A Look Back: A Year Spent Advocating for Women’s Health

Throughout my long career as an ob-gyn, I’ve never been witness to a more intense national focus on the health care provided to American women than I have in this past year as president of ACOG. We’ve seen the deaths of pregnant women during and after childbirth take center stage as our understanding of the embarrassing U.S. maternal mortality rate grew. Countless labor and delivery unit closures at rural hospitals across the country have drawn attention to access to care, and many were shocked to learn that nearly half of U.S. counties lack a practicing ob-gyn. Legislative attacks on women’s health care have spread like wildfire, as both federal and state governments have attempted to restrict women’s ability to obtain health coverage and contraception, obstruct their access to abortion care, and institute punitive measures for pregnant women suffering from drug addiction. From the beginning, it was clear that the challenges facing our specialty—and to us, the physicians who care for women throughout their lifespan—are immense.

Before I officially took the reins in May 2017, we were already in the midst of the work, advocating against efforts in Congress to strip health care from millions of women through the repeal of the Affordable Care Act (ACA). Women stood to lose access to no-copay contraception, affordable maternity care, and essential preventive services. Women were at risk of returning to a time where they might have been denied coverage based on a prior C-section or had to pay more for insurance based on their gender, and Medicaid coverage for hundreds of thousands of low-income women would have been in jeopardy.

All of this played out in the news as ACOG fought fiercely alongside five other provider organizations in a coalition called the Group of 6. We batted down every iteration of legislation that would have been detrimental to the health of the women in this country. We lobbied, we rallied, we spoke to the media, and we galvanized ACOG members in support of this common cause. I am proud of what we accomplished, and I count the tremendous effort to defeat ACA repeal as one of the successes of my presidency. But, of course, there was much more work to be done.

In addition to my time at ACOG, a large focus in my career has been on perinatal health disparities and maternal mortality. More than 60 percent of maternal deaths are preventable, and more than 65 percent occur within the first week postpartum. One way ACOG is trying to address this is through the Preventing the Maternal Deaths Act. It would provide grant funding to states to establish or bolster maternal mortality reviews committees tasked with studying the causes of these deaths, and how they can be prevented. But these statistics also indicate that as providers, we need to change the paradigm when it comes to postpartum care.

As part of my presidential task force, “Redefining the Postpartum Visit,” we began with the premise that postpartum care is the gateway to lifelong health. It is not sufficient for women to have one visit six weeks after childbirth. It is critical for women to be seen within the first three weeks and then on an ongoing basis as needed—up to 12 weeks—to address several issues, including breastfeeding complications, postpartum depression, and chronic conditions such as diabetes and heart disease that often persist long after pregnancy. Women have multiple intersecting health needs, so we must facilitate care coordination between multiple providers to ensure women are able to seamlessly access the support and care they need. The task force just released a Committee Opinion this week and, in the coming months, a companion online toolkit for providers will be developed to assist in providing more holistic care. The latest article from ProPublica outlines how this reinvention of postpartum care will require “sweeping” changes in medical practice and throughout the maternal care system if we are to truly optimize the health of moms.

Another focus of my presidency has been on innovation in technology to improve women’s health, particularly telehealth and telemedicine. According to a Health Affairs study, nine percent of rural counties experienced the loss of all hospital obstetric services between 2004 and 2014. Through my “Telehealth Task Force,” we have been working to develop best practices in ob-gyn to improve access and address fragmentation in care. This has significant implications for the Levels of Maternal Care initiative, which focuses specifically on care access in rural settings. It relies on communication and care coordination between hospitals and birthing centers so that women can be transferred to and receive care from a facility that offers the level of care that best suits their needs. Telemedicine will be key in fostering that communication.

The task force remains committed to addressing issues regarding safety, payment, experimental e-obstetrics, virtual education, video conferencing, virtual monitoring, apps, and the crossover between inpatient and outpatient care. In the future, a telehealth Committee Opinion will be developed, and an ongoing work group will be established to continue this important effort. We are also combating the access issue from a legislative perspective through the Improving Access to Maternity Care Act. It has been passed in the House and currently resides in the Senate. Through this legislation, an official maternal health designation through the Health Resources and Services Administration will be created to better determine shortage areas. This in turn will allow more providers to serve in these areas through loan forgiveness programs and scholarships offered by the National Health Service Corps.

However, in our efforts to improve care on a systematic basis, we must not forget how critical it is to address implicit biases that permeate every aspect of care delivery and contribute to the racial health disparities that have led to our high maternal mortality rate. An often-repeated statistic, is that black women in the United States are three or four times more likely to die during childbirth than white women. It is shocking to most, but it shouldn’t be. Racial health disparities have a long history, and events as recent as what happened in Charlottesville last year remind us we still have a long way to go.

Even when black women have access to health care and advanced education, they are still at a disadvantage when it comes to receiving the quality of care on par with their white counterparts, and the constant stressors of racism and racial biases often put them at higher risk for chronic health conditions. Cardiovascular disease disproportionately affects black women, and stress has been linked as a possible contributor. I have been working with Dr. Lisa Hollier, ACOG’s incoming president, to partner on initiatives with the American Heart Association to address issues with women and cardiovascular disease, and I am confident that she will make marked improvements in this area.

It has been a whirlwind. I have traveled the country and the world in pursuit of advancing women’s health and ensuring that the clock is not turned back. I have worked alongside ACOG leadership and Fellows, including my esteemed colleagues, Drs. Hollier and Gellhaus, to improve maternal health for all women in the United States and serve as a model for women’s health care throughout the world. It has been a rewarding journey, and we have made incredible progress, but I am ready to pass the torch, and wish Dr. Hollier success as she carries it forward—there is much more work to be done, and I look forward to working with her this year as immediate past president.

Advancing Women’s Health Care at Home and Abroad

Every year on March 8 we mark the occasion of International Women’s Day. For women’s health care providers, it creates an opportunity to reflect upon the patient population we serve, at home and the world. This year, to commemorate International Women’s Day, I’d like to celebrate ACOG’s recent successes in women’s health, while they are proud achievements to be sure, there is still significant work to be done to gain sustainable improvements around the globe.

ACOG is committed to leveraging the expertise and commitment of our Fellows to support women’s health programs around the world through the Office of Global Women’s Health (OGWH). Our mission is 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.

OGWH has a portfolio of programs in 11 countries, including Malawi, Uganda, Rwanda, Ethiopia, the Dominican Republic, El Salvador, Guatemala, Honduras, and more. While our work in each country is unique, it’s guided by a shared set of goals.

It would take a great many pages to provide a detailed overview of all OGWH’s efforts, but I’ll share two success stories from different parts of the globe.

In Malawi, ACOG implemented a demonstration project based on the Alliance for Innovation on Maternal Health. Together with the Malawi Ministry of Health and Baylor College of Medicine, ACOG tailored post-partum hemorrhage (PPH) bundles to improve recognition and management of obstetric complications. Hundreds of local hospital staff were trained in team communication and PPH management, and prepared for implementation of the bundles. The program reduced incidences of maternal hemorrhage and increased lifesaving interventions from 3.7 percent to 34.4 percent for patients who had uterine atony after delivery.

In Central America, ACOG works to enhance professional education and training standards through the Central American Residency Program. Our efforts support development of residency accreditation and administration of in-service exams, establishment of minimal educational standards, quality assurance processes and mentorship of hospital leaders. Over time, we’ve built very strong relationships and now engage with 75 percent of all ob-gyn residency programs in Central America.

These are just two snapshots of OGWH’s work to advance women’s health across the globe, but they help to illustrate the breadth of opportunity – from preventing maternal deaths to raising the standard of medical practice. As women’s health care providers, we must continue to work together with our colleagues near and far to build a health care system that serves every woman’s needs. In addition to the programs outlined above, ACOG annually hosts a meeting of academic ob-gyn from across the globe to ensure a continuous exchange of knowledge and experience sharing.

ACOG has a unique platform to share knowledge and resources to improve the delivery of care globally. If you’re interested in learning more about how to become involved with these opportunities, visit www.acog.org/ogwh.

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.

This Earth Day be a Champion for Environmental Science

Did you know that doctors are among the most trusted professionals in this country, specifically with regard to information about climate change? Environmental factors are hurting the health of millions of Americans every day and yet there is still a considerable lack of awareness about the harmful effects of things like extreme weather events, air pollution and other toxins.

As Earth Day approaches, it seems fitting that this year’s campaign is focused on environmental and climate literacy because it reminds us as ob-gyns how important it is for us to participate in the effort by leveraging the trust our patients have in us.  Our partner organization, the International Federation of Gynecology and Obstetrics, has kicked off the week by launching a social media awareness campaign around Earth Day.  You can follow them on Twitter under the handle @FIGOHQ.

Last month, I spoke at the launch of the Medical Society Consortium on Climate Change and Health that has brought together ten associations representing nearly 500,000 physicians, including ACOG, to help increase awareness among the public and policymakers about the negative health effects of climate change on Americans. During my talk, I spoke about the fact that women face some of the greatest risks from climate change over the course of their lives, and especially during pregnancy. In affected regions, climate change puts women at risk of disease, malnutrition, poor mental health, lack of reproductive control, and even death. Additionally, women’s exposure to toxic environmental agents during the preconception and prenatal stages can have a profound and lasting effect on obstetrical and later life outcomes, including increased risk of birth defects and childhood cancer.

In 2016, ACOG adopted a policy which recognizes that climate change is an urgent women’s health concern and a major public health challenge endangering fetal health. In fact, we discover new evidence every day of how it can disturb fetal development. A recent NIH study found that exposure to extreme hot and cold temperatures during pregnancy leads to increased risk of low birth weight in infants.

While the connection between climate change and women’s health may not at first seem obvious, there are a number of ways it directly impacts women’s health.  You can look at them in several categories: a healthy pregnancy starts with clean air, clean water, no toxic chemicals, and stable climate.

Air pollution poses serious risks for women’s health.  It is linked to pregnancy loss, low birth weight babies, and preterm delivery.  Fine particle air pollution affects the placenta in pregnancy, and can interfere with fetal brain development.  Ambient and household air pollution result in 7 million deaths globally per year; these effects are worse in low-resource areas.

Heavy downpours and flooding mixed with high temperatures can spread bacteria, viruses, and chemicals that lead to contaminated food and water. This results in higher levels of methylmercury in fish and shellfish, a known cause of birth defects.

Increased use of pesticides can interfere with the developmental stages of female reproductive functions, including puberty, menstruation and ovulation, menopause, fertility, and the ability to reproduce multiple offspring. These toxic exposures also affect fetal brain development, and contribute to learning, behavioral, or intellectual impairment, as well as neurodevelopmental disorders such as ADHD and autism spectrum disorder.

Extreme temperatures have fostered increases in the number and geographic range of insects. For example, Zika-carrying mosquitos have led to more than 1,500 infections in pregnant women across the United States and District of Columbia, and more than 3,200 infections in Puerto Rico and U.S. territories. Furthermore, extreme heat during pregnancy is tied to a 31 percent increase in low birthweight babies less than 5.5 pounds.

Unfortunately, in many cases, underserved and vulnerable populations are disproportionately affected by climate change. This includes individuals living in poverty, exposed to toxic materials via their occupation, who lack nutritious food, and live in low quality housing. That’s why access to health care is so critical.

We don’t all have to be experts in environmental science, but we all need to support rigorous scientific investigation into the effects of climate change and toxic environmental agents. With evidence to support us, ob-gyns must be the authoritative voice and help to ensure that the discussion on climate change includes protecting the health and safety of all women and children.

This blog post was co-authored by Nathaniel DeNicola, MD, MSHP, the ACOG liaison to the American Academy of Pediatrics Executive Council on Environmental Health, and social media director for the International Federation of Gynecology and Obstetrics Working Group on Reproductive and Developmental Environmental Health.

It’s Time We Talk About Endometriosis

Endometriosis—when the uterine lining grows outside of the uterus, resulting in severe pain, swelling and bleeding—is thought to affect more than 11 percent of all American women between the ages of 15 and 44. This condition impacts 6.5 million U.S. women, and 176 million women worldwide. Yet, it is still not easily recognized. It takes about 10 years from when women experience their first symptoms to receive an endometriosis diagnosis—half that time to recognize and bring up symptoms to a doctor and the other half for the doctor to diagnose it. For Endometriosis Awareness Month this March, we as obstetrician-gynecologists must do our part to raise awareness about the condition with our patients, strive to improve our understanding of the disease, and ensure more timely and accurate diagnoses.

Improving awareness and timely diagnosis of endometriosis helps women avoid unnecessary pain, and decrease infertility rates. Around 40 percent of all women with infertility have endometriosis and, of women diagnosed with endometriosis, about 40 percent experience fertility challenges. Many women struggling with infertility remain undiagnosed; others won’t be diagnosed with endometriosis until they start to experience problems conceiving. It falls to ob-gyns to reverse this trend, particularly as 63 percent of general practitioners feel uncomfortable diagnosing and treating patients with endometriosis, and as many as half are unfamiliar with the three main symptoms of the disease.

Early endometriosis diagnosis and treatment lead to better outcomes. Careful listening and discussion are integral to early detection, as many common symptoms are not so obvious, such as chronic lower back pain and intestinal problems like diarrhea, constipation, bloating and nausea. We can also look for indicators that a woman is at greater risk of having endometriosis, including if she’s in her 30s and 40s; has a close relative who has been diagnosed with endometriosis (which increases risk by five to seven times); and has a higher body mass index (which is thought to promote the development of endometriosis because fat increases estrogen levels).

Raising awareness about endometriosis and increasing its timely diagnosis improves women’s lives. While symptoms may range in terms of severity, nearly all of them take a physical toll on a woman’s day-to-day life—from increasing tiredness to limiting her physical capabilities. It’s time to talk with our patients more regularly about endometriosis, and ensure more women are getting the care and support they need.

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.