The War on Women’s Health
Part 3: Maternal Fetal Medicine
Planning for knowns while anticipating the unknowns.
Contraindications for pregnancy
Why unplanned pregnancies are bad
Women who are aware that a pregnancy would be high-risk may decide to delay getting pregnant. A high-risk pregnancy is one where there are potential complications that could affect the mother, baby, or both. Good medical practice requires high-risk pregnancies to be managed by a specialist to help ensure the best outcome for the mother and baby.
Risk come from a multitude of sources. Some conditions that can make a pregnancy high-risk include: the age of the mother,1 chronic diseases like cancer,2 – 13 infections and STDs,14 – 17, 21, 30 mental health medication,18, 31, 32 and recreational drug use including alcohol and tobacco,19, 20, 33environmentally imposed risks,22 – 24 inheritable genetic disorders.25 – 29
Many developing fetal systems are vulnerable to outside influences called teratogens, especially during the first 4 to 10 weeks after conception. The fetal neurological system can develop neural tube defects, spina bifida, and mental retardation. The cardiovascular system is susceptible to birth defects such as truncus arteriosus, atrial septal defects, and ventricular septal defects. The skeleton can develop with musculoskeletal anomalies and clubfoot. Myasthenia gravis and severe combined immune deficiency affect the immune system. Female fetuses can suffer from the masculinization of their external genitalia. Other fetus components that are susceptible to birth defects include: ears, eyes, teeth, upper lip, palate, upper & lower limbs, kidneys, and lungs.
Teratogens also produce effects on the fetus indirectly through the mother. Maternal teratogens effects include creating susceptibility to premature birth, intrauterine growth retardation (small for gestational age infants), and placental development interruptions.
A woman may not be aware that she is pregnant.
The early signs of pregnancy are variable between women and even from pregnancy to pregnancy in the same woman. Adding to the confusion is that the early symptoms of pregnancy also resemble symptoms before and during menstruation. Even more confusing is some women have periodic bleeding during pregnancy mimicking their menstrual period.
While some women are so aware of their bodies, they seem to know from the start when they become pregnant, most don’t realize they are pregnant until they miss their menstrual period.
A woman’s menstrual period isn’t a sure fire way to determine if she is pregnant. For some women, an irregular period will make it difficult to recognized if an atypical event such as a pregnancy has occurred.
Irregular periods often occur during the first few years after menarche just when women start to explore their sexuality. Irregular periods usually occur just before memopause. Menstrual irregularities can be caused by diseases such as irritable bowel syndrome, tuberculosis, liver disease, and diabetes.
Even a missed menstrual period doesn’t necessary mean a pregnancy. Other causes for a missed period include: excessive weight loss or gain, eating disorders such as anorexia or bulimia, increased exercise, emotional stress, illness, travel, pelvic organ problems such as impeforate hymen, and polycrystic ovary syndrome, or Asherman’s syndrome. This is by no means an complete list.
A pregnancy test in the only reliably way to know for certain if a woman is pregnant.
The only way a woman can avoid the birth defect dangers caused by teratogens is to know when she is pregnant. And the only way for a sexually active, fecund, non-pregnant or postpartum abstinence woman to be certain of not becoming pregnant is through the use of adequate family planning and modern contraceptives.
Only then can a woman take into account their personal and family situation and make appropriate medical decisions that are best for her and her baby’s health.
Other overlooked benefits of oral contraceptive pills37
According to the American College of Obstetrics and Gynecology (ACOG), oral contraceptive pills (OCPs) help relieve or reduce the symptoms of dysmenorrhea (menstrual pain), normalization of irregular periods, acne treatment, treatment of endometriosis caused pelvic pain, prevention of menstrual-related migraines, menorrhagia (excessive menstrual bleeding), bleeding due to uterine fibroids, hirsutism (excess hair growth), suppression of menstruation.
National data from the 2006–2008 National Survey of Family Growth shows 58% of women on the pill use it for some type of noncontraceptive reason. Noncontraceptive reasons are the only reason for 14% of the women on the pill. In addition more than one-third of the women, which use the pill for noncontraceptive reasons, have multiple non-birth control health benefit reasons.
Or pregnancy is for life
During a woman’s pregnancy, some cells from the fetus traverse through the placenta into the maternal circulation (fetal microchimerism (FMc)) and some cells from the mother travel to the fetus (maternal microchimerism(MMc)).38
“Fetal cells have been detected in the human maternal circulation as early as 4 weeks and 5 days post-conception” to “as long as 27 years after the birth of a male.”40
This exchange of cells is expected since the placenta rather than being an impassable gate, must act like a selective porous filter to allow the developing fetus to obtain nourishment etc. These immigrant cells “persist in their new host, circulating in the blood and even taking up residence in various tissues.”41
The immigrant maternal cells in the fetus can persist well into adult life.42 Another probable source of Mc in the fetus is from an older sibling or previous pregnancy of the mother.43
This means that every woman harbors foreign DNA derived from the fetuses of all her pregnancies and all fetuses harbor foreign DNA derived from their mothers and the fetuses of all her previous pregnancies. They may harbor this DNA for the remainder of their lives.
Various studies have implicated microchimerism in diseases such as systemic sclerosis (SSc), primary biliary cirrhosis (PBC), Sjögren’s syndrome, polymorphic eruption of pregnancy, myositis, and thyroid disease.39
Eighty percent of people with autoimmune diseases are women.44 Several autoimmune diseases affect women in their postpartum years. Fetus-maternal microchimerism is one hypotheses proposed to explain the gender difference.
Hashimoto’s thyroiditis is an autoimmune disease believed to be the most common cause of primary hypothyroidism. It is characterized by a range of symptoms including weight gain, depression, fatigue, mania, memory loss, panic attacks, and hair loss. Sjogren’s syndrome is an autoimmune disease. It has symptoms such as dry mouth and dry eyes. Other autoimmune diseases where fetal DNA was detected, sometimes decades after pregnancy, include progressive systemic sclerosis (PSS) and systemic lupus erythematosus.
Other diseases fetus-maternal microchimerism has been implicated in include steatosis, hepatitis C, primary biliary cirrhosis, and cardiovascular disease.43 Its role in several cancers has been the subject of investigation including thyroid cancer, cervical cancer, lung cancer and melanoma.
Its role in degenerative diseases such as Alzheimer’s disease is intriguing. It has been suggested that an abnormal accumulation of fetal origin microchimerism is responsible for the increase risk with increase number of pregnancies for Alzheimer’s disease and the five fold increased risk in mothers who gave birth to a child with down syndrome.
Fetus-maternal microchimerism derived cells have been found in bone marrow, thyroid, lungs, lymph node, skin, kidney, liver, heart, intestine, gallbladder, cervix, brain, blood, spleen, pancreas, and other tissues.
Yet there is some evidence that fetal-derived cells may provide some protection against breast cancer.45
Mc caused disease isn’t a one-way street. Chronic inflammatory disease in offspring has been linked to MMc.46 In neonatal lupus syndrome-congenital heart block (NLS-CHB), an acquired autoimmune disease, the hearts of patients have been found containing maternal myocardial cells.47 In juvenile dermatomyositis (JDM), a multisystem autoimmune disease, the presence of maternally derived chimeric cells was found and data indicates they have a direct role in the JDM disease process.48
The foreign DNA derived from siblings from previous pregnancies that a child harbors could be to its beneﬁt or detriment.43
The research into FMc and MMc, is still in its infancy. The jury is still out as to the relationship that FMc and MMc may play in disease. What can be said is pregnancies make permanent changes to a women’s body. Some of these changes are on a large scale. Some, like FMc and MMc, are small scale.
The War on Women’s Health
Part 2: Family Planning
It’s all about keeping mothers well and making healthly babies.
The CDC called family planning one of the ten greatest achievements in public health in the 20th century.1 Family planning is about deciding how many children couples want to have and when they want to have them.
Family planning has allowed the United States to achieve desired birth spacing and smaller family size. The success of family planning has been instrumental in the decline of infant, child, and maternal deaths as well as improving the overall health of infants, children, and women.2
Reproductive events in a woman’s life
The typically American woman spends about five years pregnant, recovering from being pregnant, or trying to get pregnant. However, she’ll spend most of her reproductive life, almost 40-years or 87%, trying to avoid getting pregnant. In the end she’ll have two children.3
Without family planning and modern contraceptives, the average woman would have 12 to 15 pregnancies in her lifetime.4
American Family Size
The colonial family from the founding of the Plymouth colony in 1620 to the Revolutionary War in 1775 had on average at least seven children and sometimes as many as nine or 10.5
But with the start of the Industrial Revolution, the American family size started to drop.6 The interrelationships between the social, economic, and political arenas caused fundamental changes to occur. One change was the increased opportunities for upward social and economic mobility brought about by the construction of industrial mills, primarily iron and textiles.
Adults sought to take advantage of these opportunities for themselves and their families. However, the urban locations of the mills, required them to move from the farms to the cities. Moving to the cities meant they had to give up self-sufficiency in exchange for the necessity of paying cash for housing, food, clothing, and other essentials.
Another change was the downward adjustment in the parental benefits of having children. This came from two directions. First the benefits of having a large number of children while economical on the farm had little purpose in the cities, especially after “the passage of laws restricting child labor and mandating compulsory education.” Second children in the cities cost money. The cost of supporting each additional child at a new normal level became increasingly apparent.
Herdandez tidily summed up the situation said, “In addition, the newly available goods and services competed with children for parental time and money. Since each additional child in a family requires additional financial support and makes greater demands on parental time and attention, the birth of each child reduces the time and money parents can devote to their own work or career as well as to recreation and to older children.”
Parents met this challenge “at least in part by limiting their fertility,” i.e. family planning.
Short birth intervals has medical risks for mother and fetus
Short birth intervals not only plays a significant role in determining the weight and health of the newborn baby, but has ramifications for the mother and fetus as well.
A short list of maternal risk include infection, premature rupture of the amnion and chorion membranes, third-trimester bleeding, and postpartum hemorrhage;7 placental abruption, placenta previa, and uterine rupture;8 and even maternal morbidity, and death.9
Some maternal medical conditions that can emerge during the pregnancy are anemia7 and macro- and micro-nutrient nutrient depletion.9
These conditions can affect the developing fetus causing low birthweight and small size for gestational age;8 retarded fetal growth;9 preterm births, miscarriages and stillbirths.10
Short birth interval leads to low birthweight infants
In the last three decades, advances in medical technology and neonatal intensive care have significantly improved the survival rates of infants born preterm. Yet, these very small premature babies, those under three pounds, are at high risk for delayed growth and lasting developmental problems.
The correlation between subnormal birthweight risk and birth interval is direct as shown in the graph. There is a substantial increase risk of low birth weight when babies are born less than 18 months after a previous live birth. The risk for low birth weight increases after 48 months. The best birth interval is between 24 to 47 months, i.e. the birth interval associated with the lowest risk for having a low birth weight baby.
Low birthweight has medical risks for infant and children
As advances in medical technology have for low birthweight (LBW) infants greatly increased their survival odds, there remains troubling medical outcomes for them.
Surviving LBW infants are three times more likely to have neurodevelopmental handicaps and twice as likely to have a serious congenital anomaly.11
Studies have shown LBW children have “significantly greater risk for developing respiratory symptoms, including wheezing, coughing and pulmonary infections”13 and “that these respiratory problems may persist well beyond their infancy and childhood and into adulthood.”14
LBW children are “at higher risk for psychiatric disturbances from childhood through high school” including delinquent & aggressive behavior in boys15 and anxiety & depression in girls.16 The incidence of ADHD is higher for LBW children.15
The additional familial stress puts them at higher risk for abuse and neglect.17
They have an increased risk of developing serious or prolonged illnesses throughout their lives. A host of medical complications developing in later life such as cardiovascular diseases, high blood pressure, type II diabetes (adult onset diabetes)18, and asthma19 are associated with low birthweight.
Low birthweight leads to higher risk of infant death
Obviously the worse medical risk for an infant is death. The risk of dying at less than 1 year of age sharply increases with declining birth weight.12 In the first year of life the risk of dying for very low birth-weight babies is 105 times higher than for normal birth weight babies. Even for moderately low birth-weight babies there is a 6 times higher risk of death during the first year.
The War on Women’s Health
Part 1: In the Beginning
What all the fuss is about.
In a repeat of history, the conservative Republicans are once again attacking what they perceive as a soft target – women. As is typical for their species, conservative Republicans look backward to the past, for their vision of the future.
Just Another Right-wing-conservative Fake Controversy
The brouhaha over the U.S. Department of Health and Human Services (HHS) ruling is too little, too late. The new guidelines are designed to ensure women will receive preventive health services* at no additional cost.
The guidelines also mandated coverage in many other women healthcare areas from breast feeding support to well-women visits.
To accommodate non-profits employers such as charities, hospitals, schools, universities, or other religious organizations that may have “a religious objection to providing contraceptive services as part of its health plan,” President Obama modified the guidelines4 so they no longer have to include contraceptive services. Instead, the health insurance company will cover the women’s contraceptive services needs. Thus the new guidelines “accommodates religious liberty while protecting the health of women.”
Catholic Health Association, Catholic Charities, and Catholics United have praised the new guidelines — White House (Feb 12)4.
Even with this olive branch offered to the right-wing religious community, the critics keep babbling about the infringement of their religious liberty.
Some Facts about the new law — White House (Jan 20)5:
National Academy of Sciences Report
Advise from The Supreme Council of Nerds
Where could more unbiased, dispassionate, honest, factual advice be found than with our very own National Academy of Sciences’ Institute of Medicine?
IOM states that preventive contraceptive services is the healthcare industry standard for both federal and private insurance programs. All federal employees, including members of congress have no-cost contraceptive services benefits.
The IOM concluded that “ the full range of Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity” should be provided as a preventive service for women. (Page 165)
By accepting the IOM expert advisory panel recommendations for contraceptives, supplies, and counseling services, the HHS wants to eliminate financial disincentives to using effective preventive care and improving the subsequent health outcomes.
National Business Community
The Gold Star Standard in Healthcare
The National Business Group on Health represents large employers on national health policy issues.8 In their report Investing in Maternal and Child Health they reported that all
Among NBGH’s unintended pregnancy prevention services recommendations is to include, even in their most basic benefit set:
The report concluded, “In order to reduce unintended pregnancy, employers should provide comprehensive contraception coverage for employees and dependents. Employers should also consider removing cost barriers by eliminating cost-sharing requirements on contraceptive medications, devices, procedures, and ofﬁce visits. Expanding coverage and removing cost barriers is particularly important for adolescents because many can not afford to pay for contraceptives out-of-pocket.”[4-27]
Doing this will the raise preventive contraceptive services coverage in ObamaCare to near the national business community standard.
28 States Have Similar Requirements
Or the Horses Have Already Left the Barn
Most of our citizens already live in state with similar contraceptive health requirements as the proposed federal requirements.
Twenty eight states9 require insurers to provide full coverage of all FDA approved contraceptive drugs and devices if they cover prescription drugs.
Eight states have no exemptions — Colorado, Georgia, Iowa, Montana, New Hampshire, Vermont, Washington, and Wisconsin.
Another four states allow only churches and their associations an exemption: Arizona, California, New York, and Oregon. The remaining 16 states require coverage very similar to the federal plan.
Right now 178 million people have full coverage under their state plans and the federal plan would have little, if any effect on them. The federal plan would be bringing the other 133 million people up to par.
The religious right’s outrage seems to have gone awol concerning the 28 states that have full coverage requirements where over half the population lives.
The Economics of Providing Contraceptive Coverage
Saving money by preventing unplanned pregnancies
“Debates over improving insurance coverage of contraceptives invariably touch on the issue of cost. Research and experience now suggest that contraceptive coverage does not raise insurance premiums and that employers providing such coverage can, in fact, save money by avoiding costs associated with unintended pregnancy.”10
Multiple studies from 1987 to 2010 have found contraceptive coverage does not cost more but saves money both for public Medicaid and private insurers.
Results varied from a National Business Group on Health study that had results of $0.16 for the private insurers to a Business and Health study finding of $28.57 also for private insurers. Public Medicaid savings were about $3 to $4.
Business and Health in a 1993 special report for employers, found the average costs associated with the birth of a healthy baby was $10,000 (prenatal care, delivery and newborn care for one year following birth). It also reported that the cost for oral contraceptives was $300–350 per year. Avoiding the cost for unintended pregnancies was a major factor in the savings for an insurer.
The cost looked at in the studies are only the easily determined direct cost “associated with normal live births (vaginal and cesarean), abortions, miscarriages and ectopic pregnancies.” 10 There is also the saving of indirect costs which “include wages and benefits associated with employee absences, maternity leave, and pregnancy-related sick leave, as well as costs associated with reduced productivity during an employee’s pregnancy and with replacing employees who do not return to work after a pregnancy.”
Business employers not covering contraceptives in their employee health plans pay at least an additional 15 – 17% more than if they had coverage.
Providing contraceptive coverage does not increase the bill an employer is required to pay. And may in fact reduce the bill.