Research Magazine 2010

Family Matters

buckets_familyMatters

Photo from Corbis Images

By the end of the 20th century—a century that saw women secure the right to vote, begin to follow educational and professional pathways long blocked to them, and gain control over their fertility—it was easy to think that the “Woman Question” raised by Victorian-era suffragists had at last been resolved. And yet the role of women in global society continues to change and to be contested. Women’s own perceptions of their status—and consequently, their advocacy for their own needs and the needs of their families—ripples out to affect the health and well-being of entire communities. New research from across BU’s two campuses is shedding light on the evolving roles, rights, and responsibilities of women historically and in the present day.

New Hope for Newborns

Poverty, poor infrastructure, and a lack of education have conspired to produce high infant and maternal mortality rates in Zambia’s Lufwanyama District. But early results of a study by Davidson Hamer suggest that by training traditional birth attendants (r) to avoid the three most common causes of neonatal death—sepsis, asphyxia, and hypothermia—infant mortality can be reduced by 40 percent, leading to healthier and happier mothers and babies (l).

Poverty, poor infrastructure, and a lack of education have conspired to produce high infant and maternal mortality rates in Zambia’s Lufwanyama District. But early results of a study by Davidson Hamer suggest that by training traditional birth attendants (r) to avoid the three most common causes of neonatal death—sepsis, asphyxia, and hypothermia—infant mortality can be reduced by 40 percent, leading to healthier and happier mothers and babies (l).

Photos courtesy of Davidson Hamer

Clean, dry blankets. Antibiotics. Immediate, exclusive breastfeeding. A sterile blade for cutting umbilical cords. The tools for ensuring the health and safety of newborn babies are humble—and frustratingly elusive in many parts of the world. Even as overall childhood mortality has declined, nearly four million babies die each year within their first month, the majority from entirely preventable disorders.

How to bridge the distance between what we know will save newborns’ lives and the stubbornly high neonatal mortality rate in places like Africa and South Asia? One way is to attack the problem on the ground—to go into poor, rural communities, look at exactly what happens and who surrounds a woman as she delivers her baby, and find practical, easily implementable methods of influencing those events.

That’s what Davidson Hamer has done for the past 15 years, and that’s what the Bill and Melinda Gates Foundation is doing by funding his latest project, one that looks at the effects on infant survival of a beautifully simple postnatal intervention to improve umbilical cord care in Zambia’s Southern Province.

Davidson Hamer

Davidson Hamer

Hamer, a professor of international health and medicine, has a five-year, $8.4 million grant to study the effectiveness of getting mothers to apply a 4 percent solution of chlorhexidine, a topical disinfectant, to umbilical cords in the days immediately following birth. Chlorhexidine helps to prevent sepsis, “a severe bacterial infection that probably accounts for between 20 and 40 percent of neonatal deaths, depending on the region,” Hamer says. Sepsis can arise when bacteria get into the bloodstream, either through infection of the umbilical cord stump, treatment of the cord with contaminated substances, or by cutting the cord with an unsterile knife. “The newborn’s immune system has not fully developed,” Hamer says, “and the bacteria can cause it to become very sick, very quickly.” Hamer will be assisted by Katherine Semrau, an assistant professor of international health and epidemiologist who has extensive experience living and conducting research in Zambia.

Very few large-scale neonatal survival interventions have been tried in Africa, due in part to the lack of population density in many regions. Hamer has worked in Zambia before, so navigating through the country’s topographical challenges and complex system of health ministry officials, local chieftains, community health workers, and traditional birth attendants (TBAs)—all of whom he needs to involve and engage—is familiar.

Hamer and colleagues at the Center for Global Health & Development conducted a study in the north-central Lufwanyama District. Hamer’s project trained TBAs—minimally educated women who act as midwives—to treat the most preventable causes of newborn death: sepsis, neonatal asphyxia (respiratory failure), and postpartum hypothermia. The results were so encouraging—with approximately 40 percent fewer neonatal deaths in newborns tended by the trained TBAs—that Save the Children has helped convert the study site into a five-year, community-based program to improve maternal, neonatal, and child health and to serve as a model training center for other organizations interested in carrying out similar work in poor rural populations in Africa.

His current project, Hamer hopes, will have similar long-range impact, especially when assessed alongside another Gates-funded study, also looking at chlorhexidine and umbilical cord care, in Tanzania. “If these two large, well-designed studies show similar impact—a 10, 20, 30 percent reduction in mortality—that, along with recent findings from South Asia, will be enough evidence for the World Health Organization to change global policy,” he says.

Safety in Numbers

features_safetyNumbers

Illustration by James Steinberg from ispot

When the thalidomide tragedy of the 1960s revolutionized the drug regulatory system in the United States and elsewhere, the only group that did not benefit from the new safety net was the same group devastated by thalidomide’s destructive effects: pregnant women and their babies.

The drug, touted as safe and effective, was given to treat morning sickness in pregnancy; after its dire consequences became apparent, in children born with shortened limbs and other malformations, thalidomide was quickly banned, and stricter testing protocols for medications and pesticides were later mandated.

“But when a drug comes onto the market today, it has almost never been tested in pregnant women,” says Allen Mitchell, professor of epidemiology and pediatrics and director of the Slone Epidemiology Center. There are good reasons for that, he says—ethical clinical trials would be impossible to construct—“but it means that the only time you can study the safety and risks of a drug in pregnancy is when it’s in the marketplace.”

Since 1976, Mitchell and his colleagues at Slone have done precisely that, collecting data on prenatal drug exposures in more than 40,000 women through Mitchell’s pioneering Birth Defects Study (BDS). Now the study is being expanded with a significant federal investment and an infrastructure that promises an unprecedentedly comprehensive view of risk and safety. The goal is to provide critical risk and safety data for women and their doctors, with the initial focus on seasonal flu vaccine, antiviral medicines used to prevent or treat flu, and commonly prescribed asthma medications. As the study expands, it will also gather data on the wide range of medications used by pregnant women, including over-the-counter headache cures and herbal remedies. Thus, the study will identify as early as possible which medications are relatively safe and which might pose a risk to the fetus.

BDS is one of two data collection components collaborating with the American Academy of Allergy, Asthma, and Immunology on what is being called the first broad-based, systematic study of the risks of vaccines and medicines in pregnancy. The new study—Vaccines and Medication in Pregnancy Surveillance System (VAMPSS)—was launched in September 2009 with the initial mandate to look at H1N1 vaccine, seasonal flu vaccine, two antiviral flu medications, and asthma drugs. It will combine the strengths of complementary—but separately implemented—epidemiological techniques, a case-control surveillance method developed by the Slone Center, and pregnancy registries (cohort studies) conducted by a network of specialists who collaborate through the Organization of Teratology Information Specialists.

Allen Mitchell

Allen Mitchell

Mitchell’s group identifies women in four regions of the country who have given birth to children with defects, and a smaller group of women with normal outcomes, and then conducts carefully constructed interviews designed to identify every drug or herbal remedy they took during pregnancy. Among its many findings, the BDS study has shown that antidepressant use in pregnancy is generally safe, but that among a popular group of antidepressants, SSRIs, Prozac carries the lowest risk of birth defects and Paxil the highest. That finding wound up on the medication label, and Paxil use in pregnancy has since dropped, Mitchell says.

“The Food and Drug Administration has not only the legal authority but a legal mandate to demand post-marketing safety studies for drugs that were not adequately studied in pregnancy prior to marketing—which means just about everything,” Mitchell says. The agency has been slow to flex that authority, he adds, but that may be changing. “There is considerable excitement at the FDA, and also at the Centers for Disease Control and Prevention, the National Institutes of Health, and in practitioner groups, about what our study will yield.”

Sex and Sensibility

In the history of feminism and the women’s rights movement, one group of key actors in late-18th-century Britain has been long overlooked.

Swept forward by the revolutionary currents then swirling, they socialized and debated in mixed-gender clubs, or pushed for broader educational opportunities, or courageously withstood public censure to call for full political participation for women.

Who were these bold thinkers? In a word, men—men who, for a variety of moral, philosophical, and even self-serving reasons, felt strongly that women’s rights were not just a women’s issue, but a matter of concern to society at large.

In an act of historical recovery, Arianne Chernock has brought this loosely connected group of several dozen dissenters and reformers to the fore in Men and the Making of Modern British Feminism (Stanford University Press, 2010). As she shows, these progressive educators, theologians, historians, essayists, and physicians were living in a time when the subject of individual rights—who had them and how they were conferred—was central to the intellectual and political discourse.

Utilitarian philosopher Jeremy Bentham advocated women’s suffrage as a key part of the “perfect state.”

Utilitarian philosopher Jeremy Bentham advocated women’s suffrage as a key part of the “perfect state.”

Portrait licensed by Creative Commons

These reformers were unconventional, nonconformist, and mostly fringe characters, with the exception of Jeremy Bentham, a radical jurist and philosopher best remembered as the founder of utilitarianism. “I don’t claim that they were emblematic of the broader society,” says Chernock, an assistant professor of history. “But these were men who really saw women’s rights as a social concern that had a lot to say about the health of their own state. They were broadly interested in what it would mean to live in what they called a ‘perfect state.’ This was a moment of revolution, and so we see a lot of utopian ideas circulating.”

Those ideas, and the passions they engendered, were eclectic. Most of the men shared an opposition to slavery and to the so-called Test and Corporation Acts, which penalized religious dissenters. Many were also “campaigning for their own political representation,” says Chernock, since less than one-fifth of men in Britain could vote at the time. Others championed things like vegetarianism and penal reform, or even argued “that the alphabet should be made more democratic by introducing phonetic spelling. There is a real range of figures there,” Chernock says.

Their motivations differed widely, too. Some were clearly driven by personal histories, and by a sense of their own status as second-class citizens. Others “embraced women’s rights primarily to be consistent and to avoid hypocrisy,” Chernock says, “especially those who subscribed to the theory of natural rights.”

Arianne Chernock

Arianne Chernock

Some believed that women’s unequal status actually demeaned men, though that argument was not always beneficial to women. A novelist named James Henry Lawrence, for instance, urged men to abandon patriarchy and relieve themselves of the constant burden of having to provide for their families. “He was saying, if we give women these rights, men could become this amazing group of philosophers, politicians, poets, and everything else we want to be,” Chernock explains.

That ignoble rationale is one of the reasons why she frames the book as an argument not for male feminism but for the decoupling of sex and feminism. “I’m not trying to undermine women’s contributions and accomplishments,” she says. “But we have a much more solid foundation for thinking about women’s rights when we realize the range of people who subscribed to them, and the range of reasons why they did.”

Working It Out

Want a long and happy marriage? You have to work for it. Literally.

In an important series of studies that cast a critical eye on the nostalgically driven, politically loaded idea that working women are bad for marriage, two BU economists have found that dual-career marriages are actually more stable, and less likely to end in divorce, than marriages in which only one partner works.

Looking at a cross section of U.S. states, Professor of Economics Andrew Newman and Associate Professor of Economics Claudia Olivetti have found that in states where women have a very high rate of participation in the labor force, such as Wisconsin, Minnesota, and Iowa, the divorce rate is lower than in states like Kentucky or Arizona, where the female labor force participation is low. Similarly, in states with a high percentage of two-earner households, divorce rates are much lower, even controlling for total household income.

This most real-world of applied research projects started as a conversation between two theorists. Newman and his former BU colleague Zvika Neeman, now at Tel Aviv University, were observing that in bargaining theory, “it made a difference whether the participants in the bargain were able to make what we economists call side payments to one another,” Newman says. “We said that one example of that would be a household consisting of two earners—that they’d have many more allocation possibilities than a household with just one earner.”

Claudia Olivetti

Claudia Olivetti

Predicting fewer divorces in the two-earner households, they approached Olivetti, who studies issues related to women’s employment and wages. She confirmed an under-recognized fact: since the mid-1980s, as women have increased their participation in the labor force, divorce rates have actually fallen. Theories about working women causing divorce—theories that held sway both in the popular mind and in academia, Olivetti says—“fall to pieces” when you look at the data.

Newman and Olivetti subsequently found that “for couples in which the wife can be considered a career woman, the probability of the marriage ending in divorce is 25 percent lower than for other couples,” Olivetti says. And when they looked at couples in which the wife makes at least 50 percent of the household income, those equal-earning marriages are even less likely to end in divorce.

What is driving the correlation? It’s not about total income, Newman and Olivetti stress, since marriages with one high-earning partner were not protected. It’s about the distribution of money—and purchasing power—within the household. The researchers speculate that something called flexible accommodation is at play—which brings the conversation back to bargaining theory.

Andrew Newman

Andrew Newman

“The nice thing about money, as crass as it may seem to think that this is how we relate to each other, is that it enables you to purchase a full market basket of whatever goods you like,” says Newman. “And so when things get a little difficult in a marriage, accommodations can be made.” You can hire a babysitter for a weekend away, or relieve your spouse or yourself of lawn-mowing or housecleaning duties. “In a two-earner household, you’re going to be able to accommodate more of the vicissitudes of married life,” Newman says. Money still can’t buy you love, in other words, but the equal distribution of it may buy a durable marriage.