the metablog

Tylenol, Tyranny, and Misogyny

Fri, 26 Sep 2025 04:49:00 +0000

The Misogyny of MAHA and the Politics of Health

Wrapped up in the near-incoherent warning against the use of paracetamol (Tylenol/acetaminophen) in pregnancy reveals the real story of the Make America Healthy Again project: misogyny dressed up as health advice.

This is a broader project of bad science weaponised to undermine trust and weaken the very institutions that exist to support health and wellbeing.

Let's start with the evidence: while there has been more than a decade of concern about possible associations between paracetamol use in pregnancy and neurodevelopment consequences in children, particularly ADHD and autism spectrum disorder, the best and most recent evidence is reassuring:

"Acetaminophen use during pregnancy was not associated with children's risk of autism, ADHD, or intellectual disability in sibling control analysis." – Ahlqvist et al. 2024

Science as a punching bag

Despite this, we are treated to the absurd spectacle of a brain-wormed conspiracy peddler teaming up with a carnival barker unable to even pronounce acetaminophen. Together they issue sweeping advice in direct opposition to medical organisations across the world reaffirming the safety of appropriate paracetamol use in pregnancy.

What's revealing is not the bad science itself, but who bears the consequences of these pronouncements: this is not primarily about paracetamol. It’s about a particularly regressive worldview.

“If you’re telling parents or telling society that someone should be doing this work of keeping kids safe, what you’re really saying is women should be doing this work, especially mothers. ... RFK Jr is weaponizing the supermom myth – the false idea that moms are the only ones who can keep kids safe from harm.” – Prof. Jessica Calarco (2025)

Wrapped up together with the just-asking-questions bad faith anti-vax arguments, the distracting focus on food-dyes, fructose and food-purity¹, and now the "just tough it out" advice for pregnant women with pain and fever, is exposure of this movement's misogyny. The weight of navigating decisions on food, vaccines and now, paracetamol, falls disproportionately on women, and the consequences of making the wrong decision will be to be judged by MAHA as a bad mother.² Women bear all the responsibility and blame, but get little help and support.

The burden falls on women

The rhetoric is always the same: choices, responsibility, discipline. Pregnant women are told to carry the moral weight of every decision, bearing responsibility without support, risk without remedy, and blame without resources. The politics of American healthcare is quick to blame, slow to protect.

Condemning parents for childhood nutritional shortfalls while slashing $1 billion in funding for programs bringing fresh fruits and vegetables to schools and food banks; limiting vaccine access while fanning the flames of measles outbreaks; limiting reproductive health access while doing nothing for US maternal mortality rates more than double other wealthy countries; providing no mandated maternity leave (the only high-income country without such protection) or ready access to affordable childcare; and repeatedly refusing to address the scourge of childhood exposure to gun violence, are all unforgivable moral failings. Advising pregnant women to avoid paracetamol while offering no alternative is more of the same.

Misogyny, medicine, and power

The logic here is not accidental. By shifting responsibility onto the individual while dismantling institutions that help, MAHA’s ideology performs a double trick: it leaves people unsupported, and then discredits those institutions – medical, public health, government – that would normally step in.³ The state fails, blames the individual, and then demands more power. The moralistic thread tying these ideologies together both ignores the importance of institutions in addressing these issues, and then further disempowers them.

Anesthesiologists and other clinicians must defend access to safe and effective pain relief, a basic human right. Paracetamol is cheap, effective, and globally accessible. Pretending otherwise is not just bad science, it’s political theatre designed to keep women in pain, institutions weakened, and power concentrated. Beyond the drug, the real fight is recognising when science is being twisted to advance ideological goals, when those goals reinforce sexism and inequity, and then weaponise this sexism to hollow out the very institutions that sustain public health.

The misogyny of MAHA is not an accident. It’s the point.

Yes, some food dyes are harmful and yes, high-fructose corn syrup has helped fuel the obesity epidemic. But this simplistic, reductionist thinking ignores the many real social, cultural, economic and political causes of America's abysmal health outcomes. Switching Coke to cane sugar and using natural dye in Froot Loops is branding, not public health policy. ↩
Don't get me started on this essentialist obsession with the primary role of women in society, reducing them to wombs, caregivers, and homemakers, with little value beyond reproduction. Fifty percent of the population written off as support staff... ↩
Institutions are undermined in two ways: directly, through defunding, contradiction, and performative attacks; and indirectly, by corroding the very idea of expertise. When public figures spew bad science, it doesn’t just damage trust in them—it erodes trust in any medical authority. That’s the point: if no one believes experts, institutions themselves lose their power. ↩

Australia's maternity crisis: the unasked question

Sat, 12 Apr 2025 08:02:00 +0000

The proposal

Private Healthcare Australia (PHA) CEO Rachel David advocates for a "bundled care" maternity costing model where midwives, GPs, and obstetricians offer fixed-cost maternity packages. This model promises low-cost, full-transparency care across antenatal visits, delivery, and postnatal care – supposedly providing affordable options by allowing private midwives and GPs to manage low-risk pregnancies independently, in parallel with specialist obstetricians funded by the same bundled care model.

The hidden agenda

The critical question remains unasked: Why is the PHA, representing Australia's largest health funds (98% of the market, predominantly for-profit insurers), pushing so aggressively for this model? What benefits do PHA members, such as BUPA, which recently reported over AUD$900 million in profit in the Asia Pacific, have in strongly advocating for this funding model?

David's argument hinges on the uncited claim that only 14% of deliveries require an obstetrician, contradicting the Australian government's own data. Official AIHW statistics show delivery mode alone dictates that over 50% of births require specialist obstetricians before even considering complications like haemorrhage, perineal trauma or retained placentas.

The inevitable sequela

This bundled care model would trigger devastating consequences. Private maternity hospitals will not accept the legal liability of allowing midwives or GPs to deliver independently in their facilities, especially when private midwives are unable to obtain commercial liability insurance for intrapartum care. Even ignoring legal liabilities, what happens when the majority of births require clinical intervention beyond what these practitioners can provide?

Private obstetricians will withdraw from this unsustainable model. Anaesthetists and paediatricians, apparently unpaid under this framework, will decline participation. Few of these specialists will be willing to become involved in these compromised cases.

Over 50% of women requiring obstetricians and the 33% needing epidural analgesia will instead transfer to public hospitals to become public patients in order to access specialist care – no longer costing their private insurer, and losing the continuity of care this model champions. (A continuity of care currently provided by private obstetricians!)

26% of Australian babies are delivered in private hospitals. Shifting even half of these deliveries to the public system will overwhelm already stretched public maternity services, creating a genuine national crisis.

The economic reality

This capped model is economically unviable for private obstetric practices. This is not about "insufficient profit" rather, it's about businesses forced to operate at losses. Obstetric fees represent revenue covering rent, staff, midwives, nurses, ultrasound machines, other equipment, and 24/7 on-call coverage – resources essential for quality care.

Private obstetricians will instead shift practice to gynaecology and fertility. Sadly, private obstetrics will survive only in a handful of capital cities for a wealthy few willing to pay tens of thousands in out-of-pocket fees.

The safest option dismantled

The greatest tragedy? This proposal will dismantle Australia's safest maternity care model. Recent Australian research shows that babies born in the public system suffer double the mortality rate compared with private obstetric care, along with significantly higher rates of maternal haemorrhage, birth trauma and emergency caesareans. Surprisingly, this higher-quality private care was actually AU$ 5,888 less expensive per pregnancy than care in the public system.

The endgame becomes clear: private obstetrics ends. Private midwifery and GP obstetrics will shift the costly part of maternity care – deliveries and emergencies – back to public hospitals paid for by state governments. Meanwhile, the private health funds will successfully rebate vastly smaller amounts while collecting ever-increasing premiums, protecting their record profits at our maternity system's expense.

As we consider changes, we must ask: who truly benefits, and at what cost to mothers and our health system?

Does a GA CS increase PPD risk? Plus LMA studies & COVID vaccine optimism

Thu, 22 Jul 2021 02:04:00 +0000

GA caesarean section & post-partum depression

This large study (Guglielminotti 2020) of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.

Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.

The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.

In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:

To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).

An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.

Keep it in perspective...

We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.

Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.

The take-home:

Just another reason to avoid GA CS when possible – but you already knew that, right?

"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."

Supraglottic airway training and manikins

Interesting prospective simulation & equipment study by way of the University of Freiburg. Schmutz et al. investigated how effective five different second generation supraglottic airway devices (SADs) performed in two common airway manikins: the TruCorp AirSim® and the crowd favourite, Laerdal's Resusci Anne® Airway Trainer™.

While ventilation was achieved in all SAD-manikin combinations, the Resusci Anne® Airway Trainer™ was associated with better and more consistent performance for SAD position, participant subjective assessment and ease of gastric tube insertion for most of the SADs. The TruCorp AirSim® did however achieve better leak pressures across most of the SADs (LMA® Supreme™, Ambu® AuraGain™, i-gel®, KOO™-SGA & LTS-D™).

But then, what are the implications for airway simulation training? The researchers correctly note that:

The most important quality of a manikin is the ability to simulate the real-world conditions and thus to give the trainee an authentic feedback.

The bottom line for SAD manikins?

While considering how manikin choice and SAD availability match with your aims for simulation training, the bigger picture is that the primary goal of any manikin-SAD coupling is real-life fidelity – and for that reason, participant subjective assessment is king. And so in this study at least, the Resusci Anne® Airway Trainer™ wins.

Head-rotation to improve LMA leak pressure?

Another interesting little airway study, this time out of Sapporo, Japan (Chaki 2021). A neat little randomised but-not-blinded study of the effect of head rotation on the oropharyngeal leak pressure of both the i-gel and LMA Supreme 2nd generation supraglottic airways.

The researchers investigated the leak pressure (OPLP) of the i-gel and LMA Supreme in paralysed patients with the head: 1. neutral, 2. rotated 30°, and 3. rotated 60°. They found that rotation of the head through 30° and 60° progressively increased OPLP by a clinically-significantly amount (0° vs 60° 5.5 cmH₂O (3.3-7.8) & 6.5 cmH₂O (5.1-8.0) respectively).

Before you get too excited...

The result however may not be reliably applicable to all populations, notably the study subjects were overwhelmingly small (x̄ ~160cm & 60kg) Japanese women (71%), receiving a TIVA muscle-relaxant anaesthetic (propofol, remifentanil, rocuronium). How well this improvement-with-rotation holds up among, for example, spontaneously ventilating large Caucasian males, is unclear.

Bottom-line

When using an i-gel or LMA Supreme 2nd generation supraglottic airway, careful head rotation to 60° may increased oropharyngeal leak pressure and so assist with ventilation troubleshooting. However head and neck rotation of anaesthetised, paralysed patients should be performed gently and cautiously – you are after all, not a chiropractor!

COVID mRNA vaccines and immune persistence

A great Good News study just published in Nature by researchers from Wash U Med investigated persisting COVID immunity following the Pfizer mRNA vaccination (BNT162b2). Turner et al. looked at the presence of not only circulating antibody-secreting B cells, but also germinal centre B cells found in the axillary lymph nodes of 14 study volunteers.

While the persistence of mRNA-vaccine induced immunity to SARS-CoV-2 has already been demonstrated to last at least 6 months, and likely 12 months, we do not yet know if or when vaccine boosters will be required beyond that.

Turner's study is particularly exciting because they found spike-protein binding B cells in the germinal centre of draining lymph nodes in all 14 post-immunisation participants for the full 15 weeks of the study. The germinal centre response was so vigorous and persistent that the researchers believe this could represent COVID-protection lasting for years.

"Ellebedy said the immune response observed in his team’s study appears so robust and persistent that he thinks that it could last for years. The researcher based his assessment on the fact that germinal centre reactions that persist for several months or longer usually indicate an extremely vigorous immune response that culminates in the production of large numbers of long-lasting immune cells, called memory B cells. Some memory B cells can survive for years or even decades..." – Dr Francis Collins, NIH Directors Blog

This study builds on the same team's earlier work (Turner 2021 May) looking at bone marrow plasma cells in those who have recovered from mild COVID infection, also showing a long-lived immune response.

COVID persistent immunity takeaway:

Although COVID-19 and developed vaccines have been circulating for only 12-18 months, these immune-response studies give some hope that the miracle of mRNA vaccines may not only be in their efficacy, but also in the longevity of protection.

Mentioned studies:

Guglielminotti J Li G. Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization. Anesth. Analg. 2020 Nov 1; 131 (5): 1421-1429.
Schmutz A, Bohn E, Spaeth J et al. Comprehensive evaluation of manikin-based airway training with second generation supraglottic airway devices. Ther Clin Risk Manag. 2019 Jan 1; 15: 367-376.
Chaki T, Tachibana S, Kumita S et al. Head Rotation Reduces Oropharyngeal Leak Pressure of the i-gel and LMA® Supreme™ in Paralyzed, Anesthetized Patients: A Randomized Trial. Anesth. Analg. 2021 Mar 1; 132 (3): 818-826.
Turner JS, O'Halloran JA, Kalaidina E et al. SARS-CoV-2 mRNA vaccines induce persistent human germinal centre responses. Nature. 2021 Jun 28.

Old, new and current trends in obstetric anaesthesia

Tue, 02 Jun 2020 08:00:00 +0000

Some interesting research on common and not-so-common obstetric anaesthesia topics: both new trends and continuing trends, as well as a cautionary medicolegal reminder.

Supraglottic airways for GA Caesarean?

Metodiev & Mushambi's editorial looks at the attitude shift among obstetric anaesthesiologists to more favourably consider the LMA or SGA for Caesarean section under GA.

They review the evidence for aspiration risk, particularly noting what we learned from NAP4 (2011) but contrast this with many studies showing safety of SGAs for GA CS (over 8,000 patients in total, with Halaseah 2010 investigating 3,000 alone!). Interesting, but before we get too excited keep in mind that the populations studied are likely very different from parturients you may typically look after.

They conclude:

"...there is insufficient evidence to recommend universal or selective replacement of tracheal tubes with SGA devices during general anaesthesia for Caesarean delivery. Aspiration remains the main concern." – Metodiev & Mushambi (2020)

Cautionary reminders of neuraxial injury

McCombe & Bogod reviewed 21 years of obstetric anaesthetic medicolegal claims, noting common themes around consent, types of nerve injury, and recognition and management failures.

Not only is neurological injury the second most common reason for obstetric anaesthetic claims (behind inadequately managed pain during Caesarean section), it carries the highest average claim cost.

The review is full of many useful observations, but Reynold's 2000 advice regarding interspace level choice for spinal access is by far the most important: always access the intrathecal space at the lowest possible level, and "...the L2/3 interspace should not be an option."

McCombe & Bogod spend some time exploring the variability of cord termination level, individual variability of the intercristal line, and the inaccuracy of anaesthetist interspace level estimation. Well worth reading the whole review.

Which vasopressor for spinal hypotension?

Although most recent consensus guidelines have recommended phenylephrine infusion for managing hypotension during neuraxial anaesthesia for Caesarean section, Singh's 2020 meta-analysis suggests otherwise.

Performing a Bayesian network meta-analysis of 52 high-to-moderate quality RCTs with over 4,000 patients, they compared multiple vasopressors directly and indirectly to produce a probabilistic hierarchy of benefit for improving neonatal and maternal outcomes.

They found that norepinephrine (noradrenaline), metaraminol, and mephentermine showed the lowest likelihood of adverse neonatal acid-base effects, and ephedrine the greatest.

These top three vasopressors (notably not phenylephrine) vied similarly for secondary outcomes, with an 85% combined-probability that metaraminol & norepinephrine are the two best agents for avoiding maternal nausea and vomiting.

Fitzgerald et al. conducted a similar network meta-analysis earlier in the year, although using different methodology and a different mix of trials, also ranked metaraminol and norepinephrine ahead of phenylephrine.

Alternatives to intrathecal heavy bupivacaine

Finally, in this time of common drug shortages it's reassuring to have confidence in acceptable alternatives. Two recent meta-analyses have compared intrathecal heavy bupivacaine to both plain and ropivacaine.

Sng et al. conducted a Cochrane review of hyperbaric vs isobaric/plain bupivacaine for Caesarean section, including 10 studies and over 600 subjects. They found that intrathecal hyperbaric and isobaric bupivacaine were equally clinically effective, although hyperbaric showed slightly faster block onset (but only by 1 minute!).

Malhotra et al. compared intrathecal bupivacaine to intrathecal ropivacaine using a meta-analysis of 13 trials including over 700 patients. They found intrathecal ropivacaine results in faster recovery of motor block, but no difference in onset of motor or sensory effects. (It's generally accepted to use a dose-equivalence of at least 1.5:1 ropivacaine:bupivacaine, based on previous studies showing rough equivalence at this ratio.)

Neither study demonstrated any difference in the risk of conversion to general anaesthesia, need for intraoperative supplemental analgesia or vasopressor requirement – although patients receiving ropivacaine requested postoperative analgesia earlier.

Nonetheless, either is an acceptable alternative to intrathecal heavy bupivacaine.

The elephant in the room

The funny thing with obstetric anaesthesia is the more things appear to change, the more... well, actually things don't even seem to change all that much.

We just need regular reminding of the importance of the basics: vasopressors for spinal hypotension, intrathecal access at the lowest accessible interspace, one long-acting LA is similar to the next, and treat the obstetric airway with respect.

Relevant studies:

Metodiev Y Mushambi M. Supraglottic airway devices for Caesarean delivery under general anaesthesia: for all, for none, or for some? Br J Anaesth. 2020 Mar 18.
McCombe K Bogod DG. Learning from the law. A review of 21 years of litigation for nerve injury following central neuraxial blockade in obstetrics. Anaesthesia. 2020 Apr 1; 75 (4): 541-548.
Singh PM, Singh NP, Reschke M et al. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes. Br J Anaesth. 2020 Mar 1; 124 (3): e95-e107.
Fitzgerald JP, Fedoruk KA, Jadin SM et al. Prevention of hypotension after spinal anaesthesia for caesarean section: a systematic review and network meta-analysis of randomised controlled trials. Anaesthesia. 2020 Jan 1; 75 (1): 109-121.
Sng BL, NLR Han, Leong WL et al. Hyperbaric vs. isobaric bupivacaine for spinal anaesthesia for elective caesarean section: a Cochrane systematic review. Anaesthesia. 2018 Apr 1; 73 (4): 499-511.
Malhotra R, Johnstone C, Halpern S et al. Duration of motor block with intrathecal ropivacaine versus bupivacaine for caesarean section: a meta-analysis. Int J Obstet Anesth. 2016 Aug 1; 27: 9-16.