The Cost of Child-rearing

Over the last few months, I have gotten involved in volunteering with families through Ronald McDonald House Charities. The House provides resources and shelter for families with sick children while they remain in the hospital seeking treatment. At the House, I volunteer with the siblings of sick children to make arts and crafts. Recently, we have been doing Q-tip art, and the kids really seem to enjoy it. One of the children painted a picture of her 5-month-old brother in his hospital crib.  She told me that he was getting an organ transplant, and that she hoped he would like her painting. Her mother sat at a table across from us, chatting with another parent and eating dinner with her younger daughter. She seemed exhausted as she discussed central line infections, challenges of tacrolimus, and the ups and downs throughout her son’s hospital course. On the outside, she looked weathered as she tended to the needs of everyone around her. Then I started to think about how tired she must be, and I was amazed by her strength. She is staying in a strange place with two of her young children while her infant is so sick. She is keeping everyone occupied, fed, and happy.

 

Mothers have difficult jobs. The competing interests between working and child rearing present tensions for parents, typically mothers, that we do not often appreciate. Because child rearing is not tied to a monetary gain, it is often overlooked and undervalued. Research from Salary.com estimates that it would cost on average $162,581 to fulfill the duties performed by many stay-at-home moms, who “work” over 90 hours per week providing child care. In raising their children, these stay-at-home parents are performing a critically important job, supporting the future generation.

Maureen Farrell   DUCOM 2021

https://www.salary.com/articles/stay-at-home-mom/

https://www.psychologytoday.com/us/blog/emotional-fitness/201305/top-10-reasons-why-moms-are-important

https://www.feminist.com/resources/artspeech/family/motherhood.html

Centering Pregnancy: The Group Prenatal Care Model

As a medical student in an obstetrics clinic on my 3^rd year rotation, I watched as the providers raced from room to room, rattling off anticipatory guidelines to each of their pregnant patients of similar gestational age. Blood pressures were checked. Labs were drawn. The visits were abrupt and often times seemed rushed, especially given the enormity of what was happening to the patients’ bodies and the uncertainty and hesitation written on some of the mothers’ faces. I am not saying that the quality of care provided was not adequate, but what I am saying is that pregnancy is a time of great change physically, emotionally, and socially that necessitates support that does not necessarily fit in a neat and tidy 15-minute window.

 

In the 1990’s, Sharon Schindler Rising, a Certified Nurse Midwife, had the idea of restructuring the model of prenatal and postnatal care that would allot more time with patients while still functioning within our healthcare system of efficiency. Her idea was pregnancy centering, which brings a group of pregnant women together for their prenatal visits. The thought was that through group education, providers could spend significantly more time with the patients, improving quality of education and time for anticipatory guidance, increasing patient satisfaction, and preventing provider burnout.

 

The basic structure of this model is to invite mothers-to-be to join group sessions after initial prenatal assessment and laboratory testing. There are about 10 group sessions that begin at 12-16 weeks of pregnancy and usually last 90 to 120 minutes, as described in the table. Furthermore, the women are empowered to take ownership of their health as they are encouraged to take an active role in their prenatal care as they are taught to measure their own blood pressures, calculate their gestational age, monitor their weight gain, and check urine dipsticks. The providers do routine physical assessments in semi-private rooms which also allows a time for individual and private concerns to be brought to the attention of the provider. Then, the clinicians facilitate a group discussion addressing routine prenatal care issues appropriate for the gestational age.

 

For the patients, there are numerous benefits to the group care model from hearing the answers to questions that they did not think to ask to simply having more time with providers to learn about their bodies and their pregnancies. I believe that knowledge is power and that the more time spent with mothers teaching them about their pregnancy, empowers them to make informed choices about their care and lifestyle while pregnant. Furthermore, women are given autonomy of their prenatal care as they are active participants and are empowered to ask questions in a safe community of women having a shared experience. Additionally, there is immense value in the communal support from the group as well as in the friendships formed amongst participants. 

 

Since the 1990’s, group prenatal care has increased in prevalence across the country. Centering Programs cite better health outcomes for both mothers and their newborns such as decrease rates of preterm delivery, decrease incidence of low birth weight, decrease NICU admissions, increase breastfeeding, and improved pregnancy spacing. However, these claims are controversial as a recent systematic literature review and meta-analysis found that group prenatal care was not associated with lower rates of preterm birth, NICU admission, or breastfeeding initiation. However, the results of the study did suggest that prenatal group care may decrease the risk of preterm birth in African American women, which in-it-of-itself is of great value as African American women have a greater risk of preterm delivery. Furthermore, there is no evidence that suggest that group care is detrimental to moms or babies but there is plenty of anecdotal information that moms were immensely happy with their decision to participate in group care. Individual and group care models merit further investigation with the aim of identifying populations that benefit most from either individual or group care.

                                                                                                                                             Christine Quake   DUCOM 2019

• https://www.centeringhealthcare.org/what-we-do/centering-pregnancy
• https://www.ucsfhealth.org/programs/centering_pregnancy_program/
• “ACOG Committee Opinion No. 731.” Obstetrics & Gynecology, vol. 131, no. 3, 2018, doi:10.1097/aog.0000000000002529.
• Rising, Sharon Schindler, et al. “Redesigning Prenatal Care through CenteringPregnancy.” Journal of Midwifery & Womens Health, vol. 49, no. 5, 2004, pp. 398–404., doi:10.1016/j.jmwh.2004.04.018.
• Sheeder, Jeanelle, and Kim Weber Yorga. “Group Prenatal Care Compared With Traditional Prenatal Care.” Obstetrics & Gynecology, vol. 129, no. 2, 2017, pp. 383–384., doi:10.1097/aog.0000000000001875.

                                                                                                                                             

 

 

Gender Bias in Healthcare

A few months ago, the New York Times published an article on a scandal in Tokyo University Medical School.  https://www.nytimes.com/2018/08/03/world/asia/japan-medical-school-test-scores-women.html  It was found that administrators were purposely manipulating test scores of female applicants to keep their class 30% female. Of their applicants 8.8% of men were accepted and 2.9% of women were accepted. Apparently, it is commonly practiced in many medical schools across Japan. Administrators justified their practice with belief that women were more likely to drop out of their profession after marriage or childbirth which would not help with their national doctor shortage.

I was shocked especially since Prime Minister Abe was trying to promote his policy of “womenomics”, a policy to help the stagnant economy by increasing women in the workforce. I called my close friend who has been working in Japan for almost a year to ask her opinion on the current state. Sadly, she was not surprised by the news and explained to me in job interviews, a standard question for female applicants was their future plans on marriage and children. It is common practice in Japan for married women to quit their jobs to raise their children and difficult to re-enter the workforce after pregnancy.

I found it appalling that not only are institutions are raising the credentials higher for women, but also that their marital status plays a huge role in the job search. Why couldn’t these women have children and work at the same time? Why was there no social support for women with children? And why is there a nonexistent role for the father in child rearing?

This patriarchy reminded me of one my patients who made me question my abilities as a future provider. During my prerounds, my patient inquired if being doctor was the right decision for me. Instead, he could picture me as a great housewife. I was initially speechless. Thankfully, his nurse defended me, asking why I couldn’t be both? I answered his question by explaining to him that I could not imagine myself staying at home. After leaving his room, my feelings of inadequacy turned to annoyance and frustration. I didn’t know if his comment stemmed from my skills or from his gender biases.  My interaction with him made me wonder how many other patients I would encounter during my career who have a similar mindset.

                                                                                                                                                                Cindy Kui

                  DUCOM 2019

Self-advocacy and solidarity in combatting gender bias in medicine

I recently read an article entitled, “Recognizing Blind Spots – A Remedy for Gender Bias in Medicine?” by Loren Rabinowitz. She starts off her piece describing an interaction in which a patient’s wife pushed her aside in favor of speaking to a more junior, male resident who was incapable of completing her request due to his junior status. Although actually qualified to address the request, Dr. Rabinowitz, was overlooked by her patient’s wife and, the junior resident did not bother to clarify the discrepancy. These acts of sexism and similar micro- and macro-aggressions are ubiquitous across our culture, and healthcare is no exception.

    Dr. Rabinowitz goes on to juxtapose the challenges of self-advocacy with their critical importance. She acknowledges that, “perhaps small steps such as taking ownership of our roles as physicians, enlisting allies, and educating our trainees, students, and patients can provide a starting point for the movement toward workplace equality.” I completely agree with her regarding the difficulties and discomfort in clarifying our roles, and I think this is born out of our motivations for pursuing medicine, which are grounded in the genuine provision of care for other people, rather than the nominal authority associated with our titles. Importantly, she notes that clarification is achievable in a way that is respectful to others, kind and compassionate to patients, and defines our roles as medical students or providers. This clarification is important for establishing trust and improving communication which directly impacts care delivery and outcomes. In reflecting on her story and stories of my own, I see that we find strength in solidarity, as it bolsters our care team and communities, and provides support for us when we need it most.

 

Maureen Farrell         DUCOM 2021

https://www.nejm.org/doi/full/10.1056/NEJMp1802228