Through our eyes: A birth mom and adoptive parent share their perspectives on bias in obstetric care.

Understanding the impacts of bias, and how to mitigate these impacts, on clinical care is critically important for all healthcare team members. However, the concerns and needs in our current system are likely even more fundamental, as we are continuing to hear about the experiences of patients who are struggling to seek care that contains even the most basic tenants of respect and decency. Creating inclusive and diverse environments requires constant proactive evaluation, commitment, and energy. This piece shares the experiences of a Black birth mom and a White adoptive dad (who is also an Ob/Gyn and anti-racism researcher) and the experiences surrounding the birth of their daughter.

A Review of OB/GYN, Internal Medicine, Family Medicine, and Pediatrics Residency Program Websites for Diversity, Equity, and Inclusion Elements.

Background: Residency program websites have become a central source of information for applicants due to a shift toward virtual interviewing. Applicants, particularly those from diverse backgrounds, place strong value on programs that present commitments to diversity, equity, and inclusion (DEI). The DEI content of residency program websites for primary care specialties has been largely unexplored. Objective: The objective of this study is to review, in an exploratory manner, family medicine, internal medicine, obstetrics and gynecology, and pediatrics residency program websites for number of DEI elements present. By identifying lacking DEI content, we hope to give residency programs that are seeking to increase diversity among applicants some direction for improving their websites. Methods: We reviewed all available residency program websites (1814) in the Fellowship and Residency Electronic Interactive Database (FREIDA) from August to December 2021. Each website was evaluated for the presence of 10 DEI elements chosen from previously published website reviews and informal applicant surveys. Some elements included the presence of resident and faculty photos/biographies, patient population descriptions, and dedicated DEI curricula. Program demographic information was collected, and summative statistics were performed. Results: The average number of DEI elements displayed per program ranged from 3.5 (internal medicine) to 4.9 (pediatrics). The most common elements were resident and faculty photographs/biographies. Internal medicine programs displayed significantly fewer elements than the other 3 specialties. This difference remained significant after controlling for program size, location, and type. Conclusions: This study highlights a lack of DEI elements available for residency program website visitors to review.

Perceived quality of sleep across the menopausal transition: A retrospective cohort study.

Background and Aims: To compare sleep quality among naturally and surgically post-menopausal women, and to identify lifestyle factors that predict sleep quality in pre, peri, and postmenopausal women. Methods: This is a retrospective cohort study of data collected from 429 women who participated in Fels Longitudinal Study data. Sleep quality, based on the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale, demographics, medical history, depression, quality of life, and physical activity levels were included in the analysis. Results: The four study groups did not differ on overall sleep quality with either scale (p = 0.61). Both Post-M groups were more likely to have a major sleep problem than the Peri-M and Pre-M groups (p < 0.001), and to have a history of restless leg syndrome (p = 0.016), but the two Post-M groups did not differ on these problems. Predictors of sleep quality included depression, bodily pain, vitality, and surgical menopause (p<0.001). Conclusion: Menopause is associated with sleep disrupting conditions. This study did not find any significant differences in sleep quality among the three reproductive stages or for natural versus surgical menopause. Women may benefit from addressing other lifestyle factors associated with poor sleep quality including mental health factors.

Evaluation of rapid telehealth implementation for prenatal and postpartum care visits during the COVID-19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America.

BACKGROUND AND AIMS: COVID-19 forced healthcare systems to implement telehealth programs, facilitated in Massachusetts by a policy requiring insurers to reimburse for telehealth visits. Prior studies suggest that telehealth is effective for obstetric care, but little is known about its implementation in response to policy changes in underserved communities. We utilized the RE-AIM framework to evaluate telehealth implementation in a large academic urban obstetric practice that serves a medically underserved population. METHODS: RE-AIM elements were assessed through retrospective review of electronic health record (EHR) data for all obstetric encounters between March 19 and August 31, 2020 and review of clinic implementation processes. Data extracted included demographics, number and type (in-person or telehealth) of prenatal visits, prenatal diagnoses, delivery outcomes, and number and type of postpartum visits. Data were analyzed using descriptive statistics. RESULTS: A total of 558 patients (60.6% Hispanic; 13.2% primary language Spanish) had 1788 prenatal visits, of which 698 (39.0%) were telehealth visits. A total of 209 patients had 230 postpartum visits, of which 101 (48.3%) were telehealth visits. The Reach of the intervention increased from 0% of patients at baseline to 69% in August. Effectiveness measures were limited but suggested potential for earlier diagnosis of some prenatal conditions. Adoption was high, with all 30 providers using telehealth, and the telehealth was found to likely be feasible and acceptable based on uptake. Increases in the percentage of telehealth visits over time and continuation post-lockdown suggested maintenance was potentially achievable. CONCLUSIONS: The COVID-19 pandemic has changed traditional approaches to healthcare delivery. We demonstrate that the use of the RE-AIM framework can be effective in facilitating implementation of telephone visits in a large academic urban obstetric practice after state-level policy change. This may be of particular importance in settings serving patients at higher risk for maternal morbidity and poor birth outcomes.

Health Equity Morbidity and Mortality Conferences in Obstetrics and Gynecology.

Maternal mortality and morbidity continue to occur at unacceptably high levels in the United States, with communities of color experiencing significantly higher rates than their White counterparts, even after adjustment for confounding factors such as socioeconomic status. Many obstetrics and gynecology departments across the country have begun to incorporate routine discussion and analysis of health equity into peer review and educational processes, including grand rounds and morbidity and mortality conferences. Despite the desire and drive, there is little published guidance on best practices for incorporation of an equity component into these conferences. This document outlines the current processes at four academic institutions to highlight the variety of ways in which health equity and social justice can be incorporated when analyzing patient experiences and health outcomes. This commentary also provides a list of specific recommendations based on the combined experiences at these institutions so that others across the country can incorporate principles of health equity into their peer-review processes.

Combination of Foley and prostaglandins versus Foley and oxytocin for cervical ripening: a network meta-analysis.

BACKGROUND: Trial and meta-analysis data revealed a reduction in time to delivery for Foley and prostaglandins or Foley and oxytocin vs Foley alone. However, there are limited data for the comparison of the 2 combination methods against each other. OBJECTIVE: This study aimed to determine whether Foley and prostaglandins or Foley and oxytocin decrease the time to vaginal delivery using a network meta-analysis. STUDY DESIGN: A network meta-analysis (PROSPERO CRD42018081948) was performed comparing Foley and prostaglandins (prostaglandin E1 or prostaglandin E2) vs Foley and oxytocin for cervical ripening. Foley alone and prostaglandins alone were used as nodes for indirect comparison. Database searches were performed from inception to March 2020 with data abstracted from published manuscripts. Eligibility criteria included randomized trials comparing Foley and oxytocin with Foley and prostaglandins (misoprostol or dinoprostone). Trials that compared Foley catheter or prostaglandins with a combination of Foley and prostaglandins or Foley and concurrent oxytocin were also included. Nulliparous and multiparous women were analyzed together. Foley catheters of any catheter material or size and >24 weeks' gestational age with a live fetus were included. Quasi-randomized, cohorts, and other combination methods for cervical ripening were not included. Prostaglandin E1 and prostaglandin E2 combined methods were analyzed separately in a planned subanalysis. The primary outcome was the mean time from induction to vaginal delivery in hours. Secondary outcomes included time from induction to delivery, delivery within 24 hours, cesarean delivery, chorioamnionitis, endometritis, epidural use, tachysystole, postpartum hemorrhage, meconium, neonatal intensive care unit admission, and 5-minute appearance, pulse, grimace, activity, and respiration score of <7. Data were analyzed as a network meta-analysis using multivariate meta-regression. RESULTS: A total of 30 randomized controlled trials with a total of 6465 women were considered eligible for inclusion in this network meta-analysis. When compared with Foley alone, the use of Foley-oxytocin reduced the time to vaginal delivery by 4.2 hours (mean duration, -4.2 hours; 95% confidence interval, -6.5 to -1.9). Foley-prostaglandins reduced the time to vaginal delivery compared with Foley but did not meet statistical significance (mean duration, -2.9 hours; 95% confidence interval, -5.7 to 0.0; P=.05). When compared head-to-head, there was no difference in the time to vaginal delivery between Foley-prostaglandins and Foley-oxytocin (mean duration, 1.3 hours; 95% confidence interval, -2.0 to 4.7). There was no difference in the rate of cesarean delivery, chorioamnionitis, epidural, tachysystole, postpartum hemorrhage, meconium, neonatal intensive care unit admissions, or 5-minute appearance, pulse, grimace, activity, and respiration score of <7 for Foley-prostaglandins vs Foley-oxytocin, although the rate of endometritis was high for Foley-prostaglandins. In the subanalysis by prostaglandin type, there was no difference in the time to vaginal delivery for Foley-misoprostol vs Foley-dinoprostone vs Foley-oxytocin. However, Foley-dinoprostone had a definite trend toward longer time to all deliveries compared with that of both Foley-misoprostol and Foley-oxytocin (P=.05). CONCLUSION: Time to vaginal delivery was similar when comparing Foley with combined misoprostol, combined dinoprostone, and combined oxytocin. Dinoprostone comparisons are limited by small sample size but suggest longer time to delivery compared with Foley and misoprostol or oxytocin. No significant differences were observed in maternal or neonatal adverse events except for endometritis, but this was limited by the sample size, varied reporting of studies used in the indirect comparisons, and definitions of infectious morbidity use in the studies.

Obesity Management: Clinical Review and Update of the Pharmacologic Treatment Options.

The toolbox of medications available for medical weight management is more robust than ever and includes a wide variety of mechanisms of actions and options for patients.

SGLT2 Inhibitors for Type 2 Diabetes Mellitus Treatment.

SGLT2 inhibitors are plausible second-line drugs that provide powerful additional A1c-lowering effects while inducing weight loss without hypoglycemia.