NORTHWEST PORTLAND AREA\
MATERNAL CHILD HEALTH NEWSLETTER\
September 2001, #5

Cliff O\'Callahan, MD,PhD\
Puyallup Tribal Health Authority, 2209 E.32nd St, Tacoma, WA 98404\
(253) 593 0232 #478; fax (253) 593 3311; <cocal@u.washington.edu>

Well, it\'s been a very long time. I apologize. Tons of great issues
have arisen in the literature or in meetings for us to chat about.

If you are interested in Maternal Child Health topics in Indian country
then please consider signing on to the IHS MCH email list-serve. Do so
by sending an email to Neil Murphy at
<nmurphy@SouthCentralFoundation.com>.

*IHS Pediatric Conference:* This year\'s shin dig May 10-12 was
excellent. Please see Dr Bill Green\'s summaries of pertinent issues by
getting his IHS Peds Notes. He can send you a paper copy (write to 801
Vassar NE, Albuquerque, NM 87106) or access it
[online](http://www.ihs.gov/MedicalPrograms/MCH/C/CHnwsltrs.asp#IHSpedsNotes).
Topics that Bill comments on include the Conjugate Pneumococcal Vaccine,
obesity in youth, type 2 diabetes in youth, literacy development through
the Reach Out and Read program, dental health and fluoride varnish use.
There were great workshops on FAS, Evidence-Based Pediatrics, community
based approaches to obesity, common dysmorphic syndromes etc. Keep this
conference in mind when planning CME for 2003!!

*Western Maternal and Child Health Epidemiology Conference,* June 14-15
in Portland, OR. This was my first epi conference and it was really
good. This was co-hosted by the CDC, Oregon and Washington Depts of
Health, the IHS, and the NPAIHB. I have never seen such a mix of state
health dept staff, researchers, and folk from IHS and Tribal sites
together. There was an excellent workshop on Building Data Sharing
Partnerships between Tribal organizations and state/local entities that
was very illuminating for many people not working in Indian country.
There were umpteen topics of note but I will hit on two that I feel are
important because of the implications that simple interventions could
make on the wellness of our communities.

The first topic of note was a plenary by David Olds, PhD from the Univ
of Colorado. It dealt with Nurse Home Visitations on maternal and child
life course. This is powerful stuff. The idea is to have well trained
nurses visit higher risk women an average of 7-9 times through their
pregnancy and 23-26 times up until the child\'s second birthday. \"The
nurses follow detailed visit-by-visit guidelines to help women improve
their health-related behaviors, care of their children, and life-course
development (pregnancy planning, educational achievement, and
participation in the workforce).\" This is accomplished by \"helping the
mothers to envision a future and set goals for themselves at a crucial
stage in their own personal development.\"

Their first intervention study was more than 15 years ago in upstate New
York with mostly white women, but has been duplicated in urban Memphis,
Tenn with black women, and is being conducted in Denver currently. The
benefits of this intervention are most evident in the neediest families
(low-income unmarried women). For the children it resulted in
significantly decreased rates of childhood injury, ingestions, abuse,
and neglect, and they later had fewer arrests and convictions, smoked
and drank less, and had fewer sexual partners. For the mothers it helped
them to space their pregnancies and move into the workforce, becoming
economically self-sufficient and avoiding substance abuse and criminal
behavior. See JAMA 2000;283:15: 1983-1989 Enduring Effects of Nurse Home
Visitation on Maternal Life Course by Kitzman, H et al. Tons of
references in it. Dr Olds at <olds.david@tchden.org>.

The second topic regards Emergency Contraception. Dr Robert Hatcher (the
guy who puts out the little \"Managing Contraception\" handbook) gave a
challenging plenary. The logic went like this: every day there are some
incredible number of acts of intercourse in the US. A large proportion
of them were with inadequate or failed contraceptive methods. Some
proportion of these result in pregnancy. About 60% of pregnancies in the
US are unintentional. Unintentional pregnancies result in abortion,
maternal depression, poorer care-giving etc.

At the same time, we providers know about technologies that have a 75%
chance of preventing that woman from getting pregnant. We have the
emergency contraceptive (EC) pills readily available, and they are
cheap. There is NO contraindication for using the emergency
contraception plans, especially if using Plan B. Yet, for some reason,
very few of us educate EVERY woman of childbearing age about EC, and
even if we did, we could do it better by giving every woman coming for a
Pap, pregnancy test, STD check etc a packet with information and a
course of EC.

My take-home message is that every clinic needs to update their
Emergency Contraception handout. It should give the facts and have the
info on finding the closest provider and pharmacy willing to prescribe
EC at www.not-2-late.com and telephone 1-800-NOT-2-LATE. Hopefully women
will pass this on to others who may not be eligible for IHS services. To
increase the likelihood that it will be given out, we are stapling it to
the back of PCCs for pregnancy tests and Paps. I\'ll put it in the pack
for teens. Additionally, we are looking at getting Plan B at a cheap
price so that we can give it at women\'s exams. You can look up
[www.go2planB.com](http://www.go2planB.com/) for info and ordering
details on Plan B. It\'s in a great little packet but costs \$17 apiece
commercially and can drop to \$2.50 apiece in bulk to certain buying
groups. Please inform me if you know of a way to order it cheaply.

A third excellent plenary was given by Karla Damus from Albert Einstein
College of Medicine Ob/Gyn faculty on Folic Acid Supplementation to
prevent birth defects (and other things). I was stunned by how much
about this I did not know and how important folic acid supplementation
can be. Most of this information can be found on the [March of
Dimes](http://www.modimes.org/) web site where there is a downloadable
patient and provider info sheet. There is also a very nice Perinatal
Profile for each State.

The basic gist is that everyone over 14 years old should be taking 800
micrograms of extra folic acid!! All women of child-bearing potential
should be getting extra folic acid, and the amount obtained from
fortified foods is really not enough (see the list of research abstracts
on the web site). While 400 mcg is advertized, research has shown that
800 mcg is better. Traditionally, folic acid has been directed towards
pregnant women to prevent neural tube defects but it seems the benefit
is much wider. There is good evidence that adequate levels may
substantially decrease the rate of cleft lip and palate, limb reduction,
urological defects, and Down\'s Syndrome. It seems that good levels may
help prevent cardiac disease and stroke as well as colon cancer: that\'s
where supplementation for men comes in.

Certain folk are predisposed. There is a genetic mutation that results
in lower levels of folate because affected people can\'t easily process
dietary folate. This mutation is more common in Hispanics. Medicines
like phenytoin, primidone, and barbituates will lead to deficiencies of
folate over time.

In China they took this seriously enough to institute folic acid supps
for all women in two provinces coming for pre-marriage counseling. Of
248,000 women monitored, those who took their folic acid more than 80%
of the time showed a decrease in neural tube defects of 85% in one
province where there was a high prevalence, and by 40% in the province
with low prevalence of defects (Berry et al, N Engl J Med
341:1485,1999).

What can we do practically? We can raise the issue of prevalence of
neural tube defects in Indian country and thoughts on universal
supplementation on the IHS MCH listserve. I think we need to have a
discussion about this at provider and P&T meetings and update everyone
on what current thinking is. We don\'t have it in our pharmacy except as
an ingredient in prenatal vitamins. A quick look at pricing suggests 100
tabs of 400 mcg cost 73 cents. We could look up all patients on
phenytoin and give them folic acid. We could add folic acid info to the
teen pack of information and staple it to Blue Border and contraception
PCCs. We could make sure it\'s on school health curriculum and write an
article for the local newspaper!!

Knowing what I now know, I will feel guilty when a patient delivers a
child with anencephaly or spina bifida. if I choose to do nothing about
our clinic policy.

*Other topics of interest:*

PROS is \"Pediatric Research in Office Settings.\" They are looking for
new sites and people to become involved. PROS was established by the AAP
in 1986 and the idea is for pediatricians in regular office settings to
participate in national research questions that are applicable to
primary care. Currently it\'s made up of 1,613 pediatric practitioners
in 554 practices and they are involved in topics such as Respiratory
Illness Management Study, the Child Accident Recognition and Evaluation
Study, and a future randomized control trial of anticipatory education
to decrease violence. If you are interested then call 1 800 443 9016
x7623 or [visit the web site](http://www.aap.org/pros).

There is a similar network in New Mexico called the Research Involving
Outpatient Setting Network (RIOS Net). If interested contact Dr. Robert
Williams at 505 272 3603 or <rlwilliams@salud.unm.edu>.