Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. This is the CMAJ podcast.
Dr. Blair Bigham:
Mojola, today we're talking about complications in pregnancy, specifically hypertensive related complications. From a commentary published in CMAJ titled, “Screening for preeclampsia risk and prophylaxis with acetylsalicylic acid.” So this is a really interesting commentary because it seems to me to be suggesting that basically-
Dr. Mojola Omole:
Pregnancy is a death trap.
Dr. Blair Bigham:
Pregnancy is a death trap. And that, well, maybe aspirin is your way out of the death trap.
Dr. Mojola Omole:
Possibly. It's a very elegant commentary that lays out the risks for pregnant people when it comes to preeclampsia and a very simple and affordable and easily available solution for that which is ASA.
Dr. Blair Bigham:
I didn't even know that ASA could be prescribed to prevent preeclampsia. Normally I'm looking for signs of preeclampsia, but here we have a solution to prevent it altogether. So really interesting paper and we're lucky to have the author with us today, one of the authors, to speak to us about how we can implement this more practically.
Dr. Mojola Omole:
Yes. Then our second guest today is going to just broaden the conversation regarding pregnancy related risk and looking at racialized communities and the differences that we see when it comes to pregnancy mortality and morbidity.
Dr. Blair Bigham:
We got really excited to get into this based on some recent media reporting, particularly in the New York Times, that was showing massive, massive discrepancies for pregnancy outcomes, particularly in people who are black and racialized. A very important topic and one that we definitely need to talk about here in Canada as well. Let's jump into it.
Dr. Emmanuel Bujold is an OB GYN in Quebec City. He's a professor at the Department of Obstetrics and Gynecology of Laval University School of Medicine, and he's the co-author of the commentary in CMAJ. Emmanuel, thank you so much for joining us today.
Dr. Emmanuel Bujold:
Thank you.
Dr. Blair Bigham:
Why did you feel it was necessary to write this commentary?
Dr. Emmanuel Bujold:
I think it was necessary for several reasons. First, many years ago, we demonstrated that aspirin, when initiated in early pregnancy, can prevent most cases of severe and early onset preeclampsia, a disease that accounts for many preterm births and several diseases in mothers. The second reason is the fact that many years ago we showed and other people showed that we could predict most women who would develop preeclampsia in early pregnancy. Therefore, for the last seven years, we have known that it is possible to predict preeclampsia in early pregnancy and prevent it with a very simple treatment, which is aspirin.
Dr. Blair Bigham:
We're talking about finding preeclampsia before it actually has the classic signs, things like high blood pressure or protein in the urine.
Dr. Emmanuel Bujold:
Exactly. In fact, most preeclampsia cases occur in the third trimester of the pregnancy, so in the last three months, while we show that we can predict it or detect it in the first three months, so many months before the first occurrence of sign or symptom of preeclampsia.
Dr. Blair Bigham:
And do you need the aspirin early on to prevent it from getting worse or does it just kind of manage the risk later on? Is it important to start the aspirin as early as possible?
Dr. Emmanuel Bujold:
Yes. In fact, this is what we showed in 2009. We showed that in order for the aspirin to work, it needs to be started before 16 weeks of pregnancy. So in fact, for many years, it was questioned about the potential effect of aspirin and whether or not it was preventing preeclampsia or not. What we did in a group of researchers in Quebec City, we did what we call a meta-analysis. We combined several randomized trials all together and we showed that all the studies who initiated the aspirin before 16 weeks showed a clear benefit, while most studies who initiated aspirin after 16 weeks did not show the same benefit. This is how we concluded and we validated our results in a very large multicenter study afterward, that by initiating aspirin in the first trimester of pregnancy, you can prevent most cases of severe preeclampsia.
Dr. Blair Bigham:
How long should a pregnant person take aspirin for? Is it up until labor? Is it for a little bit of their postpartum period? When on my prescription pad would I end the aspirin?
Dr. Emmanuel Bujold:
Currently, we tell the women at high risk for preeclampsia to take aspirin up to 36 weeks of gestation. But there are current trials that have been published and that are still running, and most of them are showing that very soon we could stop aspirin probably in the second trimester of pregnancy. But, we're not there yet, we need to confirm this. That means that probably very soon, maybe the woman will have to take aspirin maybe for three to four months, and therefore have extremely low risk of side effects with the same benefits. However, for now, we still recommend to take it up to 36 weeks because most of the studies used aspirin up to that gestational age.
Dr. Blair Bigham:
What are the tests that need to be ordered in the first trimester so that aspirin can be started?
Dr. Emmanuel Bujold:
Okay, so it's the Fetal Medicine Foundation in the UK who developed an algorithm, which is quite easy to use and we can use it in fact freely on the web. So you need to get the mother's height and weight. You need to get maternal blood pressure, so two things that's quite easy to get in any clinics. We need to do a blood test, which include the PAPP-A and the PlGF, two markers that are already currently used for the prediction of fetal aneuploidy. And then with the ultrasound, you can add what we call the uterine artery doppler, so it's a sign of impaired presentation.
Dr. Blair Bigham:
Are these tests easily available? Are they expensive? Are they covered by provinces?
Dr. Emmanuel Bujold:
In fact, as I said, many provinces already provided them for the prediction of fetal aneuploidy and not quite expensive. Regarding the ultrasound, this is one of the limitation. Not all hospitals provide what we call the uterine artery doppler. However, in a recent Canadian study, we showed that even without the ultrasound, your test can be quite good. In fact, almost as good as with or without the ultrasound. The good thing about the ultrasound is it confirms that you are at risk or not, but even without the ultrasound, it can provide a very good test, which you can detect almost three-quarter of the high-risk women even without the ultrasound.
Dr. Mojola Omole:
A primary care practitioner is usually the person that is taking care of the pregnant person in their first trimester. Who should they be of higher concern to screen in the first trimester for preeclampsia?
Dr. Emmanuel Bujold:
In fact, we believe that it should be available for all women. The test is not very expensive already provided for almost all women because of the aneuploidy screening. I think it's just easier to provide it to everybody because another thing that we demonstrated, there's no clear risk factor that can identify the woman at very high risk. The one who is at very high risk commonly do not have any risk factors. This is why the current way to identify women at high risk for preeclampsia has a sensitivity of about 50%, so extremely low for a false positive rate of 30%. So you would treat one woman out of three to be able to prevent only half of the cases. While, by doing the screening, you will detect three-quarters of the women at high risk and only treat about 10%, one out of 10.
Dr. Blair Bigham:
The Royal College made me memorize that big long table of risk factors for nothing. I want to pretend I'm a family doctor here, and I have a prescription pad in my hand. How much aspirin should I be prescribing for people at risk?
Dr. Emmanuel Bujold:
It's a very interesting question. The answer is 160 milligram every evening, so two pills of 80 milligrams or two pills of 81 milligrams. The two forms are available in Canada. There's still a little controversy about that. However, we recently published another meta-analysis showing that 80 milligram is good for about two-third of the women and 160 milligram would be efficient for about 90%. So I don't see much point of not getting the right dose.
Dr. Mojola Omole:
I guess my question is, before we even talk about dosage, if every person who's pregnant should be tested for this. I had a baby in the last three and a half years, but I wasn't tested for it. Why is it not widely adopted that we're just routinely testing pregnant people for a risk of preeclampsia?
Dr. Emmanuel Bujold:
It's a very good question. In fact, this is the main reason why we wrote the paper. After the publication of our maternal disease after the demonstration that we could screen, we thought five years ago that it would be very rapidly implemented everywhere, and it did not happen while we had everything in place. I think one of the reasons was that the uterine artery doppler ultrasound was not available everywhere. Now that we showed that it's not necessary to have it, I don't know what would be the reason why I'm not doing it. Another concern that I have is, currently, most provinces offer a first trimester screening for fetal aneuploidy, which involves blood testing and ultrasound. So everything is set up right now to provide pregnant women a first trimester screening for aneuploidy.
Dr. Blair Bigham:
So right now, we're getting a free ride on preeclampsia screening.
Dr. Emmanuel Bujold:
Exactly. Exactly.
Dr. Mojola Omole:
You had mentioned that the treatment is aspirin. Most people who are pregnant are very cautious about what they take. Is there any risk to the pregnancy when you take aspirin?
Dr. Emmanuel Bujold:
There's no evidence of risk if you started after 10 weeks of gestation.
Dr. Blair Bigham:
And just how effective is it? How good is it at preventing preeclampsia?
Dr. Emmanuel Bujold:
If you take the right dosage every day, the FMF showed that you would prevent more than 80% of the most severe cases, so extremely efficient.
Dr. Blair Bigham:
Wow.
Dr. Mojola Omole:
So why is it that we have all the tools and the test is already being done and can easily be done? It doesn't seem like it's expensive, but-
Dr. Blair Bigham:
The meta-analyses are pretty clear.
Dr. Mojola Omole:
Yes, but how come it hasn't turned into practice changing guidelines that it becomes a guideline that people who are in the first trimester should be screened for pre-eclampsia and then treated if they're at high risk?
Dr. Emmanuel Bujold:
I think one of the problems is that there is no money to make out of it.
Dr. Mojola Omole:
Yeah.
Dr. Blair Bigham:
Aspirin is cheap.
Dr. Emmanuel Bujold:
Aspirin is cheap.
Dr. Blair Bigham:
Ultrasounds are cheap.
Dr. Emmanuel Bujold:
Yep, and it's not the pregnant women who are making the decision about having the test or not.
Dr. Blair Bigham:
It must be frustrating as someone who-
Dr. Mojola Omole:
Deals in women's health.
Dr. Blair Bigham:
... for OBGYNs. It must be really frustrating.
Dr. Emmanuel Bujold:
Yeah.
Dr. Blair Bigham:
Emmanuel, at the end of November, as we were planning this episode, I was working a week in the ICU and Bed 5 and Bed 6 were both women who had eclamptic seizures and lost their babies in C-section. They were in bed side by side. Do you think those awful tragedies were 100% preventable, or are there always going to be some women who unavoidably lose their babies to eclampsia?
Dr. Emmanuel Bujold:
I believe that most of those severe cases can be prevented quite easily. We won't give all the answers today. However, we're working on those particular cases, but most likely the two very sad stories that you described were preventable.
Dr. Blair Bigham:
What goes through your mind when you're in the operating room and you remove a stillborn fetus in such a preventable circumstance?
Dr. Emmanuel Bujold:
It is extremely difficult for me to see that because every time that happens, I always thought that we could have prevented that. It makes no sense in my mind. It is just unbelievable. We already are planning to go and try to find testing for women in many countries in low income countries who typically are at higher risk for preeclampsia, eclampsia, and we are trying to find ways to help them do the same. But I can't believe that the type of cases that you described are still happening in Canada while we have all the tools.
Dr. Blair Bigham:
Side by side, right beside each other in the ICU. I couldn't believe it that they were going through that. It was just tragic.
Dr. Emmanuel Bujold:
When you explain to those women afterwards that there's a way to predict and prevent those very sad events with such simple treatment, they always come back to me and say, "Okay, but why didn't we have that on the first pregnancy?" And it is always difficult to answer them directly and tell them the truth that we're working on having that testing across Canada as soon as we can.
Dr. Blair Bigham:
Emmanuel, thank you so much. Merci.
Dr. Mojola Omole:
Thank you so much.
Dr. Emmanuel Bujold:
Merci. Thank you.
Dr. Blair Bigham:
Dr. Emmanuel Bujold is an OB GYN in Quebec City. He's a professor at the Department of Obstetrics and Gynecology at Laval University.
Dr. Mojola Omole:
Preeclampsia is one of the serious risks during pregnancy, but it's not the only concern, especially for racialized communities. The Black community in particular faces a range of high risk conditions that demand more attention. To dive deeper into this topic, we're joined by Dr. Modupe Tunde-Byass. Dr. Tunde-Byass is an OB GYN based in Toronto. She's the inaugural president of the Black Physicians of Canada, and the co-founder of the Women's Health Education Made Simple. She's also an associate professor in the Department of Obstetrics and Gynecology at Temerty Faculty of Medicine. Thank you so much for joining us today.
Dr. Modupe Tunde-Byass:
Thank you so much for having me. Good morning.
Dr. Mojola Omole:
Good morning. So what risks or complications are more common in pregnancy among the Black population?
Dr. Modupe Tunde-Byass:
So in the Black population, we have things like hypertensive disorders of pregnancy that people know as preeclampsia. There are other things like small babies. We also have increased cesarean section rates, postpartum hemorrhage, and almost all complications that occur in pregnancy seems to be heightened in the Black population.
Dr. Mojola Omole:
What sort of data do we have regarding pregnancy outcomes when we're looking at pregnant people in Canada?
Dr. Modupe Tunde-Byass:
Well, unfortunately, if you're talking about racialized, we don't have race-based data. That being said, we have maybe an idea of who we think might be dying based on comparative data from high income countries that are similar to Canada, specifically the United States and United Kingdom. When you look at those two data, what we are seeing is that more Black women are dying at an astronomical rate compared to their white counterparts. For example, in the United States, the rates of Black women dying is approximately 70 per 100,000 compared to 27 per 100,000 in white women. People often say, "Well, that's because there's no free health in United States." If you look at the United Kingdom where the NHS is free, that rate is the same. In fact, it's about four times more Black women dying.
Dr. Mojola Omole:
What is it that is causing pregnant people who are Black or racialized to have higher morbidity and mortality with pregnancy?
Dr. Modupe Tunde-Byass:
Well, that's a good question because you're talking about mortality and morbidity, and we know that it's a combination of everything. So it's not about the race itself, right? Rather it's a combination of social, cultural, and perhaps biological factors. But what we know that is common to all these countries, to be honest, is things like racism and also the systemic discrimination that discriminates one race over the other. But when you look at even the morbidity, there are factors that heighten some people's risk. For example, we're looking at the Black immigrant population. These are people who may have preexisting medical conditions, hypertension, diabetes, obesity, substance abuse, and these things are due to long-term effects of racism that becomes perpetuated throughout the healthcare, whether it's in pregnancy or even outside pregnancy. And of course, the social determinants of health. We know about poverty, low employment rates, and overcrowding. So these are problems that we see rather than the risk itself.
Dr. Blair Bigham:
The discrepancy in the mortality rate between people in the United States and people in the UK, is there any reason to think that discrepancy is a little bit better in Canada, or do you think that it's probably reflective of the Canadian population as well?
Dr. Modupe Tunde-Byass:
Well, it's hard to say when you don't have race--based data.
Dr. Blair Bigham:
Right.
Dr. Modupe Tunde-Byass:
With that being said, we have data about preterm birth, which is perhaps the only data that we have out of McGill, and that rate mirrors that of the United States. Black pregnant people having a higher preterm birth in the range of about 8.7 compared to 5%, and it's exactly the same in the United States. Even though we don't have the race-based data for pregnant people, we can extrapolate that it's probably going to be around the same.
Dr. Blair Bigham:
Pardon my ignorance, but why would people feel collecting the data is punitive? What's the downside to collecting the data?
Dr. Modupe Tunde-Byass:
Well, you'd be surprised that data collection has been used against the community that's supposed to help.
Dr. Blair Bigham:
I see.
Dr. Modupe Tunde-Byass:
And also, people feel they're ashamed to disclose who they are, not understanding whether this is going to be beneficial to them. So it's important for a racialized community to know that this is a way to help and also to invite them to help co-create things that may change.
Dr. Blair Bigham:
Can you give me an example where race-based data has been used to close the gap?
Dr. Modupe Tunde-Byass:
So if you think of situations whereby, for example, we hear about Covid-19 and the vaccine, we were able to show that a particular community has this health disparity, and they needed more vaccine. This is a perfect example here. Even though it wasn't as easy getting the vaccine supply, but it was helpful to show that a certain community was negatively impacted, and this will help future planning. So it's not just the pandemic now. It's what we need to do for the future.
Dr. Blair Bigham:
Got it. Thank you so much.
Dr. Mojola Omole:
So Dr. Tunde-Byass, I can't call you by your first name because I know you, so you are involved in teaching residents and medical students. In general, is it part of the curriculum for medical training to talk about the discrepancies amongst racialized community when it comes to preeclampsia and other bad pregnancy outcomes?
Dr. Modupe Tunde-Byass:
I think it's important to train our students to understand the discrepancies in health, and we cannot emphasize that more, especially when we have learners starting in a community where we know that there's disparity. And for the Black community, it's fundamental to addressing the social determinants of health, not just saying it, but actually making sure that we address the poor health, the poverty, the housing, the unemployment that we see in people of color. These things are very important. As soon as we have pregnant people looking for their first appointment, you start looking for those inequities and also those medical conditions so that you can actually tailor their care towards those complications that might arise.
Dr. Mojola Omole:
So I know you did your training in the UK, so was there a difference in patterns for emergency room visits, the UK versus here?
Dr. Modupe Tunde-Byass:
I love to talk about this, because as a resident in the UK in the late eighties, there was just overwhelmed use of emergency departments. What came about is something called the early pregnancy clinics. And this bypasses the emergency room. So anybody with bleeding early in the pregnancy, you do not go to emergency room. You go to a center called early pregnancy assessment clinics or units.
Dr. Blair Bigham:
And you can just show up?
Dr. Modupe Tunde-Byass:
Oh, you can just walk in. So there's self-referral. For people who have had previous ectopic pregnancy, they can access care. So you don't need to go to an emergency room. So if you know that you have bleeding, a little bit of spotting, you know there's a clinic that you can go to. Why would you go and spend seven hours in emerg?
So based on that, we started this model at my hospital, North York General in 2005, and we see pregnancy related complications to the first 20 weeks. And we have similar at centers like Mount Sinai and a few places, but we need to make it a standard of care. So these women do not go to emerg. They go to these clinics, and they get their ultrasound. They have timely access, and also somebody who can take them through and offer them different options related to the complications, and above all, support them because it's so important not to feel alone in the journey. This is something that is lacking in this country and is yet to be a standard of care. If there's anything, I would love to see this as an emergency bypass and a standard of care for pregnancy related complications.
Dr. Blair Bigham:
As an emergency doctor, that sounds amazing because-
Dr. Modupe Tunde-Byass:
Absolutely.
Dr. Blair Bigham:
... the emergency department is such a hostile environment even on a good day, and sometimes we're working out of hallway spaces. It's not an appropriate place to be talking about miscarriage, to be talking about bleeding in the first trimester. This sounds like a really innovative solution.
Dr. Modupe Tunde-Byass:
And you can imagine going through early pregnancy complication is bad enough. Going to emerg and being in the hallway, like you said, for hours, and not being able to access ultrasound in a timely fashion, going home, or having ongoing miscarriage. My emergency colleagues do a fantastic job considering what they have to do. There's no time to sit with someone and go through the social and also the effects of losing a pregnancy. I mean, you're talking about depression. It's profound. So having a special place will be extremely helpful in terms of reducing the burden out of emerg, and also providing care for those who need it at this critical point. And it's so common, like you're talking about one in four pregnancies being lost. So this is not just a small problem. It's huge.
Dr. Mojola Omole:
Are there any other changes that you're seeing that are making you optimistic about the future of women's health when it comes to pregnancy and complications of pregnancy?
Dr. Modupe Tunde-Byass:
So the changes that we are seeing, it's early screening. Very important, especially for preeclampsia. So it would be important for pregnant people, especially people who are racialized to access care the first trimester, so they can take advantage of the screening that it's available, it's free, and be able to understand those people who need extra care, extra ultrasound, and also commencing low dose aspirin before 16 weeks of pregnancy. These things are very important, having very early access to care when you're pregnant.
Dr. Blair Bigham:
Thank you so much.
Dr. Mojola Omole:
Thank you.
Dr. Blair Bigham:
That was so informative.
Dr. Mojola Omole:
Dr. Tunde-Byass is an OB GYN based in Toronto, and an associate professor at Temerty Faculty of Medicine. She's the inaugural president of the Black Physicians of Canada.
Dr. Blair Bigham:
Mojola, this is fascinating. First of all, we just have to start by talking about how we don't collect any race-based data here in Canada.
Dr. Mojola Omole:
Yeah, I think for me, it's something that I talk a lot about. One thing that's becoming clearer as I look at some of the discourse that has been online regarding how to systematically improve medical education, and part of that being to shift focus to not just having people who are medical expertise, but also having an understanding of what anti-oppression and systemic racism, the effects in healthcare. This is part of one of the reasons why we don't collect race-based data is because we don't have a system that systematically wants to dismantle the oppression. There's always questions of why do you as a doctor need to do anti-oppression? You should just treat everybody equally, but we're not equal because our outcomes are not equal. So therefore, we also don't have the same backgrounds. Part of addressing social determinants of health is to address systemic racism. So I think that if we shift as a country, as a medical community to understand what anti-oppression looks like and what oppression for racialized community looks like when encountering the medical community, we'll be more open to the idea of why it's important to collect this data.
Dr. Blair Bigham:
I was very interested when Dr. Tunde-Byass mentioned that sometimes collecting that data could be viewed as maybe pejorative or harmful. Mojola, what are your thoughts on that bit?
Dr. Mojola Omole:
Well, I think part of that is having an understanding that racialized communities and especially Black people throughout history have been used for medical experiments. I guess the father, as they say, of OB GYN, Dr. Sims in the US used to do experiments on Black slaves without anesthesia.
Dr. Blair Bigham:
Wow.
Dr. Mojola Omole:
So we have a system where whether you are from this country or from another country, the history that you have is that the medical community should not be trusted because of what do they do to that data? Because it's, "Well, don't treat me as if I'm Black. Treat me as if I'm white because then you won't harm me." That is the underlying current when you're talking to the Black community when it comes to healthcare, because we've come from countries where they've done experiments on us, and clearly, when you access healthcare, you are faced with systemic racism.
Even me as a physician, when I was having my baby, I was confronted with anti-Black racism and fat phobia, and this is the hospital where I've worked. Wealth or education level does not protect you from systemic racism. The data in the US actually supports that. Even amongst wealthier private insurance people who were pregnant, they still had similar pregnancy outcomes as those of poor communities.
Dr. Blair Bigham:
Based on race.
Dr. Mojola Omole:
Yes. Well, we say based on race, but what we actually mean is based on systemic anti-Black racism.
Dr. Blair Bigham:
Thank you. Yeah. No, exactly. Let's spend one more minute talking about Emmanuel Bujold's conversation and plea to have more people on aspirin. Nine out of 10 cases of severe preeclampsia can be prevented with it. I don't know. Why didn't I know about this?
Dr. Mojola Omole:
Well, because it's women's health. I think for me, as someone who's cisgendered, when it comes to health of people who identify as female, even non-binary, we just don't care. If we knew that aspirin could prevent you from having erectile dysfunction, every guy would be on aspirin.
Dr. Blair Bigham:
It would be in the water supply.
Dr. Mojola Omole:
A hundred percent. It would be mandated out of vending machines for free. And we're just trying to get free tampons. I think that part of the problem is the fact that we just finished talking about systemic racism, but there is misogyny in medicine. We've talked a few times about that on this podcast, but that is the reality that cisgendered, non-binary people, female presenting face is the fact that it's not prioritized. As someone who works in the operating room, GYN gets way less operating time than any other service.
Dr. Blair Bigham:
Really?
Dr. Mojola Omole:
A hundred percent, to get into the OR. The reason why there's a backlog for gynecological procedures, people are waiting two years for management of the fibroids as they're bleeding out.
Dr. Blair Bigham:
Wow.
Dr. Mojola Omole:
Why? Because there's just not enough operating time to get them into the operating room. At the lowest and highest level, we do not prioritize people who have uteruses and ovaries.
Dr. Blair Bigham:
And that's why we have massive discrepancies in outcomes.
Dr. Mojola Omole:
A hundred percent. And then we just sprinkle on top of that a little racism in the morning, and then that's why women are dying.
Dr. Blair Bigham:
Well, I think this is a great call to action to be collecting this data and for clinicians, as busy as we are in a healthcare system on fire, to do our best to slow down when a pregnant patient is in front of you. I remember one of my favorite preceptors in emergency medicine residency, said to me, "Blair, no one should ever die from a complication of pregnancy." And that stuck with me. And every time I see a pregnant patient, I'm just like, "Whoa, whoa. Their death is not going to be on my hands. I'm going to slow this down." And at least now, maybe I have aspirin as part of that armament to keep pregnant people safe.
That's it for this week on the CMAJ podcast. Thanks so much for listening. If you can, do us a favor. Like or share our podcast, wherever it is you download your audio or just tell a colleague, tell a friend. We'd love to get the word out.
Dr. Mojola Omole:
Please share this episode as this is very important for us-
Dr. Blair Bigham:
Really.
Dr. Mojola Omole:
... to start mobilizing and having a better understanding and funding for women's and people's health of those who have ovaries and uteruses. Until next time, be well.