nursery? Is there 24-hour anesthesia?
T= Test for potential problems such as Gestational Diabetes, Sickle Cell Trait or sexually transmitted infections.
The U.S. is one of the most industrialized countries in the world, yet we rank below Cuba and Taiwan, with respect to our national infant mortality rate. The health of a nation is judged by its national infant mortality rate. We can do better. We must do better. The health of our future generation is depending on it.