Search

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.

Heart disease is the leading cause of mortality in adult women. Beyond the traditional risk factors of obesity, diabetes, and hypercholesterolemia, women with the pregnancy complications of preeclampsia, gestational diabetes, prematurity, and low birth weight for gestational age (fetal growth restriction) are at higher risk for later development of cardiovascular disease. Education of women and providers about the association of pregnancy complications and cardiovascular disease should begin in the postpartum period. Postpartum cardiovascular risk screening and lifestyle modifications should be considered standard of care and are essential to improving cardiac health as a preventive strategy.

This study evaluated the influence of early gestational weight gain (GWG) on neonatal outcomes among women with class III obesity.Retrospective cohort of women with class III obesity who gained more than the Institute of Medicine (IOM) guidelines (20lbs). Women gaining ≥75% of total gestational weight prior to 28 weeks (EWG) were compared to women gaining75% of their total weight prior to 28 weeks (SWG). The primary outcome was a neonatal composite morbidity and mortality. Secondary outcomes included individual components of composite and LGA.Of 144 women identified, 42 (29.2%) had EWG and 102 (70.8%) had SWG. Though 11% of the total population had composite neonatal morbidity, this did not differ between groups (Though adverse neonatal outcomes were common in this population, timing of gestational weight gain was not correlated. Increased rates of LGA and higher median birth weight in the SWG group suggests excessive GWG continuing in the third trimester of pregnancy may be of import for neonatal size.

Objective To assess the impact of gestational weight gain >20 pounds (more than Institute of Medicine [IOM] recommendations) on postpartum infectious morbidity in women with class III obesity. Methods This is a retrospective cohort of term, nonanomalous singleton pregnancies with body mass index ≥40 at a single institution from 2013 to 2017. Pregnancies with multiple gestation, late entry to care, and missing weight gain data are excluded. Primary outcome is a composite of postpartum infection (endometritis, urinary tract, respiratory, and wound infection). Secondary outcomes include components of composite, wound complication, readmission, and blood transfusion. Bivariate statistics compared demographics, pregnancy complications, and delivery characteristics of women exceeding IOM guidelines (GT20) with those who did not (LT20). Regression models were used to estimate adjusted odds of outcomes. Results Of 374 women, 144 (39%) gained GT20 and 230 (62%) gained LT20. Primiparous, nonsmokers more likely gained GT20 (p Conclusion Women with class III obesity who gain more than the IOM recommends are at increased risk for postpartum infectious morbidity.

OBJECTIVE: This study explores OB/GYN providers’ knowledge about published health and healthcare disparities in women’s reproductive health. METHOD: We collected demographic and health disparities knowledge information from OB/GYN providers who were members of ACOG District IV using an online survey (n=483). We examined differences across groups using statistical tests and regression analyses in a structural equation modeling approach. RESULTS: Receiving disparities education was positively associated with higher self-reported disparities knowledge and disparities quiz performance (p

Objective The aim of this study is to describe the impact of maternal weight gain on infant birth weight among women with Class III obesity. Study Design Retrospective cohort of women with body mass index (BMI) ≥40 kg/m2 at initial prenatal visit, delivered from July 2013 to December 2017. Women presenting 14/0 weeks of gestational age (GA), delivering preterm, or had multiples or major fetal anomalies excluded. Maternal demographics and complications, intrapartum events, and neonatal outcomes abstracted. Primary outcomes were delivery of large for gestational age or small for gestational age (SGA) infant. Bivariate statistics used to compare women gaining less than Institute of Medicine (IOM) recommendations (LTR) and women gaining within recommendations (11–20 pounds/5–9.1 kg) (at recommended [AR]). Regression models used to estimate odds of primary outcomes. Results Of included women (n = 230), 129 (56%) gained LTR and 101 (44%) gained AR. In sum, 71 (31%) infants were LGA and 2 (0.8%) were SGA. Women gaining LTR had higher median entry BMI (46 vs. 43, p 0.99). After controlling for confounders, the AOR of an LGA baby for LTR women was 0.79 (95% CI: 0.4–1.4). Conclusion In this cohort of morbidly obese women, gaining less than IOM recommendations did not impact risk of having an LGA infant, without increasing risk of an SGA infant.

Objective We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity. Study Design This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m2 at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11–20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome. Results Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS. Conclusion A relationship between GWG and PPD in class III obese women was not found in this cohort.

Objective To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012-2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician-gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns. Methods We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial operations, R for statistical analysis, zonal statistics for circular distances, and friction surface for travel time analysis. Results The number of ob-gyns in public hospitals increased from 14 to 49 nationally. Before the program, 18 residents graduated over a 7-year period (two residents per year); 33 graduated by year 5 (six residents per year). Rwandan faculty increased by 45%. In 2011, most providers were in the capital city. Between 2011 and 2016, the proportion of pregnant women living 10 km from an ob-gyn-staffed public hospital increased from 13.0% to 31.6%; within 25 km increased from 28.4% to 82.9%. Travel time analysis from 2011 to 2016 showed 49.1% of Rwandan women within 1 hour of a hospital and 85.6% within 2 hours. In 2016, this coverage increased to 87.5% and 98.3%, respectively. Conclusion In 5 years, the Human Resources for Health Rwanda program improved the number of residency graduates in obstetrics and gynecology and nationwide access to these providers. The program reduced rural-urban disparities in access to ob-gyns.

Purpose The American College of Obstetricians and Gynecologists (ACOG) and the American College of Medical Genetics and Genomics (ACMG) suggest carrier screening panel design criteria intended to ensure meaningful results. This study used a data-driven approach to interpret the criteria to identify guidelines-consistent panels. Methods Carrier frequencies in >460,000 individuals across 11 races/ethnicities were used to assess carrier frequency. Other criteria were interpreted on the basis of published data. A total of 176 conditions were then evaluated. Stringency thresholds were set as suggested by ACOG and/or ACMG or by evaluating conditions already recommended by ACOG and ACMG. Results Forty and 75 conditions had carrier frequencies of ≥1 in 100 and ≥1 in 200, respectively; 175 had a well-defined phenotype; and 165 met at least 1 severity criterion and had an onset early in life. Thirty-seven conditions met conservative thresholds, including a carrier frequency of ≥1 in 100, and 74 conditions met permissive thresholds, including a carrier frequency of ≥1 in 200; thus, both were identified as guidelines-consistent panels. Conclusion Clear panel design criteria are needed to ensure quality and consistency among carrier screening panels. Evidence-based analyses of criteria resulted in the identification of guidelines-consistent panels of 37 and 74 conditions.

Pregnant and postpartum women with opiate use disorder present a challenge in perinatal care. It is important for health care teams to provide sensitive and compassionate evidence-based care for these women, who often are stigmatized during the prenatal, delivery, and postpartum periods. Women with opiate use disorder are at risk for inadequate prenatal and postpartum care and for complications. Infants are at risk for neonatal abstinence syndrome and are expected to require neonatal intensive care. Pain management during labor and for cesarean delivery requires consultation and collaboration with providers who have expertise in management of addiction. Postpartum follow-up is essential.

Post-traumatic stress disorder (PTSD) accompanies miscarriage, intrauterine fetal demise, and preterm birth. Levels of PTSD may be higher for women who experience acute, life-threatening events during labor and delivery. Severe maternal morbidities or near misses for maternal death disproportionately impact African American, Hispanic, American Indian, and women in rural communities. Expanding research demonstrates association between severe maternal morbidity or near-miss events and PTSD. Multiple preceding conditions and intrapartum and postpartum events place women at higher risk for PTSD. Postpartum evaluation provides an opportunity for PTSD screening. Untreated perinatal PTSD impacts long-term maternal and child health and contributes to health disparities.

Black enslaved women endured sexual exploitation and reproductive manipulation to produce a labor workforce on the southern plantations during the Antebellum Period. Health care inequity has continued from slavery and into the 21th century primarily due of racial segregation, poverty, access, poor quality of care, eugenics and the assault of forced sterilizations. Racial disparity in maternal and infant mortality is an outcome rooted in racial injustice, social and economic determinants as well as the stresses during pregnancy throughout the generations of Black births. Affordable, available, quality and equitable care and narrowing the economic gap for Black women and families is the most significant barrier in combating racial disparity in perinatal health outcomes and health inequity.

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, Black women are three to four times more likely to die from pregnancy-related causes and have more than a twofold greater risk of severe maternal morbidity than White women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.

To quantitate the contribution of various demographic factors to the U.S. maternal mortality ratio.This was a retrospective observational study. We analyzed data from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) from 2005 to 2014 that contains mortality and population counts for all U.S. counties. Bivariate correlations between the maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P.05) in the univariate analysis to deal with multicollinearity among the existing variables.The United States has experienced an increase in maternal mortality ratio since 2005 with rates increasing from 15 per 100,00 live births in 2005 to 21-22 per 100,000 live births in 2013 and 2014. (P.001) This increase in mortality was most pronounced in non-Hispanic black women, with ratios rising from 39 to 49 per 100,000 live births. A significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population was demonstrated. Cesarean deliveries, unintended births, unmarried status, percentage of deliveries to non-Hispanic black women, and four or fewer prenatal visits were significantly (P.05) associated with the increased maternal mortality ratio.The current U.S. maternal mortality ratio is heavily influenced by a higher rate of death among non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability and access or utilization by underserved populations are important issues faced by states seeking to decrease maternal mortality.

Introduction: Protests and the call to action in the aftermath of the deaths of Black citizens at the hands of police officers have reawakened the consciousness of American society on policing and the need for reforms. Racism in policing has a long history dating back to slave patrols following the Civil War. Criminal anti Black police behavior violates the police oath to “protect and defend” all individuals. Materials and methods: This forum was convened to gain a better appreciation for the challenges of community policing and patterns of violence against Black citizens. Members of the forum including police leaders and legal authorities were presented with a series of questions related to various aspects of policing including training of police officers, how their units would have responded to the recent episodes of police violence against Black people, and what are the legal arguments for victims and police officers accused of excessive use of force? The panel deliberated and discussed remedies for reimagining and reforming policing to prevent excessive use of force that leads to repetitive patterns of loss of life in communities of color. Conclusion: The forum panel concluded that reimagining policing especially at the community level will require multiple strategies that must include recruitment of a diverse group of police officers who can better represent their communities and society. As important, is better screening, testing and vetting of applicants to the police academy to route out those individuals who may demonstrate the potential for adverse behaviors antithetical to the police oath to protect and defend all people regardless of race and/or ethnicity.

What We Can Do about Maternal Mortality Every U.S. hospital providing obstetrical care can take four key actions to help curb the tragic trend of increasing maternal mortality. And an additional year of training could be offered for family medicine physicians who want to practice obstetrics in rural areas.

Obesity in the USA continues to be a prominent medical and public health concern. Due to increasing rates of maternal obesity, the current Institute of Medicine (IOM) guidelines recommend 11-20 pounds of total weight gain during pregnancy in women with a BMI ≥30 kg/mA retrospective cohort of women delivering at a tertiary care institution between July 2013 and December 2017 with a first-trimester baseline BMI ≥40 kg/mOf 374 women included, 144 (39.5%) gained more than guidelines. Women who gained above IOM recommendations were less likely to be multiparous and use tobacco. Additional demographic, obstetric and delivery characteristics, including BMI at the entry to care, did not differ. The neonatal composite occurred in 30 (8.0%) of all neonates; corresponding to 11.1% of women who gained more than IOM recommendations and 6.1% of those who gained at or below recommendations (In women with class III obesity, excess gestational weight gain was associated with increased odds of NICU stay7 days, with trends toward increased NICU admission risk, further emphasizing the importance of appropriate weight gain counseling in this population at risk.

In 2001, the Institute of Medicine (now known as the National Academy of Science) published a seminal monograph, Exploring the Biological Contributions to Human Health: Does Sex Matter ?,1 describing the importance of both sex and gender on human biology and physiology. Gender-specific medicine, which recognizes gender differences and similarities in cardiovascular disease recognition, prevention, and management, has exerted a powerful salutatory effect on women. Significant improvement in mortality and morbidity rates in women have been seen over the past 2 decades, in part as a result of initiatives such as the American Heart Association’s (AHA’s) Go Red For Women movement. Go Red For Women initially focused on raising awareness of heart disease as the No. 1 killer of women. This campaign expanded gender-focused research and the development of gender-based guidelines that led to a significant reduction in the rates of death among women. Despite these advances, gender-based inequalities continue, with women being less likely to receive guideline-recommended diagnostic testing and therapies. Furthermore, despite the above-stated declines in mortality, more recently there has been an increase in mortality rates in women.2 Despite significant efforts to raise awareness about heart disease, the most recent data show that only 45% of women identify heart disease as their leading cause of death and that fewer than half of primary care physicians consider cardiovascular disease to be a top concern in women, after breast health and weight.3 A majority of women consider their obstetrician/gynecologist (OB/GYN) to be their primary care physician, particularly women during their childbearing years, and we know that many of the life-span milestones for women impart unique effects on cardiovascular health, particularly pregnancy and menopause. Shaw et al4 use the term healthcare team for women to describe the importance of collaboration among clinicians who care for women …

Objective Excessive gestational weight gain (GWG) increases risk of postpartum weight retention in normal and overweight women but little is known about weight retention in morbidly obese women. We evaluated the impact of GWG on postpartum weight retention in women with class-III obesity. Study Design This is a retrospective cohort of pregnancies at a single institution from July 2013 to December 2017 complicated by body mass index (BMI) ≥ 40 at entry to care. Women were classified as GWG within (WITHIN), less than (LESS), or greater than (MORE) Institute of Medicine's (IOM) recommendations. Women were excluded for multiples, late prenatal care, preterm birth, fetal anomalies, intrauterine demise, weight loss, and missing data. Primary outcome was achievement of intake weight at the postpartum visit. Logistic regression was used to adjust for confounding factors. Results Among 338 women, 93 (28%) gained WITHIN, 129 (38%) LESS, and 144 (43%) MORE. Women in the MORE group were less likely to achieve their intake weight at the postpartum visit (adjusted odds ratio [AOR] = 0.09 95% confidence interval [CI]: 0.05–0.17, p Conclusion Excessive GWG in women with class-III obesity is associated with postpartum weight retention.

To investigate factors associated with differential state maternal mortality ratios and to quantitate the contribution of various demographic factors to such variation.In a population-level analysis study, we analyzed data from the Centers for Disease Control and Prevention National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) that contains mortality and population counts for all U.S. counties. Bivariate correlations between maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P.05) in the univariate analysis to deal with multicollinearity among the existing variables.The United States has experienced a continued increase in maternal mortality ratio since 2007 with rates of 21-22 per 100,000 live births in 2013 and 2014. This increase in mortality was most dramatic in non-Hispanic black women. There was a significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population. Cesarean deliveries, unintended births, unmarried status, percentage of non-Hispanic black deliveries, and four or less prenatal visits were significantly (P.05) associated with increased maternal mortality ratio.Interstate differences in maternal mortality ratios largely reflect a different proportion of non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability, access, or utilization by underserved populations are an important issue faced by states in seeking to decrease maternal mortality.

Objective To evaluate the Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage (PPH). Methods A prospective observational intervention study was conducted between January 1, 2013, and May 31, 2015, at Great Lakes Hospital and Moi Teaching and Referral Hospital in Kenya. Eligible participants were diagnosed with PPH (blood loss > 500 mL after vaginal or > 1000 mL after cesarean delivery, and/or hemodynamic changes suggestive of excessive blood loss) unresponsive to standard intervention and were treated using the Bakri balloon. Case report forms were completed for all participants. The primary endpoint was the frequency of surgery after use of the Bakri balloon. Results Among 58 patients, postpartum bleeding was controlled without further surgical intervention in 55 (95%). Among the 55 women with uterine atony, the Bakri balloon successful controlled PPH in 52 (95%). Two of the three hysterectomies performed were for continued bleeding after placement of the Bakri tamponade balloon. Four maternal deaths occurred. Conclusion The Bakri tamponade balloon proved an effective adjunct in the management of refractory PPH.

Vulvovaginitis is a frequent reason for women to see a health care provider and has been linked to adverse reproductive and psychosocial consequences. Accurate diagnosis is a cornerstone of effective treatment, yet misdiagnosis of this condition approaches 50%, raising the risk of recurrence. The past 3 decades have seen few improvements over the traditional means of diagnosing the 3 main causes of vaginitis: bacterial vaginosis, Candida infections, and trichomoniasis. Newer molecular tests, which are both more sensitive and specific, have introduced the potential to transform the diagnosis of vaginitis—ensuring more accurate diagnoses and timely interventions, while reducing health care costs and enhancing patients' quality of life. Clinical approaches and professional guidelines should be updated to reflect advances in molecular testing and improve the diagnosis and management of acute and recurrent vulvovaginitis.

Objective To identify the current challenges in obstetrics and gynecology residency education and propose solutions to overcome these obstacles. Methods The American College of Obstetricians and Gynecologists (ACOG) hosted the first National Summit on Women's Health on May 31 and June 1, 2017, with a follow-up meeting December 20-21, 2017, at ACOG headquarters in Washington, DC. Invitees from 20 related societies briefly presented their organizations' perspectives and discussed focused questions about specific challenges, proposed solutions, and anticipated obstacles. Finally, participants summarized their top two recommendations to improve current residency training. Results Summit participants identified four primary areas of focus: 1) align curriculum with relevant topics to practice, 2) ensure faculty have the necessary resources and time to teach effectively, 3) consider using the final months of medical school to get a jump start on residency fund of knowledge and skills, and 4) use better assessments during the course of residency. Conclusion Representatives of the Council on Resident Education in Obstetrics and Gynecology, the American Board of Obstetrics and Gynecology, and the Accreditation Council for Graduate Medical Education must work together to address these priorities and reach consensus on the curricular content of core training in obstetrics and gynecology.

In 2001, the Institute of Medicine (now known as the National Academy of Science) published a seminal monograph, Exploring the Biological Contributions to Human Health: Does Sex Matter ?,1 describing the importance of both sex and gender on human biology and physiology. Gender-specific medicine, which recognizes gender differences and similarities in cardiovascular disease recognition, prevention, and management, has exerted a powerful salutatory effect on women. Significant improvement in mortality and morbidity rates in women have been seen over the past 2 decades, in part as a result of initiatives such as the American Heart Association’s (AHA’s) Go Red For Women movement. Go Red For Women initially focused on raising awareness of heart disease as the No. 1 killer of women. This campaign expanded gender-focused research and the development of gender-based guidelines that led to a significant reduction in the rates of death among women. Despite these advances, gender-based inequalities continue, with women being less likely to receive guideline-recommended diagnostic testing and therapies. Furthermore, despite the above-stated declines in mortality, more recently there has been an increase in mortality rates in women.2 Despite significant efforts to raise awareness about heart disease, the most recent data show that only 45% of women identify heart disease as their leading cause of death and that fewer than half of primary care physicians consider cardiovascular disease to be a top concern in women, after breast health and weight.3 A majority of women consider their obstetrician/gynecologist (OB/GYN) to be their primary care physician, particularly women during their childbearing years, and we know that many of the life-span milestones for women impart unique effects on cardiovascular health, particularly pregnancy and menopause. Shaw et al4 use the term healthcare team for women to describe the importance of collaboration among clinicians who care for women …

The Patient Protection and Affordable Care Act of 2010 includes strong well-woman health care provisions as a means of optimizing preventive health care across a woman's lifetime. In 2013, The American College of Obstetricians and Gynecologists convened a task force of leading professional associations representing women's health clinicians to develop age-specific well-woman health care guidelines with a goal of improving health outcomes. The charge of the Well-Woman Task Force was to provide guidance to women and clinicians with age-appropriate recommendations for a well-woman visit. Evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement formed the foundation for the final recommendations. The resulting list of recommendations, "Components of the Well-Woman Visit," identifies needs across a woman's lifespan and is intended for use by any provider who cares for adolescents or women.

Background In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood. Objective We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery. Methods We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model. Results We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003–2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010–2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06). Conclusions Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training.

Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention. Methods: Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.

The discipline of obstetrics and gynecology has been a leader for quality and safety in women's health for decades. Obstetrics is the leading cause for admissions, triage, and hospital discharge with over 4 million hospitalizations for births annually. Appropriately, safety initiatives and use of quality measures particularly relevant to obstetrics and gynecology are essential to patient satisfaction, safe and efficient evidence-based care.

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.

The disparity in maternal mortality for African American women remains one of the greatest public health inequities in the United States (US). To better understand approaches towards amelioration of these differences, we examine settings with similar disparities in maternal mortality and ‘near misses’ based on race/ethnicity. This global analysis of disparities in maternal mortality/morbidity will focus on middle and high-income countries (based on World Bank definitions) with multiethnic populations. Many countries with similar histories of slavery and forced migration demonstrate disparities in health outcomes based on social determinants such as race/ethnicity. We highlight comparisons in the Americas between the US and Brazil—two countries with the largest populations of African descent brought to the Americas primarily through the transatlantic slave trade. We also address the need to capture race/ethnicity/country of origin in a meaningful way in order to facilitate transnational comparisons and potential translatable solutions. Race, class, and gender-based inequities are pervasive, global themes. This approach is human rights--based and consistent with the UN Millennium Development Goals (MDG) and post 2015—sustainable development goals’ aim to place women’s health the context of health equity/women’s rights. Solutions to these issues of inequity in maternal mortality are nation-specific and global.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first “Putting the ‘M’ back in Maternal-Fetal Medicine” session was held at the Society for Maternal-Fetal Medicine’s (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the “M in MFM” meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a “report card” looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.