Planning and Intention - A bit more about health and reproduction.

 

So concluding our journal club today where we had an interesting discussion about the ACES study (adverse childhood experiences study) and unwanted pregnancy (Dietz, P, Spitz, A. et al. Unintended Pregnancy Among Adult Women Exposed to Abuse or Household Dysfunction During Their Childhood. JAMA.1999: 282:1359-1364.),  I wanted to add a bit more on the unintended pregnancy issue.

One of the things we discussed was the nuances of unexpected and unwanted in terms of pregnancy. So here's some data from the National Health Statistics Reports July 24, 2012, Intended and Unintended Births in the United States:P 1982-2010. This study looked at data regarding the attitudes of women who had live births.

*Percentage unintended at time of conception 37% in the group evaluated.
*Group that demonstrated significant decline since 1982 = married, non-Hispanic white women.
*Disparity seen between them and unmarried women, black women or women who have educational or economic disadvantage.
*Intended births and teen mothers - only 23% were intended (2006-2010), therefore 4/5 unintended.
Of interest, the authors talk about unintended births as being measured as intended (meant to get pregnant); mis-timed (wanted to, but not now) and unwanted (not wanted to get pregnant or not wanted the infant in the birth order it came into.) They also talk about an 'alternative' definition breaking down the term unintended birth into two elements - action (pregnant/not) and affect or emotional interpretation (wanted or not) They felt that the data was concordant with either evaluation.
It does make you wonder though if the composite effect blurs out subgroup differences here.

Particularly interesting was the authors mention that
*Women in poverty (below 150% ) make up 56% on unintended births and only 35% intended
           (supporting the previous blog mention of poverty as a marker for unplanned births)
*More than one in five intended pregnancies and births (22.8%) are in teenage (ag 15-19) mothers. (birth rate 40.2 births/1000 in 2008. ) If we could disrupt factors such as poverty and influence the situation where unintended births to teens was postponed until age 20, we could have teen birth rates drop for 11% of all births to 4%!

Here's an interesting video about the benefits of contraception from the Guttmacher Institute

Sex and Gender Medicine - A Lens for Evaluating Sociocultural Determinants of Disease

It used to be good enough to be smart - good in science; good at figuring things out. When you only have penicillin or sulfa, then just making the right diagnosis was pretty impressive. But times of have changed - we have PET scans and PCRs; we have minimally invasive surgery and a vast (if not overwhelming array) of medications and interventions at our disposal.

So today our gold standard has migrated past being smart and finding the disease 'in' a patient - now we are expected to influence health outcomes.

When acute injury and infections were a major cause of death (and we had limited tools) we had challenges. Now, most diseases are chronic and the ability to influence runs over a longer timeframe. Diabetes, Obesity, Hypertension, Heart Disease, Cancer - not 'quick in- quick out' challenges and certainly not the easiest to impact on outcomes. Yet, it is do-able.

We just need to get all of the data - scrutinize the biomedical, be clinically and scientifically curious and obtain data about the person in her world. One of the ways we can impact health disparities (and therefore move care closer to excellent for all) is to see the whole picture. The whole person.

In understanding the whole person, we need their story - who lives with them? who helps them? who do they help? what do they think or fear is going on? how do they define a good outcome?

Just today, a short essay on the social history was published in NEJM

Complicated Lives — Taking the Social History  R. Srivastava  N Engl J Med 365:587, August 18, 2011.   I highly recommend that   you read it, as it is written by an Oncologist and gives an interesting perspective on what we need to know to care for patients.  Now worries, it's a quick read!



McGinnis, J.M. 2002;21:78-93

Sociocultural determinants of health issues need to be lenses that we use to evaluate our patients. 

Dr Schroeder from UCSF delivered the Shattuck lecture about this. (We Can Do Better - Improving the Health of American People. Schroeder SA. New England Journal of Medicine. 357(12):1221-8, 2007 Sep 20. ) Access HERE courtesy of Pubmed and NEJM.

As physicians, we need to zoom in and zoom out on the pathophysiology and the life of our patients in order to best understand what is going on and how we can best help them lead healthier lives.

For a review on our discussion about sex and gender health disparities, check out this blog entry - click on Sex and Gender Resources as well as check out our other blog entries.



Culture, Gender, Health

Our second blog is Culture Gender Health and it reviews some of the definitions we discussed. It is available on the left side of the blog

Our third blog is a patient health blog Philadelphia Ujima and is a useful place to find plain language (aka health literacy and culturally appropriate) health education info and resources.

You are invited to suggest topics or even contribute - no advanced computing skills needed!

This blog was created to help your educational experience - let us know what you think!!