OBG Management

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.

Wednesday, March 22. Day 4 of SGS.

Day 4, and the final day of the 49th SGS conference started with a sunrise run up and down the hills surrounding the JW Marriott Starr Resort. After breakfast, I entered the Tucson Ballroom to attend the last 2 scientific sessions of the conference.

Highlights from the first session included a look at postoperative outcomes and complication rates between gynecologic surgeons and general surgeons using the National Surgical Quality Improvement Program (NSQIP) database by Dr. Douglas Luchristt, who showed no difference between the 2 surgical specialties (and even better outcomes by gynecologists in certain operative measures), as well as the work of Dr. Christopher Hong who used 2 separate surgical databases (NSQIP and Michigan Surgical Quality Collaborative) to show that rates of vaginal hysterectomy have been decreasing from 2017 to 2020, even amongst patients who are likely good candidates for a vaginal route of hysterectomy. Dr. Jocelyn Fitzgerald presented her unique mixed methods research on how to better design the gynecologic office to improve the patient experience, using 3,000 Twitter responses to a question on this topic. Lastly, Dr. Emily Aldrich shared her work on better understanding the patient perception of same day discharge after major vaginal reconstructive surgery. An interesting finding of Dr. Aldrich’s study was that the most common response to her question about the “worst part of the surgical experience” was going home with a postoperative catheter, which surgeons often consider a small and temporary discomfort. The first session ended with the passing of the gavel from current SGS president Dr. Cheryl Iglesia, to the incoming SGS president Dr. Rosanne Kho, with much applause and excitement for what Dr. Kho will bring to the table in her new role.

The research presented at the final scientific session of the conference did not disappoint. A retrospective study on the influence of body mass index (BMI) on the time to surgical diagnosis of endometriosis by Dr. Melissa Markowitz found that obesity was associated with a delay of over 1 year in surgical diagnosis of endometriosis compared with normal and underweight patients. Dr. David (Ike) Rahn presented additional findings on his randomized, double-blinded, multicenter trial on perioperative use of vaginal estrogen cream in postmenopausal patients with prolapse. He found that 5 weeks of estrogen cream use was not associated with any improvement in urinary incontinence or sexual function.

Dr. Stephanie Glass Clark used the Premier Healthcare Database to show that that there was no difference in postoperative mesh exposure in patients who underwent a total hysterectomy compared with supracervical hysterectomy at the time of sacrocolpopexy. Dr. Kavita Mishra presented results from the FLOWER trial, which found no difference in postoperative outcomes for transgender women undergoing vaginoplasty for gender affirmation who did and did not undergo preoperative pelvic floor physical therapy. Finally, Dr. Carly Crowder shared her video of anatomy for sacral neuromodulation with some excellent cadaveric dissections to exhibit the peri-sacral and gluteal anatomy.

As the conference ended, raindrops pounded the sandy grounds of the resort as I waited in the lobby for my Uber to the airport. Dr. Rosanne Kho happened to walk by and stopped to speak with me and one of my attendings. She smiled as she asked about our experience at the conference and to wish us safe travels. To me, this moment embodies the spirit of mentorship and connection that is so unique to the SGS conference. I feel incredibly lucky to have met some of the physician leaders of our field, who genuinely want to get to know and help the next generation. This year’s meeting was attended by ObGyn generalists and surgeons of all gynecologic subspecialties and certainly met its goal in addressing topics with an “Impact Factor.” I am inspired by all the work that is happening across the country to move the needle and better our field. This was my first SGS experience, but it certainly won’t be the last. I hope you too will consider attending in the future!

Tuesday, March 21. Day 3 of SGS.

It’s Day 3 of the SGS conference! In addition to the academic roundtables, conference attendees had the option of doing early-morning yoga with Dr. Mireille Truong. Yoga sounded nice, but I spent the morning in bed, catching up on sleep. (My own version of wellness!) The scientific sessions of the day started at 7:30 am, and I especially want to highlight the work of Dr. Amy Askew who performed a randomized controlled trial comparing patient removal of urinary catheters placed for postoperative urinary retention to office removal. She found that patient urinary catheter removal was a feasible and safe option with excellent patient satisfaction and a reduction of in-person postoperative office visits. At the end of the session, Dr. Cheryl Iglesia gave her presidential address, where she shared her journey to becoming the physician, educator, researcher, and leader she is today. She emphasized the importance of being a continual learner and to give back by mentoring and educating the next generation. “Learn it, earn it, and return it.”

This was followed by the Te Linde lecture, given by Dr. Pamela Moalli. An exceptional surgeon-scientist, Dr. Moalli shared about her work on the impact of mesh on tissue, as well as alternative biologic options being developed, such as 3D printed membranes, extracellular matrix scaffolds, and living tissue grafts to create new ligamentous supports for the vagina. She discussed novel research using stem cell transplantation to harness the power of regeneration in the urethra or vagina following injury. I think it is safe to say that the entire room was in awe of the work she has done, and what she continues to do to find better therapeutic options for girls and women with pelvic floor disorders. Her talk ended in a standing ovation. Afterwards, all the University of Pittsburgh Medical Center-Magee Womens Hospital trainees, faculty, and several alumni took a picture with Dr. Moalli (fifth from the right in the picture).

Lunch followed, which included a brief walk around the industry exhibition hall. I then returned back to the Tucson Ballroom to listen in on the next scientific session on surgical ergonomics. Organized by Dr. Amy Park who herself suffered from work-related musculoskeletal injuries, the session was composed of an excellent video by Dr. Abby Stork on stretches to prevent and reduce the risk of surgeon-associated musculoskeletal injuries, especially in vaginal surgeons. There was then a panel of 3 experts, Dr. Noor Abu-Alnadi, Dr. Ladin Yurteri-Kaplan, and Dr. Susan Hallbeck (PhD ergonomics expert), moderated by Dr. Amanda Fader and Dr. Kimberly Kho. In particular, Dr. Hallbeck developed a timer app as a reminder for surgeons to stop every 40 minutes to stretch for 1.5 minutes (orstretch.mayoclinic.org). This has been studied and found to reduce musculoskeletal pain after surgery and improve physical performance without increasing total operating time. If you would like to see some of these between- and in-OR stretches yourself, an informative handout can be accessed at mcforms.mayo.edu.

Tuesday afternoon was left open. I joined Dr. Veronica Lerner, Dr. Kelly Wright, and Dr. Louise Perkins King on a 7.5-mile hike into the surrounding desert hills. We marveled at the many Saguaro cacti, some over 100 years old and towering many feet high, as well as the beautiful yellow, purple, and magenta flowers that were scattered among the desert brush. Several rabbits and deer wandered by us during our hike. On one of the trails, the stone skeleton of an old house stood, once a home to the Bowen family who had moved to Arizona for health reasons. I could see why they would want to move here—I felt such a peace looking at the gorgeous view from what was once their doorway.

After a shower and a lot of stretching, I got ready for the evening event, A Taste and Toast with SGS: Under the Arizona Skies. The food and drink were delicious, and I got to spend the evening catching up with a good friend. We watched as conference attendees assigned to different color teams (red, green, blue, and yellow), fought for the hallowed Golden Uterus Trophy in several competitive gynecology-themed games (eg, throwing sacral neuromodulation needle “darts” at balloons and removing small pom poms from a water bottle with a disposable operative hysteroscope). As the evening progressed, the DJ turned up the music and people made their way to the dance floor. The event served as a fundraiser for the SGS Pelvic Anatomy Group and successfully raised $35,000.

Day 2 of the SGS meeting started off with a gentle sunrise over the cacti-covered hills surrounding the JW Marriot Starr Pass Hotel, the venue for the 49th SGS annual scientific meeting. The first official event of the day after some engaging academic round tables was the recognition of the new SGS members. Much celebration was had over the 18 gynecologic surgeons who were inducted.

The second day included the first 3 scientific sessions of the conference. Some highlights include the work of Dr. Shawn Menefee on a randomized trial of sacral colpopexy, transvaginal mesh, and native tissue apical repair for posthysterectomy vault prolapse; a video by Dr. Matthew Fallon on a robotic-assisted laparoscopic approach to repairing a chronic uterine inversion; and the impact of age on regret following hysterectomy by Dr. Nathan King. Dr. Candace Parker-Autry also presented her work on the impact of perineorrhaphy on both female and male sexual function, and Dr. Cassie (Clarissa) Niino spoke elegantly on the “red bag problem” that exists in all of our operating rooms, which increases pollution and cost unnecessarily.

There were also several excellent talks given. Dr. Jason Wright spoke about the importance of surgical volume on gynecologic surgery. In particular, he noted that surgical volume needs to be considered not only at the surgeon level but also at the hospital level. Higher-volume hospitals will provide better care, in the same way that general, high-volume surgeons have less complications and better long-term outcomes. Of note, volume is not the whole picture. We need to also consider measurements of surgery and hospital quality and surgeon skill in addition to volume, as Dr. Shawn Menefee insightfully commented.

Dr. Beri Ridgeway gave the Mark D. Walters Lecture about surgeons in the c-suite and the importance of having a seat at the leadership table as surgeons and medical providers. In her words: “If we aren’t at the table, then we are on the menu.” Overworked and underpaid, burned out doctors feel powerless because they are managed by leaders with a business and not a medical background, and we need to have physicians in leadership who understand how medicine is practiced and to ensure equitable care

Dr. Kelly Wright gave a talk on the environmental impact of gynecologic care—from OR to clinic. She gave examples of how metal, reusable speculums become more cost-effective and produce less waste after only 2-3 uses and how there is no evidence that bouffants reduce surgical site infections (and a reusable scrub cap could work just as well without creating waste). Finally, Dr. Ebony Carter gave an impassioned talk on the need for equity in publication and grant funding in our field. She shared about her initiative through the Green Journal (Obstetrics and Gynecology) to create an issue focused on furthering equity and dispelling racism in medical research.

Later in the afternoon, I attended the Fellows’ Pelvic Research Network (FPRN) meeting, which includes AUGS-SGS (urogynecology fellows) and FMIGS-SGS (fellows of all other gynecologic subspecialities, including minimally invasive gynecologic surgery, family planning, reproductive endocrinology and infertility, and pediatric and adolescent gynecology). Dr. John Gebhart gave an excellent lecture with some impressive photos and videos on how to manage mesh exposure and erosion.

Afterwards, updates were given on the current FPRN projects, and 4 new projects were proposed and underwent audience feedback for improvement. It was exciting to see the multicenter collaborations fostered through the FPRN, and I look forward to seeing which projects will get funded for this upcoming year!

The evening ended with the President's Award Ceremony led by Dr. Cheryl Iglesia, the 49th SGS President, as well as the President's Reception. I also wantd to highlight the winner of the Distinguished Surgeon Award: Dr. Dee Fenner. The remaining awardees are listed on the SGS website (https://sgsonline.org).

Last night around midnight, bleary-eyed from the long flight from Pittsburgh, I walked out into the dimly lit, mild air of Tucson, Arizona. The Saguaro cacti that lined the entrance to the airport stood tall and tree-like, with welcoming green arms. It was as if they too knew that the next 4 days would be filled with the building of new relationships and the strengthening of old ones, as well as with education, innovation, and the sharing of research. That spirit of collegiality, approachability, and connection in an intimate and vibrant meeting is what the Society of Gynecologic Surgeons (SGS) meeting has been known for and why it draws people to come back, year after year.

The first day of the conference was fantastic. As a first-time attendant at SGS, I was excited to have the opportunity to meet and rub elbows with mentors and role models from across the country. My day started off with the SGS Fellows and Young Attendings Course, moderated by 3 incredible faculty: Dr. Matthew Barker, Dr. Sadikah Behbehani, and Dr. Traci Ito. Some high-yield topics such as contract negotiation, developing a urogynecology- or MIGS-based practice, billing, academic promotion, and taking advantage of relationships with industry were discussed at length, and the session ended with a roundtable, where the experts had time to answer questions in smaller groups. One of the quotes that will ring true for many fellows about to embark on the job search was from Dr. Amanda Ecker: “Up until now, you were told where to go and what your schedule is. This is the first time you have flexibility and power to decide for yourself.” Therefore, it is important to reflect on what you really desire and/or prioritize in a job, whether it is location, compensation, protected time, or opportunities for advancement.

In the afternoon, I attended a postgraduate course led by Dr. Veronica Lerner and Dr. Mireille Truong called “The Sim Factor: Making an Impact in Surgical Education.” Several other excellent postgraduate courses were available, including “Advanced Endometriosis Surgery and Pelvic Pain Patient-Centered Approach,” “Social Media Workshop- #Gynfluencing: Using Social Media to Find Your Digital Voice,” and “Urologic Surgery for the Gynecologic Surgeon: GU Injury, Ureteral Stents, Complex Fistula and More.” I was grateful for the hands-on and tangible tools that Drs. Lerner and Truong left the group with—including ideas such as Zoom-based virtual coaching for trainees learning fundamentals of laparoscopic surgery types of tasks, table-top simulation for high-stakes scenarios (eg, operative vascular injury), and the importance of grounding educational activity in objectives and evaluation. I even got to make and take home my own myomectomy model. (Fun fact: The myoma is actually a stress ball wrapped in an Ace bandage and then Glad Press n’ Seal! 

The late afternoon transitioned to an opportunity for trainees to interact with senior SGS members and a welcome reception. The indoor and outdoor spaces were filled with laughing and talking as people connected over drinks and snacks. Finally, the evening ended with a session presented by the SGS Equity Council, “What your Patients REALLY Want to Know.” Patty Brisben, of the Patty Brisben Foundation and founder of the company Pure Romance, was interviewed by Dr. Christine Vaccaro. It was heartwarming to hear how Patty took the stories of women suffering from sexual pain and dissatisfaction and chose to make it her life’s mission to improve women’s sexual health.

A few years ago, my partner emailed me about a consult.
 

“Dr. Carter, I had the pleasure of seeing Mrs. Smith today for a preconception consult for chronic hypertension. As a high-risk Black woman, she wants to know what we’re going to do to make sure that she doesn’t die in pregnancy or childbirth. I told her that you’re better equipped to answer this question.”

I was early in my career, and the only thing I could assume that equipped me to answer this question over my partners was my identity as a Black woman living in America.

Mrs. Smith was copied on the message and replied with a long list of follow-up questions and a request for an in-person meeting with me. I was conflicted. As a friend, daughter, and mother, I understood her fear and wanted to be there for her. As a newly appointed assistant professor on the tenure track with 20% clinical time, my clinical responsibilities easily exceeded 50% (in part, because I failed to set boundaries). I spent countless hours of uncompensated time serving on diversity, equity, and inclusion initiatives and mentoring and volunteering for multiple community organizations; I was acutely aware that I would be measured against colleagues who rise through the ranks, unencumbered by these social, moral, and ethical responsibilities, collectively known as the “Black tax.”¹

I knew from prior experiences and the tone of Mrs. Smith’s email that it would be a tough, long meeting that would set a precedent of concierge level care that only promised to intensify once she became pregnant. I agonized over my reply. How could I balance providing compassionate care for this patient with my young research program, which I hoped to nurture so that it would one day grow to have population-level impact?

It took me 2 days to finally reply to the message with a kind, but firm, email stating that I would be happy to see her for a follow-up preconception visit. It was my attempt to balance accessibility with boundaries. She did not reply.

Did I fail her?

The fact that I still think of Mrs. Smith may indicate that I did the wrong thing. In fact, writing the first draft of this letter was a therapeutic experience, and I addressed it to Mrs. Smith. As I shared the experience and letter with friends in the field, however, everyone had similar stories. The letter continued to pass between colleagues, who each made it infinitely better. This collective process created the beautiful love letter to Black birthing people that we share here.

We call upon all of our obstetric clinician colleagues to educate themselves to be equally, ethically, and equitably equipped to care for and serve historically marginalized women and birthing people. We hope that this letter will aid in the journey, and we encourage you to share it with patients to open conversations that are too often left closed.

Continue to: Our love letter to Black women and birthing people...

Our love letter to Black women and birthing people

We see you, we hear you, we know you are scared, and we are you. In recent years, the press has amplified gross inequities in maternal care and outcomes that we, as Black birth workers, midwives, and physicians, already knew to be true. We grieve, along with you regarding the recently reported pregnancy-related deaths of Mrs. Kira Johnson,² Dr. Shalon Irving,³ Dr. Chaniece Wallace,⁴ and so many other names we do not know because their stories did not receive national attention, but we know that they represented the best of us, and they are gone too soon. As Black birth workers, midwives, physicians, and more, we have a front-row seat to the United States’ serious obstetric racism, manifested in biased clinical interactions, unjust hospital policies, and an inequitable health care system that leads to disparities in maternal morbidity and mortality for Black women.

Unfortunately, this is not anything new, and the legacy dates back to slavery and the disregard for Black people in this country. What has changed is our increased awareness of these health injustices. This collective consciousness of the risk that is carried with our pregnancies casts a shadow of fear over a period that should be full of the joy and promise of new life. We fear that our personhood will be disregarded, our pain will be ignored, and our voices silenced by a medical system that has sought to dominate our bodies and experiment on them without our permission.⁵ While this history is reprehensible, and our collective risk as Black people is disproportionately high, our purpose in writing this letter is to help Black birthing people recapture the joy and celebration that should be theirs in pregnancy and in the journey to parenthood.

As Black birth workers, we see Black pregnant patients desperately seeking safety, security, and breaking down barriers to find us for their pregnancy care. Often, they are terrified and looking for kinship and community in our offices. In rural areas patients may drive up to 4 hours in distance for an appointment, and during appointments entrust us with their stories of feeling unheard in the medical system. When we anecdotally asked about what they feared about pregnancy, childbirth, and the postpartum period and thought was their risk of dying during pregnancy or childbirth, answers ranged from 1% to 60%. Our actual risk of dying from a pregnancy-related cause, as a Black woman, is 0.0414% (41.4 Black maternal deaths per 100,000 live births).⁶ To put that in perspective, our risk of dying is higher walking down the street or driving a car.⁷

What is the source of the fear? Based on past and present injustices inflicted on people with historically marginalized identities, we have every right to be scared; but, make no mistake that fear comes at a cost, and Black birthing people are the ones paying the bill! Stress and chronic worry are associated with poor pregnancy outcomes, and so this completely justifiable fear, at the population level, is not serving us well personally.⁸ Unfortunately, lost in the messaging about racial inequities in maternal mortality is the reality that the vast majority of Black people and babies will survive, thrive, and have healthy pregnancy outcomes, despite the terrifying population-level statistics and horrific stories of discrimination and neglect that make us feel like our pregnancies and personal peril are synonymous.

While it is true that our absolute individual, personal risk is lower than population-level statistics convey, let us be clear: We are furious about what is happening to Black people! It is immoral that Black patients in the richest country in the world are 3-4 times more likely to die of a pregnancy-related cause than White women,⁹ and we are more likely to experience pregnancy complications and “near misses” when death is narrowly avoided. Research has done an excellent job defining reproductive health disparities in this country, but prioritizing and funding meaningful strategies, policies, and programs to close this gap have not taken precedence—especially initiatives and research that are headed by Black women.^10–12 This is largely because researchers and health care systems continue evaluating strategies that focus on behavior change and narratives that identify individual responsibility as a sole cause of inequity.

Let us be clear, Black people and our behaviors are not the problem.¹³ The problems are White supremacy, classism, sexism, heteropatriarchy, and obstetric racism.^1-21 These must be recognized and addressed across all levels of power. We endorse systems-level changes that are at the root of promoting health equity in our reproductive outcomes. These changes include paid parental leave, Medicaid expansion/extension, reimbursement for doula and lactation services, increased access to perinatal mental health and wellness services, and so much more. (See the Black Mamas Matter Alliance Toolkit: https://blackmamas matter.org/our-work/toolkits/.)

Continue to: Pearls for reassurance...

Pearls for reassurance

While the inequities and their solutions are grounded in the need for systemic change,²² we realize that these population-level solutions feel abstract when our sisters and siblings ask us, “So what can I do to advocate for myself and my baby, right now in this pregnancy?” To be clear, no amount of personal hypervigilance on our part as Black pregnancy-capable people is going to fix these problems, which are systemic; however, we want to provide a few pearls that may be helpful for patient self-advocacy and reassurance:

1. Seek culturally and ethnically congruent care. We intuitively want to find a clinician who looks like us, but sadly, in the United States only 5% of physicians and 2% of midwives are Black. Demand exceeds supply for Black patients who are seeking racially congruent care. Nonetheless, it is critical that you find a physician or midwife who centers you and  provides support and care that affirms the strengths and assets of you, your family, and your community when cultural and ethnic congruency are not possible for you and your pregnancy. 
2. Ask how your clinicians are actively working to ensure optimal and equitable experiences for Black birthing individuals. We recommend asking your clinician and/or hospital what, if anything, they are doing to address health care inequities, obstetric racism, or implicit bias in their pregnancy and postpartum care. Many groups (including some authors of this letter) are working on measures to address obstetric racism. An acknowledgement of initiatives to mitigate inequities is a meaningful first step. You can suggest that they look into it while you explore your options, as this work is rapidly emerging in many areas of the country. 
3. Plan for well-person care. The best time to optimize pregnancy and birth outcomes is before you get pregnant. Set up an appointment with a midwife, ObGyn, or your primary care physician before you get pregnant. Discuss your concerns about pregnancy and use this time to optimize your health. This also provides an opportunity to build a relationship with your physician/ midwife and their group to evaluate whether they curate an environment where you feel seen, heard, and valued when you go for annual exams or problem visits. If you do not get that sense after a couple of visits, find a place where you do. 
4. Advocate for a second opinion. If something does not sound right to you or you have questions that were not adequately answered, it is your prerogative to seek a second opinion; a clinician should never be offended by this. 
5. Consider these factors, for those who deliver in a hospital (by choice or necessity): 

   a. 24/7 access to obstetricians and dedicated anesthesiologists in the hospital

   b. trauma-informed medical/mental health/social services

   c. lactation consultation

   d. supportive trial of labor after cesarean delivery policy

   e. massive blood transfusion  protocol. 

6. Seek doula support! It always helps to have another set of eyes and ears to help advocate for you, especially when you are in pain during pregnancy, childbirth, or in the postpartum period, or are having difficulty advocating for yourself. There is also evidence that women supported by doulas have better pregnancy-related outcomes and experiences.²³ Many major cities in the United States have started to provide race-concordant doula care for Black birthing people  for free.²⁴
7.  Don’t forget about your mental health. As stated, chronic stress from racism impacts birth outcomes. Having a mental health clinician is a great way to mitigate adverse effects of prolonged tension.^25–27
8. Ask your clinician, hospital, or insurance company about participating in group prenatal care and/or nurse home visiting models²⁸ because both are associated with improved birth outcomes.²⁹ Many institutions are implementing group care that provides race-concordant care.^30,31 
9. Ask your clinician, hospital, or local health department for recommendations to a lactation consultant or educator who can support your efforts in breast/ chest/body-feeding. 

We invite you to consider this truth

You, alone, do not carry the entire population-level risk of Black birthing people on your shoulders. We all carry a piece of it. We, along with many allies, advocates, and activists, are outraged and angered by generations of racism and mistreatment of Black birthing people in our health systems and hospitals. We are channeling our frustration and disgust to demand substantive and sustainable change.

Our purpose here is to provide love and reassurance to our sisters and siblings who are going through their pregnancies with thoughts about our nation’s past and present failures to promote health equity for us and our babies. Our purpose is neither to minimize the public health crisis of Black infant and maternal morbidity and mortality nor is it to absolve clinicians, health systems, or governments from taking responsibility for these shameful outcomes or making meaningful changes to address them. In fact, we love taking care of our community by providing the best clinical care we can to our patients. We call upon all of our clinical colleagues to educate themselves to be ethically and equitably equipped to provide health care for Black pregnant patients. Finally, to birthing Black families, please remember this: If you choose to have a baby, the outcome and experience must align with what is right for you and your baby to survive and thrive. So much of the joys of pregnancy have been stolen, but we will recapture the celebration that should be ours in pregnancy and the journey to parenthood.

Sincerely,

Ebony B. Carter, MD, MPH
Maternal Fetal Medicine
Washington University School of Medicine
St. Louis, Missouri

Karen A. Scott, MD, MPH
Birthing Cultural Rigor, LLC
Nashville, Tennessee

Andrea Jackson, MD, MAS
ObGyn
University of California,
San Francisco

Sara Whetstone, MD, MHS
ObGyn
University of California, 
San Francisco

Traci Johnson, MD
ObGyn
University of Missouri 
School of Medicine
Kansas City, Missouri

Sarahn Wheeler, MD
Maternal Fetal Medicine
Duke University School of Medicine
Durham, North Carolina

Asmara Gebre, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

Joia Crear-Perry, MD
ObGyn
National Birth Equity Collaborative
New Orleans, Louisiana

Dineo Khabele, MD
Gynecologic Oncology
Washington University School of Medicine
St. Louis, Missouri

Judette Louis, MD, MPH
Maternal Fetal Medicine
University of South Florida College of Medicine
Tampa, Florida

Yvonne Smith, MSN, RN
Director
Barnes-Jewish Hospital
St. Louis, Missouri

Laura Riley, MD
Maternal Fetal Medicine
Weill Cornell Medicine
New York, New York

Antoinette Liddell, MSN, RN
Care Coordinator
Barnes-Jewish Hospital
St. Louis, Missouri

Cynthia Gyamfi-Bannerman, MD
Maternal Fetal Medicine
Columbia University Irving Medical Center
New York, New York

Rasheda Pippens, MSN, RN
Nurse Educator
Barnes-Jewish Hospital
St. Louis, Missouri

Ayaba Worjoloh-Clemens, MD
ObGyn
Atlanta, Georgia

Allison Bryant, MD, MPH
Maternal Fetal Medicine
Massachusetts General Hospital
Boston, Massachusetts

Sheri L. Foote, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

J. Lindsay Sillas, MD
ObGyn
Bella OB/GYN
Houston, Texas

Cynthia Rogers, MD
Psychiatrist
Washington University School of Medicine
St. Louis, Missouri

Audra R. Meadows, MD, MPH
ObGyn
University of California, San Diego

AeuMuro G. Lake, MD
Urogynecologist
Urogynecology and Healing Arts
Seattle, Washington

Nancy Moore, MSN, RN, WHNP-BC
Nurse Practitioner
Barnes-Jewish Hospital
St. Louis, Missouri

Zoë Julian, MD, MPH
ObGyn
University of Alabama at Birmingham

Janice M. Tinsley, MN, RNC-OB
Zuckerberg San Francisco General Hospital
San Francisco, California

Jamila B. Perritt, MD, MPH
ObGyn
Washington, DC

Joy A. Cooper, MD, MSc
ObGyn
Culture Care
Oakland, California

Arthurine K. Zakama, MD
ObGyn
University of California,San Francisco

Alissa Erogbogbo, MD
OB Hospitalist
Los Altos, California

Sanithia L. Williams, MD
ObGyn
Huntsville, Alabama

Audra Williams, MD, MPH
ObGyn
University of Alabama, Birmingham

Hedwige “Didi” Saint Louis, MD, MPH
OB Hospitalist
Morehouse School of Medicine
Atlanta, Georgia

Cherise Cokley, MD
OB Hospitalist
Community Hospital
Munster, Indiana

J’Leise Sosa, MD, MPH
ObGyn
Buffalo, New York

A few years ago, my partner emailed me about a consult.
 

“Dr. Carter, I had the pleasure of seeing Mrs. Smith today for a preconception consult for chronic hypertension. As a high-risk Black woman, she wants to know what we’re going to do to make sure that she doesn’t die in pregnancy or childbirth. I told her that you’re better equipped to answer this question.”

I was early in my career, and the only thing I could assume that equipped me to answer this question over my partners was my identity as a Black woman living in America.

Mrs. Smith was copied on the message and replied with a long list of follow-up questions and a request for an in-person meeting with me. I was conflicted. As a friend, daughter, and mother, I understood her fear and wanted to be there for her. As a newly appointed assistant professor on the tenure track with 20% clinical time, my clinical responsibilities easily exceeded 50% (in part, because I failed to set boundaries). I spent countless hours of uncompensated time serving on diversity, equity, and inclusion initiatives and mentoring and volunteering for multiple community organizations; I was acutely aware that I would be measured against colleagues who rise through the ranks, unencumbered by these social, moral, and ethical responsibilities, collectively known as the “Black tax.”¹

I knew from prior experiences and the tone of Mrs. Smith’s email that it would be a tough, long meeting that would set a precedent of concierge level care that only promised to intensify once she became pregnant. I agonized over my reply. How could I balance providing compassionate care for this patient with my young research program, which I hoped to nurture so that it would one day grow to have population-level impact?

It took me 2 days to finally reply to the message with a kind, but firm, email stating that I would be happy to see her for a follow-up preconception visit. It was my attempt to balance accessibility with boundaries. She did not reply.

Did I fail her?

The fact that I still think of Mrs. Smith may indicate that I did the wrong thing. In fact, writing the first draft of this letter was a therapeutic experience, and I addressed it to Mrs. Smith. As I shared the experience and letter with friends in the field, however, everyone had similar stories. The letter continued to pass between colleagues, who each made it infinitely better. This collective process created the beautiful love letter to Black birthing people that we share here.

We call upon all of our obstetric clinician colleagues to educate themselves to be equally, ethically, and equitably equipped to care for and serve historically marginalized women and birthing people. We hope that this letter will aid in the journey, and we encourage you to share it with patients to open conversations that are too often left closed.

Continue to: Our love letter to Black women and birthing people...

Our love letter to Black women and birthing people

We see you, we hear you, we know you are scared, and we are you. In recent years, the press has amplified gross inequities in maternal care and outcomes that we, as Black birth workers, midwives, and physicians, already knew to be true. We grieve, along with you regarding the recently reported pregnancy-related deaths of Mrs. Kira Johnson,² Dr. Shalon Irving,³ Dr. Chaniece Wallace,⁴ and so many other names we do not know because their stories did not receive national attention, but we know that they represented the best of us, and they are gone too soon. As Black birth workers, midwives, physicians, and more, we have a front-row seat to the United States’ serious obstetric racism, manifested in biased clinical interactions, unjust hospital policies, and an inequitable health care system that leads to disparities in maternal morbidity and mortality for Black women.

Unfortunately, this is not anything new, and the legacy dates back to slavery and the disregard for Black people in this country. What has changed is our increased awareness of these health injustices. This collective consciousness of the risk that is carried with our pregnancies casts a shadow of fear over a period that should be full of the joy and promise of new life. We fear that our personhood will be disregarded, our pain will be ignored, and our voices silenced by a medical system that has sought to dominate our bodies and experiment on them without our permission.⁵ While this history is reprehensible, and our collective risk as Black people is disproportionately high, our purpose in writing this letter is to help Black birthing people recapture the joy and celebration that should be theirs in pregnancy and in the journey to parenthood.

As Black birth workers, we see Black pregnant patients desperately seeking safety, security, and breaking down barriers to find us for their pregnancy care. Often, they are terrified and looking for kinship and community in our offices. In rural areas patients may drive up to 4 hours in distance for an appointment, and during appointments entrust us with their stories of feeling unheard in the medical system. When we anecdotally asked about what they feared about pregnancy, childbirth, and the postpartum period and thought was their risk of dying during pregnancy or childbirth, answers ranged from 1% to 60%. Our actual risk of dying from a pregnancy-related cause, as a Black woman, is 0.0414% (41.4 Black maternal deaths per 100,000 live births).⁶ To put that in perspective, our risk of dying is higher walking down the street or driving a car.⁷

What is the source of the fear? Based on past and present injustices inflicted on people with historically marginalized identities, we have every right to be scared; but, make no mistake that fear comes at a cost, and Black birthing people are the ones paying the bill! Stress and chronic worry are associated with poor pregnancy outcomes, and so this completely justifiable fear, at the population level, is not serving us well personally.⁸ Unfortunately, lost in the messaging about racial inequities in maternal mortality is the reality that the vast majority of Black people and babies will survive, thrive, and have healthy pregnancy outcomes, despite the terrifying population-level statistics and horrific stories of discrimination and neglect that make us feel like our pregnancies and personal peril are synonymous.

While it is true that our absolute individual, personal risk is lower than population-level statistics convey, let us be clear: We are furious about what is happening to Black people! It is immoral that Black patients in the richest country in the world are 3-4 times more likely to die of a pregnancy-related cause than White women,⁹ and we are more likely to experience pregnancy complications and “near misses” when death is narrowly avoided. Research has done an excellent job defining reproductive health disparities in this country, but prioritizing and funding meaningful strategies, policies, and programs to close this gap have not taken precedence—especially initiatives and research that are headed by Black women.^10–12 This is largely because researchers and health care systems continue evaluating strategies that focus on behavior change and narratives that identify individual responsibility as a sole cause of inequity.

Let us be clear, Black people and our behaviors are not the problem.¹³ The problems are White supremacy, classism, sexism, heteropatriarchy, and obstetric racism.^1-21 These must be recognized and addressed across all levels of power. We endorse systems-level changes that are at the root of promoting health equity in our reproductive outcomes. These changes include paid parental leave, Medicaid expansion/extension, reimbursement for doula and lactation services, increased access to perinatal mental health and wellness services, and so much more. (See the Black Mamas Matter Alliance Toolkit: https://blackmamas matter.org/our-work/toolkits/.)

Continue to: Pearls for reassurance...

Pearls for reassurance

While the inequities and their solutions are grounded in the need for systemic change,²² we realize that these population-level solutions feel abstract when our sisters and siblings ask us, “So what can I do to advocate for myself and my baby, right now in this pregnancy?” To be clear, no amount of personal hypervigilance on our part as Black pregnancy-capable people is going to fix these problems, which are systemic; however, we want to provide a few pearls that may be helpful for patient self-advocacy and reassurance:

1. Seek culturally and ethnically congruent care. We intuitively want to find a clinician who looks like us, but sadly, in the United States only 5% of physicians and 2% of midwives are Black. Demand exceeds supply for Black patients who are seeking racially congruent care. Nonetheless, it is critical that you find a physician or midwife who centers you and  provides support and care that affirms the strengths and assets of you, your family, and your community when cultural and ethnic congruency are not possible for you and your pregnancy. 
2. Ask how your clinicians are actively working to ensure optimal and equitable experiences for Black birthing individuals. We recommend asking your clinician and/or hospital what, if anything, they are doing to address health care inequities, obstetric racism, or implicit bias in their pregnancy and postpartum care. Many groups (including some authors of this letter) are working on measures to address obstetric racism. An acknowledgement of initiatives to mitigate inequities is a meaningful first step. You can suggest that they look into it while you explore your options, as this work is rapidly emerging in many areas of the country. 
3. Plan for well-person care. The best time to optimize pregnancy and birth outcomes is before you get pregnant. Set up an appointment with a midwife, ObGyn, or your primary care physician before you get pregnant. Discuss your concerns about pregnancy and use this time to optimize your health. This also provides an opportunity to build a relationship with your physician/ midwife and their group to evaluate whether they curate an environment where you feel seen, heard, and valued when you go for annual exams or problem visits. If you do not get that sense after a couple of visits, find a place where you do. 
4. Advocate for a second opinion. If something does not sound right to you or you have questions that were not adequately answered, it is your prerogative to seek a second opinion; a clinician should never be offended by this. 
5. Consider these factors, for those who deliver in a hospital (by choice or necessity): 

   a. 24/7 access to obstetricians and dedicated anesthesiologists in the hospital

   b. trauma-informed medical/mental health/social services

   c. lactation consultation

   d. supportive trial of labor after cesarean delivery policy

   e. massive blood transfusion  protocol. 

6. Seek doula support! It always helps to have another set of eyes and ears to help advocate for you, especially when you are in pain during pregnancy, childbirth, or in the postpartum period, or are having difficulty advocating for yourself. There is also evidence that women supported by doulas have better pregnancy-related outcomes and experiences.²³ Many major cities in the United States have started to provide race-concordant doula care for Black birthing people  for free.²⁴
7.  Don’t forget about your mental health. As stated, chronic stress from racism impacts birth outcomes. Having a mental health clinician is a great way to mitigate adverse effects of prolonged tension.^25–27
8. Ask your clinician, hospital, or insurance company about participating in group prenatal care and/or nurse home visiting models²⁸ because both are associated with improved birth outcomes.²⁹ Many institutions are implementing group care that provides race-concordant care.^30,31 
9. Ask your clinician, hospital, or local health department for recommendations to a lactation consultant or educator who can support your efforts in breast/ chest/body-feeding. 

We invite you to consider this truth

You, alone, do not carry the entire population-level risk of Black birthing people on your shoulders. We all carry a piece of it. We, along with many allies, advocates, and activists, are outraged and angered by generations of racism and mistreatment of Black birthing people in our health systems and hospitals. We are channeling our frustration and disgust to demand substantive and sustainable change.

Our purpose here is to provide love and reassurance to our sisters and siblings who are going through their pregnancies with thoughts about our nation’s past and present failures to promote health equity for us and our babies. Our purpose is neither to minimize the public health crisis of Black infant and maternal morbidity and mortality nor is it to absolve clinicians, health systems, or governments from taking responsibility for these shameful outcomes or making meaningful changes to address them. In fact, we love taking care of our community by providing the best clinical care we can to our patients. We call upon all of our clinical colleagues to educate themselves to be ethically and equitably equipped to provide health care for Black pregnant patients. Finally, to birthing Black families, please remember this: If you choose to have a baby, the outcome and experience must align with what is right for you and your baby to survive and thrive. So much of the joys of pregnancy have been stolen, but we will recapture the celebration that should be ours in pregnancy and the journey to parenthood.

Sincerely,

Ebony B. Carter, MD, MPH
Maternal Fetal Medicine
Washington University School of Medicine
St. Louis, Missouri

Karen A. Scott, MD, MPH
Birthing Cultural Rigor, LLC
Nashville, Tennessee

Andrea Jackson, MD, MAS
ObGyn
University of California,
San Francisco

Sara Whetstone, MD, MHS
ObGyn
University of California, 
San Francisco

Traci Johnson, MD
ObGyn
University of Missouri 
School of Medicine
Kansas City, Missouri

Sarahn Wheeler, MD
Maternal Fetal Medicine
Duke University School of Medicine
Durham, North Carolina

Asmara Gebre, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

Joia Crear-Perry, MD
ObGyn
National Birth Equity Collaborative
New Orleans, Louisiana

Dineo Khabele, MD
Gynecologic Oncology
Washington University School of Medicine
St. Louis, Missouri

Judette Louis, MD, MPH
Maternal Fetal Medicine
University of South Florida College of Medicine
Tampa, Florida

Yvonne Smith, MSN, RN
Director
Barnes-Jewish Hospital
St. Louis, Missouri

Laura Riley, MD
Maternal Fetal Medicine
Weill Cornell Medicine
New York, New York

Antoinette Liddell, MSN, RN
Care Coordinator
Barnes-Jewish Hospital
St. Louis, Missouri

Cynthia Gyamfi-Bannerman, MD
Maternal Fetal Medicine
Columbia University Irving Medical Center
New York, New York

Rasheda Pippens, MSN, RN
Nurse Educator
Barnes-Jewish Hospital
St. Louis, Missouri

Ayaba Worjoloh-Clemens, MD
ObGyn
Atlanta, Georgia

Allison Bryant, MD, MPH
Maternal Fetal Medicine
Massachusetts General Hospital
Boston, Massachusetts

Sheri L. Foote, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

J. Lindsay Sillas, MD
ObGyn
Bella OB/GYN
Houston, Texas

Cynthia Rogers, MD
Psychiatrist
Washington University School of Medicine
St. Louis, Missouri

Audra R. Meadows, MD, MPH
ObGyn
University of California, San Diego

AeuMuro G. Lake, MD
Urogynecologist
Urogynecology and Healing Arts
Seattle, Washington

Nancy Moore, MSN, RN, WHNP-BC
Nurse Practitioner
Barnes-Jewish Hospital
St. Louis, Missouri

Zoë Julian, MD, MPH
ObGyn
University of Alabama at Birmingham

Janice M. Tinsley, MN, RNC-OB
Zuckerberg San Francisco General Hospital
San Francisco, California

Jamila B. Perritt, MD, MPH
ObGyn
Washington, DC

Joy A. Cooper, MD, MSc
ObGyn
Culture Care
Oakland, California

Arthurine K. Zakama, MD
ObGyn
University of California,San Francisco

Alissa Erogbogbo, MD
OB Hospitalist
Los Altos, California

Sanithia L. Williams, MD
ObGyn
Huntsville, Alabama

Audra Williams, MD, MPH
ObGyn
University of Alabama, Birmingham

Hedwige “Didi” Saint Louis, MD, MPH
OB Hospitalist
Morehouse School of Medicine
Atlanta, Georgia

Cherise Cokley, MD
OB Hospitalist
Community Hospital
Munster, Indiana

J’Leise Sosa, MD, MPH
ObGyn
Buffalo, New York

A few years ago, my partner emailed me about a consult.
 

“Dr. Carter, I had the pleasure of seeing Mrs. Smith today for a preconception consult for chronic hypertension. As a high-risk Black woman, she wants to know what we’re going to do to make sure that she doesn’t die in pregnancy or childbirth. I told her that you’re better equipped to answer this question.”

I was early in my career, and the only thing I could assume that equipped me to answer this question over my partners was my identity as a Black woman living in America.

Mrs. Smith was copied on the message and replied with a long list of follow-up questions and a request for an in-person meeting with me. I was conflicted. As a friend, daughter, and mother, I understood her fear and wanted to be there for her. As a newly appointed assistant professor on the tenure track with 20% clinical time, my clinical responsibilities easily exceeded 50% (in part, because I failed to set boundaries). I spent countless hours of uncompensated time serving on diversity, equity, and inclusion initiatives and mentoring and volunteering for multiple community organizations; I was acutely aware that I would be measured against colleagues who rise through the ranks, unencumbered by these social, moral, and ethical responsibilities, collectively known as the “Black tax.”¹

I knew from prior experiences and the tone of Mrs. Smith’s email that it would be a tough, long meeting that would set a precedent of concierge level care that only promised to intensify once she became pregnant. I agonized over my reply. How could I balance providing compassionate care for this patient with my young research program, which I hoped to nurture so that it would one day grow to have population-level impact?

It took me 2 days to finally reply to the message with a kind, but firm, email stating that I would be happy to see her for a follow-up preconception visit. It was my attempt to balance accessibility with boundaries. She did not reply.

Did I fail her?

The fact that I still think of Mrs. Smith may indicate that I did the wrong thing. In fact, writing the first draft of this letter was a therapeutic experience, and I addressed it to Mrs. Smith. As I shared the experience and letter with friends in the field, however, everyone had similar stories. The letter continued to pass between colleagues, who each made it infinitely better. This collective process created the beautiful love letter to Black birthing people that we share here.

We call upon all of our obstetric clinician colleagues to educate themselves to be equally, ethically, and equitably equipped to care for and serve historically marginalized women and birthing people. We hope that this letter will aid in the journey, and we encourage you to share it with patients to open conversations that are too often left closed.

Continue to: Our love letter to Black women and birthing people...

Our love letter to Black women and birthing people

We see you, we hear you, we know you are scared, and we are you. In recent years, the press has amplified gross inequities in maternal care and outcomes that we, as Black birth workers, midwives, and physicians, already knew to be true. We grieve, along with you regarding the recently reported pregnancy-related deaths of Mrs. Kira Johnson,² Dr. Shalon Irving,³ Dr. Chaniece Wallace,⁴ and so many other names we do not know because their stories did not receive national attention, but we know that they represented the best of us, and they are gone too soon. As Black birth workers, midwives, physicians, and more, we have a front-row seat to the United States’ serious obstetric racism, manifested in biased clinical interactions, unjust hospital policies, and an inequitable health care system that leads to disparities in maternal morbidity and mortality for Black women.

Unfortunately, this is not anything new, and the legacy dates back to slavery and the disregard for Black people in this country. What has changed is our increased awareness of these health injustices. This collective consciousness of the risk that is carried with our pregnancies casts a shadow of fear over a period that should be full of the joy and promise of new life. We fear that our personhood will be disregarded, our pain will be ignored, and our voices silenced by a medical system that has sought to dominate our bodies and experiment on them without our permission.⁵ While this history is reprehensible, and our collective risk as Black people is disproportionately high, our purpose in writing this letter is to help Black birthing people recapture the joy and celebration that should be theirs in pregnancy and in the journey to parenthood.

As Black birth workers, we see Black pregnant patients desperately seeking safety, security, and breaking down barriers to find us for their pregnancy care. Often, they are terrified and looking for kinship and community in our offices. In rural areas patients may drive up to 4 hours in distance for an appointment, and during appointments entrust us with their stories of feeling unheard in the medical system. When we anecdotally asked about what they feared about pregnancy, childbirth, and the postpartum period and thought was their risk of dying during pregnancy or childbirth, answers ranged from 1% to 60%. Our actual risk of dying from a pregnancy-related cause, as a Black woman, is 0.0414% (41.4 Black maternal deaths per 100,000 live births).⁶ To put that in perspective, our risk of dying is higher walking down the street or driving a car.⁷

What is the source of the fear? Based on past and present injustices inflicted on people with historically marginalized identities, we have every right to be scared; but, make no mistake that fear comes at a cost, and Black birthing people are the ones paying the bill! Stress and chronic worry are associated with poor pregnancy outcomes, and so this completely justifiable fear, at the population level, is not serving us well personally.⁸ Unfortunately, lost in the messaging about racial inequities in maternal mortality is the reality that the vast majority of Black people and babies will survive, thrive, and have healthy pregnancy outcomes, despite the terrifying population-level statistics and horrific stories of discrimination and neglect that make us feel like our pregnancies and personal peril are synonymous.

While it is true that our absolute individual, personal risk is lower than population-level statistics convey, let us be clear: We are furious about what is happening to Black people! It is immoral that Black patients in the richest country in the world are 3-4 times more likely to die of a pregnancy-related cause than White women,⁹ and we are more likely to experience pregnancy complications and “near misses” when death is narrowly avoided. Research has done an excellent job defining reproductive health disparities in this country, but prioritizing and funding meaningful strategies, policies, and programs to close this gap have not taken precedence—especially initiatives and research that are headed by Black women.^10–12 This is largely because researchers and health care systems continue evaluating strategies that focus on behavior change and narratives that identify individual responsibility as a sole cause of inequity.

Let us be clear, Black people and our behaviors are not the problem.¹³ The problems are White supremacy, classism, sexism, heteropatriarchy, and obstetric racism.^1-21 These must be recognized and addressed across all levels of power. We endorse systems-level changes that are at the root of promoting health equity in our reproductive outcomes. These changes include paid parental leave, Medicaid expansion/extension, reimbursement for doula and lactation services, increased access to perinatal mental health and wellness services, and so much more. (See the Black Mamas Matter Alliance Toolkit: https://blackmamas matter.org/our-work/toolkits/.)

Continue to: Pearls for reassurance...

Pearls for reassurance

While the inequities and their solutions are grounded in the need for systemic change,²² we realize that these population-level solutions feel abstract when our sisters and siblings ask us, “So what can I do to advocate for myself and my baby, right now in this pregnancy?” To be clear, no amount of personal hypervigilance on our part as Black pregnancy-capable people is going to fix these problems, which are systemic; however, we want to provide a few pearls that may be helpful for patient self-advocacy and reassurance:

1. Seek culturally and ethnically congruent care. We intuitively want to find a clinician who looks like us, but sadly, in the United States only 5% of physicians and 2% of midwives are Black. Demand exceeds supply for Black patients who are seeking racially congruent care. Nonetheless, it is critical that you find a physician or midwife who centers you and  provides support and care that affirms the strengths and assets of you, your family, and your community when cultural and ethnic congruency are not possible for you and your pregnancy. 
2. Ask how your clinicians are actively working to ensure optimal and equitable experiences for Black birthing individuals. We recommend asking your clinician and/or hospital what, if anything, they are doing to address health care inequities, obstetric racism, or implicit bias in their pregnancy and postpartum care. Many groups (including some authors of this letter) are working on measures to address obstetric racism. An acknowledgement of initiatives to mitigate inequities is a meaningful first step. You can suggest that they look into it while you explore your options, as this work is rapidly emerging in many areas of the country. 
3. Plan for well-person care. The best time to optimize pregnancy and birth outcomes is before you get pregnant. Set up an appointment with a midwife, ObGyn, or your primary care physician before you get pregnant. Discuss your concerns about pregnancy and use this time to optimize your health. This also provides an opportunity to build a relationship with your physician/ midwife and their group to evaluate whether they curate an environment where you feel seen, heard, and valued when you go for annual exams or problem visits. If you do not get that sense after a couple of visits, find a place where you do. 
4. Advocate for a second opinion. If something does not sound right to you or you have questions that were not adequately answered, it is your prerogative to seek a second opinion; a clinician should never be offended by this. 
5. Consider these factors, for those who deliver in a hospital (by choice or necessity): 

   a. 24/7 access to obstetricians and dedicated anesthesiologists in the hospital

   b. trauma-informed medical/mental health/social services

   c. lactation consultation

   d. supportive trial of labor after cesarean delivery policy

   e. massive blood transfusion  protocol. 

6. Seek doula support! It always helps to have another set of eyes and ears to help advocate for you, especially when you are in pain during pregnancy, childbirth, or in the postpartum period, or are having difficulty advocating for yourself. There is also evidence that women supported by doulas have better pregnancy-related outcomes and experiences.²³ Many major cities in the United States have started to provide race-concordant doula care for Black birthing people  for free.²⁴
7.  Don’t forget about your mental health. As stated, chronic stress from racism impacts birth outcomes. Having a mental health clinician is a great way to mitigate adverse effects of prolonged tension.^25–27
8. Ask your clinician, hospital, or insurance company about participating in group prenatal care and/or nurse home visiting models²⁸ because both are associated with improved birth outcomes.²⁹ Many institutions are implementing group care that provides race-concordant care.^30,31 
9. Ask your clinician, hospital, or local health department for recommendations to a lactation consultant or educator who can support your efforts in breast/ chest/body-feeding. 

We invite you to consider this truth

You, alone, do not carry the entire population-level risk of Black birthing people on your shoulders. We all carry a piece of it. We, along with many allies, advocates, and activists, are outraged and angered by generations of racism and mistreatment of Black birthing people in our health systems and hospitals. We are channeling our frustration and disgust to demand substantive and sustainable change.

Our purpose here is to provide love and reassurance to our sisters and siblings who are going through their pregnancies with thoughts about our nation’s past and present failures to promote health equity for us and our babies. Our purpose is neither to minimize the public health crisis of Black infant and maternal morbidity and mortality nor is it to absolve clinicians, health systems, or governments from taking responsibility for these shameful outcomes or making meaningful changes to address them. In fact, we love taking care of our community by providing the best clinical care we can to our patients. We call upon all of our clinical colleagues to educate themselves to be ethically and equitably equipped to provide health care for Black pregnant patients. Finally, to birthing Black families, please remember this: If you choose to have a baby, the outcome and experience must align with what is right for you and your baby to survive and thrive. So much of the joys of pregnancy have been stolen, but we will recapture the celebration that should be ours in pregnancy and the journey to parenthood.

Sincerely,

Ebony B. Carter, MD, MPH
Maternal Fetal Medicine
Washington University School of Medicine
St. Louis, Missouri

Karen A. Scott, MD, MPH
Birthing Cultural Rigor, LLC
Nashville, Tennessee

Andrea Jackson, MD, MAS
ObGyn
University of California,
San Francisco

Sara Whetstone, MD, MHS
ObGyn
University of California, 
San Francisco

Traci Johnson, MD
ObGyn
University of Missouri 
School of Medicine
Kansas City, Missouri

Sarahn Wheeler, MD
Maternal Fetal Medicine
Duke University School of Medicine
Durham, North Carolina

Asmara Gebre, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

Joia Crear-Perry, MD
ObGyn
National Birth Equity Collaborative
New Orleans, Louisiana

Dineo Khabele, MD
Gynecologic Oncology
Washington University School of Medicine
St. Louis, Missouri

Judette Louis, MD, MPH
Maternal Fetal Medicine
University of South Florida College of Medicine
Tampa, Florida

Yvonne Smith, MSN, RN
Director
Barnes-Jewish Hospital
St. Louis, Missouri

Laura Riley, MD
Maternal Fetal Medicine
Weill Cornell Medicine
New York, New York

Antoinette Liddell, MSN, RN
Care Coordinator
Barnes-Jewish Hospital
St. Louis, Missouri

Cynthia Gyamfi-Bannerman, MD
Maternal Fetal Medicine
Columbia University Irving Medical Center
New York, New York

Rasheda Pippens, MSN, RN
Nurse Educator
Barnes-Jewish Hospital
St. Louis, Missouri

Ayaba Worjoloh-Clemens, MD
ObGyn
Atlanta, Georgia

Allison Bryant, MD, MPH
Maternal Fetal Medicine
Massachusetts General Hospital
Boston, Massachusetts

Sheri L. Foote, CNM
Midwife
Zuckerberg San Francisco General Hospital
San Francisco, California

J. Lindsay Sillas, MD
ObGyn
Bella OB/GYN
Houston, Texas

Cynthia Rogers, MD
Psychiatrist
Washington University School of Medicine
St. Louis, Missouri

Audra R. Meadows, MD, MPH
ObGyn
University of California, San Diego

AeuMuro G. Lake, MD
Urogynecologist
Urogynecology and Healing Arts
Seattle, Washington

Nancy Moore, MSN, RN, WHNP-BC
Nurse Practitioner
Barnes-Jewish Hospital
St. Louis, Missouri

Zoë Julian, MD, MPH
ObGyn
University of Alabama at Birmingham

Janice M. Tinsley, MN, RNC-OB
Zuckerberg San Francisco General Hospital
San Francisco, California

Jamila B. Perritt, MD, MPH
ObGyn
Washington, DC

Joy A. Cooper, MD, MSc
ObGyn
Culture Care
Oakland, California

Arthurine K. Zakama, MD
ObGyn
University of California,San Francisco

Alissa Erogbogbo, MD
OB Hospitalist
Los Altos, California

Sanithia L. Williams, MD
ObGyn
Huntsville, Alabama

Audra Williams, MD, MPH
ObGyn
University of Alabama, Birmingham

Hedwige “Didi” Saint Louis, MD, MPH
OB Hospitalist
Morehouse School of Medicine
Atlanta, Georgia

Cherise Cokley, MD
OB Hospitalist
Community Hospital
Munster, Indiana

J’Leise Sosa, MD, MPH
ObGyn
Buffalo, New York

Recurrent episodic blood loss from normal menstruation is not expected to result in anemia. But without treatment, chronic heavy periods will progress through the stages of low iron stores to iron deficiency and then to anemia. When iron storage levels are low, the bone marrow’s blood cell factory cannot keep up with continued losses. Every patient with heavy menstrual bleeding (HMB) or prolonged menstrual episodes should be tested and treated for iron deficiency and anemia.^1,2

Particular attention should be paid to assessment of iron storage levels with serum ferritin, recognizing that low iron levels progress to anemia once the storage is depleted. Recovery from anemia is much slower in individuals with iron deficiency, so assessment for iron storage also should be included in preoperative assessments and following a diagnosis of acute blood loss anemia.

The mechanics of erythropoiesis, hemoglobin, and oxygen transport

Red blood cells (erythrocytes) have a short life cycle and require constant replacement. Erythrocytes are generated on demand in erythropoiesis by a hormonal signaling process, regardless of whether sufficient components are available.³ Hemoglobin, the main intracellular component of erythrocytes, is comprised of 4 globin chains, which each contain 1 iron atom bound to a heme molecule. After erythrocytes are assembled, they are sent out into circulation for approximately 120 days. A hemoglobin level measures the oxygen-carrying capacity of erythrocytes, and anemia is defined as hemoglobin less than 12 g/dL.

Unless erythrocytes are lost from bleeding, they are decommissioned—that is, the heme molecule is metabolized into bilirubin and excreted, and the iron atoms are recycled back to the bone marrow or to storage.⁴ Ferritin is the storage molecule that binds to iron, a glycoprotein with numerous subunits around a core that can contain about 4,000 iron atoms. Most ferritin is intracellular, but a small proportion is present in serum, where it can be measured.

Serum ferritin is a good marker for the iron supply in healthy individuals because it has high correlation to iron in the bone marrow and correlates to total intracellular storage unless there is inflammation, when mobilization to serum increases. The ferritin level at which the iron supply is deficient to meet demand, defined as iron deficiency, is hotly debated and ranges from less than 15 to 50 ng/mL in menstruating individuals, with higher thresholds based on onset of erythropoiesis signaling and the lower threshold being the World Health Organization recommendation.^5-7 When iron atoms are in short supply, erythrocytes still are generated but they have lower amounts of intracellular hemoglobin, which makes them thinner, smaller, and paler—and less effective at oxygen transport.

CASE Patient seeks treatment for HMB-associated symptoms

A 17-year-old patient presents with HMB, fatigue, and difficulty with concentration. She reports that her periods have been regular and lasting 7 days since menarche at age 13. While they are manageable, they seem to be getting heavier, soaking pads in 2 to 3 hours. The patient reports that she would like to start treatment for her progressively heavy bleeding and prefers lighter scheduled bleeding; she currently does not desire contraception. The patient has no family history of bleeding problems and self-reports no personal history of epistaxis or bleeding with tooth extraction or tonsillectomy. Laboratory tests confirm iron deficiency with a hemoglobin level of 12.5 g/dL (reference range, 12.0–17.5 g/dL) and a serum ferritin level of 8 ng/mL (reference range, 50–420 ng/mL). Results from a coagulopathy panel are normal, as are von Willebrand factor levels.

Untreated iron deficiency will progress to anemia

This patient has iron deficiency without anemia, which warrants significant attention in HMB because without treatment it eventually will progress to anemia. The prevalence of iron deficiency, which makes up half of all causes of anemia, is at least double that of iron deficiency anemia.³

Adult bodies usually contain about 3 to 4 g of iron, with two-thirds in erythrocytes as hemoglobin.⁸ Approximately 40 to 60 mg of iron is recycled daily, 1 to 2 mg/day is lost from sloughed cells and sweat, and at least 1 mg/day is lost during normal menstruation. These losses are balanced with gastrointestinal uptake of 1 to 2 mg/day until bleeding exceeds about 10 mL/day. In this 17-year-old patient, iron stores have likely been on a progressive decline since menarche.

For normally menstruating individuals to maintain iron homeostasis, the daily dietary iron requirement is 18 mg/day. Iron requirements also increase during periods of illness or inflammation due to hormonal signaling in the iron absorption and transport pathway, in athletes due to sweating, foot strike hemolysis and bruising, and during growth spurts.⁹

Continue to: Managing iron deficiency and anemia...

Management of iron deficiency and iron deficiency anemia in the setting of HMB includes:

• workup for the etiology of the abnormal uterine bleeding (TABLE)
• reducing the source of blood loss, and
• iron supplementation to correct the iron deficiency state.

In most cases, workup, reduction, and repletion can occur simultaneously. The goal is not always complete cessation of menstrual bleeding; even short-term therapy can allow time to replenish iron storage. Use a shared decision-making process to assess what is important to the patient, and provide information about relative amounts of bleeding cessation that can be expected with various therapies.¹⁰

Treatment options

Medical treatments to decrease menstrual iron losses are recommended prior to proceeding with surgical interventions.¹¹ Hormonal treatments are the most consistently recommended, with many guidelines citing the 52-mg levonorgestrel-releasing intrauterine device (LNG IUD) as first-line treatment due to its substantial reduction in the amount of bleeding, HMB treatment indication approved by the US Food and Drug Administration (FDA), and evidence of success in those with HMB.¹²

Any progestin or combined hormonal medication with estrogen and a progestin will result in an approximately 60% to 90% bleeding reduction, thus providing many effective options for blood loss while considering patient preferences for bleeding pattern, route of administration, and concomitant benefits. While only 1 oral product (estradiol valerate/dienogest) is FDA approved for managementof HMB, use of any of the commercially available contraceptive products will provide substantial benefit.^11,13

Nonhormonal options, such as antifibrinolytics and nonsteroidal anti-inflammatory drugs (NSAIDs), tend to be listed as second-line therapies or for those who want to avoid hormonal medications. Antifibrinolytics, such as tranexamic acid, require frequent dosing of large pills and result in approximately 40% blood loss reduction, but they are a very successful and well-tolerated method for those seeking on-demand therapy.¹⁴ NSAIDs may result in a slight bleeding reduction, but they are far less effective than other therapies.¹⁵ Antifibrinolytics have a theoretical risk of thrombosis and a contraindication to use with hormonal contraceptives; therefore, concomitant use with estrogen-containing medications is reserved for patients with refractory heavy bleeding or for heavy bleeding days during the hormone-free interval, when benefits likely outweigh potential risk.^16,17

Guidelines for medical management of acute HMB typically cite 3 small comparative studies with high-dose regimens of parenteral conjugated estrogen, combined ethinyl estradiol and progestin, or oral medroxyprogesterone acetate.^18,19 Dosing recommendations for the oral medications include a loading dose followed by a taper regimen that is poorly tolerated and for which there is no evidence of superior effectiveness over the standard dose.^20,21In most cases, initiation of the preferred long-term hormonal medication plan will reduce bleeding significantly within 2 to 3 days. Many clinicians who commonly treat acute HMB prescribe norethindrone acetate 5 mg daily (up to 3 times daily, if needed) for effective and safe menstrual suppression.²²

Iron replenishment: Dosing frequency, dietary iron, and multivitamins

Iron repletion is usually via the oral route unless surgery is imminent, anemia is severe, or the oral route is not tolerated or effective.²³ Oral iron has substantial adverse effects that limit tolerance, including nausea, epigastric pain, diarrhea, and constipation. Fortunately, evidence supports lower oral iron doses than previously used.⁴

Iron homeostasis is controlled by the peptide hormone hepcidin, produced by the liver, which controls mobilization of iron from the gut and spleen and aids iron absorption from the diet and supplements.²⁴ Hepcidin levels decrease in response to high circulating levels of iron, so the ideal iron repletion dose in iron-deficient nonanemic women was determined by assessing the dose response of hepcidin. Researchers compared iron 60 mg daily for 14 days versus every other day for 28 days and found that iron absorption was greater in the every-other-day group (21.8% vs 16.3%).²⁵They concluded that changing iron administration to 60 mg or more in a single dose every other day is most efficient in those with iron deficiency without anemia. Since study participants did not have anemia, research is pending on whether different strategies (such as daily dosing) are more effective for more severe cases. The bottom line is that conventional high-dose divided daily oral iron administration results in reduced iron bioavailability compared with alternate-day dosing.

Increasing dietary iron is insufficient to treat low iron storage, iron deficiency, and iron deficiency anemia. Likewise, multivitamins, which contain very little elemental iron, are not recommended for repletion. Any iron salt with 60 to 120 mg of elemental iron can be used (for examples, ferrous sulfate, ferrous gluconate).²⁵ Once ingested, stomach and pancreatic acids release elemental iron from its bound form. For that reason, absorption may be improved by administering iron at least 1 hour before a meal and avoiding antacids, including milk. Meat proteins and ascorbic acid help maintain the soluble ferrous form and also aid absorption. Tea, coffee, and tannins prevent absorption when polyphenol compounds form an insoluble complex with iron (see box at end of article). Gastrointestinal adverse effects can be minimized by decreasing the dose and taking after meals, although with reduced efficacy.

Intravenous iron treatment raises hemoglobin levels significantly faster than oral administration but is limited by cost and availability, so it is reserved for individuals with a hemoglobin level less than 9 g/dL, prior gastrointestinal or bariatric surgery, imminent surgery, and intolerance, poor adherence, or nonresponse to oral iron therapy. Several approved formulations are available, all with equivalent effectiveness and similar safety profiles. Lower-dose formulations (such as iron sucrose) may require several infusions, but higher-dose intravenous iron products (ferric carboxymaltose, low-molecular weight iron dextran, etc) have a stable carbohydrate shell that inhibits free iron release and improves safety, allowing a single administration.²⁶

Common adverse effects of intravenous iron treatment include a metallic taste and headache during administration. More serious adverse effects, such as hypotension, arthralgia, malaise, and nausea, are usually self-limited. With mild infusion reactions (1 in 200), the infusion can be stopped until symptoms improve and can be resumed at a slower rate.²⁷

Continue to: The role of blood transfusion...

The role of blood transfusion

Blood transfusion is expensive and potentially hazardous, so its use is limited to treatment of acute blood loss or severe anemia.

A one-time red blood cell transfusion does not impact diagnostic criteria to assess for iron deficiency with ferritin, and it does not improve underlying iron deficiency.²⁸Patients with acute blood loss anemia superimposed on chronic blood loss should be screened and treated for iron deficiency even after receiving a transfusion.

Since ferritin levels can rise significantly as an acute phase reactant, even following a hemorrhage, iron deficiency during inflammation is defined as ferritin less than 70 ng/mL.

The potential for iron overload

Since iron is never metabolized or excreted, it is possible to have iron overload following accidental overdose, transfusion dependency, and disorders of iron transport, such as hemochromatosis and thalassemia.

While a low ferritin level always indicates iron deficiency, high ferritin levels can be an acute phase reactant. Ferritin levels greater than 150 ng/mL in healthy menstruating individuals and greater than 500 ng/mL in unhealthy individuals should raise concern for excess iron and should prompt discontinuation of iron intake or workup for conditions at risk for overload.⁵

Oral iron supplements should be stored away from small children, who are at particular risk of toxicity.

How long to treat?

Treatment duration depends on the individual’s degree of iron deficiency, whether anemia is present, and the amount of ongoing blood loss. The main treatment goal is normalization and maintenance of serum ferritin.

Successful treatment should be confirmed with a complete blood count and ferritin level. Hemoglobin levels improve 2 g/dL after 3 weeks of oral iron therapy, but repletion may take 4 to 6 months.^23,29 The American College of Obstetricians and Gynecologists recommends 3 to 6 months of continued iron therapy after resolution of HMB.¹⁹

In a comparative study of treatment for HMB with the 52-mg LNG IUD versus hysterectomy, hemoglobin levels increased in both treatment groups but stayed lower in those with initial anemia.⁸ Ferritin levels normalized only after 5 years and were still lower in individuals with initial anemia.

Increase in hemoglobin is faster after intravenous iron administration but is equivalent to oral therapy by 12 weeks. If management to reduce menstrual losses is discontinued, periodic or maintenance iron repletion will be necessary.

CASE Management plan initiated

This 17-year-old patient with iron deficiency resulting from HMB requests management to reduce menstrual iron losses with a preference for predictable menses. We have already completed a basic workup, which could also include assessment for hypermobility with a Beighton score, as connective tissue disorders also are associated with HMB.³⁰ We discuss the options of cyclic hormonal therapy, antifibrinolytic treatment, and an LNG IUD. The patient is concerned about adherence and wants to avoid unscheduled bleeding, so she opts for a trial of tranexamic acid 1,300 mg 3 times daily for 5 days during menses. This regimen results in a 50% reduction in bleeding amount, which the patient finds satisfactory. Iron repletion with oral ferrous sulfate 325 mg (containing 65 mg of elemental iron) is administered on alternating days with vitamin C taken 1 hour prior to dinner. Repeat laboratory test results at 3 weeks show improvement to a hemoglobin level of 14.2 g/dL and a ferritin level of 12 ng/mL. By 3 months, her ferritin levels are greater than 30 ng/mL and oral iron is administered only during menses.

Summing up

Chronic HMB results in a progressive net loss of iron and eventual anemia. Screening with complete blood count and ferritin and early treatment of low iron storage when ferritin is less than 30 ng/mL will help avoid symptoms. Any amount of reduction of menstrual blood loss can be beneficial, allowing a variety of effective hormonal and nonhormonal treatment options. ●

Recurrent episodic blood loss from normal menstruation is not expected to result in anemia. But without treatment, chronic heavy periods will progress through the stages of low iron stores to iron deficiency and then to anemia. When iron storage levels are low, the bone marrow’s blood cell factory cannot keep up with continued losses. Every patient with heavy menstrual bleeding (HMB) or prolonged menstrual episodes should be tested and treated for iron deficiency and anemia.^1,2

Particular attention should be paid to assessment of iron storage levels with serum ferritin, recognizing that low iron levels progress to anemia once the storage is depleted. Recovery from anemia is much slower in individuals with iron deficiency, so assessment for iron storage also should be included in preoperative assessments and following a diagnosis of acute blood loss anemia.

The mechanics of erythropoiesis, hemoglobin, and oxygen transport

Red blood cells (erythrocytes) have a short life cycle and require constant replacement. Erythrocytes are generated on demand in erythropoiesis by a hormonal signaling process, regardless of whether sufficient components are available.³ Hemoglobin, the main intracellular component of erythrocytes, is comprised of 4 globin chains, which each contain 1 iron atom bound to a heme molecule. After erythrocytes are assembled, they are sent out into circulation for approximately 120 days. A hemoglobin level measures the oxygen-carrying capacity of erythrocytes, and anemia is defined as hemoglobin less than 12 g/dL.

Unless erythrocytes are lost from bleeding, they are decommissioned—that is, the heme molecule is metabolized into bilirubin and excreted, and the iron atoms are recycled back to the bone marrow or to storage.⁴ Ferritin is the storage molecule that binds to iron, a glycoprotein with numerous subunits around a core that can contain about 4,000 iron atoms. Most ferritin is intracellular, but a small proportion is present in serum, where it can be measured.

Serum ferritin is a good marker for the iron supply in healthy individuals because it has high correlation to iron in the bone marrow and correlates to total intracellular storage unless there is inflammation, when mobilization to serum increases. The ferritin level at which the iron supply is deficient to meet demand, defined as iron deficiency, is hotly debated and ranges from less than 15 to 50 ng/mL in menstruating individuals, with higher thresholds based on onset of erythropoiesis signaling and the lower threshold being the World Health Organization recommendation.^5-7 When iron atoms are in short supply, erythrocytes still are generated but they have lower amounts of intracellular hemoglobin, which makes them thinner, smaller, and paler—and less effective at oxygen transport.

CASE Patient seeks treatment for HMB-associated symptoms

A 17-year-old patient presents with HMB, fatigue, and difficulty with concentration. She reports that her periods have been regular and lasting 7 days since menarche at age 13. While they are manageable, they seem to be getting heavier, soaking pads in 2 to 3 hours. The patient reports that she would like to start treatment for her progressively heavy bleeding and prefers lighter scheduled bleeding; she currently does not desire contraception. The patient has no family history of bleeding problems and self-reports no personal history of epistaxis or bleeding with tooth extraction or tonsillectomy. Laboratory tests confirm iron deficiency with a hemoglobin level of 12.5 g/dL (reference range, 12.0–17.5 g/dL) and a serum ferritin level of 8 ng/mL (reference range, 50–420 ng/mL). Results from a coagulopathy panel are normal, as are von Willebrand factor levels.

Untreated iron deficiency will progress to anemia

This patient has iron deficiency without anemia, which warrants significant attention in HMB because without treatment it eventually will progress to anemia. The prevalence of iron deficiency, which makes up half of all causes of anemia, is at least double that of iron deficiency anemia.³

Adult bodies usually contain about 3 to 4 g of iron, with two-thirds in erythrocytes as hemoglobin.⁸ Approximately 40 to 60 mg of iron is recycled daily, 1 to 2 mg/day is lost from sloughed cells and sweat, and at least 1 mg/day is lost during normal menstruation. These losses are balanced with gastrointestinal uptake of 1 to 2 mg/day until bleeding exceeds about 10 mL/day. In this 17-year-old patient, iron stores have likely been on a progressive decline since menarche.

For normally menstruating individuals to maintain iron homeostasis, the daily dietary iron requirement is 18 mg/day. Iron requirements also increase during periods of illness or inflammation due to hormonal signaling in the iron absorption and transport pathway, in athletes due to sweating, foot strike hemolysis and bruising, and during growth spurts.⁹

Continue to: Managing iron deficiency and anemia...

Management of iron deficiency and iron deficiency anemia in the setting of HMB includes:

• workup for the etiology of the abnormal uterine bleeding (TABLE)
• reducing the source of blood loss, and
• iron supplementation to correct the iron deficiency state.

In most cases, workup, reduction, and repletion can occur simultaneously. The goal is not always complete cessation of menstrual bleeding; even short-term therapy can allow time to replenish iron storage. Use a shared decision-making process to assess what is important to the patient, and provide information about relative amounts of bleeding cessation that can be expected with various therapies.¹⁰

Treatment options

Medical treatments to decrease menstrual iron losses are recommended prior to proceeding with surgical interventions.¹¹ Hormonal treatments are the most consistently recommended, with many guidelines citing the 52-mg levonorgestrel-releasing intrauterine device (LNG IUD) as first-line treatment due to its substantial reduction in the amount of bleeding, HMB treatment indication approved by the US Food and Drug Administration (FDA), and evidence of success in those with HMB.¹²

Any progestin or combined hormonal medication with estrogen and a progestin will result in an approximately 60% to 90% bleeding reduction, thus providing many effective options for blood loss while considering patient preferences for bleeding pattern, route of administration, and concomitant benefits. While only 1 oral product (estradiol valerate/dienogest) is FDA approved for managementof HMB, use of any of the commercially available contraceptive products will provide substantial benefit.^11,13

Nonhormonal options, such as antifibrinolytics and nonsteroidal anti-inflammatory drugs (NSAIDs), tend to be listed as second-line therapies or for those who want to avoid hormonal medications. Antifibrinolytics, such as tranexamic acid, require frequent dosing of large pills and result in approximately 40% blood loss reduction, but they are a very successful and well-tolerated method for those seeking on-demand therapy.¹⁴ NSAIDs may result in a slight bleeding reduction, but they are far less effective than other therapies.¹⁵ Antifibrinolytics have a theoretical risk of thrombosis and a contraindication to use with hormonal contraceptives; therefore, concomitant use with estrogen-containing medications is reserved for patients with refractory heavy bleeding or for heavy bleeding days during the hormone-free interval, when benefits likely outweigh potential risk.^16,17

Guidelines for medical management of acute HMB typically cite 3 small comparative studies with high-dose regimens of parenteral conjugated estrogen, combined ethinyl estradiol and progestin, or oral medroxyprogesterone acetate.^18,19 Dosing recommendations for the oral medications include a loading dose followed by a taper regimen that is poorly tolerated and for which there is no evidence of superior effectiveness over the standard dose.^20,21In most cases, initiation of the preferred long-term hormonal medication plan will reduce bleeding significantly within 2 to 3 days. Many clinicians who commonly treat acute HMB prescribe norethindrone acetate 5 mg daily (up to 3 times daily, if needed) for effective and safe menstrual suppression.²²

Iron replenishment: Dosing frequency, dietary iron, and multivitamins

Iron repletion is usually via the oral route unless surgery is imminent, anemia is severe, or the oral route is not tolerated or effective.²³ Oral iron has substantial adverse effects that limit tolerance, including nausea, epigastric pain, diarrhea, and constipation. Fortunately, evidence supports lower oral iron doses than previously used.⁴

Iron homeostasis is controlled by the peptide hormone hepcidin, produced by the liver, which controls mobilization of iron from the gut and spleen and aids iron absorption from the diet and supplements.²⁴ Hepcidin levels decrease in response to high circulating levels of iron, so the ideal iron repletion dose in iron-deficient nonanemic women was determined by assessing the dose response of hepcidin. Researchers compared iron 60 mg daily for 14 days versus every other day for 28 days and found that iron absorption was greater in the every-other-day group (21.8% vs 16.3%).²⁵They concluded that changing iron administration to 60 mg or more in a single dose every other day is most efficient in those with iron deficiency without anemia. Since study participants did not have anemia, research is pending on whether different strategies (such as daily dosing) are more effective for more severe cases. The bottom line is that conventional high-dose divided daily oral iron administration results in reduced iron bioavailability compared with alternate-day dosing.

Increasing dietary iron is insufficient to treat low iron storage, iron deficiency, and iron deficiency anemia. Likewise, multivitamins, which contain very little elemental iron, are not recommended for repletion. Any iron salt with 60 to 120 mg of elemental iron can be used (for examples, ferrous sulfate, ferrous gluconate).²⁵ Once ingested, stomach and pancreatic acids release elemental iron from its bound form. For that reason, absorption may be improved by administering iron at least 1 hour before a meal and avoiding antacids, including milk. Meat proteins and ascorbic acid help maintain the soluble ferrous form and also aid absorption. Tea, coffee, and tannins prevent absorption when polyphenol compounds form an insoluble complex with iron (see box at end of article). Gastrointestinal adverse effects can be minimized by decreasing the dose and taking after meals, although with reduced efficacy.

Intravenous iron treatment raises hemoglobin levels significantly faster than oral administration but is limited by cost and availability, so it is reserved for individuals with a hemoglobin level less than 9 g/dL, prior gastrointestinal or bariatric surgery, imminent surgery, and intolerance, poor adherence, or nonresponse to oral iron therapy. Several approved formulations are available, all with equivalent effectiveness and similar safety profiles. Lower-dose formulations (such as iron sucrose) may require several infusions, but higher-dose intravenous iron products (ferric carboxymaltose, low-molecular weight iron dextran, etc) have a stable carbohydrate shell that inhibits free iron release and improves safety, allowing a single administration.²⁶

Common adverse effects of intravenous iron treatment include a metallic taste and headache during administration. More serious adverse effects, such as hypotension, arthralgia, malaise, and nausea, are usually self-limited. With mild infusion reactions (1 in 200), the infusion can be stopped until symptoms improve and can be resumed at a slower rate.²⁷

Continue to: The role of blood transfusion...

The role of blood transfusion

Blood transfusion is expensive and potentially hazardous, so its use is limited to treatment of acute blood loss or severe anemia.

A one-time red blood cell transfusion does not impact diagnostic criteria to assess for iron deficiency with ferritin, and it does not improve underlying iron deficiency.²⁸Patients with acute blood loss anemia superimposed on chronic blood loss should be screened and treated for iron deficiency even after receiving a transfusion.

Since ferritin levels can rise significantly as an acute phase reactant, even following a hemorrhage, iron deficiency during inflammation is defined as ferritin less than 70 ng/mL.

The potential for iron overload

Since iron is never metabolized or excreted, it is possible to have iron overload following accidental overdose, transfusion dependency, and disorders of iron transport, such as hemochromatosis and thalassemia.

While a low ferritin level always indicates iron deficiency, high ferritin levels can be an acute phase reactant. Ferritin levels greater than 150 ng/mL in healthy menstruating individuals and greater than 500 ng/mL in unhealthy individuals should raise concern for excess iron and should prompt discontinuation of iron intake or workup for conditions at risk for overload.⁵

Oral iron supplements should be stored away from small children, who are at particular risk of toxicity.

How long to treat?

Treatment duration depends on the individual’s degree of iron deficiency, whether anemia is present, and the amount of ongoing blood loss. The main treatment goal is normalization and maintenance of serum ferritin.

Successful treatment should be confirmed with a complete blood count and ferritin level. Hemoglobin levels improve 2 g/dL after 3 weeks of oral iron therapy, but repletion may take 4 to 6 months.^23,29 The American College of Obstetricians and Gynecologists recommends 3 to 6 months of continued iron therapy after resolution of HMB.¹⁹

In a comparative study of treatment for HMB with the 52-mg LNG IUD versus hysterectomy, hemoglobin levels increased in both treatment groups but stayed lower in those with initial anemia.⁸ Ferritin levels normalized only after 5 years and were still lower in individuals with initial anemia.

Increase in hemoglobin is faster after intravenous iron administration but is equivalent to oral therapy by 12 weeks. If management to reduce menstrual losses is discontinued, periodic or maintenance iron repletion will be necessary.

CASE Management plan initiated

This 17-year-old patient with iron deficiency resulting from HMB requests management to reduce menstrual iron losses with a preference for predictable menses. We have already completed a basic workup, which could also include assessment for hypermobility with a Beighton score, as connective tissue disorders also are associated with HMB.³⁰ We discuss the options of cyclic hormonal therapy, antifibrinolytic treatment, and an LNG IUD. The patient is concerned about adherence and wants to avoid unscheduled bleeding, so she opts for a trial of tranexamic acid 1,300 mg 3 times daily for 5 days during menses. This regimen results in a 50% reduction in bleeding amount, which the patient finds satisfactory. Iron repletion with oral ferrous sulfate 325 mg (containing 65 mg of elemental iron) is administered on alternating days with vitamin C taken 1 hour prior to dinner. Repeat laboratory test results at 3 weeks show improvement to a hemoglobin level of 14.2 g/dL and a ferritin level of 12 ng/mL. By 3 months, her ferritin levels are greater than 30 ng/mL and oral iron is administered only during menses.

Summing up

Chronic HMB results in a progressive net loss of iron and eventual anemia. Screening with complete blood count and ferritin and early treatment of low iron storage when ferritin is less than 30 ng/mL will help avoid symptoms. Any amount of reduction of menstrual blood loss can be beneficial, allowing a variety of effective hormonal and nonhormonal treatment options. ●

Recurrent episodic blood loss from normal menstruation is not expected to result in anemia. But without treatment, chronic heavy periods will progress through the stages of low iron stores to iron deficiency and then to anemia. When iron storage levels are low, the bone marrow’s blood cell factory cannot keep up with continued losses. Every patient with heavy menstrual bleeding (HMB) or prolonged menstrual episodes should be tested and treated for iron deficiency and anemia.^1,2

Particular attention should be paid to assessment of iron storage levels with serum ferritin, recognizing that low iron levels progress to anemia once the storage is depleted. Recovery from anemia is much slower in individuals with iron deficiency, so assessment for iron storage also should be included in preoperative assessments and following a diagnosis of acute blood loss anemia.

The mechanics of erythropoiesis, hemoglobin, and oxygen transport

Red blood cells (erythrocytes) have a short life cycle and require constant replacement. Erythrocytes are generated on demand in erythropoiesis by a hormonal signaling process, regardless of whether sufficient components are available.³ Hemoglobin, the main intracellular component of erythrocytes, is comprised of 4 globin chains, which each contain 1 iron atom bound to a heme molecule. After erythrocytes are assembled, they are sent out into circulation for approximately 120 days. A hemoglobin level measures the oxygen-carrying capacity of erythrocytes, and anemia is defined as hemoglobin less than 12 g/dL.

Unless erythrocytes are lost from bleeding, they are decommissioned—that is, the heme molecule is metabolized into bilirubin and excreted, and the iron atoms are recycled back to the bone marrow or to storage.⁴ Ferritin is the storage molecule that binds to iron, a glycoprotein with numerous subunits around a core that can contain about 4,000 iron atoms. Most ferritin is intracellular, but a small proportion is present in serum, where it can be measured.

Serum ferritin is a good marker for the iron supply in healthy individuals because it has high correlation to iron in the bone marrow and correlates to total intracellular storage unless there is inflammation, when mobilization to serum increases. The ferritin level at which the iron supply is deficient to meet demand, defined as iron deficiency, is hotly debated and ranges from less than 15 to 50 ng/mL in menstruating individuals, with higher thresholds based on onset of erythropoiesis signaling and the lower threshold being the World Health Organization recommendation.^5-7 When iron atoms are in short supply, erythrocytes still are generated but they have lower amounts of intracellular hemoglobin, which makes them thinner, smaller, and paler—and less effective at oxygen transport.

CASE Patient seeks treatment for HMB-associated symptoms

A 17-year-old patient presents with HMB, fatigue, and difficulty with concentration. She reports that her periods have been regular and lasting 7 days since menarche at age 13. While they are manageable, they seem to be getting heavier, soaking pads in 2 to 3 hours. The patient reports that she would like to start treatment for her progressively heavy bleeding and prefers lighter scheduled bleeding; she currently does not desire contraception. The patient has no family history of bleeding problems and self-reports no personal history of epistaxis or bleeding with tooth extraction or tonsillectomy. Laboratory tests confirm iron deficiency with a hemoglobin level of 12.5 g/dL (reference range, 12.0–17.5 g/dL) and a serum ferritin level of 8 ng/mL (reference range, 50–420 ng/mL). Results from a coagulopathy panel are normal, as are von Willebrand factor levels.

Untreated iron deficiency will progress to anemia

This patient has iron deficiency without anemia, which warrants significant attention in HMB because without treatment it eventually will progress to anemia. The prevalence of iron deficiency, which makes up half of all causes of anemia, is at least double that of iron deficiency anemia.³

Adult bodies usually contain about 3 to 4 g of iron, with two-thirds in erythrocytes as hemoglobin.⁸ Approximately 40 to 60 mg of iron is recycled daily, 1 to 2 mg/day is lost from sloughed cells and sweat, and at least 1 mg/day is lost during normal menstruation. These losses are balanced with gastrointestinal uptake of 1 to 2 mg/day until bleeding exceeds about 10 mL/day. In this 17-year-old patient, iron stores have likely been on a progressive decline since menarche.

For normally menstruating individuals to maintain iron homeostasis, the daily dietary iron requirement is 18 mg/day. Iron requirements also increase during periods of illness or inflammation due to hormonal signaling in the iron absorption and transport pathway, in athletes due to sweating, foot strike hemolysis and bruising, and during growth spurts.⁹

Continue to: Managing iron deficiency and anemia...

Management of iron deficiency and iron deficiency anemia in the setting of HMB includes:

• workup for the etiology of the abnormal uterine bleeding (TABLE)
• reducing the source of blood loss, and
• iron supplementation to correct the iron deficiency state.

In most cases, workup, reduction, and repletion can occur simultaneously. The goal is not always complete cessation of menstrual bleeding; even short-term therapy can allow time to replenish iron storage. Use a shared decision-making process to assess what is important to the patient, and provide information about relative amounts of bleeding cessation that can be expected with various therapies.¹⁰

Treatment options

Medical treatments to decrease menstrual iron losses are recommended prior to proceeding with surgical interventions.¹¹ Hormonal treatments are the most consistently recommended, with many guidelines citing the 52-mg levonorgestrel-releasing intrauterine device (LNG IUD) as first-line treatment due to its substantial reduction in the amount of bleeding, HMB treatment indication approved by the US Food and Drug Administration (FDA), and evidence of success in those with HMB.¹²

Any progestin or combined hormonal medication with estrogen and a progestin will result in an approximately 60% to 90% bleeding reduction, thus providing many effective options for blood loss while considering patient preferences for bleeding pattern, route of administration, and concomitant benefits. While only 1 oral product (estradiol valerate/dienogest) is FDA approved for managementof HMB, use of any of the commercially available contraceptive products will provide substantial benefit.^11,13

Nonhormonal options, such as antifibrinolytics and nonsteroidal anti-inflammatory drugs (NSAIDs), tend to be listed as second-line therapies or for those who want to avoid hormonal medications. Antifibrinolytics, such as tranexamic acid, require frequent dosing of large pills and result in approximately 40% blood loss reduction, but they are a very successful and well-tolerated method for those seeking on-demand therapy.¹⁴ NSAIDs may result in a slight bleeding reduction, but they are far less effective than other therapies.¹⁵ Antifibrinolytics have a theoretical risk of thrombosis and a contraindication to use with hormonal contraceptives; therefore, concomitant use with estrogen-containing medications is reserved for patients with refractory heavy bleeding or for heavy bleeding days during the hormone-free interval, when benefits likely outweigh potential risk.^16,17

Guidelines for medical management of acute HMB typically cite 3 small comparative studies with high-dose regimens of parenteral conjugated estrogen, combined ethinyl estradiol and progestin, or oral medroxyprogesterone acetate.^18,19 Dosing recommendations for the oral medications include a loading dose followed by a taper regimen that is poorly tolerated and for which there is no evidence of superior effectiveness over the standard dose.^20,21In most cases, initiation of the preferred long-term hormonal medication plan will reduce bleeding significantly within 2 to 3 days. Many clinicians who commonly treat acute HMB prescribe norethindrone acetate 5 mg daily (up to 3 times daily, if needed) for effective and safe menstrual suppression.²²

Iron replenishment: Dosing frequency, dietary iron, and multivitamins

Iron repletion is usually via the oral route unless surgery is imminent, anemia is severe, or the oral route is not tolerated or effective.²³ Oral iron has substantial adverse effects that limit tolerance, including nausea, epigastric pain, diarrhea, and constipation. Fortunately, evidence supports lower oral iron doses than previously used.⁴

Iron homeostasis is controlled by the peptide hormone hepcidin, produced by the liver, which controls mobilization of iron from the gut and spleen and aids iron absorption from the diet and supplements.²⁴ Hepcidin levels decrease in response to high circulating levels of iron, so the ideal iron repletion dose in iron-deficient nonanemic women was determined by assessing the dose response of hepcidin. Researchers compared iron 60 mg daily for 14 days versus every other day for 28 days and found that iron absorption was greater in the every-other-day group (21.8% vs 16.3%).²⁵They concluded that changing iron administration to 60 mg or more in a single dose every other day is most efficient in those with iron deficiency without anemia. Since study participants did not have anemia, research is pending on whether different strategies (such as daily dosing) are more effective for more severe cases. The bottom line is that conventional high-dose divided daily oral iron administration results in reduced iron bioavailability compared with alternate-day dosing.

Increasing dietary iron is insufficient to treat low iron storage, iron deficiency, and iron deficiency anemia. Likewise, multivitamins, which contain very little elemental iron, are not recommended for repletion. Any iron salt with 60 to 120 mg of elemental iron can be used (for examples, ferrous sulfate, ferrous gluconate).²⁵ Once ingested, stomach and pancreatic acids release elemental iron from its bound form. For that reason, absorption may be improved by administering iron at least 1 hour before a meal and avoiding antacids, including milk. Meat proteins and ascorbic acid help maintain the soluble ferrous form and also aid absorption. Tea, coffee, and tannins prevent absorption when polyphenol compounds form an insoluble complex with iron (see box at end of article). Gastrointestinal adverse effects can be minimized by decreasing the dose and taking after meals, although with reduced efficacy.

Intravenous iron treatment raises hemoglobin levels significantly faster than oral administration but is limited by cost and availability, so it is reserved for individuals with a hemoglobin level less than 9 g/dL, prior gastrointestinal or bariatric surgery, imminent surgery, and intolerance, poor adherence, or nonresponse to oral iron therapy. Several approved formulations are available, all with equivalent effectiveness and similar safety profiles. Lower-dose formulations (such as iron sucrose) may require several infusions, but higher-dose intravenous iron products (ferric carboxymaltose, low-molecular weight iron dextran, etc) have a stable carbohydrate shell that inhibits free iron release and improves safety, allowing a single administration.²⁶

Common adverse effects of intravenous iron treatment include a metallic taste and headache during administration. More serious adverse effects, such as hypotension, arthralgia, malaise, and nausea, are usually self-limited. With mild infusion reactions (1 in 200), the infusion can be stopped until symptoms improve and can be resumed at a slower rate.²⁷

Continue to: The role of blood transfusion...

The role of blood transfusion

Blood transfusion is expensive and potentially hazardous, so its use is limited to treatment of acute blood loss or severe anemia.

A one-time red blood cell transfusion does not impact diagnostic criteria to assess for iron deficiency with ferritin, and it does not improve underlying iron deficiency.²⁸Patients with acute blood loss anemia superimposed on chronic blood loss should be screened and treated for iron deficiency even after receiving a transfusion.

Since ferritin levels can rise significantly as an acute phase reactant, even following a hemorrhage, iron deficiency during inflammation is defined as ferritin less than 70 ng/mL.

The potential for iron overload

Since iron is never metabolized or excreted, it is possible to have iron overload following accidental overdose, transfusion dependency, and disorders of iron transport, such as hemochromatosis and thalassemia.

While a low ferritin level always indicates iron deficiency, high ferritin levels can be an acute phase reactant. Ferritin levels greater than 150 ng/mL in healthy menstruating individuals and greater than 500 ng/mL in unhealthy individuals should raise concern for excess iron and should prompt discontinuation of iron intake or workup for conditions at risk for overload.⁵

Oral iron supplements should be stored away from small children, who are at particular risk of toxicity.

How long to treat?

Treatment duration depends on the individual’s degree of iron deficiency, whether anemia is present, and the amount of ongoing blood loss. The main treatment goal is normalization and maintenance of serum ferritin.

Successful treatment should be confirmed with a complete blood count and ferritin level. Hemoglobin levels improve 2 g/dL after 3 weeks of oral iron therapy, but repletion may take 4 to 6 months.^23,29 The American College of Obstetricians and Gynecologists recommends 3 to 6 months of continued iron therapy after resolution of HMB.¹⁹

In a comparative study of treatment for HMB with the 52-mg LNG IUD versus hysterectomy, hemoglobin levels increased in both treatment groups but stayed lower in those with initial anemia.⁸ Ferritin levels normalized only after 5 years and were still lower in individuals with initial anemia.

Increase in hemoglobin is faster after intravenous iron administration but is equivalent to oral therapy by 12 weeks. If management to reduce menstrual losses is discontinued, periodic or maintenance iron repletion will be necessary.

CASE Management plan initiated

This 17-year-old patient with iron deficiency resulting from HMB requests management to reduce menstrual iron losses with a preference for predictable menses. We have already completed a basic workup, which could also include assessment for hypermobility with a Beighton score, as connective tissue disorders also are associated with HMB.³⁰ We discuss the options of cyclic hormonal therapy, antifibrinolytic treatment, and an LNG IUD. The patient is concerned about adherence and wants to avoid unscheduled bleeding, so she opts for a trial of tranexamic acid 1,300 mg 3 times daily for 5 days during menses. This regimen results in a 50% reduction in bleeding amount, which the patient finds satisfactory. Iron repletion with oral ferrous sulfate 325 mg (containing 65 mg of elemental iron) is administered on alternating days with vitamin C taken 1 hour prior to dinner. Repeat laboratory test results at 3 weeks show improvement to a hemoglobin level of 14.2 g/dL and a ferritin level of 12 ng/mL. By 3 months, her ferritin levels are greater than 30 ng/mL and oral iron is administered only during menses.

Summing up

Chronic HMB results in a progressive net loss of iron and eventual anemia. Screening with complete blood count and ferritin and early treatment of low iron storage when ferritin is less than 30 ng/mL will help avoid symptoms. Any amount of reduction of menstrual blood loss can be beneficial, allowing a variety of effective hormonal and nonhormonal treatment options. ●

Drospirenone vs norethindrone progestin-only pills. Is there a clear winner?

ROBERT L. BARBIERI, MD (FEBRUARY 2022)

Contraception queries

Dr. Barbieri, addressing your editorial on drospirenone and norethindrone pills, can you tell me why there are 4 placebo pills in Slynd? In addition, why did Exeltis choose a 24/4 regimen instead of a continuous regimen? And are there data on bleeding patterns with continuous drospirenone versus 24/4?

Meredith S. Cassidy, MD

Colorado Springs, Colorado

Dr. Barbieri responds

I thank Dr. Cassidy for the excellent question! The purpose of the 4 placebo pills in the Slynd (drospirenone 4 mg) 24/4 progestin-only contraceptive is to induce scheduled bleeding and reduce the number of days of unscheduled uterine bleeding. In a study of 858 patients, compared with a continuous progestin-only desogestrel contraceptive, Slynd with 4 placebo pills, was associated with significantly fewer days of unscheduled bleeding, 22 days versus 35 days (P<.0003) over 8 months of contraceptive use.¹

The norethindrone progestin-only pill (POP) , which is available in the United States has very weak anti-ovulatory properties. If there were 4 placebo pills in the norethindrone POP, ovulation rates would increase, leading to reduced contraceptive efficacy. In contrast, Slynd with 4 placebo pills has excellent anti-ovulatory efficacy.

Reference

1. Palacios S, Colli E, Regidor PA. Bleeding profile of women using a drospirenone-ony 4 mg over nine cycles in comparison with desogestrel 0.075 mg. PLoS ONE. 2020;15:e0231856.

Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?

ROBERT L. BARBIERI, MD (NOVEMBER 2022)

ERAS for all cesarean deliveries

In Dr. Barbieri’s editorial “Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?”, he and Dr. Schantz-Dunn outline several reasons why the answer is a resounding, “Yes!”

I would suggest that ERAS principles should be used for all cesarean deliveries (CDs), not only scheduled ones. Many components of CD ERAS pathways are equally applicable to scheduled and unscheduled CDs, specifically those components that apply to intraoperative care (antibiotic prophylaxis, skin preparation, surgical technique, uterotonic administration, normothermia, and multimodal anesthesia) and postoperative care (VTE prophylaxis, gum chewing, early oral intake, early ambulation, early removal of bladder catheter, predischarge patient education, scheduled analgesic prophylaxis with acetaminophen, and NSAIDS). Although scheduled CDs have the additional advantage of the pre-hospital components (breastfeeding education, shortened fasting interval, carbohydrate loading, anemia prevention, and physiologic optimization), most of the benefit of ERAS for CD is likely attributable to the intraoperative and postoperative components.

For example, in our CD ERAS program, the median postoperative opioid consumption was reduced from a baseline of more than 100 morphine mg equivalents (MME) in both scheduled CDs (23 MME, interquartile range [IQR], 0-70) and unscheduled CDs (23 MME, IQR, 0-75).¹ Remarkably, 29% of patients in the ERAS pathway used no postoperative opioids at all, a testament to the efficacy of neuraxial morphine and postoperative acetaminophen and NSAIDS. In another program, ERAS was associated with decreased postpartum length of stay and reduced direct costs in both scheduled and unscheduled CDs.²

References

1. Combs CA, Robinson T, Mekis C, et al. Enhanced recovery after cesarean: impact on postoperative opioid use and length of stay. Am J Obstet Gynecol. 2021;224:237-239.
2. Fay EE, Hitti JE, Delgado CM, et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol. 2019;221:349.e1-e9.

C. Andrew Combs, MD, PhD

Sunrise, Florida

Dr. Barbieri responds

I am grateful to Dr. Combs’ advocacy for applying ERAS principles to all CD births, including scheduled and unscheduled operations. Dr. Combs notes that the intraoperative and postoperative components of ERAS can be used for both scheduled and unscheduled CD births. Of particular note is the marked reduction in opioid medication use achieved among Dr. Combs’ patients who were on an ERAS pathway. Hopefully, due to Dr. Combs clinical and research leadership many more patients will benefit from the use of an ERAS pathway.

ObGyns united in a divided post-Dobbs America

ERIN TRACY BRADLEY, MD, MPH, AND MEGAN L. EVANS,MD, MPH (DECEMBER 2022)

ObGyns are not united on this issue

I just finished reading the article by Drs. Bradley and Evans in the December edition of OBG Management. I am an older ObGyn, and I remember when the American College of Obstetricians and Gynecologists and other organizations within our specialty were more circumspect when discussing abortion. They recognized that there were many practitioners who held sincere opinions regarding abortion, feeling that it was ending a sacred life. I am one of those practitioners. I have always felt that we, of all practitioners, should be aware of the reality of early fetal life. We scan patients every day. To see the unborn fetus in all its glory should indelibly impress on each of us that this is life.

The unborn seem not to have advocates like Drs. Bradley and Evans. In fact, those who hold pro-life opinions are regularly silenced in publications and on social media. The Facebooks and Twitters of the world tend to hold us in derision when they are not silencing us. There used to be a detente in our field where we each respected the viewpoint of the other, but now it is nonstop advocacy for abortion. Some authors want to accelerate and intensify that advocacy. I suspect that the pro-life views like mine will continue to be silenced. I just want the authors to know that we are not united in this post-Dobbs world. Many of us want appropriate limits on termination. We are not in favor of the unlimited right to abort a fetus up to the moment of delivery.

Steven G. Nelson

Phoenix, Arizona

Drospirenone vs norethindrone progestin-only pills. Is there a clear winner?

ROBERT L. BARBIERI, MD (FEBRUARY 2022)

Contraception queries

Dr. Barbieri, addressing your editorial on drospirenone and norethindrone pills, can you tell me why there are 4 placebo pills in Slynd? In addition, why did Exeltis choose a 24/4 regimen instead of a continuous regimen? And are there data on bleeding patterns with continuous drospirenone versus 24/4?

Meredith S. Cassidy, MD

Colorado Springs, Colorado

Dr. Barbieri responds

I thank Dr. Cassidy for the excellent question! The purpose of the 4 placebo pills in the Slynd (drospirenone 4 mg) 24/4 progestin-only contraceptive is to induce scheduled bleeding and reduce the number of days of unscheduled uterine bleeding. In a study of 858 patients, compared with a continuous progestin-only desogestrel contraceptive, Slynd with 4 placebo pills, was associated with significantly fewer days of unscheduled bleeding, 22 days versus 35 days (P<.0003) over 8 months of contraceptive use.¹

The norethindrone progestin-only pill (POP) , which is available in the United States has very weak anti-ovulatory properties. If there were 4 placebo pills in the norethindrone POP, ovulation rates would increase, leading to reduced contraceptive efficacy. In contrast, Slynd with 4 placebo pills has excellent anti-ovulatory efficacy.

Reference

1. Palacios S, Colli E, Regidor PA. Bleeding profile of women using a drospirenone-ony 4 mg over nine cycles in comparison with desogestrel 0.075 mg. PLoS ONE. 2020;15:e0231856.

Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?

ROBERT L. BARBIERI, MD (NOVEMBER 2022)

ERAS for all cesarean deliveries

In Dr. Barbieri’s editorial “Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?”, he and Dr. Schantz-Dunn outline several reasons why the answer is a resounding, “Yes!”

I would suggest that ERAS principles should be used for all cesarean deliveries (CDs), not only scheduled ones. Many components of CD ERAS pathways are equally applicable to scheduled and unscheduled CDs, specifically those components that apply to intraoperative care (antibiotic prophylaxis, skin preparation, surgical technique, uterotonic administration, normothermia, and multimodal anesthesia) and postoperative care (VTE prophylaxis, gum chewing, early oral intake, early ambulation, early removal of bladder catheter, predischarge patient education, scheduled analgesic prophylaxis with acetaminophen, and NSAIDS). Although scheduled CDs have the additional advantage of the pre-hospital components (breastfeeding education, shortened fasting interval, carbohydrate loading, anemia prevention, and physiologic optimization), most of the benefit of ERAS for CD is likely attributable to the intraoperative and postoperative components.

For example, in our CD ERAS program, the median postoperative opioid consumption was reduced from a baseline of more than 100 morphine mg equivalents (MME) in both scheduled CDs (23 MME, interquartile range [IQR], 0-70) and unscheduled CDs (23 MME, IQR, 0-75).¹ Remarkably, 29% of patients in the ERAS pathway used no postoperative opioids at all, a testament to the efficacy of neuraxial morphine and postoperative acetaminophen and NSAIDS. In another program, ERAS was associated with decreased postpartum length of stay and reduced direct costs in both scheduled and unscheduled CDs.²

References

1. Combs CA, Robinson T, Mekis C, et al. Enhanced recovery after cesarean: impact on postoperative opioid use and length of stay. Am J Obstet Gynecol. 2021;224:237-239.
2. Fay EE, Hitti JE, Delgado CM, et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol. 2019;221:349.e1-e9.

C. Andrew Combs, MD, PhD

Sunrise, Florida

Dr. Barbieri responds

I am grateful to Dr. Combs’ advocacy for applying ERAS principles to all CD births, including scheduled and unscheduled operations. Dr. Combs notes that the intraoperative and postoperative components of ERAS can be used for both scheduled and unscheduled CD births. Of particular note is the marked reduction in opioid medication use achieved among Dr. Combs’ patients who were on an ERAS pathway. Hopefully, due to Dr. Combs clinical and research leadership many more patients will benefit from the use of an ERAS pathway.

ObGyns united in a divided post-Dobbs America

ERIN TRACY BRADLEY, MD, MPH, AND MEGAN L. EVANS,MD, MPH (DECEMBER 2022)

ObGyns are not united on this issue

I just finished reading the article by Drs. Bradley and Evans in the December edition of OBG Management. I am an older ObGyn, and I remember when the American College of Obstetricians and Gynecologists and other organizations within our specialty were more circumspect when discussing abortion. They recognized that there were many practitioners who held sincere opinions regarding abortion, feeling that it was ending a sacred life. I am one of those practitioners. I have always felt that we, of all practitioners, should be aware of the reality of early fetal life. We scan patients every day. To see the unborn fetus in all its glory should indelibly impress on each of us that this is life.

The unborn seem not to have advocates like Drs. Bradley and Evans. In fact, those who hold pro-life opinions are regularly silenced in publications and on social media. The Facebooks and Twitters of the world tend to hold us in derision when they are not silencing us. There used to be a detente in our field where we each respected the viewpoint of the other, but now it is nonstop advocacy for abortion. Some authors want to accelerate and intensify that advocacy. I suspect that the pro-life views like mine will continue to be silenced. I just want the authors to know that we are not united in this post-Dobbs world. Many of us want appropriate limits on termination. We are not in favor of the unlimited right to abort a fetus up to the moment of delivery.

Steven G. Nelson

Phoenix, Arizona

Drospirenone vs norethindrone progestin-only pills. Is there a clear winner?

ROBERT L. BARBIERI, MD (FEBRUARY 2022)

Contraception queries

Dr. Barbieri, addressing your editorial on drospirenone and norethindrone pills, can you tell me why there are 4 placebo pills in Slynd? In addition, why did Exeltis choose a 24/4 regimen instead of a continuous regimen? And are there data on bleeding patterns with continuous drospirenone versus 24/4?

Meredith S. Cassidy, MD

Colorado Springs, Colorado

Dr. Barbieri responds

I thank Dr. Cassidy for the excellent question! The purpose of the 4 placebo pills in the Slynd (drospirenone 4 mg) 24/4 progestin-only contraceptive is to induce scheduled bleeding and reduce the number of days of unscheduled uterine bleeding. In a study of 858 patients, compared with a continuous progestin-only desogestrel contraceptive, Slynd with 4 placebo pills, was associated with significantly fewer days of unscheduled bleeding, 22 days versus 35 days (P<.0003) over 8 months of contraceptive use.¹

The norethindrone progestin-only pill (POP) , which is available in the United States has very weak anti-ovulatory properties. If there were 4 placebo pills in the norethindrone POP, ovulation rates would increase, leading to reduced contraceptive efficacy. In contrast, Slynd with 4 placebo pills has excellent anti-ovulatory efficacy.

Reference

1. Palacios S, Colli E, Regidor PA. Bleeding profile of women using a drospirenone-ony 4 mg over nine cycles in comparison with desogestrel 0.075 mg. PLoS ONE. 2020;15:e0231856.

Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?

ROBERT L. BARBIERI, MD (NOVEMBER 2022)

ERAS for all cesarean deliveries

In Dr. Barbieri’s editorial “Should every scheduled cesarean birth use an Enhanced Recovery After Surgery (ERAS) pathway?”, he and Dr. Schantz-Dunn outline several reasons why the answer is a resounding, “Yes!”

I would suggest that ERAS principles should be used for all cesarean deliveries (CDs), not only scheduled ones. Many components of CD ERAS pathways are equally applicable to scheduled and unscheduled CDs, specifically those components that apply to intraoperative care (antibiotic prophylaxis, skin preparation, surgical technique, uterotonic administration, normothermia, and multimodal anesthesia) and postoperative care (VTE prophylaxis, gum chewing, early oral intake, early ambulation, early removal of bladder catheter, predischarge patient education, scheduled analgesic prophylaxis with acetaminophen, and NSAIDS). Although scheduled CDs have the additional advantage of the pre-hospital components (breastfeeding education, shortened fasting interval, carbohydrate loading, anemia prevention, and physiologic optimization), most of the benefit of ERAS for CD is likely attributable to the intraoperative and postoperative components.

For example, in our CD ERAS program, the median postoperative opioid consumption was reduced from a baseline of more than 100 morphine mg equivalents (MME) in both scheduled CDs (23 MME, interquartile range [IQR], 0-70) and unscheduled CDs (23 MME, IQR, 0-75).¹ Remarkably, 29% of patients in the ERAS pathway used no postoperative opioids at all, a testament to the efficacy of neuraxial morphine and postoperative acetaminophen and NSAIDS. In another program, ERAS was associated with decreased postpartum length of stay and reduced direct costs in both scheduled and unscheduled CDs.²

References

1. Combs CA, Robinson T, Mekis C, et al. Enhanced recovery after cesarean: impact on postoperative opioid use and length of stay. Am J Obstet Gynecol. 2021;224:237-239.
2. Fay EE, Hitti JE, Delgado CM, et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol. 2019;221:349.e1-e9.

C. Andrew Combs, MD, PhD

Sunrise, Florida

Dr. Barbieri responds

I am grateful to Dr. Combs’ advocacy for applying ERAS principles to all CD births, including scheduled and unscheduled operations. Dr. Combs notes that the intraoperative and postoperative components of ERAS can be used for both scheduled and unscheduled CD births. Of particular note is the marked reduction in opioid medication use achieved among Dr. Combs’ patients who were on an ERAS pathway. Hopefully, due to Dr. Combs clinical and research leadership many more patients will benefit from the use of an ERAS pathway.

ObGyns united in a divided post-Dobbs America

ERIN TRACY BRADLEY, MD, MPH, AND MEGAN L. EVANS,MD, MPH (DECEMBER 2022)

ObGyns are not united on this issue

I just finished reading the article by Drs. Bradley and Evans in the December edition of OBG Management. I am an older ObGyn, and I remember when the American College of Obstetricians and Gynecologists and other organizations within our specialty were more circumspect when discussing abortion. They recognized that there were many practitioners who held sincere opinions regarding abortion, feeling that it was ending a sacred life. I am one of those practitioners. I have always felt that we, of all practitioners, should be aware of the reality of early fetal life. We scan patients every day. To see the unborn fetus in all its glory should indelibly impress on each of us that this is life.

The unborn seem not to have advocates like Drs. Bradley and Evans. In fact, those who hold pro-life opinions are regularly silenced in publications and on social media. The Facebooks and Twitters of the world tend to hold us in derision when they are not silencing us. There used to be a detente in our field where we each respected the viewpoint of the other, but now it is nonstop advocacy for abortion. Some authors want to accelerate and intensify that advocacy. I suspect that the pro-life views like mine will continue to be silenced. I just want the authors to know that we are not united in this post-Dobbs world. Many of us want appropriate limits on termination. We are not in favor of the unlimited right to abort a fetus up to the moment of delivery.

Steven G. Nelson

Phoenix, Arizona

In 2009, the Lancet called climate change the biggest global health threat of the 21st century, the effects of which will be experienced in our lifetimes.¹ Significant amounts of data have demonstrated the negative health effects of heat, air pollution, and exposure to toxic substances.^2,3 These effects have been seen in every geographic region of the United States, and in multiple organ systems and specialties, including obstetrics, pediatrics, and even cardiopulmonary and bariatric surgery.^2-5

Although it does not receive the scrutiny of other industries, the global health care industry accounts for almost double the amount of carbon emissions as global aviation, and the United States accounts for 27% of this footprint despite only having 4% of the world’s population.⁶ It therefore serves that our own industry is an excellent target for reducing the carbon emissions that contribute to climate change. Consider the climate impact of hysterectomy, the second-most common surgery that women undergo. In this article, we will use the example of a 50-year-old woman with fibroids who plans to undergo definitive treatment via total laparoscopic hysterectomy (TLH).

Climate impact of US health care

Hospital buildings in the United States are energy intensive, consuming 10% of the energy used in commercial buildings every year, accounting for over $8 billion. Operating rooms (ORs) account for a third of this usage.⁷ Hospitals also use more water than any other type of commercial building, for necessary actions like cooling, sterilization, and laundry.⁸ Further, US hospitals generate 14,000 tons of waste per day, with a third of this coming from the ORs. Sadly, up to 15% is food waste, as we are not very good about selecting and proportioning healthy food for our staff and inpatients.⁶

While health care is utility intensive, the majority of emissions are created through the production, transport, and disposal of goods coming through our supply chain.⁶ Hospitals are significant consumers of single-use objects, the majority of which are petroleum-derived plastics—accounting for an estimated 71% of emissions coming from the health care sector. Supply chain is the second largest expense in health care, but with current shortages, it is estimated to overtake labor costs by this year. The United States is also the largest consumer of pharmaceuticals worldwide, supporting a $20 billion packaging industry,⁹ which creates a significant amount of waste.

Climate impact of the OR

Although ORs only account for a small portion of hospital square footage, they account for a significant amount of health care’s carbon footprint through high waste production and excessive consumption of single-use items. Just one surgical procedure in a hospital is estimated to produce about the same amount of waste as a typical family of 4 would in an entire week.¹⁰ Furthermore, the majority of these single-use items, including sterile packaging, are sorted inappropriately as regulated medical waste (RMW, “biohazardous” or “red bag” waste) (FIGURE 1a). RMW has significant effects on the environment since it must be incinerated or steam autoclaved prior to transport to the landfill, leading to high amounts of air pollution and energy usage.

We all notice the visible impacts of waste in the OR, but other contributors to carbon emissions are invisible. Energy consumption is a huge contributor to the overall carbon footprint of surgery. Heating, ventilation, and air conditioning [HVAC] is responsible for 52% of hospital energy needs but accounts for 99% of OR energy consumption.¹¹ Despite the large energy requirements of the ORs, they are largely unoccupied in the evenings and on weekends, and thermostats are not adjusted accordingly.

Anesthetic gases are another powerful contributor to greenhouse gas emissions from the OR. Anesthetic gases alone contribute about 25% of the overall carbon footprint of the OR, and US health care emits 660,000 tons of carbon equivalents from anesthetic gas use per year.¹² Desflurane is 1,600 times more potent than carbon dioxide (CO₂) in its global warming potential followed by isoflurane and sevoflurane;¹³ this underscores the importance of working with our anesthesia colleagues on the differences between the anesthetic gases they use. Enhanced recovery after surgery recommendations in gynecology already recommend avoiding the use of volatile anesthetic gases in favor of propofol to reduce postoperative nausea and vomiting.¹⁴

In the context of a patient undergoing a TLH, the estimated carbon footprint in the United States is about 560 kg of CO₂ equivalents—roughly the same as driving 1,563 miles in a gas-powered car.

Continue to: Climate impact on our patients...

The data in obstetrics and gynecology is clear that climate change is affecting patient outcomes, both globally and in our own country. A systematic review of 32 million births found that air pollution and heat exposure were associated with preterm birth and low birth weight, and these effects were seen in all geographic regions across the United States.¹ A study of 5.9 million births in California found that patients who lived near coal- and oil-power plants had up to a 27% reduction in preterm births when those power plants closed and air pollution decreased.¹⁵ A study in Nature Sustainability on 250,000 pregnancies that ended in missed abortions at 14 weeks or less found the odds ratio of missed abortion increased with the cumulative exposure to air pollution.¹⁶ When air pollution was examined in comparison to other factors, neighborhood air pollution better predicted preterm birth, very preterm birth, and small for gestational age more than race, ethnicity, or any other socio-economic factor.¹⁷ The effects of air pollution have been demonstrated in other fields as well, including increased mortality after cardiac transplantation with exposure to air pollution,⁴ and for patients undergoing bariatric surgery who live near major roadways, decreased weight loss, less improvement in hemoglobin A_1c, and less change in lipids compared with those with less exposure to roadway pollution.⁵

Air pollution and heat are not the only factors that influence health. Endocrine disrupting chemicals (EDCs) and single-use plastic polymers, which are used in significant supply in US health care, have been found in human blood,¹⁸ intestine, and all portions of the placenta.¹⁹ Phthalates, an EDC found in medical use plastics and medications to control delivery, have been associated with increasing fibroid burden in patients undergoing hysterectomy and myomectomy.²⁰ The example case patient with fibroids undergoing TLH may have had her condition worsened by exposure to phthalates.

Specific areas for improvement

There is a huge opportunity for improvement to reduce the total carbon footprint of a TLH.

A lifecycle assessment of hysterectomy in the United States concluded that an 80% reduction in carbon emissions could be achieved by minimizing opened materials, using reusable and reprocessed instruments, reducing off-hour energy use in the OR (HVAC setbacks), and avoiding the use of volatile anesthetic gases.²¹ The sterilization and re-processing of reusable instruments represented the smallest proportion of carbon emissions from a TLH. Data on patient safety supports these interventions, as current practices have more to do with hospital culture and processes than evidence.

Despite a push to use single-use objects by industry and regulatory agencies in the name of patient safety, data demonstrate that single-use objects are in actuality not safer for patients and may be associated with increased surgical site infections (SSIs). A study from a cancer center in California found that when single-use head covers, shoe covers, and facemasks were eliminated due to supply shortages during the pandemic, SSIs went down by half, despite an increase in surgical volume and an increase in the number of contaminated cases.²² The authors reported an increase in hand hygiene throughout the hospital, which likely contributed to the success of reducing SSIs.

Similarly, a systematic review found no evidence to support single-use instruments over reusable or reprocessed instruments when considering instrument function, ease of use, patient safety, SSIs, or long-term patient outcomes.²³ While it may be easy for regulatory agencies to focus on disposing objects as paramount to reducing infections, the Centers for Disease Control and Prevention states that the biggest factors affecting SSIs are appropriate use of prophylactic antibiotics, skin antisepsis, and patient metabolic control.²⁴ Disposing of single-use objects in the name of patient safety will worsen patient health outcomes when considering patient proximity to waste, pollution, and EDCs.

The sterilization process for reusable items is often called out by the medical supply industry as wasteful and energy intensive; however, data refute these claims. A Swedish study researching reusable versus single-use trocars found that a reusable trocar system offers a robust opportunity to reduce both the environmental and financial costs for laparoscopic surgery.²⁵ We can further decrease the environmental impact of reusable instruments by using sets instead of individually packed instruments and packing autoclaves more efficiently. By using rigid sterilization containers, there was an 85% reduction in carbon footprint as compared with the blue wrap system.

Electricity use can be easily reduced across all surgical spaces by performing HVAC setbacks during low occupancy times of day. On nights and weekends, when there are very few surgical cases occurring, one study found that by decreasing the ventilation rate, turning off lights, and performing the minimum temperature control in unused ORs, electricity use was cut in half.¹¹

Waste triage and recycling

Reducing regulated medical waste is another area where hospitals can make a huge impact on carbon emissions and costs with little more than education and process change. Guidelines for regulated medical waste sorting developed out of the HIV epidemic due to the fear of blood products. Although studies show that regulated medical waste is not more infectious than household waste, state departments of public health have kept these guidelines in place for sorting fluid blood and tissue into RMW containers and bags.²⁶ The best hospital performers keep RMW below 10% of the total waste stream, while many ORs send close to 100% of their waste as RMW (FIGURE 1b). ORs can work with nursing and environmental services staff to assess processes and divert waste into recycling and regular waste. Many OR staff are acutely aware of the huge amount of waste produced and want to make a positive impact. Success in this small area often builds momentum to tackle harder sustainability practices throughout the hospital.

Continue to: Removal of EDCs from medical products...

Removal of EDCs from medical products

Single-use medical supplies are not only wasteful but also contain harmful EDCs, such as phthalates, bisphenol A (BPA), parabens, perfluoroalkyl substances, and triclosan. Phthalates, for example, account for 30% to 40% of the weight of medical-use plastics, and parabens are ubiquitously found in ultrasound gel.³ Studies looking at exposure to EDCs within the neonatal intensive care unit reveal substantial BPA, phthalate, and paraben levels within biologic samples from premature infants, thought to be above toxicity limits. While we do not know the full extent to which EDCs can affect neonatal development, there is already mounting evidence that EDCs are associated with endocrine, metabolic, and neurodevelopmental disorders throughout our lifespan.³

30-day climate challenge

Although the example case patient undergoing TLH for fibroids will never need care for her fibroids again, the climate impact of her time in the OR represents the most carbon-intensive care she will ever need. Surgery as practiced in the United States today is unsustainable.

In 2021, the Biden administration issued an executive order requiring all federal facilities, including health care facilities and hospitals, to be carbon neutral by 2035. In order to make meaningful changes industry-wide, we should be petitioning lawmakers for stricter environmental regulations in health care, similar to regulations in the manufacturing and airline industries. We recommend a 30-day climate challenge (FIGURE 2) for bringing awareness to your circles of influence. Physicians have an ethical duty to advocate for change at the local, regional, and national level if we want to see a better future for our patients, their children, and even ourselves. Organizations such as Practice Greenhealth, Health Care without Harm, and Citizens’ Climate Lobby can help amplify our voices to reach the right people to implement sweeping policy changes. ●