Social Determinants of Health Play a Key Role in Outcomes
Washington, DC— Although there is little doubt that genetics and lifestyle play a central role in shaping the overall health of individuals, the circumstances in which people are born, live, work and age play an equally important role in shaping health outcomes, according to a new Committee Opinion released today by the American College of Obstetricians and Gynecologists (ACOG).
Social determinants of health are historical, cultural, political and economic forces that help explain the relationship between environmental conditions and individual health. By recognizing the impact of social determinants, ob-gyns and other women’s health care providers will have a more complete understanding of patients and be able to more effectively communicate about health-related conditions and behavior to improve health outcomes.
“Women’s health care providers see firsthand the many factors beyond biological ones that influence our patients’ health outcomes. This document reviews the various social and structural forces that contribute to reproductive health inequities; it also provides practical guidance on how to screen for these factors and what providers can do to help address such social determinants of health,” said Carolyn Sufrin, M.D., Ph.D., lead author of the Committee Opinion. “Additionally, implementing practices to address inequalities is an important piece to the puzzle of improving health outcomes and promoting health justice. These practices may assist in addressing critical issues facing our country, such as inequities in maternal morbidity and mortality.”
The Committee Opinion provides several real-world examples. For instance, instead of labeling a pregnant patient with gestational diabetes who has not checked her blood sugar as irresponsible or noncompliant, the guidance states that an approach that recognizes the effect of social determinants of health may probe deeper. It may be discovered that the patient lacks stable housing and forgets to bring her glucose monitoring system each time she is forced to stay in a temporary location. Communication with this patient about the importance of blood sugar control as the only strategy to address diabetes would be ineffective. Furthermore, attributing her lack of checking blood sugars to “cultural beliefs” would also fail to adequately address the root causes of the problem. Rather, working with social services to address her housing issues would more likely enable her to manage her diabetes.
To improve patient-centered care and decrease inequalities in reproductive health care, the new Committee Opinion offers the following specific recommendations for ob-gyns:
- Inquire about and document social and structural determents of health (e.g., access to food and safe drinking water, utility needs, safety in the home and community and employment conditions)
- Maximize referrals to social services to help improve patients’ abilities to fulfill these needs
- Provide access to interpreter services for all patient interactions when patient language is not the clinician’s language
- Acknowledge that race, institutionalized racism and other forms of discrimination serve as social determinants of health
- Recognize that stereotyping patients based on presumed cultural beliefs can negatively affect patient interactions
- Advocate for policy changes that promote safe and healthy living environments
“Small steps like using an interpreter, partnering with medical-legal organizations and engaging with community resources can have a significant, positive impact on health outcomes,” Sufrin said. “As ob-gyns, we owe it to our patients to implement these key practices and offer practical tools.”
Committee Opinion #729, “Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care” will be published in the January issue of Obstetrics & Gynecology.
Other recommendations issued in the January Obstetrics & Gynecology:
Committee Opinion #727, Cascade Testing: Testing Women for Known Hereditary Genetic Mutations Associated With Cancer
“Cascade testing” refers to the performance of genetic counseling and testing in blood relatives of individuals who have been identified with specific genetic mutations. Testing protocols and other interventions may save lives and improve health and quality of life for these family members. Obstetrician–gynecologists should know who is eligible for cascade testing and should use all available resources to ensure that cascade testing is offered and occurs in a timely manner. Despite the clear health benefits for specific populations and individuals, obstetrician–gynecologists should be aware of the potential barriers to cascade testing and should know which options can help patients overcome those barriers. Such barriers, however, may be overcome with health care provider awareness and participation in local and state initiatives to improve implementation of cascade testing. Resources (available within federal and state agencies, professional societies, and in advocacy and community groups) are critical to the successful implementation of cascade testing. This Committee Opinion focuses specifically on cascade testing and the role of the obstetrician–gynecologist in clinical and public health efforts to increase identification of women with hereditary cancer syndromes.
Committee Opinion #728, Müllerian Agenesis: Diagnosis, Management, and Treatment
Müllerian agenesis, also referred to as müllerian aplasia, Mayer-Rokitansky-Küster-Hauser syndrome, or vaginal agenesis, has an incidence of 1 per 4,500–5,000 females. Müllerian agenesis is caused by embryologic underdevelopment of the müllerian duct, with resultant agenesis or atresia of the vagina, uterus, or both. Patients with müllerian agenesis usually are identified when they are evaluated for primary amenorrhea with otherwise typical growth and pubertal development. The most important steps in the effective management of müllerian agenesis are correct diagnosis of the underlying condition, evaluation for associated congenital anomalies, and psychosocial counseling in addition to treatment or intervention to address the functional effects of genital anomalies. The psychologic effect of the diagnosis of müllerian agenesis should not be underestimated. All patients with müllerian agenesis should be offered counseling and encouraged to connect with peer support groups. Future options for having children should be addressed with patients: options include adoption and gestational surrogacy. Assisted reproductive techniques with use of a gestational carrier (surrogate) have been shown to be successful for women with müllerian agenesis. Nonsurgical vaginal elongation by dilation should be the first-line approach. When well-counseled and emotionally prepared, almost all patients (90–96%) will be able to achieve anatomic and functional success by primary vaginal dilation. In cases in which surgical intervention is required, referrals to centers with expertise in this area should be considered because few surgeons have extensive experience in construction of the neovagina and surgery by a trained surgeon offers the best opportunity for a successful result.
Practice Bulletin #188, Prelabor Rupture of Membranes
Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.
Practice Bulletin #189, Nausea and Vomiting of Pregnancy
Nausea and vomiting of pregnancy is a common condition that affects the health of a pregnant woman and her fetus. It can diminish a woman’s quality of life and also significantly contributes to health care costs and time lost from work (1, 2). Because morning sickness is common in early pregnancy, the presence of nausea and vomiting of pregnancy may be minimized by obstetricians, other obstetric care providers, and pregnant women and, thus, undertreated (1). Furthermore, some women do not seek treatment because of concerns about the safety of medications (3). Once nausea and vomiting of pregnancy progresses, it can become more difficult to control symptoms. Treatment in the early stages may prevent more serious complications, including hospitalization (4). Safe and effective treatments are available for more severe cases, and mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes. The woman’s perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy. Nausea and vomiting of pregnancy should be distinguished from nausea and vomiting related to other causes. The purpose of this document is to review the best available evidence about the diagnosis and management of nausea and vomiting of pregnancy.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org