ACOG 2018

AUSTIN, TEX. – A new treatment for endometriosis-related pain, Elagolix, showed evidence of being effective long term, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Elagolix, an oral nonpeptide gonadotropin-releasing hormone (GnRH) antagonist, manufactured by AbbVie, would be the first treatment of its kind if approved by the Food and Drug Administration, and would fulfill a needed relief for a more tolerable approach to severe endometriosis patients, according to presenter Eric S. Surrey, MD, medical director at the Colorado Center of Reproductive Medicine, Lone Tree.

“There have been no new medications approved for a long time for systematic endometriosis and there is a huge gap because the current options are expensive, and they are often injectable drugs,” said Dr. Surrey in an interview. “This would be an oral agent, which would be fabulous because it allows for a lot of flexibility and for many patients this could be much less concerning than using something long acting.”

To test the long-term effects of Elagolix, investigators studied 570 women with moderate to severe endometriosis-related pain who had gathered to participate in a previous phase 3, randomized, placebo-controlled trial concerning the drug’s effectiveness.

In the two extension studies, all participants were given either a 150- or 200-mg dose of Elagolix.

Average age of each patient group was between 31 and 34 years, and all groups were majority white, with a mean length of time from surgical diagnosis ranging from 45.5 to 56.6 months.

Patient improvements in dysmenorrhea and nonmenstrual pelvic pain continued between the first 6 months and 12 months of treatment, with a decrease of 46%-77% in the overall number of analgesics taken per day.

After 12 months of consecutive treatment, patients given 150 mg of Elagolix saw mean dysmenorrhea scores improve by 49%-53% from baseline, and by 82% for those at 200 mg, with certain expected adverse events, according to Dr. Surrey.

One of the most common adverse events associated with Elagolix was hot flashes, an unsurprising finding for Dr. Surrey and his colleagues considering Elagolix is a drug that lowers estrogen levels. However, any hot flashes patients experienced during the trial were still better than those associated with current medications, according to Dr. Surrey.

“In this extension study nobody dropped out because of hot flashes in the additional 6-month extension time,” Dr. Surrey explained. “If you look at the gold standard drug for endometriosis now, which is a GnRH agonist, which are highly available and are either injectable or implants, [patients taking these drugs] can have very severe hot flashes that require additional medication to alleviate the hot flashes at the same time.”

Patients did also experience some loss in bone density; however, Dr. Surrey argues the frequency and level of these adverse events is still better than current treatment options. One patient was required to discontinue the trial for bone density loss.

Currently, Elagolix is under FDA priority review, and if approved will be the first oral endometriosis treatment approved in over a decade, according to Dr. Surrey.

Dr. Surrey and several coauthors receive financial support from AbbVie as consultants, board members, and/or employees. Dr. Surrey and Dr. Taylor receive additional support from companies including Pfizer, Bayer, and Obseva.

ezimmerman@mdedge.com

SOURCE: Surrey ES et al. ACOG 2018, Abstract 11OP.

AUSTIN, TEX. – A new treatment for endometriosis-related pain, Elagolix, showed evidence of being effective long term, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Elagolix, an oral nonpeptide gonadotropin-releasing hormone (GnRH) antagonist, manufactured by AbbVie, would be the first treatment of its kind if approved by the Food and Drug Administration, and would fulfill a needed relief for a more tolerable approach to severe endometriosis patients, according to presenter Eric S. Surrey, MD, medical director at the Colorado Center of Reproductive Medicine, Lone Tree.

“There have been no new medications approved for a long time for systematic endometriosis and there is a huge gap because the current options are expensive, and they are often injectable drugs,” said Dr. Surrey in an interview. “This would be an oral agent, which would be fabulous because it allows for a lot of flexibility and for many patients this could be much less concerning than using something long acting.”

To test the long-term effects of Elagolix, investigators studied 570 women with moderate to severe endometriosis-related pain who had gathered to participate in a previous phase 3, randomized, placebo-controlled trial concerning the drug’s effectiveness.

In the two extension studies, all participants were given either a 150- or 200-mg dose of Elagolix.

Average age of each patient group was between 31 and 34 years, and all groups were majority white, with a mean length of time from surgical diagnosis ranging from 45.5 to 56.6 months.

Patient improvements in dysmenorrhea and nonmenstrual pelvic pain continued between the first 6 months and 12 months of treatment, with a decrease of 46%-77% in the overall number of analgesics taken per day.

After 12 months of consecutive treatment, patients given 150 mg of Elagolix saw mean dysmenorrhea scores improve by 49%-53% from baseline, and by 82% for those at 200 mg, with certain expected adverse events, according to Dr. Surrey.

One of the most common adverse events associated with Elagolix was hot flashes, an unsurprising finding for Dr. Surrey and his colleagues considering Elagolix is a drug that lowers estrogen levels. However, any hot flashes patients experienced during the trial were still better than those associated with current medications, according to Dr. Surrey.

“In this extension study nobody dropped out because of hot flashes in the additional 6-month extension time,” Dr. Surrey explained. “If you look at the gold standard drug for endometriosis now, which is a GnRH agonist, which are highly available and are either injectable or implants, [patients taking these drugs] can have very severe hot flashes that require additional medication to alleviate the hot flashes at the same time.”

Patients did also experience some loss in bone density; however, Dr. Surrey argues the frequency and level of these adverse events is still better than current treatment options. One patient was required to discontinue the trial for bone density loss.

Currently, Elagolix is under FDA priority review, and if approved will be the first oral endometriosis treatment approved in over a decade, according to Dr. Surrey.

Dr. Surrey and several coauthors receive financial support from AbbVie as consultants, board members, and/or employees. Dr. Surrey and Dr. Taylor receive additional support from companies including Pfizer, Bayer, and Obseva.

ezimmerman@mdedge.com

SOURCE: Surrey ES et al. ACOG 2018, Abstract 11OP.

AUSTIN, TEX. – A new treatment for endometriosis-related pain, Elagolix, showed evidence of being effective long term, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Elagolix, an oral nonpeptide gonadotropin-releasing hormone (GnRH) antagonist, manufactured by AbbVie, would be the first treatment of its kind if approved by the Food and Drug Administration, and would fulfill a needed relief for a more tolerable approach to severe endometriosis patients, according to presenter Eric S. Surrey, MD, medical director at the Colorado Center of Reproductive Medicine, Lone Tree.

“There have been no new medications approved for a long time for systematic endometriosis and there is a huge gap because the current options are expensive, and they are often injectable drugs,” said Dr. Surrey in an interview. “This would be an oral agent, which would be fabulous because it allows for a lot of flexibility and for many patients this could be much less concerning than using something long acting.”

To test the long-term effects of Elagolix, investigators studied 570 women with moderate to severe endometriosis-related pain who had gathered to participate in a previous phase 3, randomized, placebo-controlled trial concerning the drug’s effectiveness.

In the two extension studies, all participants were given either a 150- or 200-mg dose of Elagolix.

Average age of each patient group was between 31 and 34 years, and all groups were majority white, with a mean length of time from surgical diagnosis ranging from 45.5 to 56.6 months.

Patient improvements in dysmenorrhea and nonmenstrual pelvic pain continued between the first 6 months and 12 months of treatment, with a decrease of 46%-77% in the overall number of analgesics taken per day.

After 12 months of consecutive treatment, patients given 150 mg of Elagolix saw mean dysmenorrhea scores improve by 49%-53% from baseline, and by 82% for those at 200 mg, with certain expected adverse events, according to Dr. Surrey.

One of the most common adverse events associated with Elagolix was hot flashes, an unsurprising finding for Dr. Surrey and his colleagues considering Elagolix is a drug that lowers estrogen levels. However, any hot flashes patients experienced during the trial were still better than those associated with current medications, according to Dr. Surrey.

“In this extension study nobody dropped out because of hot flashes in the additional 6-month extension time,” Dr. Surrey explained. “If you look at the gold standard drug for endometriosis now, which is a GnRH agonist, which are highly available and are either injectable or implants, [patients taking these drugs] can have very severe hot flashes that require additional medication to alleviate the hot flashes at the same time.”

Patients did also experience some loss in bone density; however, Dr. Surrey argues the frequency and level of these adverse events is still better than current treatment options. One patient was required to discontinue the trial for bone density loss.

Currently, Elagolix is under FDA priority review, and if approved will be the first oral endometriosis treatment approved in over a decade, according to Dr. Surrey.

Dr. Surrey and several coauthors receive financial support from AbbVie as consultants, board members, and/or employees. Dr. Surrey and Dr. Taylor receive additional support from companies including Pfizer, Bayer, and Obseva.

ezimmerman@mdedge.com

SOURCE: Surrey ES et al. ACOG 2018, Abstract 11OP.

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

dwatson@mdedge.com

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

dwatson@mdedge.com

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

dwatson@mdedge.com

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

koakes@mdedge.com

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

koakes@mdedge.com

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

koakes@mdedge.com

AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.

The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.

“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.

“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.

When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).

Kari Oakes

koakes@mdedge.com

SOURCE: Smith R et al. ACOG 2018, Abstract 26R.

AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.

The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.

“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.

“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.

When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).

Kari Oakes

koakes@mdedge.com

SOURCE: Smith R et al. ACOG 2018, Abstract 26R.

AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.

The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.

“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.

“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.

When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).

Kari Oakes

koakes@mdedge.com

SOURCE: Smith R et al. ACOG 2018, Abstract 26R.

AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.

“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.

The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.

Dr. Hart's interview:

In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.

Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”

When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.

Dr. Kon's interview:

Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).

“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.

The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.

koakes@mdedge.com

SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.

AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.

“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.

The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.

Dr. Hart's interview:

In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.

Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”

When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.

Dr. Kon's interview:

Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).

“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.

The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.

koakes@mdedge.com

SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.

AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.

“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.

The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.

Dr. Hart's interview:

In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.

Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”

When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.

Dr. Kon's interview:

Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).

“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.

The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.

koakes@mdedge.com

SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.

AUSTIN, TEX. – Utilizing intravenous treatment for iron deficiency in anemic pregnant women was more efficacious than oral iron supplements, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

With 42% of pregnancies worldwide affected by anemia, according to the World Health Organization, improving treatment beyond the standard oral treatment could have a large effect on decreasing pregnancy complications.

“Women with bariatric surgery and inflammatory bowel disease are at higher risk of failure,” said Shravya Govindappagari, MD, a gynecologist affiliated with New York–Presbyterian Hospital. “Intravenous iron overcomes the limited intestinal absorption of oral formulations, and may increase iron stores more quickly.”

Dr. Govindappagari and her colleagues conducted a meta-analysis of 11 randomly controlled trials published between 2002 and 2017 to uncover the possible benefits of intravenous iron over oral treatment.

Studies were conducted in India, Egypt, France, and Turkey, with one additional multicenter study that gathered patients from seven different countries. Participants were given iron sucrose, ferric carboxymaltose, or low molecular weight iron dextran, according to Dr. Govindappagari.

In an overall assessment of subjects who achieved target hemoglobin levels, patients receiving intravenous iron were 2.66 times more likely to reach target levels than those given oral treatment (P less than .001). After 4 weeks of treatment, patients in the intravenous groups had a mean hemoglobin increase of 0.84 g/dl higher than those in the oral group (P less than .001).

Some clinicians may be wary about switching treatment modality from oral to intravenous; however, Dr. Govindappagari and fellow investigators found those taking oral treatment were 35% more likely to experience adverse effects than those receiving intravenous treatment.

While the analysis, according to Dr. Govindappagari, has merit, she and her team did not have access to relevant blinded, randomly controlled trials, which may have affected the findings. Maternal and neonatal outcomes were also not included in any of the studies analyzed, nor was a cost analysis of the financial burden of switching from oral to intravenous treatment.

Despite these limitations, Dr. Govindappagari and her colleagues assert the use of intravenous iron could have a significant effect on this problem.

“Intravenous iron compared to oral iron has a higher number reach target, a greater increase in hemoglobin, and has fewer side effects,” Dr. Govindappagari said to attendees. “This could be particularly useful in women in labor, during the third trimester, and women who are iron deficient and are at risk for postpartum hemorrhage.”

Dr. Govindappagari and her colleagues reported no relevant financial disclosures.

ezimmerman@mdedge.com

SOURCE: Govindappagari S et al. ACOG 2018, Abstract 10OP.

AUSTIN, TEX. – Utilizing intravenous treatment for iron deficiency in anemic pregnant women was more efficacious than oral iron supplements, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

With 42% of pregnancies worldwide affected by anemia, according to the World Health Organization, improving treatment beyond the standard oral treatment could have a large effect on decreasing pregnancy complications.

“Women with bariatric surgery and inflammatory bowel disease are at higher risk of failure,” said Shravya Govindappagari, MD, a gynecologist affiliated with New York–Presbyterian Hospital. “Intravenous iron overcomes the limited intestinal absorption of oral formulations, and may increase iron stores more quickly.”

Dr. Govindappagari and her colleagues conducted a meta-analysis of 11 randomly controlled trials published between 2002 and 2017 to uncover the possible benefits of intravenous iron over oral treatment.

Studies were conducted in India, Egypt, France, and Turkey, with one additional multicenter study that gathered patients from seven different countries. Participants were given iron sucrose, ferric carboxymaltose, or low molecular weight iron dextran, according to Dr. Govindappagari.

In an overall assessment of subjects who achieved target hemoglobin levels, patients receiving intravenous iron were 2.66 times more likely to reach target levels than those given oral treatment (P less than .001). After 4 weeks of treatment, patients in the intravenous groups had a mean hemoglobin increase of 0.84 g/dl higher than those in the oral group (P less than .001).

Some clinicians may be wary about switching treatment modality from oral to intravenous; however, Dr. Govindappagari and fellow investigators found those taking oral treatment were 35% more likely to experience adverse effects than those receiving intravenous treatment.

While the analysis, according to Dr. Govindappagari, has merit, she and her team did not have access to relevant blinded, randomly controlled trials, which may have affected the findings. Maternal and neonatal outcomes were also not included in any of the studies analyzed, nor was a cost analysis of the financial burden of switching from oral to intravenous treatment.

Despite these limitations, Dr. Govindappagari and her colleagues assert the use of intravenous iron could have a significant effect on this problem.

“Intravenous iron compared to oral iron has a higher number reach target, a greater increase in hemoglobin, and has fewer side effects,” Dr. Govindappagari said to attendees. “This could be particularly useful in women in labor, during the third trimester, and women who are iron deficient and are at risk for postpartum hemorrhage.”

Dr. Govindappagari and her colleagues reported no relevant financial disclosures.

ezimmerman@mdedge.com

SOURCE: Govindappagari S et al. ACOG 2018, Abstract 10OP.

AUSTIN, TEX. – Utilizing intravenous treatment for iron deficiency in anemic pregnant women was more efficacious than oral iron supplements, according to a study presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

With 42% of pregnancies worldwide affected by anemia, according to the World Health Organization, improving treatment beyond the standard oral treatment could have a large effect on decreasing pregnancy complications.

“Women with bariatric surgery and inflammatory bowel disease are at higher risk of failure,” said Shravya Govindappagari, MD, a gynecologist affiliated with New York–Presbyterian Hospital. “Intravenous iron overcomes the limited intestinal absorption of oral formulations, and may increase iron stores more quickly.”

Dr. Govindappagari and her colleagues conducted a meta-analysis of 11 randomly controlled trials published between 2002 and 2017 to uncover the possible benefits of intravenous iron over oral treatment.

Studies were conducted in India, Egypt, France, and Turkey, with one additional multicenter study that gathered patients from seven different countries. Participants were given iron sucrose, ferric carboxymaltose, or low molecular weight iron dextran, according to Dr. Govindappagari.

In an overall assessment of subjects who achieved target hemoglobin levels, patients receiving intravenous iron were 2.66 times more likely to reach target levels than those given oral treatment (P less than .001). After 4 weeks of treatment, patients in the intravenous groups had a mean hemoglobin increase of 0.84 g/dl higher than those in the oral group (P less than .001).

Some clinicians may be wary about switching treatment modality from oral to intravenous; however, Dr. Govindappagari and fellow investigators found those taking oral treatment were 35% more likely to experience adverse effects than those receiving intravenous treatment.

While the analysis, according to Dr. Govindappagari, has merit, she and her team did not have access to relevant blinded, randomly controlled trials, which may have affected the findings. Maternal and neonatal outcomes were also not included in any of the studies analyzed, nor was a cost analysis of the financial burden of switching from oral to intravenous treatment.

Despite these limitations, Dr. Govindappagari and her colleagues assert the use of intravenous iron could have a significant effect on this problem.

“Intravenous iron compared to oral iron has a higher number reach target, a greater increase in hemoglobin, and has fewer side effects,” Dr. Govindappagari said to attendees. “This could be particularly useful in women in labor, during the third trimester, and women who are iron deficient and are at risk for postpartum hemorrhage.”

Dr. Govindappagari and her colleagues reported no relevant financial disclosures.

ezimmerman@mdedge.com

SOURCE: Govindappagari S et al. ACOG 2018, Abstract 10OP.

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.

“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.

The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.

Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”

The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.

“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.

“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.

She reported having no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.

AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.

“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.

The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.

Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”

The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.

“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.

“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.

She reported having no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.

AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.

“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.

The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.

Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”

The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.

“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.

“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.

She reported having no relevant financial disclosures.

koakes@mdedge.com

SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

dwatson@mdedge.com

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

dwatson@mdedge.com

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

dwatson@mdedge.com