Obstetric violence as immigration injustice: A view from the United States and Colombia

In September 2020, Project South, along with numerous other organizations, released a report detailing abuses in a Georgia Detention Center – including forced hysterectomies. Whatever other factors are at play, one of them is an intrinsic connection between obstetric violence against pregnant migrants and immigration injustice. It is not incidental that these acts – in US detention centers, along the US-Mexico border, in Colombian hospitals and clinics – are being perpetrated on immigrant bodies. And it is not accidental or random which immigrant bodies are vulnerable to these violations. Understanding and confronting obstetric violence directed at pregnant migrants, though, requires reconceptualizing the nature of obstetric violence itself. In particular, we must recognize that obstetric violence against pregnant Latin American migrants in the United States and Colombia is a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. As such, bioethicists need to collaborate with immigration scholars to resist it. After providing some background on the nature of obstetric violence and some ways it is perpetuated against pregnant migrants in the United States and Colombia, I will give a brief overview of how I conceptualize immigration justice. From there, I explain how this type of obstetric violence constitutes a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. My hope is that this analysis motivates bioethicists throughout the Americas to engage with immigration scholars and activists to confront the issue more forcefully.     

Antenatal corticosteroid administration and early school age child development: A regression discontinuity study in British Columbia,Canada

BackgroundThere are growing concerns that antenatal corticosteroid administration may harm children’s neurodevelopment. We investigated the safety of antenatal corticosteroid administration practices for children’s overall developmental health (skills and behaviors) at early school age.Methods and findingsWe linked population health and education databases from British Columbia (BC), Canada to identify a cohort of births admitted to hospital between 31 weeks, 0 days gestation (31+0 weeks), and 36+6 weeks, 2000 to 2013, with routine early school age child development testing. We used a regression discontinuity design to compare outcomes of infants admitted just before and just after the clinical threshold for corticosteroid administration of 34+0 weeks. We estimated the median difference in the overall Early Development Instrument (EDI) score and EDI subdomain scores, as well as risk differences (RDs) for special needs designation and developmental vulnerability (<10th percentile on 2 or more subdomains). The cohort included 5,562 births admitted between 31+0 and 36+6 weeks, with a median EDI score of 40/50. We found no evidence that antenatal corticosteroid administration practices were linked with altered child development at early school age: median EDI score difference of −0.5 [95% CI: −2.2 to 1.7] (p = 0.65), RD per 100 births for special needs designation −0.5 [−4.2 to 3.1] (p = 0.96) and for developmental vulnerability of 3.9 [95% CI:−2.2 to 10.0] (p = 0.24). A limitation of our study is that the regression discontinuity design estimates the effect of antenatal corticosteroid administration at the gestational age of the discontinuity, 34 + 0 weeks, so our results may become less generalisable as gestational age moves further away from this point.ConclusionsOur study did not find that that antenatal corticosteroid administration practices were associated with child development at early school age. Our findings may be useful for supporting clinical counseling about antenatal corticosteroids administration at late preterm gestation, when the balance of harms and benefits is less clear.

Using a regression discontinuity design, Jennifer Hutcheon and colleagues investigate the relationship between corticosteroid treatment before birth and school-age child development in British Columbia, Canada.     

Decrease in violence and delinquency in Bogota,Colombia, 1994-2002

The present article shows reliable data on Bogota's homicide decreasing rates and presents the strategies applied during the past 8 years which partly explain such decrease.     

Early pregnancy azathioprine use and pregnancy outcomes

BACKGROUND: Azathioprine (AZA) is used during pregnancy by women with inflammatory bowel disease (IBD), other autoimmune disorders, malignancy, and organ transplantation. Previous studies have demonstrated potential risks. METHODS: The Swedish Medical Birth Register was used to identify 476 women who reported the use of AZA in early pregnancy. The effect of AZA exposure on pregnancy outcomes was studied after adjustment for maternal characteristics that could act as confounders. RESULTS: The most common indication for AZA use was IBD. The rate of congenital malformations was 6.2% in the AZA group and 4.7% among all infants born (adjusted OR: 1.41, 95% CI: 0.98–2.04). An association between early pregnancy AZA exposure and ventricular/atrial septal defects was found (adjusted OR: 3.18, 95% CI: 1.45–6.04). Exposed infants were also more likely to be preterm, to weigh <2500 gm, and to be small for gestational age compared to all infants born. This effect remained for preterm birth and low birth weight when infants of women with IBD but without AZA exposure were used as a comparison group. A trend toward an increased risk of congenital malformations was found among infants of women with IBD using AZA compared to women with IBD not using AZA (adjusted OR: 1.42, 95% CI: 0.93–2.18). CONCLUSIONS: Infants exposed to AZA in early pregnancy may be at a moderately increased risk of congenital malformations, specifically ventricular/atrial septal defects. There is also an increased risk of growth restriction and preterm delivery. These associations may be confounded by the severity of maternal illness. Birth Defects Research (Part A), 2009. © 2009 Wiley‐Liss, Inc.     

Thrombosis in pregnancy and maternal outcomes

Pregnancy increases the risk of thrombosis four‐ to five‐fold. Seventy‐five to eighty percent of pregnancy‐related thrombotic events are venous and twenty to –twenty‐five percent are arterial. The main reason for the increased risk is hypercoagulability. Women are hypercoagulable because they have evolved so that they are protected against the bleeding challenges of pregnancy, miscarriage, or childbirth. Both genetic and acquired risk factors can further increase the risk of thrombosis. The maternal consequences of thrombosis of pregnancy include permanent vascular damage, disability, and death. While the maternal outcomes of thrombosis can be modified by anticoagulation therapy, management of thrombosis during pregnancy is the subject of another paper in this issue (see paper by B. Konkle). This review will focus on the epidemiology, pathophysiology, risk factors, and maternal consequences of thrombosis in pregnancy. Birth Defects Research (Part C) 105:159–166, 2015. © 2015 Wiley Periodicals, Inc.     

Domestic violence. Risk factors and outcomes.

Domestic violence is a pervasive and frequently unrecognized cause of injury among women. We reviewed data from standardized interviews with 218 women who presented to an emergency department with injuries due to domestic violence. Victims ranged in age from 16 to 66 years and constituted a wide range of socioeconomic and ethnic backgrounds. Domestic violence often resulted in severe injury; 28% of the women interviewed required admission to hospital for injuries, and 13% required major surgical treatment. The typical presentation was injuries to the face, skull, eyes, extremities, and upper torso. A third of the cases involved a weapon, such as a knife, club, or gun. In all, 10% of the victims were pregnant at the time of abuse, and 10% reported that their children had also been abused by the batterer. Most victims (86%) had suffered at least one previous incident of abuse, and about 40% had previously required medical care for abuse. Victim recognition and referral to appropriate agencies could be improved if primary care physicians were more aware of the prevalence, severity, frequency of occurrence, and typical presentation of domestic violence.     

Loss in higher multiple pregnancy and multifetal pregnancy reduction.

From early pregnancy into childhood, higher multiples have much higher rates of mortality, whether from spontaneous abortion, the 'vanishing twin' syndrome, fetal or infant death. Many parents must cope with the death of one baby whilst the siblings remain critically ill or later become disabled and yet there grief is often underestimated. Little is known about the long term feelings of parents who choose to have a multifetal pregnancy reduction (MFPR). Most say they made the right decision but also that there was insufficient respect for their loss. They are often anxious about what, if anything, to tell the survivors and how they might react. Long term follow-up studies of the children as well as the parents are needed. Meanwhile parents who chose to have a MFPR must be given more information and ongoing support.     

The San Lucas mountain range in Colombia: how much conservation is owed to the violence?

The imminence of forest conversion in the northern Andean region requires a careful evaluation of the social, political and economic context in which environmental efforts take place in order to achieve conservation. Through its socioeconomic effects violent conflict can result in threats pertinent to both conservation and resource management schemes. A survey of the San Lucas mountain range, at the northern tip of the Colombian Central Andes, is presented as a case study of factors associated with violent conflict that may hinder or enhance conservation in this complex social and political setting. Instability in land use and tenure associated with armed conflict were identified as major pressures associated with further conversion of tropical forest habitats; while low rates of settlement and measures enforced by armed rule were very effective in preserving certain tracts of forest. War certainly alleviates demographic pressure from settlers, but contemporary patterns of colonization in San Lucas suggest that armed conflict is detrimental to conservation purposes and to key members of the biological community.     

Consequences of the Armed Conflict, Forced Human Displacement, and Land Abandonment on Forest Cover Change in Colombia: A Multi-scaled Analysis

Most studies of land change have focused on patterns, rates, and drivers of deforestation, but much less is known about the dynamics associated with agricultural abandonment and ecosystem recovery. Furthermore, most studies are conducted at a single spatial scale, and few have included variables related with internal socio-political conflicts. Here we evaluated the effect of environmental, demographic, and socio-economic variables on woody cover change in Colombia between 2001 and 2010 at the country, biome, and ecoregion scales. We also incorporated factors that reflect the unique history of Colombia such as the presence of illegal-armed groups and forced human displacement. Environmental variables explained the patterns of deforestation and forest regrowth at all scales because they can restrict or encourage different land uses across multiple spatial scales. Demographic variables were important at the biome and ecoregion scales and appear to be a consequence of the armed conflict, particularly through forced human displacement (for example, rural–urban migration), which in some areas has resulted in forest regrowth. In other areas, the impact of illegal armed groups has reduced forest cover, particularly in areas rich in gold and lands appropriate for cattle grazing. This multi-scale and multivariate approach provides a new insight into the complex relationship between woody cover change and land abandonment triggered mainly by armed conflict.     

Model checking in regression via dimension reduction

Lack-of-fit checking for parametric and semiparametric modelsis essential in reducing misspecification. The efficiency ofmost existing model-checking methods drops rapidly as the dimensionof the covariates increases. We propose to check a model byprojecting the fitted residuals along a direction that adaptsto the systematic departure of the residuals from the desiredpattern. Consistency of the method is proved for parametricand semiparametric regression models. A bootstrap implementationis also discussed. Simulation comparisons with several existingmethods are made, suggesting that the proposed methods are moreefficient than the existing methods when the dimension increases.Air pollution data from Chicago are used to illustrate the procedure.     

Dimension reduction in regression without matrix inversion

Regressions in which the fixed number of predictors p exceedsthe number of independent observational units n occur in a varietyof scientific fields. Sufficient dimension reduction providesa promising approach to such problems, by restricting attentionto d < n linear combinations of the original ppredictors. However, standard methods of sufficient dimensionreduction require inversion of the sample predictor covariancematrix. We propose a method for estimating the central subspacethat eliminates the need for such inversion and is applicableregardless of the (n, p) relationship. Simulations show thatour method compares favourably with standard large sample techniqueswhen the latter are applicable. We illustrate our method witha genomics application.     

Medicare eligibility and healthcare access,affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis

BackgroundUS policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US.Methods and findingsWe used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor’s degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p < 0.001) and higher-income groups (8.0% versus 85.9%, p < 0.001). Medicare eligibility at 65 years was associated with a decreases in the percentage of low-income adults who delayed (14.7% to 6.2%; −8.5% [95% CI, −14.7%, −2.4%], P = 0.007) or avoided medical care (15.5% to 5.9%; −9.6% [−15.9%, −3.2%], P = 0.003) due to costs, and a larger decrease in the percentage who were worried about (66.5% to 51.1%; −15.4% [−25.4%, −5.4%], P = 0.003) or had problems (33.9% to 20.6%; −13.3% [−23.0%, −3.6%], P = 0.007) paying medical bills. In contrast, there were no significant associations between Medicare eligibility and measures of cost-related barriers to medication use. For higher-income adults, there was a large decrease in worrying about paying medical bills (40.5% to 27.5%; −13.0% [−21.4%, −4.5%], P = 0.003), a more modest decrease in avoiding medical care due to cost (3.5% to 0.6%; −2.9% [−5.3%, −0.5%], P = 0.02), and no significant association between eligibility and other measures of healthcare access and affordability. All estimates were stronger when examining the association of Medicare enrollment with outcomes for low and higher-income adults. Additional analyses that adjusted for clinical comorbidities and employment status were largely consistent with the main findings, as were analyses stratified by levels of educational attainment. Study limitations include the assumption adults age 64 and 66 would have similar outcomes if both groups were eligible for Medicare or if eligibility were withheld from both.ConclusionsMedicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US.

Rahul Aggarwal and colleagues explore the association of Medicare eligibility and enrollment with health care access, affordability, and financial strain from medical bills in low- and higher-income adults in the US.     

Human papillomavirus vaccine and risky sexual behavior: Regression discontinuity design evidence from Brazil

This study aims to analyze the hypothesis of moral hazard caused by vaccination against human papillomavirus (HPV), regarding girls’ beginning of sex life and, once they have begun their sex life, to understand whether it reduces the probability of girls using a condom in their first sexual intercourse. The data are from the 2015 National Survey of School Health (PeNSE). The model used is the regression discontinuity, with the discontinuity in the age of the girls who were able to participate in the public vaccination campaign. The results of the so-called Fuzzy-RDD show that the campaign was effective in increasing the likelihood of vaccination by 26.7–27.6 percentage points. There is no observable effect on young women initiating their sex lives or refraining from using condoms. The results are tested by several robustness methods. This is the first work to use quasi-experimental models in a developing country with low vaccination coverage in Latin America and show that it is necessary to increase awareness campaigns with parents, so they will know that there is no effect of vaccination on the beginning of sex life and condom use.     

Effects of aspirin consumption during pregnancy on pregnancy outcomes: meta-analysis

BACKGROUND: We assessed the effects and safety of aspirin treatment during pregnancy on fetal and neonatal outcomes. METHODS: We searched MEDLINE (1966–2001), EMBASE (1980–2000), TOXLINE (1994–2000), EBM Cochrane Database of Systematic Reviews (1991–2000), Reproductive Toxicology (2001), teratology texts, and bibliographies of all the included studies. We looked for published randomized controlled studies reporting aspirin treatment to improve outcomes of moderate‐ and high‐risk pregnancies. The key words used to search for articles about exposure to aspirin were salicylic acid, pregnancy, and pregnancy complications; key words used to search for outcome were neonatal diseases and abnormalities. Based on our search strategy, 1904 citations were identified; their titles and abstracts were reviewed by one reviewer. Of these citations, 182 papers were selected for detailed review. Two reviewers independently determined whether a study should be included in the final analysis. In cases of disagreement, the decision was based on the assessment of a third reviewer. RESULTS: Data were extracted independently by each reviewer. We calculated the pooled relative risk (RR) or weighted mean difference and 95% confidence intervals (CI), assuming a random‐effect model. Thirty‐eight studies met the inclusion criteria. The risk for miscarriage did not differ between women treated with aspirin and placebo (seven studies; RR, 0.92; 95% CI, 0.71–119). Women who took aspirin had a significantly lower risk of preterm delivery than did those treated with placebo (22 studies; RR, 0.92; 95% CI, 0.86–0.98). There was no significant difference in perinatal mortality (20 studies; RR, 0.92; 95% CI, 0.81–1.05) and in the rate of small‐for‐gestational‐age infants (12 studies; RR, 0.96; 95% CI, 0.87–1.07) among offspring of mothers treated with aspirin and those of mothers treated with a placebo. CONCLUSION: For women with moderate‐ and high‐risk pregnancies, aspirin treatment seemed to have a small but significant effect on reducing the rate of preterm deliveries, but did not reduce the rate of perinatal death. Birth Defects Research (Part B) 68:70–84, 2003. © 2003 Wiley‐Liss, Inc.     

A new dose-finding design for bivariate outcomes

For some drugs, toxicity events lead to early termination of treatment before a therapeutic response is observed. That is, there are three possible outcomes: toxicity (therapeutic response unknown), therapeutic response without toxicity, and no response with no toxicity. The optimal dose is the dose that maximizes the probability of the joint event, response, and no toxicity. The optimal safe dose is the dose, from among the doses with toxicity rate less than the maximum tolerable level, that maximizes the probability of response and no toxicity. We present a new sequential design to maximize the number of subjects assigned in the neighborhood of the optimal safe dose in a dose-finding trial with two outcomes.