Did you know that: Infertility treatment may increase the risk of maternal morbidity and mortality in pregnancy

A study published in the Canadian Medical Association Journal (CMAJ) reported that women who became pregnant with infertility treatment (e.g. ovulation induction, intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection) showed an increased risk of maternal morbidity or maternal death (30.8 per 1,000 in infertility treatment women versus 22.2 per 1,000 in women who became pregnant unassisted).

According to this publication:

“Severe maternal morbidity refers to a broad set of conditions that identify women who experience a near-fatal event during, or within 42 days of a pregnancy. The association between assisted reproductive technologies and severe maternal morbidity has been investigated recently in 3 studies in the United States, each reporting an approximate doubling of the risk of severe maternal morbidity among women with pregnancies conceived through assisted reproductive technologies compared to those with pregnancies conceived without.”

Wang ET, Ozimek J, Greene N, et al. Impact of fertility treatment on severe maternal morbidity. Fertil Steril 2016;106:423–6.Google Scholar
Belanoff C, Declercq ER, Diop H, et al. Severe maternal morbidity and the use of assisted reproductive technology in Massachusetts. Obstet Gynecol 2016; 127:527–34.Google Scholar
Vandenbroucke JP, von Elm E, Altman D, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology 2007;18:805–35.CrossRefPubMed. Google Scholar

 

Black Babies Are Dying, And So Are Their Moms … What Can We Do About It?

The recent edition of The New York Times Magazine, the article “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis” written by Linda Villarosa called out a disturbing and unnecessary truth: the discrepancy in death rates for black babies and mothers is not genetic or biological, instead it “has everything to do with the lived experience of being a black woman in America”.

There is perhaps no better day to draw more attention to this issue than Mother’s Day, a day created to celebrate mothers and their babies.

Here are the sobering facts written by Villarosa:

—Between 1915 and the 1990s, “amid vast improvements in hygiene, nutrition, living conditions and health care, the number of babies of all races who died in the first year of life dropped by over 90 percent — a decrease unparalleled by reductions in other causes of death. But that national decline in infant mortality has since slowed. In 1960, the United States was ranked 12th among developed countries in infant mortality. Since then, the rate is largely driven by the deaths of black babies.”

—The United States now ranks 32nd out of the 35 wealthiest nations in infant mortalities (most are black babies).

—Black infants in America are now more than twice as likely to die as white infants.

— 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data — a racial disparity that is actually wider than in 1850.

— Black women are up to four times more likely to die from pregnancy-related causes as their white counterparts.

It’s not just access to quality healthcare, it’s the ability/willingness of the healthcare professionals to treat every woman, whether black, white, Hispanic or otherwise the best possible way, in other words, to optimize care and to offer standardized care for all patients irrespective of race, ethnicity, or insurance status.

“Recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that leads directly to higher rates of infant and maternal death. “ And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.

Dr. Arline Geronimus, a professor in the department of health behavior and health education at the University of Michigan School of Public Health, “first linked stress and black infant mortality with her theory of ‘weathering.’ She believed that a kind of toxic stress triggered the premature deterioration of the bodies of African-American women as a consequence of repeated exposure to a climate of discrimination and insults. The weathering of the mother’s body, she theorized, could lead to poor pregnancy outcomes, including the death of her infant.”

So if “the black-white disparity in the deaths of babies is related not to the genetics of race but to the lived experience of race in this country,” the looming question is why? Why are black women having greatly poorer outcomes when genetics are not to blame?

First off, findings show “higher levels of preterm birth among women who reported the greatest experiences of racism.” Villarosa writes, “The bone-deep accumulation of traumatizing life experiences and persistent insults that the study pinpointed is not the sort of “lean in” stress relieved by meditation and “me time.”

“When a person is faced with a threat, the brain responds to the stress by releasing a flood of hormones, which allow the body to adapt and respond to the challenge. When stress is sustained, long-term exposure to stress hormones can lead to wear and tear on the cardiovascular, metabolic and immune systems, making the body vulnerable to illness and even early death.”

This is not mere speculation. The American Journal of Public Health published a study that showed that “persistent racial differences in health may be influenced by the stress of living in a race-conscious society. These effects may be felt particularly by black women because of [the] double jeopardy of gender and racial discrimination. Even when controlling for income and education, African-American women had the highest allostatic load scores — an algorithmic measurement of stress-associated body chemicals and their cumulative effect on the body’s systems — higher than white women and black men.”

Lynn Freedman, director of the Averting Maternal Death and Disability Program at Columbia University’s Mailman School of Public Health says “Disrespect and abuse mean more than just somebody wasn’t nice to another individual person. There is something structural and much deeper going on in the health system that then expresses itself in poor outcomes and sometimes deaths.”

When black women are given access to support, education, and stress management as well as quality care, the death rates for both babies (most often linked to low birth weight) and mothers dramatically decline.

How can we be allowing this to happen in 2108 in the United States, among the richest nations on earth? And the even larger question is what can we do about this?

In my personal experience, black women are more likely to get inferior levels of care because they are more likely to be impoverished, have lower levels of or no health insurances at all, and therefore, have less access to optimal health care the way women with commercial health insurances have. In my personal opinion, we should have universal health care for all pregnant women with access to any physicians or hospitals they want to. That is how it works in all other advanced countries.  Choice of healthcare is taken away when you have inadequate insurance which is not accepted by the majority of physicians. If doctors have the choice to accept a patient with a much higher paying insurance as compared to someone with an insurance that pays much less, it is clear  whom doctors will prefer to accept. And whom they will reject.

Many clinics in hospitals accepting Medicaid patients or patients without insurance have the best of intentions, but it’s still inadequate compared to individualized care that pregnant women with commercial insurances obtain.

If there is one thing I wish for on Mother’s Day it would be that all women in the U.S .have the same insurance and can choose any doctor they want to see independent of their insurance status. And that doctors must accept all patients independent of their insurances.

Perinatal depression can be prevented

Mental health is essential for everyone including pregnant women. Perinatal or pregnancy depression affects about 1 in 8 new mothers annually in the United States. It can have a devastating effect on the mother as well as the infant.

Risk factors that can be used to identify individuals at risk for perinatal depression include:

  • a history of depression
  • history of physical or sexual abuse
  • unplanned or unwanted pregnancy
  • stressful life events
  • intimate partner violence
  • complications during pregnancy

Additionally, low socioeconomic status, lack of social support, and bearing children during adolescence have been associated with a greater risk of developing perinatal depression after delivery.

The Edinburgh postpartum depression test can screen effectively for your risk of having postpartum depression.

In addition, the interactive Zhung Self-Rating Depression Scale Quiz checks the level of depression to help decide how severe it could be.

Coronavirus 2019-COVID & Pregnancy

Pregnancy and Coronavirus COVID-19

UPDATE AS OF February 2020

There is still much unknown about 2019-COVID and pregnancy. Probably for now the best and most recent answers on 2019-COVID and pregnancy can be found on the CDC website.

On 2/3/2020 it was reported that a pregnant woman with Coronavirus infection was delivered by cesarean section in China at 37 weeks. Both mother and baby are doing well.

On 2/12/2020 The Lancet reported on 9 cases of COVID-19 in the third trimester pregnant women. All were delivered by cesarean section. Symptoms of COVID-19 infections in pregnant women were similar to non-pregnant individuals. There was no evidence for intrauterine infection in these 9 cases caused by transmission from the women to the baby. Also, there is no evidence that a cesarean delivery is needed to protect the mother or the fetus.

In February 2020, most information we have on pregnancy and coronavirus derives from information on MERS and SARS coronaviruses.

One was a report of 5 pregnant women from Saudi Arabia which concluded that MERS-CoV may pose serious health risks to both mothers and infants during pregnancy. Two of the 5 mothers infected with the virus died.

Pregnant women with severe acute respiratory syndrome (SARS) appear to have a worse clinical outcome and a higher mortality rate compared to non-pregnant women.

Though there were a limited number of pregnant women among these cases, it seems pregnant women are more likely to become infected and those who became infected with SARS were more likely to get sick.

Pregnancy is a time of low immune function which generally includes:

  • older people
  • diabetics
  • people with HIV infection
  • people with long-term use of immunosuppressive agents
  • pregnant women