Neglected aspects of Obstetrics and Gynecology: Mental health, patient experience, implementation, and cost-effectiveness

Abstract

One of the most concerning papers in this issue of BJOG is a study from the Netherlands noting an increased percentage of maternal deaths (through one year postpartum) are due to suicide (Lommerse et al, BJOG 2024). The percentage of maternal deaths in the Netherlands due to suicide increased from 18% between 1996 to 2005, to 28% between 20006 to 2020. Indeed, suicide is now the leading cause of maternal death in the Netherlands. Sadly, this problem is not unique to Holland. Suicide is also the most common cause of maternal death in the U.K., France, and the U.S. (Diguisto et al, BMJ. 2022;379:e070621; Knight et al., Oxford: National

Perinatal Epidemiology Unit, University of Oxford; 2021; Khalifeh et al, Lancet Psychiatry. 2016; 3:233–42; Trost et al, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2024). Further, mortality is merely the tip of the iceberg, accounting for only a small fraction of cases of severe maternal mental health and substance use disorders. Accordingly, improved screening for and treatment of mental health conditions and substance use disorder has the potential to greatly impact maternal morbidity and mortality.

A theme linking several articles in this issue of BJOG, are the “non-scientific” aspects of medicine. These include implementation science, patient experience, and cost-effectiveness. Moffat and coworkers report on postpartum contraception uptake in the Northeast and North Cumbrian Integrated Care System in England (Moffat et al; BJOG 2024). Data were obtained via online survey, and thus, prone to bias. Nonetheless, only 38.7% of respondents accessed any contraception postpartum, and only 15.5% accessed long-acting reversable contraception. 18.8 % indicated that they could not obtain their preferred method of contraception. These data underscore the need for better implementation strategies. Although we know that contraception is effective, it only works if people can obtain it. Further work should identify barriers (educational, logistical, financial, cultural, etc.) and potential solutions to enhance utilization of contraception and other effective interventions.

The emotional impact of medical interventions is critically important, but often neglected in research studies. In work by Kwong et al, 2596 people evaluated for ovarian cancer were evaluated for anxiety using the State-trait anxiety inventory (STAI-6) and distress using the Impact of Event Scale – revised (Kwong et al, BJOG 2024). 52.1% of participants reported moderate-severe anxiety and 68.6% had moderate-severe distress. Category of anxiety or distress remained unchanged or worse after 12 months in 76%, despite finding out that they did not have cancer. This study underscores the need to provide mental health support for people being evaluated for cancer, and to consider the duress associated with false positive screening tests. In another study assessing emotional health, Cattani and coworkers reported on the relationship between pelvic floor dysfunction in pregnancy and postpartum and body image disturbance (Cattani et al; BJOG 2024). They noted that urinary incontinence, constipation, and symptoms of prolapse were associated with body image disturbance. Another study assessed the long-term impact of vaginal mesh devices on emotional health. McFadden and Henegan found increased odds of referrals for psychological services in women with SUI/POP mesh surgery in the U.K. (McFadden and Henegan; BJOG 2024). They also had increased referrals to pain clinics.

Tinelli et. al. evaluated cost effectiveness of various treatment strategies for cervical intraepithelial neoplasia in England (Tinelli et al; BJOG 2024). They used a decision analytic model to simulate the clinical course of 1,000 women treated for CIN. They report that large loop excision of the transformation zone (LLETZ) is the most cost-effective treatment overall for young women of reproductive age. For post-menopausal women, LLETZ was most cost-effective up to a threshold of 31,500 Pounds. Above that threshold, laser conization was most cost-effective for older women.

In addition to these themes, several other papers in this issue of BJOG provide information useful for patient counseling. A systematic review provides comprehensive data regarding pregnancy outcomes for people with chronic kidney disease (Jeyaraman et al; BJOG 2024). Rygaard and colleagues note that perineal wound complications in a first birth, increase the odds of obstetric anal sphincter injury in a subsequent birth (aOR 2.73, 95% CI 2.11 – 3.53) (Rygaard et al; BJOG 2024). A Swedish cohort study noted a relationship between early use of hormonal contraceptives, failure to find a suitable contraceptive, and subsequent diagnosis of endometriosis (Obern et al, BJOG 2024). In contrast, longer duration of hormonal contraception usage was associated with decreased risk of endometriosis. A meta-analysis and systematic review noted no benefit to prophylactic ureteric catheterization during complex gynecologic surgery (Gurumurthy et al, BJOG 2024). Finally, Maillet and colleagues used data from a Paris registry to note the prevalence (4.1 per 1,000, 95% CI 3.4 – 5.0) of congenital eye anomalies (Maillet et al, BJOG 2024). Fewer than 25% were diagnosed antenatally and 13.3% of isolated cases were diagnosed antenatally.

This issue contains one other noteworthy paper. Socha and colleagues examine methods of confounder selection in Obstetrics and Gynecology studies (Socha et al, BJOG 2024). They make a clear argument that using only data driven methods leads to both over and under adjustment for confounders. This may be due to inclusion of confounders that are caused by the outcome or exclusion of true confounding variables. This is a critical issue for accurate interpretation of data and should guide investigators, statisticians, and journal reviewers to optimize accuracy of research. We hope that you find this issue interesting and valuable. Enjoy.