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Preconception and Women’s Healthcare: An Interview with Dr. Michael Lu (Part Five)

[Editor's note:  This is the fifth and final part of an interview series between Science & Sensibility's Walker Karraa, and OBGYN Dr. Michael Lu.  To read the interview from the beginning, go here.  For a list of resources pertaining to this interview series, go here: resources and bibliography_dr lu interview series.]

 

 

Racial Gaps, Future Research

 

 

Walker Karraa: Your work regarding the racial gap in maternal and infant mortality in the United States is profoundly important.  How might childbirth educators begin to address that, or become part of the conversation and part of the solution?  It’s a big question.

 

Dr. Lu: It is a big question.  It’s a hard question because right now my understanding is that Medicaid still doesn’t pay for childbirth education, right?

 

Walker Karraa:  Correct.

Dr. Lu: Yeah, you know that in California, about half of all births are paid for by Medicaid and for African-American women I think it’s more like 60% or 65%.  So two-thirds of all African American women are on Medicaid, which means they have no access to childbirth education unless they pay out of pocket.   So this is an access issue.  Low income women have access to WIC, but WIC is so overwhelmed that they can’t do very much in terms of nutritional, or childbirth education counseling.

In terms of mental health –it’s hard enough for my private patients with super prenatal insurance to see a good mental health professional in a timely manner, [so] think about [what happens with] the low income women with limited access.

 

This might potentially worsen rather than improve with Health Care Reform.  Why don’t we talk about that?  What’s the impact of the Medicaid Reform going to be on infant mortality and on the racial gap of infant and maternal mortality?  There’s very little discussion about that.  I’m all for Health Care Reform, but it’s really just health insurance reform.   Instead, let’s think through what are the components of care that really optimize women’s health, and make sure there is equal access to those components for African American women.

Shouldn’t there be universal coverage for childbirth education?  Of course if it’s only known as “childbirth education,” there might not be as much support for it.  But if that education could be broadened, which I really think it should, there may be greater support for universal coverage.
Walker Karraa: Can you share what your current research involves?

 

Dr. Lu: The big research I’m doing right now is with the National Children’s Study.  It [involves following] 100,000 kids from before birth up to 21 years of age.  We’re going to their homes to collect air, water and sewer samples.  We’ll be at the birth of every child to collect placenta [samples], cord blood, etc.  Including 4,000 right here in Los Angeles [from] six different neighborhoods.  We’ve got kids living right next to the Port of Long Beach, or the oil refineries, or next to interstate interchange–what are all the environmental influences on their health?  There is still so much that we don’t know about the causes and prevention of childhood diseases like autism, diabetes, asthma, etc. — can we do a better job in terms of preventing them?  I think the National Children’s Study has the potential to give us a lot more information that would help inform in programs and better practices.

 

In terms of racial disparities, (through the NIH, Community Child Health Network) we have been creating these Best Baby Zones around the country. It’s a place-based-systems approach to addressing the problem of high infant mortality in this country.  In 12 communities from Harlem to West Oakland, we would do whatever it takes to really improve child and family health–with the goal of closing the gap of infant mortality in ten years. Whatever it takes means not only improving health care quality, but working on improving educational development, economic development, community development.  It’s basically transforming an entire community. So I’m pretty excited about it, but again, [it is] very hard work and very transformative work.

 

And then lastly I was just appointed by Kathleen Sibelius, Secretary of Health and Human Services,  to chair the Secretary’s committee on infant mortality.   The last chair was working under a different administration, so I think the environment may be more favorable for us to make some of our recommendations and have a greater impact.  I’m trying to think through what some of those recommendations might be, for example–how do we redesign Healthy Start so [that it has] greater impact?  With all of the discussion around health care reform, around Medicaid and so forth—a lot [of that currently] focuses on the elderly.  So little national discussion has been about how all of this is going to impact maternal mortality and infant mortality.  And we know it’s going to have a big impact– so what recommendations can we, as a committee, make to the secretary to make sure that we put safe guards in place?

Walker would like to thank Dr. Lu and his assistant Louise Ino for their time and support, and Kimmelin Hull for editorial assistance.


[Editor’s note:  Science & Sensibility would like to thank Dr. Michael Lu for taking the time to discuss his past, present and future work in obstetrics and preconception care.  Thank you, also, to Walker Karraa, for bringing us this fascinating and most informative interview.  Indeed, as childbirth educators, we are compelled to consider our current and future professional role in the health of childbearing women and their families
—and the ways we might expand our expertise to keep pace with the educational needs of this large segment of our population.]

 

________________________________________________

 

Michael C. Lu, MD, MPH is an associate professor of obstetrics & gynecology and public health at UCLA.    Dr. Lu received his bachelor’s degrees from Stanford University, master’s degreefrom UC Berkeley, medical degree from UC San Francisco, and residency training in obstetrics & gynecology from UC Irvine. He is widely recognized for his research, teaching and clinical care. Dr. Lu received the 2004 American Public Health Association Young Professional Award for his research on health disparities. He recently served on the Institute of Medicine Committee (IOM) on Understanding Prematurity, and is currently serving on the IOM Committee to Reexamine IOM Weight Guidelines. He is a member of the Centers for Disease Control and Prevention Select Panel on Preconception Care, and a lead investigator for the National Children’s Study in Los Angeles.  Dr. Lu teaches obstetrics and gynecology at the David Geffen School of Medicine at UCLA, and maternal and child health at the UCLA School of Public Health. He has received numerous awards for his teaching, including Excellence in Teaching Awards from the Association of Professors of Gynecology and Obstetrics. Dr. Lu sees patients at the faculty group practice in obstetrics and gynecology at UCLA Medical Center, and has been voted one of the Best Doctors in America since 2005. Dr. Lu was recently appointed by Secretary of Health and Human Services Kathleen Sebelius to chair the Secretary’s Advisory Committee on Infant Mortality.

Dr. Lu Presentation: http://dhsmedia.wi.gov/main/Viewer/?peid=8650dbb4-6b3b-4770-ab78-9fb3ebc0427b

 


Posted by:  Walker Karraa

Maternal Mortality, Maternal Mortality Rate, Series: Preconception Care, Uncategorized , , , , , , ,

  1. avatar
    Walker Karraa, MFA, MA, CD
    July 22nd, 2011 at 16:21 | #1

    “in California, about half of all births are paid for by Medicaid and for African-American women I think it’s more like 60% or 65%. So two-thirds of all African American women are on Medicaid, which means they have no access to childbirth education unless they pay out of pocket.”

    Am I the only one alarmed by this?

  2. July 22nd, 2011 at 17:08 | #2

    @Walker Karraa, MFA, MA, CD
    Not only this, but the California Maternal Mortality report that was recently released found that the maternal mortality rate African American women was 46.1/100,000 vs. 12.4 for Caucasian women. If that doesn’t speak to the HUGE racial disparity going on, I don’t know what does.

    http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

  3. avatar
    Jacqueline (Jackie) Levine
    July 23rd, 2011 at 14:41 | #3

    Dear Dr. Lu:
    I quote from your most recent interview with Walker Kerraa:
    “The big research I’m doing right now is with the National Children’s Study……There is still so much that we don’t know about the causes and prevention of childhood diseases like autism, diabetes, asthma, etc. — can we do a better job in terms of preventing them?”

    The National Children’s Study is surely a worthwhile initiative and I’m certain that the criteria for the study are comprehensive, but I suspect the study will overlook the one huge vital area that has a primary impact on the health of every baby, and can have life-long consequences as well: *how* each baby is born. Without evaluating the impact of current birth practices, using un-interfered-with natural birth as the physiological standard, the National Children’s Study cannot truly evaluate the factors that impact the health of our babies, our children. This choir is aware that labor and birth in this country is so thoroughly managed and medicalized that for most women, the normal progression of labor and birth just doesn’t exist, and this very blog is a place that points up the wealth of research showing that many of today’s obstetrical practices are not based on best evidence and are harmful to both mother and baby. We should know just how many of the areas of ill-health in children that the study will address can be attributed to the circumstances of birth.

    There’s the increased risk of asthma in C-section babies, and studies linking vacuum extraction to late-onset asthma “being significantly higher in the assisted delivery group” (Allergy 2009:641530-38), and a study in AJOG ‘09 asking if autism and ADHD might indeed be linked to the increase in medicated birth, with citations from the CDC and others (Medscape Ob/Gyn& Women’s Health 5/28/09). There are studies that go back as far as the ‘90’s showing anomalies occurring with routine use of ultrasound exams throughout pregnancy, some correlating with low birth weight (more babies with birth weights below 1500 grams [Lancet, Oct. ’93] ), and some recent statistics show that despite growing maternal obesity, birth weight overall has been dropping. Is it time to investigate any links? Another practice harmful to babies is immediate clamping of the umbilical cord. Studies abound. Fifty-to-sixty per cent of a baby’s blood is still in the placenta immediately after birth, with stores of iron and other important stuff that the baby needs for success in its first months of life and thereafter, but just ask, and women will tell you that “it all happened in a rush“, the cord clamped and cut within seconds of birth. A few minutes of patience and the baby will actually “clamp” its own cord, when its body has the right amount of blood for profusion of lungs and brain for life outside in the world. Will the study address any birth practices that surely might have a measureable impact on newborn health and beyond? Doesn’t it make sense to investigate the manner of birth itself as a component of health?

    And there’s diabetes and obesity; breastfed babies just don’t get diabetes in anywhere near the same numbers that formula-fed babies do; their rate of obesity in childhood is way lower, but, even though this blog was the battleground for the recent “epidural drugs do/don’t affect the baby’s ability to nurse” drugs routinely given to mothers in labor do have a negative impact on a baby’s normal and natural abilities to feed. If those drugs can have such a profound impact on a mother’s state of pain and other of her normal vital physiological states (blood pressure, heart rate, temperature, etc.), they surely must have impact on the baby as well, since feeding is one of a baby’s *normal* states. It would be really fine to study the births of 100,000 babies with the lens trained on birth practices in this country as one of the parameters. What is the impact of formula feeding on the newborn and infant gut immediately and long-term? How many babies actually escape the hospital never having had at least one brush with a bottle of formula?

    I wish this study great success, but I am reminded of a Medpage Today blog of August 16, 2010, which discusses the “myriad obstacles in the way of getting physicians to follow the evidence” and that “Craig A. Umscheid, Director of Penn Medicine’s Center for Evidence-based Practice note [sic] that, ‘fewer than half of treatments given to patients are supported by good evidence. We base decisions on what we learned as house staff, what our colleagues tell us, and what we read in journals when we have time.’” and broadly states that “ … it takes 14 years for an evidence-based practice to become routine.” Whatever is learned by this large study may point to the need for changes, but, as with evidence-based maternity care, how long will any real and substantive implementations take?

    I heartily wish that the National Children’s Study had an arm that would record the birthing circumstances of each child in the study to add to our understanding of how current maternity practices affect the health of babies. Perhaps it does, and if so, after that, perhaps we need a nice huge study about maternity care and the health of mothers. Given our rankings by the WHO in maternal and infant mortality, we can surely use the scrutiny of a study as big as the National Children’s study.

  4. avatar
    Walker Karraa, MFA, MA, CD
    July 24th, 2011 at 14:06 | #4

    Dear Jackie,
    My name is spelled Walker Karraa. I don’t speak for Dr. Lu in any way shape or form, but suffice it to say, he is probably busy–what with chairing the committee on infant mortality, directing the center for preconception, and establishing a best baby zone in the poorest neighborhoods in Los Angeles. Now, to your comment.

    You said:
    “I suspect the study will overlook the one huge vital area that has a primary impact on the health of every baby, and can have life-long consequences as well: *how* each baby is born.”

    Your response is emblematic of why I see our fate in the hands of what Martin Luther King, Jr. called “the drum major instinct”. Choosing to not get the information before we lead the parade. And we get lots of cheerleaders, and celebrate ourselves at conferences.

    Please, please familiarize yourself with the parts of the study you question, before you suspect anything about it. You admit in this comment that you don’t know anything about it, but feel entitled to lead the march against it. Even from the small amount we learn here (about what is being called the Framingham Study for children), the researchers will attending every of the 100,000 births for cord blood and placental samples. Where do you have evidence that they are NOT going to record birth, MOD, interventions, etc. Please show me that, because I am really depressed now.

    Secondly, you address someone who is now representing the country on infant mortality as the chair of the Secretary’s commission–in a Democratic administration…do you think he got that appointment because he ignores birth practices, their impact on maternal and infant mortality, and is secretly a shill for big pharma and “the man” who wants to see every women sectioned at 36 weeks, and babies force-fed formula?

    Third, please share with me why you had the need to infuse negativity? Do you know something he doesn’t? I am sorry, Jackie, but show me the 200 evidenced-based studies you have published–studies advocating for women, men, children and communities thriving. And do you really think you need to school Dr. Lu on the cord clamping studies? Did you read his bio? At least put citations in your comments so we know what you are referring to.

    The time frame issue: So you know more about the length of time takes to realize practice change because you read a Medpage blog? Enlighten me as to what public policy you have implemented from a strategic task force committee, to fruition–on the ground at the birth policy. What are the mechanisms to getting a study funded, published, and implemented? I am all ears.

    Furthermore, I would like to know what time frame Lamaze, or any other birth organization has planned for the advancement of childbirth education in the next 14 years. Anyone???? Studies in place? Grants written? We are still relying on the Cochrane metasynthesis LtMII in 2006, from the and the Klaus and Kennell study from nearly twenty years ago.

    Fourth–where is the respect for the manager of this site? Do we not know she would not post injurious, unfounded, material? Why can’t we follow her parade with faith in the fact that she has vetted every sentence.

    Lastly, and most disturbing to me, personally, Jackie…is that the data presented about the mortality rates for African American women and infants didn’t come up once in your comment. Not to say it didn’t effect you, but you went for the same old jugular that birthies have been stabbing since the 1970′s.

    When will we realize that we did it… We killed that beast and everyone knows the benefits of breastfeeding and natural birth. Meanwhile, Black women and infants in this country have no access to us, are dying more frequently, and what are we doing about it?

    How might you go forward here, Jackie, and get involved in the issues?

  5. avatar
    Jacqueline Levine
    July 25th, 2011 at 17:52 | #5

    Dear Walker,

    First, let me apologize for mis-typing your name. It is a breach of courtesy and it was careless of me not to check before my hasty post.

    When I first read about the NCS study last year, I remember thinking then that I’d surely love there to be such a study be directed at birth practices, and seeing Dr. Lu’s comment in your interview, I expressed that hope at the end of my post, at the same time wishing this current NCS Godspeed, so-to-speak. Those were my words. I don’t think that wish could be construed as “leading a charge against” the study or against Dr. Lu.

    As for negativity, I directed it towards the effects of maternity practices. I said: I heartily wish that the National Children’s Study had an arm that would record the birthing circumstances of each child in the study to add to our understanding of how current maternity practices affect the health of babies. Yet, you are right: I am “suspicious” that that’s not the case. While the study may collect data on MOD, there is no separate “arm” with that more narrowed focus. I apologize for lack of citation where I should have added it. Do you really think that the study will dissect the MOD into more than vaginal vs sectioned birth? Will it isolate the effects on babies of fentanyl for a few hours? many hours, how many hours, and how much fentanyl? Or the effects of pit on heart rates for mothers, for the fetus? That kind of investigation is not slated in this study so far as I can tell. There’s much that will be missed, as the study designers admit. The wording of the study that I’ve seen seems to tell us that the study is concentrating on a myriad of other influences besides birth practices.

    I agree with you and your well-placed anger when you say with exquisite irony “we have killed the beast”; yes, yes, it is not enough to agree and nod our heads about that stuff. I agree with you when you ask what birth orgs are planning to do to better birth and health for women and babies in this country. Your obvious anger at my words is a feeling with which I readily identify; you perceive my post as frivolous, as not qualified in some way, as though I sit at a remove from the realities and from the fray. I am glad of your point-by-point response to my post; it makes me aware of you as a passionate watchdog out there, determined to keep us all pointed in the right direction, turning our efforts to the just cause. And you are angry about the fact that I didn’t even mention the issues that disturb you “personally”. I reacted the same way to the part of the NCS that I perceive to be lacking. With this response to you, I hope to make myself understood, and I hope that I am aware and sensitive to your every point.

    I am old enough to have been around to experience the retreat from use of routine episiotomy…as an example of practice changes… of the thirty years or so it’s taken for that procedure to be less routine… as more OBs with updated training appear in the LDRs. I guess you can’t tell from that tiny pix that I am waaay old. I guess that I want to see the weight of public policy stimulate change for all women and babies; reading about someone actually involved in such a powerful study made want to speak out (to Dr. Lu) for what is important to me, I guess, and also gave me that depressed feeling of helplessness… and that’s where my post sprang from, and I took the moment and wrote about just some of the ills of maternity care that I see every day. The point I hoped to be making was, as I said: “We should know just how many of the areas of ill-health in children that the study will address can be attributed to the circumstances of birth”. Your interview gave me a jumping-off place from which to vent and criticize maternity practices in the light of what public policy might accomplish if aimed in that direction.

    As I said, I am quite old enough to have seen the rise of medicalization of birth, and I use the following info from the Milbank report very often to make myself (and others) feel really bad, with hopes that it will galvanize me (and others)to effective action: “…in an analysis of practice bulletins issued by ACOG between 1998 and 2004, only 23% of those practice recommendations were based on Level A evidence (consistent science), 35% were assessed as Level B (inconsistent or limited evidence) and 42% were Level C (based on consensus or the opinions of experts)”. (Sakala C, Corry M, 2008.)

    As for me reading a Medscape blog…don’t OBs write them and read them, too? Isn’t that how they talk to each other as we do here? Sometimes these conversations are as enlightening about the realities of attitudes as any prospective RCT is about statistical instances. Was I so out-of-line to use the news of Dr. Lu’s involvement with the NCS as a place to stand and complain?

    You surely struck a chord with me when you said that you are now really depressed. Working as I do at Planned Parenthood with a sorely underserved population of women, being made aware on a daily basis of the disparities between those women (and families really), with access to the best this country has to offer, and those upon whom, it seems, the system has turned its back in so many areas, I often feel terrible and helpless. It is as if nothing that I’m able to do will bring change soon enough, or at all, for the women who are mistreated at this very vulnerable time in their lives. By mistreated, I mean that they and their babies are not given best-evidence care in hospitals. I can’t think that you disagree with that.

    Let me try to address your points more specifically: I certainly do not presume to question Dr Lu’s credentials or motives, nor do I dare to presume to educate him, or accuse Dr. Lu of shilling for big pharma. Where do you see that in my post? Do you mean my mention of poor hospital policies where bf is concerned? Do you really believe that I call him out as responsible for policies in hospitals on Long Island, New York? I am merely questioning the fact that we don’t do this kind of study with a focus on birth practices, on maternity care. I can say from direct observation that all the things I mention in my post occur daily. To reiterate: we will really never know how many *exclusively* breast fed babies get that one bottle in the nursery, but so many of the mothers I help were told that their babies got a formula supplement in the nursery (with sorry, etc.). That depresses me mightily. I cannot be there with every mother all the time. I should not have to be. There’s Marsha Walker’s wonderful article” Just one bottle…it Won‘t Hurt, or Will it?

    I have not published any studies. Perhaps I can someday synthesize all the info I have about the mothers I have worked into something useful. I do work in the immediacy of “on-the-ground” (your words) birth and am subject to its varying policies. I volunteer Lamaze education, techniques for non-pharmacological ways to make labor and birth more effective and comfortable, doula services and lactation support to every pregnant woman in the Planned Parenthood center. (Here I thank Judy Lothian for setting me on this path.) At my local PP clinic, many are African American and Latina. I mention them now specifically to say that as birthing mothers, they are in my daily life and they are not getting best-evidence care in the hospitals along with all the other colors-of-women. I try to keep them, and every mother, as safe from unnecessary sections and inductions as I can. I try to ameliorate the effects of routine maternity policy on their lives one woman-at-a-time. I try to see that they get respectful, evidence-based care. At the very least, at Planned Parenthood, they are able to get good prenatal and post partum care and support, which I hope has some impact on maternal and infant mortalities in our little community. I did not mention African American women specifically as suffering from the “gap” in your title, with mortality in greater numbers, because that was the point of your article, and I didn’t feel it needed re-iteration when I was specifically addressing the NCS.

    I am a member of a local, community-based non-profit birth organization which offers free CB education, labor, birth and post partum support to indigent women and teens, which pursues small grants and local fund-raising with a vengeance in order to help as many disadvantaged as we can in our community. That means that we in this group travel far to help mothers at all hours with little or no remuneration. (I try to write successful grant proposals for this org.) That is the position from which I will continue to “go forward”, that’s where I “get involved in the issues”, as you say, not only as a “cheerleader” or celebrant “at conferences”, although they often re-ignite my purpose. It will never be enough, for sure, as I am sadly aware. But this is the place I have chosen to be for now, and I have helped hundreds of mothers-of-all-colors to have safe and healthy births with dignity and some measure of autonomy. I’ve also worked with CIMS and The Birth Survey to help to make evidence-based care standard practice.

    As for the manager of this site, I have nothing but admiration and respect for her abilities and her commitment to “vetting every sentence”. I think that you are accusing me of calling the material in your interview *injurious and unfounded* but where do you see that? I am sure that I meant no such thing. I count on Ms Hull for her perfectly attuned scrutiny, and her ability to discern intent, no matter how clumsily mine might be expressed. There should be room for all, as Ms Hull said recently, to meet on some middle ground, sometimes.

    I am not a “birthie” from the 1970’s, if by that you mean a person who thinks “awake and aware” is the panacea. I work now to make birth better now and healthier now just a little at a time, and I admit to loving now what I am doing now without regard to the color or shoe-size or ethnicity or musical preference or marital status or age of any mother-to-be that I am lucky enough to meet and work with.

    My kids were born in the ‘60s and I had the great joy and blessing of having normal and natural births. But I have to say that I fought to have those births. That should not still be the case. Martin Luther King Jr. also said something about the “arc of justice bending” towards something better (justice?)…perhaps that can someday mean real reform in maternity care, in all health care, as Dr. Lu hopes, so that there are evidence-based practices, and good maternity leave and decent affordable child-care. We have a really long way to go. I have the sense that you and I are of like mind. Am I naive to think we both want it to be better? Thank you for writing your thoughts for me and all of us all to read.

  6. avatar
    Walker Karraa, MFA, MA, CD
    July 25th, 2011 at 18:53 | #6

    Dear Jackie,
    What a lovely, welcomed, and beneficial response. Thank you. And it lifts my spirits to engage in a manner that is enlightening and encouraging.

    “Your interview gave me a jumping-off place from which to vent and criticize maternity practices in the light of what public policy might accomplish if aimed in that direction.”

    Indeed, we are of like mind, and passion, and feel quite comfortable in a hot kitchen. Fantastic! This is how we grow and potentiate each other, and I thank you.

    I want to particularly thank you for your words regarding Kimmelin–as I believe she is a drum major I would be happy to follow, and I hear that in your response.

    I have reverance for your tenure in this field and dedication to growth. I have no doubt, if you and I were lucky enough to meet, we would have a great conversation, and a great laugh. And then debate this interview again!!!

    Lastly, I am so glad the interview moved you (and me). And I wanted to share this with you, as we have met eachother as anchors in the storm.

    “The winds are going to blow. the storms of disappoinment are coming. The agonies and anguishes of life are coming. And be sure that your boat is strong, and also be very sure that you have an anchor. In times like these, you need an anchor. And be very sure that your anchor holds.” (Carson, & Holloran, 1998, p. 1999, originally published King,1968)

    I @Jacqueline Levine

  1. October 22nd, 2011 at 17:24 | #1