A Rubric to Center Equity in Obstetrics and Gynecology Research

Principal investigator gender and clinical trial success: analysis of over 3000 obstetrics and gynecology trials

BACKGROUND

In obstetrics and gynecology (OBGYN) research, gender disparities permeate through leadership, funding, promotion, mentorship, publishing, compensation, and publicity. Few studies have investigated OBGYN clinical trial leadership as it relates to investigator gender. Thus, we undertook an investigation of principal investigator (PI) gender and clinical trial success.

OBJECTIVE

To characterize United States (US) OBGYN clinical trials by PI gender and analyze the association between PI gender and features of trial success.

STUDY DESIGN

This is a cross-sectional study of all US-based obstetric and gynecologic clinical trials registered on ClinicalTrials.gov (2007-2020). We examined associations between PI gender (ie, led by women, men, or both) and four primary outcomes that capture clinical trial success: early discontinuation (ie, absence of early discontinuation is a feature of success), reporting of complete trials to ClinicalTrials.gov, publication in a peer-reviewed journal, and clinical trial participant diversity (reporting of racial and ethnic diversity data and representation of diverse cohorts). Multivariable analyses controlled for subspecialty, multiple PI status, source of funding, primary purpose, phase, number of arms, enrollment, year of trial registration, blinding, oversight by a Data Safety Monitoring Committee, and number of study sites. Sensitivity analysis accounted for individual PI who led multiple clinical trials. Univariable and multivariable logistic regression analysis models were applied. We conducted multiple imputation for missing covariable data. There were no missing exposure or outcome data in the final cohort.

RESULTS

We reviewed 12,635 clinical trials focused on OBGYN. Of the 4342 trials with at least one site in the US, PI names were available for 3087 trials (71.1%). The majority of OBGYN trials were women-led (women 1696, 54.9%; men 1272, 41.2%, coled 119, 3.9%). A greater proportion of obstetrics trials (617, 60.0%) were women-led than gynecology trials (1079, 52.4%). Family planning had the greatest proportion of women-led trials (145, 74.7%), whereas reproductive endocrinology and infertility had the lowest (50, 30.9%). A greater proportion of industry-funded trials were led by men (123, 64.7%). In adjusted analysis, women-led trials had lower odds of early discontinuation (men-led reference; women-led adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.44, 0.77). Women-led trials reported results less frequently (men-led reference; women-led aOR 0.52, CI 0.40-0.62) but no significant difference was seen in publication (men-led reference; women-led aOR 1.02, CI 0.57, 1.81). Women-led trials had greater odds of reporting race and ethnicity participant data (men-led reference; aOR 1.87, CI 1.27-2.47) but there was no difference in cohort diversity by PI gender.

CONCLUSION

Women investigators lead approximately half of OBGYN clinical trials in the US. Women-led trials discontinue less frequently, publish at similar rates, and include data on diversity more frequently than men-led trials. Women are as successful as men in conducting clinical trials and, in certain domains, more successful. Our findings place the impetus on the OBGYN professional ecosystem to support women's academic careers.

Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery.

METHODS

A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months.

RESULTS

A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related.

CONCLUSIONS

The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.

Validation of a Vaginal Birth After Cesarean Delivery Prediction Model Without Race and Ethnicity in Individuals With Two Prior Cesarean Deliveries

Previous models for prediction of vaginal birth after cesarean (VBAC) relied on race and ethnicity, raising concern for bias. In response, the Maternal-Fetal Medicine Units Network (MFMU) created a new prediction model without race and ethnicity for individuals with one prior cesarean delivery. We performed a secondary analysis of the MFMU Cesarean Registry database to evaluate whether the MFMU VBAC prediction model without race and ethnicity could accurately predict VBAC for individuals with two prior cesarean deliveries. Overall, 353 individuals were included and 252 (71%) had VBAC. An area under the curve for the receiver operating curve of 0.74 (95% CI, 0.69-0.80) was reported for the predicted probabilities for VBAC, indicating that the model can be used for prediction of VBAC in this population.

Disparities in perinatal COVID-19 infection and vaccination

The COVID-19 pandemic exposed and exacerbated persistent health inequities in perinatal populations, resulting in disparities of maternal and fetal complications. In this narrative review, we present an adapted conceptual framework of perinatal social determinants of health in the setting of the COVID-19 pandemic and use this framework to contextualize the literature regarding disparities in COVID-19 vaccination and infection. We synthesize how elements of the structural context, individual socioeconomic position, and concrete intermediary determinants influence each other and perinatal COVID-19 vaccination and infection, arguing that systemic inequities at each level contribute to observed disparities in perinatal health outcomes. From there, we identify gaps in the literature, propose mechanisms for observed disparities, and conclude with a discussion of strategies to mitigate them.