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Introduction In the US, there are striking inequities in maternal health outcomes between racial and ethnic groups. Community-based organizations (CBOs) provide social support services that are critical in addressing the needs of clients of color during and after pregnancy. Methods We conducted a descriptive, cross-sectional mixed methods study of CBOs in Greater Boston that provide social support services to pregnant and postpartum clients. In May-August 2020, we administered an online survey about organizational characteristics, client population, and services offered. In July-August 2020, we conducted semi-structured interviews focused on services provided, gaps in services, and the impact of structural racism on clients. We used descriptive statistics to characterize CBOs and services and used thematic analysis to extract themes from the qualitative data. Results A total of 21 unique CBOs participated with 17 CBOs completing the survey and 14 participating in interviews. CBOs served between 10 and 35,000 pregnant and postpartum clients per year (median = 200), and about half (n = 8) focused their programming on pregnant and postpartum clients. The most significant gaps in social support services were housing and childcare. Respondents identified racism and lack of coordination among organizations as the two primary barriers to accessing social support. Discussion CBOs face multiple challenges to providing social support to pregnant and postpartum clients of color, and significant gaps exist in the types of services currently provided. Improved coordination among CBOs and advocacy efforts to develop community-informed solutions are needed to reduce barriers to social support., Author(s): Rebecca West [sup.1] [sup.2] , Amanda DiMeo [sup.2] , Ana Langer [sup.3] , Neel Shah [sup.2] [sup.4] , Rose L. Molina [sup.2] [sup.4] Author Affiliations: (1) grid.189504.1, 0000 0004 [...]

Objectives While some medical indications for cesarean delivery are clear, subjective provider and patient factors contribute to the rising cesarean delivery rates and marked disparities between racial/ethnic groups. We aimed to determine the association between language preference and risk of primary cesarean delivery. Methods We conducted a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) deliveries of patients over 18 years old from 2011-2016 at an academic medical center, supplemented with data from the Massachusetts Department of Public Health. We used modified Poisson regression with robust error variance to calculate risk ratios for cesarean delivery between patients with English language preference and other language preference, with secondary outcomes of Apgar score, maternal readmission, blood transfusion, and NICU admission. Results Of the 11,298 patients included, 10.3% reported a preferred language other than English, including Mandarin and Cantonese (61.7%), Portuguese (9.7%), and Spanish (7.5%). The adjusted risk ratio for cesarean delivery among patients with a language preference other than English was 0.85 (95% CI 0.72-0.997; p = 0.046) compared to patients with English language preference. No significant differences in risk of secondary outcomes between English and other language preference were found. Discussion After adjusting for confounders, this analysis demonstrates a decreased risk of cesarean delivery among women who do not have an English language preference at one institution. This disparity in cesarean delivery rates in an NTSV population warrants future research, raising the question of what clinical and social factors may be contributing to these lower cesarean delivery rates., Author(s): Kimberly M. Schaefer [sup.1] , Anna M. Modest [sup.1] [sup.2] , Michele R. Hacker [sup.1] [sup.2] , Lucy Chie [sup.1] [sup.2] , Yamicia Connor [sup.1] [sup.2] , Toni Golen [...]

To date, the history of colonialism has permeated nearly every aspect of our conceptions, structures, and practices of global health; yet, there are no published medical school curricula aimed at promoting decoloniality in global health. We developed a pilot course for medical students to examine the history of colonialism, power, and positionality; promote self-reflection; and teach strategies for dismantling coloniality in global health. This five-part course was offered to students completing a scholarly project in global health with a mixed in-person/virtual format and online pre-session preparation materials. A pre-course survey on prior experiences in global health and self-efficacy was administered, and a reflection piece was analyzed for themes. After completion of the course, the students again completed the self-efficacy questionnaire, a course feedback survey and a semi-structured interview that was analyzed for themes. On average, the students felt that the course was relevant to their global health scholarly project and that the course met their learning objectives. There was a trend toward increased self-efficacy in decoloniality knowledge and skills following the course. In the post-course structured interviews, students raised issues reflected in the course materials including local project leadership; how identity, privilege and positionality influence relationships and the ability to attain mutual trust; project sustainability; and power dynamics. Undergraduate medical education in global health equity and decoloniality can play an important role in teaching future generations to dismantle the colonialism ingrained in global health and reimagine a global health practice based on equitable partnerships, community needs, and local leadership. [ABSTRACT FROM AUTHOR]

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health- ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487-2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068-1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936-991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals. Les taux d'accouchements par cesarienne au Mexique sont parmi les plus eleves au monde. Au vu de la sensibilisation accrue de la population et des professionnels a ce probleme et de la mise a jour des directives nationales de 2014 visant a diminuer la frequence des accouchements par cesarienne, nous avons analyse l'evolution des accouchements par cesarienne selon le type d'etablissement entre 2008 et 2017 au Mexique. Nous avons obtenu des donnees issues d'actes de naissance aupres de la Direction generale mexicaine des informations sur la sante et regroupe le nombre total d'accouchements par voie basse et par cesarienne en cinq categories d'etablissement: hopitaux relevant du ministere de la Sante, hopitaux publics, hopitaux relevant de l'assurance liee a l'emploi public, hopitaux militaires et autres etablissements. Les taux d'accouchements ont ete calcules pour chaque categorie a l'echelle nationale et pour chaque Etat. En moyenne, 2 114 630 (intervalle de confiance, IC, a 95%: 2 061 487-2 167 773) naissances vivantes ont eu lieu chaque annee entre 2008 et 2017 a l'echelle nationale. Parmi ces naissances, 53,5% (1 130 570; IC a 95%: 1 108 068-1 153 072) etaient des accouchements par voie basse, et 45,3% (957 105; IC a 95%: 922 936-991 274) etaient des accouchements par cesarienne, avec peu de variations dans le temps. Au cours de la periode etudiee, le nombre de naissances vivantes a augmente de 4,4% (de 1 978 380 a 2 064 507). Le taux d'accouchements par voie basse est passe de 54,8% (1 083 331/1 978 380) a 52,9% (1 091 958/2 064 507), ce qui correspond a une diminution relative du taux de 3,5%. Le taux d'accouchements par cesarienne est passe de 43,9% (869 018/1 978 380) a 45,5% (940 206/2 064 507), ce qui correspond a une augmentation relative du taux de 3,7%. Le changement le plus important concernant les taux d'accouchements a ete constate dans les hopitaux du secteur prive. Depuis 2014, les taux d'accouchements par cesarienne ont legerement diminue dans tous les secteurs, mais demeurent eleves (45,5%). Des politiques et des interventions appropriees sont necessaires pour reduire le taux d'accouchements par cesarienne aux Mexique, en particulier dans les hopitaux de secteur prive. Las tasas de parto por cesarea en Mexico estan entre las mas altas del mundo. Dada la creciente concienciacion publica y profesional sobre este problema y las directrices nacionales actualizadas de 2014 para reducir la frecuencia de los partos por cesarea, se analizaron las tendencias de los partos por cesarea segun el tipo de establecimiento en Mexico entre 2008 y 2017. Se obtuvieron datos de los certificados de nacimiento de la Direccion General de Informacion Sanitaria de Mexico y se agrupo el numero total de partos vaginales y por cesarea en cinco categorias de establecimientos: hospitales del ministerio de salud publica, hospitales privados, hospitales gubernamentales para asegurados por empleo, hospitales militares y otras instalaciones. Se calcularon los indices de partos para cada categoria a nivel nacional y segun cada estado. De media, 2 114 630 (intervalo de confianza, IC, del 95%: 2 061 487-2 167 773) nacimientos vivos se produjeron a nivel nacional al ano entre 2008 y 2017. De estos nacimientos, el 53,5% (1 130 570; IC del 95%: 1 108 068-1 153 072) fueron partos vaginales y el 45,3% (957 105; IC del 95%: 922 936-991 274) fueron partos por cesarea, con poca variacion a lo largo del tiempo. Durante el periodo de estudio, el numero de nacidos vivos aumento un 4,4% (de 1 978 380 a 2 064 507). La tasa de partos vaginales disminuyo del 54,8% (1 083 331/1 978 380) al 52,9% (1 091 958/2 064 507), lo que supone una disminucion porcentual relativa de la tasa del 3,5%. La tasa de partos por cesarea aumento del 43,9% (869 018/1 978 380) al 45,5% (940 206/2 064 507), lo que representa un aumento porcentual relativo de la tasa del 3,7%. El mayor cambio en las tasas de partos se produjo en los hospitales del sector privado. Desde 2014, las tasas de parto por cesarea se han reducido ligeramente en todos los sectores, pero siguen siendo elevadas (45,5%). Se necesitan politicas con intervenciones apropiadas para reducir la tasa de partos por cesarea en Mexico, especialmente en los hospitales del sector privado., Introduction Caesarean delivery is a vital procedure to reduce maternal and neonatal mortality. (1) However, in some middle- and high-income settings, caesarean deliveries have increased sharply. (1) Although no clear [...]

Purpose The mistreatment of women during childbirth in health facilities is a growing area of research and public attention. Description In many countries, disrespect and abuse from maternal health providers discourage women from seeking childbirth with a skilled birth attendant, which can lead to poor maternal and neonatal outcomes. This commentary highlights examples from three countries-Kenya, Mexico and the United States-and presents different forms of mistreatment during childbirth, which range from physical abuse to non-consented care to discriminatory practices. Assessment Building on the momentum from the United Nations Sustainable Development Goals, the International Federation of Gynecology and Obstetrics, and the Global and Maternal Neonatal Health Conference, the global community has placed respectful maternity care at the forefront of the maternal and neonatal health agenda. Conclusion Research efforts must focus on context-specific patient satisfaction during childbirth to identify areas for quality improvement., Author(s): Rose L. Molina[sup.1] [sup.2] [sup.3] , Suha J. Patel[sup.3] [sup.4] , Jennifer Scott[sup.1] [sup.2] [sup.3] , Julianna Schantz-Dunn[sup.3] [sup.4] , Nawal M. Nour[sup.3] [sup.4] Author Affiliations: (1) Division of [...]

Medical librarians collaborate with physicians and other healthcare professionals to improve the quality and accessibility of medical information, which includes assembling the best evidence to advance health equality through teaching and research. This column brings together brief cases highlighting the experiences and perspectives of medical librarians, educators, and healthcare professionals using their organizational, pedagogical, and information-analysis skills to advance health equality indexing. [ABSTRACT FROM AUTHOR]

Health professions educators continuously adapt curricular content in response to new scientific knowledge but can struggle to incorporate content about current social issues that profoundly affect students and learning environments. This article offers recommendations to support innovation and action as students and faculty grapple with ongoing unrest in the United States, including racism, murders of Black people by police, and COVID-19. [ABSTRACT FROM AUTHOR]

Community health centers (CHCs) and federally qualified health centers (FQHCs) are critical health care access points for medically underserved areas in the United States. They also provide opportunities for residents to learn about health system challenges, including workforce shortages, social determinants of health, and health equity. We sought to describe current obstetrics and gynecology (OB-GYN) resident engagement and training in community health settings. We conducted a website review and survey to identify the prevalence and types of OB-GYN resident exposure to CHCs, including FQHCs. We reviewed 241 program websites to identify community health electives or rotations. We then surveyed program administrators regarding departmental affiliations with CHCs, types of resident involvement, and barriers to resident rotations at CHCs. The website review revealed that 18% (44 of 241) of programs offered a community health rotation. Of the 241 programs surveyed, 78 program administrators responded (32%). Forty-three programs (55%) had at least 1 affiliated CHC, and 34 programs (44%) allowed residents to rotate at a CHC. The most common barrier to resident rotations at a CHC was inadequate resident coverage of hospital-based clinical responsibilities. Respondents reported that among 782 graduating residents in the 2016–2017 and 2017–2018 academic years, 76 (10%) planned to pursue a position at a CHC. According to their websites, a small percentage of US OB-GYN residency programs offered a CHC rotation. Of programs responding to a survey on the topic, less than half offered CHC rotations and less than 1 in 10 residents planned to work in CHCs after graduation. [ABSTRACT FROM AUTHOR]

Background: Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group. Methods: An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White). Results: A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients. Discussion: Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism. [ABSTRACT FROM AUTHOR]

Objective: To evaluate changes in quality of care after implementing an adapted safe childbirth checklist (SCC) in Chiapas, Mexico.Methods: A convergent mixed-methods study was conducted among 447 women in labor who attended a rural community hospital between September 1, 2016, and June 30, 2017. Logistic regression analysis was used to evaluate adherence to evidence-based practices over time, adjusting for provider. Participants were surveyed about their perceptions of care after hospital discharge. A purposefully sampled subgroup also completed in-depth interviews. Thematic analysis was performed to evaluate perceptions of care.Results: 384 (85.9%) women were attended by staff that used the adapted SCC during delivery. Of these, 221 and 28 completed the hospital discharge survey and in-depth interview, respectively. Adherence with offering a birth companion (odds ratio [OR] 3.06, 95% CI 1.40-6.68), free choice of birth position (2.75, 1.21-6.26), and immediate skin-to-skin contact (4.53, 1.97-10.39) improved 6-8 months after implementation. Participants' perceived quality of care improved over time. Provider communication generated positive perceptions. Reprimanding women for arriving in early labor or complaining of pain generated negative perceptions.Conclusion: Use of the adapted SCC improved quality of care through increased adherence with essential and respectful delivery practices. [ABSTRACT FROM AUTHOR]

This anthropological study explores why more women in the rural Sierra Madre region of Chiapas, Mexico birth at home rather than at the hospital. Between January and May of 2014, the primary investigator conducted in-depth, semi-structured interviews with twenty-six interlocutors: six parteras (home birth attendants), nine pregnant women, four mothers, four healthcare providers, and three local government leaders. Participant observation occurred in the health clinic, participants' homes, and other spaces in a community with a population of 1,188 people. Drawing from narrative analysis, the findings suggest that women face structural obstacles to accessing high-quality childbirth care, which lead them to give birth at home instead of the hospital. These obstacles include financial barriers in obtaining facility-based care and poor quality of care, such as mistreatment in the facility. The study highlights the importance of centreing community narratives in healthcare programming in order to bridge the implementation gap between women in rural communities, healthcare workers, and policymakers. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate the association between increases in labor and delivery unit census and delays in patient care decisions using a computer simulation module.Methods: This was an observational cohort study of labor and delivery unit nurse managers. We developed a computer module that simulates the physical layout and clinical activity of the labor and delivery unit at our tertiary care academic medical center, in which players act as clinical managers in dynamically allocating nursing staff and beds as patients arrive, progress in labor, and undergo procedures. We exposed nurse managers to variation in patient census and measured the delays in resource decisions over the course of a simulated shift. We used mixed logistic and linear regression models to analyze the associations between patient census and delays in patient care.Results: Thirteen nurse managers participated in the study and completed 17 12-hour shifts, or 204 simulated hours of decision-making. All participants reported the simulation module reflected their real-life experiences at least somewhat well. We observed 1.47-increased odds (95% CI 1.18-1.82) of recommending a patient ambulate in early labor for every additional patient on the labor and delivery unit. For every additional patient on the labor and delivery unit, there was a 15.9-minute delay between delivery and transfer to the postpartum unit (95% CI 2.4-29.3). For every additional patient in the waiting room, we observed a 33.3-minute delay in the time patients spent in the waiting room (95% CI 23.2-43.5) and a 14.3-minute delay in moving a patient in need of a cesarean delivery to the operating room (95% CI 2.8-25.8).Conclusion: Increasing labor and delivery unit census is associated with patient care delays in a computer simulation. Computer simulation is a feasible and valid method of demonstrating the sensitivity of care decisions to shifts in patient volume. [ABSTRACT FROM AUTHOR]

Objective: To evaluate risk factors associated with maternal bacteremia in febrile peripartum women.Methods: We performed a case-control study of women with fevers occurring between 7 days before and up to 42 days after delivery of viable neonates at two academic hospitals. Women with positive blood cultures were matched with the next two febrile women meeting inclusion criteria with negative blood cultures in the microbiology data without other matching parameters. We compared maternal and neonatal characteristics and outcomes between women in the case group and those in the control group with univariate analysis. We then used logistic regression to examine the association between clinical characteristics and maternal bacteremia.Results: After excluding blood cultures positive only for contaminants, we compared 115 women in the case group with 285 in the control group. Bacteremic women were more likely to experience their initial fever during labor (40.9% compared with 22.8%, P<.01) and more likely to have fever at or above 102°F (62.6% compared with 31.6%, P<.01). These associations persisted in the adjusted analysis: multiparity (adjusted odds ratio [OR] 1.75, 95% CI 1.07-2.87), initial fever during labor (adjusted OR 2.82, 95% CI 1.70-4.70), and fever at or above 102°F (adjusted OR 3.83, 95% CI 2.37-6.19). In an analysis restricted to neonates whose mothers had initial fevers before or in the immediate 24 hours after delivery, neonates born to women in the case group had higher rates of bacteremia compared with those born to women in the control group (9.0% compared with 1.3%, P<.01). Eight of the nine bacteremic neonates born to bacteremic mothers (89%) grew the same organism as his or her mother in blood culture.Conclusion: Maternal bacteremia is associated with multiparity, initial fever during labor, and fever at or above 102°F; however, 37.5% of cases of bacteremia occurred in women with maximum fevers below this threshold. Obstetricians should maintain a heightened suspicion for an infectious source of fever in women with these clinical characteristics. [ABSTRACT FROM AUTHOR]

The article discusses postpartum care in the U.S. Topics discussed include the new paradigm called for postpartum care by the American College of Obstetricians and Gynecologists (ACOG) in 2018; improved care recommendations; and postpartum complications such as pain and bleeding, high blood pressure, and lactation difficulties.

Mycoplasma genitalium is a facultative anaerobic organism and a recognized cause of nongonococcal urethritis in men. In women, M. genitalium has been associated with cervicitis, endometritis, pelvic inflammatory disease (PID), infertility, susceptibility to human immunodeficiency virus (HIV), and adverse birth outcomes, indicating a consistent relationship with female genital tract pathology. The global prevalence of M. genitalium among symptomatic and asymptomatic sexually active women ranges between 1 and 6.4%. M. genitalium may play a role in pathogenesis as an independent sexually transmitted pathogen or by facilitating coinfection with another pathogen. The long-term reproductive consequences of M. genitalium infection in asymptomatic individuals need to be investigated further. Though screening for this pathogen is not currently recommended, it should be considered in high-risk populations. Recent guidelines from the Centers for Disease Control regarding first-line treatment for PID do not cover M. genitalium but recommend considering treatment in patients without improvement on standard PID regimens. Prospective studies on the prevalence, pathophysiology, and long-term reproductive consequences of M. genitalium infection in the general population are needed to determine if screening protocols are necessary. New treatment regimens need to be investigated due to increasing drug resistance. [ABSTRACT FROM AUTHOR]

The article focuses on increase in maternal morality ratio since 1990 in high income countries such as the U.S. It discusses the causes such as rising maternal age at first birth, prevalence of diabetes and obesity among young women and increased rate of cesarean delivery. It discusses disparities in maternal outcome in the U.S. such as challenges faced by the Affordable Care Act (ACA), issues with Medicare coverage and other health care policies.

Tuberculosis (TB) infection poses substantial challenges for obstetricians and gynecologists globally, as gynecologic involvement may cause infertility, irregular bleeding, and pelvic pain. If TB-infected women are able to conceive, obstetric complications include intrauterine growth restriction and, more rarely, congenital transmission. Appropriate screening for high-risk populations is crucial for diagnosis and treatment of latent and active TB infection, which may prevent reproductive sequelae for individual patients and, eventually, contribute to complete eradication of the disease. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusionsMedical educators have increasingly focused on the systemic effects of racism on health inequities in the United States (U.S.) and globally. There is a call for educators to teach students how to actively promote an anti-racist culture in healthcare. This scoping review assesses the existing undergraduate medical education (UME) literature of anti-racism curricula, implementation, and assessment.The Ovid, Embase, ERIC, Web of Science, and MedEdPORTAL databases were queried on 7 April 2023. Keywords included anti-racism, medical education, and assessment. Inclusion criteria consisted of any UME anti-racism publication. Non-English articles with no UME anti-racism curriculum were excluded. Two independent reviewers screened the abstracts, followed by full-text appraisal. Data was extracted using a predetermined framework based on Kirkpatrick’s educational outcomes model, Miller’s pyramid for assessing clinical competence, and Sotto-Santiago’s theoretical framework for anti-racism curricula. Study characteristics and anti-racism curriculum components (instructional design, assessment, outcomes) were collected and synthesized.In total, 1064 articles were screened. Of these, 20 met the inclusion criteria, with 90% (n = 18) published in the past five years. Learners ranged from first-year to fourth-year medical students. Study designs included pre- and post-test evaluations (n = 10; 50%), post-test evaluations only (n = 7; 35%), and qualitative assessments (n = 3; 15%). Educational interventions included lectures (n = 10, 50%), multimedia (n = 6, 30%), small-group case discussions (n = 15, 75%), large-group discussions (n = 5, 25%), and reflections (n = 5, 25%). Evaluation tools for these curricula included surveys (n = 18; 90%), focus groups (n = 4; 20%), and direct observations (n = 1; 5%).Our scoping review highlights the growing attention to anti-racism in UME curricula. We identified a gap in published assessments of behavior change in applying knowledge and skills to anti-racist action in UME training. We also provide considerations for developing UME anti-racism curricula. These include explicitly naming and defining anti-racism as well as incorporating longitudinal learning opportunities and assessments. [ABSTRACT FROM AUTHOR]