It’s Never Too Early to Prepare for an Emergency

Last month, I shared an up-close look at Puerto Rico and the challenges facing their health care system following two major hurricanes. Officials were working hard to put emergency protocols into place and restore regular delivery of care. As a follow-up this month, I’d like to focus on how every hospital can evaluate and prepare for disasters and emergencies.

Large-scale catastrophic events and infectious disease outbreaks require disaster planning at all community levels well in advance. An updated Committee Opinion, released last week, outlines the key components to preparation and communication for the successful management of obstetrical care during emergencies.

Continue reading

Puerto Rico: A Long Road to Recovery

Weeks after Hurricanes Irma and Maria devastated the island of Puerto Rico, I had the privilege of speaking with Dr. Nabal Bracero, ACOG’s Puerto Rico section chair, at the Annual ACOG District IV Meeting in Charlotte, North Carolina. It was an opportunity to discuss the immense challenges patients and the medical community are currently facing but also to answer the question many ACOG members have been asking—“What can we do to help?”

The news stories about the recovery effort have been grim. While things are slowly getting better, 84 percent of the island is still without power, 40 percent lacks running water and the death toll has been steadily increasing—now at 43. A portion is attributed directly to the storms, however many deaths are now a result of the developing medical crisis in the storms’ aftermath. While it’s been reported that 98 percent of hospitals are currently open, including Puerto Rico Medical Center in San Juan, a majority are low on medication and medical supplies, inhibiting the quality and level of care they can provide. And patients, particularly those in critical condition that rely on ventilators, fetal heart rate monitors and other life-saving equipment, are dying due the lack of fuel to keep the generators running. In my conversation with Dr. Bracero, he said the medical center is managing but, like many hospitals, they are at capacity which limits their ability to accept new patients.

The lack of communication channels and resources, led to a conversation about how pregnant patients are faring and gaining access to needed medical services. According to Dr. Bracero, there are thousands of women at provisional sites that are in very poor conditions. These women will not be able to visit a doctor in the near term and there is no system to link ob-gyns outside of the metro areas with physicians at larger medical centers. For the patients that are in the vicinity of a provider, old-fashioned word of mouth has been the main mode of communication. Dr. Bracero said many patients simply made the trip to the office to find out if they were open. However, the section has also been working closely with ACOG to send email blasts to members in Puerto Rico to get a more comprehensive list of hospital units and offices that are open. Dr. Bracero plans to communicate that information via social media or main stream media outlets to let patients know where they can go for ob-gyn care.

ACOG has been working with CREOG and ABOG leadership, as well, on behalf of the medical students and residents in Puerto Rico to secure deadline extensions for applicants until they are able to gain access to adequate electronic communications. There is also a need to work with residency programs to potentially find alternate opportunities for residents who may be unable to complete the gynecology portion of their training programs on the island. However, Dr. Bracero pointed out that junior fellows were among the first responders with regard to ob-gyn care. Junior fellows from Districts I and IV here on the mainland have been eager to help in their own way and have started a fundraiser to help raise money for the residents of Puerto Rico.

But looking at the bigger picture, Dr. Bracero pointed out that there is still a need to do more and medical care will continue to be a top priority. There is a long road to recovery ahead and it will require advocacy, not just in our individual communities but in the nation’s Capital.

Listen to a portion of my interview with Dr. Bracero below.

For more information on how you can help, visit the following websites:

American Red Cross

United Way

United for Puerto Rico

UNICEF

Center for Popular Democracy

Hispanic Federation’s “Unidos”

International Medical Corps

Former U.S. presidents have expanded their One America Appeal to include recovery efforts in Puerto Rico and the U.S. Virgin Islands.

Catholic Relief Services

Americares

Direct Relief

Save the Children

Global Giving

For Ob-Gyns, Zika is Still News

Around this time last year, the Zika epidemic was covered by every major news outlet across the country and ACOG issued a statement reaffirming the latest warning from the U.S. Centers for Disease Control and Prevention (CDC) advising pregnant women not to travel to a specific area in Miami, Florida. We had recently learned that it was possible for the virus to be transmitted during all trimesters of pregnancy and ob-gyns were actively advising pregnant patients and their partners who had lived or traveled to Zika-affected areas to use contraception or abstain from sex for the duration of the pregnancy. While it was critical to get information out as soon as possible, we acknowledged that there were still many unknowns regarding transmission and the various harmful birth defects that can result from an infected fetus. During that time, we joined the CDC in recommending that all pregnant women be assessed for possible exposure at each prenatal care visit and that pregnant women with exposure be tested regardless of symptom status.

Since that time, the amount of data we have on Zika has increased and the realities regarding transmission of the virus have changed. For one, we’ve learned that the Zika virus antibodies can persist for months in some pregnant women, which makes it difficult for providers to know with certainty whether infection occurred before or during pregnancy. And, overall, the number of people infected with the virus in the United States and U.S. territories such as Puerto Rico has declined since 2016, making false-positives more likely when there is a lower occurrence of the disease. Therefore, the CDC, working with ACOG, announced at the end of July new guidance for pregnant women with possible Zika exposure. One of the significant changes is that we no longer recommend routine testing of pregnant women who are not experiencing symptoms and do not have ongoing exposure. In addition, to help address known issues with available Zika tests, pregnant women who are tested should receive concurrent IgM and NAT testing. ACOG continues to update a Practice Advisory, which further explains these changes and several others, as well as the new focus on shared decision-making when it comes to screening and testing patients, particularly those who are not experiencing symptoms.

While these new recommendations reflect the best data available on the virus to date, educating providers in a climate with rapidly changing recommendations remains challenging. It is certainly good news that the spread of the virus is on the decline in some areas, but Zika still poses a very real threat and we must remain vigilant. There is already a lot to cover at each prenatal care visit, but screening for Zika virus must continue to be a priority. Additionally, education about family planning for women who do not wish to become pregnant and condom use for pregnant women and their partners at risk of exposure are still essential. We can’t forget that contraception is an important tool in our fight against birth defects caused by Zika.

Also, adequate funding for needed resources to better understand and combat Zika are still a necessity. We need to be able to continue to track the virus through tools like the U.S. Zika Pregnancy Registry, deepen our understanding of its impact on pregnant women and fetuses, simplify and improve Zika virus testing and develop an effective vaccine. We must also remember that continued funding for Medicaid expansion and coverage of essential health benefits increases access to maternity, preventive and primary care for women at risk for the virus.

So, while Zika headlines might not be as prevalent anymore, we have a responsibility as physicians to keep it top-of-mind because there is still much work to be done.

To access ACOG’s Zika resources, visit https://www.acog.org/About-ACOG/ACOG-Departments/Zika-Virus.

Guest Blog: Hurricane Harvey Has Shown the Resilience of My Community

Over the past few days, I’ve seen up close and personal the catastrophic damage Hurricane Harvey has caused Texas and our patients.  In my role with Texas Children’s, I’ve worked with our team to coordinate disaster and recovery operations across our system of hospitals, out-patient clinics and our health plan.  Yesterday, when on-site to evaluate damage at one of our closed clinics, a pregnant mom drove up with her sick daughter, and my co-CMO and I were able to remove the sandbags, access our clinic, and provide urgent care to this frightened family.

The need is great. The scale of flooding is just disastrous, but I have been heartened to witness the resilience of my community and the immediate urge to help from across America.

As one individual on the front lines of this catastrophe, and on behalf of ACOG leadership, thanks to each of you for your outpouring of concern, thoughts, prayers, and offers to assist in any way you can.  We also extend our sincerest gratitude to federal, state and local workers and volunteers whose heroic efforts are saving lives in Texas and on the Gulf Coast.

Our work in Houston and along our Texas Gulf Coast is very far from done.  Recovery will take years of work and mountains of resources.  While ACOG is not a disaster relief organization, nor can we vet relief organizations, those of you who want to help can find options on the State of Texas Emergency Website.
 

Thank you, sincerely, for your concern and for your dedication to your patients.

Lisa Hollier, M.D., ACOG President-Elect

Charlottesville Reminds Us: We Must End Racial Bias in Medicine and Society

Earlier this year ACOG issued a Statement of Policy, originated in our Committee for Underserved Women, which acknowledges the many ways that racial bias affects our patients and colleagues. In the document, ACOG calls on all physicians to work together to create an equitable health care system that serves all women.

Reflecting on the recent events in Charlottesville has been a chilling experience for many of us, and brought to mind the, fortunately, very few experiences in my career where I was faced with racial and gender bias. In the mid-1970s, when I was a third-year medical student on General Surgery, I was assigned the task of a physical examination on a patient admitted for radical surgery for breast cancer. The patient promptly announced that she would not be examined by me because of my race. While not totally surprised to be confronted with this encounter at a southern medical school, I was surprised that someone with a potentially fatal condition was more concerned about my race than her disease and the radical surgery she was about to face.

The chief of General Surgery, when informed, entered the patient’s room on rounds and explained that he would have to cancel her surgery because she declined to have a member of his team perform her pre-operative physical examination. He could have assigned her to another team member but chose not to and gave this patient a choice. She agreed and I was assigned as the primary point of contact throughout her postoperative care until discharge. How the chief handled this event reflected his moral and core values and had a profound effect on my professional development because it taught me how to handle racial and gender bias, which I, in turn, taught to my trainees over the past 35 years.

The hate and bigotry on display in Charlottesville reminds us that we still have a lot of work to do in medicine and in society when it comes to ending racial discrimination and gender bias. We must continue to challenge them wherever they exist and encourage diversity at all levels of our profession from medical school to residency to practice to leadership positions for the benefit of our patients and society. Additionally, how can we ever achieve gender equity without ensuring women’s right to control their own reproduction in the United States and globally? The two issues are intricately tied. There is no place for legislative interference in the ob-gyn-patient relationship.

Recently, I had the occasion to attend a 50th anniversary commemoration for the Sri Lanka College of Obstetricians & Gynaecologists, along with past presidents Thomas Gellhaus, M.D., and Jeanne Conry, M.D. The highlight of the meeting was an address by Lesley Regan, M.D., D.Sc., president of the Royal College of Obstetricians and Gynaecologists, on the impact of the global gag rule on women’s health care worldwide. ACOG has opposed this rule for many years. Regan quoted in her presentation from the book by Nicholas Kristof and Sheryl WuDunn, “Women hold up half the sky.” She reminded us that in the 19th century we were confronted with abolition of slavery, in the 20th century racial discrimination, and in the 21st we must challenge gender inequity throughout the world.

I believe we, as obstetricians and gynecologists, must stand up against acts and policies that disadvantage women and show our patients that we will not tolerate any discrimination based on race, gender, color, national origin, disability, age, religion, marital status, sexual orientation, or any other basis. There is no neutral ground, and staying silent only supports their continuation and growth.

Building Strong Patient Relationships Begins in Adolescence

While many people are eager to leave their adolescence behind them, as ob-gyns, we know all too well that the development that occurs during these years lays the foundation for the rest of our lives. Not only are bodies and minds maturing, but adolescence is also defined by exposure to new ideas, experiences, and beliefs. Ideally, it is also the age where girls and young women begin to routinely visit the ob-gyn.

ACOG recommends that girls have an initial visit for screening and the provision of reproductive preventive health care services and counseling between the ages of 13 and 15 years. Caring for patients beginning in adolescence gives ob-gyns an important opportunity to focus on establishing a relationship of trust and ensuring young women are empowered with comprehensive knowledge about their reproductive health. Ensuring women get this knowledge helps them at every stage, not just adolescence. It informs all kinds of life decisions– from becoming sexually active to planning when and if to have a baby.

Of course, we cannot have these important conversations without acknowledging that while the United States has made progress reducing rates of unplanned pregnancy among teenagers, our rate remains among the highest in the developed world. Recent guidance, “Adolescent Pregnancy, Contraception, and Sexual Activity,” directly addresses the role ob-gyns can play to support adolescent girls in preventing unintended pregnancy. Contraceptive access to highly effective methods remains one of the most important factors, but comprehensive sexual education is also critical.

The success of this education relies on trust. In new guidance out this month, “Counseling Adolescents About Contraception,” ACOG highlights the importance of listening carefully to young patients concerns and priorities when discussing which contraceptive method choices are best for them. By the time they are teenagers, many young women have already been exposed to different ideas about contraception through friends, family, and pop culture. At the same time, they’re making decisions for themselves about their health care and what is important to them; physicians should be aware of these preferences and concerns and should partner with young women to assist them in making choices about their reproductive health.

Listening and respecting a patient’s perspectives and priorities truly should define the patient-provider relationship, not just one conversation. In many instances, ob-gyns may be the most trusted adult for teens who are ready to have essential conversations about their reproductive health, sexual activity, sexual orientation, gender identity, and/or mental health. We must be mindful of the sensitivities around these topics, and do our best to provide each patient with the care and knowledge she seeks. This also may include helping patients and parents navigate this new territory together; ob-gyns should encourage and support this communication when appropriate.

As late summer approaches, and more adolescents cross our paths, checking off annual doctor visits before the school year begins, we should each take time to reflect on our effort to have a lasting impact on patients’ reproductive health knowledge and relationship to their ob-gyn.

For a comprehensive overview of ACOG’s adolescent health care guidance, head to: https://www.acog.org/About-ACOG/ACOG-Departments/Adolescent-Health-Care

Contraception Is Not a Luxury, It’s Preventive Care

As women’s health care providers, we witness firsthand the impact access, or lack thereof, to birth control has on a woman’s life daily. Access to contraception is essential to women’s health and livelihood. Though contraception’s most vital role is empowering women to take control over their reproductive health, it touches every corner of their lives, from helping with management of other health issues to ensuring women can pursue their educational goals and achieve professionally without interruption from unintended pregnancy.

Fortunately, the Affordable Care Act made landmark progress for women’s health care by guaranteeing women’s access to essential preventive care, including contraceptive access with no co-pay. As a result, women went from spending 30 to 44 percent of their out of pocket health care costs on contraception to saving $1.4 billion annually on birth control. This rule ensured that women’s decisions about birth control could be singularly focused on what was best for their health and their academic, professional, economic, and social priorities—not what they can afford.

However, in the coming days or weeks the U.S. Department of Health and Human Services is expected to publish a rule that will eliminate the contraceptive coverage benefit. A political move in direct contradiction to the clinical and scientific evidence pointing to the vital role of contraception in comprehensive preventive health care, not to mention the mounting research verifying the profound positive impact increased access to contraception has on women’s economic and professional lives.

Prior to the ACA, cost was one of the greatest barriers to women’s contraceptive access. In many communities like the rural farming community in North Carolina where I was reared, people lived paycheck to paycheck, and many families did not have the privilege of prioritizing health care over basic needs of daily living. By assessing contraceptive choices by cost, we risk making birth control a luxury rather than a part of comprehensive preventive care. The average IUD costs $1000, or a month’s wages for a woman making the federal minimum wage, $7.25/hour, putting it totally out of reach for most of these women, despite being one of the most effective forms of birth control.

Women are 35 percent more likely to live in poverty, and therefore are disproportionately affected by unintended pregnancy and its consequences. Women with unintended pregnancies are more likely to delay prenatal care, resulting in a higher risk of birth defects, prematurity, low birth weight, and neonatal and infant morbidity and mortality.

This week we convened on Capitol Hill to present to a bipartisan group of representatives on maternal mortality and the role of affordable contraception on maternal health. Affordable and available contraception options enable women to make deliberate choices about if, when, and how many children they want to have and plan for pregnancy when they are more financially prepared. It can also be lifesaving for women who already face serious medical conditions. So, we cannot afford to return to a time where women did not have comprehensive reproductive health choices. This most certainly would turn back the clock on women’s health.

Our Moral Values, Our Core Values

It’s an interesting time for women’s health care, to say the least. With the recent passage of the American Health Care Act by the U.S. House of Representatives, obstetrician-gynecologists are faced with an uncertain political future. You may have the same questions that I do. Will this impact the way we practice and how we provide the best care for our patients?

As I took the reins as the 68th President of The American College of Obstetricians and Gynecologists last week, I discussed the importance of the Hippocratic Oath, one of the oldest binding commitments in history. Building from the central premise to ‘first do no harm,’ it outlines our responsibilities and obligations as ob-gyns to provide the best evidence-based care to all of our patients. These are our moral values, our core values and as women’s health care provides we have long demonstrated the passion and compassion in the clinical care of our patients.

At medical school graduations and hooding ceremonies at Duke University and many other institutions, all physicians in attendance have the opportunity to reaffirm and recite the Hippocratic Oath with the graduating medical school class. It’s a great reminder of why we do what we do:

“I will apply for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.”

“My responsibilities include those related problems, if I am to care adequately for the sick.”

Regardless of the political climate, I urge you to remember that we are ACOG: the primary advocate for women’s health care. We cannot waiver on our position on key issues including the primacy of patient welfare, patient autonomy and social justice. These values address our societal contract as physicians; considering the available resources and needs of all while taking care of the individual.

We have many challenges ahead and hurdles to overcome especially in regard to access and affordability of essential benefits for pregnancy care and age appropriate preventative well woman’s screenings. However, we must remain steadfast in our commitment to women’s health care. I look forward to working with you, my colleagues, and our new Fellows who took the oath last week to provide the best clinical care to women of this country.

A Rewarding Journey as ACOG’s President

When I started my term as ACOG’s 67th president last May, I wanted to make a difference in the lives of our members and patients, ensure ACOG’s continued growth, and lift our voice as the leading specialty organization in the nation. In many ways, what we have accomplished in 12 short months has far surpassed my expectations given the complexity of the issues we’ve had to deal with and the extraordinary circumstances we’ve had to navigate and overcome. So, in my last month, I’d like to revisit some of the things that have made this such an impactful year and taken me around the globe.

When I initially laid out my priorities for advocacy and global women’s health, there was no way to know the challenges we would face to protect women’s continued access to reproductive and maternal health care, both domestically and abroad. As my tenure progressed and new challenges presented themselves, increased member engagement became even more essential. So, we leveraged my All-in for Advocacy campaign, an effort to amplify and expand our voice with state and federal policy makers through our member stakeholders. In 2016 and 2017, I traveled throughout the country doing presentations at Grand Rounds and participating in state lobby days and was wowed by the energy and eagerness of our advocates to make positive changes in their home states.  Physicians led efforts to support our patients and our practices, successfully advancing legislation from maternal mortality to Zika and defeating legislation affecting the sacred patient-physician relationship and restricting reproductive health rights.

Also, because of ACOG’s excellent government relations team, we launched the State Legislative Action Center, where ob-gyns are able to learn more about their legislature and elected officials, search active legislation, and find opportunities to take action. And this certainly was the year for action! Ob-gyns had an important voice in the discussions on health care reform and urged policy makers not to turn back the clock on women’s health by repealing the Affordable Care Act. We fought for our patients to have continued access to affordable insurance coverage, comprehensive maternity care, no-cost preventive services such as contraceptives, and consumer protections that would prohibit insurers from denying coverage based on pre-existing conditions or setting annual or lifetime benefit caps. And while the fight is not over, the defeat of the American Health Care Act this past March is evidence that we made a tremendous impact.

We have also made great strides in ACOG’s efforts overseas. Through my own personal work to advance health care in struggling countries, I learned that we as ob-gyns can make a difference in global women’s health by sharing our knowledge and resources. However, extended time away from one’s practice is always very difficult and, for some, next to impossible. One of my goals was to make short-term projects easily accessible and identifiable for ACOG members and I am proud to say that we developed a database of non-profit organizations involved in two-week mission work that allows ob-gyns to get more information and sign up.

We’ve also grown the Alliance for Innovation in Maternal Health (AIM), which creates instructional and educational portfolios, or “safety bundles,” to fight high rates of maternal mortality in the United States. Through the hard work of ACOG’s Office of Global Women’s Health, the AIM safety bundle for postpartum hemorrhage has been instituted into practice in a low resource setting in Malawi at a community health clinic and referral hospital.  And it has meant so much to me to see the progress made and the lives saved because of this initiative. Additionally, ACOG helps educate and train local health providers in underdeveloped countries in various areas of obstetrics and gynecology through several programs, including Health Volunteers Overseas. I’m particularly proud of this work because I firmly believe that the same high standards we have for health care in the United States are the same standards that should apply to other developing countries around the world.

Lastly, another one of my goals this past year was to continue efforts to address the workforce and practice pattern changes we’ve seen in our specialty by improving ob-gyn resident education models. In 2016, the Council on Resident Education in Obstetrics and Gynecology Education Committee embarked on a complete overhaul of the learning objectives for residents. This effort resulted in the release of the Educational Objectives: Core Curriculum in Obstetrics and Gynecology, 11th edition. We are now surveying mid-career practicing ob-gyns to determine which of the core objectives they actually apply in their practices. Although this was an issue without an easy solution, we must continue to work together and discover ways to improve. And I truly appreciate all the hard work of ACOG’s education staff in helping to facilitate this endeavor.

As I pen my last blog, I feel that my time from president-elect nominee to president has been an incredibly rewarding journey that has literally spanned 400,000 miles, according to my frequent flier program. From trips to the nation’s capital to residencies across the country to small community health centers in Africa, each experience taught me so much and it was a great honor to be able to serve ACOG’s members in the process. If I had to impart any advice to ACOG’s incoming president, Dr. Haywood Brown, it would be to enjoy it because it will fly by. (No pun intended.) Enjoy the year, enjoy the people, and listen to their stories. Everyone has a story!

Conversations with Pregnant Patients Should Include Discussions About Infant Immunization Plans

This week is National Infant Immunization Week (NIIW), a time devoted to promoting the benefits of vaccination and to improve the health of children two years old or younger. As ob-gyns our active role in a baby’s health care often ends once a mother is discharged following delivery, but we play an important role in preparing women to tend to their infant child’s needs, including planning for immunization.

Pregnant women and infants are among the most vulnerable during infectious disease outbreaks. I’ve written before about ob-gyns responsibility to educate women about getting vaccinated during pregnancy, underscoring that immunization is essential to the health of both mother and fetus. Building women’s awareness about the importance of immunization during pregnancy also opens the door to discuss the importance of continuing immunization efforts into infancy and onward.

The positive outcomes associated with immunizing infants cannot be overstated. Though it’s hard for many to recall, there was a time where many infants and young children faced high risk of life threatening and debilitating illnesses. Many of these, like measles and polio, have been greatly reduced, almost eliminated due to population wide vaccination. We can protect children under the age of two from 14 different diseases, which is estimated to prevent 20 million cases of disease and about 42,000 deaths. While we should be heartened by these positive numbers, the key to keeping these infectious diseases at bay is ensuring parents understand that vaccination is safe and essential to the health of every child.

NIIW is a great time to renew efforts to educate patients about vaccine preventable diseases, and the positive impact vaccination has on all our lives. To make following immunization guidelines as straight forward as possible, ACOG has compiled all our immunization guidelines on one page, available here. Additionally, during a woman’s pregnancy, ob-gyns should encourage thinking about and planning for the infant’s health care. We can help by making referrals to pediatricians and directing women to resources that outline an infant’s necessary care, including immunization. The CDC prepares immunization schedules by age as a quick and helpful resource for providers, and childhood immunization schedule generators for parents, from age 0 to 6.

We are fortunate to live in a time where vaccination protects from some of history’s most devastating infectious diseases. We must continue to educate and support patients’ understanding about the overwhelming benefits of immunization for themselves and their children.