Homelessness in Pregnancy and Increased Risk of Adverse Outcomes: A Retrospective Cohort Study.

Limited data indicates that homelessness during pregnancy is linked to adverse outcomes for both mothers and newborns, but there is an information gap surrounding pregnant individuals struggling with homelessness. In a landscape of increasing healthcare disparities, housing shortages and maternal mortality, information on this vulnerable population is fundamental to the creation of targeted interventions and outreach. The current study investigates homelessness as a risk factor for adverse obstetrical, neonatal, and postpartum outcomes. We reviewed more than 1000 deliveries over 1 year at a large public hospital in New York City, comparing homeless subjects to a group of age-matched, stably housed controls. Multiple outcomes were assessed regarding obstetrical, neonatal, and postpartum outcomes along with social stressors. Homeless pregnant individuals were more likely to experience numerous adverse outcomes, including cesarean delivery and preterm delivery. Their neonates were more likely to undergo an extended stay in the intensive care unit and evaluation by the Administration for Children's Services, suggesting that they may be at an increased risk for family separation. After delivery, patients were less likely to exclusively breastfeed or return for their postpartum visit. Regarding personal history, they were more likely to endorse a history of violence or abuse, use illicit substances, and carry a psychiatric diagnosis. These findings indicate that homelessness is linked to numerous adverse obstetrical, neonatal, and postpartum outcomes that worsen health indices and exacerbate pre-existing disparities. Initiatives must focus on improved outreach and care delivery for homeless pregnant individuals.

Impact of Sulfadoxine-Pyrimethamine Resistance on Effectiveness of Intermittent Preventive Therapy for Malaria in Pregnancy at Clearing Infections and Preventing Low Birth Weight.

BACKGROUND: Owing to increasing sulfadoxine-pyrimethamine (SP) resistance in sub-Saharan Africa, monitoring the effectiveness of intermittent preventive therapy in pregnancy (IPTp) with SP is crucial. METHODS: Between 2009 and 2013, both the efficacy of IPTp-SP at clearing existing peripheral malaria infections and the effectiveness of IPTp-SP at reducing low birth weight (LBW) were assessed among human immunodeficiency virus-uninfected participants in 8 sites in 6 countries. Sites were classified as high, medium, or low resistance after measuring parasite mutations conferring SP resistance. An individual-level prospective pooled analysis was conducted. RESULTS: Among 1222 parasitemic pregnant women, overall polymerase chain reaction-uncorrected and -corrected failure rates by day 42 were 21.3% and 10.0%, respectively (39.7% and 21.1% in high-resistance areas; 4.9% and 1.1% in low-resistance areas). Median time to recurrence decreased with increasing prevalence of Pfdhps-K540E. Among 6099 women at delivery, IPTp-SP was associated with a 22% reduction in the risk of LBW (prevalence ratio [PR], 0.78; 95% confidence interval [CI], .69-.88; P < .001). This association was not modified by insecticide-treated net use or gravidity, and remained significant in areas with high SP resistance (PR, 0.81; 95% CI, .67-.97; P = .02). CONCLUSIONS: The efficacy of SP to clear peripheral parasites and prevent new infections during pregnancy is compromised in areas with >90% prevalence of Pfdhps-K540E. Nevertheless, in these high-resistance areas, IPTp-SP use remains associated with increases in birth weight and maternal hemoglobin. The effectiveness of IPTp in eastern and southern Africa is threatened by further increases in SP resistance and reinforces the need to evaluate alternative drugs and strategies for the control of malaria in pregnancy.

Lopinavir/ritonavir-based antiretroviral treatment (ART) versus efavirenz-based ART for the prevention of malaria among HIV-infected pregnant women.

BACKGROUND: Human immunodeficiency virus (HIV)-infected pregnant women are at increased risk of malaria and its complications. In vitro and in vivo data suggest that the HIV protease inhibitors lopinavir/ritonavir may have potent antimalarial activity. We sought to evaluate whether lopinavir/ritonavir-based antiretroviral therapy (ART) reduced the risk of placental malaria. METHODS: HIV-infected, ART-naive pregnant women were enrolled between gestational weeks 12 and 28 and randomly assigned to receive lopinavir/ritonavir-based or efavirenz-based ART. Women received daily trimethoprim-sulfamethoxazole prophylaxis and insecticide-treated bed nets at enrollment and were followed up to 1 year after delivery. The primary outcome was placental malaria, defined by the detection of malaria parasites, using microscopy or polymerase chain reaction (PCR) analysis of placental blood specimens. Secondary outcomes included placental malaria, defined by histopathologic results; adverse birth outcomes; incidence of malaria; and prevalence of asymptomatic parasitemia. Analyses were done using an intention-to-treat approach. RESULTS: Of 389 subjects randomly assigned to a treatment group, 377 were followed through to delivery. There was no significant difference in the risk of placental malaria, as defined by thick smear or PCR findings, between the lopinavir/ritonavir-based and efavirenz-based ART arms (7.4% vs 9.8%; P = .45). Similarly, there were no differences in secondary outcomes between the 2 treatment arms. CONCLUSIONS: Lopinavir/ritonavir-based ART did not reduce the risk of placental or maternal malaria or improve birth outcomes, compared with efavirenz-based ART. CLINICAL TRIALS REGISTRATION: NCT00993031.

Household food insecurity, maternal nutritional status, and infant feeding practices among HIV-infected Ugandan women receiving combination antiretroviral therapy.

Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.

Neonatal mortality in HIV-exposed infants born to women receiving combination antiretroviral therapy in Rural Uganda.

As human immunodeficiency virus (HIV)-infected women gain access to combination antiretroviral therapy throughout sub-Saharan Africa, a growing number of infants are being born HIV-exposed but uninfected. Data about neonatal mortality and the impact of premature delivery, in this population are limited. We describe the 28-day mortality outcomes in a cohort of HIV-exposed infants who had ultrasound-confirmed gestational age in rural Uganda. There were 13 deaths among 351 infants, including 9 deaths in the perinatal period. Premature delivery was a strong predictor of mortality. The prevention of HIV transmission to infants is now possible in rural low-resource settings but the frequency of neonatal death among HIV-exposed infants remains extremely high, calling for new comprehensive interventions to reduce mortality in this growing population.

Medical evidence in asylum applications: Medical versus legal approaches.

The purpose of this narrative review is to elucidate the ways the clinicians working on forensic medical evaluations can engage with asylum proceedings. We compare the legal and medical perspectives on different aspects of forensic medical evidence, asylum evaluations, and asylum applications. As asylum seekers must demonstrate a well-founded fear of persecution in order to receive asylee status, legal and medical professionals often need to collaborate in asylum cases. Although significant evidence has demonstrated that an objective expert medical opinion can support asylum claims, few studies have analyzed how the medical professional's role complements or is at odds with the goals of the legal system. This review summarizes and compares key aspects of the medical and legal perspectives on trauma, credibility, autobiographical memory, and medical evidence to better comprehend the role that medical professionals can play in writing medical affidavits for asylum applications. We dissect legal misconceptions surrounding trauma and the consequences of such misunderstandings and make recommendations for medical evaluators who are working in a forensic capacity.

Sex Trafficking in New York City and Vulnerabilities to Re-Trafficking.

Human trafficking occurs in a cycle of coercion and exploitation of vulnerable people; yet, little is known about those who are trafficked more than one time (re-trafficked). Our study sought to describe the trafficking experiences and explore vulnerabilities to re-trafficking in an urban, majority immigrant, population. This study is part of a parent cohort study that enrolls patients at the EMPOWER Center in New York City, which provides trauma-informed obstetric and gynecologic services to victims of sexual- and gender-based violence. Retrospective chart review was conducted on patients with a history of sex trafficking who were evaluated at the EMPOWER Center from February 2013 to January 2021. A total of 87 patients were enrolled in this study, 23 (26.4%) of whom had been re-trafficked. All were women. Most (88.5%) were victims of international trafficking, most often from Mexico or the Caribbean/Central America. Nine (10.3%) reported contraceptive use and six (6.9%) experienced forced substance use while trafficked. The most reported barriers that women faced in escaping trafficking were threat of violence (28.7%) and financial dependence (19.5%). Re-trafficked patients were more likely to have a history of being undocumented (odds ratio [OR] = 5.29; 95% confidence intervals [CI] [1.34, 20.94]) and experienced childhood sexual abuse (OR = 2.99; 95% CI [1.10, 8.16]), experienced childhood physical abuse (OR = 3.33; 95% CI [1.18, 9.39]), and lived with a non-parent family member (OR = 6.56; 95% CI [1.71, 25.23]). Although these vulnerabilities were no longer significant when analyzed in a parsimonious multivariate logistic regression model adjusting for the other significant variables, likely due to the limited sample size. Almost half (46.0%) reported ongoing emotional effects from being trafficked, which did not vary by re-trafficking status. Our study highlights potential pre-trafficking vulnerabilities, illustrates the complexity of the trafficking experience, and presents potential risk factors for being re-trafficked.

Are Screening Tools for Identifying Human Trafficking Victims in Health Care Settings Validated? A Scoping Review.

OBJECTIVE: Although many screening tools, resources, and programs for identifying victims of human trafficking exist, consensus is lacking on which tools are most useful, which have been validated, and whether they are effective. The objectives of this study were to determine what tools exist to identify or screen for victims of human trafficking in health care settings and whether these tools have been validated. METHOD: We conducted a scoping review of the literature on human trafficking identification in health care settings following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) protocol for scoping reviews. We searched the MEDLINE, PsycInfo, Embase, and Scopus databases without language or date limitations. Two independent reviewers screened each citation. We included human research studies in English with populations of all ages, all genders, all geographic locations, and using quantitative and/or qualitative research methods. We excluded studies that were not conducted in a health care setting, review articles, and meta-analyses. We summarized additional screening tools available online and identified through hand-searching. RESULTS: Database searches yielded 8730 studies, of which 4806 remained after removing duplicates. We excluded 4720 articles based on title/abstract review, we reviewed 85 full-text studies for eligibility, and we included 8 articles. Hand-searching revealed 9 additional screening tools not found in the literature. Through our search for validated screening tools, only 6 had been studied for validation in health care settings. CONCLUSIONS: Few studies have evaluated screening tools for identifying victims of human trafficking in health care settings. The absence of a gold standard for human trafficking screening and lack of consensus on the definition of human trafficking make screening tool validation difficult. Further research is required for the development of safe, effective approaches to patient screening.

Polyvictimization and Psychiatric Sequelae Associated with Female Genital Mutilation/Cutting (FGM/C).

Female Genital mutilation/cutting (FGM/C) is associated with enduring psychiatric complications. In this study, we investigate the rates of co-morbid abuses and polyvictimization experienced by survivors of FGM/C. This is a sub-analysis of a cohort study examining the patient population at the EMPOWER Center for Survivors of Sex Trafficking and Sexual Violence in New York City. A retrospective chart-review of electronic medical records was conducted for all consenting adult patients who had FGM/C and had an intake visit between January 16, 2014 and March 6, 2020. Of the 80 participants, ages ranged from 20 to 62 years with a mean of 37.4 (SD = 9.1) years. In addition to FGM/C, participants were victims of physical abuse (43; 53.8%), emotional abuse (35; 43.8%), sexual abuse (35; 43.8%), forced marriage (20; 25%), child marriage (13; 16.3%), and sex trafficking (1; 1.4%). There was a high degree of polyvictimization, with 41 (51.2%) experiencing 3 or more of the aforementioned abuses. Having FGM/C on or after age 13 or having a higher total abuse score was also found to be strong predictors of depression and PTSD. The high rates of polyvictimization among survivors of FGM/C are associated with development of depression and PTSD. Despite co-morbid abuses, patients still attribute substantial psychiatric symptoms to their FGM/C. Health care providers should understand the high risk of polyvictimization when caring for this patient population.

Perceptions of Female Genital Mutilation/Cutting (FGM/C) among Asylum Seekers in New York City.

Female Genital Mutilation/Cutting (FGM/C) affects millions of girls and women globally each year despite widespread criminalization of the practice. Eradication efforts have focused on the health risks associated with FGM/C however, it is important to understand the sociocultural context in which this practice exists. We conducted a cross-sectional study using retrospective chart review and structured interviews with women recruited through the Bellevue/New York University Program for Survivors of Torture. Of the 43 participants enrolled in the study, 88.4% initially indicated there is no benefit of undergoing FGM/C but when prompted, agreed that social acceptance (16.3%), religious approval (11.6%), and better marriage prospects (9.3%) are possible benefits. More sexual pleasure for the women (46.5%), avoiding pain (30.2%), and fewer medical problems (16.3%) were stated as benefits of not undergoing FGM/C. Overall, 40 (93%) participants believed the practice should be discontinued. This study highlights that there may be a perception of social benefit of undergoing FGM/C. Although most participants believed the practice should be discontinued, the complex social milieu within which this practice exists must be addressed.

A prospective cohort study comparing expulsion after postplacental insertion: the levonorgestrel versus the copper intrauterine device.

OBJECTIVES: To compare the expulsion rate at 6 months after postplacental insertion by intrauterine device (IUD) type. STUDY DESIGN: This prospective cohort included participants with a postplacental IUD inserted after vaginal or cesarean delivery, aged 18-45 and ≥24 weeks' gestation. Study enrollment took place after IUD selection and insertion. Participants returned for a postpartum visit and received a short message service survey regarding IUD expulsion, removal, vaginal bleeding and breastfeeding weekly from weeks 0 to 5 and on weeks 12 and 24 postpartum. Multivariable logistic regression examined 6-month expulsion rate by IUD type adjusting for variables that differed between the groups at baseline and in the bivariate analyses. RESULTS: Of 114 participants, 75 (65.8%) chose a levonorgestrel 52-mg IUD and 39 (34.2%) chose a copper IUD; 58 (50.9%) had a vaginal delivery, and 56 (49.1%) had a cesarean delivery. Groups were similar except that copper IUD users had a higher median parity (3 vs. 2, p=.03) and a higher proportion of senior residents compared to junior residents had performed insertion (46.2% vs. 22.7%, p=.02). The expulsion rate at 6 months was similar between the levonorgestrel and copper groups (26.7% and 20.5%, respectively; p=.38). Multivariable logistic regression also demonstrated that the odds of expulsion did not differ by IUD type (adjusted odds ratio 0.98, 95% confidence interval 0.22-4.48). CONCLUSION: The expulsion rate at 6 months after postplacental insertion did not differ between the levonorgestrel and copper IUD type. IMPLICATIONS: Prior studies demonstrate a wide range of expulsion after postplacental insertion, and recent data suggest a higher expulsion rate for the levonorgestrel compared to the copper intrauterine device. However, many studies did not control for patient-level factors or delivery route. We found that when controlling for these confounding variables, the expulsion rate at 6 months postpartum did not differ by intrauterine device type.

An Integrated, Trauma-Informed Care Model for Female Survivors of Sexual Violence: The Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) Clinic.

This article describes the Engage, Motivate, Protect, Organize, self-Worth, Educate, Respect (EMPOWER) Clinic for Survivors of Sex Trafficking and Sexual Violence located at Gouverneur Health in New York, New York, as a model for integrated gynecologic and psychiatric care of survivors of sexual and gender-based violence. Although patients with a history of sexual trauma often have critical health needs that persist long after the traumatic event, most existing services for survivors of sexual violence focus solely on the provision of acute care immediately after the violence has occurred. There are very few clinics in the United States dedicated to managing the significant long-term medical consequences and sequelae of sexual violence in a trauma-informed setting. We report on best practices for the provision of trauma-sensitive medical care to this patient population based on those employed at the EMPOWER Clinic. In particular, we outline some of the unique considerations for treating survivors relating to taking a patient history, conducting the physical and gynecologic examinations, ensuring confidentiality, and managing legal issues. Finally, we reflect on the challenges faced in sustaining the EMPOWER Clinic and the importance of the existence of a clinic dedicated to this specific population.

On Female Genital Cutting: Factors to be Considered When Confronted With a Request to Re-infibulate.

According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient's physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.

Group education sessions for women veterans who experienced sexual violence: Qualitative findings.

INTRODUCTION: The impact of sexual violence (SV) on mental health, self-care, and interpersonal relationships is profound and poses special challenges to health care delivery. Reproductive health care merits special attention because the care required may be linked to reminders of past abuse. We explored facilitators and barriers affecting the use of reproductive health services among women veterans with a history of SV. METHOD: Between June and September 2015, we conducted 2 focus groups and 3 general education sessions with 27 female veterans with a history of SV at 1 medical center. We analyzed transcripts according to applied thematic analysis and used Nvivo software for data management and retrieval. RESULTS: Three main themes emerged from the focus groups and education sessions. PARTICIPANTS: (a) expressed a desire for greater agency in relation to the control they have over their bodies and medical care; (b) described how posttraumatic stress symptoms are retriggered during medical care; and (c) expressed needs for additional education, peer and provider support within the medical system. DISCUSSION: For women with a history of SV, multiple individual and systemic barriers complicate how they utilize reproductive health services. Group education sessions were an effective mode of support, information and connection to other women within the Veterans Health Administration. (PsycINFO Database Record

Contraceptive Knowledge Assessment: validity and reliability of a novel contraceptive research tool.

OBJECTIVES: Clinicians and researchers need an accurate tool assessing contraceptive knowledge in order to understand the effectiveness of teaching efforts. However, most widely used indices are outdated. The objective of this study is to create an evidence-based assessment tool and determine its validity and reliability for measuring contraceptive knowledge. STUDY DESIGN: The study team developed the 25-question multiple-choice tool entitled the Contraceptive Knowledge Assessment (CKA). Expert reviewers examined content validity and semistructured patient interviews acquired feedback on subject matter and comprehension. A two-tiered approach explored criterion validity via (1) comparison with the gold standard (Contraceptive Knowledge Inventory) and (2) comparison between groups with lower and higher contraceptive knowledge. Repeat testing after 2-4 weeks evaluated test-retest reliability. RESULTS: Six experts and seven patients provided feedback on the initial CKA. One hundred two reproductive-aged male and female patients and 27 medical students completed the final CKA with an overall mean patient score of 9/25 (36%). The mean score on the CKA was higher than the mean score on the gold standard (9.1 vs. 5.8, p<.001). Patients scored lower on the CKA than did medical students (9.1 [36.4%] vs.19.4 [77.6%], p<.005). There were no differences within patients' results with repeat testing over time (p=.667). CONCLUSIONS: The CKA is a valid and reliable tool to measure a patient's level of knowledge regarding contraception. This research tool may allow for the assessment of baseline knowledge, educational gaps, and improvement after an intervention. Knowledge may be lower than previous studies suggest, signifying need for improved education on contraception and better understanding of the relationship between knowledge and behavior change. IMPLICATIONS: The CKA provides an evidence-based, reliable, and validated assessment of contraceptive knowledge. This modern tool may help to determine the effectiveness of interventions to improve education on contraception.

Efficacy and safety of lopinavir/ritonavir versus efavirenz-based antiretroviral therapy in HIV-infected pregnant Ugandan women.

OBJECTIVE: Combination antiretroviral therapy (ART) is now the global standard for HIV-infected pregnant and breastfeeding women at all CD4⁺ cell counts. We compared the efficacy and safety of an efavirenz versus lopinavir/ritonavir regimen for HIV-infected pregnant women initiating ART in rural Uganda. DESIGN: Randomized clinical trial. METHODS: We performed a planned secondary analysis comparing viral load suppression (HIV-1 RNA ≤400 copies/ml), safety, and HIV transmission to infants in a trial designed to test the hypothesis that lopinavir/ritonavir versus efavirenz-based ART would reduce placental malaria (PROMOTE, ClinicalTrials.gov, NCT00993031). HIV-infected, ART-naive pregnant women at 12-28 weeks gestation and any CD4⁺ cell count were randomized. ART was provided and participants were counseled to breastfeed for 1 year postpartum. RESULTS: The median age of the 389 study participants was 29 years; median CD4⁺ cell count was 370 cells/µl. At delivery, virologic suppression was 97.6% in the efavirenz arm and 86.0% in the lopinavir/ritonavir arm (P < 0.001). At 48 weeks postpartum, 91.0% of women on efavirenz and 88.4% on lopinavir/ritonavir had viral suppression (P = 0.49). Grade 1 or 2 gastrointestinal adverse events were higher among women on lopinavir/ritonavir versus efavirenz. Only two infants acquired HIV (both in the lopinavir/ritonavir arm), and HIV-free infant survival was similar between study arms: 92.9% (lopinavir/ritonavir) versus 97.2% (efavirenz) (P = 0.10). CONCLUSION: Virologic suppression at delivery was higher with an efavirenz versus lopinavir/ritonavir-based regimen. However, women in both arms achieved high levels of virologic suppression through 1 year postpartum and the risk of transmission to infants was low.