A Life-Course Perspective for Women’s Health Care

Published on 10/03/2015 by admin

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Chapter 1 A Life-Course Perspective for Women’s Health Care

SAFE, ETHICAL, AND EFFECTIVE PRACTICE

Obstetrics and gynecology is an exciting and challenging area of health care. It provides students and young physicians in training with the knowledge and skills necessary to improve the health and health care of women and their children very early in their lives. The United States spends far more on health care than any other nation in the world. Despite this economic effort, it ranks poorly on most measures of overall health status. For example, for the year 2004, the United States ranked only 46th worldwide for average life expectancy and much higher than is acceptable at 42nd in infant mortality. In the year 2000, the World Health Organization ranked the U.S. health-care system only 37th out of the 191 nations whose systems were evaluated for performance. Certainly we need to improve our standing on these and other measures of performance as our health-care delivery system is refined in the coming years. In this chapter, we provide some basic principles and guidelines for improving health care and suggest several important factors that influence the health of women and their children.

image Principles of Practice Management

There are four basic principles for practicing and improving health care that we would like to mention now and expand on later. First, the safety of our patients must always be paramount. In the past few years, we have made major improvements in patient safety, in large part by emphasizing teamwork and implementing practices proved effective in the airline industry. Second, we must always be true to our personal pledge made when taking the Hippocratic Oath—to adhere to ethical practices. Third, because medicine has become very complex, we must be open to a multidisciplinary approach to both diagnostic and therapeutic practice. Quality improvement efforts, practice management skills, and effective communication are all necessary to efficiently optimize clinical outcomes. Finally and perhaps most important, we must focus on the prevention and early mitigation of disease, in addition to our continued focus on its treatment. For this reason, we emphasize an approach called a life-course perspective for clinical practice, beginning with preconception health, continuing throughout pregnancy, and then giving children and their mothers a health perspective for adopting and maintaining healthy living. Before delving more deeply into these principles of practice, some newer concepts about the origins of disease are important to mention.

LIFE-COURSE PERSPECTIVE

Where does the rubber meet the road and lead to pathology and disease during the course of life?

First, although genetics is beginning to provide a much better understanding of the etiologic factors in poor health, it probably accounts for only about one third of the direct causes. For example, person X with gene A has a disease, but person Y with the same gene does not. Clearly there is more to human development and disease risk than one’s genetic makeup. It is thought that factors such as poverty or abnormal health behaviors and environmental conditions can influence the expression of gene A. This may occur directly, or these factors may activate another gene, A-2, downstream, which may then affect gene A. The process whereby human cells can have the same genomic makeup but different characteristics is referred to as epigenetics. It is now thought that the effect of harmful behaviors and our environment on the expression of our genes may account for up to 40% of all premature deaths in the United States. Two of the top behavioral factors related to this premature death rate are obesity (and physical inactivity) and smoking. Environmental exposures to metals, solvents, pesticides, endocrine disruptors, and other reproductive toxicants are also major concerns.

Second, in human biology, a phenomenon called adaptive developmental plasticity plays a very important role in helping to adjust behavior to meet any environmental challenges. To understand human development over time (a life-course perspective), one must first understand what is normal and what adverse circumstances may challenge and then change normal development in the fetus. These protective modifications of growth and development may become permanent—programmed in utero to prevent fetal death. The price the fetus may pay in the long run, however, for short-term survival is a vulnerability to conditions such as obesity, hypertension, insulin resistance, atherosclerosis, and even a chronic disease such as diabetes.

In relation to individual X and individual Y with the same genomic makeup but different in utero environmental influences, metabolic changes that may be initiated in utero in response to inadequate nutritional supplies (Figure 1-1) can lead to insulin resistance and eventually the development of type 2 diabetes. These adaptive changes can even result in a reduced number of nephrons in the kidneys as a stressed fetus conserves limited nutritional resources for more important in utero organ systems. This can then lead to a greater risk for hypertension later in life. This series of initially protective but eventually harmful developmental changes was first described in humans by David Barker, a British epidemiologist, who carefully assessed birth records of individuals and linked low birth weight to the development of hypertension, diabetes, atherosclerosis, and stroke later in life. The association among poor fetal growth during intrauterine life, insulin resistance, and cardiovascular disease is known as the Barker hypothesis. The process whereby a stimulus or insult, at a sensitive or critical period of fetal development, induces permanent alterations in the structure and functions of the baby’s vital organs, with lasting or lifelong consequences for health and disease, is now commonly referred to as developmental programming.

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FIGURE 1-1 The potential effects of life-course nutritional determinants (intrauterine and lifelong) on subsequent adult health.

(From Bateson P, Barker D, Clutton-Brock T, et al: Developmental plasticity and human health. Nature 430:419-421, 2004. Adapted by permission from Macmillan Publishers Ltd.)

Third, another important concept in the life-course perspective is allostasis, which describes the body’s ability to maintain stability during physiologic change. A good example of allostasis is found in the body’s stress response. When the body is under stress (biological or psychological), it activates a stress response. The sympathetic system kicks in, and adrenalin flows to make the heart pump faster and harder (with the end result of delivering more blood and oxygen to vital organs, including the brain). The hypothalamic-pituitary-adrenal (HPA) axis is also activated to produce more cortisol, which has many actions to prepare the body for fight or flight.

But as soon as the fight or flight is over, the stress response is turned off. The body’s sympathetic response is counteracted by a parasympathetic response, which fires a signal through the vagal nerve to slow down the heart, and the HPA axis is shut off by cortisol through negative feedback mechanisms. Negative feedback mechanisms are common to many biological systems and work very much like a thermostat. When the room temperature falls below a preset point, the thermostat turns on the heat. Once the preset temperature is reached, the heat turns off the thermostat. Stress turns on the HPA axis to produce cortisol. Cortisol, in turn, turns off the HPA axis to keep the stress response in check. The body has these exquisite built-in mechanisms for checks and balance to help maintain allostasis, or stability through change.

This stress response works well for acute stress; it tends to break down under chronic stress. It works well for stress one can fight off or run from, but it doesn’t work as well for stress from which there is no escape. In the face of chronic and repeated stress, the body’s stress response is always turned on, and over time will wear out. The body goes from being “stressed” to being “stressed out”—from a state of allostasis to allostatic overload. This describes the cumulative wear and tear on the body’s adaptive systems from chronic stress.

The life-course perspective synthesizes both the developmental programming mechanisms of early life events and allostatic overload mechanisms of chronic life stress into a longitudinal model of health development. It is a way of looking at life not as disconnected stages but as an integrated continuum. Thus, to promote healthy pregnancy, preconception health must first be promoted. To promote preconception health, adolescent health must be promoted, and so forth. Rather than episodic care that many women receive, as a specialty we must strive toward disease prevention and health promotion over the continuum of a woman’s life course.

IMPACT ON PUBLIC HEALTH

The public health implications of the Barker hypothesis and other life-course events leading to health or the development of disease are significant. This is the beginning of an exciting era in medicine during which young physicians can begin to take charge of these events and change our health-care delivery system in a very positive way. A large part of this will occur by encouraging patients to take responsibility for improving their own health, particularly by practicing healthy behaviors early in life. They should also be encouraged to improve and maintain a healthy “green” environment. Currently, there are only a few environmental and behavioral factors that have been clearly identified as part of the Barker hypothesis. Many others are yet to be discovered.

Adaptive developmental plasticity will take place secondary to changes in genes as a result of environmental and behavioral practices. Even the controversial concept of climate change may play a role in this phenomenon. New knowledge over the next 10 to 20 years should help us to accelerate the development of focused interventions at all levels to mitigate and prevent disease and improve the health of women and their children.

Biological processes are powerful and frequently unpredictable. Physicians must decide what role they will play in a safe, ethical, and effective practice. Learning is fun and exciting, and patients who wish to be informed about their health and health care will be grateful for the wellness and good health provided to them.

The four basic principles and guidelines mentioned earlier—patient safety, ethical practice, quality improvement, and the need for a focus on prevention—are covered next.

image Patient Safety

Safety in health care is not a new concept. Facilities have had safety programs in place since the early 1900s, but these programs have traditionally focused on emergency preparedness, environmental safety, security, and infection control. The term patient safety, meaning avoidance of medical error, was first coined by the American Society of Anesthesiologists in 1984 when they inaugurated the Anesthesia Patient Safety Foundation to give assurance that the effects of anesthesia would not harm patients.

Medical errors now rank as the fifth leading cause of death in the United States. The Institute of Medicine (IOM) published an alarming report in 1999 called To Err Is Human: Building a Safer Health System. This report estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Error is defined as failure of a planned action to be completed as intended (e.g., failing to operate when obvious signs of appendicitis are present) or the use of a wrong plan to achieve an aim (e.g., wrong diagnosis, wrong medication administered). Medication errors alone, occurring either in or out of the hospital, are estimated to account for more than 7000 deaths annually. According to the National Council on Patient Information and Education, “more than 2/3 of all physician visits end with a prescription.” An estimated 39% to 49% of all medication errors occur at the stage of drug ordering. Patient noncompliance also contributes to medical errors.

The United States Pharmacopoeia (USP) MEDMARK error tracking service estimates that as many as 100,000 medication errors occur annually. Because reporting is voluntary and does not include all medical facilities in the United States, the scope of the problem is likely to be much larger. A preventable adverse drug event (ADE) is one type of medication error. Administering the incorrect drug, an incorrect dose, wrong frequency, or incorrect route may cause an ADE.

A drug that cures one patient’s condition may be the one that causes another patient’s injury or death owing to an adverse drug reaction (ADR). The latter may account for 1 out of 5 injuries or deaths for hospitalized patients. ADRs commonly occur from an overdose, a side effect, or an interaction among several concomitantly administered drugs. To minimize ADRs, health-care providers should avoid the following actions:

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