Texting in the Fourth Trimester: mHealth for Postpartum Care.

Objective Rising maternal morbidity and mortality in the US is a complex problem and is often tied to the postpartum period. Postpartum visits are poorly attended leading to gaps in contraception, mental healthcare, and care for chronic conditions. mHealth, healthcare supported by mobile technologies, has been shown to improve antenatal care adherence. Our study aims to determine whether an mHealth intervention of interactive, educational text messages can improve care for women postpartum. Study Design We conducted a randomized-control trial of 191 women receiving OB/GYN care in our clinic from November 2019-April 2020. Patients were randomized postpartum to receive either routine care or routine care with mHealth text messages and appointment reminders specific to delivery type. The primary endpoint was attendance to the six-week postpartum visit with secondary endpoints of breastfeeding, contraception use, emergency visits, and postpartum depression scores (EPDS). A subgroup analysis was additionally conducted to assess the impact of some visits shifting to telehealth due to the timing of the COVID-19 pandemic. Results Patient demographics were similar between the two groups. There was no significant difference in postpartum appointment attendance between text message (n=57, 59%) and control groups (n=62, 66%, p=0.31). 117 patients were scheduled for in-person postpartum visits, and 74 for telehealth visits during the COVID-19 pandemic, with no significant difference in attendance rate between groups for either visit modality. Conclusion Automated text messages alone did not increase our primary outcome of adherence to postpartum care, even when visits were conducted by telehealth. While mHealth has proven successful in other care areas, such as antepartum follow-up, further research is needed to determine whether it is an effective method to improve adherence to postpartum care, or whether other strategies must be developed, including augmentation with human navigators.

Training obstetrician gynaecologists in HIV PrEP (pre-exposure prophylaxis): a 2-year experience.

OBJECTIVE: We aimed to evaluate the efficacy of PrEP (pre-exposure prophylaxis) training sessions for OBGYN (obstetrician gynaecologist) providers given underutilisation of PrEP among women despite a high HIV burden. METHODS: Three separate training sessions were held for providers in the OBGYN department at an academic medical centre in New York City from 2019 to 2021. The 1-hour training sessions were conducted by HIV specialists as in-person lectures or online live lectures. Participants were surveyed after the training on metrics of PrEP awareness, knowledge and comfort with management. Two-sample t-tests were used to compare difference in proportions of binomial variables and difference in means of Likert-scored answers pretraining and post-training events. RESULTS: 63 respondents completed the surveys. There were low rates (13%) of past PrEP prescription among the respondents, while awareness of PrEP as an HIV prevention strategy was high before (95%) and after (98%) the training. After the training, there was an increase in understanding the epidemiology of HIV transmission (40% to 97%, p<0.00), familiarity with the PrEP clinical trials (18% to 97%, p<0.00), comfort in determining PrEP candidacy (mean score 2.3 to 4.1, p<0.00) and comfort prescribing PrEP (mean score 2.0 to 3.6, p<0.00). After the trainings, the majority of participants reported feeling 'comfortable' or 'very comfortable' in determining candidacy for PrEP and prescribing PrEP with follow-up. CONCLUSION: Implementation of PrEP training courses for OBGYN providers increased knowledge and comfort in identifying and managing patients who may benefit from PrEP services. Increasing training among OBGYN providers serving women at risk for HIV infection is an effective tool to narrow gaps in PrEP access.

SARS-CoV-2 during pregnancy and associated outcomes: Results from an ongoing prospective cohort.

BACKGROUND: The COVID-19 pandemic is an ongoing global health threat, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Questions remain about how SARS-CoV-2 impacts pregnant individuals and their children. OBJECTIVE: To expand our understanding of the effects of SARS-CoV-2 infection during pregnancy on pregnancy outcomes, regardless of symptomatology, by using serological tests to measure IgG antibody levels. METHODS: The Generation C Study is an ongoing prospective cohort study conducted at the Mount Sinai Health System. All pregnant individuals receiving obstetrical care at the Mount Sinai Healthcare System from 20 April 2020 onwards are eligible for participation. For the current analysis, we included participants who had given birth to a liveborn singleton infant on or before 22 September 2020. For each woman, we tested the latest prenatal blood sample available to establish seropositivity using a SARS-CoV-2 serologic enzyme-linked immunosorbent assay. Additionally, RT-PCR testing was performed on a nasopharyngeal swab taken during labour. Pregnancy outcomes of interest (i.e., gestational age at delivery, preterm birth, small for gestational age, Apgar scores, maternal and neonatal intensive care unit admission, and length of neonatal hospital stay) and covariates were extracted from medical records. Excluding individuals who tested RT-PCR positive at delivery, we conducted crude and adjusted regression models to compare antibody positive with antibody negative individuals at delivery. We stratified analyses by race/ethnicity to examine potential effect modification. RESULTS: The SARS-CoV-2 seroprevalence based on IgG measurement was 16.4% (95% confidence interval 13.7, 19.3; n=116). Twelve individuals (1.7%) were SARS-CoV-2 RT-PCR positive at delivery. Seropositive individuals were generally younger, more often Black or Hispanic, and more often had public insurance and higher pre-pregnancy BMI compared with seronegative individuals. None of the examined pregnancy outcomes differed by seropositivity, overall or stratified by race/ethnicity. CONCLUSION: Seropositivity for SARS-CoV-2 without RT-PCR positivity at delivery (suggesting that infection occurred earlier during pregnancy) was not associated with selected adverse maternal or neonatal outcomes among live births in a cohort sample from New York City.

Cervical cancer risk factors and screening preferences among Muslim women in Monrovia, Liberia.

Cervical cancer is the most common cancer in reproductive aged women in Liberia. Lack of awareness and screening capacity are both major contributors to the prevalence of this disease. The minority Muslim population in this country is largely unscreened. The objective of the study was to assess cervical cancer risk factors and screening preferences among Muslim women living in Monrovia, Liberia and to offer self-screening with HPV testing. A multiple step implementation strategy was devised in order to outreach to the Muslim population with the engagement of community and religious leaders, about an upcoming screening program and informational session at a local clinic. Over 150 Muslim women attended the session, 120 completed the HPV screening, and 55 women completed the questionnaires. Questionnaire data revealed overall low risk factors for cervical cancer, but also low use of family planning as well as low knowledge about cervical cancer and HPV. Participants showed an interest in screening and a majority preferred self-collected tests. These preferences should be incorporated in future programming. To engage minority populations in screening programs, there may be success with targeted messages, involvement of community religious leaders, and eliciting feedback to incorporate preferred strategies and improve participation and programming.

Perceptions of Job Hazards and Requests for Accommodation Among Pregnant Women in a Large Urban Hospital System.

BACKGROUND: Many pregnant women remain uninformed about job accommodation options or have not been empowered to ask their employers. METHODS: A cross-sectional survey of a sample base of pregnant women from late first through third trimester was conducted. Associations between job perception variables, work characteristics, race/ethnicity, and income were assessed using binary logistic regression. RESULTS: Workers in service/support occupations were twice as likely as those in management to perceive need for job duty change and to request job accommodation. Perception of needed job change was higher when jobs had high physical demands and low substantive complexity. CONCLUSIONS: We found positive relationships between highly physical work, perception of harm, and need for job change in pregnancy. Further research could explore worker/employer characteristics explaining why these perceptions did not translate into requesting and receiving job accommodation during pregnancy.

The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes.

BACKGROUND: Structural racism and pandemic-related stress from the COVID-19 pandemic may increase the risk of adverse birth outcomes. OBJECTIVE: Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with 3 outcomes: SARS-CoV-2 infection, preterm birth, and delivering small-for-gestational-age newborns. Our secondary objective was to investigate the joint association of SARS-CoV-2 infection during pregnancy and neighborhood measures with preterm birth and delivering small-for-gestational-age newborns. STUDY DESIGN: We analyzed data of 967 patients from a prospective cohort of pregnant persons in New York City, comprising 367 White (38%), 169 Black (17%), 293 Latina (30%), and 87 Asian persons (9%), 41 persons of other race or ethnicity (4%), and 10 of unknown race or ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zone improvement plan code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We obtained data on preterm birth and small-for-gestational-age newborns from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zone improvement plan code to estimate associations of each neighborhood measure separately with 3 outcomes: SARS-CoV-2 infection, preterm birth, and small-for-gestational-age newborns. Covariates included maternal age, parity, insurance status, and body mass index. Models with preterm birth and small-for-gestational-age newborns as the dependent variables additionally adjusted for SARS-CoV-2 infection. RESULTS: A total of 193 (20%) persons were SARS-CoV-2-seropositive, and the overall risks of preterm birth and small-for-gestational-age newborns were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered a small-for-gestational-age infant. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered a small-for-gestational-age infant. In adjusted analyses, structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and preterm birth, but not small-for-gestational-age infants. High vs low structural disadvantage was associated with an adjusted relative risk of 2.6 for infection (95% confidence interval, 1.7-3.9) and 1.7 for preterm birth (95% confidence interval, 1.0-2.9); high vs low racial-economic segregation was associated with adjusted relative risk of 1.9 (95% confidence interval, 1.3-2.8) for infection and 2.0 (95% confidence interval, 1.3-3.2) for preterm birth; high vs low community unemployment increase was associated with adjusted relative risk of 1.7 (95% confidence interval, 1.2-1.5) for infection and 1.6 (95% confidence interval, 1.0-2.8) for preterm birth. COVID-19 mortality rate was associated with SARS-CoV-2 infection but not preterm birth or small-for-gestational-age infants. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on preterm birth or small-for-gestational-age infants. CONCLUSION: Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and preterm birth, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of preterm birth independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.

Gestational SARS-CoV-2 infection is associated with placental expression of immune and trophoblast genes.

INTRODUCTION: Maternal SARS-CoV-2 infection during pregnancy is associated with adverse pregnancy outcomes and can have effects on the placenta, even in the absence of severe disease or vertical transmission to the fetus. This study aimed to evaluate histopathologic and molecular effects in the placenta after SARS-CoV-2 infection during pregnancy. METHODS: We performed a study of 45 pregnant participants from the Generation C prospective cohort study at the Mount Sinai Health System in New York City. We compared histologic features and the expression of 48 immune and trophoblast genes in placentas delivered from 15 SARS-CoV-2 IgG antibody positive and 30 IgG SARS-CoV-2 antibody negative mothers. Statistical analyses were performed using Fisher's exact tests, Spearman correlations and linear regression models. RESULTS: The median gestational age at the time of SARS-CoV-2 IgG serology test was 35 weeks. Two of the IgG positive participants also had a positive RT-PCR nasal swab at delivery. 82.2% of the infants were delivered at term (≥37 weeks), and gestational age at delivery did not differ between the SARS-CoV-2 antibody positive and negative groups. No significant differences were detected between the groups in placental histopathology features. Differential expression analyses revealed decreased expression of two trophoblast genes (PSG3 and CGB3) and increased expression of three immune genes (CXCL10, TLR3 and DDX58) in placentas delivered from SARS-CoV-2 IgG positive participants. DISCUSSION: SARS-CoV-2 infection during pregnancy is associated with gene expression changes of immune and trophoblast genes in the placenta at birth which could potentially contribute to long-term health effects in the offspring.

Reproductive Healthcare Needs of Sex Workers in Rural South Africa: A Community Assessment.

Background: In the Limpopo province of South Africa, access and availability of women's health services are limited and many challenges exist for a growing population of transient sex workers. This study was developed to place communities at the forefront to more specifically understand regional barriers and attitudes regarding reproductive health care needs. Objective: To build strong community partnerships, gain understanding of issues in women's health services, and collaborate with community members to address those issues. Methods: A mixed-methods study approach was used in rural South Africa. Participants were recruited through voluntary interest from a local health clinic performing outreach for migrant female sex workers. We (1) created partnerships and built trust within the community and (2) worked collaboratively to collect both qualitative and quantitative data, using community groups to discuss health needs as well as "knowledge, attitude, and practice" (KAP) surveys. Findings: Ninety-four sex workers participated. The survey data identified risk factors to poor reproductive healthcare outcomes, including limited education, young age at first sexual contact, large number of sexual partners, little knowledge of sexually transmitted infections, distrust in the use of healthcare facilities, and limited use of contraception. Community discussion groups revealed a desire for easier and more accessible healthcare, showing the biggest barriers to care are lack of money and transportation, and safety concerns related to profession, including fear of violence from partner and/or client. With input from civic leaders, public interest, and community outreach groups, a community advisory board was successfully formed for future collaboration. Conclusion: By working with local stakeholders and sex workers, we created an interactive and tailored assessment to discuss healthcare disparities. We helped foster community ownership, setting the stage for future implementation of sustainable and cooperative health programming.

"Just Because You Have Ears Doesn't Mean You Can Hear"-Perception of Racial-Ethnic Discrimination During Childbirth.

Background: Black and Latina women in New York City are twice as likely to experience a potentially life-threatening morbidity during childbirth than White women. Health care quality is thought to play a role in this stark disparity, and patient-provider communication is one aspect of health care quality targeted for improvement. Perceived health care discrimination may influence patient-provider communication but has not been adequately explored during the birth hospitalization. Purpose: Our objective was to investigate the impact of perceived racial-ethnic discrimination on patient-provider communication among Black and Latina women giving birth in a hospital setting. Methods: We conducted four focus groups of Black and Latina women (n=27) who gave birth in the past year at a large hospital in New York City. Moderators of concordant race/ethnicity asked a series of questions on the women's experiences and interactions with health care providers during their birth hospitalizations. One group was conducted in Spanish. We used an integrative analytic approach. We used the behavioral model for vulnerable populations adapted for critical race theory as a starting conceptual model. Two analysts deductively coded transcripts for emergent themes, using constant comparison method to reconcile and refine code structure. Codes were categorized into themes and assigned to conceptual model categories. Results: Predisposing patient factors in our conceptual model were intersectional identities (eg, immigrant/Latina or Black/Medicaid recipient), race consciousness ("…as a woman of color, if I am not assertive, if I am not willing to ask, then they will not make an effort to answer"), and socially assigned race (eg, "what you look like, how you talk"). We classified themes of differential treatment as impeding factors, which included factors overlooked in previous research, such as perceived differential treatment due to the relationship with the infant's father and room assignment. Themes for differential treatment co-occurred with negative provider communication attributes (eg, impersonal, judgmental) or experience (eg, not listened to, given low priority, preferences not respected). Conclusions: Perceived racial-ethnic discrimination during childbirth influences patient-provider communication and is an important and potentially modifiable aspect of the patient experience. Interventions to reduce obstetric health care disparities should address perceived discrimination, both from the provider and patient perspectives.

Postpartum mood among universally screened high and low socioeconomic status patients during COVID-19 social restrictions in New York City.

The mental health effects of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the Coronavirus Disease 2019 (COVID-19) pandemic on postpartum women are of increasing concern among mental health practitioners. To date, only a handful of studies have explored the emotional impact of the pandemic surrounding pregnancy and none have investigated the consequence of pandemic-related social restrictions on the postpartum mood of those living among different socioeconomic status (SES). All postpartum patients appearing to the Mount Sinai Health System for their postpartum appointment between January 2, 2020 and June 30, 2020, corresponding to before and during pandemic imposed social restrictions, were screened for mood symptomatology using the Edinburgh Postnatal Depression Scale (EPDS). Each patient's socioeconomic status (high/low) was determined by their location of clinical service. A total of 516 postpartum patients were screened. While no differences in EPDS scores were observed by SES prior to social restrictions (U = 7956.0, z = - 1.05, p = .293), a significant change in mood symptomatology was observed following COVID-19 restrictions (U = 4895.0, z = - 3.48, p < .001), with patients living in lower SES reporting significantly less depression symptomatology (U = 9209.0, z = - 4.56, p < .001). There was no change in symptomatology among patients of higher SES (U = 4045.5, z = - 1.06, p = .288). Postpartum depression, the most common complication of childbearing, is a prevalent, cross-cultural disorder with significant morbidity. The observed differences in postpartum mood between patients of different SES in the context of temporarily imposed COVID-19-related social restrictions present a unique opportunity to better understand the specific health and social support needs of postpartum patients living in urban economic poverty. Given that maternal mental illness has negative long-term developmental implications for the offspring and that poor mental health reinforces the poverty cycle, future health policy specifically directed towards supporting postpartum women living in low SES by ameliorating some of the early maternal burdens associated with balancing employment-family-childcare demands may assist in interrupting this cycle while simultaneously improving the long-term outcomes of their offspring.

Cervical Cancer Screening in HIV-Positive Farmers in South Africa: Mixed-Method Assessment.

BACKGROUND: In 2015, a See and Treat cervical cancer screening program was implemented at a local HIV clinic in Limpopo, South Africa, where infrastructure limited adequate Pap smear usability. OBJECTIVE: The purpose of this evaluation was to determine the quality and sustainability of the implemented program. METHODS: A mixed-methods program analysis was conducted at 18-months post implementation. Data collection techniques included in-depth interviews of staff and patients, observation of healthcare workers delivering screening, and review of charts and patient logs. FINDINGS: Eighteen in-depth interviews revealed improved cervical cancer screening understanding and awareness. Privacy concerns and negative perceptions of medical care were barriers to screening. Informal observations revealed continued clinical competence among healthcare workers who had been previously trained. Review of charts demonstrated positive correlation between VIA and Pap smear results. In evaluating loss to attrition, about half of the first cohort of patients were lost to follow-up. VIAs and Pap smears were offered on an ongoing basis, and month-over-month change for overlapping four months of programming between 2015 and 2016 showed a 4.4% negative change in number of Pap smears and a 57% negative change in VIAs. CONCLUSION: Our evaluation reveals successful integration of See and Treat into current clinic services in rural South Africa and increased awareness of cervical cancer among health workers and participants. Program sustainability was challenging to assess as many patients were lost to follow-up, given the migrant and transient population attending this clinic. Acceptance by health workers and patients alike is vital for the long-term impact on cervical cancer incidence in this region.

Cervical cancer screening in rural South Africa among HIV-infected migrant farm workers and sex workers.

At an HIV clinic in the Limpopo province of South Africa, chart reviews revealed long delays in addressing abnormal Pap smears, difficulty in referrals, poor quality and lost results, and increasing cases of cervical cancer. To address these barriers, a "see and treat" approach to screening was proposed. The objective was to integrate this method into current HIV care offered by local providers and to obtain demographic and risk factor data for use in future educational and intervention programs in the region. A cross sectional study of HIV farm workers and at-risk sex workers attending an HIV clinic was performed with visual inspection with acetic acid (VIA). Those with positive screens were offered cryotherapy. Clinic charts were reviewed retrospectively for Pap smear results for the previous year at the time of program initiation and at 12 and 18 months post-program. A total of 403 participants consented and underwent screening with VIA (306 Farm workers and 97 sex workers participated). 83.9% of participants (32.9% sex workers and 100% farm workers) were HIV +. VIA was positive in 30.5% of participants, necessitating cryotherapy. There was no significant difference in VIA positivity between HIV + farm workers and sex workers. There was a positive correlation between Pap smears and VIAs results. We demonstrate successful integration of cervical cancer screening using VIA for HIV + farm workers and sex workers into an existing HIV treatment and prevention clinic in rural South Africa, addressing and treating abnormal results promptly.

Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.

OBJECTIVES: To determine whether a patient's level of assertiveness and other factors influences her comfort level in asking her provider to wash his or her hands. METHODS: In this pilot study, we developed a survey to gather cross-sectional information on a variety of factors that might explain patient willingness to ask her health-care provider to wash his or her hands. Three primary predictor variables are analyzed: (1) patient assertiveness; (2) patient familiarity with her healthcare provider; and (3) whether the patient has observed hand-washing behavior. Fifty patients participated from the Obstetrics and Gynecology Department of Metropolitan Hospital Center. RESULTS: Less assertive patients are much less likely than assertive patients to ask physicians to wash hands (25% versus 68%; Fisher's exact test P = 0.0427). Among the 3 assertiveness questions included in the survey, the ability to ask physicians questions during visits is most strongly indicative of willingness to ask about hand washing. Familiarity with the names of regular health-care providers has a statistically significant impact on willingness to ask about hand washing. Evidence suggests that observing hand washing behavior affects willingness to ask, but differences are not statistically significant. Results by socioeconomic status such as age, education, income, and race/ethnicity are inconclusive. CONCLUSIONS: A patient's level of assertiveness alone is not sufficient to determine her willingness to inquire about the hand-washing behavior of her provider. A high percentage of patients did not see their provider engaging in adequate hand washing behavior. If patients feel comfortable with their provider to inquire about their care and request hand-washing behavior, health outcomes are affected by reducing the rates of health care-associated infections.