Doing What We Can

            Dalton Conley, Kate Strully, and Neil Bennett shed much need light on the topic of low birth weight (LBW) in their book The starting gate: Birth Weight and Life Chances.  The correlation between low birth weight and later success in many avenues of life is one that is not really talked about in the general public. However after reading The Starting Gate: Birth Weight and Life Chances, I believe that the reason low birth weight is not really talked about is because of the fact that we really do not know exactly what cause LBW and its negative correlations.  Lets face it, we live in a society where unless we know direct causation, we tend not to care too much about things that seem “out of our control”.  Conley, Strully, and Bennett bring up, towards the end of the book, what I believe to the most important take away from the book: prevention.

            They mention different preventive social policy programs, where “...[their] suggestions about biosocial interaction may be applied.” (126).  These programs include Medicaid, Women, Infants, and Children (WIC), and Temporary Assistance for Needy Families (TANF), which go along with the Barker hypothesis we spoke about in lecture. Even though we may not know the exact causation, we can all agree on the fact that better prenatal care along with better nutrition and health care for these at risk babies can do nothing but help combat low birth weight and its negative correlations. We have programs in place, we just need to make the programs more accessible and eliminate the negative stigma associated with them. To me it seems that the cutoff for receiving help from these programs is often too low, and could be raised to optimize their benefits. I also believe that more education about the seriousness of low birth weight, along with the higher eligibility to receive aid, could help alleviate the stigma associated with accepting the help.  It is through these easy steps that we can help reduce LBW, even if not eliminating it, until we actually have a firmer understanding of the cause, because every child deserves to have a fair chance at the starting gate of life. 

Solving the Problem

After completing The Starting Gate, and learning all of the various consequences that go along with being born with a low birth weight, I was confused as to why more decisive measures have not been taken to solve this issue. Professor Conley and his coauthors outline various steps that can be taken in order to alleviate the problem such as considering low birth weight a risk factor throughout childhood and young adulthood instead of just in the first 2 years of life, and re-allocating funds to include benefits for pregnant women in programs such as WIC and Medicaid. However, it doesn’t seem like much has been done in terms of policy changes to address the low birth weight issue in the United States. This is surprising to me since the U.S. spends the most of its GDP on health care (16% as opposed to around 10% for other countries in the G8) when compared to other developed countries, but also has one of the highest rates of low birth weight.

If we can help solve a number of problems that occur later in life by giving an adequate amount of resources to children before their born, it would certainly benefit society as a whole and also make the health care system more efficient. It appears that this issue points out a major flaw in the U.S. health care system in that it does not allocate its funds wisely to improve overall quality of life, but rather emphasizes quick fixes for issues that are already present. This has been illustrated through the rise of specialty care and the decline of primary care in the health system in the United States as well. Maybe increasing awareness of the effects of low birth weight on future health outcomes can motivate health educators and policy makers to put more emphasis on and invest more money in preventive medicine which can both lower health care costs and increase quality of life for everyone regardless of socioeconomic or racial background.  

Baby Steps

While reading The Starting Gate, the question I asked the most was “What can we do?,” so the section on preventive measures was particularly salient for me. In particular, addressing nutrition of pregnant woman seems very important. If we can’t eliminate income inequality overnight, then can’t measures be taken in order to eliminate many of the inequalities associated with it, such as the disparities in nutritional content? Programs such as Medicaid which provides pregnant women with enough funding for two individuals rather than one and WIC’s prioritizing women at biological risk for funding should be commended. However, they also bring up a couple of issues that should be addressed. First, what implications would it have for the legal status of the fetus? This is a very politically heated topic and one that might be a roadblock to support of programs that aim to increase the nutrition of pregnant women. Second, how long does the process take to receive additional funding? How much would bureaucracy hinder the ability for pregnant women to receive adequate support? If it takes a month, that could have a substantial impact on the development of the fetus like we learned in lecture about the impact Ramadan has on the fetus particularly in the first month of development. Which brings me to my third question, how much importance does the health of the mother prior to conception impact the development of the fetus? It should be expected that addressing the health of the mother in general before she gets pregnant would potentially make significant strides in reducing the risk that she gives birth to a LBW child. It should go without saying that ideally the health of all individuals should be supported, but perhaps targeting a subset of the population, in this case pregnant women, would facilitate a larger conversation about the health of the nation. Programs that seek to reduce the risk of giving birth to LBW children are not only economically wise but they would also greatly improve future lives.

Mother/Child Individuality

When reading through the biosocial policy implication section, I noticed one common problem that the authors address which is present in each of the various programs/legislations concerning the well-being of pregnant women. This is the contention about when a fetus is considered a child, or considered a separate being from the mother. However, when a decision is reached, there is always a group that opposes it. The Bush Administration passed that the definition of a child began at conception (125), but received negative statements from those who supported the reproductive rights of women for giving rights to a fetus in order push an anti pro-choice agenda. Most attempts to address this issue eventually fall to the abortion debate, which as most of us know, is a political stalemate.

Disregarding the abortion issue (if that is ever possible), it is clear that programs such as Medicaid, Temporary Assistance for Needy Families (TANF), and the Child Tax Credit program are all dependent on when the mother and offspring are considered two people. As the authors suggest, the Medicaid program could be a preventative factor for low-weight babies if the categorically-needy category was extended to pregnant women at risk (127). However, this would mean that the child was considered a member of the family to add to the household count. The authors also state that the TANF program would be much more helpful to pregnant women at risk for low-weight babies if single pregnant females were included in the program before the birth of the child. This way, the program would provide assistance in the gestation period for healthy development, as opposed to trying to cope with already low-weight babies and their future health consequences. Again, this brings up the mother-child individuality, as, "the main criterion under TANF requires that one be a part of a family with children in order to receive assistance," (132). Finally, the authors state that the Child Tax Credit program would be of more assistance to mothers if pregnant females could categorize their unborn as a child - raising their expendable income, hopefully lowering their risk of a low-weight birth (135).

I think that for the purposes of preventing low-weight births, as we all know now are quite the risk factor, women should be able to count themselves as two individuals. While this belief seems to assume an anti-pro-choice stand, I think the these two issues should be separated. I feel that they are opposite, as the preventative programs are clearly set in place for those committed to keeping a child, while abortion is clearly not. That commitment is the personal choice, but for legislative purposes, pregnant women should not be disallowed from aid simply for not being far enough along in gestation.

Preventing (the Effects of) Low Birth Weight

In The Starting Gate, Conley, Strully, and Bennett relay that a family history of low birth weight drastically increases one’s own risk of being born low birth weight. If low birth weight parents are of a high socioeconomic class, however, the effect of their own low birth weight on their children’s birth weight decreases. Quite similarly, having been born low birth weight drastically hinders educational achievement and as a consequence, long-term economic prospects as well. If a low birth weight child is raised in a household of a high socioeconomic class, however the biological effects of low birth weight diminish. Therefore, a family’s social and biological assets interact with one another and either replicate or diminish/terminate economic and health inequalities across generations.

Because biological factors cannot be directly altered at this time, a more simple and direct solution to combat the above interaction between society and biology as well as the deleterious effects of low birth weight across generations seems to be to increase the socioeconomic status of individuals, who are at both biological and social risk, so that they have access to the commodities that are protective against the deleterious effects of low birth weight.

Conley, Strully, and Bennett’s suggested modifications to existing policies, such that family histories of low birth weight be taken into account in determining eligibility and benefit-level criteria and that pregnancies be considered “qualifying events” that raise the income eligibility criteria of various social programs benefiting low-income families, including WIC, TANF, etc, seem very practical, reasonable and realistic. It is actually quite surprising that they have not been implemented thus far, especially in the case of TANF, in which a pregnant mother (with no prior children) is not considered as two individuals, nor as a family. While TANF is geared towards needy families; isn’t it inherently obvious that a pregnant mother is bringing a child into a world and will thus become a family? Doesn’t it seem practical and reasonable to provide cash assistance to a pregnant mother, so that she can have a more healthy pregnancy and bring a healthier child into the world? Such a preventive measure would reduce later costly educational and health care expenditures related to raising an “unhealthy” child (i.e. low birth weight child suffering from numerous consequences/impairments/hurdles).

Like any other redefinition of eligibility criteria to social programs, which increases the number of people who qualify for the programs, result in the question of where the money to pay for these additional qualifiers will come from, Conley, Strutt, and Bennett make a strong claim for the fact that the money that is spent on treating the deleterious effects of low birth weight (i.e. health effects, such as cerebral palsy, mental retardation, etc) is far greater than that we would spend to prevent low birth-weight and its deleterious effects in the first place. Again, preventive measures seem to be where money should be allocated.

Conley, Strutt, and Bennett do claim that one hindrance to implementing these policy changes is the implications it would have on abortion laws and vice versa. Although this point was not emphasized in the book, I found it be interesting given our prior discussion about abortion below as well as during recitation. In the TANF program, for example, if a pregnant woman were counted as two, we are inherently treating the unborn fetus as a living being. While this may not be disagreeable to advocates of the pro-life movement, opposition could be raised for a number of different reasons. A reasonable policy change may be to begin providing cash assistance to low-income pregnant women, who have carried their fetus past the point of legal abortion.

Redefining Low Birth Weight

In The Starting Gate, Conley provides a fairly comprehensive background of how low birth weight children with disabilities are cared for in the formal education system. He makes it clear that intervention programs that provide “high quality preschool services” are shown to be successful in terms of higher IQ and less behavioral problems. However, it is also stated that these low birth weight specific intervention programs do not exist for older (elementary and secondary school) age children. I thought it was interesting how as low birth weight children get older, their developmental and health problems start to become more distinct, and are therefore more difficult to attribute to the condition of low birth weight. In Conley’s words, “these impairments are renamed as learning or physical disabilities, impairments become self-contained and etiology is moved to the periphery” (143).

Because learning and physical disabilities vary more in older, more developed children, a widespread intervention program for older low birth weight children would be difficult to design. However, Conley argues that knowledge of a low birth weight background can assist in the diagnosis of learning disabilities, and can be helpful in identifying which kind of specialized care is necessary for specific children in schools. It is suggested the low birth weight should be used as indicator of disability and should be treated as such in this process.

My interpretation of this suggestion led me to an interesting point: should low birth weight be treated as a disability in itself? By now, it is very clear that low birth weight has been more or less proven to lead to developmental problems and lower school achievement. Is this correlation strong enough to consider it a disability in itself? Personally, I feel that recognition of low birth weight as a disability and increasing public awareness in general would have a positive impact on the availability of aid to low birth weight children both earlier and later on in their development.

Birth Weight & Governmental Subsidies

The Starting Gate: Birth Weight and Life Chances provides its readers with thought provoking information on the intermingling of biological and sociological factors impacting birth weight. Ultimately, however, I found the book to fall a bit short on some of its research and its suggestions for lowering LBW births. A recent health article in the New York Times states “in 2008, about half of all pregnancies in the United States were unplanned.” The article explicates that women with unplanned pregnancies are far more likely, when made aware of the pregnancy, to continue behavior detrimental to the fetus such as drinking, smoking, and drug use. They were also likely to put off or neglect prenatal care altogether. As a result, babies from unintended pregnancies are seriously at risk for either premature birth or low birth weights (or presumably both.) Conley, Strully, and Bennett never mention this pretty simple but overarching concept as a factor contributing to LBW babies. Better access to [free or subsidized] birth control or family planning education would make a huge impact and potentially lower the correlated pattern between low-income families and low birth weight babies. Without access to cheap birth control, low-income couples are far more likely to get pregnant unintentionally and produce underweight children.

On the subject of subsidies, another concept came to mind. The Starting Gate emphasizes the importance of adequate nutrition for pregnant mothers to make sure the placenta can adequately nourish the growing fetus. Without healthful and abundant nutrients, a child is likely to be LBW. The United States government subsidizes the growing/harvesting of certain crops (for example: soybeans, corn, wheat, and some potatoes) to ensure that various foods are kept at low cost. With these crops available at such low prices, fast food restaurants are capable of providing reasonably priced, extremely filling/caloric foods. Low income families are much more likely to buy a cheap hamburger and fries for a filling meal than a slightly more expensive but more nutrient dense food of vegetables, grains, and legumes at the supermarket. Not to mention the convenience of fast food. The Starting Gate touches several times on the subject of nutrition, but it seems some of the problems that could help combat LBW susceptibility are deeply entrenched in U.S policy. In order to change these sort of genetic and/or social susceptibilities and lower LBW rate, it is imperative we change poor policies which perpetuate the cycle.