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Maternal and infant health care: A rising concern

I originally wrote this article for UNC-Asheville’s student newspaper, The Blue Banner. It was published November 18, 2015. Digital scan of the issue here.

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By Cody Jones, contributor

The United States’ maternal mortality rate is rising and the infant mortality rate has stagnated, said Blake Fagan, director of the family medicine residency program at the Mountain Area Health Education Center.

The United States’ maternal mortality rate is going up while rates in other developed countries like Canada, France and Japan are dropping, according to a study by The Lancet.

The study compares data from 1990 to 2013. In 2013, there were 18.5 maternal deaths per 100,000 live births in the United States compared to 12.4 per 100,000 in 1990.

The causes of maternal death are usually not directly related to pregnancy or giving birth, said Dan Frayne, assistant residency program director at MAHEC.

“Many people think this is something that happens during the pregnancy or labor and delivery,” Frayne said. “Cardiovascular disease is the number one cause of maternal death. When we look at the causes of maternal death, each one is related to a chronic disease that is not pregnancy-related.”

Frayne said the main causes of infant mortality are linked to the health of the mother.

“If we look at why infants are dying, the top two reasons are birth defects and preterm birth,” Frayne said. “The main drivers for these birth defects are the maternal health issues.”

Frayne said the U.S. infant mortality rate has been stagnant for more than a decade while other countries’ rates improved.

“Looking at infant mortality rate, we used to be really good compared to everybody else, but we really haven’t improved,” Frayne said. “Cuba’s infant mortality rate used to be worse compared to ours, and they have actually improved beyond us. Our rates really haven’t changed over the last 15 years.”

Frayne said the traditional emphasis on prenatal care is not the solution.

“Improved prenatal care isn’t the answer, preconception health is,” Frayne said. “Most of these risks can be improved with pre-pregnancy health care. By the time you know you’re pregnant, the horse is already out of the barn. It’s really too late to intervene to reduce risks for birth defects.”

Folic acid plays an important role during pregnancy, Frayne said, but it needs to be taken before conception in order to decrease the risk rate.

“Congenital anomalies are dramatically affected by folic acid use,” Frayne said. “That prenatal vitamin everybody wants to take when they’re pregnant? The folic acid in that actually has its effects before you’re pregnant. It’s preconception folic acid that decreases the rate by 70 percent, not pregnancy folic acid.”

Fagan said  women need to take folic acid a minimum of three months before conception.

In North Carolina, Frayne said, Medicaid provides folic acid multivitamins for free.

“Our state was a pioneer on the idea of making folic acid multivitamins free and available to everybody,” Frayne said.

Frayne said due to this initiative, birth defects in the area have reduced dramatically.

“Western North Carolina in the late 1990s was the highest neural tube defect area in the country,” Frayne said. “And since this program has been going, we are now back on par with the rest of the country. We have changed, just with that simple public health approach. It’s a no-brainer for the state budget, and the good news is that they keep putting it in, although every year it’s at risk for getting cut back out.”

Diabetes is a growing risk factor in the U.S. that affects maternal and infant health, Fagan said.

“If you have a kid today, they have a one in three chance of having diabetes if they live in the United States,” Fagan said. “The effects of having diabetes and then getting pregnant, the effect on that mother and child is unbelievably higher that they will have birth defects and poorer outcomes.”

Frayne said over half of the pregnancies in the United States are either mistimed or unwanted.

“Fifty-one percent of pregnancies in the United States are unintended,” Frayne said. “How much time do we spend planning for marriage, or getting into college or choosing a career?”

Fagan said unwanted pregnancies greatly increase the risk of depression.

“If you have an unwanted pregnancy, the chance that you’re going to have depression is multiple times higher than the general population,” Fagan said. “If you have a mother who is depressed and she’s trying to raise her child, the child’s outcomes at five years of age are greatly affected.”

Frayne said 43 percent of reproductive-age women have some type of medical condition that requires regular physician monitoring or medication, including obesity, depression, anxiety, hypertension and diabetes.

Frayne said the average age of those with first-time pregnancies is increasing, and very few women return to their physician for postpartum checkups.

“In some populations, less than 10 percent show up to their postpartum visit to have that planning for the next pregnancy,” Frayne said.

Fagan said the turnout for postpartum checkups is low in Asheville.

“We’ve done some studies here in Asheville, and in the population that we see, which is a lot of the Medicaid population, about 20 to 25 percent won’t show up for their six-week postpartum visit,” Fagan said.

Frayne said one in five women have no health insurance.

“This is one of the things that the Affordable Care Act was supposed to fix through expanding Medicaid and increasing access to health care,” Frayne said. “These women often don’t have health coverage to seek care for themselves until they are pregnant. We actually have great pregnancy Medicaid and access to care once you’re pregnant.”

In 2013, the North Carolina General Assembly passed a bill that banned Medicaid expansion. Gov. Pat McCrory signed the bill into law, but in 2014 said he would consider a plan to expand Medicaid.

Expanding Medicaid in North Carolina would provide coverage for 500,000 people, according to the North Carolina Justice Center.

“It’s actually an irony that I will have someone come in that’s pregnant and they have a laundry list of the things they need,” Fagan said. “They know they’re on the clock, they’ve got to get everything taken care of in the next seven to nine months while they’re pregnant because as soon as they deliver, they’re not going to have insurance anymore.”

Frayne cited a quote from Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services, who said systems are designed perfectly for the results they achieve.

“So the United States’ health care system is perfectly designed to have the highest costs in the world, a rising maternal death rate, and an infant mortality rate that is not improving,” Frayne said. “That’s our perfectly-designed system that we are working in right now. Is that the system we want?”

Frayne said southern residents need improved health care access and systems.

“Medicaid coverage is really important, it’s about access to care. We have to know about the care and we have to have access to it, and the care you receive needs to be of good quality,” Frayne said. “The South is in the most need of improved health care systems and yet the State is systematically not allowing us to improve upon them.”

Frayne said focusing on the health of individuals will lead to a healthy nation.

“So this is the concept that we’re trying to push,” Frayne said. “This is what we believe: the healthy woman will have a healthier pregnancy, which lead to healthier children, which lead to healthier families and communities, which will lead us to a healthier nation.”


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Community rethinks Native American health

I originally wrote this article for UNC-Asheville’s student newspaper, The Blue Banner. It was published October 21, 2015.

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By Cody Jones, contributor

10/21/2015

Panelists at a Native American health forum held on Sept. 30 in the Sherrill Center said the chronic health problems in Native American communities need to be addressed.

“There is a serious need for a different way of working with Native youth, particularly those who have experienced adverse childhood experiences,” said Lisa Lefler, director of Western Carolina University’s Culturally-Based Native Health Program.

“We were very unfortunate to hear that there were 10 young Lakota women, from the ages of 10 to 13, who committed suicide this summer,” Lefler said.

Suicide rates among Native American youth are 13 times the national average, Lefler said, and Native American youth depression rates range from 10 to 30 percent.

“I have a profound love and interest for Native youth,” Lefler said. “Particularly for those young folks who have already fallen through the cracks and are in the system for treatment.”

In Native American communities, treatment for mental health is largely based on Western models. They are sometimes modified to incorporate Native American health care traditions, but those models are broad and not specific to each community or tribe.

“I’m interested in being more tribally specific,” Lefler said. “We can do this by engaging elders and speakers of the Cherokee language in order to develop treatment models for their own communities.”

On Thursday, the new Cherokee Indian Hospital officially opened. This $90 million facility was entirely built and funded by the Eastern Band of Cherokee Indians, unlike previous facilities partially funded by the government. The health system serves approximately 11,500 people.

Though they aren’t required to, as they are a federally-recognized sovereign nation, the Eastern Band of Cherokee Indians chose to operate their health facilities under the statutes of North Carolina’s public health law.

Within the health system, which is called Public Health and Human Services, there are three areas of focus: quality of care, population health and the experience of care.

“We’re the equivalent of a local county health department and a local department of social services,” said Vickie Bradley, deputy health officer for the Eastern Band of Cherokee Indians.

After two years of planning and preparation, the health system’s department of social services officially launched Oct. 1. It is the first time that the health system has been given authority by North Carolina to be fully operational and provide the community’s own social services.

“Our vision is seven generations of wellness with family strong in mind, body and spirit,” Bradley said. “So every decision that we make, we think, ‘will it affect families for seven generations?’ and if it won’t and if it doesn’t matter, then is the juice worth the squeeze?”

Public Health and Human Services has a total of 18 programs ranging from women’s health, to a long-term health facility, to Special Supplemental Nutrition Program for Women, Infants, and Children.

“We have a huge chronic disease load in our community. Our largest diagnoses are depression, diabetes and substance abuse,” Bradley said. “We call it our triple epidemic. It’s costing a fortune, and it will break our health care system if we don’t change its trajectory and if we don’t do something to change the way people live and eat.”

In a 2013 tribal health assessment, 23 percent of the Eastern Band of Cherokee Indians’ population reported, at some point in the previous year, they went hungry because of a lack of access to food or a lack of money.

The issue of food sovereignty is an important one in the Eastern Band of Cherokee Indians community.

“As a sovereign nation, we govern ourselves, so we’re impacted by the question ‘can we even provide our own food?’ and the programs I’ve been able to work with have started to make that impact,” said Joey Owle, program coordinator of Healthy Roots, a project of the diabetes prevention program Cherokee Choices.

According to the Food Sovereignty Assessment Tool published by the First Nations Development Institute, food sovereignty is “that state of being in which all community residents obtain a safe, culturally acceptable, nutritionally adequate diet through a sustainable food system that maximizes community self-reliance and social justice.”

Besides local stores, Owle said, the majority of accessible food sources are brand name fast-food chains and restaurants. There is only one grocery store which serves 8,000 people.

“This is where we’ve got to change that, to help influence people’s minds to grow more food and to stray away from what seems to be the only option for food, especially in limited income areas,” Owle said. “But the future is not bleak. We are making progress.”

In four years, members of Healthy Roots grew 6,000 pounds of food that was sold, distributed, donated, and taken to family support services. All 6,000 pounds of food were grown on under half an acre of land.

The social services program arm of the Public Health and Human Services system was started with the intention of being distinct, said Dallas Pettigrew, social worker and manager of administrative operations for the Eastern Band of Cherokee Indian’s Pediatric Behavioral Health System.

“Our community has a bad taste in their mouth for the DSS systems that have been in place, and they don’t want us to be that,” Pettigrew said. “So we call ourselves Family Safety.”

Family Safety focuses on keeping a child in the community so long as the parents or guardians are willing to cooperate and work toward a solution to any problem.

If Family Safety finds that a child is living in unsafe conditions, they will open up a “voluntary case.”

In a voluntary case, a family agrees to send a child to live in a kinship placement. Family Safety will work with the parents in order to solve the problem until the case is closed and the child is returned home.

“Our law is very special. Our law tells us that we’re responsible for the protection of children and to intervene in instances of child maltreatment,” Pettigrew said. “But not only that, I am charged with the responsibility of preventing child maltreatment.”

Pettigrew said there is evidence that links chronic health problems in Native American communities to childhood traumas.

“We have extremely high rates of preventable chronic health conditions: depression, substance abuse, diabetes and heart disease,” Pettigrew said. “There’s really strong evidence that tells us why and how that happens.”

The Adverse Childhood Experiences Study, commissioned by Kaiser Permanente in the late 1990s, demonstrated a connection between traumatic childhood experiences and the development of chronic health problems. According to the study, traumatic childhood experiences include maltreatment, sexual, physical and emotional abuse, absent parents, and household substance abuse.

“The more of these adverse experiences children had, the worse their chronic health outcomes were when they were adults and, ultimately, they died younger,” Pettigrew said. “They died younger and in worse health.”

“When a child is living in a healthy, well-functioning household, the child will experience normal stress cycles,” Pettigrew said. “Stress goes up and, in the company of a nurturing adult, stress comes back down and children learn how to manage their stress.”

Children who are maltreated, however, experience elevated levels of stress for prolonged periods of time. Because of this, they do not experience proper social and emotional development. As they grow older and the problems go unresolved, Pettigrew said they attempt to fix their own problems.

“So then what happens? They start to self-medicate,” Pettigrew said. “They get on alcohol or marijuana or cigarettes, or they start to skip school and do other bad things. Juvenile delinquency arises from this.”