The impact of devaluing Women of Color: stress, reproduction, and justice.

This commentary is in response to the Call for Papers put forth by the Critical Midwifery Studies Collective (June 2022). We argue that due to a long and ongoing history of gendered racism, Women of Color are devalued in U.S. society. Devaluing Women of Color leads maternal healthcare practitioners to miss and even dismiss distress in Women of Color. The result is systematic underdiagnosis, undertreatment, and the delivery of poorer care to Women of Color, which negatively affects reproductive outcomes generally and birth outcomes specifically. These compounding effects exacerbate distress in Women of Color leading to greater distress. Stress physiology is ancient and intricately interwoven with healthy pregnancy physiology, and this relationship is a highly conserved reproductive strategy. Thus, where there is disproportionate or excess stress (distress), unsurprisingly, there are disproportionate and excess rates of poorer reproductive outcomes. Stress physiology and reproductive physiology collide with social injustices (i.e., racism, discrimination, and anti-Blackness), resulting in pernicious racialized maternal health disparities. Accordingly, the interplay between stress and reproduction is a key social justice issue and an important site for theoretical inquiry and birth equity efforts. Fortunately, both stress physiology and pregnancy physiology are highly plastic-responsive to the benefits of increased social support and respectful maternity care. Justice means valuing Women of Color and valuing their right to have a healthy, respected, and safe life.

Training for the future.

PURPOSE OF REVIEW: The aim of this study was to review the evolving field of Reproductive Endocrinology and Infertility (REI) and describe the current and future challenges REI fellowship programmes in the United States are facing. RECENT FINDINGS: The field of REI continues to rapidly evolve largely due to the tremendous advances within the assisted reproductive technologies (ARTs). Alongside this evolution, there is a lessening emphasis on graduates being proficient in all aspects of REI. Ongoing revisions to the REI fellowship structure reflect these changes in technology and contemporary practice patterns. SUMMARY: REI is a rapidly evolving field and fellowship training is continually adapting to meet the changing landscape of our field.

The impact of COVID-19 on REI fellowship educational experience.

PURPOSE: To assess perceived deficiencies of reproductive endocrinology and infertility (REI) fellow education due to changes in care secondary to COVID-19. METHODS: This is a cross-sectional study performed in an academic setting. A survey was generated and administered to REI fellows and attendings practicing in programs across the United States. Descriptive statistics were used to quantify results regarding clinical volume, academic responsibilities, clinical safety, and fellowship education. RESULTS: The survey response rate was 23%. Eighty-four percent of respondents self-identified as fellows, and 16% identified as program directors or other REI academic instructors. Overall, the survey responses confirmed that the COVID-19 pandemic tremendously affected clinical volume, with 91% of participants reporting their clinical volume decreased by at least half. Although 67% of attendings believed that the changes related to COVID-19 have or will have significantly affected the clinical skills of fellows, 66% of fellows did not believe that their clinical training had been significantly impacted. Sixty-seven percent of fellows and 78% of attendings do not believe that changes related to COVID-19 will affect the ability of fellows to practice independently. CONCLUSION: Even though most attendings surveyed believed that the changes related to COVID-19 would affect the clinical skills of fellows, the cessation of clinical and research activities was short-lived, likely tempering the overall effect on clinical training. Overall, most respondents did not believe that the pandemic significantly affected fellow education.

Infertility and assisted reproductive technology outcomes in Afro-Caribbean women.

OBJECTIVE: To assess the causes of infertility and artificial reproductive technology (ART) outcomes in women of African descent living in the Caribbean and Bermuda. DESIGN: Cross-sectional study composed of a questionnaire administered to providers who care for women undergoing ART in the Caribbean and Bermuda. MATERIAL AND METHODS: A questionnaire from the Deerfield Institute was adapted to meet the aims of our study with their permission. Eight infertility clinics in the Caribbean and Bermuda were identified. The primary physician at each site was contacted via email and invited to participate in the study. Questionnaires were completed via interview or electronically. Responses were collected in a REDCap database for statistical analysis. RESULTS: There were five respondents from Barbados, Bermuda (× 2), Puerto Rico, and the Bahamas. The most commonly reported etiologies of infertility among Afro-Caribbean patients were female-male factor and uterine factor. In vitro fertilization (IVF) combined with intracytoplasmic sperm injection (ICSI) is performed more often than conventional IVF. The cumulative live birth rates (LBR) after ART for those ages ≤ 34, 35-37, 38-42, and > 42 were 52%, 40%, 22%, and 12%, respectively. The cumulative live birth rate was 31.5% for total patients. The factors reported to be most important in hindering patients from cycling were coping emotionally with poor ovarian response and cost. The biggest restraints to infertility care were costs and a lack of local IVF centers on all islands. CONCLUSION: Afro-Caribbean women receiving infertility care in the Caribbean may have better ART outcomes compared to African-American women in the United States (US).

Why Causation Matters: Rethinking "Race" as a Risk Factor.

Although it is tempting to construe the correlation between Black "race" and higher rates of preterm birth as causal, this logic is flawed. Worse, the continued use of Black "race" as a risk factor for preterm birth is actively harmful. Using Black "race" as a risk factor suggests a causal relationship that does not exist and, critically, obscures what actually causes Black patients to be more vulnerable to poorer maternal and infant outcomes: anti-Black racism. Failing to name anti-Black racism as the root cause of Black patients' vulnerability conceals key pathways and tempts us to construe Black "race" as immutably related to higher rates of preterm birth. The result is that we overlook two highly treatable pathways-chronic stress and implicit bias-through which anti-Black racism negatively contributes to birth. Thus, clinicians may underuse important tools to reduce stress from racism and discrimination while missing opportunities to address implicit bias within their practices and institutions. Fortunately, researchers, physicians, clinicians, and medical staff can positively affect Black maternal and infant health by shifting our causal paradigm. By eliminating the use of Black "race" as a risk factor and naming anti-Black racism as the root cause of Black patients' vulnerability, we can practice anti-racist maternity care and take a critical step toward achieving birth equity.

Changing the Narrative, Starting With Us.

Infertility can affect anyone, including Black women who, contrary to popular belief, are most likely to suffer from infertility, less likely to seek fertility care, and more likely to delay or completely forgo fertility treatment (Chin et al Paediatr Perinat Epidemiol 29(5):416-25, 5). These trends are likely fueled by deep-rooted stigma generated from a multitude of origins. Some black women may feel uncomfortable discussing their experience with infertility due to the pervasive stereotype that Black women are hyper-fertile (Ceballo et al Psychol Women Q 39(4):497-511, 20). This stereotype also has important implications within the medical field, in which provider implicit bias may affect referrals and treatment plans, further contributing to stratified reproduction (Chapman et al J Gen Intern Med 28(11):1504-10, 15, FitzGerald and Hurst BMC Med Ethics 18(1):19, 16). It is time for the medical community to shift our focus to what we can change, starting with how we perceive the narrative. In order to effect change, providers should first become and remain aware of racial/ethnic disparities within reproduction. We can make a concerted effort to effectively counsel Black women about their fertility and future childbearing goals, as well as strive to debunk false racial/ethnic fertility stereotypes with medical evidence. We should actively work to understand our biases, where they stem from, and how to resolve them. We must aim to always provide respectful, equitable, and consistent care, especially when deciding how to counsel someone regarding fertility preservation and infertility treatment options. In sum, we can approach solving this complicated racial-ethnic gap in health equity by taking small intentional and parallel steps, starting now.

Understanding and Reducing Persistent Racial Disparities in Preterm Birth: a Model of Stress-Induced Developmental Plasticity.

Preterm birth is a leading cause of neonatal mortality and is characterized by substantial racial disparities in the US. Despite efforts to reduce preterm birth, rates have risen and racial disparities persist. Maternal stress is a risk factor for preterm birth; however, often, it is treated as a secondary variable rather than a primary target for intervention. Stress is known to affect several biological processes leading to downstream sequelae. Here, we present a model of stress-induced developmental plasticity where maternal stress is a key environmental cue impacting the length of gestation and therefore a primary target for intervention. Black women experience disproportionate and unique maternal stressors related to perceived racism and discrimination. It is therefore not surprising that Black women have disproportionate rates of preterm birth. The downstream effects of racism on preterm birth pathophysiology may reflect an appropriate response to stressors through the highly conserved maternal-fetal-placental neuroendocrine stress axis. This environmentally sensitive system mediates both maternal stress and the timing of birth and is a mechanism by which developmental plasticity occurs. Fortunately, stress does not appear to be an all-or-none variable. Evidence suggests that developmental plasticity is dynamic, functioning on a continuum. Therefore, simple, stress-reducing interventions that support pregnant women may tangibly reduce rates of preterm birth and improve birth outcomes for all women, particularly Black women.

Planned Oocyte Cryopreservation and the Black Obstetrician Gynecologist: Utilization and Perspectives.

The objective of this study was to describe the opinions and attitudes toward planned oocyte cryopreservation (POC) among Black Obstetrician Gynecologists (BOG) and their experiences in counseling patients of color. A web-based, cross-sectional survey was distributed to BOGs. The survey consisted of questions pertaining to personal family building goals, fertility preservation, education and patient counseling experiences regarding POC. Of the 136 potential participants, the response rate was 50% (n = 68). Sixty-six percent of respondents felt the need to postpone childbearing due to medical training and 19% had already undergone POC or planned to in the future. A majority (70%) felt that all women planning to undergo medical training should consider POC, and a subgroup analysis showed this was more likely to be reported within BOG trainees (p < 0.01). Fifty-seven percent received education on POC and 25% felt "very comfortable" counseling patients on POC. Those age < 35 years were more likely to feel the need to postpone family building due to their medical training (p < 0.01). Generalist attendings who had not undergone POC were significantly more likely to report regret, compared to subspecialists (p < 0.03). Medical careers may have an unfavorable impact on family building, and our results highlight this effect in Black women. A better understanding of the mitigating factors is needed to develop culturally appropriate counseling and educational interventions for Black women and other women of color.

Factors associated with disparate outcomes among Black women undergoing in vitro fertilization.

Objective: To determine if Black women have worse in vitro fertilization (IVF) outcomes than women of other races/ethnicities, and to establish which factors are associated with the IVF outcomes of Black women. Design: Retrospective cohort study. Setting: Not applicable. Patients: All patients undergoing IVF. Interventions: Not applicable. Main Outcome Measures: Spontaneous abortion rate, clinical pregnancy rate, and live birth rate. Results: A total of 71,389 patient cycles were analyzed. Of the 40,545 patients who were included, 6.4% of patients were Black, 62% were White, 7.3% were Hispanic/Latino, and 15% were Asian. After IVF, Black women had significantly more miscarriages than White but not Hispanic or Asian patients (8.0% Black vs. 6.9% White, 7.4% Hispanic, and 7.5% Asian). Clinical pregnancy rates were significantly lower for Black women compared with all other races (45% Black vs. 52% White, 52% Hispanic, and 53% Asian). The odds ratio (OR) of live birth from all cycles were 30% less than that for White women (OR, 1.00 Black vs. 1.43 White) and 22% less than that for Hispanic women (OR, 1.00 Black vs. 1.29 Hispanic). This statistically significant difference in the live birth rate persisted even after adjusting for patient characteristics (OR, 1.00 Black vs. 1.32 White, 1.23 Hispanic, and 1.18 Asian). Conclusions: Black women have worse IVF outcomes than women of all other racial backgrounds undergoing IVF. The factors associated with the disparate outcomes of Black women undergoing IVF outcomes include older age starting IVF, higher body mass index, tubal factor infertility, and diabetes.

Prevalence of Polycystic Ovary Syndrome in Patients With McCune Albright Syndrome.

STUDY OBJECTIVE: To identify polycystic ovarian syndrome (PCOS) in a population of female patients with McCune-Albright syndrome (MAS) by retrospective chart review. DESIGN: Retrospective study. SETTING: Academic setting. PARTICIPANTS: All female patients with a prior diagnosis of MAS who were more than 12 years of age at the time of chart review. Only complete medical records from January 2009 to January 2020 were included in the analysis. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Diagnosis of PCOS based on the Rotterdam 2003 criteria. RESULTS: Seventeen female patients with MAS were included in the analysis. PCOS appeared to be more prevalent in MAS patients than expected based on population estimates (exact binomial test = 0.353; CI = 0.142-0.617, P = .01). The average body mass index was not significantly different between MAS patients with and without PCOS (23.38 kg/m2 vs 23.44 kg/m2, 2-sample Wilcoxon rank-sum test with continuity correction, W = 29, P = 0.733). The majority of patients (71%) were treated with an aromatase inhibitor and/or a gonadotropin-releasing hormone (GnRH) agonist. CONCLUSIONS: The results of this study suggest that female individuals with MAS have a statistically higher prevalence of PCOS. These findings warrant further studies to determine whether the increased risk of PCOS may be associated with precocious puberty, treatment of precocious puberty, or other factors.

Primary ovarian insufficiency: a glimpse into the racial and socioeconomic disparities found within third-party reproduction.

Objective: To describe a unique case of primary ovarian insufficiency and review the systemic barriers in place that hinder reproductive autonomy for Black women who require third-party reproduction. Design: Case report and review of the literature. Setting: Safety-net hospital in an urban community. Patients: A 36-year-old Black woman, gravida 0, with primary ovarian insufficiency who desires future fertility but is restricted by systemic barriers. Interventions: Chromosome analysis. Main Outcome Measures: Not applicable. Results: Balanced reciprocal translocation between chromosomes 1 and 13: 46,XX,t(1;13)(q25;q14.1). Conclusions: The field of assisted reproductive technology has evolved at an exponential rate, yet it unfortunately benefits some and not all. It is imperative that when we advocate for full spectrum infertility care, that this encompasses everyone. As we continue to further study and develop assisted reproductive technology, we must not forget to consider the factors leading to racial and socioeconomic disparities in reproductive care access, utilization, and outcomes.

Nipple-sparing Mastectomy and Ptosis: Using a Free Nipple Graft with Tissue Expander Reconstruction.

BACKGROUND: Nipple-sparing mastectomies are increasingly offered to women with breast cancer given the evidence for oncologic safety and improved cosmetic outcomes. Women with significant ptosis are often excluded due to potential nipple malposition and increased risk of nipple ischemia. The use of a harvested free nipple graft may allow women with ptosis to conserve their nipple -areolar complex. METHODS: This is an IRB approved retrospective study of breast cancer patients at an academic center with ptosis who underwent free-nipple graft mastectomies with a single plastic surgeon and 5 dedicated breast surgeons from 2014-2017. The primary outcomes were free nipple graft viability and the need for revision. Secondary outcomes included post-operative complications. RESULTS: Fourteen women with ptosis underwent skin and nipple-sparing mastectomy with breast reconstruction involving use of harvested free-nipple graft. More than half of the women were diagnosed with early-stage invasive breast cancer (42% stage 1, 14% stage 2). Four women underwent mastectomy for prophylaxis or other benign reasons. All of the women had significant ptosis during the pre-operative evaluation (57% grade 2 ptosis, 36% grade 3 ptosis, and 7% uncategorized), with an average BMI of 30. None were active smokers. In the postoperative period, one had partial nipple necrosis in combination with skin flap necrosis and positive margin (7%). Other complications included infection (14%) and hypopigmentation (14%). All nipples lost sensation and full projection. CONCLUSIONS: This is a novel approach using a free nipple graft with a skin envelope reducing mastectomy and immediate expander-based reconstruction. This successful approach allows women with ptosis to undergo nipple-sparing mastectomy with preservation of the nipple -areolar complex.

Race, Research, and Women's Health: Best Practice Guidelines for Investigators.

Medicine has a complex history of mishandling the concept of race. This is a crucial time for the field of obstetrics and gynecology to address racial and ethnic disparities. In this commentary, we address misconceptions about race, show how race can be misused in research and clinical care, and suggest new standards to guide authors as they conduct research on disparities and race.

Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals.

INTRODUCTION: Older adults are generally considered to be at greater risk for medication non-adherence due to factors such as medication complexity, side effects, cost, and cognitive decline. However, this generalization may not apply to older adults with human immunodeficiency virus (HIV). Regardless of age, suboptimal adherence to antiretroviral therapy (ART) can lead to increased viral load, immunosuppression, drug-resistant viral strains, co-morbidities, and opportunistic infections. Understanding trends of adherence to ART among older adults is critical, especially as the population of people living with HIV grows older. OBJECTIVES: The purpose of this systematic review and meta-analysis is to determine if older individuals with HIV are less likely to be non-adherent to antiretroviral therapy than younger individuals with HIV. DESIGN: A systematic search in PubMed, Embase, and PsycINFO was conducted to identify peer-reviewed articles evaluating adherence to ART in older adults. Two independent reviewers screened abstracts, applied inclusion criteria, and appraised study quality. The bibliographies of qualifying studies were searched. Data were abstracted from studies by two independent authors. Meta-analyses were conducted, and adherence levels were reported as the relative risk of non-adherence in older individuals compared to younger individuals. RESULTS: The systematic search yielded 1,848 abstracts. Twelve studies met full inclusion criteria. The overall meta-analysis found that older age reduced risk for nonadherence by 27 % (relative risk (RR) 0.72, 95 % confidence interval (CI) 0.64­0.82). Studies assessing both short-term and long-term adherence demonstrated a significant reduction in non-adherence among older patients (RR 0.75, 95 % CI 0.64­0.87 and RR 0.65, 95 % CI 0.50­0.85, respectively). CONCLUSIONS: Older adults with HIV have a reduced risk for non-adherence to ART than their younger counterparts. Future studies should seek to elucidate contributing factors of adherence among older individuals with HIV.