Women's Health Care Providers Research Articles

ACOG Committee Opinion No. 777: Sexual Assault.

Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician-gynecologists and other women's health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

Clinical diagnosis of endometriosis: a call to action

Endometriosis can have a profound impact on women's lives, including associated pain, infertility, decreased quality of life, and interference with daily life, relationships, and livelihood. The first step in alleviating these adverse sequelae is to diagnose the underlying condition. For many women, the journey to endometriosis diagnosis is long and fraught with barriers and misdiagnoses. Inherent challenges include a gold standard based on an invasive surgical procedure (laparoscopy) and diverse symptomatology, contributing to the well-established delay of 4-11 years from first symptom onset to surgical diagnosis. We believe that remedying the diagnostic delay requires increased patient education and timely referral to a women's healthcare provider and a shift in physician approach to the disorder. Endometriosis should be approached as a chronic, systemic, inflammatory, and heterogeneous disease that presents with symptoms of pelvic pain and/or infertility, rather than focusing primarily on surgical findings and pelvic lesions. Using this approach, symptoms, signs, and clinical findings of endometriosis are anticipated to become the main drivers of clinical diagnosis and earlier intervention. Combining these factors into a practical algorithm is expected to simplify endometriosis diagnosis and make the process accessible to more clinicians and patients, culminating in earlier effective management. The time has come to bridge disparities and to minimize delays in endometriosis diagnosis and treatment for the benefit of women worldwide.

Contraceptive Use Among Women with Prediabetes and Diabetes in a US National Sample.

Although elevated blood glucose is associated with adverse maternal and fetal health outcomes, evidence suggests that women with diabetes may not be receiving comprehensive reproductive health care, including family planning and preconception care. Using a population-based sample, we evaluated the relationship between contraceptive use and biomarker-identified diabetes. This cross-sectional study used data from 5548 women in the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health) from 2007 to 2009. Women were aged 24 to 32 years, sexually active with men, and not pregnant. Hemoglobin A1C identified prediabetes and diabetes from blood specimens. The primary outcome was most effective contraception used in the past year: more effective (sterilization, intrauterine device, implant, combined hormonal methods, or injectable), less effective (condoms, diaphragms, spermicides, natural family planning, or withdrawal), or none. Multinomial regression models were adjusted for race and ethnicity, education, insurance, health care access, and body mass index. Of the women with diabetes, 37.6% used more effective contraception, 33.6% less effective contraception, and 28.8% none. Women with diabetes had higher odds of using no contraception, rather than more effective contraception, than women with normoglycemia (adjusted odds ratio [aOR], 1.90; 95% CI, 1.25-2.87). Women with diabetes who were undiagnosed had greater odds of using less effective contraception, rather than more effective contraception, compared with those who were diagnosed (aOR 3.39; 95% CI, 1.44-7.96). Contraceptive use did not differ between women with prediabetes and normoglycemia. Less effective contraceptive methods were commonly used by women with diabetes. Midwives and other women's health care providers can support women with diabetes to reach their pregnancy goals by providing preconception care and family planning.

Female Genital Cutting: Clinical knowledge, Attitudes, and Practices from a Provider survey in the US.

Migration from countries where female genital cutting (FGC) is practiced means women's healthcare providers need to meet this population's unique healthcare needs. We explored providers' FGC-related experience, knowledge of the cultural practice, prior training, attitudes towards medicalization, including reinfibulation, and clinical practice. An online, 53-question survey to a multidisciplinary sample of women's health providers in the US were recruited by email via professional organizations, medical departments, and the authors' professional networks. From a total of 508 usable surveys, nearly half of respondents did not receive formal FGC training, but a majority had cared for FGC-affected women in their practice. A 'know-do' gap existed with managing infibulated patients; and surgical defibulation procedures were not routinely offered. Most respondents (79%, n = 402) reported a desire for additional education. Women's healthcare providers in the US, regardless of disciplinary backgrounds, are inadequately prepared to meet the needs of FGC-affected women. To address these, FGC content needs to be embedded in educational and training curricula, and ongoing clinical mentorship made available.

ACOG Technology Assessment in Obstetrics and Gynecology No. 14 Summary: Modern Genetics in Obstetrics and Gynecology.

Knowledge of human genetics has increased dramatically, and obstetrician-gynecologists and other health care providers are increasingly called on to incorporate genetics and genetic testing into medical practice. Advances in our understanding of the molecular basis of inherited disorders have led to the development of DNA-based tests that can be used for prenatal and postnatal diagnosis, carrier testing, and aneuploidy screening. These techniques have allowed for diagnosis of a wide variety of genetic diseases ranging from aneuploidies to single-gene disorders. Once a specific pathogenic variant in a gene has been identified, direct testing for that specific variant is possible; this is the most accurate molecular diagnostic method. Counseling patients about genetic testing and results can be challenging and obstetrician-gynecologists and women's health care providers are encouraged to make use of and refer to genetics professionals when necessary. The correct interpretation of molecular genetic diagnostic testing is highly dependent on an accurate clinical diagnosis, test sensitivity, ethnic variability in variants and disease prevalence, genetic heterogeneity, reduced penetrance, and phenotypical variability. As genetics becomes a more integral part of routine medical practice, it is essential that obstetrician-gynecologists and other health care providers be aware of advances in the understanding of genetic disease and the fundamental principles of genetic screening and molecular testing. This technology assessment has been revised to reflect advances in clinical genetics related to obstetrics and gynecology, including epigenetics, sequencing, and testing.

ACOG Technology Assessment in Obstetrics and Gynecology No. 14: Modern Genetics in Obstetrics and Gynecology.

Knowledge of human genetics has increased dramatically, and obstetrician-gynecologists and other health care providers are increasingly called on to incorporate genetics and genetic testing into medical practice. Advances in our understanding of the molecular basis of inherited disorders have led to the development of DNA-based tests that can be used for prenatal and postnatal diagnosis, carrier testing, and aneuploidy screening. These techniques have allowed for diagnosis of a wide variety of genetic diseases ranging from aneuploidies to single-gene disorders. Once a specific pathogenic variant in a gene has been identified, direct testing for that specific variant is possible; this is the most accurate molecular diagnostic method. Counseling patients about genetic testing and results can be challenging and obstetrician-gynecologists and women's health care providers are encouraged to make use of and refer to genetics professionals when necessary. The correct interpretation of molecular genetic diagnostic testing is highly dependent on an accurate clinical diagnosis, test sensitivity, ethnic variability in variants and disease prevalence, genetic heterogeneity, reduced penetrance, and phenotypical variability. As genetics becomes a more integral part of routine medical practice, it is essential that obstetrician-gynecologists and other health care providers be aware of advances in the understanding of genetic disease and the fundamental principles of genetic screening and molecular testing. This technology assessment has been revised to reflect advances in clinical genetics related to obstetrics and gynecology, including epigenetics, sequencing, and testing.

Naval Medicine's Involvement in Global Health: The Participation of Women's Healthcare Providers in Continuing Promise 2017.

This is a retrospective review of information collected during operation Continuing Promise 2017 from the Wayuu population in Colombia, South America. Team objective was to present an overview of women's health care needs in an isolated underserved population of Colombia by a humanitarian mission of health care providers from the U.S. Navy. We analyzed demographics, contraceptive selection, presenting complaint, diagnosis, and disposition of those female patients presenting for care. The acute care clinics of this mission saw patients for 10 full clinic days in each of the countries of Guatemala, Honduras, and Colombia. In the Wayuu clinic of Colombia, 356 patients were seen in the acute care women's clinic. These women averaged 36 years of age with an age range of 9-77 years of age and a gravidity of 3 ± 3.3 and a range of 0-18. Of the women less than the age of 50, not permanently sterilized, 186/220 (84.5%) were not using any form of contraception. The most common chief complaints were vaginal discharge and pelvic pain and the most common final diagnosis was bacterial vaginosis. The two most common secondary diagnoses of the pregnant women were urinary tract infection and anemia. Other significant diagnoses included uterine cancer, preterm labor, and fetal posterior urethral valve syndrome. A majority of Wayuu women presenting to an acute clinic setting in Colombia, South America were in their mid-thirties having had three pregnancies and the majority were not using any form of contraception. The most common diagnoses were straightforward diagnoses such as vaginal infections, urinary tract infections, and abnormal uterine bleeding. Our findings suggest a need for access to routine gynecologic care, general hygiene education, and increased availability of birth control among the Wayuu population.

Low HIV testing rates among US women who report anal sex and other HIV sexual risk behaviors, 2011–2015

In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with preexposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex. We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant US women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including ≥2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis. Overall, 7.9 million of 42.4 million sexually active, nonpregnant US women (18.7%) reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse, and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs 15.9%; P < .001). HIV testing in the past year was higher for women with other risk behaviors compared with anal sex, ranging from 35.8% to 47.2%. Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women's health and well-being but that can be offered only based on HIV testing results. Women's health care providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

Reproductive Coercion and Women's Health.

Given the epidemic proportion of those affected, the impact of gender-based violence looms large in the study of women's health. One increasingly recognized facet of such violence is reproductive coercion, defined as behavior that interferes with autonomous decision-making in areas of reproductive health. Although the body of literature illustrating the pathology of reproductive coercion is limited, growing data on harms to reproductive choice, health outcomes, and future pregnancies are a sobering appeal for greater publicity and information. This review explores existing knowledge regarding reproductive coercion, highlights areas of future study, and underscores how women's health care providers can better serve this population.

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.

Mobile Applications for Women's Health and Midwifery Care: A Pocket Reference for the 21st Century.

Midwives and other women's health care providers are charged with providing high-quality care to women based on the most current available evidence. Quick, reliable, and accurate access to evidence-based information is essential. Numerous smartphone and mobile device applications (apps) are available to assist clinicians in providing care for women. This article discusses clinical reference apps, including those for evidence-based care guidelines, women's health care, pharmacologic reference, laboratory and diagnostic guides, as well as apps for information storage and management, electronic health records, and client education. Midwives and other clinicians are encouraged to thoughtfully integrate mobile apps into their clinical practices to improve client outcomes and clinician and client satisfaction. Although the thousands of health care apps that are available may seem daunting, this article highlights key apps that may help clinicians improve their care of women. By adding one app at a time, midwives and other women's health care providers can successfully integrate mobile apps into clinical practice.

Headaches Through a Woman's Life.

Headaches affect women across their life span, with menses, pregnancy, and menopause being times that pose unique challenges in diagnosis and treatment. The correct diagnosis and treatment of headache can prevent unnecessary interventions, the worsening of chronic headache disorders, and complications of secondary headaches. The objective of this article is to educate women's health care providers about the diagnosis, differential diagnosis, and treatment of headache during menses, pregnancy, the puerperium, and menopause to improve the quality of care for women with chronic and acute headache. Current articles were reviewed addressing headache during menses, pregnancy, the postpartum period, and menopause. Articles with the highest level of evidence were compiled in this article to provide a summary of recommendations. Multiple diagnostic and therapeutic options for chronic and acute headache are available for women regardless of their stage in life or comorbidities. The effects of headaches span a woman's life span, with puberty and menopause being times of increased frequency. Pregnancy is an at-risk time for women to develop secondary headache disorders. All women's health care providers should know how to screen for, diagnose, and treat headache at all stages of a woman's life. Effective treatment options are available for acute and chronic headache both during and outside pregnancy.

Management of Hepatitis B Infection in Pregnancy.

In many parts of the world, perinatal transmission is the most common route of infection for hepatitis B virus. In the United States, sexual contact is the most common source of hepatitis B virus infection. As a result, it is essential that women's health care providers become aware of the recommended strategies used to identify women infected with hepatitis B and to subsequently reduce perinatal transmission, particularly now that immigration and globalization is more common and reproductive science makes pregnancy more possible for women with liver disease. This article reviews evidence-based strategies for management of hepatitis B infection during pregnancy.

Women's Health Outpatient Care Teams: Focus on Advanced Practice Providers.

Team-based care in the outpatient women's health setting has the potential to help alleviate the demand for women's health care providers and to deliver improved quality of care to the growing population of US women. Although teamwork is necessary in the current health care system, most of the current obstetrics and gynecology and advanced practice provider (APP) workforce were not trained for collaborative practice. Core competencies for building an effective outpatient women's health care team are explained and current evidence regarding the specific role of APPs in women's health care is reviewed.

Patient-centered Contraceptive Counseling and Prescribing.

Learning how to best meet a patient's contraceptive needs improves her chances of using her birth control consistently and is crucial to providing patient-centered care. The best contraceptive method for an individual patient is the one that is safe and that she is most comfortable using. Women's health care providers must be equipped to talk to each patient about her needs and options. The shared decision-making model in contraceptive counseling allows the patient and provider to work together in order to meet a patient's needs while remaining medically safe.

Intrahepatic Cholestasis of Pregnancy: A Review of Diagnosis and Management.

Intrahepatic cholestasis of pregnancy (ICP) complicates approximately 0.2% to 2% of pregnancies and can lead to increased fetal risks in pregnancy. This review aims to increase the knowledge of women's health care providers regarding the diagnosis, management, and fetal risks associated with ICP. The diagnosis of ICP is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels. Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out. Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth. There is evidence that as bile acid levels increase, so does the risk of adverse neonatal outcomes. Ursodeoxycholic acid treatment has been shown to improve maternal pruritus symptoms, as well as biochemical tests, but no treatment has been shown to definitively improve fetal outcomes. Providers should be aware of the signs and symptoms of ICP and provide accurate diagnosis and management of affected women. Women with a diagnosis of ICP should be treated with ursodeoxycholic acid to improve maternal symptoms. Given the increased risk of stillbirth in the setting of ICP, delivery may be considered at 37 weeks' gestation.

Antibiotics Dispensed to Privately Insured Pregnant Women with Urinary Tract Infections — United States, 2014

Urinary tract infections (UTIs) occur in about 8% of pregnant women, and untreated UTIs can have serious consequences, including pyelonephritis, preterm labor, low birth weight, and sepsis (1). Pregnant women are typically screened for UTIs during early pregnancy, and those with bacteriuria are treated with antibiotics (1,2). Antibiotic stewardship is critical to improving patient safety and to combating antibiotic resistance. Because of the potential risk for birth defects, including anencephaly, heart defects, and orofacial clefts, associated with use of sulfonamides and nitrofurantoin during pregnancy (3), a 2011 committee opinion from the American College of Obstetricians and Gynecologists (ACOG) recommended that sulfonamides and nitrofurantoin may be prescribed in the first trimester of pregnancy only when other antimicrobial therapies are deemed clinically inappropriate (4). To assess the effects of these recommendations, CDC analyzed the Truven Health MarketScan Commercial Database* to examine antibiotic prescriptions filled by pregnant women with UTIs. Among 482,917 pregnancies in 2014, 7.2% of women had an outpatient UTI diagnosis during the 90 days before the date of last menstrual period (LMP) or during pregnancy. Among pregnant women with UTIs, the most frequently prescribed antibiotics during the first trimester were nitrofurantoin, ciprofloxacin, cephalexin, and trimethoprim-sulfamethoxazole. Given the potential risks associated with use of some of these antibiotics in early pregnancy and the potential for unrecognized pregnancy, women's health care providers should be familiar with the ACOG recommendations and consider the possibility of early pregnancy when treating women of reproductive age.

Optimizing Delivery of HIV Preexposure Prophylaxis for Women in the United States.

Preexposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, it is underutilized among women who are at risk for acquisition of HIV. Women comprise one in five HIV diagnoses in the United States, and significant racial disparities in new HIV diagnoses persist. The rate of new HIV diagnoses among black and African American women in 2015 was 16 times greater than that of white women. These disparities highlight the importance of HIV prevention strategies for women, including the use of PrEP. PrEP is the first highly effective HIV prevention method available to women that is entirely within their control. However, because so few women who may benefit from PrEP are aware of it, few women's healthcare providers offer PrEP to their patients, PrEP has not yet achieved its potential to reduce HIV infections in women. This article describes individual and systemic barriers for women related to the uptake of PrEP services; explains how providers can identify women at risk for HIV; reviews how to provide PrEP to women; and outlines client-centered models for HIV prevention services. Better access to culturally acceptable and affordable medical and social services may offer support to women for consistent and ongoing use of PrEP. This discussion may be used to inform HIV prevention activities for women and guide interventions to decrease racial/ethnic disparities in rates of HIV infection among US women.

Attendance at Mental Health Appointments by Women Who Were Referred During Pregnancy or the Postpartum Period

ObjectiveTo describe characteristics of women referred to mental health care during pregnancy or the year after giving birth and to identify characteristics associated with attendance at mental health intake visits. DesignRetrospective record review of referral documentation. SettingWomen's health practices and perinatal mental health clinics in urban areas. ParticipantsThe sample included 647 women during pregnancy or the year after giving birth who were referred for mental health treatment. MethodsWe reviewed the referral data sent from women's health care providers to perinatal mental health clinics to determine if mental health visits occurred. ResultsFifty percent of the 647 women who accepted perinatal mental health referrals had intake appointments. Women were more likely to participate in an intake appointment if in-home services were offered (p < .01). Those with lower income were also more likely to participate (p < 0.05). Those with histories of perinatal loss and those who self-referred tended to be more likely to participate, although these relationships were statistically nonsignificant. ConclusionEven among women who accepted referrals to mental health services, only half attended intake appointments. For this group of pregnant women and those in the first year after birth, in-home mental health visits were most likely to result in care engagement, which has important implications for service delivery.

Survivors of Child Maltreatment and Postpartum Depression: An Integrative Review

An integrative review was performed to explore the relationship between a maternal history of child maltreatment and subsequent postpartum depression (PPD) symptoms. Six electronic databases were used to explore the literature, including PubMed, CINAHL, MEDLINE, PsycINFO, Embase, and Scopus. Studies were included that used victims of child maltreatment as one of the independent variables and PPD symptoms as one of the dependent variables. Studies were excluded if they focused only on women with adult intimate partner violence or women with PPD who were perpetrators of child abuse rather than survivors. The studies were required to be original research, and there was no limit to years or language. The search yielded 589 studies, 16 of which were included in the final sample. These studies were assessed for quality, and a data display matrix was developed to extract the sample, design, methods, operational definitions for independent and dependent variables of interest, major findings with effect sizes, and limitations. Using the data display matrix, the studies' methods and findings were synthesized for divergent and convergent patterns. Studies were varied in their designs, samples, and operational definitions of child maltreatment and PPD, and were low to moderate in quality. Results were inconsistent, but a majority suggest a positive association between a maternal history of child maltreatment and subsequent symptoms of PPD. Child maltreatment and PPD are complex issues that require careful screening by women's health care providers and clearly defined operational definitions in future research. Implications for clinical practice and research are discussed.