Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan.

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

An integrated newborn care kit (iNCK) to save newborn lives and improve health outcomes in Gilgit Baltistan (GB), Pakistan: study protocol for a cluster randomized controlled trial.

BACKGROUND: Ongoing high neonatal mortality rates (NMRs) represent a global challenge. In 2021, of the 5 million deaths reported worldwide for children under five years of age, 47% were newborns. Pakistan has one of the five highest national NMRs in the world, with an estimated 39 neonatal deaths per 1,000 live births. Reducing newborn deaths requires sustainable, evidence-based, and cost-effective interventions that can be integrated within existing community healthcare infrastructure across regions with high NMR. METHODS: This pragmatic, community-based, parallel-arm, open-label, cluster randomized controlled trial aims to estimate the effect of Lady Health Workers (LHWs) providing an integrated newborn care kit (iNCK) with educational instructions to pregnant women in their third trimester, compared to the local standard of care in Gilgit-Baltistan, Pakistan, on neonatal mortality and other newborn and maternal health outcomes. The iNCK contains a clean birth kit, 4% chlorhexidine topical gel, sunflower oil emollient, a ThermoSpot™ temperature monitoring sticker, a fleece blanket, a click-to-heat reusable warmer, three 200 µg misoprostol tablets, and a pictorial instruction guide and diary. LHWs are also provided with a handheld scale to weigh the newborn. The primary study outcome is neonatal mortality, defined as a newborn death in the first 28 days of life. DISCUSSION: This study will generate policy-relevant knowledge on the effectiveness of integrating evidence-based maternal and newborn interventions and delivering them directly to pregnant women via existing community health infrastructure, for reducing neonatal mortality and morbidity, in a remote, mountainous area with a high NMR. TRIAL REGISTRATION: NCT04798833, March 15, 2021.

"No, You Need to Explain What You Are Doing": Obstetric Care Experiences and Preferences of Adolescent Mothers With a History of Childhood Trauma.

STUDY OBJECTIVE: To understand the pregnancy and childbirth experiences and preferences of adolescent mothers with a history of childhood trauma in order to develop trauma-informed care practice recommendations for this unique group. DESIGN: Mixed methods convergent parallel design involving completion of the Adverse Childhood Experiences (ACE) questionnaire, a survey of care experiences and preferences during pregnancy and delivery, and a one-on-one interview. SETTING: hHospital-based medical home program for pregnant and parenting adolescents. PARTICIPANTS: Adolescent and young adult mothers aged 12-22 years, receiving care between June 2018 and June 2019. RESULTS: A total of 29 adolescent mothers completed the questionnaire, out of a potential 38 in the program (76.3% participation). Five went on to complete an interview. The average age was 17.9 years (standard deviation 1.8 years). The mean ACE score was 5.1 out of 10, indicating childhood exposure to an average of 5 different types of potential trauma. A total of 19 participants (65.5%) reported being triggered during pregnancy or postpartum. Trauma memories were elicited during vaginal examinations in the clinic (27.6%) and in the hospital (27.6%), abdominal examinations (13.8%), measurement of vital signs (17.2%), and labor (17.2%). Ten participants (34.5%) felt that the providers delivering their baby knew how to help them cope with trauma memories. Themes that emerged included the following: acknowledgment of trauma by provider, avoiding re-telling of story, building a relationship with provider, choice and control in care, and providing coping strategies. CONCLUSION: A majority of adolescent mothers in our sample experienced trauma memories during pregnancy and postpartum medical interactions. Priorities for trauma-informed care in this population are described.

Prevalence of Rheumatic Heart Disease and Other Cardiac Conditions in Low-Risk Pregnancies in Kenya: A Prospective Echocardiography Screening Study.

Background: Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking. Objectives: Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients. Methods: We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample. Results: The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0-14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6-36.7). Mean screening time was seven minutes (SD 1.7, range: 4-17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6-23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate. Conclusions: The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study.

BACKGROUND: The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. METHODS: The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10-19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. RESULTS: There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. CONCLUSIONS: A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.

The impact of a global health elective on CanMEDS competencies and future practice.

BACKGROUND: There is evidence that participating in global health electives generates positive educational outcomes and personal benefits for medical trainees. The objective of this study was to examine the effect and impact that a global health elective has on CanMEDS competencies and anticipated future practice. RESULTS: The medical expert, collaborator, leader, scholar, and professional CanMEDS competencies were self-perceived to be strongly impacted through this elective. A total of 94% of participants indicated it increased their strengths as a medical expert and leader, 82% indicated a major impact on the scholar competency, 88% of participants reported a strong impact as a professional, and 76% of participants indicated that it strongly impacted them as a collaborator. The majority of participants continue to have involvement in global health, and 88% of respondents found this elective to be influential on their current practice and beliefs. CONCLUSIONS: These results suggest that individuals who participated in this global health elective perceived value in their experience. These findings support our hypothesis that participation in this global health elective would generate self-perceived positive impacts. Global health electives may provide an opportunity for physicians to expand on their CanMEDS competencies and become more proficient in caring for diverse patient populations.

Uterine artery and umbilical vein blood flow are unaffected by moderate habitual physical activity during pregnancy.

OBJECTIVE: This study aims to noninvasively quantify blood flow in the uterine arteries (UTAs) and umbilical vein (UV) using phase-contrast magnetic resonance imaging (PC-MRI) and test whether these correlate with maternal fitness parameters. METHOD: Resting UTA and UV flows were measured in 23 healthy 30 ± 3-year-old women who engaged in moderate-intensity physical activity during pregnancy. Participant fitness was characterized in the second and third trimesters using the submaximal oxygen uptake (VO2 ) test measuring heart rate (HR), VO2 , ventilation (ventilatory equivalent [VE]/VO2 ), and the Borg rating of perceived exertion (respiratory quotient [RQ]). Linear regression models were used to determine the associations between blood flow and maternal fitness measures. RESULTS: Blood flows in the UTA (957 ± 241 mL/min) and UV (132 ± 38 mL/min/kg) were successfully measured in 20 (87%) participants. Neither was associated with any physical fitness parameters (HR, VO2 , VE/VO2 , and RQ) nor with any second-to-third trimester change in these parameters. CONCLUSION: PC-MRI can be used to noninvasively measure blood flow in the UTA and UV. Neither resting UTA nor UV flow is associated with maternal fitness parameters. This is the first MRI-based study to provide novel hemodynamic data suggesting decoupling between maternal moderate fitness level and the maternal-placental-fetal hemodynamic system in healthy, normal body mass index (BMI) pregnancies.

A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.

Cervico-vaginal inflammatory cytokine alterations after intrauterine contraceptive device insertion: A pilot study.

In a prospective study of twenty sexually transmitted infection (STI)-free women, we examined the impact of an intrauterine contraceptive device (IUCD) insertion on cervico-vaginal cytokine levels. Nine women chose the levonorgestrel-containing IUCD and eight chose a copper IUCD. A cervico-vaginal swab was collected for cytokine analysis pre-insertion and four weeks post-insertion. Significant increases were noted in levels of IL-1α (median 483.4 versus 316.6 pg/mL, p = 0.046), IL-1ß (median 605.7 versus 147.3 pg/mL, p = 0.018), IL-6 (median 570.1 versus 157.3 pg/mL, p = 0.046), TNFα (median 1.19 versus 0.6 pg/mL, p = 0.029) and the chemokine MCP-1 (median 340.2 versus 135.2 pg/mL, p = 0.003). No significant changes were noted in the levels of GM-CSF, IL-8, MIG, MIP-3α, RANTES, IL-10, IL-17, IP-10, MIP-1ß. Whether this increase in pro-inflammatory cytokine levels decreases epithelial barrier integrity and enhances susceptibility to STIs, including HIV, merits further study.

Use of Audio Computer-Assisted Self-Interviews to Gather Information on Risk Behaviors in a Population of Pregnant Adolescents.

In a prospective study comparing the use of the Audio Computer-Assisted Self-Interview (ACASI) with a traditional clinical interview in 40 pregnant adolescents, there was significantly greater disclosure of violence with the ACASI method. Better identification of high-risk behaviors may help to optimize care and programing for pregnant adolescents.

The Who, What, Why and When of Gynaecological Referrals for Refugee Women.

Refugees have health needs relating to unstable living situations and poor access to care. We examined the nature of health problems requiring gynaecological referrals for refugee women in Toronto. A retrospective cohort design was used to examine gynaecologic referrals of women at a refugee clinic between December, 2011 and June, 2016. The primary outcome measure was the indications for gynaecological referral. 125 out of 1040 women received a gynaecologic referral for 131 unique concerns. The most common referrals were for abnormal uterine bleeding and cervical dysplasia. Fibroids were prevalent amongst African patients, while referrals for LARCs/sterilization were absent from Middle Eastern patients. 26% of patients referred had a sexual violence history. Refugee women exhibit gynaecologic needs similar to the broader population. Needs vary by geographic origins. As global conflicts shift, so too will this population's needs. High rates of sexual violence history reflect the need for further understanding and intervention.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.