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.

Fight The Flu: 4 Ways to Protect Patients

Flu season is upon us again! As we enter the time of year when many of us are at increased risk for sickness, it’s important for ob-gyns and providers to take stock of what we can do to protect ourselves, our patients, and our patients’ families. Now is the time to understand the importance of preventing and treating the flu and learn how best to treat your patients.

It’s always crucial that we protect our patients however possible — but during this time of year, it’s especially important that we protect our pregnant patients, who are at increased risk of severe disease, complications, and hospitalization related to the flu. Those risks are especially compounded for pregnant women with any underlying conditions. As ob-gyns, we’re in a unique position to help drive home the importance of flu vaccinations — and to provide crucial assessment and treatment when need be. In order to best serve our patients during this flu season, we need to be ready to address the issue of the flu from all angles.

So what can ob-gyns do to make sure we’re prepared to protect our patients?

  1. Recommend — and, when feasible, offer — flu vaccination to all patients, particularly those who are pregnant. The flu vaccine is recommended for everyone six months and older.
  2. Lead by example and get vaccinated ourselves
  3. Encourage our colleagues and staff to get vaccinated
  4. Be prepared to assess and treat pregnant patients who present to us with suspected or confirmed influenza

ACOG has prepared resources to help you take these steps. ACOG’s Committee Opinion Number 732: Influenza Vaccination During Pregnancy outlines the recommendations for vaccinating your patients and provides important safety and efficacy information. Committee Opinion Number 753: Assessment and Treatment of Pregnant Women with Suspected or Confirmed Influenza, published this October, features an algorithm that will help providers assess pregnant patients for symptoms of influenza and determine the proper treatment of suspected or confirmed cases. Additionally, ACOG has resources to help you educate your patients on the importance and benefits of getting the flu vaccine and prepare yourself to answer any questions your patients may have about the flu or the flu vaccine.

As providers, we’re responsible for not only doing our best to prevent the risk of contracting the flu but also recognizing flu symptoms, assessing their severity, and prescribing safe and effective antiviral therapy for pregnant women with the flu. With ACOG’s flu resources, providers can make sure they’re prepared to defend against the flu on all fronts. Protect women and their families this flu season by encouraging your patients and staff to get vaccinated against the flu and doing so yourself.

Health Equity Through Action on Social Determinants of Health

This summer, I had the opportunity to participate on a panel moderated by The Hill, a Washington, D.C., newspaper and website, where we addressed equity in maternal and infant health (watch a recording of the session). The session reminded me of how important it is for us as ob-gyns to consider social determinants of health when caring for our patients.

Social determinants of health are conditions in a person’s environment that can affect a wide range of health, functioning, and quality-of-life outcomes and risks. We may not think of social determinants as influential factors when it comes to health, but the environments in which our patients are born, live, work, and spend their time all impact their health outcomes. Availability of resources to meet daily needs such as safe housing and local food markets; access to educational, economic, and job opportunities; access to health care services; and social norms and attitudes such as discrimination, racism, and distrust of government — these are all determinants that affect conditions we see in our patients every day.

Social determinants also affect pregnancy outcomes. Disparities in maternal mortality and morbidity rates between women of different races, ages, geographic locations, and more can be linked to different social determinants of health. Because social determinants vary so widely, their effects manifest differently for different groups of women.

For example, maternal mortality and morbidity rates are three to four times greater for black women than for white women. Studies have shown that hospitals who serve primarily black women tend to have much higher rates of maternal morbidity. There are also numerous personal accounts, some from figures as prominent as Serena Williams, that show black mothers can feel that their health concerns are disregarded. While many factors contribute to black women’s elevated maternal mortality and morbidity rates, we can’t overlook the roles of social determinants in contributing to poorer outcomes

So why am I telling you all of this? As providers, we can benefit immensely from understanding how our patients’ environments affect their health and allowing that understanding to inform our practice. If we want to secure better health for all mothers, we must take social determinants as seriously as we would any other pre-, peri-, or postnatal condition.  Once we understand how environments can affect health outcomes, we can treat our patients more holistically. We can not only address those influences but also help create and maintain healthy environments that promote better health outcomes. Read through ACOG’s Social Determinants of Health resource overview, which offers resources that may be helpful for you and your patients related to social determinants of health.

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!

Early Screenings Can Prevent Depression in Pregnant Women and New Moms

Last month, the U.S. Preventive Services Task Force (USPSTF) issued draft recommendations for assessment and treatment of pregnant and postpartum women who are at increased risk of perinatal depression. The USPSTF recommends that pregnant and postpartum women be assessed to identify whether they are at high risk for depression so they can receive intervention before symptoms arise. ACOG joins other women’s health care organizations in applauding these recommendations, as they speak to the heart of preventing mental health issues in the women we treat.

In their draft evidence review, the USPSTF found convincing evidence that counseling interventions such as cognitive behavioral therapy and interpersonal therapy are effective in preventing perinatal depression in women at increased risk. ACOG has long believed that ob-gyns who screen women for perinatal and postpartum depression play a critical role in managing depression’s impact on women and their families throughout and after pregnancy by alerting women to their level of risk for depression and referring them for intervention.

Mental health issues are one of the most common complications during pregnancy and postpartum. On average mental health issues affect one in seven women during the perinatal period, but that rate is higher in certain groups of women. For example, women who are socioeconomically disadvantaged are at particularly high risk for depression; for them, the rate of perinatal depression rises to one in three. It’s clear that we can’t afford to let perinatal and postpartum depression slip through the cracks. ACOG’s recommendations, along with the USPSTF’s draft recommendations, aim to ensure that all mothers at high risk for depression receive the care they need as early as possible.

In Committee Opinion 630: Screening for Perinatal Depression, ACOG recommends universal screening at least once during the perinatal period and advises that systems be in place to ensure follow-up diagnosis and treatment. ACOG’s guidance aims to promote the integration of maternal mental health into perinatal care delivery. It’s important to remember that screening is an important step in achieving that goal, but it’s not a diagnostic tool. The postscreening stage is critical, and access to care — particularly in the form of psychologists, psychiatrists, and other mental health resources — can be a challenge for many, especially for those of us who are up against financial, geographic, and social barriers. That’s why I’m proud of the instrumental work ACOG has done in the passage of the 2016 Bringing Postpartum Depression Out of the Shadows Act, which will increase states’ ability to ensure women have access to routine screening and treatment.

ACOG worked to bring maternal mental health into the spotlight and supports state programs that help providers connect women to the treatment they need. We have convened a Maternal Mental Health Expert Work Group, a multidisciplinary collaboration of specialists in women’s health, obstetrics, psychiatry, psychology, nursing, social work, and public health, and established resources to help increase knowledge among ob-gyns about the need for screening and established response protocols. But we don’t intend to stop there: ACOG will continue to work with our partners to integrate maternal mental health care into perinatal care delivery.

After the public comment period, which ends September 24, 2018, the USPSTF will review the feedback received and develop a final recommendation statement and evidence review. Final recommendations will be posted on the USPSTF website.

For more information about ACOG’s guidance and initiatives to promote integration of maternal mental health into perinatal care delivery, see our depression and postpartum depression resource overview.

As I’ve mentioned previously, hearing directly from my fellow members is one of the reasons I love being ACOG President. You can always reach me viaTwitter at @TXmommydoc.

Breastfeeding in the Headlines

Breastmilk is easier to digest than formula, and contains antibodies that protect against infections, allergies, inflammatory bowel disease and sudden infant death syndrome. The benefits of breastfeeding extend into adulthood, with lower rates of obesity, cardiovascular disease risk factors, diabetes and some types of cancers. Nursing mothers also enjoy benefits such as reduced risk for breast cancer, ovarian cancer, diabetes, hypertension, and heart disease.

There is no shortage of evidence showing the value of breastfeeding for both women and their infants.  And yet, studies show that while most women in the United States initiate breastfeeding, more than half wean earlier than they desire. Barriers to breastfeeding can have a dramatic impact on the likelihood a mother will continue to nurse her child.  Common barriers include a women’s socioeconomic status, education, misconceptions, and social norms. For example, barriers such as the need to return to work sooner after giving birth and employment in positions that make breastfeeding at work more difficult contribute to lower rates of breast feeding among low-income women than women with higher incomes.

While the Affordable Care Act includes provisions to support breastfeeding mothers, there is more to be done. Supporting a woman’s decision to breast-feed takes a multifaceted approach, including advancing public policies like paid family leave, access to quality child care, break time, and a location other than a bathroom for expressing milk.

As ob-gyns and advocates for women’s health, we can also support women to achieve their infant feeding goals directly through patient care. According to  ACOG Committee Opinion NO. 658, Ob-gyns and other obstetric care providers should:

  • Develop and maintain knowledge and skills in anticipatory guidance, physical assessment and support for normal breastfeeding physiology, and management of common complications of lactation.
  • Support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.
  • Support women in integrating breastfeeding into their daily lives in the community and in the workplace.
  • Be a resource for breastfeeding women through the infant’s first year of life, and for those who continue beyond the first year.

ACOG strongly supports breastfeeding and provides resources for both you and your patients. I encourage you to visit acog.org/breastfeeding to learn more.

Let’s Speak Up for Title X

Last month, the Department of Health and Human Services announced proposed changes to the rules governing the Title X program. Created in 1970, Title X is the only federally funded grant program exclusively dedicated to providing low-income patients, including adolescents, with essential family planning and preventive health services and information.

The Title X program is an important thread in the fabric of women’s health care. As the only federal grant program of its sort, Title X plays a vital role in ensuring that safe, timely, and evidence based care is available to every woman regardless of her financial circumstances.  However, the proposed changes fundamentally change the nature of the Title X program by restricting access to essential preventive care, interfering in the patient-physician relationship and making it harder for women to make timely, informed decisions about their care. These limitations and restrictions undermine our ability to offer patients medically accurate, comprehensive care.

As ob-gyns, we know the essential role contraception plays in our patients’ lives. Contraception is cost-effective, reduces unintended pregnancy and abortion rates, and allows women to have more control over their reproductive health. It also allows women and their families to achieve greater educational, financial, and professional success and stability. Title X plays an essential role in ensuring these choices are accessible to every woman. No patient should have to sacrifice safety or efficacy because no better options are available to her.

Moreover, Title X does not just address family planning needs, but also routine preventive care. Health centers that receive Title X funds also provide services like well woman exams, breast and cervical cancer screenings, screening and treatment for sexually transmitted infections, testing for HIV, pregnancy testing and counseling, and other patient education and/or health referrals.  These services save women’s lives.

The proposed changes also raise specific concerns about government interference in the practice of medicine. While Title X funds have never been permitted to be used for abortion care, the proposed changes take a further step to exclude qualified providers from participating in the Title X program. This puts access to essential care at risk for 40 percent of Title X’s four million patients.  ACOG opposes any effort to exclude qualified providers from federal programs.

We oppose political efforts to direct health care providers to withhold information or rely on non-evidence based counseling methods. We consider any effort to move away from science-based principles to be interference in the patient-physician relationship.  Women count on their providers for clear medical information. The government should not limit what information women can know or what kinds options she should be given.

This level of interference in the practice of medicine would set a dangerous precedent for all areas of medicine.

In practice, these changes will have the most profound impact on low income women and women of color, the very patients this program was created to serve. We cannot accept less access or fewer options for some patients simply by circumstances of their geography or finances.

Your voice can make a difference on this important issue. Over the course of the next few weeks, we will be asking you to engage in advocacy on this issue, including submitting comments. In July, ACOG  members will receive a sample comment template to use.

Thank you in advance for joining me in ensuring that women have continued access to high quality, medically accurate reproductive and preventative health care through Title X. It’s essential to women’s health.

Communities at Risk: Suicide Rates Rising Across the U.S.

The loss of Kate Spade and Anthony Bourdain last week is a reminder that depression and suicide can affect anyone.  There has been a 30% rise in suicide rates from 1999 to 2016, according to a report on released by the CDC on June 7, 2018. Suicide increased in almost every state, and killed more Americans ages 10 or older than homicides did nationally. CDC Principal Deputy Director Anne Schuchat noted, “Suicide is a leading cause of death for Americans – and it’s a tragedy for families and communities across the country.”

As physicians, we are not immune to the realities of suicide.  Physicians suffer from higher rates of burnout, depressive symptoms, and suicide risk than the general population. Suicide generally is caused by the convergence of multiple risk factors — the most common being untreated or inadequately managed mental health conditions.12

The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is even more pronounced — 2.27 times greater than the general female population.3  According to one study, physicians who took their lives were less likely to be receiving mental health treatment compared with non-physicians who took their lives even though depression was found to be a significant risk factor at approximately the same rate in both groups.

What can you do? Know the signs and don’t be afraid to ask for help. As physicians we also need to take care of ourselves. Past ACOG President Dr. Mark De Francesco’s task force on physician wellness compiled several resources for ob-gyns to help cope with several issues such as adverse events and burnout. You can find additional resources here.

Ob-gyns also have a unique opportunity to play a pivotal in women’s mental health. ACOG recommends screening for depression at least once in the perinatal period. Visit ACOG’s resource overview on depression and postpartum depression for more information.

More recently, ACOG also released two new committee opinions pertinent to helping ob-gyns address mental health. In Committee Opinion 736: Optimizing Postpartum Care,ACOG emphasizes the importance of the fourth trimester. By increasing touch points with patients and asking questions, ob-gyns can better understand and assist new mothers. Committee Opinion 740: Gynecologic Care for Adolescents and Young Women with Eating Disorders highlights how the annual well women visit can serve as a women’s gateway to other health services, including mental health or behavioral health services.

Don’t underestimate the value of simply listening. If you know someone who might be suffering from suicidal thoughts, visit the National Suicide Prevention Lifeline or call 800-273-TALK.

At the Heart of Patient Care

More than 90 percent of women have at least one risk factor for heart disease, yet most women are unaware that heart disease is their leading cause of death in the United States.  Less than half (39%) of primary care physicians, including ob-gyns, consider cardiovascular disease to be a top concern for women.

Last month, ACOG and the American Health Association released a joint advisory calling on ob-gyns to use annual well woman exams as an opportunity to assess a woman’s risk for heart disease.  For many women, their ob-gyn is the only physician they see routinely, particularly women during their childbearing years. This emphasizes the important role of the ob-gyn to identify risk factors for heart disease and stroke—long before clinical signs are apparent.  Not doing so is a missed opportunity for early detection and intervention.

Research shows that pregnant women with complications like preeclampsia, gestational diabetes, and growth restricted babies, have three times the risk of later cardiovascular disease than women without these pregnancy complications.  Additionally, cardiovascular events and cardiomyopathy are the leading causes of maternal mortality in the U.S., together accounting for 25 percent of all maternal deaths.

As the leading health care providers for women, we can be a powerful voice for patients, counseling and educating them on how to achieve and maintain long-term heart health. Whether it’s advising patients about healthy diet and lifestyle, or taking advantage of high-tech solutions such as software algorithms that can trigger patient education and referrals by analyzing data contained in electronic medical records, the well woman exam is an opportunity for us to deliver patient-centered care.

I’m so excited to share more with you during my year in office, and to hear from you directly. Connect with me on twitter at @TXmommydoc.