Catherine Y. Spong, MD

Dr. Spong is Chief of the Pregnancy and Perinatology Branch at the National Institute of Child Health and Human Development (NICHD), and Program Scientist for the Maternal-Fetal Medicine Unit Network. A Maternal-Fetal Medicine Specialist with INOVA Alexan

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Women’s health research continues to be marginalized. To address and reverse this trend requires committed, accountable leadership, inclusion of diversity of thought and critical social science issues, in addition to the more well-funded basic traditional and clinical research.

There are several areas that contribute to this marginalization, first, with respect to pregnant women. Optimizing pregnancy outcome would significantly improve world health, as babies, if born early – and often thus small – have higher risks of heart disease, diabetes, and asthma. 

Therefore, a baby born without complications, at the right time and weight, has the potential for a healthier life. Similarly, optimizing a woman’s health – both for a healthier pregnancy and outcome and for her long-erm health – also has the potential to improve world health. A woman’s health is known to impact her family, including both younger and older generations, thus strategies to address women’s health are essential.

Funding for women’s health research is limited. The National Institutes of Health (NIH) categorizes research funding to provide consistent and transparent information on the categories of disease, conditions, and research areas. 

The categorization uses sophisticated text data mining based on scientific experts to define a research category. Incredibly, 

2019 was the first year that federal funding for women’s health research was classified based on scientific relevance

, rather than based on the percentage of female subjects included in the studies.

The rationale for using the percentage of females enrolled in a study to count as “women’s health research” is unclear, and unfounded, as women certainly are enrolled in studies that are not focused on women’s health.In 2019, the NIH funded $4,749M in women’s health research, with the largest percent (26%) by the National Cancer Institute (Figure 1). 

As examples, the genetics, neurosciences, biotechnology, brain disorders, pediatrics, and aging research categories all had more NIH funding in 2019 than women’s health. 

Although COVID-19 has impacted research across the board, its negative impact on women’s research cannot be underestimated. 

To prevent transmission of the virus, all non-essential visits and encounters have been appropriately stopped, thus all ongoing clinical research has effectively ceased aside from that impacting clinical care. As I mentioned in my editorial in April, when there were only 51 studies

 - pregnant and breastfeeding women are yet again excluded from research, notably from participating in COVID-19 clinical trials during this pandemic. 

This is a major missed opportunity as results with therapies studied in men and nonpregnant women may not be generalizable. Furthermore, therapies are potentially not being offered to women, or if they are offered, are not being systematically studied in this population to provide needed data with which to guide therapy. 

The impact of COVID-19 on women’s health research highlights the long-standing inequities in including this population in research. Only in the last few decades were women required to be included in clinical research. 

Only in 1993, with the passage of the National Institutes of Health Revitalization Act, were women mandated to be included in NIH-funded research. 

Yet even with this mandate, subsets of women remain excluded.

Despite mandated inclusion of women in research, women’s health research remains marginalized, as are women researchers and physician-scientists. Although data suggest that women submitting NIH research project grant (RO1) applications for the first time have the same grant success rate as men

, they are half as likely to apply for those grants

, despite the fact that just as many women as men are receiving advanced degrees. 

A natural history experiment using the investigator-initiated Canadian Institutes of Health Research Grant Programmes demonstrated that gender gaps in funding were due to female principal investigators being evaluated less favorably than male principal investigators - and not related to the quality of their research proposals.

This marginalization of women researchers is rampant. As reported in numerous studies, women are less likely to be promoted, achieve tenure, or be selected for leadership roles (Supplemental figure). 

Similarly, women with equal stature are less likely to be selected to participate in “think tanks” than men. As an example, a recent article outlining a research strategy for women’s health with 17 authors included only 4 (24%) women.

Furthermore, of the nine physician authors, only one is an ob/gyn and four are pediatricians. The themes from the “think tank” neglect critical areas of research, focusing on traditional sciences and emphasize genetics, overlooking the role of racial disparities and health inequities.

As noted by the 2018 NIH Gender Inequality Task Force Report, “Sustainable change in representation of women, and of all individuals from underrepresented groups, requires committed, accountable leadership along with effective tools to accomplish this important goal.”

 It is troubling that gender diversity in leadership positions is lacking nationally. 

Using 2019 data, only 19% of department chairs (both interim and permanent) are held by women. Extrapolating the trend lines suggests another 50 years are needed to attain parity of department chairs and medical school deans by gender (Figure 2). 

This diversity is not due to a lack of qualified women, as since 2002, women have earned the majority of all doctorates

 and in 2019, women comprise the majority of enrolled US medical students.

Underrepresentation creates a culture that perpetuates inequalities. For our patients, for ourselves, for our families, we must correct this course. This is not easy, and will require a change of culture led by a committed, accountable, proactive leadership. 

Equally important will be the inclusion of diversity and broadening of the research agenda to include critical social science issues, health disparities, and social determinants of health.

One ray of hope to address these pressing issues is the formation of the Womxn’s Health Collaborative, a group determined to identify and initiate actionable steps. 

If you are interested in participating, I encourage you to contact Dr. Michal Elovitz at 

, editor in chief, is Professor and Vice Chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.

https://report.nih.gov/categorical_spending.aspx

https://www.contemporaryobgyn.net/view/heralding-new-era-timely-topics-and-guidance

Constantine MM et al. Obstetrics & Gynecology: 

Pohlhaus JR et al. Acad Med. 2011; 86(6):759-67.

https://report.nih.gov/nihdatabook/report/132?showm=Y&chartId=176&catId=

Witteman HO et al. Lancet 2019; 393:10171:531-540

Sadovsky Y et al. AJOG 2020. PMID: 32565236

https://diversity.nih.gov/sites/coswd/files/images/2018-05/Gender%20Inequality%20Task%20Force%20final%20AD%20may%2030%202018.pdf

https://ncses.nsf.gov/pubs/nsf20301/report/u-s-doctorate-awards#sex

https://www.aamc.org/news-insights/press-releases/majority-us-medical-students-are-women-new-data-show

Articles

In this month's issue, Contemporary OB/GYN Editor-in-Chief Dr. Catherine Y. Spong talks about the ways in which women's health research has and continues to be marginalized. Addressing these inequalities, Dr. Spong says, demands a change of culture led by committed and accountable leadership.

Addressing inequalities in women's health research

In the throes of COVID-19, with cases continuing to increase daily at my hospital, we are now further stressed with the brutal death of George Floyd, an African American whose death at the hands of law enforcement, while pleading that he could not breathe, is immortalized in a visceral video. 

His death and those of others has spurred nationwide protests against systemic racism that are colliding with attempts to mitigate the COVID-19 pandemic. With these crises on multiple fronts, we face increased tensions, anxiety, and stress.

COVID-19 has resulted in myriad changes and heightened anxieties, especially for patients of mine who are among the hardest hit. With schools no longer open, their children are home – as often are their spouses, as their jobs are lost and wages scarce. 

To add to this burden, we as a society are recognizing that we do not treat people equally, and just as the slogan “Black Lives Matter” says, we need to recognize that systemic racism and implicit bias are an issue and need to be addressed directly. 

Furthermore, COVID-19 disproportionately impacts people of color, another blow we must mitigate.

Nearly every professional society I belong to has launched campaigns and sent emails highlighting a zero tolerance policy of racism, for example:

“The American College of Obstetricians and Gynecologists (ACOG) is committed to eliminating disparities in women’s health and to confronting implicit and explicit bias and racism. This means recognizing and examining our own prejudice and bias and addressing the way in which health care systems perpetuate inequality.”

“The Society for Maternal-Fetal Medicine (SMFM) recognizes the impact of racism and is committed to working towards the elimination of the racism and health inequities that impact our members and the patients they serve.”

“The American Board of Obstetrics and Gynecology (ABOG) stands in solidarity with our health care community in opposition to the institutional racism, discrimination, and violence that has plagued the country for so long.”

As healers, Alpha Omega Alpha (AΩA) condemns racism and bias in all forms, including police brutality. Racism, discrimination, and social injustice are barriers in the care of patients and public health. 

AΩA stands with and cares for people of all races, ethnicities, and gender identities. In these times of crisis for our country and world, we must guide medicine to be unbiased, open, accepting, inclusive, and culturally aware in order to be worthy to serve the suffering.”

In addition to stating their support and the importance of these issues, these professional societies are committing to action. 

SMFM is educating their members and collaborating with other groups to promote policies to improve access to care and advocating for research. 

AΩA, a medical honor society, has a new award for excellence in inclusion, diversity, and equity in medical education and patient care.

Both COVID-19 and racism have far-reaching impacts politically and medically. It is imperative that we as providers highlight these impacts, recognizing the serious consequences that may follow. 

A household survey by the Centers for Disease Control and Prevention that was intended to monitor anxiety and depression in the setting of COVID-19 – an important metric given the social distancing and isolation – takes on new meaning now.

 Anxiety and depression have tripled in the last year, with US rates for anxiety around 8% in 2019 and over 30% in 2020 (Figure 1). 

Importantly, the rates of anxiety vary notably across racial groups, and those of mixed race have the highest rates with the ongoing demonstrations and protests. During the pandemic, women are reporting more anxiety than are men. 

In addition, people of reproductive age have the highest rates of anxiety (Figure 2). As the initial collision of crises passes, it will be vitally important to understand the impact going forward.

Critically, as the movement to raise awareness of social injustice and racism escalates, the rates of cases of COVID-19 continue to increase – the directionality of the interrelationship is unclear.

Unfortunately, they are not mutually exclusive, and the critical need to raise awareness clashes with the social isolation needed to quell the spread of COVID-19. Neither is more important, neither is less.

As I round on my antepartum patients, I have a new routine speech. It is hard to live in the world today, much less to be pregnant. Being hospitalized without visitors, juggling the media and messages of racism with the need for social distancing, does not easily allow for a healthy mental or physical state. 

I listen, try to understand, and offer the services of psychiatry and psychology to provide some attempt at mental balance, although far from normalcy. 

We discuss that this is situational, not specific to my patients, and they may benefit from external support. In truth, 

American College of Obstetricians and Gynecologists. Our commitment to changing the culture of medicine and eliminating racial disparities in women's health outcomes. Available at 

https://www.acog.org/about/our-commitment-to-changing-the-culture-of-medicine-and-eliminating-racial-disparities-in-womens-health-outcomes Accessed June 15

Society for Maternal-Fetal Medicine. SMFM issues a statement to its membership on racism as a publichealth crisis. Available at 

https://s3.amazonaws.com/cdn.smfm.org/media/2391/Racism_Statement.pdf

American Board of Obstetrics and Gynecology. ABOG statement on racism. Available at 

https://www.abog.org/about-abog/news-announcements/2020/06/03/abog-statement-on-racism

Alpha Omega Alpha Honor Medical Society. Statement on inclusion, diversity, equity, and service in the profession of medicine. Available at 

https://www.alphaomegaalpha.org/#gsc.tab=0

Centers for Disease Control and Prevention. National Center for Health Statistics. Household Pulse Survey. Available at 

https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

As a pandemic and protests converge, there is a need to recognize long-term effects.

A Collision of Crises

As was done then, we are moving from an elite team approach to incorporation of patients with COVID-19 into our service, with everyone using the appropriate precautions to prevent transmission. 

We recognize that personal protective equipment is now part of our daily lives. As such, learning must continue.

 includes an expert article on cesarean scar pregnancy (CSP) by the Society for Maternal-Fetal Medicine (SMFM). 

Our valued partnership with SMFM gives us the ability to bring readers of our magazine the most up-to-date and topical information on conditions they face in practice. CSP is one of those topics. 

The rise in cesarean deliveries coupled with the widespread use of ultrasound, especially in the first trimester, provided the opportunity to identify and diagnose this condition. Cesarean delivery as the mode of delivery rose from 1996 to 2009, peaking at 32.9%. 

The most recent data from the Centers for Disease Control and prevention show that the rate in 2018 declined to 31.9%.1 Concurrent with the rise in cesarean deliveries was the rise inuse of ultrasound. 

By 2001, 67% of women with live births received an ultrasound during pregnancy, an increase from 47.7% in 1989.2 In addition, at the same time, first-trimester ultrasound was actively being evaluated for detection of aneuploidy.3 The number of articles on CSP inversely mirrors the US national cesarean rate (Figure).

The authors of the SMFM article reviewed the literature and provide recommendations based on evidence and expert opinion, the latter in the setting where evidence is not available. A PubMed search documents the recent onset of CSP. 

The first article was published in 1998 and there are only 398 articles in total (Figure). As expected, articles with concerning outcomes predominate, which is the case with any condition; normal outcomes rarely are published. 

Importantly, expert opinion is essential in guidance about new areas, to provide a reasoned approach for the practitioner when data are not available. 

As the article describes, CSP is an accepted precursor to placenta accreta spectrum (PAS), and affected pregnancies are at increased risk for hemorrhage as a result. Risk of uterine rupture, however, is less clear. As we take this information, we must be cautious and appreciate the similarities to other situations in obstetrics. Consider for example the “genetic sonogram” initially performed only in those women at high risk for fetal anomalies. 

As ultrasound technology improved, more could be visualized, and soft markers were identified in these high-risk women, associating the soft markers with aneuploidy. 

As the use of ultrasound expanded to low-risk women, it was found that many of these soft markers are normal variants, and that they alone do not increase the risk of aneuploidy. 

As the SMFM experts note, “The true incidence of CSP is unknown, as the condition is likely underdiagnosed and underreported.” There are limited studies available following the course of CSPs to determine the outcome with expectant management. 

A key question is whether only a subset of these patients might require immediate treatment to avoid uterine rupture. In the remainder of cases, if indeed they are at risk for PAS alone, it might be beneficial to have a discussion that incorporates shared decision-making, given the lack of evidence, and particularly because the pregnancy is likely to be the woman’s last. 

One recently published study attempts to address this question. However, the women were identified at 10 to 13 weeks’ gestation, which is later than the expert opinion recommends, and it is not clear that all met the criteria for CSP. 

Interestingly, this study found that only eight of the 40 women required a hysterectomy and 82% delivered vaginally.4 We should be attentive to these findings as we become more comfortable identifying and diagnosing CSP.

Current research on CSPs is extremely limited. Searching the National Institutes of Health Reporter database revealed no currently funded studies. A search of clinicaltrials.gov identified six trials, of which two are recruiting and none are in the United States.

We appreciate the partnership with SMFM, and the help from their experts with our practice.

1. US National Center for Health Statistics. Births – Method of delivery. 

https://www.cdc.gov/nchs/fastats/delivery.htm

2. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM, Sutton PD. Births: Final data for 2001. National vital statistics reports; vol 51 no. 2. Hyattsville, Maryland: National Center for Health Statistics. 2002.

3.Neiger R. First trimester ultrasound in prenatal diagnosis—part of the turning pyramid of prenatal care. 

4. Happe SK, Rac MWF, Moschos E, et al. P

prospective first-trimester ultrasound imaging of low implantation and placenta accreta spectrum.

.2020 May 6. doi: 10.1002/jum.15295. Online ahead of print.

As we are now incorporating the new post-COVID-19 “normal” into our routines, our editor-in-chief, Dr. Catherine Spong, reflects on parallels with changes that went into play with the identification and management of patients with HIV. 

Paucity of evidence limits known impact of CSPs

The “new normal” is not normal in any sense of the word. Hearing what our colleagues are going through in areas most affected by COVID-19 is almost beyond comprehension, until we realize that it is actually happening. 

We are in a global pandemic, and as ob/gyns in the trenches, our business never stops. Babies will continue to be born, no matter what crisis is ongoing in the world. That said, as many will joke we think it is bad now, imagine what our specialty will be facing in the next 9 to 12 months.

Unlike many physicians in other specialties, ob/gyns are still going to hospitals and offices every day. Our service – at least obstetrics – is business as usual in an otherwise stark hospital, and the complications are compounded rather than diminished. Our pregnant patients are staying home longer to arrive in either the very active stage of labor or with a severe complication that requires immediate attention – adding to the issues to handle as we have no idea of their COVID-19 status and need to use the limited personal protective gear.

In an attempt to shield trainees, faculty are thrust into new roles – and then often go home to try to homeschool their children. (On a side note, there is a reason I don’t homeschool my children as I do not have the ability to do this successfully – wish I could – and I will freely admit, this crisis is proving that point).

We all hope that the “new normal” will end soon, but we are faced with an uncertainty of what the next phase of the pandemic may bring. 

Approaching recovery in phases is key, but we are all coming to the realization that the next phase will not be the “normal” to which we want to return. It will be different. Temperatures will be taken for admittance to facilities at which that would have been unheard of a month ago. Use of personal protective gear may become commonplace; changes to mass transit, entertainment, sporting events, and travel are expected.

During this crisis, my university restricted faculty over age 65 and those with significant medical conditions from having face-to-face encounters with patients. Modeled studies suggest that even in the new normal, it will take years for herd immunity to occur.1 That implies that the impact of COVID-19 may reverberate throughout society for at least 2 to 3 years in its impact on this faculty, their families, and our communities. 

The financial ramifications for practices, especially private practices and those focused on gynecology, may well be significant. The outcome for our specialty is unclear and the tension is constant. Of course, we all have faced variations of “new normal,” such as the changes after 9-11 to travel and airports that were once unfathomable but we now accept as routine. We will work through this together, but to say it is very uncomfortable is an understatement.

As practitioners on the frontlines, we must try to focus on the positive. 

How and what are we learning? Which of the changes thrust upon us during the pandemic should we keep and which to let go? 

At my university, we are keeping track of the changes made – as examples: telemedicine visits, longer time between visits, changing indications for sonography and follow-up, indications for admission-and identifying metrics to use to determine if they are successful and sustainable.

Understanding the impact of these changes on outcomes (stillbirth, maternal and fetal morbidity, gynecologic health, follow-up rates) is critical to determine which to sustain. Some steps we are taking will result in efficiencies and enhance follow-up, while others are merely of necessity. Recognizing that for obstetrics the flow of patients will continue full-fledged (and likely even increase in 9 to 12 months), how to adjust, provide care, and mitigate exposures in the new normal is our next challenge.

Furthermore, rescheduling our gynecology patient visits, cancelled surgeries, and procedures while continuing the current schedule will require collective patience on the part of everyone in the health care system.

As we move to this new normal, we must recognize and empathize with the impact on our patients, colleagues, and their families - especially their mental and physical health. We know from other epidemics that these situations, for those on the frontline and at home, take a major toll. Our patients and patience will be paramount in this new normal we face.

The American College of Obstetrics and Gynecologists' (ACOG) and the Society for Maternal Fetal Medicine (SMFM) clarify CDC's 

COVID-19 FAQs for ob/gyns regarding telehealth

1. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 14 Apr 2020: 10.1126/science.abb5793.

Editor-in-Chief Catherine Y. Spong, MD, gives her perspective on what ob/gyns can learn from the pandemic as the specialty is business as usual in an otherwise stark hospital.

Author | Catherine Y. Spong, MD

Articles

Addressing inequalities in women's health research

A Collision of Crises

Paucity of evidence limits known impact of CSPs

Lessons from COVID-19 are key to moving forward