Society for Maternal-Fetal Medicine Special Statement: Utilizing telemedicine to address disparities in maternal-fetal medicine: a call to policy action.

The combination of deserts in maternal-fetal medicine coverage across the United States and the COVID-19 pandemic accelerated the implementation of telemedicine programs for maternal-fetal medicine care delivery. Although telemedicine-based care has the potential to facilitate timely access to maternal-fetal medicine services, which can improve maternal and neonatal outcomes, telemedicine is a relatively novel healthcare modality that needs to be implemented strategically. As with any medical service, telemedicine care requires rigorous evaluation to assess outcomes and ensure quality. Important health policy considerations, including access to services and insurance coverage, have substantial implications for equity in the implementation of telemedicine, particularly for reproductive healthcare following the 2022 United States Supreme Court decision in Dobbs v Jackson Women's Health Organization that overturned the constitutional right to an abortion. Investing resources and advocating for a rigorous, widely accessible telemedicine infrastructure at this crucial moment will establish an important foundation for more equitable pregnancy care. Key advocacy priorities for maternal-fetal medicine telemedicine include (1) expanding insurance coverage of telemedicine across payers, regardless of geographic location; (2) advocating for interstate licensure parity; (3) increasing access to affordable Internet and digital literacy training; and (4) ensuring access to reproductive healthcare, including abortion care, delivered via telemedicine.

Opioid use disorder at delivery hospitalization in the United States: 2012-2016.

BACKGROUND AND OBJECTIVES: The objective of this paper is to evaluate national trends, socioeconomic risk factors, and maternal and obstetric outcomes for patients with and without opioid use disorder (OUD) at delivery hospitalization. METHODS: This is a retrospective cohort using the National Inpatient Sample 2012-2016 of 3,554,477 deliveries to analyze trends in OUD in patients at delivery hospitalization. We conducted univariable and multivariable logistic regression to compare clinical, demographic, hospital, and geographic associations for patients with OUD during delivery hospitalization. RESULTS: The incidence of OUD at delivery hospitalization increased from 4.48 per 1000 deliveries in 2012 to 7.67 in 2016. The highest rate of OUD was in the Northeast and the lowest in the West (9.29 vs. 4.13 per 1000, respectively, p < .001). After adjusting for confounders, history of concurrent cocaine use (adjusted odds ratio [aOR] = 5.95, 95% confidence interval [CI]: 5.38-6.59), sedative use (aOR = 17.28, 95% CI: 14.71-20.31), and amphetamine use (aOR = 4.05, 95% CI: 3.71-4.43), were strongly associated with OUD. Additionally, hepatitis C infection, (aOR = 21.98, 95% CI: 20.89-23.11), white race (aOR = 3.12, 95% CI: 3.00-3.24), and public insurance (aOR = 3.92, 95% CI: 3.77-4.08) were also associated with OUD. DISCUSSION AND CONCLUSION: The continued increase in rates of OUD at delivery hospitalization and its association with adverse perinatal outcomes highlights the need for universal screening and resource allocation for programs directed toward pregnant people. SCIENTIFIC SIGNIFICANCE: Our study builds upon the prior literature that reports trends in OUD at delivery hospitalization from 1998 to 2011 as well as presents a more in-depth look at risk factors and adverse pregnancy outcomes than previously reported.

Ethical Issues in Providing and Promoting Contraception to Women with Opioid Use Disorder.

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because the rate of unintended pregnancy in this population is almost 80 percent, there has been a push to increase the use of contraceptives among reproductive-aged women with OUD.1 The patient-level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that access to reproductive education and care be improved to ensure autonomous decision making by women with OUD. It is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to be manifested in the form of more subtly oppressive policies in contemporary medical practice. Such policies point to the ongoing stigmatization of, and implicit biases held against, women with OUD. Based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels.

Impact of Medical Students on Patient Satisfaction of Pregnant Women in Labor and Delivery Triage.

OBJECTIVES: Clinical rotations are an important aspect of undergraduate medical education. However, as patient satisfaction scores receive increasing attention, the impact of medical student participation on patient satisfaction and perception of quality of care is unclear. Previous studies from the Emergency Department and outpatient settings show that medical students do not negatively impact satisfaction scores. The authors sought to examine the effect of medical student involvement on patient satisfaction in the Labor and Delivery Triage setting. METHODS: The authors conducted a survey study of a convenience sample of pregnant patients seen in and discharged from Labor and Delivery between January 2015 and April 2016. Surveys addressed questions about the overall satisfaction with the care patients received, as well as other outcome measures such as comfort with asking questions, time spent with a physician, and politeness of staff. RESULTS: 240 total surveys were collected. After excluding surveys from those that were unsure whether a medical student was involved in their care, 168 surveys were used in the final analysis. Of these, 63.7% of subjects reported being seen by a medical student. There was no significant difference (p = 0.76) in overall patient satisfaction between groups. CONCLUSIONS FOR PRACTICE: Given the lack of a negative impact of medical student involvement on patient satisfaction, medical students should continue to be active members of the healthcare team, including in specialties such as obstetrics and locations such as Labor and Delivery triage with highly sensitive and time-dependent evaluations.

Association of Opioid Use Disorder and Provision of Highly Effective Inpatient Postpartum Contraception.

We sought to examine the rates of the inpatient provision of postpartum long-acting and permanent methods (IPP LAPM) of contraception in patients with opioid use disorder (OUD). This is a retrospective cross-sectional regression analysis of the National Inpatient Sample between 2012 and 2016. Patients with a diagnosis of OUD that delivered and received postpartum permanent contraception or long acting reversible contraception placement during the same hospitalization were identified. Regression analyses were performed to identify the demographic and clinical factors associated with long acting and permanent contraception method utilization. Of the 22,294 patients with OUD who delivered during the study period, 2291 (10.3%) received IPP LAPM. The majority of patients (1989) (86.6%) with OUD who chose inpatient provision of long acting or permanent methods after delivery received permanent contraception. After adjusting for covariates, patients with OUD had an overall decreased probability of receiving IPP LAPM (aOR=0.89, 95% CI: 0.85-0.95), decreased probability of receiving permanent contraception (aOR: 0.82, 95% CI: 0.78-0.88), but an increased probability of receiving long-acting reversible contraception (aOR: 1.29, 95% CI: 1.04-1.60) compared to patients without OUD. This study highlights the continued need to ensure appropriate measures (such as antepartum contraceptive counseling, availability of access to inpatient LAPM, and removal of Medicaid policy barriers to permanent contraception) are in place so that the contraceptive needs of patients with OUD are fulfilled.

The urgent need for physician-led abortion advocacy.

When the Supreme Court of the United States decided Dobbs v. Jackson, it overruled Roe v. Wade and the decades of legal protections that physicians and patients have relied upon in making pregnancy decisions, including but not limited to abortion care. Abortion access has been limited before Dobbs, but the new legal landscape substantially limits patient access to abortion care by greatly curtailing legal provision of these services in many states, restricting physicians' ability to provide legal abortion care through confusing, inconsistent, and burdensome legal requirements, and by upending decades of reliable standards and leaving physicians and lawyers guessing about possible future court decision. Medical societies and healthcare organizations over the last 50 years since Roe have largely been silent in the face of attacks to abortion rights. Their silence left a void in which politicians and legislators without an understanding of abortion care promoted their own ideology and political interest at the expense of patient access to abortion care, patient autonomy, the physician-patient relationship, and physician autonomy. Physicians have an ethical duty to organize and advocate. Abortion legislation exemplifies the impact of unjust policies limiting our ability to provide patients with autonomy over their medical decision-making and interfering in the provision of evidence-based care, and in some cases preventing us from upholding our oath to do no harm. We must regain control of the examination room from political ideologies so that we can provide equitable, patient-centered, evidence-based, autonomous healthcare to our patients.

Postpartum contraceptive choice and fulfillment in patients with opioid use disorder.

OBJECTIVE: We examined the differences in postpartum contraception between patients with and without opioid use disorder (OUD). STUDY DESIGN: We conducted a retrospective, single-institution, cohort analysis assessing differences in desired method of postpartum contraception and plan fulfillment. RESULTS: Patients with OUD comprised 200/8654 (2.3%) of our study cohort. After 2:1 matching, method desired (matched odds ratio [mOR] 0.86, 95% confidence interval [CI] 0.60-1.23 for highly vs. moderately effective) and receipt (mOR 0.77, 95% CI 0.53-1.12) of desired method were comparable between groups. CONCLUSION: Patients with and without OUD were similar in their choice and fulfillment of postpartum contraception.