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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My antepartum rounds reflect the impact of the pandemic - women struggling with substance abuse and mental illness fill the beds. 

One patient, wearing her designated green hospital gown that signals “at-risk” status and assigned a one-on-one sitter, explained, (

 thoughts now? I have three kids at home – two I try to make the computer work for so they can attend school, a 1-year-old, and here I am pregnant again. We lost our jobs, tensions are high, we cannot visit or see anyone, we have no help…. At times it all just boils up and I explode. Then I think life is not worth living. I get over it, but yes, I have bad thoughts.”

As demonstrated by my patients, the very measures used to prevent the spread of COVID-19 increase the risk of depression and suicidal thoughts: economic stress, social isolation, decreased access to community, barriers to mental health treatment, and illness.

According to the Centers for Disease Control and Prevention (CDC), the national rates of anxiety increased nearly four-fold from one year ago. In 1999, national rates of anxiety in adults were 8.2%, whereas data from August 19-31, 2020, are 31.4%. 

Similarly, rates for anxiety or depression have increased from 11.0% to 36.4%. All are higher in women, those with less education, and Black, Hispanic, and multiple other races.

A separate survey in June found similar rates of anxiety or depression (30.9%). In addition, 10.7% of the respondents reported “having seriously considered suicide in the prior 30 days” – these were significantly higher among those aged 18-24 (25.5%), minority racial and ethnic groups (Hispanic 18.6%; Black 15.1%) and essential workers (21.7%)(Figure 1).

Beyond its impact on our patients, it is vital to realize its effect on us as caregivers. 

As the impact of the pandemic continues, our ob/gyn practices and families are affected. Eighty-three percent of obstetrics and gynecology residents are female – the highest percentage of any specialty

 – and they are often playing a dual role as the family’s primary caregiver in addition to practicing medicine. 

Setting aside the burden of virtual schooling for both caregivers and children, the effects of social isolation and decreased access

to community are also affecting our children. They also mirror increased rates of anxiety and depression, yet may not have the access or resources for identification and treatment.

So what to do, what to do? In our practices, departments, and families, providing an opportunity for open communication and a safe space to share feelings without judgment is essential.Proactively, one of my colleagues’ practices meets biweekly with a psychologist. All of the providers gather and discuss both practice and personal stressors. Although predating the pandemic, this has been especially beneficial with an ongoing opportunity for open communication to discuss and identify solutions. These sessions help to identify feelings, conflicts, and provide strategies to communicate them effectively. They also allow a platform to discuss complications and poor patient outcomes, serving as a forum to process these deeply traumatizing events and rise, rather than stagnate, or worse, fall. We as physicians need this type of forum in order to heal ourselves.

Our patients and families deserve similar support and we should strive to help them get it. We need to provide opportunities for open communication in a safe space. Referrals to our colleagues in psychiatry and psychology are essential to ensure appropriate care. Although there is always a shortage of therapists, these at-risk populations need to be prioritized. Furthermore, we need to be on the alert for signs and symptoms of anxiety and depression in not only ourselves but also in our colleagues, families, and patients

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.

1. Regar MA, Stanley IH, Joiner TE. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? 

. Published online April 10, 2020. doi:10.1001/jamapsychiatry.2020.1060

2. Centers for Disease Control and Prevention. National Center for Health Statistics. Accessed Sept. 21, 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

3. Czeisler ME, Rashon I, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020 CDC MMWR Aug 14, 2020 vol 69, No. 32

4. Association of American Medical Colleges. Percentage of Women Residents by Specialty 2018. Accessed Sept. 21, 2020. https://www.aamc.org/sites/default/files/aa-data-reports-state-of-women-residents-specialty-2018_0.jpg

 know what you thought of this month’s cover story?
Feel like telling Dr. Spong what you thought of her editorial or how your practice is responding to COVID-19?

Email Dr. Spong at CSpong@mjhlifesciences.com

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The editors reserve the right to shorten or edit letters and comments.

Articles

The very measures used to prevent the spread of COVID-19 increase the risk of depression and suicidal thoughts: economic stress, social isolation, decreased access to community, barriers to mental health treatment, and illness.

Mental health support is critical during pandemic

Many obstetric and gynecologic practices are not based on strong evidence, despite the great strides that we’ve made in the last several decades in identifying therapies

 and providing data to support existing practice recommendations.

We rely on expert opinion and common-sense management strategies for many conditions - in part, due to limited research for pregnant and lactating women.

 We are always in search of a new therapy, a new intervention, and data to support the therapies we provide. 

Often we adopt practices that seem intuitive; however, once evaluated, we find that what seemed to make complete sense at the time is not actually supported by evidence.

As detailed in the September issue, the Society for Maternal-Fetal Medicine (SMFM) is highlighting one of these situations: the role of activity restriction in obstetric management. For decades, activity restriction – from bedrest to reducing daily activities, exercise, and/or work – was recommended with the intent to improve pregnancy outcomes. 

With the concern that activity may increase uterine activity, rest was felt to be important in women with preterm labor and preterm rupture of membranes to reduce the risk of preterm birth (PTB). In the setting of premature cervical dilation, in addition to reducing uterine activity, rest – specifically bed rest or lying down – was used to reduce the “pull of gravity.” 

Finally, the concept that rest might improve placental perfusion underlies recommendations in the setting of fetal growth restriction and hypertension.

Given the widespread implementation of activity restriction, evidence for or against this recommendation has been difficult to obtain. As outlined in the article, research is now available to provide guidance for our practitioners recommending against routine use of activity restriction. Furthermore, the data demonstrating risk of activity restriction – both physiologic and psychologic - are outlined. 

Translating clinical research findings into practice requires a number of steps for implementation, including endorsement by professional organizations. A study that evaluated three practices (antenatal corticosteroids for fetal lung maturity, progesterone for PTB prevention, and magnesium sulfate for neuroprotection) that were endorsed by obstetric professional organizations demonstrated that duration of endorsement was important. 

The longer the practice had been recommended the more likely it was to be administered.4 In addition, the setting was important, as the intervention in the outpatient setting (progesterone) was the least administered. Interestingly, over 90% of providers were satisfied with their knowledge and stated they used all three interventions, yet when eligible patients were identified, 93% were offered antenatal steroids, 71% magnesium sulfate, and 39% progesterone.

The translation of research findings, especially when they go against common opinion, takes decades. 

The initial randomized controlled trials of activity restriction for PTB – demonstrating no benefit – were published 15 and 26 years ago. I am hopeful that 

 will provide the final impetus to put this advice “to rest” – pun intended.

NIH Consensus Statement. Effect of corticosteroids for fetal maturation on perinatal outcomes. 1994; Feb 28- Mar 2;12(2):1-24

TitaATN, Landon MB, Spong C, Lai Y, Leveno KJ, Varner W, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. 

. 2009; 8;360(2):111-20 doi: 10.1056/NEJMoa0803267

Spong, C. Addressing inequalities in women’s health research. 

 SZ, Rice MM, Moss J, Todd A, Rincon M, Mallett G, et al. Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals. 

As detailed in the September issue, the Society for Maternal-Fetal Medicine (SMFM) is highlighting one of these situations: the role of activity restriction in obstetric management. 

Putting activity restriction to rest

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

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.

Author | Catherine Y. Spong, MD

Articles

Mental health support is critical during pandemic

Putting activity restriction to rest

Addressing inequalities in women's health research

A Collision of Crises