Gaps in the congenital syphilis prevention cascade: qualitative findings from Kern County, California.

BACKGROUND: Congenital syphilis is preventable through timely access to prenatal care, syphilis screening and treatment of pregnant women diagnosed as infected. In 2018, California had the second highest number of congenital syphilis cases in the United States (U.S.), a nearly twofold increase in cases since 2014. This study assessed gaps in preventing congenital syphilis in the high morbidity region of Kern County, California. METHODS: Between May 2018 and January 2019, we conducted five focus group discussions with pregnant/postpartum women and ten semi-structured interviews with prenatal care providers in Kern County. Focus group and interview data were recorded, transcribed, and analyzed to identify emergent themes pertaining to facilitators and barriers at each step (prenatal care, syphilis screening and treatment) in the congenital syphilis prevention cascade. RESULTS: Gaps in congenital syphilis prevention discussed in focus group discussions with pregnant/postpartum women were related to limited prenatal care access, social-, economic-, and cultural-barriers, and substance use and co-occurring intimate partner/domestic violence. The gaps identified from interviews with prenatal care providers included social economic vulnerabilities of pregnant women and stigma and shame around the vulnerabilities, distrust in medical system, prenatal substance use, limited prenatal substance use disorder treatment facilities, and inadequate provider training on context-specific congenital syphilis management strategies. Gaps in partner notification, screening and treatment for syphilis were brought up by pregnant/postpartum women and prenatal care providers. CONCLUSIONS: Congenital syphilis continues to increase in Kern County and throughout the U.S. In high syphilis morbidity areas, comprehensive and tailored public health approaches addressing setting-specific gaps in prenatal screening and treatment are needed.

Understanding perinatal patient's health preferences and patient-provider relationships to prevent congenital syphilis in California and Louisiana.

BACKGROUND: Congenital syphilis (CS) has reemerged as a global maternal and child health crisis. Kern County, California and East Baton Rouge Parish, Louisiana are among the highest CS morbidity regions in the United States. We previously reported on social-ecological and structural barriers to prenatal care and maternal syphilis testing and treatment in these two regions. The aim of this study was to examine perinatal patient's health preferences and perceptions of patient-provider relationships in the prenatal care clinic setting. METHODS: Between May 2018 and January 2019 we conducted 20 in-depth qualitative interviews with prenatal providers and 8 focus group discussions with pregnant and postpartum individuals in Kern County and East Baton Rouge Parish. We applied an adapted health services framework to analyze participants' understanding of health disparities and vulnerable populations; perinatal patient's health and prenatal care preferences; and participants' perspectives of clinical encounters in the context of prenatal care and maternal syphilis testing and treatment. RESULTS: Site-specific determinants of syphilis infection emerged but participants from both locations felt CS prevention efforts should be prioritized among youth, racial/ethnic minority populations, people experiencing socioeconomic limitations and people with other commonly occurring health conditions. Although perinatal patients expressed clear health preferences, they reported inconsistent receipt of respectful, patient-centered care. Inconsistencies were connected with limited ethnic and cultural competence among providers, and implicit, negative attitudes toward patients using substances, experiencing homelessness, or engaging in sex work. Providers clearly aimed to offer high quality prenatal care. However, some clinic and health systems level factors were thought to reduce positive and communicative patient-provider relationships, contributing to gaps in use of prenatal care and syphilis testing and treatment. CONCLUSIONS: Our findings suggest that interventions tailored to address setting-specific determinants (including clinic and health system factors) of disparities in CS risk could improve pregnant people's access to prenatal care and ensure they and their sex partners receive timely syphilis screening and treatment. We recommend all prenatal care providers receive training on how to identify and mitigate implicit biases and provide competent and compassionate patient-centered care.

Congenital syphilis in East Baton Rouge parish, Louisiana: providers' and women's perspectives.

BACKGROUND: Congenital syphilis is completely preventable through screening and treatment, but rates have been rising in the United States. Certain areas are at particularly high risk. We aimed to assess attitudes, knowledge, and barriers around effective prevention of congenital syphilis among health care providers and community women potentially at risk. METHODS: Two parallel studies were conducted: in-depth interviews with health care providers and focus groups with community women in the area of Baton Rouge, Louisiana. Each group was questioned about their experience in providing or seeking prenatal care, knowledge and attitudes about congenital syphilis, sources of information on testing and treatment, perceptions of risk, standards of and barriers to treatment. Results were transcribed into QSR NVivo V10, codes developed, and common themes identified and organized. RESULTS: Providers identified delays in testing and care, lack of follow-through with partner testing, and need for community connection for prevention, as major contributors to higher rates of congenital syphilis. Women identified difficulties in accessing Medicaid contributing to delayed start of prenatal care, lack of transportation for prenatal care, and lack of knowledge about testing and prevention for congenital syphilis. CONCLUSIONS: Providers and community members were in broad agreement about factors contributing to higher rates of congenital syphilis, although some aspects were emphasized more by one group or another. Evidence-based interventions, likely at multiple levels, need to be tested and implemented to eliminate congenital syphilis.

Psychological First Aid: A Model for Disaster Psychosocial Support for the Perinatal Population.

The psychosocial needs of childbearing families drastically change after a disaster. Perinatal nurses providing postdisaster maternal-newborn care at community shelters, field hospitals, or acute care facilities must be prepared as "first responders" to address the immediate psychological distress and social needs of women and families in the first few chaotic days or weeks. The purpose of this article is to demonstrate ways nurses can integrate psychosocial and interpersonal interventions in perinatal disaster care using the framework of Psychological First Aid (PFA) developed by a team of mental health experts, along with The National Child Traumatic Stress Network and the United States (US) National Center for posttraumatic stress disorder (PTSD). The PFA framework offers evidence-informed stepwise approaches nurses can employ within their scope of practice aimed at reducing disaster survivors' initial distress and to promote short- and long-term adaptive functioning. Purposive interactions are suggested to provide emotional support, empathy, and guidance to reduce stress, restore coping skills, and help families use their strengths to begin the recovery process. Nurse leaders engaged in hospital disaster planning need to ensure that essential resources and community networks are available to provide mental health and psychosocial support for childbearing women and families in a postdisaster environment.

Mental health and worries of pregnant women living through disaster recovery.

The health and well-being of pregnant women during and after natural disasters remains an international concern. In this mixed methods study we described pregnant women's mental health, psychosocial concerns and sources of stress living in New Orleans during long term recovery from Hurricane Katrina. Our survey of 402 pregnant women indicated poor social support was associated with higher levels of depression symptomology, post-traumatic stress disorder, anxiety, and stress. Women were interviewed and described seven common areas of worry. We concluded that pregnant women living in post-disaster communities have stressful lives years after the event, needing innovative models of care to build resilience.

Birth Outcomes in a Disaster Recovery Environment: New Orleans Women After Katrina.

OBJECTIVES: To examine how the recovery following Hurricane Katrina affected pregnancy outcomes. METHODS: 308 New Orleans area pregnant women were interviewed 5-7 years after Hurricane Katrina about their exposure to the disaster (danger, damage, and injury); current disruption; and perceptions of recovery. Birthweight, gestational age, birth length, and head circumference were examined in linear models, and low birthweight (<2500 g) and preterm birth (<37 weeks) in logistic models, with adjustment for confounders. RESULTS: Associations were found between experiencing damage during Katrina and birthweight (adjusted beta for high exposure = -158 g) and between injury and gestational age (adjusted beta = -0.5 days). Of the indicators of recovery experience, most consistently associated with worsened birth outcomes was worry that another hurricane would hit the region (adjusted beta for birthweight: -112 g, p = 0.08; gestational age: -3.2 days, p = 0.02; birth length: -0.65 cm, p = 0.06). CONCLUSIONS: Natural disaster may have long-term effects on pregnancy outcomes. Alternately, women who are most vulnerable to disaster may be also vulnerable to poor pregnancy outcome.

Healthy start: description of a safety net for perinatal support during disaster recovery.

Publicly funded programs and safety net organizations have key roles during post disaster recovery to care for vulnerable populations, including pregnant women with low resources. The objective of this study was to compare the health of prenatal women who accessed the New Orleans Healthy Start program to those women who only used traditional prenatal care (PNC) during long-term recovery from the Hurricane Katrina disaster. During 2010-2012, this descriptive, cross-sectional study recruited 402 prenatal women (24-40 weeks) from prenatal clinics and classes. All women were enrolled in PNC, with 282 experiencing only traditional PNC, while 120 women added Healthy Start participation to their usual PNC. Measures were obtained to determine, past hurricane experience, hurricane recovery, perceptions of prenatal care, mental health, and birth outcomes. Women accessing Healthy Start-New Orleans were more socially "at risk" (younger, lower income, not living with a partner, African American), lived through more hurricane trauma, and had a higher incidence of depression (40 %) and post-traumatic stress disorder (PTSD) (15 %) than women in traditional PNC (29 % depression; 6.1 % PTSD). Women using Healthy Start reported more mental health counseling and prenatal education than did women in only traditional PNC. Birth outcomes were similar in the two groups. The Healthy Start participants with less resources and more mental health difficulties after disaster, represented a more vulnerable population in need of additional support. This study underscores the necessity for community and governmental programs to develop disaster response plans that address needs of vulnerable populations during prolonged recovery.

Disaster research: a nursing opportunity.

Nurses working or living near a community disaster have the opportunity to study health-related consequences to disaster or disaster recovery. In such a situation, the researchers need to deal with the conceptual and methodological issues unique to postdisaster research and know what resources are available to guide them, even if they have no specialized training or previous experience in disaster research. The purpose of this article is to review issues and challenges associated with conducting postdisaster research and encourage nurses to seek resources and seize opportunities to conduct research should the situation arise. Current disaster studies and the authors' personal experiences conducting maternal-child research in post-Katrina New Orleans (2005-2013) provide real-life examples of how health professionals and nurses faced the challenges of doing postdisaster research. After catastrophic events, nurses need to step forward to conduct disaster research that informs and improves future disaster planning and healthcare responses.

Healing Touch: A Strategy for Acute Care Nurses' Stress Reduction.

The purpose of the study is to determine whether administering healing touch (HT) is more effective than deep breathing (DB) for reducing acute care nurses' stress during a shift. A randomized cluster trial assessed 150 nurses' vital signs and Visual Analog Scale for Stress (VASS) levels pre, post, and at follow-up to achieve a power of .7 and medium affect size. Open-ended questions following the intervention enriched quantitative findings describing the experience, facilitators, and barriers to potential use in nursing. The generalized estimating equation 1 (GEE1) comparisons of mean change over time, found that nurses in the HT intervention, had significantly lower VASS stress scores at posttreatment (-0.95, p = .0002) and at follow-up (-0.73, p = .0144) than the DB group, and the respiratory rate (RR) rate differences were nearly significant at post-intervention and significant at follow-up, respectively (1.36, p = .0568 and -2.28, p = .0011), indicating lower RR after HT. These findings support the use of HT as an effective stress reduction strategy as a relevant strategy to sustain a viable nurse work force post-COVID-19.

A qualitative assessment of structural barriers to prenatal care and congenital syphilis prevention in Kern County, California.

Congenital syphilis is the result of placental transmission from mother to fetus of Treponema pallidum. Although congenital syphilis is preventable through timely treatment, the rate of new infections in the United States (US) has increased each year since 2013, and is increasing at a noticeably greater pace in California (CA). Most research into congenital syphilis has focused on individual psychosocial and behavioral factors that contribute to maternal vulnerability for syphilis. The aim of this study was to evaluate structural barriers to prenatal care access and utilization and congenital syphilis prevention in Kern County, CA. Transcripts from 8 in-depth interviews with prenatal care providers and 5 focus group discussions with 42 pregnant and postpartum persons were examined using thematic analysis. Structural barriers experienced by pregnant and postpartum persons to prenatal care access and utilization included (1) burdens of poverty; (2) stigma around substance use in pregnancy; (3) citizenship status; (4) lack of healthcare coverage; (5) low sexual health literacy; and (6) gender inequality Structural barriers experienced by prenatal care providers in congenital syphilis prevention included (1) limited guidance on clinical management of syphilis in pregnancy; (2) decay in public health infrastructure; and (3) inadequate support for managing patients' social comorbidities. The response to congenital syphilis prevention will require an examination of the complex context of social determinants of health in which persons diagnosed with syphilis live in.

Experiences of Intimate Partner and Neighborhood Violence and Their Association With Mental Health in Pregnant Women.

Both intimate partner violence and neighborhood crime have been associated with worse mental health outcomes, but less is known about cumulative effects. This association was studied in a sample of pregnant women who were enrolled in a study of disaster exposure, prenatal care, and mental and physical health outcomes between 2010 and 2012. Women were interviewed about their exposure to intimate partner violence and perceptions of neighborhood safety, crime, and disorder. Main study outcomes included symptoms of poor mental health; including depression, pregnancy-specific anxiety (PA), and posttraumatic stress disorder (PTSD). Logistic regression was used to examine predictors of mental health with adjustment for confounders. Women who experienced high levels of intimate partner violence and perceived neighborhood violence had increased odds of probable depression in individual models. Weighted high cumulative (intimate partner and neighborhood) experiences of violence were also associated with increased odds of having probable depression when compared with those with low violence. Weighed high cumulative violence was also associated with increased odds of PTSD. This study provides additional evidence that cumulative exposure to violence is associated with poorer mental health in pregnant women.

Genetic influences on preterm birth.

This article summarizes the scientific evidence supporting a genetic predisposition to preterm birth (PTB) and current molecular methods used to study the genetic links. Selected candidate genes currently under consideration for study are also discussed. Understanding the etiology and pathophysiology of PTB remains at the forefront of research efforts to solve this critical problem. Awareness of the contributing factors is imperative to the development of prevention and early intervention strategies that can reduce the incidence of PTB and the consequence of long-term neonatal complications. The possibility of a genetic predisposition to preterm delivery is a relatively new area of study to emerge over the past few years, although for a long time it has been suspected that PTB results from gene-environment interactions. More advanced genetic research methods are now being applied to study this hypothesis. A sample of candidate genes under study and their speculated role in PTB are presented in this article. There will be more research that links genetic influences and environmental factors to PTB in future, and researchers are hopeful that genetic knowledge can be applied to better understand the entire spectrum of prematurity.

Association of Complementary and Alternative Therapies With Mental Health Outcomes in Pregnant Women Living in a Postdisaster Recovery Environment.

PURPOSE: The objective of this study was to determine if complementary and alternative medicine therapies are associated with mental health in postdisaster environments. DESIGN: Pregnant women (N = 402) were interviewed between 2010 and 2012 as part of a larger cross-sectional study on hurricane recovery and models of prenatal care. METHODS: Symptoms of depression (Edinburgh Postnatal Depression Screen), prenatal anxiety (Revised Prenatal Distress Questionnaire), posttraumatic stress (PCL-S), and perceived stress (PSS) were examined. Logistic regression was used to adjust for income, race, education, parity, and age. The most commonly reported therapies were prayer, music, multivitamins, massage, and aromatherapy. FINDINGS: Mental illness symptoms were common (30.7% had likely depression, 17.4% had anxiety, and 9.0% had posttraumatic stress). Massage was protective for depression (Edinburgh Postnatal Depression Index [EDSI] >8; adjusted odds ratio [aOR] = 0.6, 95% confidence interval [CI] = 0.3-0.9), while use of aromatherapy (aOR = 1.9, 95% CI = 1.1-3.2) and keeping a journal (aOR = 1.9, 95% CI = 1.1-3.2) were associated with increased odds of depression. Aromatherapy was associated with symptoms of pregnancy-related anxiety (aOR = 2.0, 95% CI = 1.1-3.8). CONCLUSIONS: Symptoms of mental illness persist after disaster, when untreated. Nurses should consider assessing for complementary and alternative medicine utilization in pregnancy as a potentially protective factor for mental health symptoms.

A multicultural and multilingual outreach program for cervical and breast cancer screening.

Partners in Health: The Breast and Cervical Health Cooperative is a New Orleans-based community health intervention program designed to increase the access of underserved multicultural, multiethnic, and multilingual women to cervical and breast cancer health education and screening. This article describes innovative approaches used over the past 4 years to successfully link the services of a university cancer center to women in the community through a culturally sensitive outreach program. In addition to cancer screening, health referrals were made for many other diverse medical/social complications such as hypertension, obesity, and violence. The program initially targeted African American women but during the past year has successfully integrated Latinas. Key to the program's success was the collaboration of community lay health educators, community churches, advanced practice nurses, and public health programs. This article provides an overview of program strategies and outcomes and discusses multicultural and multilingual issues.

Men of diverse cultures: knowledge and attitudes about breastfeeding.

OBJECTIVE: The purpose of this study was three-fold: (a) to describe the knowledge of and attitudes on breastfeeding of men from diverse racial backgrounds, (b) to determine the relationship between knowledge and attitude toward breastfeeding, and (c) to determine the relationship between specified demographic variables and men's knowledge or attitudes on breastfeeding. DESIGN: Descriptive SETTING: An inner-city teaching hospital and its associated prenatal clinic located in the southern United States. PARTICIPANTS: One hundred men from diverse cultures who spoke either English or Spanish, were 18 years of age or older, and were present at either the hospital maternity units or associated prenatal clinic. RESULTS: Eighty-one percent (81%) of the men in this study indicated that they would prefer their infants to be breastfed. Ethnicity and age were found to be linked to attitudes and knowledge of breastfeeding. CONCLUSIONS: This study demonstrated that men had a strong desire that their infants be breastfed and wanted to be included in decisions concerning breastfeeding.

Changing men's involvement in reproductive health and family planning.

The shift in focus on men's reproductive health was influenced by the 1994 Cairo (ICPD) Action Plan to promote gender equality and equity, empower women, and improve family health in society. Changing and improving the way in which men are involved in reproductive health can only have a positive impact on women's, men's, and children's health. Educating and counseling men about contraceptive choices is essential if they are to be supportive of women's reproductive health. Research on new male contraceptive methods must continue if the bias of women shouldering the major responsibility for contraception is to be eliminated.

Perinatal considerations in the hospital disaster management process.

Nurses play a vital role in providing care to mothers and infants during a disaster, yet few are fully prepared for the challenges they will encounter under extreme conditions. The ability to provide the best possible care for families begins with understanding the perinatal issues in relation to each phase of the disaster management process. This article reviews the hospital and perinatal nursing role in the mitigation, preparedness, response, and recovery phases of disaster management.

Post-Katrina perinatal mood and the use of alternative therapies.

PURPOSE AND DESIGN: The purpose of this cross-sectional, exploratory study is to describe perinatal moods and complementary alternative therapy (CAT) use among childbearing women living in New Orleans, post-Hurricane Katrina. How women coped with the disaster with limited access to mental health services was not known. METHOD: A convenience sample of 199 postpartal/expectant mothers completed two questionnaires. The Edinburgh Postnatal Depression Scale measured risk for perinatal depression (>10 for depression risk) and the Perinatal Alternative Therapy Index (PATI) obtained subjects' self-perceived overall scores for anxiety and overall mood, frequency and type of use of alternative therapies, and health behaviors. Open-ended questions solicited qualitative data. FINDINGS: The mean EPDS score was 8.47, yet 37% of the postpartum subjects had scores >or=10, indicating risk for depression, while 25% of the women in the prenatal group had scores >or=10. Ninety-five percent of women reported using CATs to improve their mood during pregnancy. Two themes emerged from the qualitative data: (a) Distress and Instability: The Katrina Effect and (b) Life Transitions. CONCLUSION: Post-Katrina, most women were proactive in seeking ways to improve their mood. Knowing that there are effective, alternative therapies to improve mood during the perinatal period, nurses and other care providers can offer more information about these nonmedical, accessible interventions.