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.

Guest Blog: We Took AIM at Maternal Mortality and Made a Difference

No woman should die on what ought to be the happiest day of her life. Yet that is exactly what’s happening in the United States at a rate unmatched in the developed world. ProPublica-NPR recently highlighted the realities of maternal mortality in an article about a 36-year-old African-American mother—an epidemiologist at the Centers for Disease Control and Prevention—who died after giving birth from complications of high blood pressure.

The rates of maternal mortality in our home state of Michigan are stunning. There are 10.6 pregnancy-related deaths per 100,000 women, and African-American women die at a rate that is 4.9 times higher than white women. There are many causes of maternal death. The leading causes include heart attack or heart failure, stroke from high blood pressure, severe bleeding, serious infection, and blood clots. And, as more pregnant women have chronic health conditions such as obesity and heart disease, they become more likely to die during or after pregnancy. Even more startling is that, for every woman who dies, there are 100 more who suffer severe maternal morbidity—life-threatening injuries, infection, or disease due to chronic or acute conditions

Last month, the Alliance for Innovation for Maternal Health (AIM), a national initiative championed by 19 women’s health care organizations including ACOG, has already shown early steps toward reducing severe maternal morbidity. The goal of AIM is to reduce preventable maternal mortality and morbidity through hospital implementation of proactive patient safety bundles and resources for common pregnancy-related complications, such as preeclampsia and hemorrhage.

In 2015, Michigan became one of the first eight states to join AIM. ACOG’s Michigan Section teamed up with the Michigan Health & Hospital Association and the Michigan Department of Health & Human Services, along with the American College of Nurse Midwives and the Association of Women’s Health, Obstetrical and Neonatal Nurses to align resources and work cohesively as a single initiative for all birthing hospitals in the state. The initiative is called MIAM.

Roughly 80 hospitals in Michigan have committed to implementing the AIM safety bundles. They have also committed to collecting and reporting data on maternal outcomes to drive quality improvement. This reporting allows hospitals of similar size and capacity to assess and compare their performance and progress.

While this type of work requires a culture shift that will take time to fully adopt, we are already seeing dramatic improvements in maternal health. In Michigan alone, there has been a

  • 10.5 percent decrease in severe maternal morbidity since 2016
  • 17.9 percent decrease for other complications during labor and delivery among women who experience hemorrhage
  • Five percent decrease among women who experience hypertension

Recent data from four of the original eight AIM states, which collectively represent 266,717 births, also shows a marked difference in maternal outcomes. There has been a 20 percent decrease in the severe maternal morbidity rate.

Mother’s Day is a good reminder that we as health care providers must resolve to remain diligent in our efforts to reduce maternal mortality and morbidity. We commend each of our AIM hospitals and urge hospital administrators to stay focused on the task at hand: to provide the necessary support to make the AIM initiative a priority so we can succeed at keeping mothers safe.

For a long time, Michigan hasn’t been the safest place for moms—especially African-American moms—to give birth. The good news is that, over the past few years, the numbers have been finally going in the right direction. We are poised to continue making improvements and ensuring that every mom can safely give birth in Michigan, and every state in the country.

Written by ACOG Members Jody Jones, MD, and Matt Allswede, MD

We MUST Do Better on Maternal Health

The first time I saw a new mother die, I was early in my career. A healthy, young woman had a complication during labor and needed a C-section. While the care team delivered a healthy baby, the mother never regained consciousness and eventually passed away. I remember seeing her husband late that night in the hospital, holding his new baby. It was supposed to be the happiest moment of his life, but instead he looked completely lost.

That moment had a profound effect on me and is one of the reasons I’ve committed my career—and now my ACOG presidency—to reducing preventable maternal mortality. As I said last week at the 2018 ACOG Annual Meeting in Austin, Texas, where I was sworn in as the 69th president of ACOG, “To achieve our full potential not just as women, but as a country, and as a global community, the health of women MUST be a priority.”

As ob-gyns, we dedicate our lives to advancing women’s health, and there is no contradiction more stunning than the rise of maternal mortality and morbidity in the United States. While other countries have been able to reduce maternal deaths over the last 20 years, the U.S. continues to see rates grow. Worse yet, African American women are two to four times as likely to die from pregnancies than Caucasian women.

During my year as president, ACOG will continue its good work surrounding the issue of maternal mortality through three initiatives:

  1. Advocacy on the state and federal level to establish maternal mortality reviews. These state-based reviews offer a valuable opportunity to understand maternal death through a detailed review of medical records and autopsy reports. By finding causes of and contributing factors to maternal death, we can identify opportunities to prevent them.
  2.  A stronger culture of patient safety in hospitals. ACOG helped found the Alliance on Innovation on Maternal Health (AIM), a national maternal safety and quality improvement initiative to reduce maternal mortality and severe morbidity. Together with 19 partner women’s health care organizations, ACOG has worked with hospitals and health systems to implement patient safety bundles across the country. Today, 23 states are part of AIM, and it’s our goal to sign on all 50 states.
  3. A taskforce devoted to heart disease in pregnancy. Cardiovascular disease is the number one cause of death in women in the U.S. (400,000 deaths annually), and cardiovascular events and cardiomyopathy are the leading causes of maternal mortality, accounting for nearly 25 percent of deaths. This multidisciplinary taskforce will concentrate on creating evidence-based, best practice guidelines addressing screening for, diagnosis, and management of cardiovascular disease in women, before, during and after pregnancy. It will also address the pregnancy-related contributions to lifelong cardiovascular risk by evaluating the evidence, making recommendations, and prioritizing research that will drive better care.

While I’m excited to have this opportunity to focus on safe motherhood, one of the most enjoyable aspects of this position is to meet you, my fellow members. I look forward to working with you, and our new class of Fellows who took the oath last week, to provide the best clinical care to women of this country. Please connect with me on Twitter @TXmommydoc, and follow @acognews to keep up with the latest news in our profession.

How Dedication to Black Maternal Health Honors the Legacy of Henrietta Lacks

Sixty-seven years ago, two tissue samples taken from a young, African-American woman diagnosed with cervical cancer led to the most important cell lines in medical research. Her name was, of course, Henrietta Lacks. Today, it would be difficult to find someone who isn’t familiar with her story. The “immortal” He-La cells have been used in more than 74,000 studies and have led to the discovery of the Polio and HPV vaccines, treatments for diseases, including diabetes and AIDS and other life-saving research around the world.

The contributions Lacks made to medical science have been heralded in the best-selling book, “The Immortal Life of Henrietta Lacks,” by the foundation created in her name, in countless news stories, in an HBO movie starring Oprah Winfrey and by the National Institutes of Health (NIH) through the establishment of a working group in her honor. In 2013, the NIH stated that Lacks and her family were the “greatest philanthropists of our time.” However, it wouldn’t be until 1987, 36 years after her cells were replicated and shared widely amongst the research community, that the NIH would institute a policy “encouraging” the inclusion of minorities in clinical studies. And it would be another six years before Congress would make it law through a section in the NIH Revitalization Act of 1993 entitled Women and Minorities as Subjects in Clinical Research. The reason for this move by the NIH is obvious. We cannot appropriately evaluate the effects of drugs in clinical trials without a racially diverse sample.

Therefore, it should be considered one of the greatest conundrums of our time that a black woman is responsible for thousands of breakthroughs in biomedical research and yet, in 2018, black women are three or four times more likely to die during childbirth than their white counterparts. When it was discovered that Lacks had cervical cancer, she had just given birth to her fifth child. At 31 years of age, Lacks suffered from a severe hemorrhage after childbirth and died eight months later after receiving routine cancer treatments and experiencing continued abdominal pain.

By today’s definition, Lacks would be counted among the women lost to maternal mortality. According to the Health Resources and Services Administration, the maternal mortality rate in the 1950s was 83.3 deaths per 100,000 live births. And while that number has decreased significantly since then, it is well-known that the United States is considered one of the most medically advanced developed countries— and yet, it has the highest maternal mortality rate amongst its peers, with even higher numbers for minority women.

I’ve done several media interviews on the topic of racial disparities in maternal mortality. Reporters always ask why these disparities exist, especially among well-educated, affluent black women where access to care is not an issue. In my interview with Essence magazine, I explain that there is a complex web of causes, but it often involves social determinants of health and structural barriers to health care. Whether an African-American woman is rich or poor, has a GED or a PhD, she is susceptible to morbidity and mortality and implicit biases of race and class. This not only impacts the quality of care she receives, but can also have negative physiological effects. The relationship between stress and how we respond to that stress physiologically has well-documented associations with prematurity and cardiovascular disease. The “microaggressions” that black women endure throughout their lives also make them predisposed to chronic conditions that can make a pregnancy high risk, such as hypertension and diabetes. It is a failure in our medical care as providers if we do not 1) recognize and accept this and 2) meet the necessary cultural and systemic challenges that impact health outcomes.

During my ACOG presidency, much of my focus has been on providing guidance on how to make these system level changes. In May, ACOG will release a revised “Optimizing Postpartum Care” Committee Opinion developed by my presidential task force, “Redefining the Postpartum Visit,” and the Committee on Obstetric Practice. It will stress the importance of the fourth trimester and propose a new paradigm for postpartum care. When women fail to receive postpartum care, it impedes management of chronic health conditions. Attendance rates are often lower among populations with limited resources, which contributes to health disparities.

As we celebrate Black History Month and the contributions of African-American mothers like Henrietta Lacks, we must honor her legacy by not accepting the deaths of black women from pregnancy and childbirth as a reality of race.

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.

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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Setting the Record Straight on Drinking During Pregnancy

When confronted with so many different types of infections and viruses that can threaten the health of an unborn baby, it’s unfortunate that drinking during pregnancy is still the leading cause of birth defects in this country and abroad. Without knowledge of the devastating effects, it’s easy to have a casual attitude toward drinking but when a fetus is exposed to any amount of alcohol it can lead to a number of permanent and debilitating conditions. These are known as fetal alcohol spectrum disorders (FASD) and can include anything from severe brain damage and growth deficits to lifelong learning and behavioral problems in children. September is designated as FASD Awareness Month but my hope is that at some point in the near future there is no longer a need to observe it because the fact is—FASD is 100 percent preventable.

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Ob-Gyns Can Empower Women to Choose Breastfeeding

Only 22 percent of mothers in the United States are exclusively breastfeeding their babies at six months. Although most U.S. women initiate breastfeeding, more than half wean earlier than they desire and fall short of their personal goals. These are startling statistics given all the research and evidence we have that shows how beneficial it can be for both women and babies. That says to me that we, as providers, can do more to empower women with the knowledge to make this critical decision. As National Breastfeeding Month comes to a close, it seems like an appropriate time to remind us how important our guidance really is and the potential impact it could make on health outcomes.

There are many barriers to successful breastfeeding but I believe the key to overcoming them starts with education—the one factor that physicians have the most control over. Misinformation can often be the culprit when it comes to a mother making the decision not to breastfeed. Discussions about breastfeeding should be integrated into maternity care. Providers should obtain a thorough history and find out early what expectant mothers know or have heard about breastfeeding. Often times, it’s as simple as mitigating fears regarding pain associated with breastfeeding and letting mothers know that it might not come naturally at first and that, with the right support, techniques are learned and will improve over time. Providers should respect and support a woman’s informed decision whether to initiate or continue breastfeeding, as each woman is uniquely qualified to decide which feeding option is best for herself and her infant.  However, pregnant mothers take their doctors’ advice seriously, so we shouldn’t underestimate our influence. By saying nothing, we imply that it doesn’t matter—and it does.

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Immunization is Crucial for Pregnant Patients and Their Babies

As ob-gyns, we know the important role that vaccination plays in the health of mother and baby. It is one of our best options in reducing their chances of morbidity and mortality from vaccine-preventable diseases. Additionally, vaccination helps prevents the spread of certain infectious diseases.

The fall is usually when we start reminding women to get their annual flu vaccine, especially if they are pregnant. However, recent reports of whooping cough (pertussis) and measles exposure underscore the need to discuss other vaccinations with our patients. August is National Immunization Awareness Month and a great time to talk to your pregnant patients about immunization.

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Zika Provider Action Week

The White House has declared this week Zika Provider Action Week. This call to action could not come at a better time. The Zika virus has occupied our profession and our patients nearly non-stop since news of it broke last fall. There is no doubt that Zika presents a very real concern to patients and challenge to health care providers. With the discovery of virus transmission by mosquitoes here in the United States, many of us are faced with the even more real possibility of treating patients with potential or confirmed exposure.

As ob-gyns, we are on the front lines of patients’ concerns about Zika. As each new finding is played out in the news, our patients call or come in looking for answers to help their understanding of the risk, and more often than not, assuage their fears. Unfortunately, in the instance of Zika, we too are often scrambling for knowledge, seeking elusive answers from research institutions and government agencies. The Centers for Disease Control and Prevention (CDC) has done an admirable job working quickly and efficiently to assess, address, and educate the American public about the Zika outbreak.

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