Many of you know about my involvement in the organization Save the Children. Seven months ago, I and two other trustees founded The LA Associates of Save the Children. We asked over 50 women to join us and they in turn have recruited others. I am proud to say that we have already raised enough money to establish 3 schools in Africa. Construction has begun on the first school in Mozambique; we completed the funding for a school in Ethiopia and are almost ready to fund a school in Mali. (We can use some help completing the latter …if you would like to contribute please log onto www.savethechildren.org/LA-Associates ) Each school will have an early education program for children under the age of five and will involve parents and the community in efforts to stimulate learning. Save the Children works with the local country and state government in order to ensure appropriate teacher training, classroom maintenance and sustainable programs. Save also provides education and play material. Each school project includes health care and nutritional supplementation for the children. The LA Associates plan to continue to focus on education, especially early education in under-served rural communities here in the U.S.

The reason I am bringing this up (and if you have paid attention to my newsletters, you will have read about the Associates and the schools we are building several months ago…) is that a series of articles just appeared in the medical journal The Lancet that emphasize the importance of these types of programs. The series is appropriately titled “Child Development” and reports on evidence-based strategies that improve developmental outcomes for young children in low-income and middle-income countries.

As concerned individuals, no matter what our political affiliation, I feel that we should look at the results of this world wide and world class survey:

Let me start with some startling numbers presented in a survey in The Lancet in 2007: More than 200 million children younger than 5 years of age in low-income and middle-income countries were not attaining their developmental potential, primarily because of poverty, nutritional deficiencies, and inadequate learning opportunities. That number is felt to have significantly increased as a result of the past years of economic crisis and climate change.

The authors of the present Lancet series searched over 12 databases, which included Google Scholar, the World Bank, Global Health and even one called Psycinfo. They reviewed papers published since July 2006. They analyzed 42 studies and program assessments that included more than 50 children, focused on children from 0 to 5, had an appropriate research design and used valid outcome measures. Based on these studies, the authors created a “simulated model” of the long-term economic effects of increasing preschool enrollment to 25% or 50% in every low-income and middle-income country. The benefit-to-cost for increasing enrollment to 25% was 12.6 (which was calculated to be worth $10.6 billion) and rose to 17.6 for an increase to 50% enrollment (which would be worth more than $33.7 billion!) Just in case all these numbers are stultifying…. what it means is that for every dollar invested in enrolling 50% of the children in preschool education, the return for the economic potential of these children in their lifetime is multiplied by 17.6. And that is just the economic terms…the quote at the conclusion of the article says more:  ”By investing in early child development programs, we have the opportunity to break the cycle of inequities that has dominated the lives of millions of children and families in low-income and middle-income countries.”   And I can proudly state that Save the Children is one of the organizations that is in the global forefront for the promotion and establishment of early childhood education.

P.S. When this newsletter appears, I will be in Ethiopia. I am visiting Dolo, the large refugee camp on the border with Somalia. Save the Children supports many of the child programs there including feeding programs, reunification, child protection and safe play areas. My weekly articles will resume when I return.

And if you are a patient, please know that you can call the office for any medical needs; my staff will be there to help you. I will return in the beginning of November.

I hope that most women who are pregnant know that they are supposed to take prenatal vitamins. In general, I am not a great believer in mega vitamins; we have all read recent data that confirms that nutrition is the key to health, not all those “super” supplements that line the shelves of pharmacies, health food stores and supermarkets. Most experts do, however agree that the “eat it rule” excludes supplementation with calcium, vitamin D and perhaps a simple multivitamin, especially if you don’t inundate your diet with calcium rich foods and expose your skin to unblocked sun rays. And I’ll also use that now famous phrase, “and one more thing”, to add a promo for folic acid supplementation, BEFORE as well as during pregnancy. Folic acid is necessary for development of the nervous system in the fetus. Lack of appropriate levels of this B vitamin had been associated with increased risk for neural tube defects, specifically spina bifida.

The human nervous system develops from a small, specialized plate of cells. Early in development, the edges of this plate begin to curl up toward each other, creating the neural tube that closes to form the brain and the spinal cord of the embryo. (The top portion becomes the brain, the lower, the spinal cord.) This process is usually complete by the 28th day of the pregnancy. That’s just 2 weeks after the missed period; about the time a lot of women first realize that they are pregnant.  If the folding of the neural plate is not complete, a spina bifida or “cleft spine” occurs and development of the brain and/or the spinal cord is incomplete. This then leads to severe neurologic defects and lower limb paralysis. In the United States, spina bifida occurs in 1,500 to 2,000 of the more than 4 million babies born in the country each year. The correlation between folic acid and neural tube development has been know for decades and indeed in an effort to decrease this malformation products containing processed wheat flower (breads, cereals, certain pastas etc.) have been fortified with folic acid. But this is probably not enough and currently the recommendation is for supplementation of at least 400 micrograms of folic acid daily to prevent neural tube defects. Most prenatal vitamins contain 1000 micrograms. For optimal efficacy, supplementation should begin before a woman knows she is pregnant. Remember by the time her period is late the neural plate has formed and is “curling” and this process should be complete by 2 weeks after the missed period, or 28 days after conception.

Unfortunately, fifty percent of women who conceive in the U.S.A. do so without prior planning. Hence the recommendation is that during the reproductive years, all women (and especially those not using “absolute” contraception), take folic acid supplements “just in case”. And if a patient tells me she plans to conceive in the next year or so I usually prescribe prenatal vitamins or good multivitamins at least 3 months before she conceives to ensure the appropriate folic acid level when she does becomes pregnant. Indeed, folic acid may help prevent premature pregnancies if taken an entire year before conception, so obviously the earlier the start of supplementation, the better.

It turns out that low folic acid levels before and during pregnancy can also cause other neurological difficulties. The October 2011 issue of JAMA has an interesting article titled “Folic Acid Supplements in Pregnancy and Severe Language Delay in Children”. This was a prospective observational study of Norwegian mothers and their children conducted between 1999 and 2008. Mothers whose children were delivered before 2008 were asked to return a questionnaire 3 years after their children were born. The researchers looked at use of folic acid supplements within the interval for 4 weeks before conception to 8 weeks after. The mothers were asked to assess their children’s language competency based on a 6-point language grammar score. (This sounds rather complicated, but a mother knows if her child can speak…. If only 1-word or unintelligible utterances were spoken, the child was rated as having severe language delay.) Among the 38,954 children, 204 (0.5%) had severe language delay.  (Amazing that so many moms completed the survey…but hey this was Norway, where the medical response of individuals to questionnaires and national health statistics are the best in the world!)

The results showed that if the women took other supplements but no folic acid, the relative risk of their children having severe language delay was 1.04; if they took folic acid only it was 0.55 (about half that of the children of the women who had no folic acid) and if they took folic acid in addition to other supplements it was also 0.55. In other words, maternal use of folic acid supplements in early pregnancy was associated with a reduced risk of severe language delay.

Bottom line: Every woman who is “at risk” of conception and certainly those who plan to get pregnant should begin to take folic acid supplements, before and certainly during pregnancy.

I was honored with an award at the annual luncheon of the Magnolia Council this week. (The Council consists of a fabulous group of women who support and foster the Tower Cancer Research Foundation (TCRF).) The foundation awards research grants, conducts clinical trials, supports and educates patients and most importantly humanizes care for cancer patients and their families. The doctors at Tower Oncology have always been the “go-to” referrals for most of my patients who have been diagnosed with cancer. So I was truly delighted to receive the award. Indeed, many of my patients came…and to those who were there and are reading my newsletter this week: Thank you!

There is, however, no “free’ award…The organizers of the luncheon asked me to give a brief talk on women’s health. Brief being 10 minutes; nearly the same time it takes to become calm, cool and collected after a hot flash. So in order to increase audience participation, I requested that the executive director read the following statements and then asked the 500+ women (and a few men) to raise their hands if they thought these statements ware true, or false. Here they are with just a brief explanation for each:

I need a Pap smear every year.
(False) To know why, you can review the full article I wrote titled “More Information on those Ubiquitous HPV Infections”. But if you don’t want to take the trouble to go back and review it (I know it’s sort of like homework), remember that cervical cancer is caused by HPV and hence is a sexually transmitted disease. It takes years for high-risk human papilloma viruses to enter the nuclei of cervical cells and cause the mutations that lead to cancer.. So we (the doctors) don’t start doing Pap smears on young women until they are 21 years old. After 21 (if normal), the Pap should be repeated every 2 years until the age of 30 at which time Pap and co-testing with HPV testing should be done. If both these tests are negative and a woman is in a mutually monogamous sexual relationship, she needs a Pap smear just every 3 years. And the current recommendations are that a Pap smear is not needed beyond the age of 65 or 70 as long as screening has been normal for the past 10 years and there have been no new partners that could possibly cause an HPV exposure. Moreover, if a woman has had a hysterectomy with removal of the cervix for non -cancer reasons, she does not need a Pap smear.

BUT (and this is very important), if a woman is high risk: i.e. is HIV positive, has had high risk HPV infections, pre-cancer or cancer of the cervix, or was DES exposed, then Pap smears have to be repeated annually and in some cases every 6 months. I know that many women confuse the gyne visit with “I need my Pap smear”. You still need to have regular gynecologic exams with or without a Pap smear; it will include a breast exam, pelvic exam, and discussion of contraception, fertility, cycles, hormonal issues, and general women’s health issues.

I should drink 8 glasses of water every day to stay healthy.
(False) We don’t know where this “rule” came from…it won’t make your skin dewier and it won’t make you thinner. Your body has a marvelous mechanism to maintain your fluid intake …it’s called thirst. If you are constantly drinking water and your kidneys are working properly, you will constantly fill your bladder and have to go. Your bladder may be overactive because your water intake is excessive. And if you overload what your kidneys are capable of “handling” you may cause an electrolyte imbalance. Remember everything you eat and drink has water, so you are already accessing fluids for your body with every bite and sip. Having said this, I will give a caveat or two: increase your water intake if you exercise rigorously or if you are in a very hot climate. (Obviously, I am not selling decorative shoulder straps for quart sized designer water bottles.)

C -section is the safest way to have a baby.
(False, probably)… especially if mom wants more children. Of course if the size of the baby or its position before birth poses a problem or if maternal conditions make labor and vaginal delivery unsafe, or if there is fetal distress, a C-section may be very necessary (and safest for mom and baby). I don’t want to downplay decision making by a well-trained obstetrician or midwife…that’s what my training was all about. But elective C -sections may mandate repeat C-sections with potential side effects for the mother and baby. (Here I do refer you to my article last week “Too Many or Too Few C-Sections?”)

If I take calcium and Vitamin D my bones should be fine
(Not necessarily) You have a chance to build bone until your late 20′s. Your bone filling cells are active and outpace your bone drilling cells when you are young. (Remember bone is a living tissue and not static, so there is always turn around which consists of cells that , like “Pac Men” create microscopic holes in the bone (osteoclasts) and those cavities are filled by bone filling cells (osteoblasts). After 30, the drilling begins to outpace the filling. So if you haven’t started with a good bone base to stand on (literally), it will get weaker with time. We lose about ½% of our bone density a year with age and 2% a year for up to 7 years once we no longer have estrogen (after menopause).

There is no question that calcium is essential for bone strength. We lose about 1000mg of calcium a day through excretion, sweating and general activities. If we don’t intake the calcium our body loses it gets it from our calcium storehouse…our bones. And Vitamin D is needed to help absorb and utilize the calcium we consume. So yes, we need it…for most adults the amount should be 1200 mg. a day and we should also get 600 to 1000 units of vitamin D. But we can’t always rely on this alone to guarantee bone strength. Bouts of low estrogen when we were young (irregular periods), a lifelong dietary deficit of calcium, diseases such as rheumatoid arthritis, medications (especially steroids), and family history of osteoporosis may all contribute to poor bone density. Indeed 50% of women over the age of 50 will suffer an osteoporotic fracture in their lifetimes. So discuss this with your doctor and if you are at risk or you have reached the age of 65, get a bone density test. If your bone density is low, and a calculation called FRAX (you can download this) shows you are at significant risk for fracture, you may need to start medication to prevent continued bone loss or even reverse it.

I went through several other statements during my presentation….and will share them with you in future newsletters. It seems that it takes longer to write my answers than to present them at a luncheon.

My daughter’s first labor and subsequent delivery were not easy. I was not in the delivery room… her doctor had been my resident and I felt that my presence might make him nervous and rush to do a C- section. Well he did anyway; after several hours of labor he noted some ominous changes in the fetal heart rate and he performed a C- section for fetal distress. My daughter had a healthy baby girl. In her second pregnancy a few years later, she and her doctor (with my blessings) decided to schedule an elective C-section . She had a healthy boy at 39 and ½ weeks. This time I was there.

The reason I am sharing this with you is that there is an ongoing debate among patient advocates, obstetricians, health care economists and parents about the current high rate of cesarean section births. To wit: a recent article in the Journal of Obstetrics and Gynecology published by The American College of Obstetricians and Gynecologists concluded that C Sections help prevent pelvic floor disorders. (A term that describes diminished support of the uterus, bladder and rectum so that some or all of these organs descend from their normal position.) This article was based on data from John’s Hopkins University Hospital in which 1,011 women were followed after delivery for 5 to 10 years. The researchers found that compared with C section without labor, spontaneous vaginal birth was associated with a more than 500% increase in the risk of subsequent stress incontinence (losing urine with coughing, sneezing or increased abdominal pressure) and prolapse of the uterus, or bladder to or beyond the area of the hymen. Moreover operative vaginal delivery (this would include forceps and vacuum extraction) increased the odds for all pelvic disorders, especially prolapse by over 700%. Active labor before an actual C-section did not increase the odds for any of these pelvic floor disorders.

So does this mean we (physicians and expectant mothers) should advocate for C -section in order to prevent future pelvic floor weakening? Another article in the same journal published a month earlier said no…the author emphasized the adverse consequences of C-sections for both the mother and the baby. He pointed out that currently more than 32% of all births are now via C-section; making it the most common operation in the United States. Since 1996, the cesarean section rate has increases by 50%. In 1998 when the C-section rate was 21.2% in the U.S., the maternal mortality rate was 10 per 100.000. In 2004, with a C-section rate of 29.1%, the maternal mortality rate increased to 14 per 100,000 (and apparently is now higher). More than 35% of Cesarean sections are performed electively before a full 39 weeks and as a result there has been an increase in respiratory distress and other adverse neonatal outcomes in these infants. They are statistically more likely than babies born full term, after labor and vaginal delivery, to need neonatal intensive care and a longer length of hospital stay.

Now the cons for the moms, especially if they have repeat C-sections: (And in the U.S. most moms who have had their first baby by C-section repeat this procedure the next time.) In subsequent pregnancies, there will be uterine scarring, possible weakening in the area of the scar and an increased risk for abnormal implantation and position of the placenta (placenta praevia) or growth of  placenta into the wall of the uterus (accrete).  If at time of surgery, bleeding is not controlled because of placental problems, scarring or lack of uterine contraction (atony), may make a hysterectomy at the time of C-section necessary.  These can cause serious complications and contributes to the increasing rates of maternal mortality.

In December 2007, the American College of Obstetricians and Gynecologists published a Committee Opinion acknowledging cesarean delivery on maternal request, but outlined that it should not be motivated by the unavailability of effective pain management and that it is not recommended for women desiring several children given that the risk of placenta previa, placenta accrete, and need for gravid (at the time of delivery) hysterectomy increase with each cesarean delivery.

Bottom line: There is no absolute best or safest way to plan an elective delivery. If there are complications during labor that necessitate a C-section then, of course, it should be performed. But if a C-section is scheduled electively because it’s convenient, will prevent labor pains  or it’s felt to  be the safest way to deliver a baby, a full discussion of the pros and cons is necessary. Yes, a C-section may help decrease future pelvic floor disorders, but it can also lead to complications for the infant and mother.

I’m grateful my daughter had healthy children… and has completed her family safely.

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