Sandra Fyfe

The newly released US Commission on Civil Rights report, 

, analyzes the federal government’s responsibility to act in reducing racial maternal health disparities, including reducing maternal death and poor pregnancy-related health outcomes.

A public virtual briefing was held in November 2020

 by the Commission to gather information from experts such as health care providers, advocates, government officials, academics, and impacted persons.

“Testimony received by the Commission shows the federal government can play an influential role in reducing racial disparities in maternal health outcomes. Improving access to quality maternity care for women is critical, including preconception and inter-conception care to manage chronic illness and optimize health; prenatal care; delivery care; and postpartum care for 12 months post-delivery, all of which is necessary for improving pregnancy-outcomes,” Norma V. Cantú, chair of the U.S. Commission on Civil Rights, told 

According to the report, Black women are 3 to 4 times more likely to die than White women from pregnancy-related complications. Pregnancy-related complications are over 2 times more likely to kill Native American women.

The Commission’s research found that in 2004, 45% of US rural counties did not have obstetrics services in hospitals. It reported that services grew by 9% in 10 years, totaling 54% by 2014, but this growth is inadequate. The most severe impacts for maternal racial health disparities were in states with the strictest Medicaid eligibility requirements, and in largely Black counties. “Black women were found to be 10 times as likely as White women to live in a county that had no in-hospital obstetric services and 4 times as likely to live in a county where hospital obstetric services had recently closed,” the Commission reported. Reductions in care maintain and increase racial health care disparities, according to the Commission, “as many obstetrics services are being cut from hospitals that serve Black women in rural America, who experience some of the worst birth outcomes in the US.”

The Commission reported that Blacks and Latinos make up almost 1/3 of the US population, “yet Black and Latino health care professionals each make up only 3% to 6% of the total, and only about 9% of physicians identify as Black, Latino, or Native American.”

"At the federal level, efforts can be made to improve hospital quality, particularly for women of color if maternal health disparities are to be eliminated.” Cantú said in a 

. She noted that safety culture improvements are correlated with better maternal health outcomes. “One recommendation for improving safety in maternal health care is to implement standardized care practices across hospitals and health systems and to standardize data collection systems,” she said.

As a call to action, the Commission recommended the following to reduce racial maternal health outcomes as a distillation of the report in the email interview with 

Increase cultural competency training, including implicit bias training, among health care workforces.

Improve the quality of maternal health care through the development of a plan for collaborative partnerships with hospitals and their ambulatory providers to implement evidence-based, culturally sensitive training, education, and best practices.

Endorse the best practice of having a maternal ‘check-up’ prior to the standard 6-week infant check-up and continuing ‘maternal-focused’ checkups for at least 1 year postpartum.

Encourage health care providers to screen for postpartum depression in the first visit.

Provide physicians with objective checklists to screen for common postpartum complications such as cardiomyopathy, embolism, and infection.

Ensure that rural and Native-servicing health care centers have adequate resources to provide this more robust care.

A program in North Carolina is being hailed for promoting evidence-based quality maternity care and should be scaled and replicated nationwide, according to the Commission. The program is known as 

, which improves the quality of perinatal care among Medicaid customers and provides increased access to comprehensive care for women receiving Medicaid.

Develop a statewide framework for scaling home visiting programs. Home visiting has been shown to improve both maternal and infant health outcomes.

Invest in community-based programs to hire women from the community to provide doula support, home visiting, care navigation, breastfeeding, postpartum classes, and childcare assistance.

US Commission on Civil Rights. Racial disparities in maternal health, 2021. 

https://www.usccr.gov/files/2021/09-15-Racial-Disparities-in-Maternal-Health.pdf

. Published 2021. Accessed September 17, 2021.

Articles

The report released on September 15 reveals that racial maternal health disparities have greatly increased over the last 30 years, and the federal government has an active role to play in reducing them.

Government has important role in reducing racial maternal health disparities

Researchers in Nanjing, China, have found that exposure to multiple endocrine disruptors is associated with UL and EM. These conditions represent a major public health issue, and environmental causes have not been adequately examined, study authors said.

Yuqing Zhang, of the Department of Women Health Care at the Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital and colleagues examined the effects of endocrine disrupting chemicals such as phthalates, which can be found in plastic packaging for food and water, toys, building materials, and some cosmetics and personal care products.

“Among the chemicals, the exposure of endocrine-disrupting chemicals (EDCs) raised great concern as their potential disturbance on ovarian steroid hormone. The chemicals disrupting the balance of female hormones could play a role in the development of uterine leiomyomata and endometriosis,” the authors reported.

Zhang and colleagues looked at data from 1,204 women between the ages of 20-54 years who completed the National Health and Nutrition Examination Survey (NHANES) 2001-2006. NHANES used a multiple-layered probability sampling design that focused on a representative sample population located in counties across the US, according to the study report. The participants were evaluated for exposure to 10 common endocrine-disrupting chemicals: monobutyl phthalate (MBP), monoethyl phthalate (MEP), mono(2-ethylhexyl) phthalate (MEHP), monobenzyl phthalate (MBzP), mono(3-carboxypropyl) phthalate (MCPP), mono-isobutyl phthalate (MIBP), cadmium (Cd), lead (Pb), and mercury (Hg). Blood and urine were collected with mobile examination centers and were frozen before being evaluated.

Samples were examined with various chromatography methods depending on the chemical substance. High-performance liquid chromatography-electrospray ionization-tandem mass spectrometry was used for phthalate metabolites. High performance liquid chromatography–atmospheric pressure photoionization–tandem mass spectrometry was employed for equol. Inductively coupled plasma mass spectrometry was used for Pb and Cd levels, and cold vapor atomic absorption spectrophotometry was used to detect Hg.

Women answered questions about EM and UL. Researchers asked 2 questions based upon the diagnosis of either condition: 1. Has a doctor or other health care professional ever told you that you had endometriosis? 2. Has a doctor or other health care professional ever told you that you had uterine fibroids? Those with positive answers were classified as patients and they then were asked about their age at receiving the first diagnosis, according to the report.

Researchers then examined how detected chemicals were correlated with UL and EM with a multivariable logistic regression model, a weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR) models.

Researchers reported chemicals most strongly associated with UL in single chemical analysis included Hg (OR: 1.91, 95% CI: 1.14, 3.25) and equol (OR: 1.90, 95% CI: 1.11, 3.27). They said results with the WQS and BKMR models further confirmed the association between Hg, equol, and UL (OR: 2.54, 95% CI: 1.52, 4.29), and added that WQS and BKMR found a negative association between mono(2-ethylhexyl) phthalate (MEPH)and UL.

“Our study found a positive association between urinary equol levels and uterine leiomyomata, which hasn’t been reported before,” researchers said. EM was not associated with individual chemicals in tertile 3, according to the authors. However, EM had a marginally positive association in the WQS index (OR: 2.01, 95% CI: 0.98, 4.15), “and a significant positive association was identified in sub- analysis with participants restricted to premenopausal women (OR: 2.18, 95% CI: 1.03, 4.70). MIBP and MBzP weighted high in model of EM and MEHP weighted the lowest,” they reported.

The researchers reported several study limitations. Among these, they said that the NHANES study is designed cross-sectionally, and that disease was diagnosed years before chemical exposures were measured. They noted that changes in exposure levels following diagnosis could result in measurement bias. They also said when patients self-report UL and EM, cases may be missing due to a lack of symptoms. They also added that the effects of other endocrine disruptors such as pesticides, phenols, and polychlorobiphenyls were not included in the study due to a lack of exposure data.

The authors emphasized that the study provides evidence that endocrine-related chemical mixtures do have an effect on the female reproductive system, and that more research is needed to discover the ways in which chemical endocrine disruptors cause these effects.

Zhang Y, Lu Y, Ma H, Xu Q, Wu X. Combined exposure to multiple endocrine disruptors and uterine leiomyomata and endometriosis in US women. 

. 2021;12:726876. Published 2021 Aug 20. doi:10.3389/fendo.2021.726876

A study published in Frontiers in Endocrinology correlates US women’s multiple chemical exposures to uterine leiomyoma (UL) or uterine fibroids (UF) and endometriosis (EM).

Endocrine disrupting chemicals associated with uterine leiomyoma and endometriosis in US women

 reports that sickle cell disease (SCD) providers have a wide variety of attitudes, preferences, and practices when addressing adolescents and young adults’ (AYA) sexual and reproductive health (SRH) in female patients.

Maayan Leroy-Melamed, MD, MPH, an adolescent medicine pediatrician at Tufts Children’s Hospital in Boston, and colleagues conducted the study. Researchers surveyed 78 providers in the American Society of Pediatric Hematology/Oncology SCD interest group electronically. Study authors collected data on SCD provider preferences, practices, and attitudes in addressing SRH concerns for female patients with SCD and analyzed results with descriptive statistics.

Of providers surveyed, 95% scored SRH discussions with SCD AYA as moderately important or above. Eighty-nine percent said SRH care should be standardized. Despite overall agreement, researchers reported differences in content, timing, and approach of these conversations with AYA SCD patients. Researchers said that while most SCD providers agreed that SRH discussions with AYA patients should occur in early adolescence post-menarche, “there was a wide variation in terms of frequency of discussion of contraception, pregnancy, and teratogenic medications.” Researchers found a wide variety of comfort levels in prescribing estrogen containing combined hormonal contraceptives (CHC), and said most providers opted for progestin-only methods.

Researchers reported that providers more frequently discussed contraception with AYA SCD patients, and less frequently discussed pregnancy. Providers reported wanting more training, which researchers said may suggest they feel uncomfortable managing pregnancy in SCD patients.

Study authors reported that, at least yearly, most providers discussed contraception (90%), menses (78%), and teratogenic medications (61%), among other SRH topics, with their patients. Providers reported barriers to SRH discussions that included time constraints (74%), presence of parents in the exam room (50%), their own lack of SRH knowledge (50%), parent discomfort (28%), and lack of rapport (17%).

Most providers (83%) referred SCD AYAs for birth control. Thirty-nine percent of providers offered the patients’ preferred method of contraception. Thirty-three percent of these were for levonorgestrel intrauterine devices and 40% were for injectable contraception. “Approximately half of respondents (57%) reported that the use of combined hormonal contraceptives (CHC) was unacceptable despite published guidelines that support potential benefits outweighing theoretical risk in AYAs with SCD,” researchers said. This highlights the need for more evidence-based contraceptive recommendations and more SCD provider education. Researchers said in addition to 

2018 Sickle Cell Guidelines from the United Kingdom

 indicate that the advantages of CHC are greater than the risks.

To facilitate SRH discussions, providers reported that training curricula or modules would be helpful 63 providers (81%). Fifty-four respondents (69%) said guidelines from the Foundation for SCD Research would help, and 29 providers (37%) said small group discussions at the SCD Association of America conference would be beneficial. Researchers said 72% of respondents (56) thought standardized partnering with SRH specialists would improve care.

Preference among providers for educational resources included online resources (83%), pamphlets or books (76%), a mobile device application (72%), and video education modules (40%).

Researchers concluded that the study showed the need for consensus on how providers address SRH in AYA with SCD. They noted that ongoing studies are required to assess the safety of various contraceptives and effective provider training for SRH. They said patient perspectives on SRH need to be included, and these responses should be compared with provider practices. They also said implementation studies were necessary to examine how SRH information is distributed to have better communication between providers and patients to improve SRH outcomes.

®, Leroy-Melamed said that for ob-gyn providers who see young women with SCD, “it's important to recognize that patients may or may not have had clear recommendations from their hematologist related to their reproductive health and enter the conversation with an open mind.” She added that there are very few studies on SRH in SCD.

“This study exposes gaps in reproductive health care provision for women with sickle cell disease who have been historically underserved,” she said. “We would love to get more information from the patient side about their sexual and reproductive health care experiences and needs. We'd like to clarify the barriers among providers and patients to help improve reproductive health care provision for this population.”

 that she always likes to advocate for reproductive justice and listening to patients. “For patients with SCD, we need to consider each individual's reproductive goals and inform them of the known risks and benefits, and what is not yet known, about choices like contraception and pregnancy, and respect their decision,” she said.

Leroy-Melamed M, Jacob S, Shew ML, Kazmerski TM. Provider attitudes, preferences, and practices regarding sexual and reproductive health for adolescents and young adults with sickle cell disease [published online ahead of print, 2021 Jul 19]. 

. 2021;S1054-139X(21)00290-1. doi:10.1016/j.jadohealth.2021.06.008

The data suggest that both SCD providers and AYA need better evidence and educational resources for contraception, as well as coordinated SRH counseling, according to researchers.

Adolescents and young adults with sickle cell disease need standardized sexual and reproductive health counseling 

However, when women seek care for bleeding-related symptoms, the chance of admission increases. Location, age, and method of payment also factored into ED visits and admissions.

Erica E. Marsh, MD, MSCI, who is chief of the division of reproductive endocrinology and infertility at the Center for Reproductive Medicine at Michigan Medicine Von Voigtlander Women’s Hospital, conducted the study along with colleagues. Researchers were looking for national trends and associated charges by hospitals, in addition to identifying causes of hospital admissions.1

 database, the largest publicly available for all payers. They performed a retrospective examination of ED visits between 2006 and 2017 by women aged 18 to 55 years with a primary leiomyoma diagnosis as determined by ICD diagnosis codes. 

Researchers also analyzed hospital charges, current procedural terminology codes, and secondary IDC diagnoses; they used a multivariate regression model to find admission predictors. “Gaining insight into the volume of these visits and drivers of admission could help redirect appropriate patients to alternative care settings, resulting in significant cost savings,” study authors wrote.

Marsh and colleagues reported 533,963 ED visits for leiomyomas during the study period out of 487,688,338 total ED visits by women.

 Between 2006 and 2017, researchers said there was a 129% increase in ED visits for leiomyomas, from 28,732 to 65,685 visits.

“The proportion of all ED visits that were for a primary diagnosis of leiomyomas also increased over the study period, from 0.079% in 2006 to 0.154% in 2017, suggesting that the increase was not simply from an increase in overall population volume,” researchers said. In contrast, admission rates fell from 23.9% in 2006 to 11.1% in 2017.

 Researchers noted that admission for all other diagnoses to the ED was only 8.5% during the study period.

Women aged 36 to 45 years accounted for 44.5% of ED and admissions for leiomyomas, while women aged 18 to 25 years had 3.4% of the share, according to the study. In addition, 36.1% of women coming to the ED were in the lowest income quartile, while women in the highest income quartile made up 16.4%. 

Women from the geographic South were most likely to present to the ED (46.2%), while women from the Midwest (12.2%) were least likely. Private insurance was the most common payment method (38.3%), followed by Medicaid (27.1%) and self-pay (24.4%). 

Researchers said uninsured patients were least likely to be admitted (Medicare: odds ratio [OR] 1.37, 95% CI 1.21-1.54; Medicaid: OR 1.26, 95% CI 1.16-1.36; private: OR 1.44, 95% CI 1.32-1.56).1

Marsh and colleagues said the decline in hospital admissions indicates that many ED visits for leiomyomas could be treated in non–acute care settings. They also noted that rates of admission varied greatly by location and method of payment, perhaps because of local policy or biases of health care professionals. 

Bleeding was a strong factor in admissions, with the symptom presentation increasing admission odds 15-fold, according to the study. 

“Improving our understanding of patients with leiomyomas who present to the ED, but are not admitted, will help target interventions to better care for these patients in the outpatient setting and ultimately reduce the burden of leiomyomas for both patients and society,” researchers said.

Fortin CN, Jiang C, Caldwell MT, As-Sanie S, Dalton V, Marsh EE. Trends in emergency department utilization among women with leiomyomas in the United States

. 2021;137(5):897-905. doi:10.1097/AOG.0000000000004333

Emergency department (ED) visits in women affected by leiomyomas, or uterine fibroids (UFs), are increasing, but hospital admissions for this patient population are decreasing, according to a study published in the journal Obstetrics & Gynecology.

Sandra Fyfe

Articles

Government has important role in reducing racial maternal health disparities

Endocrine disrupting chemicals associated with uterine leiomyoma and endometriosis in US women

Adolescents and young adults with sickle cell disease need standardized sexual and reproductive health counseling

Emergency department visits increase for fibroids, while hospital admissions decrease