Search

To explore providers' perspectives about decisional authority, conflict resolution, and diverse family structures within the context of periviable delivery (eg, between 22 and 25 weeks of gestation), with the ultimate goal of helping practitioners support, engage, and navigate conflict with parents facing periviable delivery.Qualitative interviews with 30 neonatologists and obstetricians sought opinions about whether and how a pregnant person's partner should be involved in making periviable treatment decisions and how health care teams should proceed when parents do not agree on a treatment plan. Physicians were asked to consider whether their opinions changed under different scenarios involving marriage, biological relationship, adoption, and surrogacy.Interviews revealed 4 main themes corresponding to providers' perspectives regarding partner involvement and decisional authority: providers care; involvement matters; mom is the priority; and uncertainty and guidance needed. Unique themes arose when discussing diverse family structures.Shared decision making is optimal in the setting of periviable delivery, where decisions are both preference sensitive and value laden. Our interviews suggest that incorporating the dynamics and impact of partners' involvement in periviable resuscitation decision-making may facilitate more shared, equitable, and high-quality decision-making tailored to the needs of both pregnant people and their partners.

We estimate the effect of the Affordable Care Act's (ACA) Medicaid expansions on Medicaid coverage of reproductive-aged women at varying childbearing stages.Using data from the American Community Survey (ACS) (n = 1,977,098) and a difference-in-differences approach, we compare Medicaid coverage among low-income adult women without children, postpartum mothers, and mothers of children older than one year in expansion states to non-expansion states, before and after the expansions.The ACA's Medicaid expansion increased Medicaid coverage among adult women with incomes between 101 and 200% of the federal poverty line (FPL) without children by 10.7 percentage points (54 percent, p 0.01). Coverage of mothers with children older than one year increased by 9.5 percentage points (34 percent, p 0.01). Coverage of mothers with infants rose by 7.9 percentage points (21 percent, p 0.01).Within the population of adult reproductive-aged women, we find a "fanning out" of effects from the ACA's Medicaid expansions. Childless women experience the largest gains in coverage while mothers of infants experience the smallest gains; mothers of children greater than one year old fall in the middle. These results are consistent with ACA gains being the smallest among the groups least targeted by the ACA, but also show substantial gains (one fifth) even among postpartum mothers.

Objective: The recruitment of diverse populations in research is essential for representing marginalized groups. We discuss the successes and challenges of recruiting pregnant-parent dyads for a study examining neonatal decisional authority within diverse partnerships. Methods: We aimed to recruit 30 adult, first-time pregnant people between 18-26 weeks gestation, along with their partner. Heterosexual, same-sex, married, and unmarried partnerships were recruited to ensure a sample of diverse partnerships. Study advertisements were shared on pregnancy-related Reddit and Facebook groups. Flyers were distributed to OB/GYN clinics, LGBTQ+ healthcare providers, public events, and coffee shops. In-person recruitment at local clinics began in July 2022. Ads included a hyperlink or QR code to direct individuals to a brief screening questionnaire. If deemed eligible, the research team contacted the candidate to confirm eligibility and to schedule interviews. Virtual interviews lasted 1-hour and each participant received a $50 gift card. Results: A total of 88 (51.4%) individuals were initially eligible. Of those, 35 (39.8%) did not leave contact information and 23 (26.1%) did not respond. To date, 20 parent dyads have been interviewed, with most recruited from Reddit (n=17, 85%). The majority of dyads were white. Four (10%) participants were non-white and four were Hispanic/Latinx. Additionally, 4 (10%) participants identified as LGBTQIA+. All eligible dyads were married. Challenges to recruitment include lacking access to private social media groups, a high prevalence of scammers, unresponsiveness, and difficulty getting buy-in from clinicians to share study ads with patients. In-person recruitment is promising but difficult to coordinate and limits the study’s generalizability. Conclusions: Online recruitment provides potential for recruiting diverse populations but yields several challenges. This presentation can provide insight for studies needing to recruit these populations.

Objective We conducted a study to examine the impact of COVID on patients' access and utilization of prenatal genetic screens and diagnostic tests at the onset of the COVID‐19 pandemic in the United States. Methods We conducted telephone interviews with 40 patients to examine how the pandemic affected prenatal genetic screening and diagnostic testing decisions during the initial months of the pandemic in the United States. An interview guide queried experiences with the ability to access information about prenatal genetic testing options and to utilize the tests when desired. Audio recordings were transcribed and coded using NVivo 12. Analysis was conducted using Grounded Theory. Results The pandemic did not alter most participants' decisions to undergo prenatal genetic testing. Yet, it did impact how participants viewed the risks and benefits of testing and timing of testing. There was heightened anxiety among those who underwent testing, stemming from the risk of viral exposure and the fear of being alone if pregnancy loss or fetal abnormality was identified at the time of an ultrasound‐based procedure. Conclusion The pandemic may impact patients' access and utilization of prenatal genetic tests. More research is needed to determine how best to meet pregnant patients' decision‐making needs during this time., Key Points What is already known about this topic? Prenatal genetic screens and diagnostic tests are a core component to the delivery of high‐quality, evidence‐based prenatal care.It is critical that pregnant patients have the information and resources to make an informed decision about a growing array of prenatal genetic screening and diagnostic testing options.In the decision‐making process, pregnant patients commonly weigh the risks and benefits of gaining genetic information about the fetus with the risks and benefits of the available screens and diagnostic tests. What does this study add? The pandemic has led to significant changes in healthcare delivery and insurance benefits for prenatal genetic testing, raising key questions about how pregnant patient are weighing the risks and benefits of the available prenatal genetic screening and diagnostic testing options against the risks of COVID exposure by presenting to a healthcare facility for testing.COVID‐19 appears to impact how women view the utility of prenatal genetic testing, including how they weigh the risk and benefits of prenatal genetic screening and diagnostic testing in addition to when in the pregnancy they may elect to undergo testing.The COVID‐19 pandemic has resulted in increased levels of concern and anxiety that may be encountered by pregnant women in the testing process, raising awareness of the need for additional resources to support patients' decision‐making during the pandemic.

BACKGROUND The COVID-19 pandemic brought significant changes in healthcare, specifically the accelerated use of telehealth. Given the unique aspects of prenatal care, it is important to understand the impact of telehealth on healthcare communication, quality, and patient satisfaction. This mixed-methods study examined challenges associated with the rapid and broad implementation of telehealth for prenatal care delivery during the pandemic. OBJECTIVE In this study, we examine patients' perspectives, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time. METHODS Pregnant patients who received outpatient prenatal care in Cleveland, Ohio participated in in-depth interviews and completed the Coronavirus Perinatal Experiences- Impact Survey (COPE-IS) between January-December 2021. Transcripts were coded using NVivo12 and qualitative analysis used an approach consistent with grounded theory. Quantitative data were summarized and integrated during analysis. RESULTS Thematic saturation was achieved with 60 interviews. Lead themes focused on: establishing patient-provider relationships that support shared decision-making (SDM), accessing the information needed for SDM, and using technology effectively to foster discussions during the COVID-19 pandemic. In the COPE-IS, 59 (100.0%) felt very well supported by their provider, 31 (52.5%) were moderately to highly concerned about their child’s health, and 17 (28.8%) reported the single greatest stress of COVID-19 was its impact on their child. CONCLUSIONS While telehealth was recognized as an option to ensure timely access to prenatal care during the COVID-19 pandemic, it also came with multiple challenges and opportunities to adapt to diverse patient populations. It is important to address the unique needs of this population during the pandemic and as healthcare increasingly adopts a telehealth model.

To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7–24 6/7 weeks). Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12. We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a “means to an end.” Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby’s comfort, pain, or suffering. These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Background and Hypothesis: During periviable deliveries, parents are confronted with overwhelming and challenging decisions, about which they may know little. This study aimed to explore qualitatively the language that mothers and important others (IOs) utilize when discussing palliation, or ‘comfort care,’ as a treatment option in the context of periviability. Project Methods: We prospectively recruited pregnant women (and designated IOs) admitted to labor and delivery for a threatened periviable delivery (22-25 weeks GA) at two hospitals between September 2016 and January 2018. Using a semi-structured interview guide, we explored participants’ perceptions of palliation and neonatal treatment options. Women were asked items such as, “How was the choice of resuscitation presented to you?” and “What were the options presented?” Research assistants developed a codebook for the interview transcripts, and NVivo 12 was used for qualitative analysis. Results: Thirty women and 16 IOs were recruited in total. Participants’ descriptions of palliation fell into five broad categories – ‘doing nothing,’ ‘not resuscitating,’ ‘withdrawal of care,’ ‘implicit comfort care,’ and ‘explicit comfort care.’ The majority of parents perceived comfort care not as a distinct treatment option, but rather as the absence of treatment. Several barriers to the comprehension of comfort care were observed, including subjects’ unfamiliarity with the terminology or the inability to remember its explanation during antenatal consultation. Parents described comfort care with either neutral or negative connotations, and even those parents able to discuss the concept neutrally chose resuscitation as their preferred treatment option. Conclusion and Potential Impact: This study revealed that many parents facing periviable delivery may lack understanding of comfort care as a neonatal treatment option. These parental perceptions highlight the need to improve counseling efforts in order to maximize parents’ informed decision-making.

The United States maternal mortality rate has been rising for many years putting the US out of step with peer countries. There are many complex reasons for the rise in maternal deaths and recent data has demonstrated that there is a disproportionate risk for women of color. This article provides an overview of current policy and policy issues aimed at improving the maternal mortality rate in the United States.

PLUS (Program to Launch Underrepresented in Medicine Success) is a 2-year cohort program at Indiana University School of Medicine providing professional development, funding and skills to produce scholarship, and a community to mitigate social and/or professional isolation for underrepresented in medicine (URiM) faculty. In year 1, scholars participate in leadership and professional development seminars and regular meetings with their mentor(s). They are assigned a PLUS Advisory Council advisor with whom they meet 2 to 3 times annually. In year 2, scholars participate in monthly seminars focused on research methods, writing productivity, and wellness. Additionally, scholars engage in a writing accountability group and practice reflective writing. Connections events, designed to combat isolation and cultivate community, occur monthly. At program completion, scholars complete a project resulting in a scholarly product for submission and dissemination in a peer-reviewed forum. To date, 3 cohorts, totaling 24 people, have participated: 20 (83%) Black, 4 (17%) Latinx; 12 (50%) females. Five scholars have completed the full program, whose pre- and postsurvey results are described. Program surveys demonstrate significant gains in scholars' confidence to secure leadership opportunities, connect with colleagues, and advocate for themselves and others. Scholars reported statistically significant increases in confidence to pursue leadership roles (t = -3.67, P = .02) and intent to submit their dossier for promotion (t = -6.50, P = .003). They were less likely to leave academic medicine (t = 2.75, P = .05) or pursue another academic appointment (t = 2.75, P = .05) after PLUS completion than at baseline. All scholars adequately met requirements for their third-year review (tenure track only), were promoted, or achieved tenure in less than 3 years since program completion. This article describes PLUS program objectives, evaluative components, and lessons learned during implementation, as a model to support URiM faculty at other institutions.

Motivation and Purpose: The experience of giving birth to a periviable neonate between 22-25 weeks gestation varies greatly among women depending on numerous factors. Studying periviable narrative experiences will allow us to isolate those factors that create a more positive experience, even in the instance of a negative neonatal outcome (infant death). Results may be used to advise future caregiving approaches so they may be tailored to the needs of women in these situations. This study aimed to qualitatively assess the extent of the relationship between neonatal outcome and the language used by women and their important others (IOs) to describe periviable birth experience three months postpartum. Method: A semi-structured interview guide was used to investigate participants’ perceptions of their delivery experience and subsequent NICU experience, if applicable, at three months postpartum. Interviews were transcribed verbatim and coded for themes by three investigators. Conventional content analysis was conducted using NVivo 12. Results: Twenty-three women and twelve IOs were recruited at two hospitals between 2016 and 2018. Women and IOs who experienced infant death negatively described their delivery experience if they also negatively described healthcare team (HCT) interactions, including providers’ communication, clinical judgement, and personality traits. Specifically, participants with overall negative birth experiences described not understanding various clinical decisions and felt uninformed on topics pertinent to their or their infant’s care. Alternatively, women and IOs who experienced infant death who positively described their delivery experience also positively described NICU care (including HCT interactions) and infant death experience (comfort care). These results highlight the impact of HCT interactions and communication on a patient’s perception of delivery despite a negative neonatal outcome. Conclusion: These findings could suggest that improvements in communication and information dissemination from the HCT may have the ability to improve a patient’s periviable birth experience despite a negative neonatal outcome.

Motivation and Purpose: The experience of giving birth to a periviable neonate between 22-25 weeks gestation varies greatly among women depending on numerous factors. Studying periviable narrative experiences will allow us to isolate those factors that create a more positive experience, even in the instance of a negative neonatal outcome (infant death). Results may be used to advise future caregiving approaches so they may be tailored to the needs of women in these situations. This study aimed to qualitatively assess the extent of the relationship between neonatal outcome and the language used by women and their important others (IOs) to describe periviable birth experience three months postpartum. Method: A semi-structured interview guide was used to investigate participants’ perceptions of their delivery experience and subsequent NICU experience, if applicable, at three months postpartum. Interviews were transcribed verbatim and coded for themes by three investigators. Conventional content analysis was conducted using NVivo 12. Results: Twenty-three women and twelve IOs were recruited at two hospitals between 2016 and 2018. Women and IOs who experienced infant death negatively described their delivery experience if they also negatively described healthcare team (HCT) interactions, including providers’ communication, clinical judgement, and personality traits. Specifically, participants with overall negative birth experiences described not understanding various clinical decisions and felt uninformed on topics pertinent to their or their infant’s care. Alternatively, women and IOs who experienced infant death who positively described their delivery experience also positively described NICU care (including HCT interactions) and infant death experience (comfort care). These results highlight the impact of HCT interactions and communication on a patient’s perception of delivery despite a negative neonatal outcome. Conclusion: These findings could suggest that improvements in communication and information dissemination from the HCT may have the ability to improve a patient’s periviable birth experience despite a negative neonatal outcome.

Background/Objective: The optimal mode of delivery (MOD) for malpresentation in periviable deliveries (22-24 weeks), remains a source of debate. Neonatal and maternal complications can arise from both vaginal (VD) and cesarean delivery (CD), and the threat of maternal morbidity extends to subsequent pregnancies. It has been difficult to compare these risks while counseling patients about MOD options, so we sought to create a decision tree that maps probable outcomes associated with breech deliveries at 23- and 24-weeks’ gestation, as well as complications posed for subsequent pregnancies. Methods: An extensive literature review was conducted to identify risk estimates of periviable maternal and neonatal outcomes, along with elective repeat CD (ERCD) and trial of labor after cesarean (TOLAC) for subsequent pregnancies. Probabilities were inputted into TreeAge software, starting with primary maternal health states that may result from CD and VD – “death”, “hysterectomy”, or “no hysterectomy”, followed by the probability of neonatal health states– “death”, “severe morbidity”, or “no severe morbidity”. The likelihood of placenta previa or normal placenta was considered for subsequent pregnancies. We factored in the possibility of ERCD or TOLAC and the associated maternal and neonatal risks for each. Results: Final design of the tree is complete and risk estimates have been inputted. Primary analysis and sensitivity analyses are planned for August 2021. Ultimately, we will also be able to use measured utility values to calculate quality adjusted life years (QALYs) for each health state. Conclusion and Clinical Impact: Whether CD or VD is optimal for breech presentation in periviable delivery is influenced by a complex array of factors, including future reproductive plans and maternal values related to potential neonatal and maternal morbidity and mortality. Quantifying risks associated with each MOD will aid providers in their efforts to help families make informed decisions and reduce morbidity across the reproductive lifespan.

Background Prenatal genetic screens, including carrier screening (CS) and aneuploidy screening (AS), comprise an important component of reproductive healthcare delivery. Clinical practice guidelines emphasize the importance of informed decision-making and patient’s preferences regarding the use of these screens. Yet, it is unclear how to achieve this ideal as prenatal genetic screening options rapidly become more complex and increasingly available to patients. With increased complexity and availability of reproductive testing options, decision-support strategies are critical to prepare patients to consider AS and/or CS. Methods A self-administered survey evaluated knowledge and decision-making preferences for expanded carrier (CS) and aneuploidy (AS) prenatal screening. The survey was administered to participants before their first prenatal visit to assess baseline decision-making needs and preference at the initiation of prenatal care. Analysis was approached as a descriptive process. Results Participants had similar familiarity with the concepts associated with AS compared to CS; mean knowledge scores for CS was 0.59 [possible range 0.00 to 1.00] and 0.55 for AS. Participants reported preferences to learn about a range of conditions, including those with severe or mild impact, childhood-onset, and adult-onset. Decision-making preference with respect to learning about the associated disease phenotypes for the contained on AS and CS panel shifted with the complexity of the panel, with a greater preference to learn about conditions post-test compared pre-test education as panels increased from 5 to 100 conditions. Conclusion Patients’ baseline knowledge of prenatal genetic screens coupled with evolving decision-making preferences presents challenges for the delivery of prenatal genetic screens. This calls for the development and implementation of innovative approaches to support pregnant patients’ decision-making commensurate with advances in prenatal genomics.

BACKGROUND Although telehealth appears to have been accepted among some obstetric populations before the COVID-19 pandemic, patients’ receptivity and experience with the rapid conversion of this mode of health care delivery are unknown. OBJECTIVE In this study, we examine patients' prenatal care needs, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time. METHODS This study involved qualitative methods to explore pregnant patients’ experiences with prenatal health care delivery at the onset of the COVID-19 pandemic. We conducted in-depth interviews with pregnant patients in the first and second trimester of pregnancy who received prenatal care in Cleveland, Ohio, from May to July 2020. An interview guide was used to probe experiences with health care delivery as it rapidly evolved at the onset of the pandemic. RESULTS Although advantages of telehealth were noted, there were several concerns noted with the broad implementation of telehealth for prenatal care during the pandemic. This included concerns about monitoring the pregnancy at home; the need for additional reassurance for the pregnancy, given the uncertainties presented by the pandemic; and the ability to have effective patient-provider discussions via a telehealth visit. The need to tailor telehealth to prenatal health care delivery was noted. CONCLUSIONS Although previous studies have demonstrated that telehealth is a flexible and convenient alternative for some prenatal appointments, our study suggests that there may be specific needs and concerns among the diverse patient groups using this modality during the pandemic. More research is needed to understand patients' experiences with telehealth during the pandemic and develop approaches that are responsive to the needs and preferences of patients.

Purpose. To measure utility values that describe women’s willingness to tradeoff maternal morbidity for fetal benefit among pregnant and nonpregnant women of reproductive age. Methods. We recruited English-speaking women aged 18 to 45 years in clinical and community-based settings. Eight health states were studied: 4 maternal (healthy, stroke, hysterectomy, death) and 4 neonatal (healthy, severe cerebral palsy [CP], severe mental retardation [MR], death). Utilities were assessed on a subset of 9 pairs of mom/baby delivery outcomes. Participants ranked the 9 pairs of outcomes in order of preference, then standard gamble methods were used to calculate utilities. Numeracy skills were assessed. Results. Utilities were obtained from 477 participants (recruitment rate = 94%). Twenty-one percent were pregnant, 63% were parents, and 54% were African American. Utilities did not differ significantly between pregnant and nonpregnant women or based on numeracy score. The highest (nonhealthy) values were assigned to baby healthy/mom hysterectomy (0.999), baby healthy/mom stroke (0.946), and baby CP/mom healthy (0.940). The lowest values were assigned to baby death/mom hysterectomy (0.203), baby MR/mom death (0.150), and baby death/mom stroke (0.087). Nonwhite participants assigned a significantly higher value to baby MR/mom death ( P = 0.01), baby MR/mom stroke ( P = 0.02), baby MR/mom healthy ( P < 0.01), and baby MR/mom hysterectomy ( P = 0.02) than white participants. Conclusion. When asked to value pairs of maternal/fetal outcomes that required a tradeoff of morbidity and mortality, women tended to assign the highest utility to combinations that resulted in a “healthy baby.” They assigned the lowest values to combinations that resulted in a baby’s death or MR. Our findings highlight the importance of 1) assessing individual preferences and goals of care for pregnancy outcomes and 2) measuring utilities among reproductive-aged women when modeling obstetric decision making.

Objective To describe periviability counseling practices and decision making. Study Design This is a retrospective review of mothers and newborns delivering between 22 and 24 completed weeks from 2011 to 2015 at six U.S. centers. Maternal and fetal/neonatal clinical and maternal sociodemographic data from medical records and geocoded sociodemographic information were collected. Separate analyses examined characteristics surrounding receiving neonatology consultation; planning neonatal resuscitation; and centers' planned resuscitation rates. Results Neonatology consultations were documented for 40, 63, and 72% of 498 mothers delivering at 22, 23, and 24 weeks, respectively. Consult versus no-consult mothers had longer median admission-to-delivery intervals (58.7 vs. 8.7 h, p Conclusion Areas requiring improvement included delivery/content of neonatology consultations, social work support, consideration of centers' patient populations, and opportunities for shared decisions.

To assess the relationship between decision quality and mental health outcomes for women and their important others (IO) 3 months following periviable birth. Mental health outcomes were assessed prior to delivery and at 3 months postpartum using depression (PHQ-9), anxiety (GAD-7), and post-traumatic stress disorder (PTSD) (IES-22) scales. Decision quality was measured in terms of Decisional Conflict, Control, Regret, and Satisfaction with Decision. Descriptive analyses and linear regression modeling were conducted using SAS version 9.4. We recruited 30 eligible women and 16 IOs. Participants had mild anxiety and depression, and symptoms of PTSD were among bereaved parents. Participants with lower decision control had higher levels of depression (women: p = 0.014; IOs: p = 0.059) and anxiety (women: p = 0.053; IOs: p = 0.032). Depression was also associated with higher decisional regret (women: p = 0.073; IOs: p = 0.023). Our findings suggest that decision quality is associated with mental health outcomes for families who experience periviable delivery.

To assess women's attitudes and preferences related to recent changes in cervical cancer screening guidelines.We distributed 380 surveys in three University based and Community clinics. Study participants anonymously completed surveys, which included questions related to demographics, cervical cancer, screening practices, risk perception and attitudes towards changing practices.315 women agreed to participate (83%). 60% (185/310) of participants had some college education or higher and 12% (36/305) worked in the medical field. On average, participants answered 4.1 (SD = 1.3) of the 8 knowledge questions correctly. Knowledge scores significantly increased with education level (Kruskal-Wallis test p-value 0.001). The majority (72%, n = 228) reported that they should be screened annually, and that screening should be initiated with the onset of sexual activity (63%, n = 197). Participants that were more knowledgeable of current screening practices were more comfortable extending screening intervals (Kruskal-Wallis test p 0.001).Even among a relatively highly educated population of women, participants had limited knowledge of cervical cancer and current screening guidelines. Many participants reported discomfort with less frequent screening intervals.This study supports the need for improvement in cervical cancer prevention education especially with regards to the new screening guidelines.

Purpose To examine outcomes of a 2-visit protocol for placement of intrauterine or subdermal contraception. Methods We identified all women ages 15 to 27 who received an order for an intrauterine or subdermal contraceptive between January 2014−December 2016. We examined time from order to contraceptive placement and reasons for incomplete orders. Results We identified 1,192 unique patients who received 1,323 orders for intrauterine or subdermal contraceptives; 68% were completed at a second visit. The median time from order to placement was 22 days (interquartile range = 15−35). Of incomplete orders, 41% were related to logistics of a subsequent visit. Twenty-eight percent of patients had a subsequent pregnancy within the study period. Conclusions Efforts to provide same-day access for all contraceptive methods are needed.

Introduction: In the wake of George Floyd’s murder, White faculty in our department began to express the desire to gain a greater understanding of structural racism and racial inequity. To facilitate this learning, support allyship, and mitigate the emotional labor and taxation that frequently falls on faculty of color to respond to these appeals, we developed AWARE (Allies Welcomed to Advance Racial Equity), a faculty seminar series primarily designed for and led by a majority White faculty to tackle the topics of structural racism, Whiteness, and Anti-racist action. Methods: We developed a 6-session seminar series, identifying 5 White faculty as lecturers and a cadre of Black and White volunteer facilitators, to lead 60-minute sessions comprised of lecture, facilitated small group reflection, and large group sharing, that reviewed key topics/texts on structural racism, Whiteness, and Anti-racism. Results: Attendance ranged from 26 to 37 participants at each session. About 80% of faculty participated in at least 1 session of the program. The majority of participants (85%) felt “more empowered to influence their current environment to be more inclusive of others” and were “better equipped to advocate for themselves or others.” Most (81%) felt “more connected to their colleagues following completion of the program.” Ultimately, faculty thought highly of the program upon completion with 26/27 (96%) stating they would recommend the program to a colleague. Discussion: We offer a reproducible model to improve departmental climate by engaging in the shared labor of educating our colleagues and communities about structural racism, Whiteness, and Anti-racism to create a point of entry into reflection, dialogue, and deliberate actions for change.

California has focused on health equity in the state’s COVID-19 reopening plan. The Blueprint for a Safer Economy assigns each of California’s 58 counties into 1 of 4 tiers based on 2 metrics: test positivity rate and adjusted case rate. To advance to the next less-restrictive tier, counties must meet that tier’s test positivity and adjusted case rate thresholds. In addition, counties must have a plan for targeted investments within disadvantaged communities, and counties with more than 106 000 residents must meet an equity metric. California’s explicit incorporation of health equity into its reopening plan underscores the interrelated fate of its residents during the COVID-19 pandemic and creates incentives for action. This article evaluates the benefits and challenges of this novel health equity focus, and outlines recommendations for other US states to address disparities in their reopening plans.

Patients may request care from a woman obstetrician-gynecologist for various reasons, including privacy concerns, religious or cultural reasons, and in some cases, a history of abuse. They should be given the opportunity to voice their reasons for requesting a woman obstetrician-gynecologist but should not be compelled to do so. Respect for patient autonomy is a compelling reason to consider honoring a patient’s gender-based request. When a patient requests a woman obstetrician-gynecologist, efforts should be made to accommodate the request if possible. However, medical professionals and institutions are not ethically obligated to have a woman obstetrician-gynecologist on call or to make one available at all times. If it is not feasible for a woman obstetrician-gynecologist to provide care because of staffing or other system constraints or patient safety concerns, accommodation is not required, and physicians do not have an overriding responsibility to ensure that patients receive gender-concordant care. Patients have the right to decline care and may choose to seek care elsewhere if their requested healthcare provider type is not available. Institutions and medical clinics should have policies and procedures in place for managing patient requests for women obstetrician-gynecologists, and patients should be made aware of these policies preemptively. These policies and procedures should include information about whom to contact for assistance and how to document the encounter. They should also be accessible and familiar to physicians and trainees. Care should be taken to ensure that adequate educational opportunities in obstetrics and gynecology are available for all medical trainees, regardless of gender.

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities. However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation. Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois’ mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.

Background and Hypothesis: Tetrahydrocannabinol (THC) is the most commonly used illicit substance during pregnancy. Little research, most with conflicting data, exists on its impact on the developing fetus or birth outcomes. Reporting THC positive urine drug screen (UDS) to social worker (SW) has been left to provider discretion. Similarly, SW has discretion in reporting to Department of Child Services (DCS) if the newborn tests negative for drugs at birth. We hypothesize that there are racial and socioeconomic differences in reporting patterns that result in non-white and publicly insured patients being reported to SW or DCS at higher rates than white or privately insured patients. Methods: Data were collected via Cerner and CareWeb chart abstraction of patients who delivered at IU Health hospitals between 1/1/16 to 12/31/17 and tested positive for THC, but no other drugs, during any stage of pregnancy. Data was entered into the secure and encrypted Redcap database. Demographic variables included mother’s age, race, ethnicity, insurance type, and number of previous pregnancies. Descriptive statistics were calculated for demographics by overall, SW, and DCS referral. p-values were calculated using Fisher’s Exact Test for small sample sizes and considered significant at the 0.05 level. The effects of age and number of previous pregnancies were analyzed using two-sample t-test for equal variances. Results: 152 patients met inclusion criteria for the analysis. The study population was mostly white (68.4%) and black (30.3%). Their insurance type was 74.3% public, 17.8% private, and 7.9% uninsured. The vast majority of cases were referred to SW (90.8%) and DCS (87.7%). Neither patient race nor insurance were associated with referral to SW (p=.80, p=.79) or DCS (p=.30, p=.25). Conclusion: There was no statistically significant association between demographic characteristics and referral patterns, though the study may be underpowered due to low non-referral rate. Addition of 2018-2019 data are planned.

Background: Access to family planning care and the full-spectrum of contraception, including same-day access to long acting reversible contraception (LARC) is critical to reduce unintended pregnancy and maternal/infant mortality. However, access remains variable for many women in Indiana. We sought to examine access to various contraceptive practices within the Indianapolis metropolitan area. Methods: A telephone survey of clinic managers was conducted between June-July 2020 of all identified IU Health, Eskenazi, and HealthNet primary care and OB/GYN providers in the Indianapolis metropolitan area. The 27-question survey gathered information regarding contraceptive practices (e.g. contraceptive method availability, same-day LARC insertion/removal, pregnancy intention screening, educational materials, and parental consent policies). The data was compared based on type of medical provider (OB/GYN, Family Medicine, and Pediatrics). Results: In total, 82 sites were identified, 58 surveys (70.7%) were completed. Oral contraception is the most commonly offered contraception (91.4%), followed by depot medroxyprogesterone acetate (DMPA) injection (84.5%), and the contraceptive patch (81.0%). LARC placement is available in 51.7% of all clinics, but only 34.5% offer same-day placements. Routine pregnancy intention screening is offered in 43.1% and educational materials in 74.1% of practices. OB/GYN clinics provide the most comprehensive access, 69.2% provide same-day LARC insertion (84.6% LARC removals). Family medicine practices are variable regarding contraceptive choices: over 91% offer oral contraception and DMPA injections, but only 20.8% place LARCs and 41.7% remove LARCs. Half (50%) of pediatric clinics provide oral contraception, while 50% do not provide any contraceptives. Parental consent for minors to obtain contraception provision is highly variable. Conclusion: Contraceptive practices vary among primary care and OB/GYN providers in the Indianapolis area. This variability in access leads to barriers for use, particularly for young women. Efforts to ensure comprehensive, same-day access to all forms of contraception (including LARCs), pregnancy intention screening, and contraceptive educational materials are needed.

Objective To elicit advice from women who have experienced periviable birth to optimize periviable counseling, care, and decision support. Methods We conducted a qualitative study among 21 women who experienced periviable deliveries within three years. Using semi-structured interviews, we asked participants what advice they would offer providers and women/families based on their own experiences. Interviews were independently coded by three trained coders. Results For providers: Participants said to be ‘patient’ and appreciate the novelty of each family’s experience. They suggested being ‘realistic’ and ‘factual’; favored joint OB/Neonatology counseling; and encouraged providers to attend to maternal guilt and self-blame. For women/families: They encouraged asking questions, avoiding the internet, and finding joy in whatever time they had with their child. For hospitals: They advocated for changes to facilitate more mother/baby contact. Conclusion Providers can support parents by presenting facts, showing empathy and patience, and reassuring women that they are not to blame. This study highlights patient perspectives to improve interactions with providers, optimize women/families’ experiences, and advance efforts toward developing patient-centered systems of periviable care. Practice implications Women who experience periviable birth desire counseling that is empathetic and ‘realistic’, encouragement to ask questions, and reassurance that outcomes are not their fault.

An institution's marketing materials are an important part of presenting its culture. In 2018, communication professionals in the Office of Faculty Affairs, Professional Development, and Diversity at the Indiana University School of Medicine recognized after reviewing the literature that using images illustrating diversity in marketing materials may have unintended negative consequences and could potentially reflect poorly on the institution. Representations of diversity that are discordant with the actual demographics of an institution can create distrust among faculty, students, and staff who discover an institution is not as diverse or supportive of diversity as their marketing materials suggest. If institutions adopt an aspirational approach to images and depict more diversity than actual demographics reflect, the authors of this Perspective recommend that they both develop marketing materials that present a widely diverse selection of images and demonstrate transparency in their communication strategies.To improve their promotional materials, the authors conducted an analysis of their institution's strategy for selecting images for these materials, identified institutional goals related to the strategic use of images, created training materials for staff, and drafted a public-facing statement about diversity in images. These measures are a significant step forward in cultivating the ethical use of images illustrating diversity. In the future, institutions should highlight their approaches to using images to portray diversity, as well as photograph and document a wide range of events that represent diverse topics and individuals. When these images are used for marketing purposes, it is also important to ensure that they are used in an appropriate context and not selected with the single goal of presenting diversity. Future research should focus on how underrepresented students and faculty interpret the use of diverse images in marketing, as well as their preferences for the use of their own images in marketing materials portraying diversity.

Objective This study aimed to compare attitudes of providers regarding perinatal management and outcomes for periviable newborns of caregivers at centers with higher resuscitation (HR) and lower resuscitation (LR) rates in the delivery room. Study Design All obstetric and neonatal clinical providers at six U.S. sites were invited to complete an anonymous online survey. Survey responses were compared with clinical data collected from a previous retrospective study comparing centers' rates of planned resuscitation. Responses were analyzed by multivariable logistic and linear regression to assess how HR versus LR center respondents differed in management preferences and outcome predictions. Results Paradoxically, HR versus LR respondents, when adjusting for other variables, were less likely to respond that interventions such as antenatal steroids (odds ratio: 0.61, 95% confidence interval [CI]: 0.42–0.88, p Conclusion Despite higher rates of planned resuscitation at 22 and 23 weeks, steroid usage and survival rates did not differ between HR and LR sites. In this subsequent survey, respondents from HR centers had a less favorable outlook on interventions for these newborns than those at LR centers, suggesting that instead of driving practices, attitudes may be more closely associated with experiences of clinical outcomes.

Objective Advances in prenatal genetics place additional challenges as patients must receive information about a growing array of screening and testing options. This raises concerns about how to achieve a shared decision-making process that prepares patients to make an informed decision about their choices about prenatal genetic screening and testing options, calling for a reconsideration of how healthcare providers approach the first prenatal visit. Methods We conducted interviews with 40 pregnant women to identify components of decision-making regarding prenatal genetic screens and tests at this visit. Analysis was approached using grounded theory. Results Participants brought distinct notions of risk to the visit, including skewed perceptions of baseline risk for a fetal genetic condition and the implications of screening and testing. Participants were very concerned about financial considerations associated with these options, ranking out-of-pocket costs on par with medical considerations. Participants noted diverging priorities at the first visit from those of their healthcare provider, leading to barriers to shared decision-making regarding screening and testing during this visit. Conclusion Research is needed to determine how to restructure the initiation of prenatal care in a way that best positions patients to make informed decisions about prenatal genetic screens and tests.

Introduction Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling. Methods We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus. Results Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter. Discussion Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences—two critical elements of SDM.

Addressing bias and disparities in counseling and care requires that we contend with dehumanizing attitudes, stereotypes, and beliefs that our society and profession holds towards people of color, broadly, and Black birthing people in particular. It also necessitates an accounting of the historically informed, racist ideologies that shape present-day implicit biases. These biases operate in a distinctly complex and damaging manner in the context of end-of-life care, which centers around questions related to human pain, suffering, and value. Therefore, this paper aims to trace biases and disparities that operate in periviable care, where end-of-life decisions are made at the very beginning of life. We start from a historical context to situate racist ideologies into present day stereotypes and tropes that dehumanize and disadvantage Black birthing people and Black neonates in perinatal care. Here, we review the literature, address historical incidents and consider their impact on our ability to deliver patient-centered periviable care.

IMPACT: We present new programs aimed at training, retaining and preparing a diverse cadre of scientists to lead the field in transforming population health and advancing health equity OBJECTIVES/GOALS: To mitigate biases inherent to the R01 grant funding process, trainees from backgrounds underrepresented in medicine (URM) may benefit from enhanced mentorship and a longer ‘runway’ to funding. As such, we have deployed two synergistic programs that aim to support URM retention and advancement. METHODS/STUDY POPULATION: The URM Program for Advising in Research and Development (UPwARD) pairs URM trainees with 2 mentors: 1) an institutional leader from outside their discipline to serve as an internal advocate and 2) an external eminent scholar who will facilitate the scholar’s development and prominence within their discipline. Additionally, the KL2 Program to Launch URM Success (KL2 PLUS) offers URM trainees a third year of funding to focus on scholarship, grant writing and leadership development. Four specific training components of KL2 PLUS include: 1) PLUS II Seminar Series, 2) Faculty Success Program, 3) attendance at the AAMC Minority Faculty Leadership Conference, and 4) CTSI Committee Service. RESULTS/ANTICIPATED RESULTS: Along with measures of productivity (papers, grants, K to R transition), we will utilize social network analyses and measures of collaboration, retention, and future CTSI engagement to evaluate the programs “success’‘ as both are designed to enhance trainee scholarly development and expand their professional and social networks. UPwARD does so by supporting engagement with external mentors at professional meetings and travel to present work across institutions. PLUS writing accountability groups will enhance publication rates and grant submissions, while also building connections with other URM faculty. Trainees also serve on IN CTSI committees to groom talent for future IN CTSI leadership. DISCUSSION/SIGNIFICANCE OF FINDINGS: Systemic inequities underlie the ‘leaky pipeline’ challenge we face in cultivating a diverse cadre of senior scientists and independent investigators. With intentional programming and targeted investments, IN CTSI aims to advance more equitable funding outcomes and diverse leadership.

OBJECTIVE: To examine prospective parents’ perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period. STUDY DESIGN: Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases). RESULTS: Participants most often recalled being involved in resuscitation, cerclage and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like “brain damage,” “disability,” and “handicap.” The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a “fighting chance;” others voiced concerns about “best interest,” a “healthy baby,” “pain and suffering,” and religious faith. CONCLUSION: Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.