U.S. Birth Practices 1940 to 2040: Part I

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As I am approaching my fifth anniversary of publishing Common Science®, I hope that it is apparent how much I enjoy writing these columns, particularly when the topic brings in threads of history, politics, economics, and culture along with the science. This is one of those weeks. And as often is the case, I will use some of my own family history to help in the telling of the story.

In 1940, the year my mother was born at home without the assistance of any trained medical professionals, the United States was still reeling from the Great Depression and home births were the norm. World War II brought economic prosperity, rapid industrialization, modernization of medical practices, and the commercial introduction of penicillin and other antibiotics. Further, the success of the U.S. armed forces during the war was at least partially attributed to advances in science and engineering, which helped to foster an attitude that most human problems could and should be addressed with technology.

Post-war economic prosperity drove the construction of a tremendous number of hospitals staffed with doctors and nurses trained either during the war or afterwards through funding from the G.I Bill. Within these shiny, new facilities, the view that educated men – and I say men on purpose – wielding the latest scientific knowledge could improve over Mother Nature held sway. This perspective was bolstered by benefits flowing from improved hospital sanitation practices and the use of antibiotics. During the post-war era, two important transitions in birth practices took place. First, there was a dramatic increase in the percentage of babies delivered in hospitals instead of in homes. Second, by the time my sister was born in 1964, birth had become highly medicalized and was treated more like an illness requiring the intervention of technology than a natural process. This was also the time period during which pregnant women were prescribed thalidomide for morning sickness, which resulted in thousands of birth defects. During my sister’s birth, my mother was given general anesthesia. Even today, 52 years later, you can sense that she can still feel the disorientation of going to sleep pregnant and waking up and being told that she had delivered a baby girl who was now in a different room.

In parallel with the changes in birth practices, the use and overuse of antibiotics in the U.S. grew dramatically after World War II. As I have discussed in previous columns (links), we now know that indiscriminate use of antibiotics in the U.S., in both humans and livestock, has been the key factor in driving increases in rates of obesity, diabetes, asthma, heart disease, and high blood pressure, as well as the rise of drug-resistant super bugs.  We now also know that reducing the population and diversity of beneficial bacteria in women due to overuse of antibiotics results in their children starting life with a deficiency of needed bacteria, which can have long-term negative impacts.

The rise of the Women’s Movement in the 1970s brought a wide range of issues to the political forefront, including reproductive issues such as contraception, abortion, and choice of birth method. In all of these arenas, male-dominated legislatures and medical associations were dictating and limiting options for women. While public debates on contraception and abortion received more public attention, a movement to empower women’s choices regarding birth options also began. In particular, Rahima Baldwin’s book, Special Delivery, published in 1979, detailing the potential benefits of midwifery and home birth, attracted a dedicated following.

With that historical perspective in hand, let’s fast forward to 2016. Currently in the United States 99% of all babies are delivered in the hospital, one-third of those via Caesarian section. Utilization of the expensive and specialized equipment and personal in the hospital for all types of deliveries, ranging from the routine to the complicated, results in birth being a very high-cost procedure. But despite utilizing the full arsenal of tools available to the medical field, the United States is one of only a hand-full of countries in the world with a rising rate of maternal mortality.   Currently 17.8 per 100,000 mothers in the U.S. die during or in the aftermath of childbirth, which puts the U.S. in 33rd place worldwide.

Maternal mortality is rising in the United States for a variety of reasons. These include:

  • an increasing number of pregnant women who are in poor health due to obesity, diabetes, and high blood pressure;
  • poor pre-natal care due to lack of access to affordable health care;
  • an increase in the number of C-sections; and
  • an increasing number of hospital-acquired infections.

This circumstance is similar to many other medical issues in the United States. We spend a tremendous amount of money but receive less than stellar results. So what can and should be done? The first two bullet points above are part of a general problem in public health in the United States. To address these issues, we need to ensure that everyone can afford to go to the doctor, find a way to ensure that everyone has access to nutritious foods, and transition to a more rational use of antibiotics.

The issues in the final two bullet points are intimately intertwined with the manner in which we approach birth options in the United States. This will be the topic of Part II next week, in which I will discuss how these issues are handled in the United Kingdom. I’ll also provide a summary of my conversations with Jane Gledhill, Certified Nurse Midwife, Nurse Manager at Women’s Birth and Wellness Center in Chapel Hill, NC and Secretary of the Legislative Committee for the North Carolina Chapter of the American College of Nurse Midwives regarding the future of birth options in the U.S.

Jeff Danner discussed this week’s column on WCHL with Aaron Keck.


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New UNC Hospice Home Breaks Ground In Chatham Park

About a hundred people turned out in Pittsboro on Tuesday as officials broke ground on UNC Health Care’s new Hospice Home.

“We’re glad to be celebrating UNC Health Care’s newest opportunity to serve the people of North Carolina,” said Brian Goldstein, chief operating officer of the UNC Health Care System, as he welcomed onlookers to the site.

The hospice home is set to open in February. When it opens, Goldstein said, it will be a major addition for hospice care – Chatham County’s first inpatient hospice facility.

“In total, (it will have) 11,000 square feet,” he said, “complete with kitchen, dining room, meditation space, family visiting areas, and ten private rooms, each with an individual outdoor patio.”

Brian Goldstein speaks at the groundbreaking. (Photo by Aaron Keck.)

Brian Goldstein speaks at the groundbreaking. (Photo by Aaron Keck.)

In addition to serving as a boost for medical care, the building will also serve as a boost for the town of Pittsboro. It’s the second building to start construction in Chatham Park, Pittsboro’s new mega-development – the first, already under way, will open in December.

“We are pleased to partner with UNC Health Care,” said Chatham Park developer Tim Smith, who was on hand for the groundbreaking. “This hospice will provide end-of-life care options not previously available to local residents.”

Pittsboro town commissioner Pamela Baldwin – also present for the ceremony – agreed. “This is an honor, as well as an unparalleled privilege, to participate in the groundbreaking,” she said.

Large crowd on hand to break ground on UNC's Hospice Home. (Photo by Aaron Keck.)

Large crowd on hand to break ground on UNC’s Hospice Home. (Photo by Aaron Keck.)

The crowd spilled out beyond the tent.

The crowd spilled out beyond the tent.

Officially, the building will be named the SECU Jim and Betsy Bryan Hospice Home of UNC Health Care. (Jim Johnson of the SECU Foundation was on hand to provide a major donation to the project – a $1 million challenge grant.) Dr. James Bryan, the building’s namesake, has been with the UNC Department of Internal Medicine since 1964; in the 1970s he introduced the modern hospice care movement to North Carolina.

Jim Johnson reveals the $1 million grant.

Jim Johnson reveals the $1 million grant.

Jim and Betsy Bryan.

Jim and Betsy Bryan.

That movement began in England with a physician named Cicely Saunders – and an idea that began to grow in the 1940s, when she was a nurse treating a Polish refugee who was terminally ill.

“There he was, undertaking this terminal course, and they became very close,” said Bryan at Tuesday’s ceremony. “And they talked about how ideal it would be to be at a home…with a window overlooking a park, with music, with friends and with family…

“And so when he died, he left a legacy to her – and said, ‘I want you to build a window.'”

That “window” eventually became St. Christopher’s in London, which opened in 1967 as the first modern facility devoted to hospice care. Today, there are “windows” like St. Christopher’s around the world – and come February, there will be another new “window” in Chatham Park.

UNC Hospice House Groundbreaking 8

UNC Hospice House Groundbreaking 9

UNC Hospice House Groundbreaking 12

Artist's rendering of the future Hospice Home. (Photos by Aaron Keck.)

Artist’s rendering of the future Hospice Home. (Photos by Aaron Keck.)


SCOTUS Keeps Affordable Care Act Subsidies

***UPDATE: The Supreme Court has issued a 6-3 ruling allowing subsidies to continue to be offered in states that did not establish their own marketplace. You can read the full opinion here.***

The U.S. Supreme Court will release a decision within the next few days that may affect more than half a million North Carolinians who purchased health insurance through the Affordable Care Act.

The question before the Court in King v. Burwell is whether the federal government overreached when it allowed subsidies to flow to states, like North Carolina, that did not set up their own health insurance exchanges.

North Carolina is among 34 states that do not have state-run health insurance marketplaces. That means North Carolina residents who want to buy insurance through the Affordable Care Act have to do so through the federally-run exchange. About 550,000 North Carolinians did just that, and most of them, says Duke University public policy professor Don Taylor, received tax breaks to help pay for their premiums.

“Ninety-one percent of the North Carolinians have gotten a subsidy,” Taylor said,  “and the average amount of that subsidy is about $315 a month.”

The plaintiffs in the case argue the Affordable Care Act does not allow the federal government to give those subsidies to people in states that don’t have a state-run exchange.

“So if the Supreme Court had a simple finding for the plaintiffs,” Taylor said, “then the tax credits that are coming to North Carolinians today, they would lose those tax credits, their insurance bills would then go up, and then presumably many of them would them drop their coverage.”

Taylor says not only would such a ruling affect those who dropped their coverage because they couldn’t afford the premium, it could topple the entire federally-run exchange:

“The problem is the people who wouldn’t drop coverage, the people who are desperate to keep their insurance, are probably people who are sick. And any type of insurance market—whether it’s car insurance, homeowner’s or health insurance—if the healthy people flow out because the premiums go up, and you only have sick people left, then that’s called ‘death-spiral,’ and that insurance market is unsustainable.”

If the Court does rule for the plaintiff, Taylor says depending on the details of the ruling, there could be some legislative fixes at the national and the state levels to keep the tax breaks coming.

“Maybe North Carolina could pass a simple law that says we desire for the subsidies to still flow in North Carolina. But then it’s back to a political question again.”

The Supreme Court is expected to release a decision by Monday, June 29.


Chapel Hill Public Library Offering Assistance as Open Enrollment Deadline Looms

The open enrollment period to file an application for health insurance is coming to a close on February 15.

The Chapel Hill public library is offering assistance to those who are looking for help navigating the path to sign up for health care.

Shannon Bailey, the library’s Reference Librarian, says enrollment sessions are scheduled throughout the next week, leading up to an all-day sign up event on Friday.

“Anybody can come in and meet with a certified application counselor in our library computer lab,” she says. “And on Friday, Feb. 13, from 10 a.m. – 5 p.m. we will be hosting an all-day enrollment session.”

Leading up to Friday, Bailey says they will have sessions on Saturday, Feb. 7, from 1-4 in the afternoon, Monday evening from 5-8, and Tuesday afternoon from 2-5.

She adds they have picked Friday for their all-day session, even though the enrollment deadline is Sunday.

“We cannot predict, obviously, what the website is going to do this year,” she says. “We did learn from experience last year that the day before and the day of the site gets overloaded.”

Bailey says there are some things you will need to bring to sign up for coverage.

“In order to enroll, they will need their social security number – for themselves and everyone in their household that needs coverage,” she says. “They will need employer and income information for everyone in their household; that can take the form of W-2’s, wage statements, tax statements, [or] pay stubs.”

Bailey adds if you currently have any health coverage, you will need those policy numbers. And if you are eligible for health insurance from your employer, you will need to fill out a waiver on healthcare.gov.

Bailey says it takes a lot of teamwork to make this assistance possible.

“All of our certified application counselors are from UNC Healthcare, the League of Women Voters of Orange-Durham-Chatham, Planned Parenthood of Central North Carolina, and UNC’s Student Health Action Coalition,” she says.

You can call ahead to reserve a time during the enrollment session; walk-ins are also welcome.

This is the second year of open enrollment since the Affordable Care Act was put into place. The law provides subsidies to those who need assistance in paying for health coverage, and it makes having health care a requirement by law. Those who are not covered are subject to a fine.


HIV Survival Rates Disproportionately Low in South

Survival rates for those infected with HIV/AIDS in the South are the lowest across the nation.

Nine southern states, including North Carolina, are hit disproportionately hard by HIV/AIDS, according to new research out of Duke University. The study found 15% of those diagnosed with HIV, and 27% diagnosed with AIDS, died within five years of their diagnosis, based on numbers from 2003 – 2004.

Lee Storrow, Executive Director of the North Carolina AIDS Action Network, says the disease has grown beyond its initial profile of mainly affecting young-to-middle-aged white gay men.

“Unfortunately, we have really seen this disease evolve over the last 20 years,” he says. “[We’re] seeing a new focus and new outbreaks amongst poor residents of this county – and a concentration of new epidemics in the South.”

Storrow adds many factors play into the increased HIV rates – and the lower survival rate associated with the disease – particularly in our region.

“When you look at poverty rates in the deep South, when you look at lower levels of education, and you look at the social stigma,” he says, “I think all of those are factors that are contributing to increased rates of HIV in the South.”

Storrow says the stigma associated with the disease is a major obstacle in battling its treatment.

He adds, while sexual contact is the main form of transmission, the disease can also be passed by sharing needles, among other avenues.

Unfortunately, Storrow says our social environment can be deadly for those who are HIV positive.

“That stigma is something that means that people don’t share their medical conditions. They don’t receive testing,” he says. “And there’s a number of people who have received testing, and might know that they’re HIV positive, but aren’t actually in care to receive the treatment that they need.”

He adds battling the stigma is difficult on several layers, including not being able to legislate against a social stigma as you can with other more overt obstacles.

Of what can be controlled, access is a major theme for treatment, according to Storrow.

“One thing we know,” he says, “is that if you have access to stable-consistent-safe housing, you’re ability to access medical care significantly increases.”

And access to steady-affordable medical care can then translate to more effective treatment of the disease.

Storrow says the biggest way state legislators can help in the fight against HIV/AIDS is by expanding Medicaid.

He adds it will take teamwork – between lawmakers, everyone in our community, and beyond – to fight back against HIV/AIDS.


UNC: Health Benefits For Same-Sex Spouses

Following a court ruling last week, the state of North Carolina has begun recognizing same-sex marriages – and as a consequence, state employees (including UNC employees) will now be able to enroll same-sex spouses in the State Health Plan.

UNC Chancellor Carol Folt made that announcement Tuesday along with Felicia Washington, the Vice Chancellor for Workforce Strategy, Equity, and Engagement.

Their statement is below.

Dear Carolina Community,

On Friday, Judge Max Cogburn, Jr., a United States District Court Judge for the Western District of North Carolina, entered an order ruling that North Carolina’s law prohibiting same-sex marriages is unconstitutional as a matter of law. This is, indeed, a historic ruling in our state.

We are pleased to share with you that earlier today, the State Health Plan and NCFlex informed us that employees can immediately begin to enroll same-sex spouses. Coverage can become effective as early as November 1, 2014, for same-sex marriages performed prior to October 13, 2014. This applies to marriages performed in North Carolina, as well as same-sex marriages lawfully solemnized outside of North Carolina. Same-sex marriages performed after this date would be treated as qualifying events, just as with opposite-sex marriages.

To view the State Health Plan’s official announcement regarding coverage, click here.

Instructions to complete the enrollment of a same-sex spouse are available at http://hr.unc.edu/?p=20974.

We will continue to communicate any important updates relating to this late-breaking news. Likewise, we will inform you of any instructions we receive from the Office of State Human Resources, the State Health Plan and NCFlex related to any policy changes…


Carol L. Folt, Chancellor
Felicia A. Washington, Vice Chancellor for Workforce Strategy, Equity,
and Engagement


Post Health Care Deadline, Officials Say More Than 7 Million Enrolled

As the March 31st deadline for Americans to enroll in health care has come and gone, early estimates indicate that more than 7 million Americans successfully signed up for coverage, despite problems and long wait times.

Sherry Hay, UNC Family Medicine Director of Community Health Initiatives, says her department and community partners have been working to help locals sign up for health care since open enrollment under the Affordable Care Act began on October 1 of last year.

On Monday, Hay says UNC Family Medicine was still taking calls and answering people’s questions about enrolling for health care.

“Through the month of March, we tried to do a variety of events— some more global type of community events with other partners such as UNC General Internal Medicine and others in the community, to scheduling patients around their medical appointments here at family medicine to see a certified application counselor,” Hay says.

The last-minute rush before Monday’s midnight deadline was a headache for some, as people reported call wait times of more than two hours and constant glitches with the HealthCare.gov website. Such problems have plagued the system since its debut.

“During these tight times when we are all dependent on the system, it is really frustrating, and people were frustrated by that when it didn’t operate as it should,” Hay says.

Still, federal officials estimated that about 2 million Americans were able to successfully enroll in the two weeks leading up to the deadline.

According to data released in February, Hay says it was estimated that more than 200,000 North Carolinians had enrolled through the federal health care exchanges.

In 2013, 1.5 million people in North Carolina were uninsured.

“It has been an interesting change in healthcare, one of the biggest in decades. There was no state agency that was necessarily deemed the agency to be responsible for the change,” Hay says.

All people, with few exceptions, are required to have health insurance. People who are already covered by health insurance through a private provider are not required to change coverage.

Citizens who can afford health insurance but did not purchase it by the March 31 deadline will be fined $95.

However, the enrollment period has been extended for those who began the application but were unable to finish.

“The Obama Administration did release that if someone had started the process by midnight [on March 31st], they will have until April 15th to complete the application process,” she says.

Now that this open enrollment period has ended, Hay says UNC Family Medicine and its partners will regroup, assess what went well and what didn’t in helping to get people signed up and focus on the next open enrollment, which begins in November and runs through February of 2015.


Gender May Be Key To ACA Impact On Small Biz

How is the Affordable Care Act affecting small business owners in the Chapel Hill-Carrboro area?

The answer may depend on the gender of the workers they employ.

That, at least, is the tentative finding of a survey of local business owners conducted by the Chapel Hill-Carrboro Chamber of Commerce.

When asked how the Affordable Care Act was impacting them, 30.5 percent responded “negatively” or “very negatively,” while 23.9 percent responded “positively” or “very positively.” (The rest—not quite half—were either unaffected or unsure.)

But Chamber president Aaron Nelson says a closer look at the responses reveals something interesting.

“Some of that is about the neutralizing of men and women, (who) cost differently in the old world and cost the same now,” he says. “So if you had a predominantly younger female staff, your rates likely go down – (but) with a predominantly male staff…your rates could go up. So gender has had a real impact on cost.”

Nelson says auto body shops, in particular, have reported their health care costs going up—while the Chamber itself, with a mostly-female staff, has seen its costs decline.

Chamber economic briefing ACA slide

Additional results from the survey are available at www.slideshare.net/carolinachamber/2014-economic-outlook-briefing (also the source of this image). As seen here, there’s only a slight lean towards the ACA having a “negative” effect if severity is not taken into account, but that changes if severity is considered: a far greater percentage of respondents reported a “very negative” effect than a “very positive” effect.

Nelson presented the results of the survey at last week’s annual Economic Outlook Briefing at the Sheraton Chapel Hill.


This Weekend In OC: Arts! Concerts! Tax Relief?

With tax season officially upon us, Orange County is once again offering the RSVP-VITA tax preparation service for low- to middle-income residents in need of assistance this year.

“VITA” is short for Volunteer Income Tax Assistance. It’s a free program sponsored by the IRS. It begins in February in Orange and Chatham Counties.

You can find out if you’re eligible and make appointments either online or by phone. Visit OrangeCountyNC.gov/aging/VITA.asp, or to make an appointment by phone, call:

Orange County: 919.245.4242 (English)
Orange County:  919.245.2010 (Spanish)
Compass Center for Women and Families: 919.968.4610 (English only)
Chatham County: 919.542.4512 (Angel Dennison)
Chatham County: 919.742.1448 (Spanish)


From now through March, the Hillsborough Arts Council is offering walking tours of the town’s sculptures. The guided tour is called “Take A Closer Look”; it will focus on four of the six sculptures that have been on display since last April.

Tours begin at the Hillsborough Arts Council Gallery on N. Churton Street, at 1:00 p.m. every Friday and Saturday. The tours are free (though donations are accepted), and they last one to one and a half hours.


This weekend brings the third annual “Mixed Concrete” art auction to Chapel Hill, with proceeds to benefit Habitat for Humanity. Featuring local artists working with a variety of materials, the show runs from Friday to Sunday, January 24-26, at TRU Deli + Wine Bar on the corner of Rosemary and Henderson. There will be an opening reception on Friday at 7:00 p.m.

To see some of the art online or to donate to the cause, visit MixedConcrete.org.


If you’re still unsure about the new federal Health Insurance Marketplace, UNC Family Medicine is holding a “Health Insurance Enroll-A-Thon” on Saturday, January 25, from 10:00 a.m. to 3:00 p.m. Officials will be on hand to answer questions and help you enroll.

The event will take place in the UNC Family Medicine Center at 590 Manning Drive. For more information or to schedule an appointment, visit UNCFamilyMedicine.org.


The Orange County main library in Hillsborough is hosting an exhibition of folk art from January 24-March 24. It’s called “Road Trip: Folk Art from Mike’s Art Truck”—and it’s comprised of 20 pieces all created by self-taught artists.

Curators Greg and Karen Mack of Hillsborough will be on hand for a reception at the library on Saturday, February 1, from 2-5 p.m.


Orange County’s Department on Aging and the Friends of the Seymour Center are inviting you to attend a Celebration Concert honoring the memory of Pearl Seymour on Saturday, January 25.

The concert will take place at 3:00 p.m. at the Seymour Center on Homestead Road; admission is free. Immediately following the concert, there will be a reception and a silent auction, with proceeds going to benefit the Department on Aging and the Friends of the Seymour Center.

For more information about the concert, visit FriendsSeymourCenter.org.


Saturday, January 25, you’re invited to a free performance of actor Mike Wiley’s “Dar He: The Story of Emmett Till” at 2:00 p.m. in the Chapel Hill Public Library. The performance is co-presented by the library and the UNC Program in the Humanities, part of a community dialogue on the legacy of Jim Crow and its impact today.

There will be an audience discussion following the performance.


Rep. Price Sees Progress In Affordable Care Act Sign Up Process

CHAPEL HILL – Open enrollment for health insurance under the Affordable Care Act began on October 1, but many people have been dissatisfied with the sign-up process online.

The health care website has had a number of problems over the past month that have made signing up challenging, but Congressman David Price says that the health care website is going to be a valuable asset to many people.

“Many people are going to be depending on this and I’m confident that we will get it right, (though) I think the website problems are of course very regrettable,” Price says.

Although accessing the website has been difficult, people can visit the Piedmont Health Center in Carrboro to sign up, or even call the 24-hour hotline at 1-800-318-2596.  Price says many people are working hard to get the website running right.

“We’ve got to get this website running and they’re working on it day and night. Reports I have had are that people are now getting through and that its improving day by day,” Prices states.

The Affordable Care Act website is only one of the concerns in Washington right now.  Budget talks have begun in Congress and Price says there are many issues that will need to be reviewed.

“What are going to do about the fact that our tax code simply doesn’t pay our way? What about the long term future of entitlement programs like Medicare, social security? asks Price. “And what about the overly severe sequestration cuts, across the board cuts, that have already occurred?”

For more information about the Affordable Care Act, click here.