Caring for Muslim Patients: A Primer for the Obstetrician Gynecologist.

Studies show that Muslim American patients experience discrimination and feel uncomfortable seeking appropriate health care for various reasons. Obstetrician-gynecologists should be educated regarding Islamic perspectives on topics such as modesty, sexual health, contraception, abortion, infertility, and fasting during pregnancy. Understanding the barriers Muslim patients face and improving cultural humility will improve the quality of sexual and reproductive care delivered to Muslim patients.

An assessment of postpartum contraception rates with evolving care during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic presented new care delivery obstacles in the form of scheduling procedures and safe presentation to in-person visits. Contraception provision is an indispensable component of postpartum care that was not immune to these challenges. Given the barriers to care during the initial months of the pandemic, we sought to examine how postpartum contraception, sterilization, and visit attendance were affected during this period. STUDY DESIGN: We performed a retrospective chart review to examine contraception initiation, sterilization, and postpartum virtual and in-person visit attendance rates during the first six months (March 15 to September 7, 2020) of the COVID-19 pandemic compared to the rates in the same period in the year prior at a single tertiary academic care center. We abstracted data from the first prenatal visit through twelve weeks postpartum. RESULTS: With the initiation of virtual appointments, postpartum visit attendance significantly increased (94.6 % vs 88.4 %, p < 0.001) during the pandemic with no difference in overall contraception uptake (51 % vs 54.1 %, p = 0.2) or sterilization (11.0 % vs 11.5 %, p = 0.88). During the pandemic, contraception prescribed differed significantly with a trend towards patient-administered methods including pills, patches, and rings (21 % vs 16 %, p = 0.02). In both periods, there was a significantly younger mean age (p < 0.001), higher proportion of non-White and non-Asian race (p < 0.001), public insurance (p = 0.003, 0.004), and an established contraceptive plan prenatally (p < 0.001) in the group that received contraception. CONCLUSION: As virtual postpartum visits were instituted, contraception initiation and sterilization were maintained at pre-pandemic rates and visit attendance rose despite the obstacles to care presented by the COVID-19 pandemic. Provision of virtual postpartum visits may be a driver to maintain contraception and sterilization rates at a time, such as early in the COVID-19 pandemic, when patient care is at risk to be disrupted by social distancing, isolation, and avoidance of medical campuses.

Ramadan fasting and pregnancy: an evidence-based guide for the obstetrician.

Pregnant Muslim women may be religiously exempt from fasting during the Islamic month of Ramadan, especially if there is concern for undue hardship or harm to maternal or fetal health. However, several studies demonstrate that most women still choose to fast during pregnancy and avoid discussing fasting with their providers. A targeted literature review of published studies on fasting during Ramadan and pregnancy or maternal and fetal outcomes was performed. We generally found little to no clinically significant effect of fasting on neonatal birthweight or preterm delivery. Conflicting data exist on fasting and mode of delivery. Fasting during Ramadan has been mainly associated with signs and symptoms of maternal fatigue and dehydration, with a minimal decrease in weight gain. There is conflicting data regarding the association with gestational diabetes mellitus and insufficient data on maternal hypertension. Fasting may affect some antenatal fetal testing indices, including nonstress tests, lower amniotic fluid levels, and lower biophysical profile scores. Current literature on the long-term effects of fasting on offspring suggests possible adverse effects, but more data are required. The quality of evidence was negatively impacted by the variation in defining "fasting during Ramadan" in pregnancy, study size and design, and potential confounders. Therefore, in counseling patients, obstetricians should be prepared to discuss the nuances in the existing data while demonstrating cultural and religious awareness and sensitivity to foster a trusting relationship between patient and provider. We provide a framework for obstetricians and other prenatal care providers to aid in that effort and supplemental materials to encourage patients to seek clinical advice on fasting. Providers should engage patients in a shared decision-making process and offer them a nuanced review of the evidence (including limitations) and individualized recommendations based on clinical experience and patient history. Finally, should certain patients choose to fast while pregnant, providers should offer medical recommendations, closer observation, and support to reduce harm and hardship while fasting.

Perspectives of women of refugee background on healthcare needs in a major urban metropolitan community in the US: A qualitative needs assessment.

The objective of this study was to describe the healthcare needs and experiences of women of refugee background in Chicago-home to one of the largest and most diverse refugee populations in the United States. We used a phenomenological study design with a desire-centered rather than damage-centered approach to conduct a series of focus group discussions with 24 women of refugee background in their native languages in Chicago, Illinois between December 2018 and February 2019. Convenience sampling was used to recruit women of refugee background at least 18 years of age living in the Chicago metropolitan area who attended educational women's health workshops at local refugee community centers. An inductive approach to the analysis was used to code transcripts and generate themes. Our study identified four major healthcare priorities for women of refugee background in a major metropolitan area: (1) central and centralised healthcare, (2) continuity of care, (3) trauma-informed care and (4) community engagement and partnerships. The healthcare priorities identified by the participants in this study should inform existing and future healthcare models and clinics providing care for women of refugee background in urban and sub-urban contexts across the United States.

The role of digital examination in the setting of a sonographically short cervix.

BACKGROUND: Universal transvaginal cervical length screening has been associated with a reduction in the frequency of preterm birth. However, there is no clinically set standard to guide the performance of a digital cervical examination in the setting of a sonographically short cervix. OBJECTIVE: To investigate the prevalence of cervical dilation at various midtrimester transvaginal cervical length thresholds. Furthermore, we sought to identify sonographic or clinical characteristics associated with cervical dilation that may inform who would benefit from a digital cervical examination in the setting of a sonographically short cervix. STUDY DESIGN: This retrospective cohort study was conducted at an academic institution and included women with a singleton gestation and an ultrasonographically detected short cervix (defined as a transvaginally obtained cervical length ≤25 mm) who had a documented digital cervical examination within 1 week of the ultrasonography. Bivariable analyses were used to determine the relationship between cervical length and the presence of cervical dilation. Multivariable logistic regression and receiver operating characteristic curve were used to evaluate the relationship between clinical and sonographic risk factors and cervical dilation. RESULTS: Of the 256 women who met eligibility criteria and had a sonographically detected short cervix, 103 (40.2%) were found to be dilated on digital cervical examination. The prevalence of cervical dilation increased as sonographic cervical length decreased; cervical dilation was identified in 15%, 39%, 53%, 64%, and 69% of women with a cervical length between 20.0 and 25.0 mm, 15.0 and 19.9 mm, 10.0 and 14.9 mm, 5.0 and 9.9 mm, and 0.0 and 4.9 mm, respectively. Maternal race or ethnicity (examined as a social construct), insurance status, nulliparity, previous cervical excisional procedure, funneling on ultrasonography, and sonographic cervical length were each associated with cervical dilation. However, including all of these variables into a regression yielded a model with only moderate predictive ability to identify cervical dilation, with receiver operating area under the curve of 0.77 (95% confidence interval, 0.71-0.83). CONCLUSION: Consideration should be given to performing a digital cervical examination in the setting of a sonographically short cervix (especially <20 mm) to detect cervical dilation.

Female Genital Cutting: An Evidence-based Review for the OBGYN of Long-term Sequelae and Management Options.

Female genital cutting (FGC) is a persisting global practice that increases patients' risk for experiencing long-term health sequelae. Existing meta-analysis evidence strongly supports an association between FGC and the development of long-term dyspareunia, urinary tract infections, and sexual dysfunction as well as increased risk obstetrically of prolonged labor, cesarean section, perineal lacerations, and episiotomy. Surgical defibulation is recommended in patients with type III FGC to decrease obstetric and gynecologic morbidity. Existing evidence does not seem to definitively support clitoral reconstructive surgery. More research is needed to study conservative treatment and management approaches to long-term sequelae of FGC.

The Unique Landscape of Abortion Law and Access in the Occupied Palestinian Territories.

Abortion remains a highly debated topic in women's health in the Middle East and specifically in the occupied Palestinian territories (OPT), where it is illegal in most cases. Abortion access is challenging and complex due to laws, hospital policies, and the fragmented nature of the OPT and its health care system. This paper explores several barriers to accessing safe abortion care in the OPT, many of which are unique to living under occupation and at the interface of multiple legal systems. Legal restrictions on the provision of abortion services and the negative impact of the occupation on freedom of travel create a complex landscape in which Palestinian women are forced to navigate multiple legal and medical systems when seeking abortion services.

Delivery-to-Delivery Weight Gain and Risk of Hypertensive Disorders in a Subsequent Pregnancy.

OBJECTIVE: To estimate whether weight gain between deliveries is associated with an increased risk of hypertensive disorders in a subsequent pregnancy. METHODS: This is a case-control study of women who had two live singleton births of at least 24 weeks of gestation at a single maternity hospital from January 1, 2005, to December 31, 2015, with no hypertensive disorder documented in the index pregnancy. Maternal weight gain between deliveries was measured as the change in body mass index (BMI) at delivery. Women who were diagnosed with any hypertensive disorder in the subsequent pregnancy were compared with those who experienced no hypertensive disorder in the subsequent pregnancy using χ statistics for categorical variables and t tests for continuous variables. Logistic regression was used to determine whether weight gain remained independently associated with hypertensive disorders after adjusting for potential confounders. RESULTS: Of 1,033 women, 188 (18.2%) were diagnosed with a hypertensive disorder in the subsequent pregnancy. Of these, 166 (88.3%) had a hypertensive disorder specific to pregnancy (gestational hypertension; preeclampsia; superimposed preeclampsia; or hemolysis, elevated liver enzymes, and low platelet count syndrome), and 22 (11.7%) had chronic hypertension only. Greater weight gain between deliveries was significantly associated with a higher frequency of hypertensive disorders, which remained significant for a BMI increase of at least 2 kg/m in multivariable analyses (adjusted odds ratio [OR] 1.76, 95% CI 1.14-2.74 for 2 to less than 4 kg/m, adjusted OR 3.19, 95% CI 1.86-5.47 for 4 kg/m or more). Conversely, weight loss of 2 kg/m or more was associated with a decreased risk of a hypertensive disorder (adjusted OR 0.41, 95% CI 0.21-0.81). CONCLUSION: Among women with no hypertensive disorder noted in an index pregnancy, an increase in BMI of at least 2 kg/m between deliveries was independently associated with an increased risk of a hypertensive disorder in a subsequent pregnancy.

Perspectives on induced abortion among Palestinian women: religion, culture and access in the occupied Palestinian territories.

Induced abortion is an important public health issue in the occupied Palestinian territories (OPT), where it is illegal in most cases. This study was designed to elicit the views of Palestinian women on induced abortion given the unique religious, ethical and social challenges in the OPT. Sixty Palestinian women were interviewed on their perceptions of the religious implications, social consequences and accessibility of induced abortions in the OPT at Al-Makassed Islamic Charitable Hospital in East Jerusalem. Themes arising from the interviews included: the centrality of religion in affecting women's choices and views on abortion; the importance of community norms in regulating perspectives on elective abortion; and the impact of the unique medico-legal situation of the OPT on access to abortion under occupation. Limitations to safe abortion access included: legal restrictions; significant social consequences from the discovery of an abortion by one's community or family; and different levels of access to abortion depending on whether a woman lived in East Jerusalem, the West Bank, or Gaza. This knowledge should be incorporated to work towards a legal and medical framework in Palestine that would allow for safe abortions for women in need.

Attitudes of Palestinian medical students on the geopolitical barriers to accessing hospitals for clinical training: a qualitative study.

BACKGROUND: The movement of Palestinians in the occupied Palestinian territories is restricted by bureaucratic and physical obstacles. To date, no studies have examined the barriers that Palestinian medical students face in accessing hospitals for clinical training. The objectives of this study were to characterize these barriers and understand how they affect Palestinian students' medical education and quality of life. METHODS: Convenience sampling was used to recruit 4th-6th year medical students from Al-Quds University to participate in focus group discussions. A total of 36 students participated in the discussions. Transcripts of the discussions were coded to identify major themes. RESULTS: Palestinian medical students expressed facing numerous challenges during their clinical training. Students emphasized the difficulties of obtaining permits to train at Jerusalem hospitals, including arbitrary permit rejections and long wait times. Significant delays, searches, and mistreatment at checkpoints during their commute to hospitals were particularly burdensome. The majority of students who participated in the focus groups felt that their education and quality of life had been strongly negatively affected by their experience trying to access hospital training sites. CONCLUSIONS: Our findings suggest that medical students living and studying in the occupied Palestinian territories receive sub-optimal training due to ambiguous permit rules, barriers at checkpoints, and the psychological burden of the process. These results highlight the impact that military occupation has on the education and quality of life of Palestinian medical students in a setting in which there is regular violence and many health indicators are already poor.

Cross-Cultural Obstetric and Gynecologic Care of Muslim Patients.

With the growing number of Muslim patients in the United States, there is a greater need for obstetrician-gynecologists (ob-gyns) to understand the health care needs and values of this population to optimize patient rapport, provide high-quality reproductive care, and minimize health care disparities. The few studies that have explored Muslim women's health needs in the United States show that among the barriers Muslim women face in accessing health care services is the failure of health care providers to understand and accommodate their beliefs and customs. This article outlines health care practices and cultural competency tools relevant to modern obstetric and gynecologic care of Muslim patients, incorporating emerging data. There is an exploration of the diversity of opinion, practice, and cultural traditions among Muslims, which can be challenging for the ob-gyn who seeks to provide culturally competent care while attempting to avoid relying on cultural or religious stereotypes. This commentary also focuses on issues that might arise in the obstetric and gynecologic care of Muslim women, including the patient-physician relationship, modesty and interactions with male health care providers, sexual health, contraception, abortion, infertility, and intrapartum and postpartum care. Understanding the health care needs and values of Muslims in the United States may give physicians the tools necessary to better deliver high-quality care to this minority population.

A comparative study of outcomes for endoscopic diverticulotomy versus external diverticulectomy.

OBJECTIVES: Current literature on the treatment of Zenker's diverticulum (ZD) favors the use of various endoscopic procedures over external surgical techniques for patients, arguing that endoscopic approaches reduce intraoperative time and anesthesia, length of hospital stay, and days until oral diet is restarted. However, such techniques often have higher symptomatic recurrence rates and require further interventions. Because of our experience with both endoscopic diverticulotomy (ENDO) and external diverticulectomy (EXT) using the GIA-stapler, we sought to compare these 2 procedures in terms of in-hospital parameters, complications, return to normal diet, and rates of symptom recurrence. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary care hospital. SUBJECTS: Patients with Zenker's diverticulum who underwent surgical repair. METHODS: Retrospective analysis of 67 patients seen at Brigham and Women's Hospital between 1990 and 2012 with Zenker's diverticulum who underwent either an endoscopic Zenker's procedure (36) or an external stapler-assisted diverticulectomy with cricopharyngeal myotomy (31). RESULTS: Although the external stapler-assisted procedure for ZD does carry a longer intraoperative time and a slightly longer hospital stay than the endoscopic approach, it provides similar days until initiation of an oral diet and a similar incidence of postoperative complications. Further, it is superior to the endoscopic approach when one considers its much lower rate of symptomatic recurrence and need for revision procedures. CONCLUSION: We argue that the external stapler-assisted diverticulectomy with cricopharyngeal myotomy should be considered as a viable treatment in patients who need definitive, single-session treatment for ZD, especially to prevent life-threatening aspiration pneumonia.