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More Black Mothers Deliver by Cesarean, Not Always by Choice

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More Black Mothers Deliver by Cesarean, Not Always by Choice

June 16, 2022 — When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, SC.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

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Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection -– on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist  at the Icahn School of Medicine at Mount Sinai in New York City.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be — were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

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More than 1 million women undergo cesarean deliveries in the Unites States every year, composing over 31% of all births in 2020, according to the CDC.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of white women. Black women are also about three times more likely to die of pregnancy-related causes than white women.

Risk Becomes Reality

Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

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“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Glazer says.

Clinical Discretion Leads to Biased Judgement Calls

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Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in white women.  Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among white women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Glazer says. “Once you adjust for all these measures, pre-pregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown.  Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.

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Dealing With the Aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

 “Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, DC.  The cost of a cesarean delivery averages about $17,000, compared to about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery, but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

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Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system; if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for white women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

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“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine in Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decision making, and that by standardizing practices we could address these differences — people were somewhat resistant at first,” Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3 to reduce maternal mortality through mobile technology.

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The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine in Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

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Childhood Melatonin Poisonings Skyrocket in the Past 10 Years

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Childhood Melatonin Poisonings Skyrocket in the Past 10 Years

The number of children in the United States who unintentionally ingested melatonin supplements over the past 10 years has skyrocketed to the point where, as of 2021, melatonin ingestions by children accounted for almost 5% of all poisonings reported to poison control centers in the United States, data from the National Poison Data System (NPDS) indicate.

This compared with only 0.6% of melatonin ingestions reported to poison control centers in 2012, the authors added.

“Basically the number of pediatric melatonin ingestions increased 530% from 8,337 in 2012 to 52,563 in 2021 so it’s a 6.3-fold increase from the beginning of the study until the end,” Michael Toce, MD, one of the study authors and attending, pediatric emergency medicine/medical toxicology, Boston Children’s Hospital, said in an interview.

“And I think the biggest driver of this increase is simply that sales of melatonin have increased astronomically so there is just more melatonin at home and studies have shown there is a correlation between the amount of an individual medication in the home and the risk of pediatric exposure — so simply put: The more of a single substance in a home, the greater the chance that a child is going to get into it,” he underscored.

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The study was published in the Morbidity and Mortality Weekly Report.

Melatonin Ingestions

All cases of single substance melatonin ingestions involving children and adolescents between Jan. 1, 2012, and Dec. 31, 2021, were included in the analysis. During the 10-year study interval, 260,435 pediatric melatonin ingestions were reported to the NPDS. Over 94% of the reported ingestions were unintentional and 99% occurred in the home.

Over 88% of them were managed on-site; most involved young male children aged 5 years and under, and almost 83% of children who ingested melatonin supplements remained asymptomatic. On the other hand, 27,795 patients sought care at a health care facility and close to 15% of them were hospitalized. Among all melatonin ingestions, 1.6% resulted in more serious outcomes; more serious outcomes being defined as a moderate or major effects or death. Five children required mechanical ventilation in order to treat their symptoms and 2 patients died.

The largest number of patients who were hospitalized were adolescents who took melatonin intentionally but the largest increase in the rate of exposure was in young, unintentional patients, as Toce observed. Interestingly, the largest yearly increase in pediatric melatonin ingestions — almost 38% — coincided with the onset of the COVID-19 pandemic.

“This might be related to increased accessibility of melatonin during the pandemic, as children spent more time at home because of stay-at-home orders and school closures,” the authors speculate. Moreover, sleep disturbances were common during the pandemic, leading to a greater likelihood that parents were buying melatonin and thus exposing children to more melatonin at home.

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Taken appropriately and at normal does, melatonin in itself is quite safe, as Toce stressed. However, “for any substance, the dose makes the poison, so taken in any significant quantity, anything is going to be dangerous.” Moreover, it’s important to appreciate that melatonin, at least in the United States, is regulated as a dietary supplement, not as a pharmaceutical.

“Thus, it doesn’t get the same rigorous testing that something like acetaminophen does by the FDA and that means two things,” Toce noted. First, if the product says that each gummy contains 3 mg of melatonin, no independent body is verifying whether or not that statement is true so there could be 3 mg of melatonin in each gummy or there could be 10 mg.

Secondly, because there is no impartial oversight for dietary supplements, there may in fact be no melatonin at all in the product or something else may be added to it that might be harmful. “Just because something is sold over-the-counter does not necessarily mean that it’s safe,” Toce stressed. To keep children safe from pharmaceuticals and supplements, he recommended several generic poison prevention tips. This advice could be passed on to patients who are parents.

  • Keep all pharmaceuticals and supplements preferably locked away so there is less risk of children and adolescents taking products either unintentionally or intentionally

  • If parents have no place to lock their products up, put them out of reach, high-up so children cannot easily access them

  • Keep the product in the original child-resistant packaging as opposed to taking the pills out of the packaging and putting it in a plastic bag. “Certainly we’ve seen that when medications are moved into a non-child-resistant container, ingestions go up,” Toce warned

  • Don’t refer to any medicine or supplement a child might take as “candy.” “A lot of children have difficulty taking medications so some families will say: ‘It’s time for your candy,’ ” Toce explained. Then, if a child does discover the “candy” on a table where they have access to it, they will not recognize it as medication and they’re likely to pop it into their mouth, thinking it is candy

Lastly, and most importantly, parents who are considering trying a melatonin supplement to help a child sleep better should first establish a stable sleep routine for their child. “They also need to limit caffeinated beverages before bed as well as screen time,” Toce added.

And they should talk with their primary care provider as to whether or not initiation of a melatonin supplement is appropriate for their child — “and not just jump right into giving them melatonin without first discussing whether it is appropriate to do so,” Toce stressed.

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Remarkable Rise

In a comment on his own experience with melatonin poisoning over recent years, toxicology expert Kevin Osterhoudt, MD, of the University of Pennsylvania, Philadelphia, and the Children’s Hospital of Philadelphia, noted that it has been their experience that there has been a remarkable rise in poison center reports of children ingesting melatonin in the recent past. For example, the Poison Control Center at CHOP received nearly 4,000 calls involving melatonin ingestion by children 5 years old or younger in the 5 years between 2017 and 2021 with increasing numbers every year.

“The [current study] supports our regional observation that this has been a national trend,” Osterhoudt said. Osterhoudt agreed with Toce that good sleep is healthy, and it is very important to develop good sleep habits and a regular bedtime routine. “In some situations, melatonin may be useful as a short-term sleep aid and that’s a good discussion to have with your child’s health care provider.”

If parents do decide to give their child a melatonin supplement, they need to keep in mind that melatonin may alter how the body handles other drugs such as those used to treat epilepsy or blood clotting. They also need to know experts are still uncertain about how melatonin affects the body over the long term and whether it is safe for mothers to take during pregnancy.

Osterhoudt offered his own recommendations for safe melatonin use in the home:

  • Discuss planned melatonin use with your health care provider

  • Buy only high-quality supplements by looking for the “USP Verified” mark

  • Insist that manufacturers sell products in child-resistant bottles

  • Periodically inspect the medications in your home and dispose of medications that are no longer being used

  • Program the phone number of your regional poison control center into your phone; poison center experts are available 24/7 to answer questions and concerns about ingestions of melatonin (in the United States the number is 1-800-222-1222)

The study authors and neither Toce nor Osterhoudt had any relevant conflicts of interest to declare.

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This story originally appeared on MDedge.com, part of the Medscape Professional Network.

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CDC Releases New Details on Mysterious Hepatitis in Children

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CDC Releases New Details on Mysterious Hepatitis in Children

A new analysis from the Centers for Disease Control and Prevention (CDC) provides further details on mysterious cases of pediatric hepatitis identified across the United States. While 45% percent of patients have tested positive for adenovirus infection, it is likely that these children “represent a heterogenous group of hepatitis etiologies,” the CDC authors write.

Of the 296 children diagnosed between October 1, 2021, and June 15, 2022, in the United States, 18 have required liver transplants and 11 have died.

On April 21, 2022, the CDC issued an alert to providers to report pediatric hepatitis cases of unknown etiology in children under 10 after similar cases had been identified in Europe and the United States. While the United Kingdom has found an uptick in cases over the past year, researchers from the CDC published data on June 14 that suggested pediatric hepatitis cases had not increased from 2017 to 2021.

This newest analysis, published Friday, June 24, in the CDC’s Morbidity and Mortality Weekly Report, provides additional demographic data on affected patients and explores possible causes, including previous infection with COVID-19. Investigators had earlier ruled out COVID-19 vaccination as a potential factor in these cases, as most children were unvaccinated or not yet eligible to receive the vaccine. According to the analysis, only five patients had received at least one dose of a COVID-19 vaccine.

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The 296 cases included in the analysis occurred in 42 US states and territories, and the median age for patients was 2 years and 2 months. Nearly 60% of patients were male (58.1%) and 40.9% were female. The largest percentage of cases occurred in Hispanic or Latino children (37.8%), followed by non-Hispanic White (32.4%) children. Black patients made up 9.8% of all cases, and 3.7% of affected children were of Asian descent. Vomiting, fatigue, and jaundice were all common symptoms, and about 90% (89.9%) of children required hospitalization..

Of 224 children tested for adenovirus, 44.6% were positive. The analysis also included information on 123 of these hepatitis patients tested for other various pathogens. Nearly 80% (98/123) received a COVID-19 test and just 10.2% were positive. Twenty-six percent of patients had previously had COVID-19, and hepatitis onset occurred, on average, 133 days after the reported SARS-CoV-2 infection.

Other viruses detected included:

  • rhinovirus/enterovirus (24.5%)

  • rotavirus (14.0%)

  • acute Epstein-Barr virus (11.4%)

Simultaneous infection with SARS-CoV-2 and adenovirus occurred in three patients.

There was no evidence of viral inclusions in the 36 patients who had pathologic evaluation liver biopsies, explants, or autopsied tissue.

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The findings suggest that there may be many different causes behind these severe hepatitis cases, the authors write, and it is estimated that about one third of hepatitis cases in children do not have a known cause. However, the identification of adenovirus infection in many cases “raises the question whether a new pattern of disease is emerging in this population or if adenovirus might be an underrecognized cause or cofactor in previously indeterminate cases of pediatric hepatitis,” the authors write. As the investigation continues, they added, “further clinical data are needed to understand the cause of these cases and to assess the potential association with adenovirus.”

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Risk of premature death in patients with childhood immune-mediated inflammatory disease over three times greater

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Risk of premature death in patients with childhood immune-mediated inflammatory disease over three times greater

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Credit: CC0 Public Domain

Patients with a pediatric onset immune-mediated inflammatory disease (pIMID) have a significantly higher risk of premature death, according to new research being presented today at the 54th Annual Meeting of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).

Whilst higher mortality was found in patients across all included pediatric onset immune-mediated inflammatory conditions compared to controls, pediatric autoimmune liver disease (pAILD) and pediatric vasculitis patients had the highest risk of mortality with a fourteen times (aHR* 14.3) and fifteen times (aHR 15.8) greater chance of death respectively.

For pAILD patients specifically, the study reveals for the very first time that the high death rate was driven by the risk of cancer, which was thirty times greater in pAILD patients. Coupled with the 6-times increased risk of death from cancer in pediatric onset inflammatory bowel disease (pIBD) patients, the researchers believe the findings show a definitive need to establish early cancer screening in pAILD and pIBD patients to prevent unnecessary premature deaths.

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The study also revealed a significantly higher suicide risk (almost two-and-a-half times greater [aHR 2.4]) amongst pIMID patients compared to controls. Primarily driven by pIBD and juvenile idiopathic arthritis (JIA) patients, the median age of suicide was just 25 years.

These findings show a possible impact on the mental health of patients, spotlighting the true burden of these conditions. As the majority of suicides occurred in patients after transfer into adult care, an increased focus is warranted on systematic transitioning programs in pediatric departments. This focus must be continued into the period after the transfer of the patient to an adult department, due to this critical life period.

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The survey also showed that being diagnosed with more than one IMID appears to be a risk factor, with significantly higher mortality risk found in these patients (aHR 9.2). This is important as previous studies have found that patients diagnosed with one IMID are at an increased risk of subsequently being diagnosed with an additional IMID.

The Danish population-based study recorded data from 12,036 pIMID patients between 1980—2018, consisting of 5,671 (47%) pIBD, 396 (3%) pAILD, 6,018 (50%) JIA, and 300 (2%) individuals with pediatric onset vasculitis. Of these, 342 (3%) individuals were diagnosed with more than one pIMID.

Commenting on the findings, lead author, Dr. Mikkel Malham from the Department of Paediatrics and Adolescent Medicine at the Copenhagen University Hospital Hvidovre in Copenhagen, Denmark, stated: “This is the first study to report an increased mortality in pIMID. While for pIBD this risk is quite well known, for the rest of the included pIMIDs the presented risk estimates should raise considerable concern.”

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“The increased risk of dying from several different causes should warrant a multidisciplinary approach which includes caring for a child’s mental health. It is of utmost importance that this multidisciplinary approach is continued into early adulthood, as this is when suicide typically occurs.”

“Additionally, cancer screening in IMID patients diagnosed in childhood, particularly with IBD and AILD, should probably be initiated early to prevent premature death,” adds Dr. Malham.

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Referencing the higher mortality rate, particularly amongst pAILD patients, and the prominent role of suicide as a cause, Chair of the ESPGHAN Hepatology Committee, Professor Giuseppe Indolfi elaborates on the broader implications: “The clinical and therapeutic management of children and adolescents with autoimmune liver and gastrointestinal diseases remains a significant challenge for pediatric hepatologists and gastroenterologists. This study reinforces that every effort should be made to further improve our knowledge and ultimately the quality of care for children with immune-mediated inflammatory diseases.”



More information:
Conference abstracts: journals.lww.com/jpgn/Documents/54th%20Annual%20Meeting%20of%20ESPGHAN_Abstract_Book.pdf

Provided by
The European Society for Paediatric Gastroenterology Hepatology and Nutrition

Citation:
Risk of premature death in patients with childhood immune-mediated inflammatory disease over three times greater (2022, June 24)
retrieved 24 June 2022
from https://medicalxpress.com/news/2022-06-premature-death-patients-childhood-immune-mediated.html

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