Ashish Premkumar | Northwestern University Feinberg School of Medicine (original) (raw)

Papers by Ashish Premkumar

Culture, Medicine, & Psychiatry, 2019

In the United States, the historical condemnation and punitive legal consequences of substance us... more In the United States, the historical condemnation and punitive legal consequences of substance use during pregnancy-ranging from incarceration to termination of parental custody of a newborn-render pregnant women in state of biosocial precarity. Yet pregnant women who use illicit substances who desire to parent must generate a legible narrative for bureaucratic groups, such as Child Protective Services, through engagement with biomedical care in order to demonstrate parental capacity. Based on longitudinal interviews with pregnant women who were actively using illicit substances and attempting to parent after delivery, we posit that the relationship between biosocial precarity and biomedical care is a procedural interaction that is rooted in the potential to parent, described as the ability to have a "take-home baby." In order to achieve this goal, the need for engagement in biomedical care and the creation of a biomedical narrative, described as a "résumé for the baby" is required. The relationship between care and biosocial precarity is a unique, underdeveloped concept within medical anthropology and has important consequences not only for the ethical turn within anthropology, but also how applied researchers consider engagement with this highly marginalized, vulnerable population.

American Journal of Perinatology, 2019

OBJECTIVE: The objective of this study was to investigate the role of gestational hypertension (... more OBJECTIVE:
The objective of this study was to investigate the role of gestational hypertension (gHTN) and chronic hypertension (cHTN) on rates of preterm birth (PTB) among black women.
STUDY DESIGN:
Singleton live births between 20 and 44 weeks' gestation among black women in California from 2007 to 2012 were used for analysis. Risk of PTB by subtype and gestational age among women with cHTN or gHTN, including preeclampsia, was calculated via Poisson's logistic regression modeling. Risks were adjusted for maternal factors associated with increased risk of PTB.
RESULTS:
A total of 154,950 women met the inclusion criteria. Of the 5,948 women in the sample with cHTN, 26.2% delivered preterm; for the 11,728 women with gHTN, 21.6% delivered preterm. Women with gHTN or cHTN had a higher risk of medically indicated and spontaneous PTB, both at less than 32 and 32 to 36 weeks, when compared with nonhypertensive women (adjusted relative risks [aRRs]: 3.4-11.6). Women with superimposed preeclampsia had higher risks of spontaneous (aRR: 2.8, 95% confidence interval [CI]: 2.3-3.4) and medically indicated PTB (aRR: 2.8, 95% CI: 2.0-3.8), especially PTB < 32 weeks, when compared with women with preeclampsia.
CONCLUSION:
Among black women, superimposed preeclampsia increased the risk for spontaneous and medically indicated PTB, especially PTB < 32 weeks.

Obstetrics & Gynecology, 2019

OBJECTIVE: To systematically review maternal and neonatal outcomes associated with opioid detoxif... more OBJECTIVE:
To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy.
DATA SOURCES:
PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016.
METHODS OF STUDY SELECTION:
English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale.
TABULATION, INTEGRATION, AND RESULTS:
Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9-100%) and illicit drug relapse (0-100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]).
CONCLUSIONS:
Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.

The issue of race and ethnicity within obstetrics and gynecology has come to the forefront in the... more The issue of race and ethnicity within obstetrics and gynecology has come to the forefront in the current social and political climate. Understanding the ill effects of racism within the clinical space requires an acknowledgment of both the ongoing problem and current limitations in the state of knowledge and praxis among clinicians, trainees, and educators alike. In this commentary, the issue of race and racism within obstetrics and gynecology is discussed through a case of discrimination experienced by an intern working in an urban, academic hospital. By attending to the different layers of hierarchy within medical education and care as well as the multitude of silences from potential allies, we demonstrate a critical need to understand racism and inequality in the clinical and educational space. We deconstruct the issue of race and racism by contextualizing it with ongoing discussions in the social sciences and public health as well as wider discussions of the relationship of race with professional training and employment in biomedical fields. Finally, we offer both action items and calls for future educational and practice-based solutions to affect change in the way obstetrics and gynecology is taught and practiced.

In the United States, the historical condemnation and punitive legal consequences of substance us... more In the United States, the historical condemnation and punitive legal consequences of substance use during pregnancy-ranging from incarceration to termination of parental custody of a newborn-render pregnant women in state of biosocial precarity. Yet pregnant women who use illicit substances who desire to parent must generate a legible narrative for bureaucratic groups, such as Child Protective Services, through engagement with biomedical care in order to demonstrate parental capacity. Based on longitudinal interviews with pregnant women who were actively using illicit substances and attempting to parent after delivery, we posit that the relationship between biosocial precarity and biomedical care is a procedural interaction that is rooted in the potential to parent, described as the ability to have a ''take-home baby.'' In order to achieve this goal, the need for engagement in biomedical care and the creation of a biomedical narrative, described as a ''résumé for the baby'' is required. The relationship between care and biosocial precarity is a unique, underdeveloped concept within medical anthropology and has important consequences not only for the ethical turn within anthropology, but also how applied researchers consider engagement with this highly marginalized, vulnerable population.

BACKGROUND: In both the biomedical and public health literature, the risk for preterm birth has b... more BACKGROUND: In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well- documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature.
OBJECTIVE: The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth.
STUDY DESIGN: This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hy- pertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are re- ported as odds ratios, with 95% confidence intervals and significance set at P 1⁄4 .05.
RESULTS: In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P <
.001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their non- hypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P 1⁄4 .4).
CONCLUSION: The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.

The ISIS-led attacks on Paris, Beirut, and Baghdad in November 2015 were covered in a variety of ... more The ISIS-led attacks on Paris, Beirut, and Baghdad in November 2015 were covered in a variety of ways by major news outlets globally. Coverage of the Paris attack was widespread, and layered with personal stories about those personally affected and analysis about the effects of terrorism on the French way of life. By comparison, little coverage was given to either the Beirut or Baghdad events, the experiences of those suffering on the ground, or the wider issue of the effects of terrorism within Lebanese and Iraqi communities. In this think piece, the bombings in Beirut are used as a lens for examining the politics and consequences of mediated silence or ‘forgetting’ of violence and suffering in the Middle East. We employ a critical humanitarianism, rooted in a social medicine analysis, to connect these media trends to the training of health professionals. Our approach helps build accountability for the inequalities present in the Western construction of suffering and the emotive aspects of global violence, and promotes a wider conversation about the long-term biomedical effects of violence.

Since the police-involved deaths of Michael Brown and Freddie Gray, activists have argued for con... more Since the police-involved deaths of Michael Brown and Freddie Gray, activists have argued for connecting police violence with reproductive justice. We argue that sys- tematic violence, including police violence, should be evaluated in relation to reproductive health outcomes of individual patients and communities. Beyond emphasiz- ing the relationship between violence and health out- comes, both qualitative and epidemiologic data can be used by activists and caregivers to effectively care for individuals from socially marginalized communities.

Within the realm of bioethics, the construction of pregnancy classically has focused on principle... more Within the realm of bioethics, the construction of pregnancy classically has focused on principle-based ethics, essentially separating maternal and fetal interests. Respect for maternal autonomy becomes distinct from an obligation of fetal beneficence, placing practitioners in complicated ethical situations when the goals of pregnant women may be at odds with the best health interests of the fetus as defined by both professional groups and society in general. As a result, clinical care is framed by an ethical "maternal-fetal conflict," with important downstream legal and policy consequences for the well-being of pregnant women. Developments in the social sciences highlight the value of attending to the biosocial realm that a pregnant woman inhabits rather than relating to her and to her fetus as discrete entities. By understanding the needs, concerns, and context within which a woman lives, clinicians can practice an ethics of accompaniment. With a focus on an ethics of accompaniment, assumptions about the maternal moral responsibility to fetal health made by practitioners and society in general can directly affect not only clinical care, but also the way policy surrounding reproductive health is constructed and implemented.

The critiques leveled towards medical humanitarianism by the social sciences have yet to be felt ... more The critiques leveled towards medical humanitarianism by the social sciences have yet to be felt in medical education. The elevation of biological suffering, at the detriment of sociopolitical contextualization, has been shown to clearly impact both acute and long-term care of individuals and communities. With many medical students spending a portion of their educational time in global learning experiences, exposure to humanitarianism and its consequences becomes a unique component of biomedical education. How does the medical field reconcile global health education with the critiques of humanitarianism? This paper argues that the medical response to humanitarian reason should begin at the level of a social history. Using experiential data culled from fieldwork with Palestinian and Syrian refugees in Lebanon, the authors argue that an expanded social history, combined with knowledge derived from the social sciences, can have significant clinical implications. The ability to contextualize an individual's disease and life within a complex sociopolitical framework means that students must draw on disciplines as varied as anthropology, sociology, and political history to further their knowledge base. Moreover, situating these educational goals within the framework of physician advocacy can build a strong base in medical education from both a biomedical and activist perspective.

Theoretical work in critical medical anthropology and biomedicine on substance use in pregnancy h... more Theoretical work in critical medical anthropology and biomedicine on substance use in pregnancy has yet to develop a cohesive framework of the maternal-fetal unit (MFU) as a dynamic object. As a result, patient history, risk, and agency continue to be driven by an Enlightenment-era, monolithic conception of individual will. I use the example of Carla, a young woman actively using heroin in her pregnancy, to illustrate the limits of the MFU as it is currently conceived. By using critiques of subjective utilitiarianism, as discussed by Byron Good, and the concept of becoming, as elucidated by Gilles Deleuze and Félix Guattari, this article seeks to articulate an ethics of accompaniment, focused on both individual patient care and wider sociopolitical advocacy. These ethics help to redefine the MFU, and support new and unique ways of providing services to this often marginalized and vulnerable population.

Consequently, those who resist or rebel against a form of power cannot merely be content to denou... more Consequently, those who resist or rebel against a form of power cannot merely be content to denounce violence or criticize an institution. Nor is it enough to cast the blame on reason in general. What has to be questioned is the form of rationality at stake.

The role of confessionalism in the Lebanese healthcare sector, especially since the resolution of... more The role of confessionalism in the Lebanese healthcare sector, especially since the resolution of the Lebanese civil war (1975–1990), has yet to discussed at length in reproductive health research. Using biopolitical and structural violence models to describe how community leaders in two low-income neighbourhoods in Beirut describe reproductive healthcare – specifically through judgments of perceived sect size vis-a`- vis perceived use of birth control measures – this paper attempts to provide critical analysis of the state of reproductive health in this setting. By using a theoretical model of analysis, which we refer to as the political anatomy of reproduction, we hope to unmask how confessionalism is perpetuated through discussions of reproductive health and how public health and medical communities can challenge this technique of power.

Drafts by Ashish Premkumar

We applaud ACOG for focusing on the issue of race/ethnicity in reproductive health. 1 While we co... more We applaud ACOG for focusing on the issue of race/ethnicity in reproductive health. 1 While we commend the authors for highlighting patient, practitioner, and health system-level factors for disparities in health outcomes, the authors provide little contextualization of the landscape in which the aforementioned factors exist. Foremost, the authors neglect the historical construction of obstetrics and gynecology in the United States, particularly how it sits firmly within the context of the eugenics movement, Jim Crow, and the socioeconomic domination of minorities. 2-4 To quote physician and anthropologist Paul Farmer, "If we cannot study structural violence without understanding history, the same can be said for biology." 5 We must be ready to name inequality at its' historical source, if for nothing else to understand its' longstanding effects on the health outcomes of our patients and communities. Without giving a specific name to the exploitation, racism, and violence that birthed the current mode of care provision and assessment of reproductive health, how can we hope to move beyond its' shortcomings?

Culture, Medicine, & Psychiatry, 2019

American Journal of Perinatology, 2019

Obstetrics & Gynecology, 2019

In the United States, the historical condemnation and punitive legal consequences of substance us... more In the United States, the historical condemnation and punitive legal consequences of substance use during pregnancy-ranging from incarceration to termination of parental custody of a newborn-render pregnant women in state of biosocial precarity. Yet pregnant women who use illicit substances who desire to parent must generate a legible narrative for bureaucratic groups, such as Child Protective Services, through engagement with biomedical care in order to demonstrate parental capacity. Based on longitudinal interviews with pregnant women who were actively using illicit substances and attempting to parent after delivery, we posit that the relationship between biosocial precarity and biomedical care is a procedural interaction that is rooted in the potential to parent, described as the ability to have a ''take-home baby.'' In order to achieve this goal, the need for engagement in biomedical care and the creation of a biomedical narrative, described as a ''résumé for the baby'' is required. The relationship between care and biosocial precarity is a unique, underdeveloped concept within medical anthropology and has important consequences not only for the ethical turn within anthropology, but also how applied researchers consider engagement with this highly marginalized, vulnerable population.