A pilot randomized controlled trial comparing prenatal yoga to perinatal health education for antenatal depression.

We conducted a pilot randomized controlled trial (RCT) comparing a prenatal yoga intervention to perinatal-focused health education in pregnant women with depression. Findings document acceptability and feasibility of the yoga intervention: no yoga-related injuries were observed, instructors showed fidelity to the yoga manual, and women rated interventions as acceptable. Although improvements in depression were not statistically different between groups, they favored yoga. This study provides support for a larger scale RCT examining prenatal yoga to improve mood during pregnancy.

The relationship between maternal-fetal attachment and cigarette smoking over pregnancy.

Cigarette smoking during pregnancy is one of the most preventable causes of infant morbidity and mortality, yet 80 % of women who smoked prior to pregnancy continue to smoke during pregnancy. Past studies have found that lower maternal-fetal attachment predicts smoking status in pregnancy, yet past research has not examined whether maternal-fetal attachment predicts patterns or quantity of smoking among pregnant smokers. The aim of this study was to examine the relationship between maternal-fetal attachment and patterns of maternal smoking among pregnant smokers. We used self-reported and biochemical markers of cigarette smoking in order to better understand how maternal-fetal attachment relates to the degree of fetal exposure to nicotine. Fifty-eight pregnant smokers participated in the current study. Women completed the Maternal-Fetal Attachment Scale, reported weekly smoking behaviors throughout pregnancy using the Timeline Follow Back interview, and provided a saliva sample at 30 and 35 weeks gestation and 1 day postpartum to measure salivary cotinine concentrations. Lower maternal-fetal attachment scores were associated with higher salivary cotinine at 30 weeks gestation and 1 day postpartum. As well, women who reported lower fetal attachment reported smoking a greater maximum number of cigarettes per day, on average, over pregnancy. Lower maternal-fetal attachment is associated with greater smoking in pregnancy. Future research might explore whether successful smoking cessation programs improve maternal assessments of attachment to their infants.

Low cost, high yield: simulation of obstetric emergencies for family medicine training.

BACKGROUND: Simulation is now the educational standard for emergency training in residency and is particularly useful on a labor and delivery unit, which is often a stressful environment for learners given the frequency of emergencies. However, simulation can be costly. PURPOSE: This study aimed to assess the feasibility and effectiveness of low-cost simulated obstetrical emergencies in training family medicine residents. METHODS: The study took place in a community hospital in an urban underserved setting in the northeast United States. Low-cost simulations were developed for postpartum hemorrhage (PPH) and preeclampsia/eclampsia (PEC). Twenty residents were randomly assigned to the intervention (simulated PPH or PEC followed by debriefing) or control (lecture on PPH or PEC) group, and equal numbers of residents were assigned to each scenario. All participants completed a written test at baseline and an oral exam 6 months later on the respective scenario to which they were assigned. The participants provided written feedback on their respective teaching interventions. We compared performance on pretests and posttests by group using Wilcoxon Rank Sum. RESULTS: Twenty residents completed the study. Both groups performed similarly on baseline tests for both scenarios. Compared to controls, intervention residents scored significantly higher on the examination on the management of PPH but not for PEC. All intervention group participants reported that the simulation training was "extremely useful," and most found it "enjoyable." CONCLUSIONS: We demonstrated the feasibility and acceptability of two low-cost obstetric emergency simulations and found that they may result in persistent increases in trainee knowledge.

Mercury, lead, and cadmium in umbilical cord blood.

The study described in this article aimed to determine if measurable levels of mercury, lead, and cadmium are detected in the umbilical cord blood specimens collected in a community hospital in Rhode Island and if prenatal exposure correlates with prematurity or fetal growth indicators. Total mercury, lead, and cadmium concentrations were measured in 538 specimens of cord blood and correlated with demographic characteristics and pregnancy outcomes for each mother-infant pair. Lead concentrations determined in the cord blood of Rhode Island women (geometric mean 0.99 microg/dL) were similar to those reported in U.S. biomonitoring studies. The overall geometric mean for mercury concentration (0.52 microg/L) was slightly lower than in other comparable studies. Cadmium concentrations were generally below the limit of detection. A statistically significant correlation was detected between elevated mercury concentrations and racial and ethnic characteristics of the study participants. Non-Hispanic African-American mothers were 9.6 times more likely to have a mercury concentration > or = 5.8 microg/L compared to women of other racial/ethnic backgrounds. No association was detected between elevated mercury levels and adverse birth outcomes.

Family Medicine Maternity Care Call to Action: Moving Toward National Standards for Training and Competency Assessment.

BACKGROUND: Maternity care is an integral part of family medicine, and the quality and cost-effectiveness of maternity care provided by family physicians is well documented. Considering the population health perspective, increasing the number of family physicians competent to provide maternity care is imperative, as is working to overcome the barriers discouraging maternity care practice. A standard that clearly defines maternity care competency and a systematic set of tools to assess competency levels could help overcome these barriers. National discussions between 2012 and 2014 revealed that tools for competency assessment varied widely. These discussions resulted in the formation of a workgroup, culminating in a Family Medicine Maternity Care Summit in October 2014. This summit allowed for expert consensus to describe three scopes of maternity practice, draft procedural and competency assessment tools for each scope, and then revise the tools, guided by the Family Medicine and OB/GYN Milestones documents from the respective residency review committees. The summit group proposed that achievement of a specified number of procedures completed should not determine competency; instead, a standardized competency assessment should take place after a minimum number is performed. The traditionally held required numbers for core procedures were reassessed at the summit, and the resulting consensus opinion is proposed here. Several ways in which these evaluation tools can be disseminated and refined through the creation of a learning collaborative across residency programs is described. The summit group believed that standardization in training will more clearly define the competencies of family medicine maternity care providers and begin to reduce one of the barriers that may discourage family physicians from providing maternity care.

Maternal-child health fellowship: maintaining the rigor of family medicine obstetrics.

BACKGROUND AND OBJECTIVES: The United States has a growing shortage of maternity care providers. Family medicine maternity care fellowships can address this growing problem by training family physicians to manage high-risk pregnancies and perform cesarean deliveries. This paper describes the impact of one such program-the Maternal Child Health (MCH) Fellowship through the Department of Family Medicine at Brown University and the careers of its graduates over 20 years (1991--2011). METHODS: Fellowship graduates were mailed a survey regarding their training, current practice and teaching roles, and career satisfaction. Seventeen of 23 fellows (74%) responded to the survey. RESULTS: The majority of our fellowship graduates provide maternity care. Half of our respondents are primary surgeons in cesarean sections, and the majority of these work in community hospitals. Nearly all of our graduates maintain academic appointments and teach actively in their respective departments of family medicine. CONCLUSIONS: Our maternal child health fellowship provides family physicians with the opportunity to develop advanced skills needed to provide maternity care for underserved communities and teaching skills to train the next generation of maternal child health care providers.

Teaching maternity care in family medicine residencies: what factors predict graduate continuation of obstetrics? A 2013 CERA program directors study.

BACKGROUND AND OBJECTIVES: Maternity care is an essential component of family medicine, yet the number of residency graduates providing this care continues to decline. Residency programs have struggled to identify strategies to increase continuation of obstetric practice among graduates. Leaders in family medicine obstetrics previously proposed a tiered model of training to ensure adequate volume for those desiring to continue maternity care upon graduation. However, whether this approach will be successful is unknown. This study aimed to identify program characteristics and teaching methods that may influence residents to continue obstetrics practice upon graduation. METHODS: A nationwide survey of family medicine residency program directors (PDs) was conducted as part of the 2013 CERA survey to characterize teaching in maternity care and identify program-level predictors of graduate continuation of obstetrics (OB). RESULTS: Family medicine programs, which were community-based, university-affiliated programs in the Midwest and West, contributed more trainees who continued to provide OB care upon graduation. Trainees at these programs received greater supervision by family medicine faculty preceptors on labor and delivery, reported at least 80 deliveries by graduates during residency, and experienced greater autonomy in decision-making during OB rotations. CONCLUSIONS: This study supports a targeted approach to teaching maternity care in family medicine residency programs. Prioritizing continuity delivery experiences and fostering resident independence are strategies toward promoting increased provision of obstetric care by family medicine graduates. Further research is needed to evaluate the impact of tiered or track systems in practice.

Potential for prenatal yoga to serve as an intervention to treat depression during pregnancy.

BACKGROUND: When left untreated, antenatal depression can have a serious negative impact on maternal, and infant outcomes. Many affected women do not obtain treatment for depression owing to difficulties accessing care or because they do not find standard antidepressant treatments to be acceptable during pregnancy. This study examined the acceptability and feasibility of a gentle prenatal yoga intervention, as a strategy for treating depression during pregnancy. METHODS: We developed a 10-week prenatal yoga program for antenatal depression and an accompanying yoga instructors' manual, and enrolled 34 depressed pregnant women from the community into an open pilot trial. We measured change in maternal depression severity from before to after the intervention. RESULTS: Results suggested that the prenatal yoga intervention was feasible to administer and acceptable to the women enrolled. No study-related injuries or other safety issues were observed during the trial. On average, participants' depression severity decreased significantly by the end of the intervention based on both observed-rated and self-report depression assessment measures. CONCLUSION: The current study suggests that prenatal yoga may be a viable approach to addressing antenatal depression, one that may have advantages in terms of greater acceptability than standard depression treatments. Research and policy implications are discussed.

Maternal-fetal attachment differentiates patterns of prenatal smoking and exposure.

OBJECTIVE: Smoking cessation during pregnancy may reflect altruistic motives on behalf of the unborn baby. We test the hypothesis that pregnancy quitters have higher maternal-fetal attachment than persistent smokers, and secondarily explore how maternal-fetal attachment differs among non-smokers, pregnancy quitters, and persistent smokers. METHODS: Participants were 156 women in the Behavior and Mood in Babies and Mothers study who provided report of smoking throughout pregnancy via timeline follow back interviews, with salivary cotinine confirmation of reported cessation at 30 and 35 week gestation, and postpartum day one. Maternal Fetal Attachment Scale total and subscale scores (role-taking, differentiation of self from fetus, interaction with fetus, attributing characteristics to fetus, giving of self) were examined among non-smokers, pregnancy quitters, and persistent smokers. RESULTS: At 30 weeks, pregnancy quitters scored higher on the 'giving of self' subscale compared to persistent smokers (21.6±2.4 versus 19.9±2.9; p=.004). Maternal 'giving of self' also differentiated pregnancies exposed to cigarette smoking from those without exposure from 30 weeks through delivery (19.9±2.9 versus 21.2±2.2; p=.002). Controlling for age, income, unemployment, gravida, and father's smoking status, 'giving of self' differentiated pregnancy quitters from persistent smokers [OR=5.144; 95% C.I. 1.509 - 17.538; B (SE)=1.638 (.626); p=.009]. CONCLUSIONS: Women who reported a greater desire to maintain their personal health for the health of their fetus were more likely to quit smoking during pregnancy. Implications of findings for interventions and understanding mechanisms of risk are discussed.

Promotion of family-centered birth with gentle cesarean delivery.

PURPOSE: In this commentary we describe our experience developing a "gentle cesarean" program at a community hospital housing a family medicine residency program. The gentle cesarean technique has been popularized in recent obstetrics literature as a viable option to enhance the experience and outcomes of women and families undergoing cesarean delivery. METHODS: Skin-to-skin placement of the infant in the operating room with no separation of mother and infant, reduction of extraneous noise, and initiation of breastfeeding in the operating room distinguish this technique from traditional cesarean delivery. Collaboration among family physicians, obstetricians, midwives, pediatricians, neonatologists, anesthesiologists, nurses, and operating room personnel facilitated the provision of gentle cesarean delivery to families requiring an operative birth. RESULTS: Among 144 gentle cesarean births performed from 2009 to 2012, complication rates were similar to or lower than those for traditional cesarean births. Gentle cesarean delivery is now standard of care at our institution. CONCLUSION: By sharing our experience, we hope to help other hospitals develop gentle cesarean programs. Family physicians should play an integral role in this process.

Developing future leaders in reproductive health through a scholarly concentration for medical students.

OBJECTIVES: To evaluate the impact of a scholarly concentration for medical students, which aims to develop students' research, clinical and advocacy skills to promote women's reproductive health. STUDY DESIGN: Scholarly concentration programs provide opportunities to engage in scholarship beyond the traditional medical school curriculum. Faculty from the Family Medicine and Obstetrics and Gynecology Departments at Brown University collaboratively developed the Scholarly Concentration in Women's Reproductive Health. Three to five students per class enroll and carry out a 3-year mentored research project, attend monthly seminars, write position papers on reproductive health controversies and complete clinical electives in reproductive health. Students are required to disseminate their work through conference presentations and/or peer-reviewed publications. The program evaluation included measures of scholarly productivity and qualitative analyses of interviews with students and mentors as well as written and verbal feedback from students. RESULTS: Ten students comprised the first 3 classes completing the program, producing 24 national presentations and 9 peer-reviewed publications. Reported program benefits included increased knowledge, scholarship skills and support for career development in reproductive health. Key factors facilitating these results were as follows: effective mentoring relationships, the community of practice that emerged through the monthly seminars and student independence in project work. CONCLUSIONS: A scholarly concentration for medical students provides a unique platform to support the development of talented students as future leaders in women's reproductive health.

Neonatal herpes infection: case report and discussion.

Neonatal herpes simplex virus (HSV) infections are often life-threatening. Although sometimes difficult to diagnose, most infections can be treatable when found early. Infection with HSV should be kept high on the differential diagnosis of a febrile newborn younger than 1 month old, and treatment should be strongly considered for infants with certain risk factors, even before definitive culture or polymerase chain reaction results are available. The case presented here exemplifies the benefits of maintaining a high suspicion of and empirically treating for HSV in a 10-day-old febrile infant.

Malabsorption of oral antibiotics in pregnancy after gastric bypass surgery.

Gastric bypass surgery, by definition, changes the absorption capabilities of the stomach and small intestine. The use of oral medications in patients post gastric bypass may need to be adjusted by medical providers to account for this absorption change. The following case exemplifies this dilemma in a pregnant patient status post gastric bypass surgery with a complicated urinary tract infection.