Women also face a long-documented “tampon tax” in the form of sales tax on menstrual products, which results in period poverty for many low-income Americans. Advocacy around this issue has resulted in positive policy changes; more than 15 states have exempted menstrual products from sales tax; the CARES Act of 2020 expanded the list of qualified medical expenses to include menstrual care products; and in May, Congresswoman Grace Meng reintroduced a bill to combat period poverty. 

Is there a “pink tax” in healthcare as well? A recent report by Deloitte* finds that women have 18% higher annual out-of-pocket costs on average compared to men. Notably, this estimate excludes pregnancy-related costs, which are typically credited for increased healthcare costs for women.

What explains this difference?

In general, women have more contact with the healthcare system. Women live longer than men and tend to seek out and receive healthcare at higher rates, which is a major contributor to their healthcare costs. Radiology, laboratory work, mental health, emergency room, office visits, physical/occupational therapy, and chiropractic care are all sought out at higher rates by women than men, according to the Deloitte report. The report also found that women tend to surpass their deductible from these encounters, leading to both a lower value in care for each premium dollar spent as well as higher out-of-pocket costs.

Specific checkups like gynecological exams or breast cancer screening do tend to be more expensive than other types of check-ups, though. We’ve written about the benefits and harms of early, widespread breast cancer screening before; this report comes to similar conclusions, advocating for more specific guidelines on who and when to screen.

While increased utilization of healthcare services is certainly not the only factor, it is a contributing one. Part of the problem may not actually be that we’re charging women too much, but that men aren’t receiving the healthcare they need. 

So, is the “pink tax” a problem in healthcare? Maybe. But maybe it’s just a symptom of other dysfunctions like the imbalance between underuse and overuse or general price gouging. 

*Due to the sex and gender data that was available, this report was constricted to the binary of men and women and does not represent gender-diverse people. For consistency, this blog follows those constraints.

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Mifepristone is safe

Mifepristone is a safe and effective drug to take when inducing abortion and miscarriage. It has been repeatedly scrutinized over its two decades on the American drug market (it’s been approved in Europe since the 1980s) and has time and time again been found to be effective and safe. A robust analysis of over 11,000 patients in California found a 0.31% major complication rate, and another systematic review of over 45,000 patients had similar findings. This is significantly lower than the complication rates of other drugs the FDA has approved. With Aduhelm, for example, around 40% of patients experienced dangerous side effects. 

Mifepristone is typically part of a two-drug regimen for medication abortion, alongside the drug misoprostol. While misoprostol on its own works as an abortifacient, research has shown that it is more effective and causes fewer side effects when taken alongside mifepristone. 

What’s behind the lawsuit

The plaintiffs argue that the FDA fast-tracked approval of mifepristone and has not sufficiently tracked adverse events and thus, its approval should be rescinded. The government asserts that mifepristone’s approval occurred four years after the application and did not involve an official accelerated review. A core part of the lawsuit is the Administrative Procedures Act Subpart H. The plaintiffs say the FDA had no right to utilize subpart H; the FDA firmly disagrees, arguing subpart H actually helped maintain safety by restricting the manufacturer’s distribution of mifepristone. In 2011 the FDA implemented a Risk Evaluation and Mitigation Strategy (REMS) to the dispensing requirements as an extra safety measure. The plaintiffs also argue that although they are not abortion providers, mifepristone patients experiencing complications will take up so much of their time and energy and detract from other patients’ care, despite the demonstrated low complication rate.

Regulatory chaos

If Judge Kacsmaryk rules in favor of the plaintiffs, this could open the door to drug regulatory chaos. Currently, the FDA’s process for approving and withdrawing drugs is largely self-contained– their job is to evaluate evidence from clinical trials, convene advisory groups and hold hearings to discuss evidence, and eventually make decisions on whether or not a drug is effective and safe. Drugmakers, outside experts, and patient groups have many opportunities to give their input, but they cannot overrule the FDA’s decision. 

The mifepristone case could change all that. The decision could set a precedent for anyone to challenge an FDA approval based on the existence of any adverse events, even in drugs that are overwhelmingly more beneficial than harmful. This would essentially put every drug on the market at risk of withdrawal by a legal challenge– especially those that have become politicized such as hormone treatments or COVID-19 vaccines. 

This would also lead to big ripple effects within the drug development pipeline. Why would a pharma company bother to invest millions into research and development for a new drug for birth control or an HPV vaccine if they thought that it might be withdrawn later through a legal challenge? 

If millions of patients and decades of research are not enough to support the FDA’s decision, what will be? While the morality of abortion can be debated, the safety of mifepristone is clear. If we start using personal mortality to decide whether or not a drug can be on the market, we should all start hoping there’s nobody out there with a strong moral stance against other safe and effective drugs like ibuprofen. 

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The dark origins of obstetrics and gynecology

James Marion Sims was one the most famous surgeons of the 19th century and is recognized as the father of modern gynecology. He pioneered the technique to fix vesicovaginal fistulas, which were a common and severe complication of pregnancy at the time. He invented the modern speculum and the Sims position for examinations. In 1855 he founded the Women’s Hospital, the first hospital for women in the United States. 

He practiced and developed these techniques on enslaved women. 

The women Sims’ experimented on were never given anesthetics, which were in fact available. As a slaveowner himself, he understood the capital generated by enslaved workers as well as the financial benefits of high rates of reproduction. For many years, his experiments were unsuccessful and his patients went through agony. Once he perfected his techniques, he took them to white women experiencing gynecological problems–alongside anesthetics.

Today, Sims has a complicated legacy. Monuments to him stand tall across the country, though some are beginning to come down after public outcry. As the medical field grapples with the exploitative nature of the emergence of gynecology, it must also reckon with the consequences of structural racism still present in the modern-day system.

Black moms matter

The United States has a maternal mortality crisis, and its compounded by systemic racism. The CDC estimates that 80% of pregnancy-related deaths are preventable, and Black women die due to pregnancy-related complications at over 3 times the rate of white women. Neither education, income, nor fame are guaranteed to be protective factors, as evidenced by the tragic cases of Dr. Chaniece Wallace and Shalon Irving, as well as Serena Williams’ harrowing near-death experience. A new study from the National Bureau of Economic Research was featured in the New York Times for its findings that regardless of income, outcomes for both Black moms and their babies tend to be far worse than for other racial and ethnic groups.

But on a positive note, more Americans are becoming aware of the Black maternal mortality crisis, and policymakers are taking action. The Black Maternal Health Caucus, led by Representative Lauren Underwood, introduced the Momnibus Act to address these challenges. The Momnibus includes 12 bills all aimed at reducing Black maternal mortality. Some of those provisions have been signed into law.

Communities are stepping up to protect Black maternal and infant health as well. By advocating for non-traditional supports such as birth centers, doulas, and more Black healthcare providers, which are all associated with better health outcomes for Black women and their babies, community members are showing up and supporting a better future. In Minneapolis, a brand new birth center opened up and was named as Dr. Uché Blackstock’s bright spot of the year during the 2022 Shkreli Awards. Another community in Colorado rallied to save a birth center after a private equity firm shut it down. The movement to include Medicaid coverage for doulas is building momentum, following the success of the movement to extend Medicaid coverage for postpartum care. Community action and advocacy are working. 

The history of obstetrics and gynecology is a dark one, and racial inequities remain persistent. But progress is possible and we need to demonstrate that our Black moms and babies matter.

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Preterm birth (defined as delivery before 37 weeks) impacts one in ten births in the US, and accounted for 16% of infant deaths in 2020. However, there are significant racial disparities. According to the CDC, the rate of preterm birth among Black women was 14.8% in 2021, much higher than the rate among white (9.5%) or Hispanic women (10.2%).

Given the devastating consequences of preterm birth, it’s tempting to want to take any action possible to fix it. If there is a chance that a drug could reduce premature births and racial disparities in infant death and disability, shouldn’t we take that chance? Those who approve drugs for serious conditions are not immune to the desire for hope in treating these conditions — it’s what drove approval of the recent ALS drug, for example.

But the Makena case shows how the logic of “What do we have to lose?” falls apart when you look at the evidence. From approval to withdrawal, the story of Makena shows some of the major pitfalls of the FDA’s drug approval process.

What is Makena?

Makena is a compound version of a synthetic hormone called hydroxyprogesterone caproate that was first developed in the 1950s. For decades, doctors thought the drug might reduce preterm births, but there was no evidence to show it worked. Bristol-Myers Squibb marketed the drug as Delalutin until the FDA issued a warning in the 1970s about the lack of effectiveness and safety issues, and BMS took it off the market.

A 2003 trial brought the hormone back into the public eye. The National Institute of Child Health and Human Development conducted a randomized trial of hydroxyprogesterone caproate for women with a history of spontaneous preterm birth. They found a significant difference in rates of preterm birth and low birth weight, although there were no differences in infant mortality or morbidity.

Seems promising, but researchers noted some concerning methodological issues. For one, the placebo group had higher rate of preterm birth before the trial, indicating that the randomization was not done correctly. Another issue was that a large proportion of trial participants were from a single site, so the study results may have been confounded (ie. something particular about that site is driving the results, not the effect of the drug). The FDA statistical review noted these limitations and concluded that the evidence wasn’t strong enough to approve Makena based on a single study.

Accelerated approval

Despite these concerns, K-V Pharmaceuticals (which owned Makena at the time) was still able to gain approval for the compound through the FDA’s accelerated approval process in 2011. Accelerated approval allows for drugs to be greenlit without evidence that they improve meaningful clinical outcomes, as long as they prove effective on a “surrogate endpoint” (a metric that is “reasonably likely to predict clinical benefit”).

In the case of Makena, the drug was approved based on reduction in delivery before 37 weeks, a surrogate endpoint for infant mortality associated with premature birth. The company was required to conduct a “confirmatory” trial to ensure that the drug was indeed effective.

Cut to 2019 when the new trial results came out. The PROLONG trial showed no significant difference in frequency of preterm birth or infant mortality for those taking Makena. In 2020, an FDA advisory panel voted to withdraw Makena from the market, but Covis pharmaceuticals, the private equity-backed new owner of the drug, demanded a hearing with the FDA before withdrawal. That hearing didn’t happen until October 2022.

What’s at stake?

Between the time it took to conduct the follow-up trial and the delay for the hearing, Makena was on the market for 11 years. That’s more than a decade of giving pregnant people a drug with an unclear benefit.

It’s also an immense cost to the system. Although hydroxyprogesterone caproate was first developed 80 years ago, after the FDA approved it, K-V pharmaceuticals marked up Makena 75 times the generic price. Medicaid, which covers about half of all births in the US, spent $700 million on the drug since 2018. Advocates have pointed out that this $700 million could have been used on other interventions to improve birth outcomes, such as funding birth centers and cultural competency training for medical professionals.

Makena is just one example of the waste generated by unproven drugs greenlit through the accelerated approval pathway. According to a recent report from the Office of the Inspector General, Medicare and Medicaid spent more than $18 billion from 2018 to 2021 for accelerated approval drugs with incomplete follow-up trials past their original due dates.

What’s next?

Covis’ “hail mary” hearing didn’t work, but that doesn’t mean Makena is off the market instantly. The FDA will deliberate for a few months before deciding whether to remove the drug. The Makena saga provides an important lesson for the FDA and the drug approval process: An ounce of prevention is worth a pound of cure.

We could save so much time and money by ensuring that evidence supports the approval of drugs in the first place, rather than approve them and wait for the evidence. Makena is not an anomaly in terms of drugs approved through the accelerated pathway that later prove ineffective. A 2019 study found that out of 93 cancer drug indications granted accelerated approval, only 19 (20%) had confirmatory trials that demonstrated a benefit in overall survival. The case of Makena should urge the FDA to raise the bar on evidence for accelerated approval.

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According to the CDC, this trend applies across race and ethnicity as well as gestational age, though individuals identifying as non-Hispanic Native Hawaiian or Other Pacific Islander have a much higher rate of first time C-sections. The rise in this type of surgery also cuts across states, with 31 states plus Washington, DC all experiencing rising rates. 

Studies have shown that C-sections are associated with higher rates of maternal complications and mortality. Research has also found that the likelihood of a pregnant person delivering via C-section is higher when they deliver at hospitals with higher profits from C-section procedures. The rising rates of C-sections are concerning enough for the U.S. Department of Health and Human Services to make it a Healthy People 2030 goal to reduce C-section rates.

Are C-sections being overused at the detriment of our vulnerable new parents?

C-Sections: Life-saving in some cases, overuse in others

The earliest c-sections were performed to save lives, and still serve this purpose in many cases today. Modern C-sections can be undoubtedly life-saving, preserving the health of both mother and baby, and are an essential tool for reproductive health care providers. Many pregnant people elect to have a C-section to allow them to plan around delivery or simply because they would prefer not to deliver vaginally. Others are pressured into surgery, or have their wishes ignored. Autonomy over delivery methods is vital and ideally the person delivering the baby should be able to choose their delivery method based on solid information, conversations with their healthcare providers, and a deep understanding of their own circumstances. Thus, Americans are increasingly choosing to undergo C-sections even if they are considered low-risk and the surgery is not medically indicated.

There are a few considerations to be made prior to electing for a C-section that are not well-known by the public. C-sections are surgery, meaning that all of the risks of a standard surgery including infection and complications are possibilities. In fact, C-sections are associated with higher risks of blood clotting and infections, with some studies tying them to higher rates of maternal mortality and morbidity and potentially factoring into the ongoing maternal mortality crisis. C-sections have a longer healing time than vaginal deliveries, and those who delivered via C-section are likely to have repeat C-sections that increase risks with each surgery. 

All of these factors led the American College of Obstetricians and Gynecologists (ACOG) to address their concerns about the overuse of C-sections, years ago. 

“Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.”

American College of Obstetricians and Gynecologists (ACOG)

ACOG reaffirmed this guidance in 2019, indicating that this problem is difficult to address even over the course of multiple years. The latest CDC data supports the concept that cesarean overuse is ongoing and likely to continue. Maternal preference, provider preference, and financial incentivization of elective surgeries are all big parts of the puzzle, making it difficult to identify the best leverage point for change. California was able to reduce their rates from 26.0% to 22.8% over the course of 5 years, demonstrating that reducing rates is possible through coordination, data collection, and targeted public messaging. What is clear is that C-sections provide no better outcomes than vaginal delivery for low-risk patients and may in fact be putting them at increased risk for complications. 

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Lown Institute Health Communications Specialist Brenna Miller co-authored a new piece in The Lancet analyzing the potential implications of the fall of Roe v. Wade.

A total abortion ban will increase maternal deaths

Pregnancy is significantly more deadly than an abortion. This is especially true for Black women, who face a maternal mortality 3 to 4 times that of white women – regardless of educational status or financial class. Many of the states banning abortion have a significant Black population that already does not have equitable obstetrical care. By restricting access to abortion, states are forcing Black pregnant people to risk their lives carrying to term. A new study estimates that a total abortion ban across the United States could results in an estimate 21% increase in maternal deaths across race, and a 33% increase in maternal deaths amongst Black individuals. With an ongoing maternal mortality crisis, it is clear that overturning Roe v. Wade will exacerbate circumstances and result in extra, needless maternal deaths, especially concentrated amongst the Black American population.

Restricting access does not eliminate abortions

Up to 28 states have some variation of trigger laws in place that would effectively make abortion illegal the moment Roe v. Wade is overturned. While illegality may serve as a deterrent, pregnant individuals with financial means will still be able to access whatever care they need by traveling to another state or country. Pregnant individuals without financial means will face two options: continue with the pregnancy and risk death, or figure out a way to get an abortion without a physician’s guidance. The development of mifepristone and misoprostol has provided a safer option for self-managed abortions and drastically decreasing fatalities from “illegal” abortions. The effects of these medications are identical to those of a natural miscarriage and thus are undetectable by law enforcement. With increased access to these medications through mutual aid funds and other abortion networks, these restrictions will only serve to harm poor pregnant people or push them to taking their care into their own hands.

Should the Supreme Court overturn Roe v. Wade – and it looks likely that they will – the evidence shows that those impacted most will be poor, Black pregnant people. Imposing forced birth on individuals at increased risk of death will only make the ongoing maternal mortality crisis worse. Read the full commentary in The Lancet.

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This ratio is drastically different when broken down into racial categories. While non-hispanic white women face a maternal mortality rate of around 19.1 deaths(still two times higher than the next comparable country), Black women experience triple that rate at 55.3 deaths per 100,000 births. Disparities in outcomes do not disappear when controlling for education or socioeconomic status, and the CDC estimates that 60% of these deaths are preventable. With so many lives on the line, what are the solutions? 

At this year’s Black Maternal Health Conference, hosted by Black Mamas Matter Alliance chapter at Tufts University in Boston, participants focused on the impact of policy on Black maternal health. Throughout the course of the conference, panelists discussed a variety of solutions to address this crisis, ranging from expanding paid maternity leave to strengthening our national midwifery workforce. Here are some of our key takeaways. 

From prenatal to postnatal, we are failing our Black mothers

Pregnancy-related complications can occur before, during, and after birth, with about a third of deaths falling into each category. Prenatal health care is dependent on the individual’s home state and socioeconomic status, as many states have chosen not to expand Medicaid. Massachusetts State Representative Liz Miranda emphasized how life expectancy in the city of Boston can be predicted by zip codes, noting that the top 10 poorest zip codes also had the highest rates of poor maternal outcomes. 

“Massachusetts is the most expensive state to give birth in the United States…and maternal mortality is on the rise. How are we letting this happen?”

-Massachusetts State Representative Liz Miranda

This makes it difficult for uninsured women to access prenatal care, leading to worse health outcomes. The leading causes of death during delivery are hemorrhage and other cardiovascular conditions, though for Black women the leading causes of death are preeclampsia, eclampsia, and embolism. The very fact that different racial groups have different leading causes of death with vastly different maternal mortality rates is an indicator that racism is at play. In fact, reports show that when Black individuals are treated by Black physicians, they have better outcomes. 

But there’s still a lot we don’t know about the roots of racial disparities in maternal health. 

“Key open questions include the following: 1) whether physician race proxies for differences in physician practice behavior, 2) if so, which practices, and 3) what actions can be taken by policymakers, administrators, and physicians to ensure that all newborns receive optimal care,”  said Rachel Hardeman, Associate Professor at the University of Minnesota School of Public Health.

Improving maternal outcomes

The care team in charge during a pregnancy and birth can make a massive impact on the individual’s health outcomes. One study from the Commonwealth Fund indicates that there is a significant shortage of maternity care providers, especially midwives. Whereas most other countries have a larger ratio of midwives to OBGYNs, here in the United States, OBGYNs are proportionally overrepresented. Another consideration for care teams is the inclusion of a doula, a non-clinical member of the team who provides guidance and support during labor. While studies examining the benefits of a doula are limited, a 2017 Cochrane Review found that continuous support of a pregnant person improves outcomes without any identified adverse effects.

Policymakers have a few options when it comes to reducing maternal mortality rates via legislation. First and foremost is securing insurance for pregnant people, as uninsured individuals have poorer health outcomes than those privately insured or on Medicaid. Midwives should be utilized; we need to simultaneously ramp up our training of this vital health care workforce as well as allowing midwives to fully work within their scope of practice. Doulas could be subsidized as well, reducing the financial barriers for low-income families. Postpartum care needs to be a top priority as the United States currently has a dearth of postpartum supports such as provider home visits or paid parental leave.

It’s clear that the United States needs to address its maternal mortality crisis, especially for Black women. Just last year, the Black Maternal Health Caucus introduced the Momnibus Act of 2021. This comprehensive set of twelve bills aimed at tackling the maternal mortality crisis is promising, but passing these bills is easier said than done. A study from 2021 examining maternal health policies proposed from 2010-2020 found that only two policies were actually signed into law. As more research comes out from organizations dedicated to this cause such as MOTHER Lab and the National Birth Equity Collective, more pathways forward may become clear. 

“Even as Black women were doing this work, they weren’t always centered in this movement. It deprioritized them as worthy populations…how can we make our own space, pull up at our own table?”

– Dr. Jallicia Jolly, Professor at Amherst College

Ending these preventable deaths requires not just changing current systems but focusing instead on how to create new ones that value Black lives. 

Watch the 5th Annual Black Maternal Health Conference here.

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The risk of maternal mortality is also distributed very unevenly in the American population. Black and American Indian/Alaska Native women in the US are 2-3 times as likely to die from pregnancy-related causes as white women. Even Black women with good insurance, high levels of education, and high incomes are more likely to die in childbirth than white women. In fact, the maternal mortality rate for Black women with a college degree is 1.6 times higher than for white women without a high school diploma.

In the face of these disturbing disparities, the Vice President Kamala Harris convened the first Maternal Health Day of Action this week. Here are some of the steps being taken that may reduce the risk for new moms.

Expanding Medicaid access postpartum

While we might think of maternal deaths as those that happen during labor, a significant proportion of deaths happen in the days and weeks after the birth. According to the Commonwealth Fund, 19 percent of all maternal deaths occur between one and six days postpartum, and 21 percent of all maternal deaths are between one and six weeks postpartum.

Until now, Medicaid has only covered new moms up to 60 days after they give birth, which is woefully inadequate. As part of the American Rescue Plan Act of 2021, states have a new option to extend Medicaid postpartum coverage from 60 days to one year. CMS also developed new guidance to states to help them provide that coverage. In fact, Virginia, New Jersey, and Illinois have already begun the process. Making sure that new mothers don’t get “dropped off” Medicaid after just two months is a long-awaited improvement in maternity care.

Birthing-friendly hospital designation

The Centers for Medicare and Medicaid Services (CMS) is creating a new designation for hospitals based on the quality of their maternal health care. Hospitals can receive this designation by implement patient safety practices and participating in a program to improve their maternal outcomes.

Improving hospital maternal care is incredibly important, because hospital quality contributes significantly to maternal and birth outcomes. One study of maternal complications in New York City estimated that 35 percent of the difference in outcomes by race were due to care quality issues at the delivery hospital. And we know from California’s success story that improving preparedness and training for common high-risk complications like blood pressure spikes and excessive bleeding can reduce maternal deaths.

Accountability for hospitals to improve their maternal care is growing in popularity. US News & World Report just released their ranking of “Best Hospitals for Maternity Care” for uncomplicated pregnancies. Hospitals get better rankings for low levels of unnecessary c-section, early elective delivery rates, and newborn complications. They get better scores for high rates of breastfeeding after delivery and routine support for VBAC (vaginal birth after c-section). Other supplemental information such as rate of episiotomy, private rooms, and allowing midwives to attend births is on the website as well, but not part of the score.

Funding for rural obstetrics care

More than half of rural counties in the US had no hospital obstetric services in 2014, leaving them “maternity deserts.” However, hospitals with very low patient volumes are at higher risk of complications during birth, creating a tough choice of whether or not to keep their obstetric units open.

As part of the Maternal Health Day of Action, $12 million has been added to the Federal Office of Rural Health Policy’s RMOMS Program, which gives hospitals grants to try and improve access to and continuity of maternity care in rural areas. This seems like a small step to address a significant access problem, but a step in the right direction nonetheless.

More in the “Build Back Better Act”

The White House notes that $3 billion in funding for key maternal health investments are dependent on passing the Build Back Better Act, which is currently stalled in the Senate. This investment includes:

• Funding for implicit bias training for healthcare providers, to help recognize and reduce unconscious bias toward women of color
• State pregnancy medical home programs, which provide case management and additional preventive services in exchange for reducing unnecessary procedures
• Enhanced Maternal Mortality Review Committees, which review maternal deaths to learn from these events and prevent future deaths
• Increased funding for the Title X Family Planning program, the HHS Office for Civil Rights, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

What’s missing?

Despite the wide array of programs and funding in this action plan, there are a few items that could have been added. I was surprised to see little emphasis on reducing overuse of c-sections. C-sections are associated with greater maternal mortality, as well as increased risks of “uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth,” according to a 2018 series in The Lancet. It is unclear whether the “birthing-friendly hospital” designation will take low-risk c-section rate into account. Hopefully reductions in unnecessary procedures during birth will be among the measured outcomes.

There is also basically nothing in the plan about increasing patient access to midwives, even though we have a dire shortage of midwife professionals, compared to other developed countries. It would be great to see Medicaid expanding coverage for midwives, so more women have access to non-invasive birth techniques and advocacy.

Last, but most importantly, we have to address systemic racism in our society if we want to move the needle on racial disparities in maternal and infant health. A recent study in JAMA Network Open highlights how neighborhoods with a high police presence create a higher risk of birth complications. For both white and US-born Black mothers, living in a neighborhood with a high police presence about doubled the risk of preterm birth, compared to those living in neighborhoods with little to no police presence — even controlling for age and insurance status.

These effects may be because of the long-term toxic stress from policing, from crime itself, or other environmental factors of these areas, which can lead to chronic health conditions like high blood pressure or diabetes. While it’s difficult to untangle what exactly is causing higher rates of preterm births for mothers in these neighborhoods, the study speaks to the need to examine systemic factors beyond just health care access when looking at these health outcomes.

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Two recent studies shine a light on the problem of overuse in women’s health. One shows the scope of cervical cancer screening overuse and another provides a successful example of reducing overuse of c-sections.

Cervical cancer screening overuse

It wasn’t too long ago that cervical cancer was the leading cause of cancer deaths in women. The discovery of the Pap smear in the 1920s by Dr. George Papanicolaou and Anna Marion Hilliard’s creation of a simplified test in 1957 made cervical cancer deaths largely preventable. However, access to these tests are still uneven. Four thousand women still die each year from cervical cancer and eight million women do not get necessary screening, according to the Centers for Disease Control and Prevention (CDC). Black, Hispanic/Latinx, and Asian American and Pacific Islander women are more likely to be diagnosed with–and die from–cervical cancer.

At the same time, many women are being over-screened for cervical cancer, which can lead to patient anxiety, unnecessary biopsies and other procedures, and increased cost of care. Specialty guidelines for cervical cancer screening recommend Pap smears every 3 years or co-testing with an HPV test and Pap smear every 5 years in women aged 30 to 65 years. For women age 21-29, Pap smears every three years are recommended. However, it’s unclear the extent to which gynecologists are adhering to these (relatively new) guidelines.

“How often are cervical cancer screening tests overused in women with average risk in the United States?”

In a recent study in JAMA Network Open, Dr. Jason Wright, chief of gynecologic oncology at Columbia University Irving Medical Center, and colleagues explored the question, “How often are cervical cancer screening tests overused in women with average risk in the United States?” They analyzed a sample of more than 2 million women age 30-65 years with commercial insurance who underwent cervical cancer screening in 2013 through 2014. They looked at how often these women received a follow-up test within three years of receiving their first test.

They found that among these women, cervical cancer screening tests were frequently overused. About half of the women they studied received more than one Pap test within two years, and nearly two-thirds of patients in their sample had repeated screening within three years. Interestingly, overuse of testing was more common in the Northeastern US, despite the low rates of overuse often found in this region.

Why is overscreening for cervical cancer so common? The authors point out a few factors: clinicians may not know the most recent guidelines, patients may request screening every year, clinicians often screen out of habit, and clinicians may be worried about getting sued if they don’t screen and the patient has cancer. Another potential reason is that patients are less likely to see their doctor every year if they don’t have to come in for a screening. Clinicians may try to use screening as a way to make sure they have a chance to check up on their patients each year and maintain the relationship. Some doctors may fear that not providing screening will lower their patient ratings, although new research shows no connection between low-value care and patient satisfaction scores for primary care clinicians.

Electronic health record alerts, clinician education, and point of care guidelines have been used to try and reduce overscreening, but the authors point out that more research on these interventions — especially randomized trials– are needed.

How California reduced unnecessary c-sections

The next study is a success story about overuse in obstetrics. Overuse of c-section for low-risk births is a growing global health concern, because the procedure exposes mothers and infants to unnecessary risks. Cesarean section is associated with greater maternal mortality, as well as increased risks of “uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth,” according to a 2018 series in The Lancet.

In 2014, California’s rate of c-sections for first-time mothers with low-risk pregnancies was 26%, about the national average. By 2019, the state had brought that rate down to 22.8%, according to a recent study in JAMA.

How did they do it? It took four years of public health messaging, data reporting, incentive programs, and quality improvement, in coordination with state government agencies, nonprofits, media partners, and health plans.

Reporting c-section rates at each hospital in the state laid the groundwork. Hospitals that achieved c-section rates of 23.9% or lower (the benchmark set by the CDC’s Healthy People 2020 program) were awarded by the state’s Department of Health and Human Services. For hospitals not doing as well, the peer comparison information was a wake-up call, showing hospitals and physicians how they could improve.

“It’s that balance of monitoring the baby and observing the baby’s tolerance of the labor, as well as giving Mom more support to have that labor and not rush to interventions.”

California Maternal Quality Care Collaborative, NBC News

Hospitals that had rates above the benchmark were offered an 18-month quality improvement initiative. The California Maternal Quality Care Collaborative (CMQCC) and Smart Care California, an initiative of the California Healthcare Foundation (CHCF), led the quality improvement effort. This included educational tools, peer mentorship, giving labor nurses more power to help support vaginal births, and providing access to national guidelines. Physicians and nurses gave grand round presentations at hospitals on reducing c-sections for low-risk pregnancies to help educate clinicians.

At the same time, CHCF, CMQCC, and Consumer Reports created “My Birth Matters,” an educational campaign for expectant mothers to let them know about risks of unnecessary c-sections, and give them tools for communicating their birth plan to their clinical team.

Not all hospitals improved their rates equally. According to another study of the initiative in the Annals of Family Medicine, hospitals with some of the greatest improvements in c-section rates had some characteristics in common: a culture of flexibility and collaboration, leadership that were engaged in the process, and access to resources on best practices. Still, California’s reduction in c-section rates is a remarkable achievement, and this research can help other hospitals and states improve their rates as well.

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What makes the US so different from other wealthy countries when it comes to maternal health? A new report from the Commonwealth Fund compares maternal care workforce composition and access to postpartum care and social protections in the U.S. with 10 other high-income countries, to better understand differences in maternal mortality.

The report finds that the US is an extreme outlier in rates of maternal mortality. For every 100,000 live births in the US, 17.4 women die. That’s twice the rate of the next-highest country, France (8.7 deaths per 100,000 births) and ten times the rate of New Zealand (1.4 deaths per 100,000 live births).

Where are the midwives?

What makes the US so different from the other developed countries studied? The Commonwealth Fund report points out that in almost every other wealthy country, midwives outnumber ob-gyns. For example, Sweden has 66 midwives for every 1000 live births, while the US has just 4.

The lack of midwifery care in the US contributes to a dire shortage of maternal health professionals. While Sweden and the US have the same ratio of ob-gyns per live births, the paucity of midwives in the US means that fewer mothers can access care. Most other countries have at least 35 maternal health professionals per 1000 live births; the US has only 15.

Midwifery care is one of the “reliably high-quality forms of maternal and newborn care” outlined in a recent report from the National Partnership for Women & Families. The report cites research demonstrating that midwifery care is associated with fewer episiotomies, more vaginal birth after cesarean, and better psychological experience for patients compared to physician care alone, and may reduce hospitalization during pregnancy.

Why is the US so short on midwives? Not all private insurers cover midwife care, and Medicaid only universally covers care from Certified Nurse Midwives (midwives with a nursing degree as well as midwife training), not Certified Midwives without nursing degrees. Additionally, laws restricting the scope of practice for midwives and rules requiring physician supervision of midwives make it more difficult for midwives to practice.

The NPWF recommends enacting legislation like the Maximizing Optimal Maternity Services (Midwives for MOMS) Act, which would increase the supply of midwives with nationally recognized credentials; increasing public insurance coverage of certified midwives; ensuring pay equity for midwives that do the same work as physicians; and amending restrictions at the state level so enable midwives can “practice at the top of their license.”

The need for post-partum care

While we might think of maternal deaths as those that happen during labor, a significant proportion of deaths happen in the days and weeks after the birth. According to the Commonwealth Fund report, 19 percent of all maternal deaths occur between one and six days postpartum, and 21 percent of all maternal deaths are between one and six weeks postpartum. In comparison, 17 percent of deaths occur during birth.

Postpartum care in the US lags behind that of other developed countries. All other countries in the Commonwealth Fund report mandate two weeks of paid maternity leave; the US has no paid maternity leave requirements, which puts undue stress on mothers that could negatively impact health.

Insurance coverage of postpartum care is also lacking in the US. Medicaid programs in some states cover home visits after birth, but this is not universal. Having multiple health contacts within the first six weeks can help providers recognize urgent health problems, but most US women only have one physician visit during this period, and some not even one.

“Many women will have access to prenatal care and coverage until the six week visit and then, boom — they’re dropped off,”

Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief, Weill Cornell Medical Center

Although 12 percent of maternal deaths take place more than six weeks after birth, Medicaid coverage in most states only covers postpartum visits within six weeks after birth. “Many women will have access to prenatal care and coverage until the six week visit and then, boom — they’re dropped off,” said Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief at New York-Presbyterian/ Weill Cornell Medical Center, at the Atlantic Pulse Conference last year. “We can’t drop people off at six weeks,”she said.

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