By BloggersUnite.org _
Medical Professionals
Dr. Deirdre Logan, Watts Health Center
Dr. Laura Reynard, St. Johns
Federally Qualified Health Center
Watts Health Center
Marcela Rodriguez, Health Educator
Clinica Monsenor Oscar Romero
Maria Valdez, Women and Infant Program Division at the East LA site
Clinic (FQHC Look-Alike)
We Care More 2
Coco Dominguez, Comprehensive Perinatal Service Program rep
Cynthia Liddy, Nurse practitioner
Kaiser, Blue Cross Prenatal Care Subscriber:
Sarah Tuttle-Singer
Pasadena Public Health Dept. Black Infant Health Program Commuity Service Representative, Doula, Certified Childbirth Educator, Certified Birth Assistant, Assistant Midwife, Certified Health Education Specialist, Masters in Public Health and Health Education and Promotion/Maternal Health:
Cordelia Hanna-Cheruiyot
Doulas
Nora Oppenheimer
Ana Markel
UC Irvine Researcher (Pollution > risk than anything else)
Jun Wu
University of Washington Assistant Professor
Amelia Gavin
Hospitals I tried
LA County
St. Francis
Public Health Service Act: Here
Federal poverty guidelines: Here
(US Dept of Heath and Human Services) Healthy people.gov (midcourse review): Here
Medi-Cal: Here
Federally Qualified Clinics: Here
A paper on “true presumptive eligibility: Here
US Welfare system: Here
Time magazine…re: preventing preemies: Here
UCI Research: "Association between Local Traffic-Generated Air-Pollution and Preeclampsia and Preterm Delivery in the South Coast Air Basin of California": Here
UC Irvine/Jun Wu-provided supplemental material: Here
University of Washington Assistant Professor Amelia Gavin: Here
Los Angeles Times article about potential new Kaiser building: Here
LA’s Best Babies Network: Here
Additional Reading
Cynthia Golen’s, Phd, research “Maternal Upward Socioeconomic Mobility and Black—White Disparities in Infant Birthweight” : Here
Gavin's study "Depression during Pregnancy and Adverse Birth Outcomes: A meta-Analytics Review" : Here
Gavin's field: "Maternal and Infant Care Center Database--Depression and Anxiety in Pregnancy Study" : Here
Michelle Pearl’s, Phd, research “The Relationship of Neighborhood Socioeconomic Characteristics to Birthweight Among 5 [sic] Ethnic Groups in California” : Here
Sarah Mustillo’s, Phd, research “Self-Reported Experiences of Racial Discrimination and Black-White Differences in Preterm and Low-Birthweight Deliveries: The CARDIA Study” : Here
Richard David’s, Phd, research “Disparities in Infant Mortality: What’s Genetics Got To Do With It?” : Here
Michael Lu’s, MD, MPH, commentary: “Racial and Ethnic Disparities in Birth Outcomes: A Life-Course Perspectives” : Here
Richard David’s, MD, research: “Differing Birth Weights Among Infants of U.S.-Born Blacks, African-Born Blacks, And U.S.-Born Whites” : Here
Dolores Acevedo-Garcia, Mah-J. Soobader and Lisa F. Berkman’s research “Low birthweight among US Hispanic/Latino subgroups: The effect of maternal foreign-born status and education” : Here
Though the piece went up a few days back now, I wanted to wrap up, discuss the reporting process a bit more and include a source list for anyone who may be interested in one.
The piece I set out to report was not the one I found. But I’ll get to that.
I encountered a great deal more information in the two weeks transpiring between the last blog post and this one.
Numerous daily phone calls to LA County and South LA Lynwood-based St. Francis hospitals found me no further than the institutions’ PR.
And while very nice, they could not tell me what kind of preterm birth rates they saw amongst their patients, and among those, of what race and cause were these instances.
They could, however, describe the care women using Medi-Cal would receive and whether those visiting the hospital tended to use that form (they did).
My calls to King Drew were not successful, but phoning the Watts Health Center and realizing it’s the area’s largest and seemingly most reliable health resource made me want to visit.
Intersecting Compton and the city’s upper 100 streets, the health center takes up nearly a full block in what appears to be each direction.
As I entered the large clinic through the back, I was struck by what seemed to be a highly functional, hospital-resembling institution. Fair assumption or not, I have to admit I did not expect that.
After asking for the prenatal care unit, I was able to speak to one of the health educators, Marcela Rodriguez. She walked me (so to speak) through the care women receive while describing the instances she’d encountered of preterm births.
Touching upon noncompliance as a factor, she pointed to diet and stress as main instigators of preterm births. The prenatal care unit lies separate to the OB, and as I walked down the halls and past the courtyard, I noticed art pictorially describing need for racial tolerance and a lasting civic peace. Bloods embraced Crips, prisoners walked free and Hispanics stood with Blacks.
As I had come in without notice, it seemed unlikely I would be able to speak to an OBGYN this visit. But I got lucky. Dr. Deirdre Logan ushered me into her office for a very helpful conversation (which we would later conclude over the phone a few days later).
She discussed the prenatal care women using Medi-Cal or attending FDHCs receive—starting with the preliminary visits and ending with labor—while explaining that many women in the neighborhood do not open their mail and do not apply for Medi-Cal in the first place.
She said the women’s nutrition—often consisting of very salty or fattening foods—definitely contributed to the high instances of preterm births, but she said more than anything the fault likely lay with STDs and stress.
Many of the women in what is a dangerous area who have preterm births are on welfare and are single moms without a familial support system. Those stresses, she said, have an effect.
One of the challenges I found with this story was in trying to locate numbers to corroborate any of these theories. Because I couldn’t really reach the hospitals or their records, I couldn’t know for sure how many women coming in of lower means had preterm births and of those what were their races and situations and of those what had caused these early births.
In the past few years, certain South LA areas like Compton and Lynwood have experienced demographic changes. No longer predominantly African American, such areas are now anywhere from 50 + percent to 80 percent Hispanic.
The instances of teen pregnancy (healthy or otherwise) in South L.A. are still very high, and LAUSD has three schools, one, Thomas Riley, just across the street from the Watts Health Center, for high school-aged girls who are pregnant.
Yet the African American women among them still tend to have more preterm births—from what the assistant principal, Dolores Magana, with whom I spoke on the phone, has said. She also said she thinks it may be a cultural issue. She indicated she and the school teachers make sure the girls see a doctor and comply with their medical visits.
But she cannot regulate their food-intake or their private lives. And that, she said, is where the pregnancy could go awry. She explained that while Hispanic women may face the same financial and discriminatory obstacles as do African American women in South L.A., Hispanic women tend traditionally to maintain strong ties with their parents and the fathers of their children (even if they do not marry) and tend, also, to eat more balanced (or at least more varied) diets.
I realize these are huge and dangerous generalizations to be making, but I heard them cropping up again and again.
I faced the same discomfort writing about how African American women may have higher incidences of preterm births because of, as doula/masters in public health/health educator Cordelia Hanna-Cheruiyot and U-Dubb professor Amelia Gavin put it, the “institutionalized racism” that makes it more difficult for Blacks to buy houses and get loans, etc.
I see the logic behind all these arguments and am in no position to argue with them. But a dearth of hard numbers also made it difficult for me to write with ease about what are somewhat controversial topics and claims.
And I would be remiss were I not to mention that there are other causes for preterm births not stemming from socioeconomic difficulty.
For example, St. Johns Hospital OBGYN Dr. Laura Reynard, an obstetrician dealing more often with women who use private insurance, explained preterm births are common among older—often wealthy—women who use In vitro fertilization.
She also said professional women in high stress jobs—such as those within medicine or law—tend to have preterm births quite commonly.
Ana Markel, a doula dealing most often with women of high social strata as “poorer women cannot afford doulas” said the same thing.
On the other hand, Jun Wu, an assistant professor in public health from the department of epidemiology at UCI, thought preterm birth rates had little to do with prenatal care, race, class, stress or nutrition and everything to do with pollution.
She and her colleagues had published a study (linked in the article and will likely be in the source list) showing women living near busy highways tend to have a higher risk for premature birth and preeclampsia.
Yet Hanna-Cheruiyot (see above), who worked at a Pasadena clinic for many years and especially saw Black infants and women using Medi-Cal, spent a great deal of time describing what she termed the “assembly line care” these women received and how doctors will deprive these women of the choice to have a vaginal birth, for example, because it takes longer.
She then went on to highlight how, physically-speaking, women on Medi-Cal could be receiving decent care, but because no one, such as a doula, is attending to their mental well-being, they’re less likely to have healthy births.
But she emphasized that at the end of the day, Black women have more premature births because they face more discrimination.
So mid-way through all this, I became completely confused and unsure as to which path to follow, how to structure the reporting I had left and how to put together the article I was to write.
The piece I had thought to report—one showing the possibly great disparities in prenatal care in Los Angeles—was not necessarily the one I was finding.
I know that’s ok, but what I was finding seemed at first jumbled, contradictory and hard to support.
And that was where the stats Dr. Logan provided me finally made me feel like I had something that could tie all these voices together.
Having these numbers really allowed me to breathe a bit more freely as I wouldn’t simply be making allegations—through human sources on specific “sides” or otherwise—that I couldn’t back up. I couldn’t simply say “South LA tends to have the highest rate of gonorrhea in the county” until I had the numbers to support that.
Once I had these documents I could put together a bit more where Wu’s or Gavin’s statistics fit in, where I could include the Best Babies Collective information or where I would add in the facts about Medi-Cal, presumptive eligibility, the poverty line, welfare, etc.
I found reporting and writing this a challenge. Though it may seem otherwise, there has not been that much research done, and the statistics, I believe, are still somewhat shaky.
But I truly enjoyed delving into this tough subject and trying to figure out how to tell an important story.
No matter what—whether it’s faulty prenatal care, pollution, diet, sexually transmitted diseases and infections, stress, racism, or what-have-you, there are great forces at play here affecting the pregnancies and thus children of entire groups of women (as well as tax-payers), and health still does accompany wealth (for the most part), so none of this is an exercise in futility.
Because my conversation with U-Dubb's Professor Gavin had piqued my curiosity as to whether it really is true that Hispanic women tend to have healthier births than do African American women, I thought I'd look into the care given both communities of women in Los Angeles.
I made a list of clinics to call in Lynwood as well as those I should try in Compton. Hispanics comprise roughly 80 percent of Lynwood, African Americans about the same percentage in Compton. These two south L.A. cities lie adjacent to one another.
I started cold-calling pages worth of clinics, trying the county hospitals but expecting such institutions to require many, many more attempts before getting through to the PR and then eventually the prenatal care untis (if).
Finally, I reached We Care More Family Clinic 2. Though it's located in Compton, it serves primarily Hispanic. Nevertheless, the two nurse practitioners manning the phones and attending to patients, Coco Dominquez and Cynthia Lidy, both said the only clinic-visiting-women they'd seen give premature births are African American.
Prescribing standard prenatal care and monthly visits, prenatal vitamins, ultrasounds, etc., they said those who tended to have premature births also tended to have them at the end of "noncompliant pregnancies."
Lidy described the many women who did not know they were pregnant or who were substance abusers.
But most concluding adverse pregnancies did so, she said, because of their nutrition.
"They want fast food: french fries, hamburgers," Dominguez said of the women who had had preterm births. "They said 'I don't like this, I don't like that.'"
Sometimes drug addicts, she said they feared coming into the clinic--which serves a majority of Medi-Cal subscribers--because they did not want their infants taken away from them.
So these nurses would say the effort to extend standard prenatal care is there, and they're trying their best, but those who have premature births have them because they do not come in to receive the prenatal care they should, ignoring visits, doctor warnings, eating unhealthily, often abusing substance.
I would like to know what kind of care women receive in county hospitals here. No hospital could refuse care to a woman in labor--even should she have no insurance. So theoretically, a woman living in Watts could take a bus to Cedars-Sinai, and if she's in labor, the hospital will not turn her away.
But when I visited Clinica Monsenor Oscar Romero, a federally qualified health center (FQHC) based out of Alvarado and twice in East L.A. (across the street from Marengo St.-bound L.A. County-USC), Prenatal Case Manager Sandra Rivera explained that the clinic sends pregnant women to county long before labor, so the women could acquaint themselves with those who will give them care during their baby's birth.
Such women, she said, will, by labor time, have developed a rapport with the hospital's staff and would want to go where they felt comfortable. And even were they not to have done so, she added, many of these women, uninsured and in the case of the Hispanic women, often undocumented, would not wish to go to a hospital that did not tend to serve their community--on the comfort level.
But that brings me back to county hospitals. I've been trying to reach:
-UCLA Harbor
-L.A. County
-CA
-...and what used to be MLK.
Looks like I will be able to speak to L.A. County's PR, Rosa Saca, tomorrow--which would be excellent. I think the county hospitals hold the key to the differences in prenatal care visible throughout the city.
And the hospitals may be able to answer Kim's question: how much do premies cost for the insured? How much do they cost for the uninsured?
L.A. County's prenatal care unit is robust, or so I have heard. And small wonder. Growing out of Marengo street like a Noir monolith dedicated to the memory of The Shadow, the hospital is, to say the least, imposing.
But does it provide quality prenatal care (for the uninsured? For Medi-Cal holders)? I don't know.
I will be returning to Clinica Monsenor Oscar Romero--whose mission it is to provide that quality care to those who would not otherwise be able to afford it. But those with whom I spoke, Sandra Rivera, Women & Children Program Director maria Valdez and Development Director James Hoyne, were adamant that the 15,000 people (mostly undocumented) they serve receive that quality care.
Nine or so doctors see patients at that branch of the clinic, three of them staff members. All, said Hoyne and Valdez, followed stringent medical methods.
Though women do not give birth at the clinic--tending, instead to cross the street to county--the clinic's representatives follow the progress of their 400 or so former pregnant patients.
Hoyne said this clinic, along with Venice Free Clinic or the Sabon Free Clinic and the 60-odd clinics serving Medi-Cal and Medicaid users or the uninsured, is very serious in its attempt to prevent preterm births. Medi-Cal only requires 10 prenatal visits, both he and Valdez said, but the women "patronizing" such places receive "many, many, more."
So I need to find out how big the difference in pregnancy and birth health is among women who use these clinics and receive what appears to be very decent-to-good care and those who are non-compliant, are scared to come to these places or do not know of their acceptance (or do come, receive sub-standard care compared with that of doula-using and/or afluently-targeted prenatal care-having women).
West side mom, Sarah Tuttle-Singer is a blogger. She writes the Crazy Baby Mama blog about her adventures in toddler mothering and those involving her current pregnancy. She was kind enough to give me the names of her doctors (and I was able to reach St. John Hospital OBGYN Dr. Laura Reynard, whose premature birth-delivering mothers tended to do so because of in vitro, among other non-care related causes) as well as offer me the chance to come along on her next doctor visit, Wednesday the 5th ("remember, remember, the fifth of November...").
If I could compare such a visit and the care it implies to that visible in a South L.A. clinic and/or hospital, I could, perhaps, gain some real insight into the potential care differences.
Clinica Monsenor Oscar Romero's employees pointed me to L.A.'s Best Babies Network, which, with its stated goals of improving prenatal care in the city, could be a very good source.
Going back to the erstwhile MLK hospital:
Yes, it's closed. But I believe it's line is still functional, its records still "available." It would be interesting to see what kind of premature birth numbers they had, "serving" a very poor African American community based in Watts. The care was so low in quality, the city had to shut the place down.
But I feel it would be valuable to know whether they saw more premature births than other hospitals and clinics and areas, and if they did, whether the causes of those births hinged on the sub-standard care, the diets of the mothers, that background stress or other factors.
No one I have spoken to has yet mentioned obesity--yes imbalanced nutrition, yes, pollution, yes, care, yes, substance abuse, yes, childhood stress and racial discrimination, and yes, race/genetics--as an element of the adverse pregnancy outcome equation.
Of course, bad nutrition and obesity make good bedfellows, but malnutrition and obesity fall just as often in diametric (and physical) opposition. Given the latter relationship, or lack thereof, then, it would likely be imperative to find out how obesity affects pregnancy and birth outcome as well as to find out how many of the women of lower means have premature births as a result of obesity (and diabetes?).
I'll be trying King Drew and clinics located in Watts tomorrow.
Posted by Deborah Stokol on 10/29/09...Picking up where I left off...
Doulas are already seeing a self-selected group who can afford good care. So the preterm births they encounter don't tend to come as a result of a societally wrought malaise. We think.
But here's a clincher I did not anticipate. University of Washington Social Welfare Professor Amelia Gavin, among whose "professional interests" lie "racial disparaties in birth outcomes," explained many academics now maintain that women who grew up with significant stresses face a higher risk of frought pregnancy and premature birth.
That is, those growing up poor are more likely to go into labor early. The only thing that may really be surpising about this, though, is that the studies Gavin alluded to showed that even those who were no longer poor, who kept a healthy diet, who received thorough prenatal care, still sustained a higher risk for premature births.
What we know: African American women are more likely to give birth prematurely.
So Gavin discussed the many theories she and her colleagues held about that grouping. She said she wished to debunk what she felt was a myth that African American give birth earlier because they are genetically predisposed to do so. Calling such an explanation an excuse for apathy or lack of policy change, she pointed to studies (of which I have yet to comb through) conducted by a Chicago-based scholar (more tk) concerning analogous birth rates among Africans and Caucasians and how those rates began to differ after Black women had lived in the States for a couple of generations.
She cited what she felt was the likelihood that the stresses of racial discrimination lay a groundwork for future corporeal weakness. I.e. difficult [rife with hunger or malnutrition as well as racial discrimination] childhood/formative years-->possibility of pregnancy with "adverse" outcome.
But would not that response also generate an unwillingness to examine the differences in prenatal care among the Los Angeles Haves and Have Nots? If you can pin future pregnancy problems on childhood, why bother with attending to the pregnancy itself, as it would be, "too late" to do any good?
Common sense would likely suggest that stress of any kind is bad for pregnancy (and health in general), but wouldn't concentrating on past stress alleviate care-givers or even those expecting of accepting the responsibility that dealing with present stress would require?
Moreover, how does this theory speak to studies Gavin mentioned, ones that show Hispanic women do not tend to suffer the same level of preterm births African American women do?
South L.A. houses majority Black and Hispanic populations. But both often face racial discrimination as well as poverty--in childhood and into adulthood. So that study would support either the "it's a genetic thing" theory (and I have to say, getting into racial genetics/tendencies is almost always a very slippery slope) or, more likely, one that would show there are other factors at play here.
(So perhaps it would be interesting to speak to those doulas who donate their services to those who would otherwise be unable to afford them. I had been in contact with Doula Nora Oppenheimer, Doula trainer/Doula Association rep Ana Paula Markel and Doula/Volunteer/Birth Educator/Midwife Cordelia Hanna-Cheruiyot.)
Would this care lead to a greater number of healthy births among even the poor and those living freeway-and-pollution-adjacent?
But how do such doulas choose their clients? Who, among the underserved, gets the benefit of a doula, and who simply tries her hand at care [with or without insurance?] the old-fashioned way?
[See next post as the reporting process continues to unfold]
Posted by Deborah Stokol on 10/29/09Of course the story hinges on this possibly polar comparison of prenatal care received in one area of the city v. that in another. But upbringing has come up far more than I expected it to.
My foray into Facebook guided me to a doula, a child birth educator, a midwife, a Pasadena public health official and a professor, among others.
For those who do not know what "doula" refers to (and I can tell you that until a few days ago, I counted myself among those ranks), it describes an individual who provides support to a woman during her pregnancy, labor or postpartum. Though often called a "helper," the doula is neither a doctor, nurse nor midwife. She does not assist the actual birth.
The doula supports the mother or soon-to-be-mother emotionally, psychologically, through physical therapy or through the giving of advice concerning preferable prenatal vitamins or exercise routines or those that would best ease the expecting process.
Thing is, those who can afford a doula likely face the best the prenatal care world has to offer. So the doulas may see fewer premature births. Those they do see tend to occur as a result of the fact that the pregnant woman are older, wealthier and have been given In vitro fertilization.
[It would be interesting to find how often the use of In vitro catalyzes premature birth and how often In vitro paired with higher age raises the risk for that premature birth.]
(More on background and the adverse effect of even distant childhood poverty on pregnant women to come in a few hours time)--
Posted by Deborah Stokol on 10/20/09
I've been working on gathering data for the infographics -- by the way March of Dimes has a bunch of useful info -- and I'm also pondering presentation.
The beauty of infographics is the ability to see a whole world of information in one glance. It's the thing I also love about reporting and what got me into this field as well.
I can make static graphics, like you may see in your local newspaper. They're simple and graphic. Or I can use a program or software to build something that will be embeddable, so you can share the information.
I wonder how often these types of graphics are really shared? The New York Times uses the same technology as IBM's Many Eyes. Many Eyes is sharable and embeddable, with public information, and the NYTimes is not.
I prefer the idea of embeddable shareable and even editable graphics. You can take the data sets and alter them if you want.
But then again, does that detract from my work? Do you think that it's easier to use somethingl ike Many Eyes or Google Fusion Charts than it is to build something from scratch?
You can leave comments on the pitch page about this and let me know what you think.
Posted by Kim Bui on 10/20/09So, I'm Kim, and I'm the other half of the reporting team working on this story.
I suppose I'll start with a brief bio. I'm a web producer and was a reporter for about 2 years in California and Missouri. i started web production work while at the San Luis Obispo Tribune. I've worked for start-ups and newspapers.
Data visualization is a huge interest of mine, but I don't have an formal graphics training. I love design though, so it works out for me.
As far as the story, I think it has big potential for graphics because the numbers are a large part of the story.
Deborah noted the three graphics we're thinking of: a map of pollution and premature births, a comparison of healthcare for the two neighborhoods and an "overall" graphic.
My plan right now is to spend about a week on gathering data ,a week on the graphcs and week on tweaking.
So that leads us to right now. It's research time and I should really be looking at a pile of studies.
If you have any insights or ideas for numbers, please get in touch with Deborah or myself.
Posted by Kim Bui on 10/11/09Hello-
I'd like to introduce myself. My name is Deborah Stokol, and I'll be reporting the story with the help of P. Kim Bui.
I've been tyring to lock down a series of angles, approaches.
I figured I'd begin by casting a few electronic nets (pun?) over Facebook and Twitter, seeing whether that would yield potential sources.
This, like many others, seems to be the kind of story that will tell itself the more deeply the reporter delves. And I think that while speaking to hospitals and healthcare officials will be crucial toward seeing what the story's really about, what the numbers and large story experiences imply, I'm going to need to spend time with women who are pregnant in south and west LA, women who have experienced prenatal care in both areas and those who have had the grave misfortune to give premature births in one, either or both places.
I don't know to what degree we may attribute care, pollution, the varying lifestyles and socioeconomic differences implicit in the geographic divide as causes...I guess that's the point.
So for the sake of maximum transparency:
-A fellow Facebook just sent me a message saying she knew a few women of the aforementioned ilk who could be willing to discuss such things with me. Excellent.
-Kim, who will be putting together accompanying infographics to illustrate the story visually, and I planned for roughly three such graphics (static, rather than flash): one showing the pollution-->premature births statistics using a map of LA and each area's proximity to the city's many freeways (also included as threads running through the map), one showing a sort of contiguous set of care-->premature births stats for women living in each area and one that sort of sums the whole "story" up...taking into account, of course, that outliers exist, that folks lead their own lives, and that while generalities may be made, they can't accomodate for individual quirks.
-What that means in terms of diving in: calls to hospitals, healthcare officials, specialists, study research (UCLA/USC/those showing freeway pollution causes diminished lung capacity in children...a link to premature birth problem?), Lexis visits and the women themselves...
-If it is, indeed, more a traffic issue than one of prenatal care, this is most certainly an LA story. If it isn't, it's still a propos, as healthcare has, more than ever, been on the national mind, and where better to begin than one of the country's largest cities?
We have a little less than a month, so if there's anyone contextually relevant with which you're acquainted, any way you can help, by all means, let me, let Kim know. This is a big story; it's an important story. And we want it to be as good, as true and as in depth as we can make it given everything.
Thanks, and I'll be posting!
Posted by Deborah Stokol on 10/10/09
