4 Simple Steps Ob-Gyns Can Take to Increase Flu Vaccination Rates Among Pregnant Women

Recently, the Centers for Disease Control and Prevention (CDC) released data indicating that about two-thirds of pregnant women have not been vaccinated against the flu this season. As clinicians, we know that the flu shot is safe, effective and the best protection our patients have against influenza. It is our job to communicate these messages to all of our patients, especially pregnant women.

The flu vaccine is safe and recommended during all trimesters of pregnancy, especially the second and third trimesters, when there is an increased risk of severe disease, hospitalization and even death as a result of contracting the flu. By getting vaccinated, pregnant women can protect themselves while also providing protection to their babies through placental antibody transfer until they are able to be vaccinated at six months of age.

Despite the benefits of vaccination, the latest CDC data shows us that low vaccination rates among pregnant women are pervasive. They are not just low among all age groups, but also among women of different races and ethnicities, across all education levels and regardless of whether women have health insurance or not. Among white, black and Hispanic women, the vaccination rate is 35.9, 31.5 and 35.4 percent, respectively. Also, while roughly 39.1 percent of pregnant women with a college degree were vaccinated, that is only 4.4 percent higher than women with a high school education or less.

However, one interesting data point indicates that flu vaccination is highest among women who reported that their doctor offered or recommended the vaccine. Among women who visited a health care provider at least once since July 2017, 52.4 percent received the flu vaccine from a provider who offered it. Also, according to the data, 50.1 percent of pregnant respondents received their vaccination at their ob-gyn’s office, which far surpassed other locations, including other doctor’s offices (29.2 percent); the drugstore, supermarket or pharmacy (10.3 percent); and work or school (5.9 percent).

This indicates that we, as ob-gyns, have a lot more influence over our patients than we think we do and that they trust us when we counsel them on their health and well-being. By simply educating women about the benefits and recommending the vaccine or offering them the opportunity to get vaccinated, we have the power to increase vaccination rates among pregnant women in this country.

Four steps you can take today:

1. Educate all pregnant women about the flu vaccine and the severity of influenza disease.

2. Strongly recommend and offer flu shots to all patients in your practice, particularly pregnant women. Flu shots can and should be given as soon as the vaccine is available.

3. Document flu conversations and flu vaccine administration in your patients’ chart and, when possible, your state’s immunization information system.

4. Lead by example—educate and vaccinate yourself and your staff against influenza.

For more information and updates on the 2017-18 flu season, visit http://immunizationforwomen.org/2017-2018-influenza-season and http://immunizationforwomen.org/fluseasonnewsletter.

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.

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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

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.

Ob-Gyns Can Be the Secret Weapon in the Fight Against Heart Disease

As ob-gyns, we know that the care we provide to women goes far beyond reproductive health. Thirty-five percent of women consider their ob-gyn their sole health care provider, putting us in a unique position to address an array of common health conditions. Since heart disease is the number one killer of women—and February is Heart Health Month—now is a good time to remember the part we can play in changing the outcomes of this devastating disease.

Perhaps the biggest threat of heart disease is lack of awareness of the condition’s prevalence and dangers. Though heart disease causes one in three deaths among American women every year—and 90 percent of women have at least one risk factor for developing heart disease—only one in five believes that heart disease is her greatest health threat, according to the American Heart Association (AHA). Equipped with these statistics, ob-gyns should feel confident initiating a conversation with patients about their heart health.

Helping patients address heart disease risk factors, ideally before a heart disease diagnosis, is key. Nearly two-thirds of women who die suddenly of coronary heart disease have no previous symptoms, according to the Centers for Disease Control and Prevention. For many women, the first signs of heart disease are actually the symptoms of a stroke, heart failure or heart attack, when serious damage may have already occurred. However, a number of risk factors are mostly under a patient’s control: an unhealthy diet and/or lack of exercise (both of which can lead to other important risk factors, including being overweight and having high blood pressure, high LDL cholesterol, and diabetes); smoking; and drinking to excess. When women are educated about how to make important lifestyle changes, it can be lifesaving. According to the AHA, 330 fewer women are dying from heart disease every day as a result of making heart healthy choices.

There are some factors that are out of a patient’s control, including a family history of heart disease, preterm labor and delivery, and preeclampsia. Ob-gyns can play an essential role by communicating the steps women can take to reduce their odds of a heart disease diagnosis. Even by simply acknowledging and discussing the risks, ob-gyns can make a difference. So, while these conversations aren’t always comfortable, they’re important because many women may not be hearing this information from any other health provider.

Lastly, since the symptoms of heart disease are widely misunderstood, particularly in women, it’s critical to share them with at-risk women. While angina is the most common symptom associated with heart disease, women are actually more likely to experience pain in the neck, jaw, throat, abdomen or back; shortness of breath; and nausea/vomiting. Lightheadedness, dizziness or fainting are common signs, as well. These symptoms don’t always occur during exercise or periods of stress; they can happen during rest, too. By ensuring your at-risk patients are aware of these signs, it could mean they get treatment faster, which will ultimately lead to better outcomes.

Ob-gyns have a powerful opportunity to be the secret weapon in the fight against heart disease. We can help inform our patients about the dangers, symptoms, and necessary preventative care. Communicated early and effectively, we can help women manage the factors that are in their control to help them live healthier, longer lives.

We Cannot Afford to Have the Clock Turned Back on Women’s Health

As we begin a new year, a lot is at stake for Americans’ health. Our nation’s leaders have promised substantial changes to the Affordable Care Act, from partial to full repeal, without the certainty of a replacement plan. While it can be easy to get caught up in the politics of health care, as ob-gyns our focus has always been on our patients and ensuring that they have access to safe, high-quality health care. That is why a critical part of our work here at ACOG is to advocate for the health of women, and as millions of people face the possibility of losing health insurance coverage in the coming months or years, ACOG’s work has never been more important.

Earlier this month, ACOG partnered with three leading medical organizations—the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians—to urge Congress to avoid repealing the ACA without an immediate replacement which would protect and retain the landmark women’s health provisions in the law.

The ACA is not perfect. In fact, ACOG didn’t endorse it originally because we felt it didn’t meet the needs of our physician members. However, while there’s lots to improve, the ACA does include really important protections for our patients’ health. Insurers must now cover maternity and preventive care and contraceptives. It stops insurers from charging women more than men for the same coverage, prevents insurers from denying coverage to women who were victims of domestic violence or who had a Cesarean delivery in the past. The ACA also guarantees women direct access to their ob-gyns without any limitations.

The coverage provided under the ACA allowed many women to schedule routine doctor’s appointments for the first time in their lives. We all know that when people have insurance, they’re more likely to use preventive care like mammogram and diabetes screenings that prevent more costly and life threatening health problems down the line.

Whatever one’s reservations may be about the law, as physicians we know how devastating it would be for a cancer patient to suddenly lose her coverage or for a pregnant woman to go without prenatal care and deliver a baby preterm because she could no longer afford health coverage. The fact is, low-income women are more likely to suffer from often preventable pregnancy complications and, unfortunately, that is the very population that stands to lose the most unless Congress protects these important benefits, including Medicaid expansion.

Today, 31 states and D.C. have expanded their Medicaid programs, offering coverage to 11 million newly eligible individuals. The most important part of the expansion to women is that those Medicaid programs cover low-income women even if they’re not pregnant. Regular Medicaid programs routinely only cover pregnant women through delivery and a few weeks after.

But speaking more broadly, all women stand to lose essential preventive care if the ACA is repealed. Access to breast cancer screenings decreases women’s likelihood of dying from the disease by up to 50 percent. Routine cervical screenings decrease the odds of late-stage cancer diagnosis by 60 percent. Finally, when women have access to more choices of affordable and effective contraception, including IUDs and implants, rates of unintended pregnancy, unplanned birth, and abortion drop dramatically.

In 2016 alone, 6.8 million girls and women gained health insurance coverage. If the law is repealed, those gains will likely be lost. We cannot turn back the clock on women’s health. The care we provide doesn’t stop in our exam or delivery rooms. It’s our responsibility to advocate on our patients’ behalf and protect their access to affordable, comprehensive health care. So let’s mobilize and use our collective community’s influence and expertise to ensure access to health care in this country.

To become involved in ACOG’s advocacy efforts, join us at the 35th Congressional Leadership Conference, The President’s Conference in Washington, D.C., in March.

Prevention of Preterm Birth Starts with a Healthy Mom

November 17 is World Prematurity Day. It gives us, as health professionals, an opportunity to direct our attention to a devastating health issue that impacts 15 million babies each year and rededicate ourselves to reducing that number. Several organizations, including ACOG, are supporting the cause through education, awareness, and advocacy events. However, there’s one event in particular that, coincidentally, started this week and stands to make the most significant impact in terms of lowering the preterm birth rate in this country and that’s open enrollment through the Health Insurance Marketplace.

Prevention of preterm birth starts with a healthy mom and that means access to prenatal care and preventive services. There are several risk factors for preterm birth, some of which include high blood pressure, low pre-pregnancy weight, alcohol and drug abuse, smoking, a prior preterm birth and a birth less than 12 months ago. Adequate health insurance coverage can make the difference between a pregnant woman carrying to term or delivering too early and the Affordable Care Act has helped make that coverage accessible to millions of women.

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