09/17/2019
Tiffany DohertyOur approach to alcohol and pregnancy is full of good intentions, but may lead to more harm than good. Punitive policies can dissuade women from getting prenatal care, which runs counter to the overall goal of healthier mothers and infants.
This video was adapted from a column Aaron wrote for the Upshot. Links to sources can be found there.
09/13/2019 Tiffany DohertyElectronic cigarettes, like Juul, have been in use in the United States for over a decade now, so what’s up with the sudden spike in e-cigarette related illnesses? Spoiler: We wish we knew more.
09/10/2019 Tiffany DohertySickle Cell Disease affects 100,00 Americans, and has been pretty well understood for a long time. So, why are there only two drugs available for the condition? Why are so few research dollars allocated to the problem? Well, the answers aren’t very nice.
This video was adapted from a column written by Aaron Carroll for the Upshot. Links to sources can be found there.
09/01/2019 Tiffany DohertyA new study out this month claims plant-based diets are associated with lower risk of not only cardiovascular disease and mortality but of all-cause mortality as well. Let’s see how the results stand up to scrutiny.
08/27/2019 Tiffany DohertyGMOs. Vaccines. Death Panels. There are a lot of “beliefs” circulating about a wide variety of health policy issues. Luckily, these are all pretty well researched areas. Thanks to thorough investigations, we can conclude with certainty that vaccines are safe and effective, that GMOs are generally safe, and that the Affordable Care Act was not intended to execute any old people. But here’s a funny thing about these beliefs: giving the facts to people who are against these things doesn’t convince them to change their mind. Often, the people who hold to these ideas most stridently are the least knowledgeable about science, but BELIEVE they are the most knowledgeable about these subjects. Let’s talk about Dunning-Kruger and the paradox of incompetence.
This video was adapted from a column Aaron wrote for the Upshot. Links to sources can be found there.
08/23/2019 Tiffany DohertyTitle X is a federally funded Family Planning Program that has been around since 1970 as part of the Public Health Service Act. Following new restrictions on healthcare providers in clinics receiving Title X funding, Planned Parenthood announced this week that it would withdraw from the federal program.
08/21/2019 Tiffany DohertyThe following originally appeared on The Upshot (copyright 2019, The New York Times Company)
In many areas of health policy, the best of intentions can lead to more harm than good. Such is the case with America’s approach to alcohol and pregnancy.
The best evidence shows that punitive policies — such as equating drinking while pregnant as child abuse and threatening to involve child protective services — can dissuade women from getting prenatal care.
Fetal alcohol spectrum disorders refer to a collection of problems in babies and children. These include low birth weight; impaired growth; and problems in the heart, kidneys and brain. Children can have developmental delays, communication difficulties, learning disabilities and lower I.Q. Some of these last a lifetime.
It’s hard to know how many American children are affected. Studies done by the Centers for Disease Control and Prevention have estimated that between 2 and 15 infants per 10,000 born in the United States have fetal alcohol syndrome, the most severe form of the disorders.
Some community-based studies that use the broader definition of the disorder have found more affected children, up to 5 percent.
We know that infants of women who drink alcohol in pregnancy may develop these disorders. The problem is what we don’t know. We don’t know the level of alcohol exposure in utero that could cause a child to develop these disorders. We don’t know if the timing of the exposure matters. We don’t know why some women who drink little might have a child who is affected, while some can binge drink during pregnancy and have a child with no apparent problems.
Because of this, most medical organizations, including the American Academy of Pediatrics and the C.D.C., recommend that women forgo alcohol during pregnancy. The only dose known to be “safe” is none, they say, and therefore women should not drink at all.
Many women in the United States comply with this directive. But a significant number do not.
A study published in April found that 11.5 percent of women who are pregnant report drinking alcohol. Almost 4 percent report binge drinking — defined as four or more drinks on any occasion — in the last month. Given that women may be ashamed to acknowledge this, the true numbers may be higher.
To combat this, 43 states have enacted policies. These can be affirmative measures, like giving pregnant women priority for substance-abuse treatment, or punitive ones, like defining drinking alcohol during pregnancy as child abuse or neglect.
Proponents of such policies believe that they are making things better, especially for children. A recent study suggests they’re wrong.
Researchers gathered birth certificate data for more than 155 million live births from 1972 to 2015. The researchers were interested in how many children were born at a low birth weight or prematurely. They compared the rates of these undesirable outcomes in times and places when alcohol-pregnancy policies did and did not exist. They controlled for a number of demographic and related factors, including those known to be associated with poorer birth outcomes, like poverty and cigarette smoking.
They found that policies that defined alcohol use during pregnancy as child abuse or neglect were associated with an increase of more than 12,000 preterm births. The cost of these were more than $580 million in the first year of life. Policies mandating warning signs where alcohol was sold were associated with an increase of more than 7,000 babies born at low birth weight, at a cost of more than $150 million.
A previous study looking at how these policies affected women’s drinking found mixed results. States with punitive policies had more drinking, not less. Over all, neither type of policy seemed to be associated with lower levels of drinking.
It’s possible that states that already had more drinking might have put such policies in place in response to it. But the research methods used accounted for this and state-level data on drinking, and the prevalence of fetal alcohol spectrum disorders weren’t available when most of the policies were enacted, making it hard to believe that the relative levels of problems were what spurred policymakers to act.
Dr. Sarah Roberts, an associate professor of obstetrics and gynecology at the University of California, San Francisco, is an author of this study and other related work. Doctors have long discussed potential dangers with patients, one on one, with many benefits, she noted. But policies that punish women for or publicly warn them about harms from alcohol or drug use during pregnancy may lead to further harms by scaring women into forgoing prenatal care, she said.
Such policies may even convince them that talking with their physicians isn’t a good idea.
“Qualitative research finds that pregnant women who use drugs avoid prenatal care out of fear that, if their providers find out about their drug use, they will be reported to child protective services and lose their children,” she said. “Our study found that child abuse/neglect policies led to decreased prenatal care use.”
Other research confirms this hypothesis. Three years ago, researchers (including me) published the findings of a survey on legal requirements for drug testing in prenatal care. Although most women were tolerant of laws requiring screening of pregnant women, 21 percent reported they would be offended if their doctors asked them about drug use as part of prenatal care, and 14 percent said that mandatory testing would discourage prenatal care attendance.
It’s that last bit that most concerns physicians. Avoiding medical care is not what we’d like to see happen.
The goal of all of these policies is to improve the health not only of pregnant women, but also of the children they bear. Many people assume that if physicians simply provide more information — if women are just warned — things will improve. Without research, those assumptions are just unproven hopes.
Dr. Roberts had two suggestions for what might work better. The first: Start over and go through a rigorous process of engaging with women who drink during pregnancy to find out — from them — what would help. Second, stop treating pregnancy as a special case when it comes to alcohol.
“There is some evidence that general population alcohol policies — such as limiting where alcohol can be sold — are associated with improved birth outcomes,” Dr. Roberts said. “This makes sense as research shows that the biggest predictor of drinking during pregnancy is drinking before pregnancy. Women don’t start drinking during pregnancy; if they drink during pregnancy, it’s usually a continuation of the way and the amount they were drinking prior to pregnancy.”
It might be better to spend time making sure that women are connected to the health care system in general, and that they enter pregnancy healthy — rather than focusing on the nine months of pregnancy, as if that were the only time that mattered.
It’s easy to stigmatize women who drink during pregnancy, with words and with policy. The goal, though, is healthier mothers and infants. To achieve that, policymakers may need to stop stigmatizing and start over.
08/20/2019 Tiffany DohertyThere are many, many factors that contribute to high drug prices. Regulating them is complicated. We try to shed some light on the situation.
This video was adapted from a column written by Austin Frakt for the Upshot. Links to sources can be found there.
08/19/2019 Tiffany DohertyThe old chestnut that eating red meat leads to cancer is back. A study last week claimed that eating red meat increased cancer risks by up to 28 percent! That sounds scary, but this study has a lot of problems.
08/13/2019 Tiffany DohertyWe’ve been hearing a lot of pretty general plans to implement Medicare for all Americans. How would that work? Medicare as it exists today has some coverage gaps. How would that be addressed in Medicare for All?
This video was adapted from a column Austin Frakt and Elsa Pearson wrote for the Upshot. Links to sources can be found there.
