Screening for Social Determinants of Health During Prenatal Care: Why, What, and How.

As more data from maternal mortality reviews are available, it has become clear that social determinants of health have major impacts on the morbidity and mortality of mothers and infants. The ability to verify and address these requires an effective screening process during prenatal care. The challenges include selection of an appropriate tool for use in pregnancy; incorporating the tool into the clinical flow to ensure screening of all pregnant patients; and developing an approach to address the issues, be it providing emotional support, management within the clinic, or referring to outside resources.

Teaming Up for Women's Health: The 2015 American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting.

63rd Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists, 2-6 May, 2015, San Francisco, CA, USA. In response to major practice changes in obstetrics and gynecology (OB/GYN), the 2015 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists responded with modification of the program organization, methods of presenting the information (debates, hands on, flip classrooms) and increased emphasis on current clinical research. The Presidential Program covered broad themes of changes in healthcare technology, teamwork in OB/GYN practice and the importance of advocating for patients. Over 400 abstracts representing a broad range of clinical and basic science research were presented. Changes in the Annual Clinical and Scientific Meeting should allow the membership to be more prepared and pro-active as the practice of OB/GYN evolves.

Women's Health Care Teams and the Future of Obstetrics and Gynecology.

Health care delivery is in a stage of transformation and a meaningful change in provision of care must also be accompanied by changes in the educational process of health care professionals. This article lays out a roadmap to better prepare obstetrician-gynecologists (ob-gyns) to succeed in interdisciplinary women's health care teams. Just as our current educational programs emphasize the development of competent surgical skills, our future programs must encourage and support the development of communication, teamwork, and leadership skills for ob-gyns. Formal integration of these fundamentals at all levels of the health care training continuum will create an educational system designed to equip all practitioners with a basic level of knowledge and provide opportunities to acquire additional knowledge and skills as needs and interest dictate. Integral to the implementation will be the evaluation of the effects of the contributions of interprofessional education on patient, practice, and health system outcomes. Successful demonstration of value will lead to the sustainability of the educational programs through recognition by physicians, health care teams, academia, health care systems, and payers.

Smoking cessation in pregnancy.

More than 400,000 deaths occur per year in the United States that are attributable to cigarette smoking; the risks to the general public are widely known. The risk to women, especially those who are pregnant, is less commonly known. During pregnancy, smoking increases the risk of low birth weight infants, placental problems (previa and/or abruption), chronic hypertensive disorders, and fetal death. It is proposed that much of this happens because of vasoconstriction with decreased uterine blood flow from nicotine, carbon monoxide toxicity, and increased cyanide production. Infants of smoking mothers have increased risks, such as sudden infant death syndrome.

Umbilical cord prolapse.

Umbilical cord prolapse is an obstetric emergency that can have negative outcomes for the fetus. It is diagnosed by a palpable or visible cord and is often accompanied by severe, rapid fetal heart rate decelerations. Cases of cord prolapse should be delivered as soon as possible, usually by cesarean section. While awaiting delivery, the fetal presenting part should be elevated off the cord either manually or by filling the bladder. Although an untreated case of umbilical cord prolapse can lead to severe fetal morbidity and mortality, prompt and appropriate management leads to good overall outcomes.

Sources of potential lead exposure among pregnant women in New Mexico.

The objectives of this study were to ascertain the prevalence and potential sources of lead exposure among pregnant women residing in a socially-disadvantaged immigrant community in Albuquerque, New Mexico. Pregnant women (n = 140) receiving prenatal care through a community clinic participated in a structured interview and screening to measure their blood lead levels (BLLs). Potential sources of lead exposure were ascertained by the CDC and New Mexico Department of Health questionnaires. Self-reported risk factors were examined as predictors of BLLs using multiple linear regression and partial least squares discriminant analysis. Most patients were Spanish-speaking (88.6%), Latina (95%), foreign-born (87.1%), lacked health insurance (86.4%), and had a high school education or lower (84.3%). While risk factors were prevalent in this population, only three women (2.1%) had BLLs ≥3 µg/dL. Results of multivariate analyses demonstrated that pica symptoms in pregnancy, history of elevated BLLs before pregnancy, use of non-commercial pottery, and living in older houses were important predictors of elevated BLLs. Although the prevalence of other risk factors relevant to immigrant communities (i.e., use of traditional/folk remedies and cosmetics, seasonings and food products from Mexico) was high, they were not predictive of elevated BLLs. Clinics providing prenatal care to immigrant Hispanic communities should carefully assess patients' pica symptoms, use of non-commercial pottery, and a history of elevated BLLs. Moreover, additional efforts need to focus on the development of screening questionnaires which better reflect exposures of concern in this population.

Improved climate, culture, and communication through multidisciplinary training and instruction.

OBJECTIVE: The objective of the study was to determine the effectiveness of multidisciplinary team training on organizational culture and team communication. STUDY DESIGN: The training included a 6-step protocol: (1) a pretest survey assessing cultural attitudes and perceptions, (2) a baseline high-fidelity simulation session, (3) invitational medical rhetoric instruction, (4) a second high-fidelity simulation session, (5) a posttest survey assessing changed cultural attitudes and perceptions, and (6) a debriefing with participants. Teams of 4 physicians trained together: 2 obstetricians and 2 anesthesiologists. Forty-four physicians completed the training protocol during 2010 and 2011. RESULTS: Paired-sample t tests demonstrated significant decreases in autonomous cultural attitudes and perceptions (t = 8.23, P < .001) and significant increases in teamwork cultural attitudes and perceptions (t = -4.05, P < .001). Paired-sample t tests also demonstrated significant increases in communication climate that invited participation and integrated information from both medical services (t = -5.80, P < .001). CONCLUSION: The multidisciplinary team training program specified in this report resulted in increased teamwork among obstetricians and anesthesiologists.

Renal disease in pregnancy ambulatory issues.

Acute and chronic renal disease will complicate prenatal care. Normal physiological changes during pregnancy make the urinary tract system more vulnerable to infectious complications or worsening of preexisting disease. Much of the focus of prenatal care includes screening for these concerns both at the onset of prenatal care and through the pregnancy and postpartum course. With careful and attentive care, the pregnancy outcome for women with significant renal disease has improved and the occurrence of renal injury or obstetric complications due to infectious insults has decreased. This manuscript reviews the current ambulatory prenatal care as it relates to the urinary tract in pregnancy.

Promotion rates for assistant and associate professors in obstetrics and gynecology.

OBJECTIVE: To estimate promotion rates of physician faculty members in obstetrics and gynecology during the past 30 years METHODS: Data were collected annually by the Association of American Medical Colleges from every school between 1980 and 2009 for first-time assistant and associate professors to determine whether and when they were promoted. Data for full-time physician faculty were aggregated by decade (1980-1989, 1990-1999, 2000-2009). Faculty were included if they remained in academia for 10 years after beginning in rank. Data were analyzed by constructing estimated promotion curves and extracting 6-year and 10-year promotion rates. RESULTS: The 10-year promotion rates (adjusted for attrition) declined significantly for assistant professors from 35% in 1980-1989 to 32% in 1990-1999 to 26% in 2000-2009 (P<.001), and for associate professors from 37% to 32% to 26%, respectively (P<.005). These declines most likely resulted from changes in faculty composition. The most recent 15 years saw a steady increase in the proportion of entry-level faculty who were women (now 2:1) and primarily on the nontenure track. The increasing number of faculty in general obstetrics and gynecology had lower promotion probabilities than those in the subspecialties (odds ratio 0.16; P<.001). Female faculty on the nontenure track had lower promotion rates than males on the nontenure track, males on the tenure track, and females on the tenure track (odds ratio 0.8 or less; P<.01). CONCLUSION: A decline in promotion rates during the past 30 years may be attributable to changes in faculty composition. LEVEL OF EVIDENCE: II.

Agreement between self-report and prescription data in medical records for pregnant women.

BACKGROUND Clinical teratology studies often rely on patient reports of medication use in pregnancy with or without other sources of information. Electronic medical records (EMRs), administrative databases, pharmacy dispensing records, drug registries, and patients' self-reports are all widely used sources of information to assess potential teratogenic effect of medications. The objective of this study was to assess comparability of self-reported and prescription medication data in EMRs for the most common therapeutic classes. METHODS The study population included 404 pregnant women prospectively recruited from five prenatal care clinics affiliated with the University of New Mexico. Self-reported information on prescription medications taken since the last menstrual period (LMP) was obtained by semistructured interviews in either English or Spanish. For validation purposes, EMRs were reviewed to abstract information on medications prescribed between the LMP and the date of the interview. Agreement was estimated by calculating a kappa (κ) coefficient, sensitivity, and specificity. RESULTS In this sample of socially-disadvantaged (i.e., 67.9% high school education or less, 48.5% no health insurance), predominantly Latina (80.4%) pregnant women, antibiotics and antidiabetic agents were the most prevalent therapeutic classes. The agreement between the two sources substantially varied by therapeutic class, with the highest level of agreement seen among antidiabetic and thyroid medications (κ ≥0.8) and the lowest among opioid analgesics (κ = 0.35). CONCLUSIONS Results indicate a high concordance between self-report and prescription data for therapeutic classes used chronically, while poor agreement was observed for medications used intermittently, on an 'as needed" basis, or in short courses.

Patient utilization of information sources about safety of medications during pregnancy.

OBJECTIVE: To examine information sources about the safety of medications during pregnancy among predominantly Latina pregnant women. STUDY DESIGN: Consecutively chosen pregnant women (n = 404) attending the University of New Mexico clinics were offered participation and interviewed by a bilingual interviewer. RESULTS: Patient-initiated questions about the safety of medications in pregnancy were addressed most frequently to prenatal care providers (62.1%) and family members (25.2%). The Internet, books and clinic pamphlets/brochures were the most frequent self-identified sources of information. Among the 181 women with medical conditions (44.8%), education, marital status and parity were important predictors of information-seeking behavior. Specifically, women with higher education were 3.0 times (95% CI 1.2-7.5) more likely to seek advice than women with less than a high school education. Single (OR = 0.3; 95% CI 0.1-0.7) and multiparous (OR = 0.4; 95% CI 0.1-0.9) women were less likely to seek advice than married and nulliparous patients, respectively. CONCLUSION: Prenatal care providers need to more actively engage pregnant women in a decision-making process and discuss risks and benefits of medication management during pregnancy.

Retention of entry-level faculty members in obstetrics and gynecology.

OBJECTIVE: The purpose of this study was to examine retention rates of entry-level physician faculty members in obstetrics and gynecology. STUDY DESIGN: Ongoing data were collected by the Association of American Medical Colleges between 1981 and 2009 for full-time, entry-level assistant professors to determine whether they remained at their original departments, switched to another school, or left academia. Retention curves and 5- and 10-year retention rates at their original department and for academia were determined. RESULTS: The number of entry-level faculty members per year increased significantly for women and those faculty members in general obstetrics and gynecology. Retention rates at the original departments improved for all disciplines in recent years (2000-09), regardless of sex. Among those faculty members who left their original department, faculty members in general obstetrics/gynecology were more likely than subspecialists to leave academia. CONCLUSION: Growth in the number of entry-level physician faculty members was accompanied by higher retention rates at their original departments only in recent years.

Tobacco education and counseling in obstetrics and gynecology clerkships: a survey of medical school program directors.

The 16,000 medical students completing OB/GYN clerkship programs each year provide a unique opportunity to motivate and mentor students in facilitating tobacco cessation. To determine the scope of current tobacco teaching in obstetrics/gynecology (OB/GYN) education at US medical schools and to assess opportunities for including new tobacco teaching, a 28-question survey was administered to directors and assistant directors at US medical school OB/GYN clerkship programs. Surveys were completed at 71% of schools. Only 9% reported having at least 15 min of dedicated teaching time for improving tobacco cessation skills. Nearly three-fourths of respondents reported teaching students how to intervene to reduce smoking during a work-up in the OB/GYN clinic, but only 43% reported that students would know where to refer someone wishing to quit. Only a third of respondents reported teaching students both to intervene with and refer OB/GYN patients who smoke. These findings suggest that although medical students see many OB and GYN patients who smoke, they have few opportunities to learn comprehensive cessation skills during their clerkships.

Periconceptional binge drinking and acculturation among pregnant Latinas in New Mexico.

Binge drinking during pregnancy might lead to the development of Fetal Alcohol Spectrum Disorders in the offspring. Latinas are often considered a low-risk group for alcohol abuse, although recent reports indicate that the prevalence of alcohol consumption in this group is increasing due to changing cultural norms. The predictors of alcohol consumption during pregnancy among Latinas are largely unknown. We explored predictors of periconceptional drinking among Latinas (n=155) recruited into an ongoing cohort study at the University of New Mexico. Women were interviewed by a bilingual trained interviewer about any episodes of binge drinking (>or=4 drinks/occasion) a month around their last menstrual period (LMP) and were administered a TWEAK questionnaire. Sociodemographic, lifestyle, and reproductive health characteristics were also ascertained. Predictors of binge drinking were identified by Chi-square test and logistic regression in univariate and multivariable analyses, respectively. Backward selection procedure was used to identify covariates that were independently associated with binge drinking in the final model. The mean age of participants was 27.0+/-5.8 years and 69% were foreign born. In the entire sample, 17.4% of pregnant Latinas admitted at least one binge-drinking episode in the month around their LMP. Results of multivariate analysis indicate that Latinas born in the United States have a much greater risk of binge drinking in the periconceptional period (odds ratio [OR]=3.2; 95% confidence interval [CI]: 1.2, 8.9) compared with foreign-born Latinas. Similarly, Latinas who primarily speak English at home were at much greater risk (OR=3.6; 95% CI: 1.3, 10.5) compared with primarily Spanish-speaking women. No other variables were identified as significant predictors in multivariable models. Our results indicate that more acculturated Latinas are at much greater risk of binge drinking before conception and in early pregnancy compared with less acculturated Latinas. Culturally sensitive interventions should be developed to address risky alcohol consumption among Latinas of reproductive age.

Obesity in minority women: calories, commerce, and culture.

Obesity is increasing at epidemic rates in all women, but especially in minority women and children. Factors that contribute to this include changes in caloric intake and expenditure (calories), cost and ease of acquiring food along with pressures from the marketplace and media (commerce) and the community response to the increasing prevalence of obesity and sedentary lifestyle (culture).

Components and timing of prenatal care.

The primary objective for prenatal care has not changed in the past 100 years: to have the pregnancy end with a healthy baby and mother. By identifying risk factors for pregnancy complications or other maternal health concerns that need to be addressed, the provider hopes to optimize pregnancy outcome. By using a series of screening and diagnostic tests, as well as serially trending certain components of the physical examination, the provider monitors the ongoing "health" of the pregnancy. As the ability to screen and intervene has improved over the last century, the issues to be assessed have expanded to include not only medical aspects of care but also barriers to access, psychologic considerations, and patient education about general health, pregnancy, and childbirth.