BMC OBGYN in the news!

From BMC’s Morning Buzz:

Diverse Boston Neighborhoods Recruited For Sweeping Study of Genetics and Health Outcomes
By Marilyn Schairer

Medical researchers in Boston are helping sign up one million volunteers for a first-of-its-kind study examining the link between genes and our health. Researchers are actively recruiting volunteers of different races and ethnicities to ensure that the study reflects the diversity of the United States.

The All of Us Research Program uses people’s DNA and genomic science to study the connection between genes and health. It was launched in 2018, and the goal is to better understand why some people are more likely to develop a disease, while others are not.

“It’s almost the basic mystery of life as to, why does the person beside me get cancer and I don’t?” said Dr. Robert Green, a professor of medicine at the Division of Genetics at Brigham and Women’s Hospital who is a co-investigator on the study. “Why does the person on the other side of me get a heart attack?”

A consortium of local community health care centers and Boston hospitals, including Brigham and Women’s and the Boston Medical Center, are involved in the $1.2 billion, nation-wide research, funded by the National Institutes of Health.

Research recruiters and engagement coordinators are going out into local communities to reach diverse populations of volunteers.

At a Mexican Independence Day celebration in East Boston earlier in September, hundreds of people came to listen to mariachi music and celebrate. Boston hospital researchers were there, too. They set up an information booth outside the Veronica Robles Cultural Center to tell people about the study and to sign up volunteers.

Researchers across the country are nearly to their goal — about 413,000 people have registered since recruitment began three years ago.

Susana Cruzes, who was born in Mexico City and is now living in Boston, said she never considered volunteering for a research study before.

“I never thought about it until I heard about it at Veronica Robles one day, [that it’s] only thinking about medicine for white people,” Cruzes said. “And I say, well, as you can see, I’m not a white [person], so if I can help, I’m going to do it.”

Dr. Cheryl Clark, hospitalist and researcher at Brigham and Women’s Hospital, is the study’s principal investigator for engagement. The study is unique, she said, because it includes people who historically have been excluded from biomedical research.

“And that could be on the basis of age, of enrolling women, enrolling people from diverse racial and ethnic groups, enrolling people who are diverse along the lines of sexual orientation and gender identity,” Clark said.

Finding a diverse group of volunteers involved in the study isn’t easy, said Dr. Nyia Noel, assistant professor of obstetrics and gynecology at Boston Medical Center and Boston University School of Medicine, and co-investigator of the study.

“We do know that in the U.S. alone, African Americans and Hispanics, respectively, represent 12% and 16% of the population,” Noel said, “but only about 5% and 1% of clinical trial participants. So, we know that there is room to grow.”

Noel understands there is a lingering mistrust of studies after such events as the Tuskegee syphilis study, where, beginning in the 1930s, hundreds of Black men infected with syphilis went untreated so that scientists could study the disease.

Dianne Austin, director of diversity, inclusion and engagement at Massachusetts General Hospital, is on the All of Us Community Advisory Board. As a breast cancer survivor, she said she chose to be a study volunteer because she knows Black people are often excluded from studies or choose not to get involved.

“This is our opportunity as citizens and as people of color to play a role in how health care is administered and how to play a role in new discoveries in terms of treatment of disease,” Austin said.

The hope is that volunteers will stick with the study for at least ten years — and there is a real payoff. Unlike other studies, volunteers will get some answers. Their motto is “If we know it, you can know it.”

“We’re offering to return to people a limited set, approximately 59 genes, that are associated with some medically actionable conditions like heritable cancers, heritable breast cancer, heritable colon cancer or cardiovascular disorders,” Green said.

At the Mexican Independence Day festival, Nathan Yoguez, research and enrollment coordinator for the All of Us Research program, said community outreach is going well and they had several dozen people sign up.

“I think because they’re very comfortable seeing people that look like them, you know, to share about the research program,” Yoguez said.

Carlos and Lucy Mendoza immigrated to Boston from Mexico and said they are excited about being involved in the All of Us study and the idea of medical breakthroughs.

“The research has been, mostly, like in other communities. Like in the Hispanic community,” Carlos Mendoza said. “They haven’t done a lot of research. So, they don’t know, like our genes, for example.”

Lucy Mendoza said she worries about diabetes and wants to know as much as she can. According to the NIH, an estimated 18% of Mexicans will develop diabetes.

“The most important thing is, you can have all the information in your hand,” she said.

From BMC’s Morning Buzz:

The Texas Abortion Ban Hinges On ‘Fetal Heartbeat.’ Doctors Call That Misleading
Heard on All Things Considered


The term “fetal heartbeat,” as used in the new anti-abortion law in Texas, is misleading and not based on science, say physicians who specialize in reproductive health. What the ultrasound machine detects in an embryo at six weeks of pregnancy is actually just electrical activity from cells that aren’t yet a heart. And the sound that you “hear” is actually manufactured by the ultrasound machine.

The Texas abortion law that went into effect this week reads: “A physician may not knowingly perform or induce an abortion on a pregnant woman if the physician detected a fetal heartbeat for the unborn child.”

The new law defines “fetal heartbeat” as “cardiac activity or the steady and repetitive rhythmic contraction of the fetal heart within the gestational sac” and claims that a pregnant woman could use that signal to determine “the likelihood of her unborn child surviving to full-term birth.”

But the medical-sounding term “fetal heartbeat” is being used in this law — and others like it — in a misleading way, say physicians who specialize in reproductive health.

What we’re really detecting is a grouping of cells that are initiating some electrical activity. In no way is this detecting a functional cardiovascular system or a functional heart.

“When I use a stethoscope to listen to an [adult] patient’s heart, the sound that I’m hearing is caused by the opening and closing of the cardiac valves,” says Dr. Nisha Verma, an OB-GYN who specializes in abortion care and works at the American College of Obstetricians and Gynecologists.

The sound generated by an ultrasound in very early pregnancy is quite different, she says.

“At six weeks of gestation, those valves don’t exist,” she explains. “The flickering that we’re seeing on the ultrasound that early in the development of the pregnancy is actually electrical activity, and the sound that you ‘hear’ is actually manufactured by the ultrasound machine.”

That’s why “the term ‘fetal heartbeat’ is pretty misleading,” says Dr. Jennifer Kerns, an OB-GYN and associate professor at the University of California, San Francisco.

“What we’re really detecting is a grouping of cells that are initiating some electrical activity,” she explains. “In no way is this detecting a functional cardiovascular system or a functional heart.”

Kerns adds that health care providers might use the term “fetal heartbeat” in conversations with patients during this early stage of pregnancy, but it’s not actually a clinical term.

“This is a term that is not widely used in medicine,” Kern says. “I think this is an example of where we are sometimes trying to translate medical lingo in a way that patients can understand, and this is a really unfortunate side effect of this type of translation.”

Verma likens it to the term “stomach bug” — she might use that term with a patient who has gastroenteritis, she says, “but I would never use that term to talk to my colleagues or in my clinical documentation, because it’s not a precise term, it’s not a scientific term.”

In fact, “fetus” isn’t technically accurate at six weeks of gestation either, says Kerns, since “embryo” is the scientific term for that stage of development. Obstetricians don’t usually start using the term “fetus” until at least eight weeks into the pregnancy.

But “fetus” may have an appeal that the word “embryo” does not, Kern says: “The term ‘fetus’ certainly evokes images of a well-formed baby, so it’s advantageous to use that term instead of ’embryo’ — which may not be as easy for the public to feel strongly about, since embryos don’t look like a baby,” she explains. “So those terms are very purposefully used [in these laws] — and are also misleading.”

Later in a pregnancy is when a clinician might use the term “fetal heartbeat,” after the sound of the heart valves can be heard, she says. That sound “usually can’t be heard with our Doppler machines until about 10 weeks.”

The term “fetal heartbeat” has been used in laws restricting access to abortion for years. According to the Guttmacher Institute, which tracks reproductive health policy, the first such law was passed in North Dakota in 2013, but it was struck down in the courts. Since then, over a dozen states have passed similar laws, but Texas’ is the first to go into effect.

What cardiac activity means — and doesn’t mean — early in pregnancy

The text of the Texas law claims that “fetal heartbeat has become a key medical predictor that an unborn child will reach live birth” and continues, “the pregnant woman has a compelling interest in knowing the likelihood of her unborn child surviving to full-term birth based on the presence of cardiac activity.”

But obstetricians say that’s not how this information is used by health care providers. “We don’t use it to date a pregnancy,” says Dr. Samantha Kaplan, an OB-GYN at Boston Medical Center and assistant professor at Boston University’s School of Medicine.

“Or, honestly, to predict that pregnancy is going to continue until delivery.” For plenty of people, she says, this activity is detected and the pregnancy still ends in a miscarriage.

“There is nothing specific and meaningful and relevant about the detection of cardiac activity at this gestation that implies anything that’s relevant for women’s health or for pregnancies,” says Kerns. “It is one indicator — among many indicators — that a pregnancy may or may not be progressing with some expected milestones.”

Under the Texas law, women have to know they are pregnant very quickly: “Six weeks is just not enough time”

In reality, it would be really hard for a woman to know she’s pregnant before the point at which cardiac activity would be detectable by an ultrasound. She would have to be tracking her periods carefully, have regular periods, notice her period was late and then be able to quickly get an appointment with her doctor to confirm a pregnancy.

“Periods vary in length — and can be normal — from 21 to 42 days,” Kaplan says, adding that “late” periods can happen for many reasons, some of which have nothing to do with being pregnant. “It can be because of stress, it can be because of changes in sleep, changes in weight, travel — all of those things can do it. We actually aggressively counsel women they shouldn’t be panicked about being a week or two late.”

Pregnancies are dated from the start of a woman’s last period. A few weeks after that, if fertilization and implantation occur, Kern says, there’s “a window of a few days, maybe a week or two at the most, where you can actually detect an intrauterine pregnancy [with an ultrasound] before you detect any kind of cardiac motion or electrical activity,” says Kerns.

The Texas law is “clearly trying to move the needle back to almost to the point of detection of pregnancy with the goal of outlawing nearly all abortions,” she adds.

The way pregnancies are clinically dated is not intuitive and causes people to misunderstand the real impact of these laws, says Verma. “I actually did research around the general public’s understanding of ‘six weeks,’ ” she says. “A lot of people thought that ‘six weeks’ referred to six weeks from your first missed period, but it’s actually six weeks from your last period.”

“Six weeks is just not enough time,” she adds. “If someone has regular periods — they have a period every month at the same time — that means that once they miss a period that’s [just] two more weeks until they’re ‘six weeks pregnant.’ ”

More Abortion Restrictions Have Been Enacted In The U.S. This Year Than In Any Other

Many people do not find out they’re pregnant that quickly. The women who are highly attuned to their cycle timing and able to get into a clinic promptly tend to be more affluent and educated, says Kaplan.

“Somebody who has easy access to health care is going to say, ‘Well, I feel a little bit nauseated. I have a little breast tenderness. I think I’ll get a pregnancy test,’ ” she says.

“Somebody who is working to get through the day and to get food on the table is not going to do that.” Getting a pregnancy test, she says, “is going to be the last thing on their list, and by the time they are doing that, it’s going to be too late.”

From BMC’s Morning Buzz:

Systemic Racism in the U.S. Affects All Mothers and Their Babies, Study Suggests

A new study at BMC shows that U.S.-born birthing people have an increased risk of adverse perinatal outcomes compared to patients born elsewhere.
By  Jazmin Holdway
September 14, 2021

It is well documented that Black women in the U.S. experience inequities in maternal and child health outcomes. The mortality rate for Black newborns is approximately twice that of babies born to non-Hispanic white mothers in the U.S, and Black women are more than 50% more likely to deliver a premature baby. And research has shown that these disparities are not the result of intrinsic differences between racial groups, but due to systemic racism.

Now, new research findings from Boston Medical Center (BMC) show that birthing people born in the United States have an increased risk of experiencing adverse perinatal outcomes—including preterm birth, hypertensive disorders, low birth weight, and NICU admission—compared to patients born outside of the U.S. but cared for in the country. The study emphasizes the racial and ethnic disparities in birth outcomes and the impact of race-based inequities and racism in healthcare within the U.S.

Research suggests deleterious effects of racism on U.S.-born mothers

Published in the Maternal and Child Health Journal, the results show an impact of nativity, or place of birth, on the outcomes overall for all mothers and their babies. But that impact is not uniform. While birth outside the U.S. was protective for white and Hispanic mothers and infants, Black mothers consistently experienced the most pronounced adverse outcomes, regardless of birthplace.

Researchers studied a large sample of 11,097 BMC patients, 3,476 who were born in the U.S. and 7,621 who were foreign-born, including naturalized citizens, temporary migrants, refugees, asylum-seekers, undocumented immigrants, and permanent residents with varying lengths of stay in the U.S. The study was done using the electronic health records of all births of at least 20-week gestation that occurred from January 1, 2010 to March 31, 2015 at BMC.

There was an overall increase of risk to birthing people born in the U.S. compared to abroad. Study results showed that 10.6% of patients born in the U.S. experienced preterm birth compared to 8.2% of foreign-born patients. The prevalence of early preterm birth (at or before 32 weeks of pregnancy) and low birth weight at term were more than twice as high for those born in the U.S.

“While birth outside the U.S. was protective for white and Hispanic mothers and infants, Black mothers consistently experienced the most pronounced adverse outcomes, regardless of birthplace.”

But among people giving birth who were born in the U.S., Black patients experienced a 22% higher prevalence of hypertensive disorders, 28% higher prevalence of preterm birth, and 83% increased prevalence of early preterm birth compared to white patients.

“Differences in birth outcomes based on maternal birthplace do not uniformly apply when race and ethnicity are considered,” says Tejumola Adegoke, MD, MPH, an obstetrics & gynecology physician and director of equity and inclusion at Boston Medical Center. “Our data suggests that the health advantage previously noted among migrants to the United States is attenuated for Black birthing people and their children. This underscores the impact of race-based discrimination and differences in care. As we understand the factors that impact maternal inequities better, we can use that to combat disparities and improve outcomes for all women.”

Consistent inequitable pregnancy outcomes for Black women

The prevalence of preterm birth was highest among U.S.-born Black patients at 12%, and U.S.-born Hispanic patients at 10%. However, the largest association between being U.S.-born and experiencing adverse outcomes was among white patients, where there was a 40% increased prevalence of hypertensive disorders and similar prevalence of preterm delivery, diabetes, and cesarean delivery and NICU admission.

Researchers speculate that this is driven by disproportionately higher rates of substance use disorder (SUD) among U.S.-born white women in the BMC sample. The retrospective study of patients includes a large cohort of women with SUD, who have been noted to have a higher risk of maternal and neonatal morbidity. For this study, researchers used a sensitivity analysis to exclude women with SUD and found that the disparity between U.S.-born Black and white patients widens substantially. Since substance use in pregnancy is known to adversely impact birth outcomes, this analysis demonstrates the true extent of the racial inequity in this study population, which might otherwise be obscured.

“[F]or Black women, the effect [of racism and its related stress] on maternal mortality and perinatal outcomes is seemingly inescapable.” Click to tweet

Among those who were foreign-born, Black patients delivering babies still had a higher prevalence of many maternal and neonatal complications, while Hispanic patients had a lower prevalence of complications, compared to white. Black birthing people and infants consistently experienced worse outcomes regardless of their nativity, while foreign-born Hispanic patients experienced less disparate outcomes.

Future research should continue to assess the best practices for addressing modifiable risk factors for perinatal outcomes, including systemic racism and disparate care provisions. According to the study authors, the focus should be on innovative interventions targeted to at-risk populations.

“The system of race-based segregation and discrimination in the United States affects access to all social and economic resources, including healthcare,” says Adegoke. “Individuals who have lived outside of this system for some time may temporarily avoid the cumulative effect of racism and its related stress on their health, but for Black women, the effect on maternal mortality and perinatal outcomes is seemingly inescapable.”