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November 1, 2014
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Taking Care of Mom: Why Women’s Health Matters Most

“Tulsa County has a higher rate of premature births and infant deaths than the State of Oklahoma or the nation.”(source Healthy Women, Healthy Futures, OU-Tulsa)

It really is all about Mom. For generations mothers have been blamed and credited for everything. It turns out that biology may support that claim. While the scientific research is relatively new, the implications of what we now know about the impact of a woman’s environment on the health of her baby before, during and after pregnancy may dramatically change the way we look at women’s health.

Last October Michael Lu, M.D., MPH, a national expert on maternal/child health from UCLA was the keynote speaker at a conference on maternal health hosted by OU-Tulsa.  Dr. Lu, author of “Get Ready to Get Pregnant,” Dr. Lu has been recognized for his work using the Life Course Perspective, which addresses the influences of the biological, social and environmental impacts on a woman throughout her life, not just during the 9 months of pregnancy. Dr. Lu was recently named Associate Administrator of the Maternal & Child Health Bureau (MCHB), which oversees the Block Grant Program of Title V of the Social Security Act, the Healthy Start Program, Universal Newborn Hearing Screening, Emergency Medical Services for Children, Sickle Cell Services and Family to Family Information Centers.

The Life Course Perspective

In light of new science, OB-GYNs and other medical and mental health professionals now know that even the point of conception is too late for women to plan for the best outcome for their babies. And, because over half of all births in the United States and 65 percent locally are unintended, it is critical that women of childbearing age receive information about prenatal care long before they have children.

“We’re pushing reproductive life-planning,” Dr. Lu said. “Doctors need to ask their patients at every visit if they [patients] have a reproductive life plan, about their personal goals about having children, and under what circumstances they want to have children before they get pregnant.”

Such things as high blood pressure, being under or overweight, medications, social and mental health, inflammation and nutrition can all affect a developing fetus. Dr. Lu believes that these issues must be addressed throughout a woman’s life rather than at the point of conception.

Dr. Lu says that pregnancy is too late to begin prenatal care. “Doctors should target every woman, every couple, every time they see them. The fate of the pregnancy has been written in implantation. A baby’s vital organs are being programmed inside the womb.”

Everything from the mother’s nutrition to her stress level can affect her developing child, not only at birth, but throughout life.

Su An Arnn Phipps, Ph.D., RN, CNE, is the director of Healthy Women, Healthy Futures and assistant professor in the College of Nursing at OU-Tulsa. She said that a reproductive life plan should take into consideration all areas of a woman’s life. “We tend to think of [reproductive planning] as just birth control,” she said. “But women need to ask, how will this pregnancy impact the rest of my life?”

Part of the plan should include careful spacing of children with pregnancies being no closer together than 24 months.

“I hear women say that they want their children to be close together so they’ll be close friends,” Phipps said, “but women don’t realize the toll having a baby has on their body. You want your body to be as healthy as it can be when you get pregnant.”

Women of childbearing age should also be taking a multivitamin every day to ensure that they get enough folic acid, which is crucial to preventing spinal chord abnormalities. The spinal chord forms within the first three to six weeks of pregnancy, often before a woman knows she’s pregnant.

Nutrition

Pregnant women should be eating for quality rather than quantity, with the first trimester caloric needs being about the same as non-pregnant needs said Dr. Lu. After that, women can add 350 calories a day during the second trimester and about 500 calories during the third.

According to Jennifer Hays-Grudo, Ph.D., George Kaiser Family Foundation Chair in Community Medicine and professor of medicine in the OU School of Community Medicine, pregnant women need to stay within the recommended weight guidelines, which is relatively new thinking for this generation of pregnant women.

“If you’re overweight, you’re not supposed to gain more than 15 or 20 pounds,” she said. “Mothers who are overweight or obese, or mothers who gain more than the recommended amount of weight are more likely to have children at risk for diabetes and obesity, and this has been found in children as young as 7 years old.”

Moreover, the risk doesn’t stop with one generation. Hays-Grudo said that animal studies show that when mothers have too much glucose in their bloodstream and are producing too much insulin, the metabolic regulatory genes of the children actually become permanently altered.

“The gene that is switched off [by the mother having too much glucose] actually gets passed along in that switched off state to subsequent generations,” she said.

While not every overweight mom will have an overweight child, “knowing that pregnancy is a critical time because of the response of the fetus’s DNA to the mother’s environment” means that women should monitor how much weight they gain during pregnancy.

In order to maintain a healthy weight and get good nutrition, Dr. Lu recommends that pregnant women eat more whole foods such as whole grains, vegetables, fruits, beans and nuts and less processed foods. Top brain foods include beans, eggs, nuts, olive oil, wild salmon, yogurt, whole grains, spinach, kale, prunes, berries, oranges and red bell pepper. Toxic foods include swordfish, mackerel, soft cheeses and unpasteurized milk, hotdogs, luncheon meats, raw or uncooked meat, liver (vitamin A overdose), saturated fats, transfats, partially hydrogenated vegetable oil, added sugar and refined flour.

And, for optimum maternal and fetal health, women should maintain a healthy weight for three to six months prior to pregnancy.

Outside Environment

“Detoxify your home,” he said. “Get rid of anti-bacterial soap, air fresheners, glass cleaners with ammonia, vinyl wallpaper and blinds and #3, #6 and #7 plastic bottles.”

While you may think that bar of anti-bacterial soap in your shower is benign enough, Dr. Lu said that you should get rid of it. And that plastic office water cooler jug? Don’t use it. Most office coolers are #7 plastic.

“Detoxify your home,” he said. “Get rid of anti-bacterial soap, air fresheners, glass cleaners with ammonia, vinyl wallpaper and blinds and #3, #6 and #7 plastic bottles.”

During pregnancy, avoid dry cleaning, too. Dr. Lu said that the chemicals are a proven reproductive toxin. If you must pick up the dry cleaning, open all your car windows and air out the clothes for at least one hour once you get them home.

Smoking, drinking and substance abuse are also damaging to a baby. “Smoking and drinking during pregnancy sets a child up for learning difficulties,” Hays-Grudo said. “It affects the way the brain is structured.”

 

 

In addition, Dr. Lu advises women to get rid of any ongoing infections or inflammations before getting pregnant. Vaccines also should be up to date, and women should schedule a trip to the dentist, brush and floss to keep teeth healthy.

Stress and Pregnancy

Some of the most dramatic biological research regarding life in the womb is in epigenetics, and much of Dr. Lu’s Life Course model is based on the scientific research in this field. Epigenetics can be thought of as a kind of early programming of a fetus. Scientific evidence, says Dr. Lu, has shown that this early programming from prenatal exposure to such things as maternal diabetes, malnutrition, stress and substance abuse can lead to a host of physical and mental health issues that follow a child into adulthood and even into the next generation.

“What I understand [in defining epigenetics],” Hays-Grudo said, “is that because of the sensitivity of the fetus to hormones and other chemicals in the mother’s bloodstream, that if the fetus is exposed to prolonged chemicals like coritsol or even insulin, that genes that normally would be turned on and expressed, do not get turned on. They’ve been exposed to other substances that prevent them from being expressed. You still have the gene, but it doesn’t get turned on, or it gets turned on halfway.”

And these “switches” are passed on from one generation to the next. So what’s happening to Mom not only affects her child through adulthood, it affects her child’s children.

Stress is one of those switches. When a pregnant woman is experiencing on-going stress, whether from living in a violent environment, being consistently hungry or the like, she is bathing her child in the stress hormone cortisol. According to Dr. Lu, extreme maternal trauma and stress have been linked to children having lower language development scores, and a higher incidence of the child getting schizophrenia, depression, ADHD or having behavioral problems. Because women living in poverty are exposed to more on-going stress than the general population, these women and children are most at-risk. The maternal stress acts as a switch that affects whether or not certain genes are turned on or off in the developing fetus, possibly “programming” the baby for lifelong problems such as hypertension and cardiovascular disease, glucose intolerance and insulin resistance, infection and inflammation and even changes in mental abilities. And, even if the life situation changes for the child, the problems can persist for subsequent generations.

“Prenatal stress can lead to impaired fetal growth,” Dr. Lu said. “It can also lead to preterm birth.”

Children who are born very premature (under 32 weeks) and moderately premature (between 32 and 35 weeks) tend to have more physical, cognitive and behavioral problems than their full-term peers.

Stress and Young Children

Extreme stress, trauma and depression have also been shown to affect young children.

According to Hays-Grudo, research shows that traumatic experiences in childhood were highly correlated with those children developing illnesses such as heart disease, cancers, arthritis and engaging in risky behaviors such as substance abuse as adults.

“The theory goes that when you’re exposed to adverse or traumatic experiences in childhood, this high level of cortisol (stress hormone), that is flooding your system does several damaging things. One is that cortisol has a physiological effect on you so that you are producing more and more stress hormones. It’s also related to diabetes because cortisol is a hormone related to regulation and metabolism of food, of sugar in the blood.”

Hays-Grudo said that because the body is constantly being bathed with the stress hormone, certain parts of the brain become underdeveloped or overdeveloped. “The part associated with fear and panic grows too large, which then sets up this kind of vicious cycle. The other parts of the brain associated with learning and reasoning are less well developed.”

Data collected at Educare Centers, which are high-quality early learning centers for children living in poverty, shows that parental stress can a impact even very young children, Hays-Grudo said. The more stressors that the parents were dealing with, the higher incidence and frequency of illnesses such as asthma and eczema the researchers saw in the preschoolers, who were as young as 2 years.

“Depression in the mother is also a difficult thing for children to overcome,” Hays-Grudo said. “The most important thing for children is that in the first two years, they learn that they can trust their environment, that when they cry, somebody attends to their needs. It’s often difficult for mothers to come out of the fog of their own depression to be present for their children.”

Quality childcare, however, can help children who live in difficult environments. “We do see that the earlier children go to Educare,” Hays-Grudo said, “the more likely they are to be ready to go to kindergarten.”

 

 

She was also quick to point out that unless the stressors that the family is dealing with are addressed, the child will be returning to an unhealthy environment at home, which is the reason Educare Centers provide wrap-around services for families.

Policy

 “Multiple generations suffer from our short-sightedness,” Figart said. “It causes us to look at who we are, what we are and how we are.”

The Life Course Model of women’s health not only impacts individual women, but also has a huge impact on the way policy makers look at community health. If what happens in one generation is going to affect future generations, then the policies need to reflect a continuum of care, especially to women living in poverty.

“This is an exciting moment in time, where multiple disciplines in science have meshed in women’s health. We have better science than we’ve ever had before,” said Jan Figart, MS, RN, associate director of the Community Services Council. “You cannot do episodic intervention because it’s not effective. As policy makers, we look at one year at a time. But if we begin thinking of life as a life course – what you do now is going to have a long shadow on generations – how would you do things differently?”

Figart uses the example of cutting funding to WIC, which may affect 5,000 children in Oklahoma. “That may save a couple million dollars, but the impact on learning, physical health and pregnancy can’t be remediated by putting the money back later. What we add or take away affects more than the moment.”

The Healthy Women, Healthy Futures program that is being directed by Su An Arnn Phipps at OU-Tulsa, and supported by the George Kaiser Family Foundation, is using Dr. Lu’s Life Course model to improve the lives of women in Tulsa. By focusing on the entire life of women in poverty, the program hopes to not only impact women today, but also future generations. Women are in the program for two years and take weekly classes on site at Educare and Head Start Centers. They learn to cook nutritious food, have exercise classes, get basic healthcare, an individualized health plan, dental care, counseling and emotional/social support.

“The program is community-based rather than clinic-based,” said Phipps. “Our program is one of the few in the nation.”

“We spend about half the money on young children that we spend on the aged,” Hays-Grudo said. “From a policy standpoint, it makes no sense at all. We would get much more return on our investment if we spent money on well-timed interventions in early childhood.”

Dr. Lu says that the influence of social determinants on health begins even before we are born. A woman’s health, diet and stress level during pregnancy affects her newborn’s life chances: everything from neurological and emotional development to the likelihood of adult obesity, risky behavior and disease. Proper nutrition, prenatal care, and exercise are important, but class, racism, loving relationships and place can also affect pregnant women.

Despite obstacles, Dr. Lu is optimistic that communities can create what he calls “Best Baby Zones” by providing comprehensive, wrap-around services that address physical, social and emotional health for women throughout their lives. “We have to start doing the right things by having a common vision,” he said.

 “Multiple generations suffer from our short-sightedness,” Figart said. “It causes us to look at who we are, what we are and how we are.”

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