Firm is good, dense may not be… I’ve written articles on the current California law that requires imaging centers to send you a letter if, at time of mammogram, it’s noted that your breasts are dense. And as I expected, I’ve received quite a few phone calls with queries as to what sort of follow up “dense” mandates. The official committee opinion from the American College of Obstetricians and Gynecologists on this subject was published in April 2014 in (you guessed it) the Journal of Obstetrics and Gynecology.

Perky, firm and dense (breasts) are not always synonymous. Dense breast tissue is usually found in younger women. When we are (were) young, our breasts lack abundant fat separating the glands. And some of us stay that way breast-wise… Dense glands in breast tissue absorb more radiation during mammography than fat and look radiographically white whereas fatty tissue allows the radiation to pass through and appears more translucent in the image. A small tumor or calcification that could be the hallmark of a very early cancer or DCIS will also appear white on mammogram. White on white does not allow for good differentiation. And to somewhat complicate the matter it turns out that women with dense breasts i.e. glands that are close together with less surrounding fat, have a modestly increased risk of breast cancer in addition to a reduced sensitivity of mammography to detect cancer.

Just so you know how we categorize breast density by mammogram, the percent of the women within each category and what that means, here is a chart:

DENSITY

PERCENT

MAMMOGRAM
SENSITIVITY

RELATIVE RISK CANCER
(compared to average density)

Almost entirely fat:

10 %

88%

-

Scattered densities:

43%

82%

-

Heterogeneously dense

39%

69%

Relative risk 1.2

Extremely dense

8%

62%

Relative risk 1.4

Once the imaging center lets you know that your mammogram demonstrated that your breasts are dense, their letter then states that this increased density limits their ability to diagnose cancer (which also covers their tuches) and they usually go on to suggest that you discuss this with your physician. In turn, we then may recommend that you get additional ultrasound tests and perhaps even an MRI to address your newly induced concerns. Offering these exams also diminishes potential physician neglect and culpability and, of course, also gives reassurance that a diagnosis of early breast cancer is not missed.

I wish I could leave it at that, but the committee opinion does not agree with this line of action. They negate the need for these extra tests stating they are not appropriate in women with dense breasts who do not have additional risk factors. They state that “current published evidence does not demonstrate meaningful outcome benefits (eg, reduction in breast cancer mortality) with supplemental test (eg, ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (eg, breast tomosynthesis or thermography).” They go on to say “evidence is lacking to advocate for additional testing until there are clinically validated data that indicates improved screening outcomes.”

But before we all feel frustrated, please note that the committee did bless mammogram, especially digital mammogram as the best diagnostic screening tool that has consistently demonstrated a reduction in breast cancer mortality. The College does not, however, recommend routine use of alternative or adjunctive test to screening mammogram in women with dense breasts who have no symptoms and no additional risk factors.

I still urge you to call your physician if you get that “density” letter. We can then discuss your risk factors such as family history, previous biopsies, excessive alcohol consumption, obesity, even hormone therapy and try to figure out how to best to assess and reassure you.

Baby boomers are overwhelmed with studies and concerns about future risk of Alzheimer’s and dementia. There is a book or article that appears weekly telling us what we can do to keep our cognitive function functioning. (I am hoping that reading medical journals and writing about them will help mine! I would also like to point out another mind issue that should not be dismissed with a “never mind”, which is stroke. Of the estimated three quarters of a million new or recurrence strokes in the United States each year, 53.5% occur in women. And according to a new article that came out in the March 12 JAMA women account for about 60% of stroke related deaths. An estimated 3.8 million women and 3 million men are living in the United States after having a stroke. Yes, let’s mind…

So I thought it appropriate to review the new guidelines that have recently been issued by the American Heart Association/American Stroke Association for prevention of stroke in women. Many of their guidelines pertain to both women and men and these include the need to control blood pressure, avoiding or quitting smoking, maintaining a healthy weight and exercising. The recommendations unique to women are centered on reproductive health. Here they are:

  • Women with a history of high blood pressure should consider taking low-dose aspirin and calcium supplement therapy when they become pregnant. Since women who have developed preeclampsia will have twice the stroke risk and four times the risk of high blood pressure later in life they should be evaluated frequently, beginning six months after delivery. If they have additional risk factors such as smoking, high cholesterol and obesity, they should be counseled and treated.
  • Pregnant women with moderately high blood pressure (150-159/100-109 mmHg) may need medication and if blood pressure is even higher (more than 160/110) they should definitely be treated with anti-hypertensive medication.
  • Before taking oral contraceptives, all women should be screened for high blood pressure. The combination of hypertension and birth control pills can increase the risk of stroke.

I know these recommendations are specifically geared to younger women but the medical societies (and the rest of us) now acknowledge that what we do at every stage of our lives impacts our future health and brain span. Blood pressure should be checked regularly from childhood and it turns out that elevation in pregnancy can be especially ominous. Appropriate therapy together with healthy lifestyle maintenance throughout our lives will impact our risk of a catastrophic brain event at every age.

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I spent part of last weekend volunteering for the Care Harbor/LA Free Clinic. This once-a-year event has received extensive media coverage so you may have heard or read about it. But for those who did not, I thought I would share what I saw on this week’s website. (And it will give me a chance to express my amazement that it was (a) so well organized and (b) there is such a need for free health services.)

Thousands of individuals lined up before the weekend to get wristbands that allowed them to access the three day event. Four thousand succeeded but demand was much higher and many of those who waited in line did not. The clinic was held at the LA Sports Arena and offered free dental care, vision care, general health care and women’s health care. Women of all ages (including teens) could get Pap smears, STD testing, pregnancy tests, blood tests and if 40 or older, mammograms. When necessary, pelvic ultrasound was available. All the health care providers, assistants, organizers and translators were volunteers and all supplies, instruments and lab tests were donated. Each patient signed in, gave an address and was directed to the medical area that she or he requested or needed. There was food, hairdressers for the women and areas that could help patients sign up for needed referrals, Medicare, Medicaid and government insurance. I was overwhelmed by the number of volunteers who cared enough to come down and spend their weekend donating their services.

I know I don’t usually wax political on my website emails (well not that usually) but this time I will… When you see how this very basic offering of healthcare was so welcomed to the thousands of people who stood in line for hours to get their wristband, and then returned and waited to be seen; you have to acknowledge that our lack of universal health care is wrong! As many of my readers know, my family lives in Israel and I go there frequently. Healthcare in Israel is available and covered for everyone, no matter age, work status, ethnicity or religion. A comparison (indeed comparison to just about every other developed nation) is embarrassing and depressing. Many of the people that were seen at this three day clinic LA clinic had received no other health care. And although on-going care referrals to community and public health clinics were offered, few would get vision or dental care after this event.

I hope that the Affordable Care Act (Obama Care) will help rectify some of these inequities. It will (or should) happen. But there will continue to be a need for events such as the Care Harbor/ LA Free Clinic in the future… especially for those women, men and children who are currently undocumented or remain uninsured. Events such as the one last week show that the community cares, and hopefully will continue to do so.

I searched this last week’s medical journals to find an article to write about. Unfortunately there was nothing I felt would be of interest to most of my patients. My fall back is usually JAMA, but the latest issue dealt with combat casualties, care for mass casualty events, treatment of post dramatic stress disorder and suicide… I pass. So I thought that this week I would write about the recommendations that were published in the Clinical Updates in Women’s Healthcare by the American College of Obstetricians and Gynecologists from April. There was a section dealing with physical activity for “older” adults and I, of course, wondered what their definition of older was… and as usual it encompassed anyone at or over the age of 65. Upon reviewing their recommendations, I realized that these are probably relevant to women and men of any age; so here they are:

AEROBIC ACTIVITIES

  • 30 to 60 minutes of moderate intensity exercise, performed on five days each week or more. This can include walking, jogging, running and bicycling.
  • 20 to 60 minutes a day of vigorous intensity exercise performed on three days a week or more. Higher endurance activities will include swimming, cross-country skiing and aerobic dancing. Team sports such as basketball, soccer and volleyball and racket-sports such as tennis and racquetball included. They obviously can be very vigorous but since they also include intermittent periods of exercise and rest their effectiveness for continuous aerobic activity makes the calculation of duration more difficult.

MUSCLE-STRENGTHENING ACTIVITIES

  • Resistance exercise that involves each major muscle group should be performed on 2to 3 nonconsecutive days per week using a variety of exercise equipment or body weight resistance. This can be done with weight training machines, free weights, elastic resistance ( bands) or body weight resistance activities (push-ups, pull ups, sit ups, stair climbing and Pilates). Most individuals should aim for 10 to 15 repetitions of approximately 8 to 10 exercises to improve strength and power. The recommendations also includes correct breathing techniques… There should be exhalation during the effort phase and inhalation during the lengthening days.( All those exercise coaches were right!)

FLEXIBILITY

  • A series of flexibility exercises for each of the major muscle – tendon units, performed two days a week or more for at least 10 minutes is recommended to improve joint range of motion. This should include static stretches, performed by slowly stretching a muscle or tendon group and holding for a period of 10 to 30 seconds. Slow stretching allows greater stress relaxation and generates lower forces on the tendon. Holding the stretch at the point of tightness or mild discomfort for 10 to 30 seconds enhances joint range of motion. There is still a debate regarding the best time to stretch. Current evidence suggests that it is most effective when the muscle temperature is elevated after light to moderate exercise.

BALANCE

  • As we get older, coordinated actions become increasingly important in preventing falls and injuries. Walking on uneven or difficult terrain (try sand) is said to improve balance. The Chinese wellness practices such as can tai chi and qi gong which emphasize posture, breathing and meditation will increase our balance. Regular yoga practice can be quite amazing; it has been shown to be associated with improved gait, balance, flexibility, lower body strength and weight loss. To add to its increasing popularity, it also has been found to be effective in reducing blood pressure, glucose levels and cholesterol levels. Then we come to Pilates which is my favorite… It’s an exercise system focused on improving flexibility, strength and body awareness. It enables us to build core muscle strength and achieve better spinal alignment. One of the more fabulous benefits of Pilates is that it helps us become more aware of maintaining correct posture (I remembered to sit up straight as I wrote this) and activating core muscles in our every day activities.

So there you have it; it’s a fairly inclusive list and perhaps seems to be overly time intensive for many adults. But the impact of exercise (and it can be low-impact) on our health and longevity can be greater than many of the “preventive” medications that physicians prescribe. So I hope you’ll sit up, pay attention and get going.

Every once in a while you’ll see a “how awful” media story about a young woman who had a stroke or clot in her lungs that was ostensibly caused by oral contraceptive pills (OCPs). Lawyers are suing, OCP users are scared and I get lots of calls from concerned patients and parents. And then there are those ads that come on at night, often on non-network channels, that ask you to call a specific law firm if you have had “fill-in the blank” complications after taking Yaz or Yasmin or for that matter, any birth control pills. So although I have tried over the years to both reassure and address the pros and cons of birth-control pills to patients and concerned family members, unfounded and founded concerns remain. Hence I was delighted to see a new review in The Journal of Obstetrics and Gynecology titled ” Risk of Acute Thromboembolic Events With Oral Contraceptive Use”. The authors reviewed 6476 citations that reported on an association between exposure to oral contraception and outcomes of venous clots (thromboembolism), stroke and heart attack. They looked at every study’s design and quality as well the number of women who took OCPs and control women (who did not) and the number of years in which the women and controls were followed. In the end they found that 50 of the studies included the data that made them appropriate for their review.

Having given you ” the how they got to their conclusions”, I will skip the 7 dense pages of data and charts in the article… They found that there was a threefold increase in the odds of a venous thromboembolism diagnosis among current users of oral contraceptive pills compared to women who did not use OCPs. There was no evidence that the pills that had the progestin drosperinone ( found in Yaz, Yasmin and the generic equivalents) or other pills that had new second- generation progestins where associated with an increased risk of venous thromboembolism in many of the studies. Altogether, they did not find evidence for a difference in risk among the four types of progestins used in birth control pills. They also found a twofold increased risk of stroke from clot obstruction to cerebral vessels among current oral contraceptive pill users. But as they pointed out, the risk of a clot or stroke in pregnant and postpartum women is increased much more, threefold to eightfold that of non pregnant women. (In other words, a woman is far more likely to get a clot during pregnancy then she is using the pill to prevent pregnancy.) Additionally, there was no increase in heart attacks in women who took the pill when compared to women who did not.

The issue of whether OCPs that contain 20 ug of ethinyl estradiol or less (very low-dose pills) versus those that contain 35 ug (low dose pills) was not resolved because many of the studies did not distinguish between these two doses of birth control pills. The authors also pointed out that women who were high risk for clot formation because of heredity, obesity, previous clots or cardiovascular problems were less likely to get prescriptions for OCPs and hence the complication stats could be skewed.

So now when I’m asked, I can say yes, there is a slight increase in risk of clots with birth control pills but that risk of this complication is far greater during pregnancy. And I also want to remind women that birth control pills can regulate cycles, decrease cramps and heavy menstrual bleeding, treat acne, help overcome hormonal changes, reduce the risk of endometrial and ovarian cancer and of course prevent unwanted pregnancy. (But I should now add that there are other forms of contraception that are highly effective and for certain patients may be more appropriate, this is not an ad paid for by Ortho!)

The choice of OCP brand, amount of estrogen or type of progestin depends on a woman’s symptoms, side effects from previous use and her physician’s prescribing habits. This new analysis of multiple studies has shown that there is no difference between OCP types with regards to risk of thromboembolism. I hope the malpractice attorneys pay heed.

We’ve all been hearing more and more about HPV infections; that they cause cervical cancer, vaginal cancer, anal cancer, throat cancer, mouth cancer and venereal warts. I’ve written several articles about the need to immunize girls and boys with the HPV vaccine. The most common vaccine, Gardasil is given in 3 doses, it is a quadravalent vaccine, which means it gives immunity to 4 types of HPV (6,11,16 and 18). These are the ones that cause 70% of cervical cancers, many of the other above mentioned cancers as well as venereal warts. But alas, despite the multiple direct to consumer ads in the media, recommendations by most doctors and the studies in peer-reviewed journals, only one third of adolescents are currently being immunized.

We would certainly expect the prevalence of these infections to be significantly diminished in those whose parents had the clinical acumen to have their children immunized. But they represent just 30% of their peers. So it was pleasantly surprising to find that a study published online in the Journal of Infectious Diseases reported that the prevalence of infections with the human papilloma virus types included in the Gardasil vaccine dropped by almost 60% among females aged 14 to 19 years during the four-year period after the vaccine became available and was recommended. Dr. Thomas Frieden, the CDC director, said during a press conference held to announce the results of the study, that increasing the vaccination rate to 80% would prevent about 50,000 cases of cervical cancer among girls alive today. “We owe it to the next generation- our sisters, our daughters, our nieces and to protect them against cervical cancer.”

Just to remind you, a three dose series of the quarivalent HPV vaccine was recommended in 2006 by the CDC as a routine vaccination for females age 11 to 12 years and for females aged 13 to 26 years who had not been previously vaccinated. In 2011, the recommendation for the vaccine was expanded to include boys aged 11 and 12 years and for non vaccinated males up to 26 years. No data is yet available on the proportion of males who have been vaccinated and/or the impact of vaccination on their infection rates.

The nearly 60% drop in HPV infection is greater than expected but can be due to “herd immunity” from vaccination (nothing to do with animals, it means that those who got the vaccination were unable to infect those who did not).

Remember, HPV is the most common STD in United States. The estimate is that 14 million people becoming infected with HPV every year. According to the CDC, 79 million of the those who have become infected with HPV are in their late teens and early 20s. Every year, about 19,000 cancers in women are caused by HPV; most are cervical cancer. And of 8,000 cancers caused by HPV that occur in men in the United States, most of them are oropharyngeal (mouth and throat).

Wow, this vaccine can make a huge difference. It may be too late for many of us who are over the age of 26 but we certainly can make sure that the younger (and youngest) generation are vaccinated… Not to do so is malparenting!

I know this is the Fourth of July weekend and many of my patients and readers will be busy with family, barbecues and hopefully celebrating the independence of the fabulous country we live in. (And, of course, there are those wonderful sales!). But if you happen to be glancing at this website, I want to take this opportunity to indulge in a modicum of self-congratulation; a committee opinion from the American College of Obstetricians and Gynecologists was just released and it supports what I’ve been telling my patients for years; that hormone therapy does not increase coronary heart disease risk for healthy women who have recently become menopausal. What also makes this committee opinion novel is that it states that if a woman’s quality of life is diminished by menopausal symptoms past the age of 65, extended therapy may be considered. Let me repeat: The American College of Obstetricians and Gynecologists now recommends against routine discontinuation of systemic estrogen at age 65 for women who need HT to manage their vasomotor symptoms (hot flashes and night sweats).

So that’s the summary. And you can go back to your holiday celebrations. But if you want to read further here are some of the studies and facts that the committee used in its announcement:

Much of the controversy about the impact of hormone therapy (HT) on cardiovascular disease came out of the Women’ Health Initiative (WHI) and the Heart and Estrogen/progestin Study (HERS) which seemed to show an increase in heart attack and stroke in women who took hormone therapy. But more recent studies have cast doubt on some of the methodologies used. Many of the women who were in the those two studies were over the age of 63 when they started hormone therapy and already had underlying coronary heart disease, hence they had an underlying increased risk for developing heart attack and stroke, which perhaps was augmented by hormone therapy. But newer studies indicate that when hormone therapy is started at a younger age, in women aged 50 to 59, the opposite occurs. An important study used CT scans to examine the distribution of calcification (plaque) in the coronary arteries in 1064 women who were in that 50 to 59 year range. Those who took estrogen had calcium scores that were lower than women who took a placebo, moreover, those who stayed on estrogen for more than five years had a significant reduction of 40% in their calcification scores.

The committee also looked at other variables of hormone therapy that could affect cardiovascular disease. They stated that synthetic medroxyprogesterone acetate (Provera) causes constriction of blood vessels whereas natural progesterone causes the vessels to relax and therefore may have a positive effect on blood pressure. In addition, unlike synthetic progestins, natural progesterone causes little or no reduction in high density lipoprotein. (Remember, high density lipoprotein is the good cholesterol and works like a rotor router to protect vessels from plaque formation). The committee doesn’t go so far as to state that ET or HT improve cardiovascular outcomes, they simply state that the evidence is as yet insufficient. But they do say that recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for estrogen therapy or combined estrogen and progesterone therapy for relief of their menopausal symptoms. And women over 65 should talk to their doctor. If their symptoms are persistent, it’s OK to consider continuing their hormone therapy.

My final summation: If you develop symptoms that make you miserable – start hormone therapy in the early years of menopause, there is no increased risk of CHD if you are healthy… and continuation beyond age 65 may be an appropriate option if your quality of life is significantly reduced by these symptoms. We still have to discuss risk- benefits (most specifically breast cancer risk…) There is no free lunch or hormone!

I just spent an amazing week at a spa near San Diego where I was able to hike, perform tai chi, yoga, dance, work out in a gym, meditate and even create art. It was a wonderful week of healing and renewal for my body and soul. Upon return, my state of “zen-hood” was altered when I discovered that only 20% of adult Americans meet federal recommendations for aerobic and muscle-strengthening activity.

Although during my spa week, I didn’t have the time nor the desire to read medical journals, once home on Sunday I felt a wee bit guilty (so much for being at peace with my zen-being) and quickly glanced at my favorite journal, JAMA. And there was an article titled “US Adults Are Lax On Meeting National Exercise Guidelines”. And in my current exercise euphoric state, I just had to read the article and feel a sense of exercise superiority as I unpacked. (It was a short article.) Here is what it reported:

Only 20% of adult Americans meet federal recommendations for both aerobic and muscle-strengthening activity. The federal government’s physical activity guidelines for Americans recommend two hours and 30 minutes of moderate intensity exercise or 75 minutes of vigorous aerobic exercise or an equivalent combination of both each week. Aerobic exercise can be walking, running, swimming and bicycling and should be in increments lasting at least 10 minutes spread throughout the week. They state that the health benefits of aerobic exercise include lowering the risk of coronary heart disease, stroke, hypertension, type 2 diabetes and depression. (We also know that it significantly increases longevity, perhaps more so then any medication!) Adults should also get at least two sessions a week of muscle strengthening exercise that works the body’s major muscle groups in the legs, hips, back, chest, abdomen, shoulders and arms. Working with a resistance band, lifting weights, doing push-ups and sit-ups or Pilates are a few of the recommended ways to increase bone strength and muscular fitness. Although the official physical activity guidelines don’t set a defined amount of time for this the exertion, they do state that it should be continued to the point that another repetition would be difficult. (We have all been there, after 10 or 15 reps, lifting that weight one more time or repeating that stretch is just too much of an effort.)

These woeful statistics were gathered through The Behavioral Risk Factor Surveillance System, a telephone survey of adults aged 18 years or older conducted by state health departments. It showed that Colorado did best and 27% of residents met the guidelines for both aerobic and muscle-strengthening exercise. The lowest rate in the country was in Tennessee with about 13% meeting the guidelines.

Although I won’t have a chance to go back for a glorious spa week for another year, I do intend to keep up the daily walking and twice weekly muscle strengthening work out. Statistics are worrisome, but sensing how well one feels as a result of doing the “right thing” is convincing.

This week’s article is not meant to address the truly frightening experience in which the pilot gets on the intercom system and says “Well folks, we’re having some engine problems and have to make an emergency landing.” I do, however, want to discuss the incidence and risks of experiencing a major medical emergency while flying. As many of you know I’ve spent a lot of time on airplanes. I commuted over 10 years between Los Angeles and New York in order to do the Today Show. And since I have family in Israel, I fly to Tel Aviv frequently. Then there are the flights I take to see programs we have established in the developing world for Save the Children. Despite my frequent miles (and happily, frequent flyer points!) I can count on one hand the times I have been asked to assist an ill patient while on board a flight. The rarity of these requests was mirrored in an article that came out in the May 30 issue of the New England Journal of Medicine titled “Outcomes of Medical Emergencies on Commercial Airline Flights”.

The authors point out that worldwide, 2.75 billion passengers flying on commercial airlines annually. They reviewed the records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communication center from January 1, 2008 through October 31, 2010.. Did you know that airlines partner with healthcare institutions to deliver real-time medical advice from an emergency call center to airline personnel. I felt this was both impressive and reassuring. The airlines that they surveyed represented approximately 10% of the global passenger flight volume on those dates. The Communication Center received calls for 11,920 in-flight medical emergencies among an estimated 744 million airline passengers during the study period. And there were over 7 million flights by these airlines, so the representative incidence was one in-flight medical emergency per 604 flights. (A lot of calculations went into these numbers; but no wonder I was rarely called on…even I have not taken that many flights!)

The following data was reported in the survey: The average age of the passengers that had medical emergencies was 48; their ages ranged from 14 days (who would take a 14-day-old baby on a plane, these were not medical flights) to 100 years (wow). The most common medical problems were syncope, (fainting), (37.4%), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). And when the airplane staff requested assistance from any medical personnel on board the response was quite good; it was provided by physicians 48.1% of the time, nurses 20.1%, EMS providers 4.4%, and other healthcare professionals 3.7% of the time for these medical emergencies.

Aircraft diversion, i.e.landing before the plane got to the scheduled airport in order to take care of the ill passenger occurred in 7.3% of the medical emergencies. Of the 10,914 patients from whom post-landing follow-up data was available, 25.8% were transported to a hospital by emergency medical service personnel, 8.6 % were admitted to a hospital and only 0.3% died. The most common reasons for admission were possible stroke, respiratory symptoms and cardiac symptoms.

As an OB/GYN, I’ve often wondered how often planes have had to make non scheduled landings because a pregnant passenger was miscarrying or in labor. Ican attest to the fact that I was never called on to help with this type of emergency while flying.(Delivering a baby during a flight would have been a remarkable experience for the mother, the other passengers and the flight attendants; and could have garnered free future flights for the newborn and me!) The office reported that of the 61 cases of obstetrical emergency symptoms in their study most ( 60.7%) occurred in pregnant women at less than 24 weeks of gestation who had signs and symptoms of possible miscarriage. Only 11 occurred in women who went into labor beyond 24 weeks, of which, 3 resulted in non scheduled landings (and there were no in-flight deliveries.) So altogether, obstetrical symptoms were rare causes of in-flight medical emergencies. This supports existing recommendations that air travel is safe for pregnant women (and the other passengers on the plane who have tight schedules) up to the 36th week of gestation.

Based on their assessment of this data the authors estimate that 44,000 in-flight medical emergencies occur worldwide each year. So although medical emergencies during commercial airline travel is rare, on a per passenger basis they do occur daily and physicians and other healthcare professionals who are in the plane at the time can be called on to aid ill passengers.

I think this article is reassuring both for passengers and medical personnel who happen to be on a plane when a medical emergency occurs. The fact that we can get real-time medical advice from an emergency call center is extremely helpful. The airlines have also improved the emergency kits available for use.

A word of advice: if you have a medical condition it would be a good idea to have a card in your wallet that indicates the diagnosis and current therapies that you receive. You should keep your medications with you on the airplane, in your purse or a case that is under your seat rather than stored in the over head compartment or suitcase down below. Don’t board if you feel sick (especially if you have the flu…think of others seated near you). Take all your regular meds on time, hydrate and if you can’t eat the food served on the plane (or they don’t serve it) bring your own! The friendly skies can be medically friendly if we all do our part.

Imagine going through an entire pregnancy only to have your baby die at or within a month of birth. Nor do we expect to lose our lives during childbirth. Most American women would say that this is a tragic scenario that is far more likely to occur in developing countries. That’s correct, but a new report issued by Save the Children for Mother’s Day gives us pause for concern about our self satisfaction regarding our country’s maternal, newborn and child safety status. But before I report on America’s less than stellar statistics, let me give you some global ones:

Every year, nearly 7,000,000 children die before the age of five.
Every year, 40 million women give birth at home without the help of the skills birth attendant.
Every day, 100 women died during pregnancy or childbirth and 8,000 newborn babies die during the first month of life.
Newborn death accounts for 43% of all deaths among children under age 5.
3 million newborn babies die every year – mostly due to easily preventable or treatable causes such as infections, complications at birth and complications of prematurity.
60% of the infant deaths occur in the first months of life. Among those, nearly 3/4 die in their first week. And more than a third die on the date of birth.

Save the Children has compiled a yearly mother’s index that uses five indicators, definitions and data sources in order to rate the well-being of mothers and their children. These include: Lifetime risk of maternal death, under-five mortality rate, expected number of years of formal schooling, gross national income per capita and finally participation of women in national government. Now as underwhelming as this may be, our country ranks 30th on this mother’s index. Overall, the US performs quite well on educational and economic status (10th best in the world) but it lacks behind all other top ranked countries on maternal health (46th in the world) and children’s well-being (41st in the world) and performs poorly in political status (89th in the world!) And here is why:

In the US, women face a 1 in 2,400 risk of maternal death. Only five developing countries in the world – Albania, Latvia, Moldova, the Russian Federation and Ukraine – perform worse than in the United States on this indicator. A woman in the US is more than 10 times as likely as a woman in Estonia, Greece or Singapore to eventually die from a pregnancy related cause.
In the US, the under five mortality rate is 7..5 per 1,000 life births. This is roughly the same as the rates in Bosnia and Herzegovina, Qatar and Slovakia. At this rate, children in the US are three times as likely as children in Iceland to die before their fifth birthday.
Women hold only 18% of seats in the United States Congress. Half of all countries in the world perform better on this indicator. Sixteen countries have more than doubled this percentage of seats occupied by women. In Finland and Sweden, for example, women hold 43 and 45% of parliamentary seats respectively.

So who ranks first? Finland wins, followed by Iceland and the Netherlands and then Denmark. Ahead of us in the mother’s index is Estonia, followed by Canada, United Kingdom, Czech Republic, Israel, Belarus, Lithuania, Poland and Luxembourg. Then and only then we follow. The worst countries for mothers and their children are in sub-Saharan Africa and include Niger, Mali, Sierra Leone; last on the mother’s index is the Democratic Republic of the Congo.

Most of my patients, as well as readers of my website, know that I’m very involved with Save the Children and indeed serve as a trustee. I am particularly proud of our global newborn and child survival campaign. We are currently working on four fronts:

  • Increasing the awareness of the challenges and solutions to maternal, newborn and child survival. (as part of the campaign Save put out this year’s state of the world mothers report.
  • Encouraging action by mobilizing citizens around the world to support programs to reduce maternal, newborn and child mortality.
  • Working in partnership with national health ministries and local organizations and are supporting efforts to deliver high quality health services throughout the developing world. This means improving pregnancy and delivery care, vaccinating children, treating diarrhea, pneumonia and malaria as well as improving nutrition
  • The program Saving Newborn Lives launched in 2000 with the grant from Bill and Melinda Gates Foundation has helped deliver better care practices and improve health interventions to save newborn lives in 18 countries.At home we, the concerned women (and men) can help. Our votes and letters can have a huge impact…Congress should create a national commission on children to address the needs of 16 million children in the US now living in extreme poverty. Congress should also protect US global health funding and increase support for maternal and child health and nutrition. If every woman is afforded appropriate maternal health care (and hopefully the new health laws that go in effect in 2014 will help ensure this), we need not be ranked 30th in the world.

    So now I will do my trustee thing….If you want to learn more or help us make a difference in the lives of millions of children please go to www.savethechildren.org/newborn-action.

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