key: cord-0691077-6le954az
authors: Holcomb, Denisse S.; Rayburn, William F.
title: Postscript: Women’s Health and the Era after COVID-19
date: 2021-07-02
journal: Obstet Gynecol Clin North Am
DOI: 10.1016/j.ogc.2021.06.002
sha: 199780aabc9f538e10a1022000baf111356a3cd0
doc_id: 691077
cord_uid: 6le954az

As the world clamored to respond to the rapidly evolving coronavirus 2019 (COVID-19) pandemic, healthcare systems reacted swiftly to provide uninterrupted care for patients. Within obstetrics and gynecology, nearly every facet of care has been influenced. Rescheduling of obstetrics and gynecology visits, safety on labor and delivery and the operating room, and implementation of telemedicine are examples. Social distancing has particularly impacted academic centers in the education of trainees. COVID-19 vaccine trials have increased awareness of including pregnant and lactating women in clinical trials. Lastly, the pandemic has reminded us of issues related to ethics, diversity and inclusiveness, marginalized communities, and the women’s health workforce.

In response to COVID-19, ob-gyn practices rapidly adapted by quickly implementing telehealth 82 visits. Publication of the Clinics issue pertaining to telehealth in obstetrics and gynecology 83 (Telemedicine and Connected Health in Obstetrics and Gynecology, Obstet Gynecol Clinics, 84

Vol. 42.2, June 2020 was well-timed. Interim measures by the Centers for Medicare and 85

Medicaid Services (CMS) and the Department of Health and Human Services (HHS) helped 86 decrease barriers to the speedy adoption of telehealth services. 10,11 Physicians suddenly found 87 themselves able to see new patients via telehealth, provide audio-only visits when most 88 convenient to patients, get reimbursed for these visits at the same rates as in-person visits, and 89 see patients across state lines without barriers. 11,12 Longer term policies adopted by CMS and 90 across all payors will be essential to allow this improved access to care and thus help reduce 91 travel, especially from rural locations. 92

As the pandemic commenced in the United States, attention focused on limiting outpatient clinic 94 visits. Gynecologists quickly had to consider how to prevent barriers to contraception in this new 95 paradigm. ACOG quickly provided guidance on the use of telehealth visits for contraceptive 96 family members are all factors that have contributed to the nearly 3-fold higher prevalence of 104 depression symptoms noted in the United States as compared to the pre-COVID era. 13 As we 105 continue to move past this pandemic, we must remember to address both the physical and 106 emotional needs of our patients to improve recognition of potential mental illness. Healthcare 107 systems and professional organizations will need to come up with innovative ways to increase 108 access to mental health resources for all patients in order to meet the increasing demand. 109

Labor and Delivery 111

The Labor and Delivery (L&D) unit is the most frequent site for direct hospitalization in 112 obstetrics. As L&Ds throughout the country struggled to keep up with steady obstetrical volumes 113 despite quarantine efforts and social distancing mandates, attention was directed at maintaining a 114 safe environment for both patients and hospital personnel. From employee and patient screening 115 efforts, use of personal protection equipment (PPE) for hospital personnel, universal mask 116 mandates for patients and visitors, and universal COVID-19 testing for patients in labor, we have 117 learned a great deal about infectious disease transmission best practices. 14-15 Those practices 118 developed during the past two years will continue in some ways. Visitors will likely continue to 119 be limited, and some form of universal infection screening will persist despite many persons 120 being asymptomatic. Vigilant use of PPE, performance of frequent handwashing, and universal 121 precautions will likely continue more than before the pandemic. 122

Gynecology 123

The COVID-19 pandemic led to recommendations that non-emergent elective medical and 124 surgical services be cancelled or delayed, to reduce exposures and allow for preservation of PPE 125 for emergency procedures. 16-17 National guidance prompted hospitals to adopt universal pre-126 operative COVID-19 testing to allow for extra protective measures used during aerosolizing 127 procedures in the event of COVID-19 exposure. As the number of cases slowly declined and 128 PPE manufacturing continued to improve, resumption of elective surgical procedures will 129 commence. We expect an uptick of gynecological cases as patients return to their gynecologists. 130

As we move forward past this pandemic, we suspect that pre-surgical screening for infectious 131 disease will remain. 132 133

The COVID-19 pandemic has dramatically impacted the educational experience for trainees at 135 all levels. For medical students, opportunities for direct patient care were placed at a standstill to 136 preserve precious PPE. 18 Didactic sessions became virtual (live or recorded), and small group 137 teaching was limited due to the absence of patient assignments. An assessment from this lack of 138 direct patient contact will be necessary to determine whether a student's knowledge base was 139 undermined as a result. The interview process for students applying for obstetrics and 140 gynecology residencies were converted to virtual experiences to reduce exposure to potentially 141 infected individuals. As the COVID-19 pandemic recedes, we should consider whether residency 142 interviews should remain virtual, given its advantages such as reduced cost and decreased time 143 away from elective courses. 144

The importance of resident and fellow safety, supervision, and work hour requirements 145 will continue to be closely scrutinized. 19 Lessons were learned from the COVID-19 experience 146 about team building and interprofessional education. Any impact on suspending normal block 147 rotations and deploying residents and fellows to cover obstetrical services and urgent 148 gynecologic cases will warrant examination. Close attention will need to be paid to the impact of 149 suspending elective surgical procedures on resident surgical experience and education. As 150 graduating residents join practices, post-graduate training workshops and seminars in addition to 151 targeted mentorship programs may help provide support for this cohort of 152 obstetrician/gynecologists as they enter the workforce. 153

Virtual conferences, rather than onsite regional or national meetings, are likely to remain 154 as a popular option. Some hybrids of virtual learning (synchronous and asynchronous) with in-155 person teaching will be necessary, bringing both benefits and challenges. The mode of delivery 156 will depend on the educational activity to address the practical needs of learners to better close 157 their knowledge gap and improve their performance. Furthermore, special attention should be 158 paid to provide training in telemedicine for trainees of all levels, as this is most likely to remain 159 substantial means of healthcare delivery. 20 160

While unclear at this time, it will be interesting to discover how the American Board of 161

Obstetrics and Gynecology (ABOG) will alter its approach to certification and recertification of 162 graduating ob-gyn residents and those in practice. Whether the COVID-19 pandemic will affect 163 the timing and administration of written and oral examinations and collection of cases remains to 164 be seen. The requirement of answering questions pertaining to select medical journal articles 165 will probably remain a popular means of focused learning at the home or office for continuing 166 education credit. 167 168

Research in Women's Health 170 Viral infection outbreaks from the HIV, Zika, and COVID-19 prompted needs for immediate and social distancing, with many research activities being suspended early. 21 Reduced productivity 173 was seen. Research meetings became mostly virtual, and many national scientific organizations 174 either cancelled their in-person meetings or replaced them with virtual meetings. As we move 175 past this pandemic, it is likely that virtual meetings as a mode for data exchange will persist. 176

Furthermore, lessons were learned during COVID-19 about the need for research practices to be 177 prompter and more nationwide. This rapidly evolving situation led to the development of protocols that attempted to meet 265 the health care needs of patients. Frequently encountered ethical dilemmas were also 266 encountered. Examples of frequently asked questions to ACOG, as shown in Box 1, required 267 frequent updated responses. 40 As we move past the COVID-19 pandemic, ob-gyns will have 268 gained knowledge on how to balance patient care and public safety simultaneously. We will also 269 feel better prepared to respond to such ethical dilemmas that may be encountered in future public 270 health emergencies. pandemic, we will continue to meet the needs of our patients and families. Every health care 277 organization faces crises at one time or another, but the ones who weather them best have a clear 278 

Department of Health and Human Services Office for Civil Rights (OCR)

Notification of enforcement discretion for telehealth remote communications during the 324 COVID-19 nationwide public health emergency

Telehealth transformation: COVID-19 and the rise of 330 virtual care

Depression Symptoms in US Adults Before and During the COVID-19 Pandemic

Universal screening for SARS-CoV-2 in 335 women admitted for delivery

Obstetricians on the 337 coronavirus disease 2019 (COVID019) front lines and the confusing world of personal 338 protective equipment

Non-emergent, elective medical services, and treatment recommendations

American College of Obstetricians and Gynecologists. Practice Advisory. Vaccinating 370 Pregnant and Lactating Patients Against COVID-19

COVID-19 vaccines and neglected 375 pregnancy

Emergency Use Authorization (EUA)

Emergency Use Authorization (EUA). Moderna COVID-19 Vaccine/mRNA-1273

COVID-19 and African Americans

COVID-19's Crushing Effects on Medical Practices, Some of Which Might Not 392

American College of Obstetricians and Gynecologists. Financial Support for Physicians 394 and Practices during the COVID-19 Pandemic

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

Mental Health and the Covid-19 Pandemic

K-12 Virtual Schooling, COVID-19, and Student 404

Challenges for the female academic during 406 the COVID-19 pandemic