Friday, July 27, 2012

Summer Fluff: The Bobs

Here's a little musical fluff to brighten up your summer day.  Anybody else here a fan of The Bobs?

I've seen The Bobs perform a few times over the years, and I love their off-beat virtuosity. They are an a capella group with a twist.  And they are awesome.

I'm a big fan of a capella music (just vocals, no instruments) and doo wop music in general.  However, this is not your grandma's a capella music.  They've been called "New Wave A Capella" and they specialize in very off-beat, often humorous songs, either covers of other material or original songs written by members of the group. They merge pop, blues, and jazz, often utilize non-traditional harmonies, and generally push the envelope of a capella music in a major way. They describe themselves on their website in the following way:
The Bobs (prat)fall outside a cappella traditions, landing in a hot tub of humor and vocal prowess. What other band can headline The American Songbook series, open for Frank Zappa and The Dead, and perform for 700 million people on the Emmy Awards?
The Bobs were founded in 1981 but hit the big time in 1984:
Matthew Stull and Gunnar Madsen founded The Bobs in 1981 in Berkeley, California, and were quickly joined by bass singer Richard Greene and ├╝ber-alto Janie Scott. They performed in the San Francisco area until a 1984 Grammy nomination for their unique vocal cover of the Beatles’ “Helter Skelter” catapulted them into a national and international tour schedule.
As is common in many groups, they have rotated through several different singer line-ups over the years. MatthewBob and RichardBob are the longest-serving members of the group, and are currently joined by DanBob and AngieBob. (Yes, all the members have "Bob" in their psuedo-names.) More information (including upcoming concerts and how to buy their albums) is available at their website, The Bobs.

If you ever get the chance to see them in person, take it!  They're famous for their show patter, so it's usually a very entertaining show.  If you are very traditionally-minded in your music preferences, you might not enjoy some of their songs (which can be pretty offbeat harmonically), but generally speaking, the humor and the sheer virtuosity with which they perform is enough to win over most people.

Here are a few videos of some of their more wide-appeal songs to get you started.

The first is "There Ain't Nobody Here But Us Chickens."  It's a cover of an old Louis Jordan song, and it's straightforward and fun.  Check out the cool scatting by DanBob Schumacher.



Here is "The Tight Pants Tango", a tribute to the dancing that happens when your cell phone rings when ensconced in the pocket of pants that are far too tight.



Here is a link to another video of "The Tight Pants Tango". You can't see everyone, so it's not as good a video, but it's got all the lyrics listed, so some might enjoy looking at that one instead.

Finally, for cat fans everywhere, a very bizarre but funny song called "Fluffy's Master Plan for World Domination" about how cats are plotting to take over the world. It's a fan's amateurish video of The Bobs soundtrack, mind, but it's still fun.  Enjoy!



Saturday, July 21, 2012

CesareanRates.com: Transparency in Maternity Care

www.cesareanrates.com 

There's a new website out that I've been wanting to highlight for a while.  Now, as the author struggles to finance her work on the site, it's even more important that I publicize the site.

The site is called cesareanrates.com and it has the cesarean rates for most of the states in the U.S. and the provinces in Canada.

Most importantly, not only does it have the cesarean rates by state/province, it also has the cesarean rates by individual hospital.

Earthy-birthy types who read my blog probably already know about this wonderful resource, but others may not.  It makes for very interesting reading and I recommend the site.

Having cesarean rates available by hospital is incredibly useful information.  If you live in an area where you have the choice of more than one hospital, you can see which ones have very high baseline cesarean rates and which ones don't.

Such information has to be interpreted with caution, of course, since some hospitals have higher loads of high-risk patients who might be expected to have higher cesarean rates. This is a legitimate concern.  However, even among hospitals that serve higher-risk patient populations, cesarean rates can vary widely. So while caution has to be used when viewing this data, it still can be useful to the consumer.  Some hospitals really do have a strong climate of overutilization of cesareans, and consumers should have access to that information before choosing to become a customer of that hospital.

So let's talk a little bit more about the variations in cesarean use and the importance of transparency in cesarean rates for quality control purposes.
Image Use Disclaimer: I received express permission from creator Jill Arnold of The Unnecesarean to use the cesareanrates.com images. If you want to use them, please ask her permission first.
Variations in Cesarean Utilization

One of the attitudes we have to fight against all the time in Cesarean Awareness advocacy is the common public perception that cesareans are only done when necessary.  In other words, most people assume that if a woman had a cesarean, it was usually because she needed it and it saved her or her baby's life.

Yes, cesareans can be life-saving, and there is no doubt that having them available is a wonderful thing.  Absolutely no argument there.

However, while cesareans mostly used to be used only when truly needed, there are many cesareans being performed today that are not medically indicated.  And the strong regional variations in cesarean use just reinforce this.

Below is a chart from Jill's site of the ten hospitals with the highest c-section rates in Florida.


Now look at a chart from Jill representing the ten hospitals with the highest c-section rates in Utah.


So the hospital with the highest cesarean rate in Florida has a rate TWICE as high as the hospital with the highest cesarean rate in Utah.

Come on, are the uteri of women in Utah really that much more efficient as the uteri of women in Florida? No, of course not.  The fact is that cesarean rates are highly variable by region, by hospital, and by doctor, and many of these variations are not explainable by demographic differences or risk caseload.

Even within one regional area with similar demographics and patient risk profiles (and eliminating cesareans for indications like breech, thought to be "necessary" by some providers), cesarean rates can vary widely.


While doctors like to blame women for high c-section rates (the overused "women are too old or too fat" or "women are requesting these cesareans" arguments), the truth is that provider practice patterns have far more influence on cesarean rates than factors attributable to women themselves.

The Childbirth Connection, an organization devoted to improving maternity care, confirms this trend:
The cesarean rate varies broadly across states and areas of the country, hospitals, and maternity professionals. Most of this variation is due to "practice style" rather than differences in the needs and preferences of childbearing women.
In other words, your chances of "needing" a cesarean at one hospital in your area may be quite different than your chances of "needing" a cesarean in a different hospital in your area.  Even if you fall into a supposedly "high-risk" category, your chances of "needing" a cesarean can vary widely, depending on who you see and their practice patterns around birth.

While some cesareans truly are prudent and at times even life-saving, many cesareans performed today are not.  Women deserve to know which hospitals have high rates of cesarean utilization and which do not, so that they can make informed choices about where they go to birth, should they choose to have a hospital birth.

Caveats

I would like to tell you that hospital-level cesarean rates area available for all 50 states, but alas, that's not true.  Last I checked Jill's site, the following states did not have hospital-level information about cesarean rates available:
Why is this information not available uniformly? The reasons vary. Some states don't think consumers are interested in this information and so don't provide it. Or pencil-pushers decide that providing cesarean rates to the public is not a Department of Health budget priority.  A few states have decided that health consumers have no right to this information and refuse to release hospital-level cesarean rates, despite many requests to do so.

There is information in each of the links above on how to contact these states directly to request that this information be made public.  Sometimes, if a state gets enough requests, they make providing hospital-level cesarean rates more of a priority.  (We were able to do this recently in my state.)

On the other hand, sometimes states actively refuse to provide hospital-level cesarean rates because doctors have actively campaigned to keep these rates private, on the grounds that the public is not smart enough to understand the concept of mitigating factors (like a high-risk caseload, etc.).  Or they simply don't want the bad publicity for their hospitals.

This is ridiculous.

As health consumers, we deserve to have public health information about various hospitals and their quality of care.  And we deserve this information for maternity-related care as well as basic overall care.  

The Importance of Transparency

Transparency is a HUGE up-and-coming issue in healthcare.  As one quality watchdog group notes:
You may not realize there are differences in the quality of care provided by different hospitals. Hospitals are busy and complex places. Every day, hundreds of patients are receiving hundreds of different procedures. Medical mistakes are a leading cause of death each year, causing more deaths each year than car accidents, breast cancer and AIDS. 
There is good news! Hospitals can take steps to prevent mistakes and protect patients from unnecessary injury. Even better, there is information available to help you determine the quality of your local hospitals.
More and more, groups such as consumerreports.org and the Leapfrog Group have begun to document basic information on Quality of Care measures, such as which hospitals have high rates of hospital-acquired infections, which have poor overall patient safety, and which have high rates of medical mistakes or medication errors.

However, these quality monitoring efforts are in their infancy.  Some hospitals participate voluntarily, but some actively resist any attempt to shine a spotlight more closely on care practices. Yet experience shows that when substandard results are highlighted and a program is developed to address these issues, outcomes can be improved.

It is important to be careful when comparing results from different hospitals, but even with this caution in mind, transparency in Quality of Care measures can be useful in improving care and patient outcomes.

Transparency and Participatory Medicine are concepts whose time has come.

How does this translate to maternity care?  In maternity care, substandard care translates to high rates of maternal or neonatal infections, high rates of early scheduled deliveries, higher-than-average deaths, and a too-high cesarean rate.

Some hospitals would argue that a high cesarean rate is not a sign of substandard care. The World Health Organization disagrees, noting that high rates of non-medically indicated cesareans translate into a higher rate of adverse maternal outcomes, including admission to Intensive Care Units, blood transfusions, hysterectomies, and maternal deaths. Other risks include blood clots, wound infections, anesthesia accidents and other problems.  Clearly, overuse of cesareans has risks.

There is an ongoing argument over what the "most optimal" cesarean rate should be, but that's beside the point.  Whatever the "ideal" rate is, women deserve to know the baseline cesarean rate of their hospital of choice, and how that compares to other hospitals.  Then it is up to them which hospital they choose.

Final Thoughts

CesareanRates.com is a powerful new tool for healthcare consumers.

One of the many useful things on the website is the listing of the cesarean rates of all the U.S. states (both alphabetically and by highest-to-lowest rates). There is also a graph showing the increase in cesarean rates over time in the U.S.  Rates from the Canadian Provinces are available as well.

I like the Top Ten slideshow, where slides from several representative states list the hospitals with the highest cesarean rates in those states.  You'll see that quite a few hospitals have c-section rates around 50%-60%, while other states' rates are not nearly so high. This is a good micro-demonstration of how much variation there can be in cesarean rates from hospital to hospital and state to state.  (Click on the page number on the bottom to freeze a particular state's slide.)

Another useful thing is a state-by-state listing of the VBAC ban policies of individual hospitals.  This information can already be obtained from the International Cesarean Awareness Network’s VBAC Policy Database but it's useful to have it all in one place with the hospital-level cesarean rates.

You can read more here about why Jill Arnold created this new site:
CesareanRates.com is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus. The initial goals of the site are to a) show the (poor) quality and inaccessibility of hospital-level information available to the public, b) to assess whether there is public demand for this information and c) to work toward establishing a precedent for hospital data transparency.
How might this site be useful for a typical healthcare consumer?  Jill elaborates on that question here:
As with everything pregnant people can get their hands on, it is one of many tools. Everyone makes decisions differently and weighs things based on their unique experiences, values, preferences and education. For example, a 60% total cesarean rate might trigger a different reaction for different people. A woman that passionately wants to avoid an unnecessary cesarean section might be deterred from giving birth there, while one hoping for an elective primary section might infer something about the culture of the hospital and seek a provider that delivers babies there. Another person might try to evaluate what exactly that means and start investigating why it is so high, while someone else might not care one way or the other where they give birth as long as they are with a care provider they like. 
Ideally, it would be nice to see the site used by pregnant people for the purpose of seeking preference-sensitive care and opening up dialogue with their provider about what they can expect at the hospitals at which their provider has privileges.
If you want to know more about how cesarean rate information is reported. watch the following short video on the technical aspects of such data collection.



Go, check out www.cesareanrates.com. If you get an additional moment, go to its Facebook Page and "like" it as well.  Blog about it and pass on the link so more people know about this invaluable resource.

And if you can, donate to the author so she can continue carrying on this work.


Thank you, Jill, for your hard work on this site.  Brava!


References

Health Aff (Millwood). 2006 Sep-Oct;25(5):w355-67. Epub 2006 Aug 8. Geographic variation in the appropriate use of cesarean delivery. Baicker K, Buckles KS, Chandra A.   PMID: 16895942
There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristics but are greatly influenced by nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure. Areas with higher usage rates perform the intervention in medically less appropriate populations-that is, relatively healthier births-and do not see improvements in maternal or neonatal mortality.
Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL, et al.   PMID: 17547880
OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.
Obstet Gynecol. 2010 Jun;115(6):1201-8. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Hanley GE, Janssen PA, Greyson D.   PMID: 20502291
OBJECTIVE: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery. METHODS: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839)...RESULTS: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries. CONCLUSION: Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.
Birth. 2005 Sep;32(3):170-8. Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Mahoney SF, Malcoe LH. PMID: 16128970
BACKGROUND: Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations...METHODS: We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999... RESULTS: The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03). CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

Monday, July 16, 2012

Prior Vaginal Birth Decreases the Risk for Uterine Rupture in VBAC

Here's an entry in the no-duh Olympics.  You would think this didn't need to be pointed out, but sadly, to some folks it does.

Most caregivers know that once a woman has had a VBAC, she is at decreased risk for rupture  (the scar coming apart) in any future pregnancies.

The risk is never zero, mind.....once a cesarean, always a risk to some degree, whether you choose VBAC or repeat cesarean, which is why it's important to avoid that first cesarean whenever possible.....but a prior vaginal birth (either before or after the cesarean) does seem to lessen the risk for rupture.

However, once in a while, we in ICAN (the International Cesarean Awareness Network) hear about some ignorant caregiver telling women that they can only have one VBAC and then must have all repeat cesareans, or that the risk for rupture remains just as high each time, even after you've already had a VBAC. Wrong!

For all the Homer Simpson caregivers out there who need a primer on this topic, here's a research review that clearly shows that the risk for uterine rupture is significantly decreased in women who have had a prior vaginal birth.  D'oh!

This is another reason why it is so important to prevent cesareans whenever possible.  A vaginal birth is protective against so many complications, including one of the most serious, uterine rupture.  Even if a cesarean becomes truly necessary in a particular pregnancy, it is strongly to everyone's advantage if the woman has had a vaginal birth first, or if she has a vaginal birth (VBAC) afterwards. In most cases, it is more risky to expose them to successive cesareans, particularly multiple repeat cesareans.

Yet research shows the primary cesarean rate rising, and the VBAC rate dropping.

Graph from U.S. National Center for Health Statistics

Don't get me wrong.  I don't hate cesareans. It is wonderful to have life-saving technology and surgery available when truly needed, and there certainly are cases where a cesarean makes more sense. But don't underestimate the power of nature.

On a population-wide basis, vaginal birth offers the most benefits to most mothers and babies. We evolved to give birth vaginally, and we circumvent that casually at our peril.

This research points out yet again that it is to most birthing women's advantage to have a vaginal birth in their history. Most of the time, unnecessary primary cesareans and routine repeat cesareans should be avoided if possible.


Reference

Arch Gynecol Obstet. 2011 Nov;284(5):1053-8. Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery. de Lau H, et al. PMID: 21879334
PURPOSE: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery.
METHODS: A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method.
RESULTS: Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P less than 0.00001).
CONCLUSION: Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.

Sunday, July 8, 2012

Kids' Bucket List

A little fluff for the post-Holiday week.....how about an Open Thread Question?

What's on your "bucket list" of must-have skills for kids to learn before they grow up and move out?

I'm not talking about bucket lists in the usual sense (things you want to do before you die), but instead, vital skills you think children should have before they move out of the house and start living on their own.

If you are a parent, what things have you made (or intend to make) a priority in your house?  If you aren't a parent, what did you wish your parents had taught you that you really needed to live on your own?  Or conversely, what were the things your parents did teach you that were very helpful or fulfilling skills to have?

My bucket list for my kids includes a lot of life skills and practical stuff, as well as things to keep them well-balanced human beings.  Some we are doing well on, and some are still on the "to-do" list.  Let's chat about a few.

Life Skills

In terms of life skills, I want my kids to have what I consider to be essential skills like first-aid/CPR, knowing how to swim, what to do in a disaster, that sort of thing.  You'd be surprised how many people don't know basic first-aid, for example.  It's just common sense for everyone to have good training in this.

I also think every child should know how to do some basic gardening.  My mom taught me a little bit of gardening, but I was known as the Black Thumb of Doom for many years because I killed plants left and right.  It took a number of tries before I figured it out as an adult and could raise a halfway decent garden.  I'm still a pretty casual gardener by serious gardening standards, but I raise enough that I could help our family in hard times. I'm trying to pass this along to my kids, but they certainly aren't overly enthusiastic about it.  Still, they'll have at least some knowledge in it.

Similarly, I think kids should know how to put up food.  This is a skill that has been lost in many families. Despite growing up on or near farms (in the Depression and WWII, no less!), neither my parents nor my in-laws ever learned canning or putting up food from their own parents, and so we in turn, never learned it either. But we as a society are far too dependent on a food supply system that is easily broken down during disasters or sudden fuel-supply crises.  It's important to not only have some of your own bought food reserves, but also to know how to grow your own and store it safely.  I'm still learning this skill; I'm making my oldest two learn it with me as well this summer.

I think all kids should have some experience with camping, nature, fire-making, and outdoor skills. Sadly, I got little of this in my upbringing.  As a result, I am just not Nature Girl; I get too cold too easily to be comfortable camping for long.  However, I'm working on building up some practical skills like fire-making and outdoor cooking skills anyway, just in case. Luckily, my husband is an Eagle Scout so he has made sure his boys are involved in Boy Scouts and are getting plenty of practical outdoor skills.  We haven't been as good with my daughters, mostly for coincidental (not sexist) reasons, but it's something I want to remedy.  My oldest has some significant medical issues so she's not going to be Nature Girl either, but we still have time to teach my littlest one some good skills, and the older one, like me, can at least learn some stuff. Definitely something we need to work on.

Another thing we've really fallen short on in our house is practical skills like how to take care of mechanical stuff, like cars and other machinery. I don't know anything about it; I've always depended on my husband.  Not a good idea. I want all my kids to have these skills, but frankly, we have just been too busy to pursue this, and so I feel like I've really fallen down on this important skill. It's on our "to-do" list.

What other life/essential skills can you think of that kids should learn before they become adults?

Practical Skills

On the practical side, I think all kids should know how to cook for themselves, do their own laundry, clean house properly, take care of the yard, etc.  It floors me how many kids leave home without knowing how to do these things, or with minimal cooking skills etc.

Start slowly when they are young, then gradually add chores for these things as they age.  This is important not only for life skills, but this is also how kids learn to be responsible, good workers.

We sometimes have playdates with friends, and it always shocks me when children eat a meal but don't take their dishes to the sink, or open a fruit leather and then just drop the wrapper on the floor and walk off.  What am I, your slave?  But apparently that's the way some houses are run.  Gah!

I'm not a fan of what I call Martyr Mothering ─ doing it all for your family so they don't have to. I don't like Martyr Mothering because it doesn't make your children (or husband) independent functioning humans, it makes a slave out of you by taking up most of your time (that could be spent on other activities), it doesn't teach children responsibility for themselves and their own actions, and it teaches a lack of acknowledgement/gratitude for the work of others and for the tasks that make a pleasant family home.

Now, of course, every family negotiates their own balance of chores ─ who does what, etc.  And that balance doesn't have to be the same for your family as for mine. Yet I see that many children don't have to do many chores and aren't learning how to care for themselves. You're really not doing your child any favors if you do everything for them or they have few chores.

Please, teach your children how to help out and how to be reasonably self-sufficient before they leave home.

Well-Balanced Human Being Skills

I think kids need experience in a variety of interest and pursuits in order to make them well-balanced human beings.  Enable your children to explore many activities.

I dislike the "specializing" approach that many parents take with their kids today ─ the kid has sports sports SPORTS all the time but never has a music class (or vice-versa).  Or the child never has the opportunity to take an art class, or to learn how to sew. Some become obsessed with one or two things and never explore anything else.

Children need to explore a variety of things before they can understand where their own interests and skills lie; it's good for kids to try new things and to experience gentle failure as well as success.  It's part of building their character.  Even highly specialized people like the Olympic-level athlete or the professional musician need to have other interests; being a well-rounded person will only help them in their chosen specialty.

Another important thing is to give children the opportunity to help in causes larger than themselves, to volunteer their time/energy for a good cause or to help others.  It's too easy to become centered only on yourself in our society; seeing the needs of others helps make children deeper, more empathetic people.

But while kids should have the opportunity to explore many different activities and to work in charitable causes, I'm also not a fan of over-scheduling children.  Children need "down" time to just play.  Imagination is a vital part of a child's life, and not just for little children. Teens need it too.

Turn off the computer and TV regularly, provide kids with a few basic games, toys, dress-up clothes, balls, swings, or whatever, and then just stand back and let them figure out how to play by themselves.  They struggle a bit at first, but in time they figure it out, and they are so much healthier for exercising those imagination muscles.  And "down time" really helps de-stress kids in a very stressed society.

Final Thoughts

Of course, all this is easy to say, harder to do.  We all fall down in some areas, and no parent ever "perfectly" prepares their children 100%.  You do the best you can to make them well-rounded and give them essential life skills, but you always have to remember that you are only the facilitator.

In the end, children are their own people and they make decisions about priorities for themselves as they grow.  We try to help them be well-rounded and diverse, but sometimes you can lead a horse to water but you can't make them drink, as the saying goes.  Some things children have to learn on their own.

For me, the goal is to offer the opportunity for building important skills and pursue lots of different interests, but it's always subject to the realities of life.  Sometimes the budget doesn't have room for all the classes you'd like to give your children.  Sometimes you just don't have the opportunity to help them pursue a certain activity. Sometimes you just don't have the skill set, budget, or extra time to help them with certain things.  You can seek out other mentors to help, but there are always limits that have to be acknowledged.  That's normal.

A kids' bucket list is not about making parents feel guilty for all the things they can't do, but rather just a road map to help parents be thoughtful about what they are doing to prepare their children for adulthood. Realizing that there will be gaps in these skills and forgiving yourself for that is part and parcel of the journey of parenting.  You just do the best you can, realize that you can't do it all, and let the rest go.  Remember that teaching children to be self-actualized learners goes a long long way towards filling any gaps.

So, in an ideal world, what are the things on your "bucket list" for your child?  If you don't have kids, what skills did your parents give you that were helpful, and what do you wish you had gotten? What do you wish people would give their kids more of?

This is an open thread; I welcome lots of comments and discussion.