A Long and Dangerous Journey: Women, Pregnancy, and Death

Every year, about half a million women die during or shortly after childbirth. The vast majority of these deaths occur in the developing world and most are preventable. The UN Millenium Development Goals include a goal to reduce maternal mortality by three-quarters by 2015. 

The following is a lecture I presented at the Iowa City Foreign Relations Council in 2012. SKIP THE INTRODUCTIONS - VERY BORING! Move to about minute 4 or 5 ...

A Long and Dangerous Journey: Women, Pregnancy, and Death

Teaching = LOVE

Teaching is a joyful, exhilarating experience – more so when you know you have done it well. The most important words I hear are, “this is the best course I have ever taken …” or even, “this is the best course of my graduate program…” There are other ways that I know I have done my job, not least of which is when my students earn good grades – thus demonstrating their own increase in knowledge from the class lectures and their hard work.

I have been thinking a lot recently about teaching epidemiology; specifically, teaching epidemiology to undergraduates. Should it be taught differently than to graduate students? If so, how? Why? Does it matter if the students are young undergraduates or more seasoned third- and fourth-year students?

For the next three weeks, my colleague Dr. Alexandru Coman and I will be teaching epidemiology to first-year undergraduates at the new Cluj School of Public Health in Cluj-Napoca, Romania.

Challenges abound.

Our goal? To inspire. To make these kids LOVE epidemiology. Is that possible? Is epidemiology loveable to anyone but us happy few?

So, the plan is to keep it fun. I have insisted on Leon Gordis’ text – it’s the classic (succeeding Lilienfeld’s classic). He based this text on Epidemiology I as it is taught – and as I studied it – at Johns Hopkins. What inspired me in that class was what one of my mentors, Dr. Bernard Guyer, called the “epidemiological way of thinking.”

So – keeping it fun, Anne? Hmmmm … well, how about this … Alex will show “Contagion” for the first lab/discussion section, then later this week, the PBS documentary on the Spanish flu … and we have more planned … 

"Gun-ho" Questioning the sacred tenets of the gun debate

Anne Wallis & Beth Magie, Mammoth PA, Summer 2012

I first met guest blogger, Beth Magie, when we were skinny 6th graders at Ramsay Jr. High in Mt. Pleasant, Pennsylvania -- that was 1974. We graduated from Mt. Pleasant High School together. I went to college in Virginia and she joined the Air Force. Beth is a huge fan of women's professional tackle football, and she loves the Pittsburgh Passion; she also loves fishing, hunting for rocks and gems, and in her spare time, she writes poetry and letters to legislators.

I'm constantly hearing about all the "what if" scenarios in the long reaching "gun-ho" defense.  I've heard alot of attitudes regarding a "shoot first, ask questions later" mentality.  I've also (once again) been called a hypocrite for my beliefs on gun control. 

    

Let me ask three questions:

1.  Have you ever had someone thrust the barrel of a gun into your chest and threaten to kill you?

2.  Have you ever had 7+ rounds from a semi-automatic weapon, fired just outside of your bedroom window in the middle of the night?

3.  Have you ever been the subject of an armed robbery/"mugging"? 
  

I am not asking ...if you know someone, or if you have heard of someone, or a friend of a friend had that happen, or that such and such happened down the street, or this happened at the store you go to all the time.   I am asking anyone reading this, personally, as an individual yourself... Have YOU??

Guess what.  True story(ies).   I have, and I've lived (without a scratch, I might add) to tell.  In each of these situations, it did not make me think that I should run out and buy a gun.  Not even when I lived in the midst of the Crips, Bloods, the 9th St Neuvo's, the Garfield Gang, or the other one that I can't remember that was just south of me, in Phoenix.      

The attempted robbery occurred in that same neighborhood.  I was not shot.  I was not injured.  And, I actually got an apology, a handshake, and unknown to the "assailant" ...went home with my money in my pocket.

The firing of a gun outside my bedroom window, was a warning.  To me.  Because earlier in the day, I had identified someone who had broken into my vehicle.  ( One of the 9th St. Neuvo's )  I still lived there several months afterwards.  It still did not make me think that I "have to have a gun" to protect myself.    

The gun thrust into my chest, was during an argument.  **With someone I actually knew.**  

I've thought about buying one a couple of times, I won't lie.  But not because I "feared something would happen".  But now?  ...Nope.  I've lived through much that many still don't and won't know about me and I did it without owning or having a gun. 

So, when you throw out all of your "what if" scenarios and try to convince me that everyone needs/should have one?  I have been thinking..........................it must be hell to live in and as, a victim of fear. 

-- Beth Magie, Mt. Pleasant, PA, January 2013

2012 [bloga.epidemiologica] in a few words

The year in words: first as a concept cloud, then as a concept web, and finally as a correlation wheel. Use Text is Beautiful to do your own visual analysis of text.

Guest blogger: Dr. Erin Reynolds on "Adventures in Lecturing: The Gambia"

Escape to the beach ...

[Dr. Erin Reynolds is a newly minted PhD in Epidemiology from the University of Iowa, College of Public Health. She is from Davenport, Iowa.]

Day 1: Hit the ground running

Well, I arrived safe, sound, and exhausted in The Gambia on Monday evening at 9:30 pm. I had started this journey just a short 48 hours before. It seemed so long ago, because it was. Very long...via NY and Brussels to the terminal which houses the 3 or 4 gates that go only to Africa. I sat and waited there for another ~5 hours where I became very popular when it was discovered I had an adapter plug that worked in European outlets...Three computers and one phone later, we finally boarded the plane for Banjul...the same plane that had been sitting at the gate since we got there at 8 am! 

I got into Banjul, fingers crossed that my entry letter that was supposed to stand in for a visa would work and that my luggage would have made four plane changes. Verdict: suitcase made it minus one wheel; faux-visa worked and received its official stamp.

The university housed me in a lovely house in the African Union (AU) Village. The subdivision was built for the AU gathering held in The Gambia back in 2005 or 2006. So, an African President stayed in my house! I met the neighbors two doors down: tan American professor from St. Mary’s College in Maryland, Sandy Ganzell, and his family. There are a lot of ex-pats in this neighborhood. I am looking forward to meeting the Irish priest, Father Joe, who has been in the Gambia for 30 years and has a yard full of bird statues.

One 11-hour sleep and then it was off Ito campus for my first lecture. No day of rest for me! Luckily, I had used my time in the Brussels airport to work on my Tuesday lecture. Now if only I had Wednesday’s lecture ready to go! Instead of my normal two lectures a week (T-TH) I asked to do three and make the best use of my time here. Now I felt rushed to get them done! I also planned two seminars, one viewing of the movie Contagion this week, and one next week on writing manuscripts and plagiarism. 

Day 3

So two days down. I am sitting in the dark, yet still on the internet thanks to my 3G hotspot provided by the University of The Gambia (UTG). The power supply here is...well...variable. Sometimes you have it, sometimes you don't. It was on when I got home from class, and went off half-way through cooking dinner. I am hoping it comes back soon since my battery won't last too much longer and I still have lectures to work on tonight!

I have not had a lot of time to explore The Gambia, even the area around my house which is known as Ghanatown and supposedly has a beautiful beach. The UTG sends a car for me in the morning and takes me home at night. Similar to my experience in India, they seem to not want me go off on my own. I mentioned that I was going to walk to the beach on Saturday (I am probably 500 yards from the ocean where I am staying and have yet to see water!) and I got ‘the look’. ‘The look’ happens when I mention that I would like to do something that is considered unsanctioned by my overprotective hosts. I also got ‘the look’ when I said it would be ok to pick up food from the market rather than going to the expensive grocery store with Western food. And today when I said it would be ok for them to go home while I waited for the car. And that it was ok for me to sit outside (i.e., not in the air conditioned office). In India, I got ‘the look’ anytime I mentioned taking a taxi to the city center by myself, eating street food, wanting to live in the village to do data collection, or going to the tailor by myself. Being a single, female visitor came sometime be stifling, but I know ‘the look’ comes from my hosts wanting me to have a good experience. So, instead of me venturing onto the beach by myself, a visit to the beach has been added to my itinerary. Meaning that I will most likely be accompanied by at least Bai and potentially a few others. Dr. Kuye, the head of the department, heard I was going to the beach and has requested that the beach trip be used to introduce me to the fishing industry so I can see the public health concerns associated with fishing in this country. Only I could mention I want to go sightseeing and have it turn into an educational field trip!

Day 4

Today, I finally visited the beach!! But I am getting ahead of myself. I should probably start with the French toast. Yeah, you heard me right, French toast. I was sitting around this morning in my pjs because the power was off again this morning and that meant the water heater was not available. And big baby that I am, I was reluctant to get ready for the day if it meant taking a cold shower. So when I got a knock on my door at 9:30 am (a half hour before I was scheduled to be picked up), I thought I it was my driver! Instead, it was my neighbor, Maribeth, whom I had met Tuesday. She invited me to have coffee with her and another neighbor and later to go exploring after class. Exploring! This would be the first time I would be able to escape the itinerary and do something just for fun so I was excited. We arranged to meet in the afternoon at 4:30. So by the time we finished talking, I had 20 minutes before my ride came (if he was on time), so I bit the bullet and took a shower...and my god, the water was hot! It must have been left over from the night before. It was lovely! I think I will turn the heater on every now and again just to store up hot water for times when the electricity is out! I had just got out of the shower and another knock on the door. This time it must be the driver. Nope, Maribeth again, this time bearing gifts. Lucy, the Russian/Greek woman married to the Egyptian doctor across the street heard I was new in the neighborhood and sent breakfast over. Beautiful, prefect, French toast. With powdered sugar on top. I did manage to take a picture before inhaling it!

Finally, the driver picks me up and I get into campus. Only to find the power is out there too. My 12:00 pm seminar...The one where I planned to show the movie Contagion and discuss possibilities for pandemics...yeah, I kind of need electricity. Backup plan, have the students tell me their ideas for their Master's thesis and we can discuss study design. They were kind of reluctant to share because they did not have proposals prepared to discuss, but after a few brave students went, they really got into sharing their ideas and giving their peers advice on sources of data or study designs. So it turned out that Plan B worked and may have been a better use of time than my original plan.

Day 6

Friday, I visited the Monkey Park at Bijilo National Park with the Ganzell family. As it turns out, I was a little overdressed for this afternoon of hiking since I had been planning on meeting with the Vice Chancellor of the university, but who says you can’t hike in business causal? Jolie and Kia showed me how to feed the monkeys and darned if they weren't right. You hold out a peanut and they politely take it out of your hand. They go a little crazy if they see the whole bag of peanuts, but in general, much nicer then the Indian monkeys I have encountered. At some point while hiking in the forest, we realized we were really close to the beach. So we found a faint trail and followed it to the beach. Gorgeous! After a hot hike, the breeze from the water and frolicking in the ocean felt amazing! I wasn't going to let some work clothes stop me from enjoying the ocean, so I rolled up my pants and waded straight into the ocean!

Day 12

Saturday I visited a fishing village in Tanji, just south of where I am staying. What a busy place! And apparently this wasn't even as busy as it gets! There were people everywhere, about ten boasts just off shore, and people running into and out of the water. There is an interesting system in place. Women buy the fist from the boats. Women then sell their fish to either: the smoking facilities, the people who dry fish, the people who salt fish, or those waiting to take fresh fish to various markets. The women used to go out into the water to get the fish, but now it seems like the women form a line about 20 ft from the water and have young adolescent boys venture into the water to collect the fish from the boats. These boys are paid by the bucket which means they run in and out of the water in order to make as many trips as possible. As they come out of the water, they tend to lose some fish (the slippery buggers just won't stay in the bucket while they run). There was almost an incident involving me, one of the fish boys, several small children, and a lot of fish. I barely got out of the way in time. I cannot express my joy at not having a bucket of fish dumped on me! Bai also took me to see the smoking facilities and the place where people dry their fish. Interesting, if very smelly. I sucked it up and maintained a professional level of curiosity. I still don't like fish.

Sunday was supposed to be my 'rest' day. Turned out to be anything but restful! I again joined up with the Ganzell family for their planned outing. Maribeth had a scheduled batik lesson with two of the St. Mary's College students. Sandy, Jolie, Kaia, and I tagged along since this lesson took place next to the Katchikally Sacred Crocodile Pond. There are about 100 very tame crocodiles here that don't mind being petted and posed with...although you do not try and go near the pregnant females! Those are not at all friendly according to our guide! Next, we went to a fortune teller. While I don't really believe...he was pretty darn interesting. Without asking a single question and barely looking at me, he addressed my concern about employment. Several other things too, but he was pretty accurate with all of my current concerns.  So maybe I could be convinced to change my views...

After this, I rushed home, leaving the Ganzell family to change clothes and wait to be picked up for my appointment with the vice chancellor of the university. Really, he is the President of UTG and Gambia College since the President of the Gambia is the Chancellor. Great meting! The first thing he asked me was if I was on Facebook, Twitter, and LinkedIn. The man is as American as they get. While I am coming back to teach with Gambia College (undergrads), I think the VC has a lot of plans for me to work with UTG. So, it looks like I will be a busy bee when I come back...I'm slated to teach 3 classes (2 for Gambia College and 1 for UTG). And do journal club. And mentor students. And faculty. Oh, and if I have the time, do a research project on malaria in my spare time. So I would definitely say that my meeting with the VC (the meeting that was rescheduled 4 times!), was a success when we finally did get around to meeting!

My final week of lectures went smoothly, as did my second seminar. I also met with several students to talk about their master's projects. And I went shopping in Banjul! That was fun. Although I do dislike people trying to overcharge me. I am a master bargainer much to their dismay but I got some excellent deals!

After my final lecture of the week, I arrived home just in time to jump into the car with the Ganzell's to go watch an ultimate Frisbee game between Peace Corps volunteers and the MRC (Malaria Research Center). Hopefully I will have the chance to meet more people from both groups when I return! Although maybe not where they play Frisbee...I've never seen so many mosquitoes (or soussousla in mandinka) in one place! I honestly hope the malaria meds work, because I definitely got several mosquito bites while out there despite a virtual bath in mosquito repellent. I swear that stuff never works for me. Or I am just so irresistible to mosquitoes that they overcome their dislike of OFF to bite anyway.

Hope you all enjoyed my stories! I'll have to set up a blog for my return to the Gambia in February!

The Danger of Ignorance: Improving Patient Education Guidance about Preeclampsia to Save Women’s Lives

Getty Images, Wall Street Journal, 2011

Who among us can forget the episode in the first season of ER when Dr. Green admits a pregnant woman with a bladder complaint? We watched in horror as the woman went into labor and began having seizures. Dr. Green is overwhelmed; he delivers the baby, but loses the mother and is faced with giving grave news to the waiting father. 

This episode has remained imprinted on my mind through almost 20 years and two pregnancies. I am not alone. I have known researchers who have used the show as a deliberate stressor in psychological studies. This episode, “Love’s Labors Lost,” which aired in 1995, was my first exposure to the hypertensive disorders of pregnancy and served as a persistent reminder that pregnancy, even in late-20th century America, can carry unexpected risks.

Eclampsia is, thankfully, rare, but it carries a high risk of mortality and morbidity for both the mother and the infant. More common are gestational hypertension and preeclampsia. Preeclampsia – differentiated from gestational hypertension primarily by the presence of protein in the mother’s urine – affects somewhere between 5% and 8% of pregnancies. The only treatment known is delivery; therefore, obstetricians manage preeclampsia with bed rest, often in the hospital, hoping to maintain the pregnancy until the fetus is viable. Preeclampsia and eclampsia are two of the most important causes of maternal mortality in the US and worldwide.

Epidemiologic research conducted by Drs. Audrey Saftlas, Hani Atrash, myself, and others indicate that hypertensive conditions of pregnancy, including preeclampsia, are on the rise. Globally, preeclampsia and other hypertensive disorders of pregnancy are a leading cause of maternal and infant illness and death. By conservative estimates, these disorders are responsible for 76,000 maternal and 500,000 infant deaths each year.

Preeclampsia is a condition that follows a rapid progression, beginning after the 20^th week of gestation and up to 6 weeks postpartum. It is characterized clinically by high blood pressure and the presence of protein in the urine. Prior to diagnosis, a woman may notice swelling, sudden weight gain, headaches and changes in vision, although some women with rapidly advancing disease report few symptoms.

While we can identify risk factors – first pregnancy, obesity, family history, age under 20 or over 40 – the cause remains unknown.

Obstetric providers are acutely aware of the dangers of preeclampsia. Because of its potential severity, rapidity of onset and progression, access to high-quality prenatal care that includes education about preeclampsia seems like a no-brainer. The interesting thing is that the historical underpinnings of prenatal care provision were largely developed around the detection of eclampsia, yet preeclampsia education is not a required component of prenatal care visits. 

Perinatal practice guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) provide no guidance to providers regarding patient education. While these professional guidelines provide the definition and incidence of preeclampsia and offer management recommendations based on severity, there is no guidance about educating women to recognize early signs and symptoms of preeclampsia, which could guide them to early diagnosis and improved clinical management. ACOG publishes a pamphlet describing blood pressure during pregnancy, including types of high blood pressure, effects on pregnancy, and risk factors; unfortunately, the language is targeted to a clinical audience rather than to PNC patients.

The Preeclampsia Foundation and Kaiser Permanente offer information on hypertension during pregnancy. Both organizations provide information about what preeclampsia is, warning signs, risks, and what women should do if they experience sudden weight gain, edema, headaches, blurred vision, or upper abdominal pain.

Little is known about how many prenatal care providers discuss preeclampsia with their patients or if women understand what is communicated to them when such discussions occur. One recent study (You, Wolfe, Bailey, et al., 2010) of 112 pregnant women attending an academic hospital prenatal clinic in Chicago reported that only 14% were able to define preeclampsia, strongly suggesting that knowledge and understanding of this potentially fatal complication of pregnancy is inadequate.

In response to this fundamental gap in knowledge, the Preeclampsia Foundation conducted an internet-based survey in March and April of 2008 to determine what women learned about preeclampsia in the context of prenatal care during their first pregnancy (2000-2008). Respondents (n=754) were primarily visitors to the Preeclampsia Foundation website, with extended outreach by the respondents to their friends and family. All survey responses were anonymous and data confidentiality was maintained, following Preeclampsia Foundation guidelines.

Respondents represented all regions of the US, were well-educated and middle-to-high income. Virtually all of these women received prenatal care.  Just over 40% of the women indicated that their prenatal care provider “definitely” described preeclampsia; 35% said they were “definitely not” given information about preeclampsia, and the remaining 16% did not remember. Of those who definitely had preeclampsia described to them, slightly more than half said they “fully understood the explanation,” 37% “understood most of the explanation,” while 15% either “understood some of the explanation,” or did not remember. Most of the women (69%) who remembered receiving information about preeclampsia from their provider received that information in the first or second trimester.

Here is the really interesting bit:  a full 75% of women who said they “definitely” received information on the signs and symptoms of preeclampsia and understood “fully” or “most” of the explanation, indicated that because of this information, they took one or more of the following actions: 1) reported symptoms to their provider, 2) went to the hospital, 3) monitored their own blood pressure, 4) complied with an order of bedrest, or, 5) responded in some other way (e.g., made dietary changes, did their own research on preeclampsia). However, of those who did not understand the explanations provided, only 6% responded in one of the ways noted above.

The importance of what we learned from this online survey is clear: even among well-educated, middle-to-high income women, a substantial proportion were not told about preeclampsia or did not fully understand their providers’ explanations about the signs and symptoms of preeclampsia. Our findings suggest that when women know how to recognize the signs and symptoms of preeclampsia and they understand the explanation offered, they are likely to act on that information and contact their provider or go to an emergency department.

However, if a well-educated, well-resourced sample of pregnant women such as those in our sample are lacking in knowledge of preeclampsia, then what about the millions of less-educated, low-income women around the world who may be receiving less than adequate prenatal care?  In fact, data from a recent study show that knowledge of preeclampsia is directly associated with a woman’s health literacy, history of preeclampsia, and receipt of information about preeclampsia from a clinician, the internet, or a book (You, et al., 2010).

For about 100 years – since the basic framework for prenatal care was established in the 1920s – the content of prenatal care has changed little.  While the content of prenatal care, particularly with regard to detecting preeclampsia, is largely unchanged, the role and education level of women has changed. Thus, education about the signs and symptoms of preeclampsia holds promise as a powerful means of achieving earlier detection and management of this disorder.

Our findings, in combination with those of other studies, indicate that women know very little about any of the hypertensive conditions of pregnancy. Moreover, they are provided with little education or follow-up to ensure they understand the basics (i.e., what it is, signs/symptoms to look for, what to do if these signs/symptoms occur). The observation that the well-educated participants in our internet survey received and/or retained little information is concerning. It follows logically that women with fewer resources and less education, who may also be at higher risk for preeclampsia, may receive and retain even less information; and due to disparities in health care access, they may not have adequate health insurance to report symptoms to a provider.

We argue further that education about preeclampsia and related hypertensive disorders must continue into the post-partum period so that women can recognize prodromal symptoms of post-partum and late post-partum eclampsia. In their research, Chames and colleagues (2002) have shown that late-postpartum eclampsia can be prevented through patient education and improved healthcare response. 

This consideration is important because while prenatal and intrapartum rates of eclampsia have dropped since 1990, there has been a relative increase in rates of post-partum eclampsia. Most cases of eclampsia that develop after the first 48 postpartum hours are first seen in an emergency department. Therefore, it is also critical that emergency care providers retain “a high index of suspicion” about a preeclampsia or eclampsia diagnosis even after delivery (Chames, et al., 2002).

Our colleague, Dr. Baha Sibai, has pointed out that in the coming years, we can expect to see more limits on healthcare spending and reductions in hospital and clinic staff. A woman with legitimate complaints who presents at an emergency department may leave untreated if the staff are emergency or trauma providers, not OB/GYN specialists. Thus, we argue that women not only need basic education in preeclampsia, but they require repeated education to ensure they understand the risks and can be empowered with knowledge that will allow them to advocate strongly for their own care.

We offer several recommendations based on our observations. First, the usual mantra: more research is needed to fully assess the health literacy, knowledge, attitudes, and behavior of pregnant women and to examine the practices of prenatal care providers. Second, ACOG/AAP guidelines for prenatal care should follow the recommendations of You, et al. (2012) and the Preeclampsia Foundation and “...include deliberate and pictorially based explanations of the hypertensive conditions of pregnancy...” as well as information about exactly what their patients should do if they experience or recognize any of the signs or symptoms,  Finally, all women should be hearing a strong public health message that they can and should be advocates for their own care. 

[See a version of this article in the December Preeclampsia Foundation newsletter: http://www.preeclampsia.org/component/lyftenbloggie/2012/12/04/157-the-danger-of-ignorance-improving-patient-education-to-save-womens-lives. 

Authors: Anne B Wallis (University of Iowa), Eleni Tsigas (Preeclampsia Foundation), Audrey Saftlas (University of Iowa), and Baha Sibai (University of Texas Medical Center)

REFERENCES

1.         Wallis AB, Saftlas A, Hsia J, Atrash HK. Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987-2004. Am J Hypertens. 2008;21:521-526.

2.         Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric mortality in the United States. Obstet Gynecol. 2009;113(6):1299-1306.

3.         Alexander GR, Kotelchuck M. Assessing the role and effectiveness of prenatal care: History, challenges, and directions for future research. Public Health Rep. 2001;116:306-316.

4.         American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Sixth Edition ed. Elk Grove, IL; Washington, DC: AAP, ACOG; 2007.

5.         American College of Obstetricians and Gynecologists. High Blood Pressure During Pregnancy. Washington, DC: ACOG; 2011.

6.         Preeclampsia Foundation. Signs & Symptoms. 2011; www.preeclampsia.org/health-information/signs-and-symptoms. Accessed 1/3/2011, 2011.

7.         Kaiser Permanente. Preeclampsia: High Blood Pressure During Pregnancy. In: The Permanente Medical Group I, ed. Vol E-Handout #7325-E (Revised 3-08) RL 8.1: The Permanente Medical Group, Inc.; 2008.

8.         You W, Wolf M, Bailey S, et al. Factors associated with patient understanding of preeclampsia. Hypertens Pregnancy. 2010;September 2010 [Epub ahead of print].

9.         Chames M, Livingston J, Ivester T, Barton J, Sibai B. Late postpartum eclampsia: A preventable disease? Am J Obstet Gynecol. 2002;186:1174-1177.

[sotto voce] ... occasional observations from the ivory tower

This blog entry has been moved to my new slow blog, frisson - on life inside and outside the academy