BMC OBGYN in the news!
From BMC’s Morning Buzz:
Black women are more likely to get sick and die from pregnancy. A simple medical device could help
February 06, 2023
Kennise Nevers holds AJ in her arms at home. (Jesse Costa/WBUR)
With both feet flat on the floor, Kennise Nevers settled into the sofa in her Brockton living room and peeled open a blood pressure cuff.
She strapped it around her left arm and exhaled as it squeezed her bicep.
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After a minute, she got the reading. “It’s perfect,” she said.
Nevers tracked her blood pressure at home each day for months as part of a program at Boston Medical Center for patients who are pregnant or recently had babies and are at risk for hypertension.
Blood pressure is just one way to measure a person’s health, but during pregnancy and soon after, it’s a critical metric. Unchecked, high blood pressure can contribute to serious complications for the pregnant person and baby, and increase the risk of death.
So for Nevers, it was a relief to know that health care providers were tracking her numbers so closely.
“Of course, you’re always going to worry: It’s pregnancy. Things change all the time,” she said. “But it eased some of my worry. I feel like I had doctors always on my side, looking after me. I wasn’t forgot about.”
Studies show that Black people are more than twice as likely as white people to experience severe pregnancy-related complications — and nearly three times as likely to have a pregnancy-related death. The U.S. has the worst maternal mortality rate of high-income countries in the world.
Dr. Tina Yarrington, director of maternal-fetal medicine at BMC, said problems often start with high blood pressure.
“It’s the root cause for many, many maternal health inequities,” she said. “People who are marginalized by structural racism, people who are Black, African American, Latina, Hispanic, suffer higher levels of hypertension and higher levels of complications when that hypertension strikes.”
Blood pressure measures the force of blood pushing against the artery walls. When that force is too high during pregnancy — a condition called pre-eclampsia — it can lead to stroke, organ damage, pregnancy loss or low birth weight for the baby. It also raises the risk of death for the pregnant person and baby.
Pre-eclampsia affects about 14% of BMC’s white patients, but 18% of its Black patients — a small but significant difference.
“That’s the fuel for this fire,” Yarrington said. “That’s why we’re putting so much energy and work into pre-eclampsia, in the interest of not just better outcomes, but better outcomes specifically for the populations that have suffered from inequities.”
Maternal-fetal medicine specialist Tina Yarrington at Boston Medical Center. (Jesse Costa/WBUR)
High blood pressure is sometimes called the “silent killer” because it can suddenly rise to dangerous levels without causing pain or other symptoms. That’s why BMC has assigned a nurse, Megan O’Brien, to watch patients’ numbers daily.
Each time a patient takes a reading at home, their blood pressure cuff sends the numbers straight to their electronic health record. The cuffs don’t need an internet connection; they use the signal of nearby cell towers.
“The first thing I do every morning is look at all of the high readings that have come in since the night before,” O’Brien said.
If she sees a concerning number, she follows up right away — often with the help of interpreters for patients who don’t speak English.
The patient might need a new medication. Or they might need to come to the hospital to be monitored. Sometimes, blood pressure spikes so rapidly that patients have to deliver their babies early to avoid serious complications.
After delivery, some patients are still at risk of developing seizures, stroke, heart attacks or other problems. O’Brien monitors their numbers, too.
The daily at-home blood pressure checks allow nurses and doctors to spot problems early and act sooner. “We’re intervening so much quicker in these potential problems that could be happening at home,” O’Brien said. “It’s really about catching those as fast as possible.”
In celebration of Midwifery Week, our midwives highlight the programs that focus on health equity and improvement of maternal child health outcomes. Link and article below:
Can Group Prenatal Care Improve Health Equity in Pregnancy?
“The Centering model really engages the patient to become more assertive about their healthcare.”
Among 11 of the world’s wealthiest countries, the U.S. has the worst maternal health outcomes, especially for Black and Indigenous Americans. Racial disparities in maternal health are so stark that the U.S. Commission on Civil Rights (USCCR) is now required to publish an annual report documenting how the federal government will address them. As outlined in the 2021 report, access to quality prenatal care and education was determined to be critical in closing the gap in maternal health outcomes.
More than 20 years earlier, CenteringPregnancy had already developed an evidence-based model of group prenatal care that works to “create a future where the risk of preterm birth, the inequities of Black women dying from pregnancy related causes and the disparities in early childhood are greatly reduced.” Now available at nine locations in Massachusetts, including at the Obstetrics and Gynecology Adult Ambulatory Clinic at Boston Medical Center (BMC), CenteringPregnancy aims to empower and educate pregnant people in a supportive learning environment.
A different model of prenatal care
Unlike a traditional prenatal model in which a pregnant person has quick, individual visits with their provider, Centering participants meet in a group of 8 to 12 other pregnant people for 10 to 12 sessions throughout their pregnancies and then twice during the postnatal period. Each two-hour visit includes an individual health visit, collaborative learning, and social support. Weekly topics are often suggested by participants and range from developing a birth plan, preventing anemia and hypertension, preparing for breastfeeding, and knowing the risks of postpartum depression.
Lorenis Liriano, who participated in a CenteringPregnancy group at BMC, says the connections she made with her peers and her midwife, Melissa Nelson, CNM, made for a “beautiful” experience.
“Melissa genuinely loves her job. Throughout the whole experience, she was educating us and supporting us. The fact that she was also a woman of color was important,” she tells HealthCity. And about her fellow pregnant peers, she says, “We were able to talk about our different cultures — Dominican, African, Indian, American — and learn about each other’s traditions.”
In hospital, BMC offers CenteringPregnancy in Spanish and English, which helps increase access and establish trust with patients. For patients looking for sessions in Haitian Creole, Codman Square Health Centerand Mattapan Community Health Center, two BMC-affiliated centers, have made those available. A care navigator co-leads the sessions to connect patients to community resources, including WIC and Room to Grow.
“If a patient doesn’t have housing or doesn’t have the financial means to make it to their next appointment, we need to resolve that first before they’ll want to talk about their pregnancy,” says midwife Estefany Flores-Godaire, CNM, director of CenteringPregnancy at BMC and leader of the Spanish-language group. “We normalize, destigmatize, and close a lot of loops for our patients.”
Flores-Godaire says that many pregnant people seeking care at BMC have never before seen a primary care provider, so the prenatal period is a chance to engage them in their overall health.
“Pregnancy is a window where we can see what we might suffer from later in life,” she explains. “It’s a great time to capture folks and motivate them to take care of their health, because not only are they going to be living for themselves, but also for their babies and families. The Centering model really engages the patient to become more assertive about their healthcare.”
Proven outcomes of CenteringPregnancy
In a 2012 focus group of CenteringPregnancy participants, four themes emerged about their care and experience:
- “It’s about respect.”
- “Knowledge is power.”
- “I’m a better mother.”
- “Supporting each other.”
These themes resonate with Liriano. “For my first two pregnancies, I thought we just had to do whatever the doctor told us to,” she recalls. “I didn’t know a mother had rights. I loved Centering for my third pregnancy because I could openly ask questions, and we talked about our personal views on just about everything. They let us know we have options.”
For extra support, Liriano also had a Birth Sisters Program doula. “My third delivery was the most painful, but mentally, I was in a better place. I was prepared to the point that I gave birth with one push.”
Flores-Godaire says this type of feedback is supported by published research in the Journal of Midwifery and Women’s Health on how the CenteringPregnancy model of group prenatal care holds promise for improving the birth outcomes of all pregnant persons, especially Hispanic and Latinx patients. Similarly, a 2017 study in the American Journal of Obstetrics and Gynecology found that Black pregnant people who participate in group prenatal care experienced lower rates of preterm birth, though more research on larger sample sizes is needed in both cases.
Flores-Godaire and her colleagues are working on tracking, evaluating, and reporting on their data, which they are confident will show that CenteringPregnancy leads to improved maternal and newborn health outcomes, including:
- lower rates of preeclampsia
- lower preterm births
- higher rates of normal spontaneous vaginal deliveries
- higher vaginal birth after cesarean VBAC success rates
- higher rates of breastfeeding
- reduction in postpartum hemorrhage
- higher rates of postpartum retention
- higher rates of postpartum contraception
Liriano’s experience is a perfect example of how Centering can improve the health of the pregnant person and the baby. While carrying Naveen, Liriano had debilitating pelvic pain due to symphysis pubis dysfunction. Some days, it was hard to even get out of bed.
“I was going through a lot of personal things,” she shares. “Even though I had depression and anxiety, Centering helped me know that I wasn’t the only one going through it.”
Is group prenatal care scalable?
CenteringPregnancy has near universal coverage, making it easy for other institutions to adopt and scale. Flores-Godaire already has specific visions for ways to enhance and expand the program within BMC.
“I have visions of eventually offering Centering to more higher risk populations as a way to normalize their pregnancies and birth,” Flores-Godaire says, noting that currently the CenteringPregnacy model at BMC is geared toward low-risk pregnancies. “A specific group of pregnant persons who may benefit from CenteringPregnancy are those with gestational diabetes. It would be ideal to also engage these folks and provide them with the education and tools they need to be assertive about their healthcare. We already have the foundations of a great collaboration with our maternal fetal medicine doctors to make this possible.”
She adds that there are other groups within BMC — Project RESPECT, the Fibroid Center, and the Immigrant & Refugee Health Center — that are starting to offer a Centering model, so she also sees unlimited potential to expand from within, thanks to what she calls the “magic” of BMC.
“We are all here for the same mission, we all work together and support each other when we see a benefit to our patients.”
Philip Connors, MS, CGC quoted in the article below:
Restrictive abortion laws are limiting the options parents have after receiving genetic test results, experts say
During a pregnancy, women are offered prenatal genetic screening and diagnostic testing to determine whether a fetus is healthy or has certain genetic disorders or anomalies.
This information can help patients and their doctors prepare for the pregnancy. But some opt out of such testing, believing that babies should be born regardless of potential abnormalities.
For those who do choose to undergo such testing, maternal-fetal medicine specialists and genetic counselors usually work closely with the pregnant person or couple to explain in detail what the results mean for a birth, for mother and child, if a genetic disorder or fetal anomaly is detected. These health care providers can also provide the pregnant person or couple with guidance on what options are available to them after a diagnosis, which can include aborting a pregnancy. That option, however, is limited or no longer available to women in many U.S. states.
Prenatal tests can’t diagnose a genetic condition before 6 weeks
Without the protection of Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide and was overturned in June, the procedure has become illegal or heavily restricted in at least 14 states. Six states — Mississippi, Missouri, Tennessee, North Dakota, South Dakota and Ohio — prohibit abortions when the fetus may have a genetic anomaly, and in five of those states, it’s now nearly impossible, because it is banned at about six weeks. This is so early in a pregnancy that many women at that point don’t even know they are carrying a child.
“A person’s first [doctor’s] appointment in pregnancy doesn’t usually happen until eight or 10 weeks, so never mind the rest of the story. That’s when obstetric care begins,” said Philip D. Connors, lead genetic counselor at Boston Medical Center.
“Three [percent] to 4% of all pregnancies are going to be affected by some sort of complication related to a difference in fetal or embryonic development, a genetic condition. And essentially none of those can be screened for or diagnosed until after the gestational age limits that are being placed by some of these really discriminatory laws,” Connors added.
Dr. Tani Malhotra, a maternal-fetal medicine specialist in Cleveland, Ohio, a state where abortions are now illegal after six weeks and where there are no exceptions for cases of rape, incest or fatal fetal anomalies, said it is impossible to assess whether there are any issues with the fetus at such an early point in pregnancy.
“The size of the embryo at six weeks is somewhere between 6 to 7 millimeters. It’s less than 1 centimeter, and that centimeter is like the size of my finger, right? So it’s just impossible for us to be able to detect abnormal findings on an ultrasound at that point,” Malhotra said.
Katie Sagaser, director of genetic counseling at Juno Diagnostics, a women’s health company, told Yahoo News: “There’s no genetic testing or screening … that can be done prior to six weeks.”
One method of testing — which she said has revolutionized “the landscape of prenatal chromosome screening” and is mostly used today — is a noninvasive prenatal screening technology known as NIPT or NIPS. This can detect genetic variations as early as nine weeks into pregnancy, using a blood sample from the mother. But the test, Sagaser said, can only indicate if there is a potential problem, and does not replace diagnostic testing, such as chorionic villus sampling (CVS) or amniocentesis, which study the cells from the fetus or placenta and can confirm a diagnosis.
The earliest a CVS diagnostic test can be performed is at the 10th week of pregnancy. Amniocentesis is usually conducted at between 15 and 20 weeks of pregnancy, but can technically be done up until a person gives birth, according to the American College of Obstetricians and Gynecologists.
Aborting a pregnancy because of genetic anomalies
As prenatal screening testing like NIPS has become more common, selective terminations involving genetic conditions have too. Some studies have shown that parents often decide to terminate a pregnancy, even after finding a mild form of a genetic condition, including Turner and Klinefelter syndromes.
Down syndrome is the most common chromosomal disorder in the U.S., and about 6,000 babies are born with it in the U.S. each year, according to the Centers for Disease Control and Prevention.
A published review of studies, which included 24 publications studying pregnancy terminations after a prenatal diagnosis of Down syndrome in the U.S., found that 67% of those pregnancies end in abortion.
Terminating a pregnancy after the 2nd trimester because of medical complications
It’s notable, however, that the majority of abortions in the U.S. (91%) occur at or before 13 weeks of gestation. Abortions late in pregnancy are rare, but Malhotra said some of the main reasons why they do happen include delays and other barriers in obtaining abortion care, or after discovering medical complications. Those complications often include the discovery of lethal fetal anomalies, which can be detected during a fetal anatomy scan that is usually performed at around 20 weeks of pregnancy. Terminations at this stage, Malhotra said, are difficult and traumatic, because these pregnancies are often desired.
“It’s really tragic, as you’re telling these patients who have been continuing their pregnancy. They’re at 20 weeks. They’re excited about the pregnancy. They’re planning their baby showers. They come to that ultrasound hoping to be able to find out the sex of the baby … and you tell them this devastating news, that there is an abnormality that is either not compatible with life, or is going to have significant impact on the quality of life after birth,” the Ohio doctor said.
Malhotra told Yahoo News that Ohio’s new abortion law has made her job even tougher, because she also has to tell patients in these situations who wish to terminate the pregnancy that they cannot receive such care in their state.
“It is just horrible, because not only are you giving them this tragic, heartbreaking news, but you’re stigmatizing their care, because you’re saying, ‘Oh, this thing is illegal here, but you could go to another state.’ So they have to travel to another state to do something that’s illegal, which is a part of medical care,” Malhotra said. “If they’re not able to go out of the state, then we’re asking them to take on risks associated with a pregnancy, which we know inherently, pregnancy is not risk-free.”
In addition, she explained, she needs to inform these patients that they must act rapidly. Abortions later in a pregnancy are more complex and also more expensive. Medication abortion, which can be taken at home, can only be safely used in the first 70 days, or 10 weeks of pregnancy. After that, women need a surgical abortion, which typically takes about two days and requires inpatient care. A patient who needs to go out of state to receive care must therefore also take into account additional costs related to travel and lodging.
Because of the abortion bans that have gone into effect in the Midwest, surrounding states where the procedure is protected have seen an increase in patients, Malhotra said. “They are really backed up,” currently complicating the scheduling of an abortion, she said.
Another important reason to act quickly in these situations, according to Malhotra, is because most states do not permit abortions after 24 weeks — when a fetus has reached viability and can survive outside the uterus. According to the Guttmacher Institute, a research group focused on reproductive health, 17 states impose a ban at viability.
Little research has been conducted on what happens to women who are unable to terminate a pregnancy because of a fetal genetic condition or anomaly. However, one study conducted by the University of California, San Francisco, that tracked 1,000 women unable to get an abortion because they had passed the gestational limits, found they were more likely to fall into poverty, as well as have “worse financial, health and family outcomes,” than those who had terminated their pregnancies.
Opponents of abortions conducted as a result of screening for disabilities believe that such procedures are unjust, because all human beings have inherent value from the moment of conception. Malhotra, on the other hand, told Yahoo News that she finds it “absolutely horrible” to put patients “in a position where they don’t have a choice anymore.”
There are multiple reasons women may choose to terminate a pregnancy because of a genetic condition or anomaly, ranging from the emotional and financial cost of raising a disabled child to the effect that this may have on the existing children in a family, as well as the feeling that it is cruel to give birth to a child who may need a lifetime of constant medical intervention.
Connors said that terminations due to genetic or fetal anomalies are comparatively rare, but are often emphasized unduly in conversations on abortion and abortion care. “It inadvertently leads to a narrative about what makes a good or a bad abortion,” he said.
Sagaser agreed, saying: “There’s no benefit to us as a society to say, ‘Oh, there’s this one population that really needs access to abortion care — more so than other people.’
“Everyone deserves to be able to make the choices that are right for them and their family in that unique situation,” she added.
Hard-won reproductive health rights could be threatened by US Supreme Court decision on abortion
Reviewed by Emily Henderson, B.Sc.
Religious campaigns and political interference could threaten hard-won reproductive health rights in the global South in the wake of the US Supreme Court decision on abortion, health advocates fear.
Cross-border solidarity and coordination will be needed to face down the growing global threat to reproductive rights, health and policy experts have told SciDev.Net.
Unsafe abortion is a leading cause of maternal death worldwide. Around ten percent of abortion-related maternal deaths occur in Latin America and Sub-Saharan Africa, where abortion access is most restricted. Yet, evidence shows that legal restrictions do not reduce abortions – they occur most often where abortions are legally restricted.
Health advocates fear the US Supreme Court decision to eliminate the federal standard that protected the right to abortion, enshrined in Roe v. Wade, will have a cooling effect on funding and political support for sexual and reproductive health services in the global South.
But abortion should not be treated as a foreign funding policy issue, says Rasha Khoury, an assistant professor of obstetrics and gynecology at Boston University. “[Abortion] is a medical provision and everyone should be entitled to it,” Khoury says.
For almost 40 years, the controversial US ‘global gag rule’ has been used by Republican presidents to block federal funding to non-US organizations that provide abortion counseling, referrals, and related services, or those that advocate for greater legal rights to abortion.
While President Joe Biden overturned the Trump administration’s gag rule in January 2021, there are constant efforts by members of Congress to permanently introduce the policy, according to Rebecca Dennis, associate director of US policy and advocacy at PAI (formerly Population Action International). Some opponents are working to have it permanently removed, she says.
The expanded reach of the global gag rule under the Trump administration meant that public health services were broadly affected, resulting in some clinics closing down if they refused to be gagged, says Dennis. “This policy really had the effect of weakening many health systems around the world right before we went into a massive global health crisis,” says Dennis.
Abortion opponents are taking their message to the world – and focusing their sights on the global South. Marleen Temmerman, an obstetrics and gynaecology professor and former Belgian senator, says nationalistic and religious groups are mobilizing, leading some European governments to reverse reproductive health rights.
The fight for the legalization or decriminalization of abortion has been going on in many, many countries. What we currently see here, at least in Kenya and African countries, is the evangelistic churches are getting more and more powerful.”
Marleen Temmerman, Head of the Center of Excellence in Women and Child Health, Aga Khan University
Religious opponents from the US are emboldening European groups to take their fight to Africa, says Martin Onyango, associate director of legal strategies for Africa at the Center for Reproductive Rights. “Opposition groups that operate across the continent – and particularly Sub-Saharan Africa – are led by church groups, they are transnational, traversing the US to Europe, Europe to Africa,” Onyango says.
“The same tactics you see being deployed in the US and Europe are the same tactics being deployed in Sub-Saharan Africa, they work with the same groups – largely the evangelical church groups. They have morphed from just being a religious focus group, [there are] also professional groups within those religious groups that then use tactics like litigation to further restrict access to reproductive healthcare.”
South Africa’s Choice on Termination of Pregnancy Act states that counseling of pregnant women must be “non-directive”. When the government proposed amendments to the act in 2004, the US-based Catholic anti-abortion organization Human Life International (HLI) campaigned to overturn this provision.
HLI says it has branches in more than 100 countries, funds pregnancy care centers in 25 countries and carries out anti-abortion activities around the world, including increasing efforts to “keep Latin America pro-life”. The abortion advocacy group Equity Forward has reported that HLI has spent millions of dollars in developing countries to counter legal abortion campaigns, including in Rwanda, the Philippines, Mexico, and El Salvador.
In Sub-Saharan Africa, anti-contraception messages are now being pushed on to teenagers, Onyango says, to disrupt their access to information and services.
Onyango points out that abortion bans have a colonial legacy. In North Africa and the Middle East, abortion is heavily restricted in more than 55 percent of countries, says Khoury, a board member of Médecins Sans Frontières USA who has carried out surgical assignments in Iraq, Lebanon and Afghanistan.
“Those are laws that are based in penal code that often was instated by colonial entities,” says Khoury. “You can’t divorce the history of coloniality from the current restrictions on abortion and contraception access in these spaces. It is not an indigenous problem of trying to restrict women’s access to this very necessary health service, it’s really a vestige of coloniality.”
The systemic vulnerabilities in global reproductive health services have been 100 years in the making, says Sarah Hawkes, director of the Centre for Gender and Global Health at University College London.
Trump’s expansion of the reach of the global gag rule led to an estimated US$8-12 billion being withheld from health services around the world – up from $600 million under previous administrations, says Dennis. The UK, meanwhile, has slashed its support for family planning services via swingeing cuts to foreign aid.
“This is a situation that we’ve got ourselves into because we have relied on an incredibly old model that was developed back in the 1920s, of how population control programs were financed,” Hawkes says. “What we haven’t done is shared the responsibility, particularly within the countries that people live, operate, work within.”
Hawkes says it is time for states to take control of funding and to support reproductive rights in their communities. “The entire structure of who we are – as individuals, as families, as communities, as societies – is at stake,” says Hawkes, who is also co-director of the non-profit Global Health 50/50.
Temmerman agrees: “We have to think how to organise ourselves better not to be dependent that much on the US. With the necessary efforts, we can have this debate at the level of the [Inter-Parliamentary Union], which we did for HIV. We could look to work toward parliament and having that structure revitalized for family planning and reproductive health.”
Advocates say a coordinated global response and allyship between rights movements could protect hard-won abortion rights.
Latin America and Caribbean campaigner Catalina de la Mar Calderón says that while there are political and social nuances between countries and regions, the US Supreme Court decision highlighted the need for more interaction between regional movements.
“We are under threat… the Dobbs decision is the best example of things going backward instead of moving forward,” says Calderón, a member of the Women’s Equality Centre, referring to the Supreme Court case known as Dobbs v. Jackson Women’s Health Organization. “We need to be holding together: regardless of latitude, country, or which community this is happening in, it will affect the whole world.
“We’re here to share whatever we have learnt but we also need to learn a lot from other countries. We’ve been conquering legal changes, but access – we’re far from it. And in countries where regulation is still needed, we’ve been fighting [in Latin America] for 20, 30 years, so we can also share what has and hasn’t worked, so you don’t have to go through that.”
POV: Overturning Roe v. Wade Will Worsen Health Inequities in All Reproductive Care
The burden of impact will be borne disproportionately by people of color
On Friday, the US Supreme Court released its decision on Dobbs v. Jackson Women’s Health Organization. In one of its most consequential decisions of the past 50 years, the Court’s 6-3 decision reversed Roe v. Wade, the landmark 1973 decision certifying a constitutional right to an abortion. The reversal of Roe leaves the legality of abortion care in the hands of state governments. While some states have recently reaffirmed the right to an abortion, 26 states are likely or certain to ban abortion in most or all circumstances.
The recent national conversation has appropriately focused on the devastating impact of limiting or banning access to abortion care. Conservative estimates show that in the year following the overturning of Roe, at least 75,000 people who want, but cannot get, abortions will give birth instead. And these people are facing higher than ever—and rising—pregnancy-related mortality rates. Despite our world-class healthcare facilities, at least 700 women already die of pregnancy-related complications each year in the United States (use of the gender-specific term throughout reflects limitations in research). But not all pregnant people are at equal risk. Black and American Indian or Alaskan Native (AIAN) women have pregnancy-related mortality rates that are over three times (American Indian) and two times (Alaskan Native) higher compared to the rate for white women (40.8 and 29.7 vs. 12.7 per 100,000 live births). Women of color are more likely to enter prenatal care late or not at all, which is a risk factor for preterm birth and low birth weight. This is one of the reasons that infants born to Black and native Hawaiian and other Pacific Islander women are over twice as likely to die relative to those born to white women (10.8 and 9.4 vs. 4.6 per 1,000), and the mortality rate for infants born to AIAN women (8.2 per 1,000) is nearly twice as high.
Yet the impact of the fall of Roe will go well beyond people who are denied wanted and needed abortions. There are four other areas of reproductive health that will be affected by lack of abortion care. And as with abortion care, the burden of impact will be borne disproportionately by people of color.
Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity, most often in the fallopian tube. Ectopics occur in 2 percent of pregnancies, but are the leading cause of death in the first trimester, when the pregnancy ruptures. People of color are at an increased risk of ectopic pregnancy, as much as 50 percent higher than white women.
Many state laws banning abortion have written legislation that refers to a pregnancy at any point after fertilization. And many do not carve out an exception for pregnancies that are not viable (meaning healthy enough to continue to term). The vast majority of ectopic pregnancies (those that do not self-resolve) can be treated only with medication or surgery that terminates the pregnancy. Already, a patient in Texas with an ectopic pregnancy has been turned away for care because the clinicians were afraid that treating her pregnancy would violate S.B.8, the state law banning most abortions. And at least one Texas pharmacy has let area physicians know that they would no longer dispense methotrexate, the medication used to treat ectopic pregnancy, citing the law. Restrictive abortion laws in more states are likely to lead to more cases of patients with ectopic pregnancy being unable to secure timely, and life-saving, care.
Black women are more likely to experience a loss of pregnancy after 10 weeks of gestation, including stillbirth, compared to white and Hispanic women. Stillbirth is often managed with induction of labor, but earlier pregnancy loss is managed with the same procedures and medications used for abortion. As the number of centers and doctors who can provide abortion care decreases, pregnant people experiencing pregnancy loss may have fewer options for care without traveling great distances.
Moreover, in states that have banned abortion, clinicians and pharmacists may be hesitant to prescribe mifepristone and misoprostol, the evidence-based regimen of medications to treat early pregnancy loss. As these are the same medications used for induced abortion, they fear criminal prosecution or civil action (under “bounty hunter” laws) if someone questions their intent—if they are caring for a patient with miscarriage or aiding and abetting an abortion. Pharmacists in Texas have already refused to dispense these medications to patients having a miscarriage. Thus, abortion bans can directly impact the care of people experiencing complications of very wanted pregnancies.
Outlawing abortion may have additional consequences, including banning some of the most popular types of birth control. Bills that define the life of an “unborn child” as starting at fertilization or conception could be used to ban emergency contraception, oral contraceptives (“the pill”), or intrauterine devices. These methods of birth control do not stop a pregnancy after fertilization; hormonal methods delay ovulation and thicken the mucus in the cervix, making it harder for sperm to reach an egg if ovulation does occur. And the copper IUD makes sperm less likely to fertilize an egg. But some abortion rights opponents consider these methods of contraception “life-ending” because of the possibility that implantation may be disrupted. Even though these claims are not based on evidence, all scientists know that it’s impossible to prove a negative. And women of color are already less likely to use contraception overall, use different contraceptive methods, and have higher rates of contraceptive failure than white women.
In addition to the abortion laws with this widespread impact, legal scholars have raised the possibility that the overturning of Roe sets the stage for the overturning of Griswold v. Connecticut, the 1965 Supreme Court decision permitting the provision of contraception to married people. (Single people didn’t get this right until 1972.) As Griswold established a right to privacy and legalized birth control (for married couples only at the time), the Court could use its ruling in Dobbs and other recent cases to overturn Griswold altogether.
Assisted reproductive technologies
Black women are twice as likely to report experiencing infertility, but are only half as likely to be evaluated and treated for infertility as white women. Furthermore, people of color have a lower rate of achieving pregnancy and live birth after the use of assisted reproductive technology, such as in vitro fertilization (IVF). IVF often requires the fertilization of multiple eggs to maximize the chance of a successful pregnancy. Any healthy embryos created that are not implanted in the uterus are often frozen and stored for possible further implantation; embryos that are not healthy are often discarded.
Legislation banning abortion after fertilization may have a profound impact on IVF. It is possible that clinics may have to limit the number of embryos created, which reduces the likelihood of a successful pregnancy. Doctors may even need to implant more embryos than is healthy for the patient, to reduce the number of embryos remaining. And if a fertilized egg is considered a life, clinicians could conceivably be charged with manslaughter for discarding them. Any of these limitations would make IVF more expensive and more difficult to gain access to.
Make no mistake about it: the overturning of Roe v. Wade will have immediate and far-reaching impacts on the reproductive health of all pregnancy-capable people. And as with all healthcare delivery in the United States, the impact will be felt most acutely by people of color, worsening already tragic health inequities.
“POV” is an opinion page that provides timely commentaries from students, faculty, and staff on a variety of issues: on-campus, local, state, national, or international. Anyone interested in submitting a piece, which should be about 700 words long, should contact John O’Rourke at email@example.com. BU Today reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Boston University.
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.”