Doctors speak out on conflicts of interest in obstetrics

In 2016, the National Partnership for Maternal Safety (NPMS) released a list of recommendations for reducing deaths from blood clots in pregnant and postpartum women in the journal Obstetrics & Gynecology. One of these recommendations was expanding the use of blood thinners to most women after a cesarean birth. Since nearly one third of births in the US are by c-section, that’s about 1.3 million women a year who would be put on blood thinners after giving birth. 

However, the NPMS did not include disclosure of their financial ties to pharmaceutical companies that manufacture blood thinners. It took three years for Obstetrics and Gynecology to publish a correction, which noted that NPMS receives industry funding from three companies that manufacture or sell blood thinners, but did not include the names of these companies.

As doctors noted in an accompanying editorial, the broad expansion of blood thinners to all women who have a c-section “is not justified by the available data and has the very real potential of doing more harm than good.”

A few months ago, we called attention to these conflicts of interest and the doctors who are pushing back, such as Dr. Adam Urato, Chief of Maternal-Fetal Medicine at the MetroWest Medical Center in Framingham, Massachusetts. “We really need public attention on this issue and we need to make sure that this type of industry influence is not allowed to be hidden and go unchecked,” said Urato. 

Why industry-independent experts are essential

When Urato uncovered this conflict in the NPMS recommendations, he reached out to investigative journalist and author Jeanne Lenzer and Lown Vice President Shannon Brownlee to help him spread the word. About ten years ago, Lenzer and Brownlee created a List of Industry-Independent Experts, to help health journalists find sources, like Urato, that aren’t biased by financial ties to industry.

Soon, Gary Schwitzer, journalist and founder of Health News Review, and Adriane Fugh-Berman, Georgetown professor and director of PharmedOut, joined the effort to help grow and disseminate the List. Currently, the List has over 100 sources and is still growing.

Brownlee and Lenzer helped Urato quickly recruit dozens of clinicians from the List to serve as signatories for the letter to Obstetrics & Gynecology. Being able to reach non-conflicted experts is extremely valuable, not only for journalists looking for sources, but for clinicians and patient advocates trying to take action against financial conflicts of interest in medicine.

The letter of protest

Urato and about fifty other doctors made sure these conflicts of interest did not go undetected. They wrote a letter to Obstetrics and Gynecology, which was just published in the journal. In their letter, they write of their concern that the conflicts of interest were not disclosed when the recommendations were originally published, and the companies were not explicitly named in the journal’s correction published three years later.

Urato and colleagues write that NPMS receives funding from “Abbvie, Allergan, AMAG Pharmaceuticals, Bayer Health Care, Ferring Pharmaceuticals, Hologic, Illumina, Johnson & Johnson, Masimo, Myriad, Pfizer, Premier, and Salus Global.” Among these companies, three manufacture anticoagulants. The doctors express concern “radical approach” recommended by the NPMS to prescribe anticoagulants to all large numbers of women has risks that are “unknown but could be considerable.” They also note that there are other non-pharmacological methods of reducing blood pressure that could have been recommended first.

Fortunately, this important issue is starting to pick up steam. The Wall Street Journal recently covered the issue and spoke with the companies that fund the NPMS. Johnson & Johnson, Bayer AG, and Pfizer, Inc all confirmed their financial support for NPMS, but insisted they had no input on the recommendations. However, these financial ties may still influence the organizations recommendations, because NPMS knows that industry money will continue to flow if they recommend broader use of medications.

Research on conflicts of interest has shown that financial support from industry organizations influences clinical practice guidelines, regardless of whether the company has direct input on guideline content. For example, one study compared industry payments for the authors of two different stroke guidelines, and found 35% of doctors who recommended an unproven drug treatment for stroke were being paid by industry, compared to 0% of doctors who did not recommend this treatment.

It is encouraging to see doctors taking a stand against industry influence in medical guidelines and recommendations. The NPMS recommendation has already affected millions of women, and will create unknown risks for millions more in coming years. With the work of industry-independent clinicians, and the help of a network to connect them, we can continue to put pressure on clinician groups to disclose—and hopefully eliminate—their financial conflicts.