Balance for Better Women’s Health Care Globally

Jeanne Conry, MD, PhD, FACOG is president elect of FIGO, ACOG Past President, and a member of the FIGO executive board. She is chair of the United States Women’s Preventive Services Initiative, a collaborative initiative of health professional organizations and consumer advocates who recommend and guide preventive health services across a woman’s life span; and cochair of the FIGO Working Group on Reproductive and Developmental Environmental Health.  Read her guest blog:

As an ob-gyn, I’ve devoted my career to doing right by women, both inside the exam room and out. That means supporting women’s health in the United States and globally through advocacy, research, and education. This International Women’s Day, let’s talk about how we as women’s health care professionals can improve women’s health to build a more equitably balanced world and propel change to improve quality of life for generations to come.

The theme of this year’s International Women’s Day is Balance for Better. Balance for better means not just supporting more diversity in the workforce but also working to advance women’s health with equal thought and care. We see women’s health inequalities every day, whether it’s U.S. taxes on menstrual products or political debates about which women’s health services should be covered by insurance. The truth is that a more equitably balanced world means better access to quality care for all women. Exceptional health care requires the empowerment of women, the elimination of violence, the rejection of reproductive coercion, and a demand for dignified, high-quality services.

Last year, when I became president-elect of the International Federation of Gynecology and Obstetrics (FIGO), I promised to use the distinguished honor to advocate for bringing women’s health to the forefront of international issues, support effective family planning choices for all women, and educate and advocate for awareness about the effect of the environment on reproductive health. FIGO is in a position to galvanize support for these objectives by partnering effectively with regional, national, and global organizations and effectively integrating and collaborating with its member societies. but all ob-gyns can play a role supporting women as we work to balance for better.

Ob-gyns are in a unique position to be a strong and effective voice for access to health care all over the world, particularly in places where the need for access to obstetric and gynecologic surgery and preventive services are critical. At ACOG, the Office of Global Women’s Health (OGWH) seeks to increase women’s access to quality health care by building provider skills, supporting implementation of high-impact interventions, and scaling proven solutions to decrease maternal mortality and morbidity and improve care throughout a woman’s life. OGWH was founded on the premise that by leveraging ACOG and its members’ unique capabilities, we can help to improve women’s health everywhere.

In 2018, the OGWH launched an effective e-learning program in India; provided consultation to the development of international guidance documents; joined a coalition to improve maternal, newborn, and child health in Madagascar; launched a new surgery training curriculum in Uganda; and successfully closed out a multiyear collaboration with the Ethiopian Society of Obstetricians and Gynecologists. These achievements advance the well-being of women, ensure women and girls access to better sexual and reproductive health care services, and improve the delivery of maternal and women’s health care around the world. You can learn more about OGWH programs and the work they are doing to balance for better by visiting their website. I also encourage you to join their Listserv to learn about new opportunities and how you can become involved.

As an ACOG member and president-elect of FIGO, I look forward to collaborating with you as we strive for excellence in our clinical practice and women’s wellness worldwide. If you haven’t yet, please take a moment today to support International Women’s Day by posting on social media using #balanceforbetter.

ACOG Battles Maternal Mortality in Texas Through Maternal Site Surveys

Eugene Toy, MD

Eugene Toy, MD, is the medical director of ACOG’s Texas Levels of Maternal Care (LoMC) Verification Program, vice chair of District XI, and an ob-gyn at the University of Texas Medical School at Houston.

Levels of maternal care play an important role in supporting Dr. Hollier’s signature initiative to reduce preventable maternal mortality. The ACOG/Society for Maternal-Fetal Medicine Levels of Maternal Care (LoMC) Obstetric Care Consensus supports this initiative by proposing uniform designations for levels of maternal care related to hospital capabilities and resources. Through the LoMC Verification Program, ACOG aims to foster collaboration among facilities at varying levels of care so that pregnant women receive care at a facility appropriate for their risk.

ACOG launched the LoMC program in Texas, where Level II, III, and IV facilities that provide maternal care must undergo site surveys to receive the level of care designations that will allow them to receive Medicaid reimbursement. I had the privilege of attending the site visits for each of the 11 surveys the LoMC program completed in 2018. Here are some observations:

  • Build purposeful partnerships. By using a collaborative and transparent approach, ACOG serves as a resource and mentor as well as a survey organization. This partnership builds trust with hospital leadership.
  • Quality is key. Maternal quality programs are the key to reducing severe morbidity and mortality. Each hospital has its strengths and excellent initiatives, but can also make improvements, including implementation of consistent triggers for quality reviews, monitoring outcomes or closing the loop, and providing education to staff.
  • It’s about the team. In many settings, the obstetrical unit is fairly isolated and lacks communication, shared processes and guidelines, joint team training, and joint quality reviews. In our surveys, we bring all key hospital services and leadership to the table over dinner to discuss how each area interfaces to work together for the maternal patient.
  • Trust but verify. Our approach is to verify that the processes put in place by the maternal leadership are utilized consistently and documented. We do this with chart reviews, hospital tours, and interviews of bedside staff.
  • Show flexibility. ACOG’s approach has been to be open-minded to how medicine is practiced in different settings, since Texas is so geographically diverse. Ultimately, our top priority is patient care.

I’m happy to report that after six months, our Texas LoMC Verification Program has already made a substantial impact in equipping hospitals, doctors, and nurses to improve care for Texas mothers. If you know someone working in a hospital in Texas, tell them to schedule their survey with ACOG and join our efforts in reducing maternal mortality.

ACEs: What You’re Not Asking Patients and How Their Answers Affects Care

Connie Gayle White, MD, MS, FACOG is an ACOG member and practiced as an OB/GYN physician in Frankfort, Kentucky for over 20 years.  She is currently the Senior Deputy Commissioner in the Kentucky Department for Public Health (KDPH) overseeing all the clinical services provided by the Department throughout the state – all chronic disease programs, women’s health services, maternal child health, and overseeing development of new programs. Read her guest blog post below. 

I once had a patient who smoked cigarettes. Over the years I treated her, I diligently counseled her on the harmful effects of smoking and gave her resources to help her quit. Yet every visit she returned a smoker. One day, I casually asked why she started smoking. She confided to me that she began smoking at the age of 10 because her father hated the smell of tobacco. She knew if she smelled like smoke he wouldn’t come into her room to assault her at night. She then revealed she had taught her younger 8 year old sister to smoke too. Tearfully, she asked if she was a bad sister. I had of course taught her all about the consequences of smoking and now she worried she had inadvertently put her sister’s health at risk. Instead of helping her, I had retraumatized her each year because I hadn’t known anything about ACEs.

Adverse childhood experiences (ACEs) are stressful traumatic events occurring in childhood — such as physical, emotional, or verbal abuse or neglect against any member within a household, or other forms of violence and household dysfunction — can interrupt healthy social-emotional development in children, and their consequences are more far-reaching than most physicians may realize. The first two years of a child’s life are a critical period wherein the brain is hardwired for social-emotional development. Secure attachment stemming from a nurturing, consistent relationship with a caregiver is the foundation of healthy social-emotional development, which in turn becomes the foundation of an individual’s cognitive development and sense of self-identity.

ACEs lead to an increase in risky and unhealthy behaviors in adolescents and adults. For example, as the number of ACEs a teen has experienced increases, it follows the dose-response curve and the likelihood that that teen will have had sex by age 15, become pregnant as a teen, or impregnate someone as a teen. More ACEs are also correlated with higher risk of attempting suicide at age 18 or below. In Kentucky, which has one of the highest rates of children with three or more ACEs in the country, adults with high ACE scores (three or more ACEs) smoke or binge drink at higher percentages than their low-ACE score counterparts.

However, risky behaviors are not the only way ACEs manifest later in life.  Chronic toxic stress resulting from conditions producing high ACEs starting at birth and beyond increases serum cortisol levels over prolonged periods Arthritis, asthma, chronic obstructive pulmonary disease, and depression are more prevalent in adults age 18 and over with low ACE scores than in adults without, and even more prevalent still in adults with high ACE scores. Astonishingly, you’re more at risk for lung cancer if your ACE score is high than you are if you are a smoker. ACEs aren’t just a matter of psychology or emotion — they’re based in science, and knowledge of them can be a powerful tool for treating patients.

I’ve seen firsthand the serious and long-lasting effects of ACEs on women’s health, and now I realize that compassionate, trauma-informed treatment is a crucial skill for ob-gyns to learn so that we can not only effectively treat our patients but also avoid retraumatizing them without realizing it. Patients with ACEs are not just bringing themselves into our exam rooms — they’re bringing their experiences, too. By learning about ACEs, ob-gyns and their staff can treat patients with compassion and find real, effective solutions to issues that neither the ob-gyn nor the patient could solve otherwise. Start by watching this TED Talk: How childhood trauma affects health across a lifetime | Nadine Burke Harris and learn how to use ACEs when evaluating patient care options.

Join Us for ACOG Advocacy Month

Katie McHugh, MD, is the Current ACOG Junior Fellow Congress Advisory Council (JFCAC) chair and an obstetrician gynecologist at Indiana University in Indianapolis. Read her guest blog post below. Connect with her on Twitter at @KtMcH.

I’m honored to take over Dr. Hollier’s President’s Blog today to share something that’s so near and dear to my heart: advocacy! As your JFCAC chair, I’ve been waiting for October all year, and not just because I love costumes and candy corn. October is ACOG Advocacy Month!

ACOG Advocacy Month is a project the JFCAC launched because we want everyone — Junior Fellows and Fellows alike — to know that ACOG is more than practice guidelines and conferences. ACOG is also how we make our voices heard around the country and around the world and speak out about the issues that matter most to our specialty. Through the strength of our numbers, using the resources and connections ACOG has established, our specialty organization can be the megaphone or the password we need to make sure our message is heard where our voices are needed the most. And the best part? It’s incredibly easy to get involved wherever you are, no matter your schedule, and make a difference on the issues that are most important to you.

Before we get into the details, watch our short video about advocacy and how ACOG can help you advocate for issues you care about.

Each week of October will have a different advocacy focus, including at least one action item to help you find your passion and take action to make a difference right away. Check out our website each week for new updates, ideas, tips, and tricks and keep an eye on #JFAdvoMonth on social media for inspiration. Whether you’re a newcomer or a veteran advocate, I promise you’ll learn something new!

I’ve loved traveling the country with ACOG since my term began, making new friends and learning all of the different things our colleagues love most about our specialty. At every meeting and event I’ve attended, I’ve been inspired to see one trait overwhelmingly present in our community: Passion. It’s no surprise that folks who sign up for a life of long work hours, constant education, and high-pressure performance circumstances are a passionate group. Our patients and our practices rely on that dedication and enthusiasm every day — but our patients need us outside of the exam room too. Our commitment to our specialty must be heard in the places where decisions that impact our lives and the lives of the women we serve are made.

Advocacy is an integral part of our mission as physicians. This month, I hope you’ll join us in learning new ways to use our clinical experience and expertise to make an even bigger difference for women’s health.

On behalf of the JFCAC, happy ACOG Advocacy Month!

How I Unexpectedly Became A Powerful Voice for Women’s Health

Lynne Coslett-Charlton, MD, is a 2018 ACOG McCain Fellow and practicing gynecologist at Ob-Gyn Associates in Wilkes-Barre, PA. She shares why she’s a passionate advocate for women’s health in the guest blog post below. 

As a young physician in practice, I witnessed the power one person can have—and the impact an entire medical community can make when we speak together. I’m from a small town in Pennsylvania and work as a private-practice ob-gyn in a community hospital near where I grew up. To paint a full picture: I even joined the practice that delivered me some 50 years ago. While my practice provided excellent clinical teaching, it offered little education on the business of medicine. In fact, I was completely unprepared for the realities of the hostile medical liability climate that dominated my early years as an ob-gyn. Malpractice cases in my hometown soared and I was disheartened to see many of my excellent mentors and colleagues forced to alter or quit clinical practice altogether.

The ACOG Pennsylvania Section quickly mobilized in my tiny community, offering ob-gyns like me guidance and support on ways we can use our voice to send a clear message to policy makers. Eventually, malpractice in my community gained national attention and then President George W. Bush’s reelection campaign took notice and added it to his presidential platform.

It was then that I realized the importance of advocating not only for our patients—but for our needs as physicians. I quickly became engaged in my Section’s work on the broad scope of women’s health issues being legislated at both the state and national levels. In May 2018, I had the honor of becoming an ACOG McCain Fellow, which gives ob-gyns like me firsthand exposure to policy development and the legislative process in the federal and state governments.

During my first week on the job, a lot of progress was made on maternal health. First, there was the second annual March for Moms in Washington, D.C., where supporters marched for improved maternal care. ACOG President Dr. Lisa Hollier spoke at the march in support of initiatives like Maternal Mortality Review Committees (MMRC), which provide critical analysis into the causes of maternal mortality. That same week, The Pennsylvania governor signed into law HB 1869, which established Pennsylvania’s first MMRC under the state Department of Health.  MMRCs have since received wide support across party lines—and our message that all states should be consistent on their abilities to evaluate maternal deaths and make recommendations based on expert reviews resonated both at the state and national level. It was voices like ours in the women’s health community that helped maternal health legislation pass with bipartisan support in a political climate where very few issues are considered bipartisan.

It’s revealing when I look back at the road to becoming the strong advocate I am today for women’s health and our profession. When I started my career as an ob-gyn, I didn’t necessarily think of myself as a political force. But we must remember that our patients need us both inside the exam rooms—and outside.

My ACOG Section gave me a platform to make my voice heard and helped facilitate opportunities to meet with my representatives about women’s health issues that mattered to me. ACOG National built on those local experiences and helped me network with like-minded ob-gyns in ways I wouldn’t have been able to otherwise. During my weeks as an ACOG McCain Fellow I not only had the timely opportunity to advocate for MMRCs, but also attended briefings on sex education, sat in on the Advisory Committee Meeting on Women’s Veterans Health, and accompanied ACOG’s Government Relations team to a multitude of political events.

Something I hear often from my peers is “I don’t have time to advocate” or “I’m interested but I just don’t know where to start.” ACOG has so many easy ways for you to be involved—whether its sending out a pre-filled message or comment to your representatives or donating to the ACOG Ob-GynPAC, which is the only federal PAC dedicated to electing representatives who support our specialty. Get started and find your voice by visiting acog.org/advocacy or follow ACOG advocacy on Twitter at @acogaction.

The Case of the 132-Pound Ovarian Tumor

ACOG Member Vaagn Andikyan, MD, a board-certified gynecologic oncologist with the Western Connecticut Health Network (WCHN), and Assistant Professor for the University of Vermont Larner College of Medicine, shares his experience performing a lifesaving surgery on a patient with a 132-pound ovarian tumor in a guest blog post.

When I first saw the patient, she was unable to walk. She had shortness of breath and severe abdominal pain. She was malnourished because what we later learned was a 132-pound ovarian tumor was sitting on her digestive track, making it difficult to hold down food or water.

She sought care when she started to gain about 10-pounds a week. When she was ultimately referred to me, this 38-year-old woman had endured about two months of rapid weight gain. I saw fear in her eyes. I was determined to help her and I knew that I could at Danbury Hospital.

A computed tomography scan revealed a large ovarian mass. I suspected it was a benign mucinous ovarian tumor. The size of the tumor — measuring about three feet in diameter — along with its location made it a life-threatening situation. The tumor occupied the patient’s entire abdomen, and was compressing her aorta and vena cava. I was concerned about an underlining blood clot. The question became how do we remove this tumor and ensure the patient’s safety?

I assembled a team of nearly 25 highly skilled, caring clinical specialists, including fellow ACOG member and gynecologic oncologist Linus T. Chuang, MD, Chairman of Obstetrics and Gynecology for WCHN, plastic surgeon David Goldenberg, MD, Section Chief, Plastic Surgery Subsection at Danbury Hospital, and anesthesiologist Karl Kulikowski, MD, Vice Chairman, Department of Anesthesia, Medical Director, Operating Rooms, Department of Anesthesiology at Danbury Hospital.

Extensive pre-operative planning was crucial because there were many unknowns and hurdles to address. For example, because the tumor was so large, a concern was the amount of excess skin and our ability to close the incision.

We developed and practiced plans for five potential scenarios. Our goal was to perform the tumor resection and abdominal reconstruction at the same time to reduce the number of surgeries for the patient and improve her outcome.

In the end, the surgery took about five hours. We successfully removed the tumor — and only the patient’s left ovary. The patient went home just two weeks later and is expected to make a full recovery.

This was one of the most challenging, complex cases of my career. I might expect to see a 25-pound ovarian tumor, but a 132-pound ovarian tumor is rare. It reminded me how important it is to have colleagues you can rely on and trust. Our ability to pull together our expertise and experience is what gave us the confidence and knowledge-base to tackle this case, especially because this was the first surgery of its kind at Danbury Hospital. Danbury Hospital’s cardiovascular experts were instrumental to ensuring the patient’s safety. Medical residents conducted imperative research to aid in developing the care plan. The operating room staff prepped a room to accommodate a tumor of this magnitude. Dr. Goldenberg removed excess skin that was stretched by the tumor and reconstructed the patient’s abdomen. Danbury Hospital’s Intensive Care Unit and Inpatient Rehabilitation helped the patient to convalesce safely and quickly, and social workers helped the patient and her family to navigate her care plan.

The tumor tissue is currently with WCHN researchers at the Rudy L. Ruggles Biomedical Research Institute. They are conducting genetic tests. We want to understand why the tumor grew so quickly so we and our patient can learn from this case.

This case also reminded me how important it is to participate in community outreach to encourage women to routinely see their primary care providers and gynecologists for wellness screenings.

Thank you for the opportunity to share this extraordinary case with you all.