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Background: Stillbirth is a devastating event for families as well as hospital staff. Hospital practices around internal and external staff communication, debriefing, and training are unknown. Methods: We systematically sampled U.S. hospitals that provide obstetrical care. Staff knowledgeable of bereavement care on labor and delivery were invited to participate in an anonymous survey linked to hospital descriptors. We evaluated stillbirth communication, debriefing, and training for staff. Results: We received 289 usable surveys from 429 eligible staff (67% response). Most (94%) noted hospitals' marked rooms housing bereaved families, but only a third (37%) reported a marker on the paper or electronic medical record. Half of the hospitals had no standard debriefings post-loss, and 38% reported no perinatal loss training for labor and delivery nurses. Conclusions: Hospitals have significant variations and gaps in staff communication, support, and training, which are key aspects of respectful stillbirth care. [ABSTRACT FROM AUTHOR]

Objectives: The quality and scope of perinatal bereavement care in the United States has been evaluated by surveying bereaved parents, but little is known about how care varies across hospitals. We sought to survey clinicians about stillbirth bereavement care practices at U.S. hospitals and to evaluate care by hospital birth volume. Methods: Using American Hospital Association data, we employed stratified random sampling to select 300 hospitals from all centers with at least 100 annual deliveries. Within each state, we divided all hospitals into size quartiles and randomly selected from each until we reached the goal number per state. We then identified a staff member knowledgeable about typical bereavement care on labor and delivery at each hospital and sent an on-line survey about care. We linked survey data with hospital characteristics and used summary statistics, Chi squared, and Fisher's Exact test to compare care by hospital birth volume. Results: We reached an eligible respondent at 429/551 hospitals and 396 of the 429 (73%) agreed to participate. We received 289 usable surveys for an overall response rate of 67%. Only one third of hospitals (n = 96, 33%) reported staff protected time for perinatal bereavement care. Of 17 bereavement topics, just six were routinely offered by at least two-thirds of the hospitals. Financial limitations and staff shortages were the most commonly identified barriers to care and were most pronounced at small-volume hospitals. Conclusions for Practice: This study offers a snapshot in bereavement care and identified important gaps for both large and small hospitals. Significance: What is already known on this subject?: While there have been efforts to improve hospital bereavement care for families after stillbirth, no researchers have surveyed U.S. hospital practices to assess current bereavement practices or how these practices vary across hospitals. What this study adds?: This study systematically sampled hospitals in all U.S. states to assess stillbirth bereavement care including memory-making, parental education, and barriers to optimal care and analyzed differences by hospital birth volume. The study found significant gaps including limited bereavement education about normal grief, mental health, impact on relationships, return to work, and the father's experience. [ABSTRACT FROM AUTHOR]

Physician suicide and well-being are critical issues but studies use varying methodologies and suicide is frequently underreported. This study sought to update data on physician suicides in the United States. The National Violent Death Reporting System (NVDRS) at the Centers for Disease Control collects details about violent deaths. The study used 2010–2015 data from 27 NVDRS states to identify suicide deaths among physicians or non-physicians and calculate annual standardized mortality rates (SMR). Of 63,780 victims total, there were 357 physicians identified over 6 years, (307 men and 50 women). If results are extrapolated to all 50 states, there would be approximately 119 physician suicides annually. The SMR for physicians overall was not statistically different from that of non-physicians. This is the first study in 16 years to update estimated physician suicide rates in the United States. The research used strict criteria to identify physicians so results likely represent the lower boundary of physician suicides. Findings show that physician suicide is not significantly lower than that of non-physicians and emphasizes the importance of focusing on structural changes to reduce stigma around mental health in the medical community. [ABSTRACT FROM AUTHOR]

As life expectancy in Ghana improves, a large and growing population of older adults require healthcare. Despite governmental support for the care of older adults, there have been no geriatricians and no in‐country educational path for those desiring to become specialists in this field. In fact, 23 of 54 countries in sub‐Saharan Africa (SSA) lack even a single geriatrician. We describe a novel and collaborative approach used to develop the first geriatric training fellowship in Ghana. Faculty from the Ghana College of Physicians and Surgeons and the University of Michigan worked together to develop a rigorous and evidence‐based geriatrics curriculum, based on US standards but adapted to be appropriate for the cultural, economic, educational, and social norms in Ghana. This approach led to a strong training model for care of older adults while also strengthening the ongoing collaboration between the two partner universities in Ghana and the United States. The fellowship has been inaugurated in Ghana and can serve as a concrete educational model for other countries in SSA. J Am Geriatr Soc 67:1718–1723, 2019 [ABSTRACT FROM AUTHOR]

Fetal deaths account for nearly one percent of all births in the United States. The cost of hospital care associated with fetal deaths may be substantial. However, there is very limited data on the economic burden of fetal death. We conducted a retrospective medical chart review of stillbirths at three large hospitals in Michigan over a ten-year period and identified medical complications, hospital costs, and length of stay for these deliveries. Mothers with stillbirth were matched with mothers of the same age who delivered a live-born infant at the same hospital during the same year. Our final sample was comprised of 533 stillbirths and 1,053 matched live births. Average hospital cost for stillbirth was $7,495 (±7,015) and the average length of stay was 2.8 days (±2.8). Having a serious maternal medical complication was associated with higher costs and longer length of stay among women with stillbirth. Early stillbirths between 20 and 28 weeks gestational age, epidural/spinal/general anesthesia, and cesarean delivery were also associated with longer length of stay. Average hospital costs for women with stillbirth were more than $750 higher than women with live births but length of stay was not significantly different between the two. This study suggests that stillbirths were associated with substantial maternal hospital costs. Future research examining the economic impact of stillbirths beyond labor and delivery such as increased costs associated with additional testing and care in subsequent pregnancies will help better understand the overall economic impact of stillbirths. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Physician suicide is an important public health problem as the rate of suicide is higher among physicians than the general population. Unfortunately, few studies have evaluated information about mental health comorbidities and psychosocial stressors which may contribute to physician suicide. We sought to evaluate these factors among physicians versus non-physician suicide victims. Methods: We used data from the United States National Violent Death Reporting System to evaluate demographics, mental health variables, recent stressors and suicide methods among physician versus non-physician suicide victims in 17 states. Results: The data set included 31,636 suicide victims of whom 203 were identified as physicians. Multivariable logistic regression found that having a known mental health disorder or a job problem which contributed to the suicide significantly predicted being a physician. Physicians were significantly more likely than non-physicians to have antipsychotics, benzodiazepines and barbiturates present on toxicology testing but not antidepressants. Conclusions: Mental illness is an important comorbidity for physicians who complete a suicide but postmortem toxicology data shows low rates of medication treatment. Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians. [Copyright &y& Elsevier]

Abstract: Objectives: Suicide during pregnancy and postpartum is a tragic event for the victim and profoundly impacts the baby, the family and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors. Methods: The analysis used data from 17 states reporting to the NVDRS from 2003 to 2007 to evaluate suicide patterns among pregnant, postpartum, and nonpregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems and suicide methods were compared among groups. Results: The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood, with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely to die via asphyxia as cause of death compared to poisoning or firearms. Conclusions: These findings describe important mental health, substance use and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population. [Copyright &y& Elsevier]

Objective: Although births of multiracial and multiethnic infants are becoming more common in the United States, little is known about birth outcomes and risks for adverse events. We evaluated risk of fetal death for mixed race couples compared with same race couples and examined the role of prematurity and low birth weight as potential mediating risk factors. Methods: We performed a retrospective cohort analysis using data from the 1998–2002 California Birth Cohort to evaluate the odds of fetal death, low birth weight, and prematurity for couples with a mother and father who were categorized as either being of same or different racial groups. Risk of prematurity (birth prior to 37 weeks gestation) and low birth weight (<2500 g) were also tested to see if the model could explain variations among groups. Results: The analysis included approximately 1.6 million live births and 1749 stillbirths. In the unadjusted model, compared with two white parents, black/black and black/white couples had a significantly higher risk of fetal death. When all demographic, social, biological, genetic, congenital, and procedural risk factors except gestational age and birth weight were included, the odds ratios (OR) were all still significant. Black/black couples had the highest level of risk (OR 2.11, CI 1.77-2.51), followed by black mother/white father couples (OR 2.01, CI 1.16-3.48), and white mother/black father couples (OR 1.84, CI 1.33-2.54). Virtually all of the higher risk of fetal death was explainable by higher rates of low birth weight and prematurity. Conclusions: Mixed race black and white couples face higher odds of prematurity and low birth weight, which appear to contribute to the substantially higher demonstrated risk for stillbirth. There are likely additional unmeasured factors that influence birth outcomes for mixed race couples. [ABSTRACT FROM AUTHOR]

The article discusses the findings of a survey which examines how obstetricians in the U.S. cope with stillbirth or neonatal death. The survey aims to identify physicians' experiences and attitudes about perinatal death, their coping strategies and their beliefs about the adequacy of their training on this issue. The survey found that perinatal death has a significant effect on obstetricians.

Although no guidelines support the use of benzodiazepines in bereavement care, clinicians continue to use this medication for surviving family members. An anonymous survey about perinatal death was sent to 1500 United States obstetricians. One question assessed beliefs about prescribing sedatives to bereaved mothers. Almost half (49%) of 804 obstetricians endorsed the use of sedatives, such as benzodiazepines, for acute bereavement. Grieving families may experience mental and physical anguish after a death; however, benzodiazepines are not part of recommended care for bereavement. The surprisingly high support from physicians for the use of sedatives in the case of maternal grief raises important questions about how physicians can best support bereaved mothers and what effect benzodiazepines may have in the grieving process. [ABSTRACT FROM AUTHOR]

Katherine J. Gold responds to a letter to the editor submitted in response to her article "Details on Suicide Among U.S. Physicians: Data From the National Violent Death Reporting System".

Objective: After stillbirth or early infant death, parents often query when they can try for another pregnancy. We conducted a national survey of US obstetricians to assess attitudes about optimal timing of next pregnancy and advice given to parents. Study Design: The study was an anonymous mail survey of 1500 randomly selected US obstetricians asking about physician experiences with perinatal death. Results: In all, 804 of 1500 obstetricians completed the survey for a 54% usable response rate. Two-thirds of respondents endorsed a waiting time <6 months for parents bereaved by stillbirth who desired another pregnancy. Conclusion: Physicians in this national survey supported very short interpregnancy intervals for parents bereaved by perinatal death. Responses may reflect efforts to support parents emotionally while recognizing individuals vary in coping and clinical circumstances. However, this is a provocative finding since short intervals may confer greater fetal risks for poor outcome. [Copyright &y& Elsevier]

Objective: To estimate the rates of pregnancy-associated homicide and suicide in a multistate sample from the National Violent Death Reporting System, to compare these rates with other causes of maternal mortality, and to describe victims' demographic characteristics.Methods: We analyzed data from female victims of reproductive age from 2003 to 2007. We identified pregnancy-associated violent deaths as deaths attributable to homicide or suicide during pregnancy or within the first year postpartum, and we calculated the rates of pregnancy-associated homicide and suicide as the number of deaths per 100,000 live births in the sample population. We used descriptive statistics to report victims' demographic characteristics and prevalence of intimate-partner violence.Results: There were 94 counts of pregnancy-associated suicide and 139 counts of pregnancy-associated homicide, yielding pregnancy-associated suicide and homicide rates of 2.0 and 2.9 deaths per 100,000 live births, respectively. Victims of pregnancy-associated suicide were significantly more likely to be older and white or Native American as compared with all live births in National Violent Death Reporting System states. Pregnancy-associated homicide victims were significantly more likely to be at the extremes of the age range and African American. In our study, 54.3% of pregnancy-associated suicides involved intimate partner conflict that appeared to contribute to the suicide, and 45.3% of pregnancy-associated homicides were associated with intimate-partner violence.Conclusion: Our results indicate that pregnancy-associated homicide and suicide are important contributors to maternal mortality and confirm the need to evaluate the relationships between sociodemographic disparities and intimate-partner violence with pregnancy-associated violent death. [ABSTRACT FROM AUTHOR]

Background and Objectives: With the emergence of COVID-19, telemedicine use has increased dramatically as clinicians and patients have looked for alternatives to face-to-face care. Prior research has shown high levels of patient satisfaction and comparable quality of care. Video visits have been hypothesized to be one way to reduce burnout among clinicians, but there has been minimal research on physician views of virtual care. We sought to measure family physician experience with video visits at the start of the COVID-19 pandemic., Methods: We identified all faculty and resident physicians at a large academic department of family medicine who had conducted a video visit in the prior month and conducted an anonymous online 12-question survey about their experiences, satisfaction, and barriers with care., Results: Most eligible physicians responded (102/109, 94%), of whom half (52%) reported this was their first month trying a video visit. There was very high satisfaction (91% very or somewhat satisfied). The majority of respondents felt that video visits were shorter (54%) or took the same amount of time (38%) as in-person visits. There was concern that many physicians had experienced a visit in which they felt video was not the appropriate platform given patient concerns., Conclusions: This study is among the first to assess physician experience with video visits. As the visits are perceived as shorter, they may offer a unique opportunity to address clinician burnout. There was a high level of satisfaction at our institution despite multiple technical challenges.

Purpose: Up to one-third of female smokers with Medicaid deny tobacco use during pregnancy. Point-of-care urine tests for cotinine, a tobacco metabolite, can help to identify women who may benefit from cessation counseling. We sought to evaluate patient and clinician perspectives about using such tests during prenatal care to identify smokers, with particular focus on the impact of testing on clinical relationships and the potential for tobacco cessation., Methods: We conducted 19 individual interviews and 4 focus groups with 40 pregnant or postpartum women covered by Medicaid who smoked before or during pregnancy. Patients also took the urine cotinine test and received sample results. Interviews were conducted with 20 health care practitioners. We analyzed the transcripts using an inductive approach and developed a model of how prenatal testing for cotinine could affect the patient-clinician relationship., Results: Patients were more likely than clinicians to believe that testing could encourage discussions on tobacco cessation but emphasized that the clinician's approach to testing was critical. Clinicians feared that testing would negatively affect relationships., Conclusions: Despite having reservations, low-income patients had a surprisingly favorable view of using point-of-care urine testing to promote smoking cessation during pregnancy, which could increase the availability of cessation resources to women who do not disclose their tobacco use to clinicians., (© 2018 Annals of Family Medicine, Inc.)

Background: In the United States, approximately one in 110 pregnancies end in stillbirth affecting more than 26,000 women annually. Women experiencing stillbirth have a threefold greater risk of developing depressive symptoms compared to women experiencing live birth. Depression contributes negatively to health outcomes for both mothers and babies subsequent to stillbirth. Physical activity may improve depression in these women, however, little is known about acceptable physical activity interventions for women after stillbirth. This is the purpose of this descriptive exploratory study., Methods: Eligible women were between ages 19 and 45, and experienced stillbirth within one year of the study. An online survey was used to ask questions related to 1) pregnancy and family information (i.e., time since stillbirth, weight gain during pregnancy, number of other children) 2) physical activity participation, 3) depressive symptomatology, and 4) demographics., Results: One hundred seventy-five women participated in the study (M age = 31.26 ± 5.52). Women reported participating in regular physical activity (at least 150 minutes of moderate activity weekly) before (60%) and during (47%) their pregnancy, as well as after their stillbirth (61%). Only 37% were currently meeting physical activity recommendations. Approximately 88% reported depression (i.e., score of >10 on depression scale). When asked how women cope with depression, anxiety, or grief, 38% said physical activity. Of those that reported using physical activity to cope after stillbirth, they did so to help with depression (58%), weight loss (55%), and better overall physical health (52%). To cope with stillbirth, women used walking (67%), followed by jogging (35%), and yoga (23%). Women who participated in physical activity after stillbirth reported significantly lower depressive symptoms (M = 15.10, SD = 5.32) compared to women who did not participate in physical activity (M = 18.06, SD = 5.57; t = -3.45, p = .001)., Conclusions: Physical activity may serve as a unique opportunity to help women cope with the multiple mental sequelae after stillbirth. This study provides data to inform healthcare providers about the potential role of physical activity in bereavement and recovery for women who have experienced stillbirth. Additional research is necessary in this vulnerable population.

Background: Over one third of reproductive age women in the US are obese. Pregnancy is a strong risk factor for obesity, with excess weight gain as the greatest predictor of long term obesity. The majority of pregnant women gain more weight than recommended by the Institute of Medicine guidelines. The objective of this study was to understand prenatal care providers' perspectives on weight gain during pregnancy., Methods: Semi-structured qualitative interviews of 10 prenatal care providers (three family physicians, three obstetricians, and four nurse midwives) at a University Hospital in the Midwest, that included the ranking of important prenatal issues, and open-ended questions addressing: 1) general perceptions; 2) approach with patients; and 3) clinical care challenges., Results: Providers felt that appropriate weight gain during pregnancy was not a high priority. Many providers waited until patients had gained excess weight before addressing the issue, were not familiar with established guidelines, and lacked resources for patients. Providers also believed that their counseling had low impact on patients, avoided counseling due to sensitivity of the topic, and believed that patients were more influenced by other factors, such as their family, habits, and culture., Conclusions: Both providers and patients may benefit from increased awareness of the morbidity of excess weight gain during pregnancy. Practice-level policies that support the monitoring and management of weight gain during pregnancy could also improve care. Research that further investigates the barriers to appropriate weight gain is warranted.

Background: Pregnancy loss is common, but its significance is often minimized by family, friends, and the community, leaving bereaved parents with unmet need for support. This study sought to describe demographics, usage patterns, and perceived benefits for women participating in Internet pregnancy loss support groups., Methods: We requested permission to post an anonymous Internet survey on large and active United States Internet message boards for women with miscarriages and stillbirths. The study purposefully oversampled stillbirth sites and included both closed- and open-ended questions. The University of Michigan Institutional Review Board approved the study. Closed-ended questions were summarized and evaluated with bivariate analysis. We performed a qualitative analysis of open-ended data using an iterative coding process to identify key themes., Results: Of 62 sites queried, 15 granted permission to post the survey on 18 different message boards. We collected 1,039 surveys, of which 1,006 were complete and eligible for analysis. Women were typically white, well educated, and frequent users. They noted message boards helped them to feel less isolated in their loss and grief and they appreciated unique aspects of Internet communication such as convenience, access, anonymity, and privacy. Pregnancy loss message boards are an important aspect of support for many bereaved mothers. African-American women seem to be substantially underrepresented on-line despite being at higher risk for stillbirth., Conclusion: Internet message boards serve a unique function in providing support for women with miscarriage and stillbirth. The benefits are often significantly different from those encountered in traditional face-to-face bereavement support., (Copyright © 2012 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: The goal was to evaluate marriage and cohabitation outcomes for couples who experienced a live birth or fetal death at any gestational age., Methods: For married and cohabitating women who experienced live births, miscarriages, or stillbirths, we conducted a survival analysis (median follow-up period: 7.8 years), by using data from the National Survey of Family Growth, to examine the association between birth outcomes and subsequent relationship survival. The Cox proportional-hazards models controlled for multiple independent risk factors known to affect relationship outcomes. The main outcome measure was the proportion of intact marriages or cohabitations over time., Results: Of 7770 eligible pregnancies, 82% ended in live births, 16% in miscarriages, and 2% in stillbirths. With controlling for known risk factors, women who experienced miscarriages (hazard ratio: 1.22 [95% confidence interval: 1.08-1.38]; P = .001) or stillbirths (hazard ratio: 1.40 [95% confidence interval: 1.10-1.79]; P = .007) had a significantly greater hazard of their relationship ending, compared with women whose pregnancies ended in live births., Conclusions: This is the first national study to establish that parental relationships have a higher risk of dissolving after miscarriage or stillbirth, compared with live birth. Given the frequency of pregnancy loss, these findings might have significant societal implications if causally related.

Objective: Maternal mental health disorders in pregnancy are common and are associated with prematurity, low birth weight and delivery complications. We explored whether existing mental illness was associated not just with fetal complications but also with fetal death., Method: We conducted a retrospective cohort analysis using data from the National Comorbidity Survey (NCS). The NCS is a nationally representative multistage probability study of the prevalence of psychiatric disorders in the United States. We analyzed the association between a prepregnancy mental health diagnosis and subsequent miscarriage or stillbirth, using multivariable logistic regression to control for maternal age, race, health risks and other independent risk factors for fetal death., Results: Patients with any mental health disorder prior to pregnancy [odds ratio (OR)=1.8], specifically those with affective disorders (OR=1.6) or substance use disorders (OR=1.4), were at significantly higher risk for fetal mortality in pregnancy. This risk remained significant even when controlling for health and behavioral risk factors that cause fetal loss., Conclusion: These results are consistent with studies showing mental health to be independently associated with morbidity and mortality in heart disease, stroke and cancer. The etiology remains poorly understood, but may include neuroendocrine, behavioral and genetic mediators.