08/26/2021
Tiffany DohertyYou’ve probably heard before that acetaminophen during pregnancy is associated with symptoms of ADHD and Autism in offspring. Well, we’ve got another study on that association. In today’s episode, we examine that study and revisit why we need to be cautious with observational data.
07/28/2021 Tiffany DohertyPregnancy comes with a lot of advice concerning everything from how to determine the sex of the baby to how to ease both pregnancy symptoms and the oft-dreaded task of labor and delivery. Most of these stand on little to no evidence, but some are attached to data. In today’s episode, we examine the quality of the data behind two popular pieces of advice about easing labor and delivery outcomes.
12/06/2019 Tiffany DohertyAaron Carroll talks to Dr. David Haas about gestational diabetes. You may know that women can develop diabetes during pregnancy, and may know that their blood sugar and insulin return to normal shortly after giving birth. What you may not know is that this condition is associated with a host of negative outcomes. Insulin treatment during pregnancy can impact the growth of the baby in utero. Experiencing gestational diabetes is also associated with a huge increase in risk for developing type II diabetes later in life. So, what can we do about this?
The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.
IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.
Available wherever you get your podcasts! Including iTunes.
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.
12/07/2018 Aaron CarrollThe number of abortions in the US continues to drop. Why? Well, there are a number of factors, but the biggest factor is more effective and more easily available than it’s ever been. Also, people know about it!
10/24/2017 Aaron CarrollIn a new rule about coverage of contraception, the Trump administration argues that birth control is bad for your health. But it’s a claim that doesn’t stand up to scrutiny. That’s the topic of this week’s Healthcare Triage.
This episode was adapted from a column I wrote for the Upshot. Links to further reading and sources can be found there.
Also – I’ve got a book coming out November 7. It’s called The Bad Food Bible: How and Why to Eat Sinfully. Preorder a copy now!!
07/04/2017 Aaron CarrollFrom JAMA, “Effect of an Internet-Based Program on Weight Loss for Low-Income Postpartum Women“:
Importance Postpartum weight retention increases lifetime risk of obesity and related morbidity. Few effective interventions exist for multicultural, low-income women.
Objective To test whether an internet-based weight loss program in addition to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program) for low-income postpartum women could produce greater weight loss than the WIC program alone over 12 months.
Design, Setting, and Participants A 12-month, cluster randomized, assessor-blind, clinical trial enrolling 371 adult postpartum women at 12 clinics in WIC programs from the California central coast between July 2011 and May 2015 with data collection completed in May 2016.
Interventions Clinics were randomized to the WIC program (standard care group) or the WIC program plus a 12-month primarily internet-based weight loss program (intervention group), including a website with weekly lessons, web diary, instructional videos, computerized feedback, text messages, and monthly face-to-face groups at the WIC clinics.
Main Outcomes and Measures The primary outcome was weight change over 12 months, based on measurements at baseline, 6 months, and 12 months. Secondary outcomes included proportion returning to preconception weight and changes in physical activity and diet.
Pretty much all mothers gain weight during pregnancy. Keeping that extra weight after pregnancy, however, carries with it risks and issues. This study wanted to test an Internet-based program coupled with WIC for lower-income women. It was a year-long randomized controlled trial of 371 postpartum women at 12 clinics in California. Control clinics got standard WIC. Intervention clinics also got a website with weekly lessons, a diary, videos, automatic feedback, text messages, and monthly face-to-face meetings. The main outcome of interest was how much weight changed over a year.
I’d have bet money this wouldn’t work. It’s just some web based stuff and the usual outreach. Nothing significant. But the intervention group lost 3.2 kg over the year versus 0.9 kg in the control group. Almost a third of women in the intervention group returned to the preconception weight by a year versus less than 19% in the control group. There were no differences in their physical activity, calorie intake, incidence of injury, or low-milk supply.
So this pretty simple intervention worked, and it worked at a year. That’s better than a lot of diets, and this focused on women at the low end of the socio-economic spectrum. Seems like it’s at least worth more study and some consideration.
09/23/2016 Aaron CarrollCeliac disease prevalence is stable; gluten free diets are not. And does contraception work? Spoiler… yes. This is Healthcare Triage News.
For those of you who want to read more:
08/26/2016 Aaron CarrollMost people, in general, would like to reduce the incidence of teen pregnancy. Yes, it’s at an all-time low here in the US, but that doesn’t mean there isn’t room for improvement, here and abroad.
A number of people, and programs, have decided that one way to combat teen pregnancy is to teach teens how hard it is to raise a baby. They sometimes force kids to “couple up” in school and pretend they have a child. Sometimes, they even give them a doll – one that cries, wakes up at night, etc. – to bring home the point.
I’ve often rolled my eyes at such things, but never said anything. Until now. From the Lancet, “Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia“:
Background: Infant simulator-based programmes, which aim to prevent teenage pregnancy, are used in high-income as well as low-income and middle-income countries but, despite growing popularity, no published evidence exists of their long-term effect. The aim of this trial was to investigate the effect of such a programme, the Virtual Infant Parenting (VIP) programme, on pregnancy outcomes of birth and induced abortion in Australia.
Methods: In this school-based pragmatic cluster randomised controlled trial, eligible schools in Perth, Western Australia, were enrolled and randomised 1:1 to the intervention and control groups. Randomisation using a table of random numbers without blocking, stratification, or matching was done by a researcher who was masked to the identity of the schools. Between 2003 and 2006, the VIP programme was administered to girls aged 13–15 years in the intervention schools, while girls of the same age in the control schools received the standard health education curriculum. Participants were followed until they reached 20 years of age via data linkage to hospital medical and abortion clinic records. The primary endpoint was the occurrence of pregnancy during the teenage years. Binomial and Cox proportional hazards regression was used to test for differences in pregnancy rates between study groups.
This was a school-based randomized controlled trial of an infant simulator-based program to prevent teen pregnancy in girls age 13-15 years from 2003 through 2006. Fifty-seven schools participated, and more than 2800 girls were followed until they were 20. The outcome of interest was pregnancy during the teenage years.
And… more girls in the intervention group got pregnant. In the intervention group, 8% of the girls had at least one birth, compared to 4% of those in the control group. Even after adjusting for potential confounders, the intervention group had a more-than one-third higher relative risk of pregnancy in the teenage years.
So not only are those baby-doll-simulators likely a waste of time and money, they may be leading to an increase in teenage pregnancy.
This is why research is important. So is what we do with it. I know if they try this kind of program with one of my kids, I’m going to open my mouth.
03/13/2016 Aaron CarrollLabor induction doesn’t lead to more C-sections, and the unintended birth rate is dropping in the US. This is Healthcare Triage News.
For those of you who want to read more:
