Initial Contraceptive Choices of Women Enrolled in a Cluster-Randomized Trial in Southwest Trifinio, Guatemala.

INTRODUCTION: The aim of this analysis is to present initial contraceptive choices of women offered postpartum contraception in rural Guatemala. METHODS: We trained community nurses participating in the delivery of a home-based antepartum and postpartum care program in rural Guatemala in contraceptive implant placement and had them offer condoms, pills, an injection, or an implant at women's home-based 40-day postpartum visit in intervention clusters of a non-blinded, cluster-randomized trial. Women who had already started postpartum contraception or were over the age of 35 were excluded from participation. The primary outcome of the trial was contraceptive use at 3 months postpartum, so this initial analysis describes immediate preferences in the population. RESULTS: Of 208 women enrolled in the study, 108 were in intervention clusters and 100 lived in control clusters. In the intervention group, 32 women declined contraception, 36 women received the injectable, 30 women had an implant placed, 5 women started pills, 2 women chose condoms, and data on 3 women were missing. In the control clusters, 43 women were planning on the injectable, 11 planned on the implant, 10 did not want to start a method, 5 planned on sterilization, 2 aimed for natural family planning, 2 wanted a copper IUD, 1 woman wanted condoms, 18 did not know, and data on 8 women were missing. DISCUSSION: The contraceptive implant, which was not previously available in this community, had high uptake at 27.8% in the intervention group. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019, https://clinicaltrials.gov/ct2/show/NCT04005391 Protocol: https://doi.org/10.1186/s13063-019-3735-3.

Is Exposure to Intrapartum Prostaglandins for Labor Induction Associated with a Lower Incidence of Neonatal Respiratory Distress Syndrome?

OBJECTIVE: Respiratory distress syndrome (RDS) is implicated in 30% of neonatal deaths. Since prostaglandins promote surfactant secretion and labor is associated with a lower risk of RDS in term neonates, it is plausible that synthetic prostaglandin (sPG) exposure is associated with a lower risk of RDS. Thus, we evaluated the association between sPG exposure and RDS in neonates born after the induction of labor (IOL). STUDY DESIGN: Secondary analysis of women with singleton pregnancies undergoing IOL at 340/7 to 420/7 weeks in the nuMoM2b study, a multicenter prospective cohort of nulliparous women. RDS rates and secondary neonatal outcomes in neonates with intrapartum sPG exposure were compared with those who had IOL with non-sPG methods (e.g., balloon catheter, amniotomy, oxytocin, and laminaria). Logistic regression models estimated the association of sPG with RDS and with secondary outcomes after adjustment for clinical and demographic factors (including gestational age). A sensitivity analysis was performed in which analysis was restricted to those with an admission cervical dilation ≤2 cm. RESULTS: Of 10,038 women in the total cohort, 3,071 met inclusion criteria; 1,444 were exposed and 1,627 were unexposed to sPGs. Antenatal corticosteroid exposure rates were low (3.0%) and similar between groups. In univariable analysis, neonates with sPG exposure had higher rates of RDS (3.2 vs. 2.0%, odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.01-2.50). This relationship was similar by gestational age at delivery (term vs. preterm, interaction p = 0.14). After adjustment, the association between sPG and RDS was no longer significant (adjusted odds ratio: 1.4, 95% CI: 0.9-2.3). When analysis was restricted to subjects with admission cervical dilation of ≤2 cm, there was also no association between sPG exposure and RDS. CONCLUSION: In pregnancies between 34 and 42 weeks of gestation, exposure to sPG for cervical ripening or labor induction was not associated with newborn RDS. KEY POINTS: · RDS is implicated in 30% of neonatal deaths.. · sPG exposure was not associated with RDS.. · Avoiding preterm birth remains crucial in RDS prevention..

Interpregnancy Interval in a Rural Guatemalan Population: Results from a Quality Improvement Database.

OBJECTIVE: This analysis describes the interpregnancy interval (time from livebirth to subsequent conception) in a convenience sample of women living in Southwest Guatemala and the association of antepartum characteristics and postpartum outcomes with a short interpregnancy interval (< 24 months). METHODS: This is an observational study of a convenience sample of women enrolled in the Madres Sanas community antenatal/postnatal nursing program supported by the Center for Human Development in Southwest Trifinio, Guatemala, between October 1, 2018 and October 1, 2019. We observed the distribution of interpregnancy intervals among the population of women with a reported date of last live birth, and used bivariate comparisons to compare women with a short interpregnancy interval (< 24 months) to those with an optimal interval ([Formula: see text] 24 months) by antepartum, obstetric and delivery, and postpartum outcomes. RESULTS: 171 parous women enrolled in the Madres Sanas program between October 1, 2018 and October 1, 2019, and reported the date of their last live birth. One hundred-forty-one (82.5%) women delivered and 130 of those women (92.2%) were seen for their 40-day postpartum visit. The mean interval was 37.1 months with a 22.1-month standard deviation. The median interval was 33.7 months with an interquartile range of 19.6-49.5 months. Among these women, 113 (66.1%) the interpregnancy interval was at least 24 months. The only covariate of all sociodemographic, obstetric and antepartum, delivery, and postpartum characteristics that differed between women who achieved an interval ([Formula: see text] 24 months) compared to those that did not (< 24 months), was age (median 22.9, interquartile range (IQR) [19.1,27.0] vs median 24.8, IQR [21.6,27.9], respectively, p = 0.006). A regression model found that with each increasing year of age, the interpregnancy interval increases by 1.08 months, p = 0.025. CONCLUSION: Among parous women, two-thirds of women space pregnancies at least 24 months. Older women were more likely to have a longer interval between live births.

Primary and secondary three-month outcomes of a cluster-randomized trial of home-based postpartum contraceptive delivery in southwest Trifinio, Guatemala.

DESIGN: This a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with implant utilization rates at 3 months post-enrollment. METHODS: In a region of rural Guatemala referred to as the Southwest Trifinio, twelve communities are served by a community-based antenatal and postnatal care program. The communities were combined into eight clusters based on 2017 birth rates and randomized to receive the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit. All participants receive comprehensive contraceptive counseling beginning at the first antenatal visit, so control clusters received this as part of routine care; this education preceded the study intervention. RESULTS: Once the 12 communities were combined into 8 clusters by expected birth volume and nurse team, which we expected to translate to eventual postpartum visits, the allocation sequence was generated in SAS. Of 208 women enrolled in the study, 108 were in four intervention and 100 in four control clusters. We used descriptive statistics to produce counts and percentages of characteristics of the study population overall and by intervention arm followed by univariate modeling using a mixed effects regression adjusted for cluster. Three-month contraceptive initiation rates were 56.0% in the control clusters compared to 76.8% in the intervention clusters, p < 0.001. Women in control clusters overwhelmingly opted for the injectable contraceptive (94.6%) while women in intervention clusters chose both the injection (61.5%) and the implant (33.7%), p < 0.001. Implant use by 3 months, the primary outcome of the study, was significantly higher in the intervention arm (25.9%) compared to the control arm (3.6%), p < 0.001, RR 1.3 CI [1.2, 1.4]. CONCLUSION: Our study was designed to respond to previously identified barriers to contraceptive uptake, and it was successful. Not only did it increase overall use of contraception by 3 months, but it shifted that contraceptive use away from short-acting methods in favor of longer-acting methods, with high continuation and satisfaction rates and no adverse outcomes reported. TRIAL REGISTRATION: clinicaltrials.gov , NCT04005391 ; Retrospectively Registered 7/2/2019.

Trends in the Mode of Delivery of Pregnant Women in Rural Guatemala from a Quality Improvement Database.

Purpose To evaluate trends and factors associated with mode of delivery in the rural Southwest Trifinio region of Guatemala. Description We conducted a retrospective analysis of self-reported antepartum factors and postpartum outcomes recorded in a quality improvement database among 430 women enrolled in a home-based maternal healthcare program between June 1, 2015 and August 1, 2017. Assessment Over the study period, the rates of cesarean delivery (CD) increased (from 30 to 45%) and rates of vaginal delivery (VD) decreased (70-55%) while facility-based delivery attendance remained stable around 70%. Younger age (23.5 years for VD vs. 21.6 years for CD, p < 0.001), nulliparity (25.1% for VD vs. 45.0% for CD, p < 0.001), prolonged/obstructed labor (2.4% for VD vs. 55.6% for CD, p < 0.001), and fetal malpresentation (0% for VD vs. 16.3% CD, p < 0.001) significantly influenced mode of delivery in univariate analysis. The leading indications for CD were labor dysfunction (47.5%), malpresentation (14.5%), and prior cesarean delivery (19.8%). The CD rate among the subpopulation of term, nulliparous women with singleton pregnancies in vertex presentation also increased from 20% of all CD in 2015, to 38% in 2017. Conclusion Among low-income women from rural Guatemala, the CD rate has increased above the World Health Organization (WHO) recommendations in a period of 3 years. Additional research on the factors affecting this trend are essential to guide interventions that might improve the appropriateness of CD, and to determine if reducing or stabilizing rates is necessary.

A Qualitative Assessment of Community Attitudes and Barriers to Family Planning Use in the Trifinio Region of Southwest Guatemala.

Introduction Our aim was to identify beliefs about and specific barriers to use of birth spacing methods that married and cohabitating women in the Trifinio Sur-Oeste region of Guatemala report in order to design future family planning educational programs. Methods We conducted key informant interviews with community health workers and focus groups with married or cohabitating women. We used inductive and deductive coding to identify common themes. Using these themes, we created explanatory models for decision-making context and identified barriers to family planning use, community educational needs, and potential interventions. Results Thirty-seven women, aged 20-47 years, with an average of 3.5 children and a 2nd grade education level, were included in focus groups. Women had accurate knowledge about benefits of birth spacing however had poor knowledge of family planning methods. Most common barriers included lack of spousal approval, difficulty accessing contraceptive methods, lack of knowledge, and fear of adverse effects. Women were interested in increased education for men, adolescents, and themselves. Discussion Targeted education for women, men, and adolescents is needed to improve family planning uptake in the Trifinio region. Programming should focus on increasing knowledge and acceptability of birth spacing methods and increasing constructive dialogue among couples.

Estimating the attack rate of pregnancy-associated listeriosis during a large outbreak.

BACKGROUND: In 2011, a multistate outbreak of listeriosis linked to contaminated cantaloupes raised concerns that many pregnant women might have been exposed to Listeria monocytogenes. Listeriosis during pregnancy can cause fetal death, premature delivery, and neonatal sepsis and meningitis. Little information is available to guide healthcare providers who care for asymptomatic pregnant women with suspected L. monocytogenes exposure. METHODS: We tracked pregnancy-associated listeriosis cases using reportable diseases surveillance and enhanced surveillance for fetal death using vital records and inpatient fetal deaths data in Colorado. We surveyed 1,060 pregnant women about symptoms and exposures. We developed three methods to estimate how many pregnant women in Colorado ate the implicated cantaloupes, and we calculated attack rates. RESULTS: One laboratory-confirmed case of listeriosis was associated with pregnancy. The fetal death rate did not increase significantly compared to preoutbreak periods. Approximately 6,500-12,000 pregnant women in Colorado might have eaten the contaminated cantaloupes, an attack rate of ~1 per 10,000 exposed pregnant women. CONCLUSIONS: Despite many exposures, the risk of pregnancy-associated listeriosis was low. Our methods for estimating attack rates may help during future outbreaks and product recalls. Our findings offer relevant considerations for management of asymptomatic pregnant women with possible L. monocytogenes exposure.

Is Hymenoplasty Anti-Feminist?

Hymenoplasty is a practice that must be judged from within its cultural confines and not only from outside. It offers women who have grown up within the sexual norms of a Western society the chance to return to their parental culture, with its female-specific virginity expectations. Hymenoplasty allows women to be sexually active prior to marriage, which equalizes the discrepancy between gender norms on premarital sexual experience. Caution is needed when comparing hymenoplasty to female genital mutilation. However, comparing hymenoplasty to other cosmetic genital modification procedures raises unique ethical, social, and medical quandaries that highlight the importance of patient's autonomy.

Delivery of home-based post-partum contraception in rural Guatemalan women: feasibility, recruitment and retention in a cluster-randomized trial.

BACKGROUND: Few cluster-randomized trials have been performed in rural Guatemala. Our objective was to describe the feasibility, recruitment and retention in our cluster-randomized trial. METHODS: In our cluster-randomized trial, a range of contraceptives were brought to mothers' homes in rural Guatemala. RESULTS: Of 173 women approached, 33 were excluded. Of the 140 eligible women, 127 (91%) consented to participate. Of the 87 women who should have been assessed for the primary outcome, three were lost to follow-up, which represents a retention rate of 97%. CONCLUSIONS: Nurses who are both clinical providers and study staff can feasibly conduct research, which leads to high enrollment and retention rates.

The Addition of Traditional Birth Attendant Care to a Home-Based Skilled Nursing Program in Rural Guatemala: A Secondary Analysis from a Quality Improvement Database.

INTRODUCTION: The use of traditional birth attendants (TBAs) in low- and middle-income countries remains controversial. The aim of this secondary analysis was to observe factors associated with visiting a TBA in addition to a skilled nurse for antepartum care and how this additional care was associated with birth characteristics and outcomes. METHODS: The study included a convenience sample of women living in Southwestern Guatemala enrolled in a community nursing program between October 1, 2018, and December 3, 2019. This analysis describes the sociodemographic characteristics, antepartum care, birth outcomes, and postpartum behaviors of women who received antepartum care with skilled nurses only compared with women who received antepartum care with skilled nurses and a TBA. RESULTS: Of the 316 enrollees, 259 had given birth and completed their postpartum visit at the time of analysis. Three women were excluded because of missing data. The majority of women in the study sample reported visiting a TBA over the course of their pregnancies (80.9%). Women who saw a TBA in addition to the nurse were similar to the comparator sample except that they were almost 3 times more likely to have 8 or more prenatal contacts with the nurse. In separate multivariable logistic regression models adjusted for number of prenatal visits, women who saw a TBA in addition to nurses had a reduced likelihood of cesarean birth, increased likelihood of birth with a TBA, and increased likelihood of breastfeeding within one hour of birth compared with women who only received antenatal care from nurses. Patient-reported adverse outcomes were not included in the analysis because of low prevalence and concern about data quality and missing data. DISCUSSION: Among a convenience sample of women in the Trifinio community in rural Guatemala, a large proportion of women continued to seek the care of a TBA in pregnancy while using a skilled nursing program for antenatal care. Intentionally integrating the TBA into the maternity care workforce may be beneficial for improving pregnancy care quality measures.

Prevalence and Predictors of Low Birth Weight in a Rural Guatemalan Community.

BACKGROUND: The intention of our study was to establish the prevalence of low birth weight (LBW) as well as risk factors for LBW in infants born to a convenience sample of women enrolled in a home visitation maternal care program associated with the Center for Human Development in Southwest Trifinio, Guatemala. METHODS: This is an observational study analyzing self-reported data from a quality improvement database. We recorded the distribution of birthweights of infants born to women enrolled in Madres Sanas that delivered between October 2018 and December 2019. We grouped women by LBW (<2500g ) and adequate birthweight (≥2500g) infants, and performed bivariate comparisons using sociodemographic, obstetric, and intrapartum data. Using the independent variables shown to have an association with LBW, we then performed a multivariable analysis. RESULTS: There were 226 births among our program participants, 218 with recorded birthweights. The median birthweight was 3175g; 13.8% were LBW (<2500g), higher than Guatemala's average of 10.9%. Through our bivariate analysis, we determined women with LBW infants were younger, with a median age of 20.8 (IQR [17.8-23.7]) compared to a median age of 23.2 (IQR [19.8-27.3]) among women with infants ≥2500g (P=0.03). Women with LBW infants were also more likely to have fewer than 4 prenatal visits (33.3% vs 19.3%, P=0.04). CONCLUSION: Two significant findings emerged from our analysis: LBW infants were more commonly born to women who were younger in age and who had received fewer than 4 prenatal visits. These findings are consistent with existing literature on LBW in Latin America. Our study helps to strengthen the data around these associations and gives credence to programming and policy efforts in Latin America that support adequate prenatal care for all and youth education about reproductive health and contraceptive access.

Tampon use in patients with anorexia nervosa can cause persistent vaginal bleeding: a case series.

OBJECTIVE: To describe the phenomenon of persistent vaginal bleeding in two patients with severe anorexia nervosa. METHOD: We report two cases of young women with severe anorexia nervosa reporting vaginal bleeding that persisted for months despite trials of topical and systemic conjugated estrogen therapy. RESULT: A speculum exam by a gynecologist ultimately revealed the source of the bleeding to be tampon-induced vaginal ulcers. These resolved, along with the vaginal bleeding, with vaginal estrogen cream and cessation of tampon use. DISCUSSION: Most patients with anorexia nervosa are amenorrheic due to reversion of the hypothalamic-pituitary-ovarian axis to a prepubertal state. Vaginal bleeding in patients with anorexia nervosa may trigger needless systemic hormonal treatments, radiographic studies, and multiple physician visits. A careful exam is warranted to evaluate for the presence of tampon-induced vaginal ulcer in patients with anorexia nervosa who have persistent vaginal bleeding.

Characteristics Associated with Choosing Long-Acting Reversible Contraception in Rural Guatemala: A Secondary Analysis of a Cluster-Randomized Trial.

DESIGN: We conducted a secondary analysis of a cluster-randomized trial to observe characteristics associated with women who chose to use long-acting reversible contraceptives (LARC) compared to those who chose a short-acting method 12 months after enrollment. METHODS: The trial studied four control and four intervention clusters where the intervention clusters were offered contraception at their 40-day routine postpartum visit; control clusters received standard care, which included comprehensive postpartum contraceptive counseling. Women were followed through twelve months postpartum. RESULTS: The study enrolled 208 women; 94 (87.0%) were in the intervention group and 91 (91.0%) were in the control group. At twelve months, with 130 (70.3%) women using contraception at that time. 94 women (50.8%) were using a short acting method compared to 33 (17.9%) who chose a long-acting method, irrespective of cluster. In mixed effect regression modeling adjusted for cluster, characteristics associated with a reduced likelihood of choosing long-acting contraception in multivariate modeling included age (aRR 0.98 [0.96,0.99], p = 0.008) and any education (compared to no education; aRR 0.76 [0.60,0.95], p = 0.02). Women who were sexually active by their enrollment visit (40 days postpartum) were 30% more likely to opt for a long-acting method (aRR 1.30 [1.03,1.63], p = 0.03). CONCLUSION: Older and more educated women were less likely to be using LARC a year after enrollment, while women with a history of early postpartum sexual activity were more likely to choose LARC.

Twelve-Month outcomes of a Cluster-Randomized Trial of Home-Based Postpartum Contraceptive Delivery in Southwest Trifinio, Guatemala.

DESIGN: We executed a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with three and 12-month contraceptive utilization, satisfaction, and pregnancy rates. METHODS: Eight clusters were randomized to receive either the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit in addition to routine care, or routine care alone, which included comprehensive contraceptive counseling throughout antepartum care. RESULTS: 208 women were enrolled in the study, 108 in the intervention clusters and 100 in control clusters. 94 (87.0%) women in the intervention group and 91 (91%) of women in control clusters were evaluated 12 months post-enrollment. Likelihood of using contraception at that time was borderline increased in intervention clusters (RR 1.1 [1.0,1.3], p = 0.05) with an increased likelihood of long-acting contraceptive use (the implant; RR 1.6 [1.3,1.9], p < 0.001). Pregnancy rates were also borderline reduced in the intervention clusters (RR 1.0 [1.0,1.1], p = 0.07). There was no difference in satisfaction of women with contraceptive use between arms with about 95% of women very satisfied or a little satisfied in each arm. Continuation rates at twelve months of contraceptives in the intervention group were 0.0% for condom users, 80.0% for contraceptive pill users, 57% for injectable users, and 83% for implant users. Most women who discontinued their initial method chose a more long-term or permanent method. There was a trend toward a significant association with reduced short interval pregnancy. CONCLUSION: Our study had a borderline increase in overall use of contraception by 12 months, did have an increased likelihood of long-acting contraceptive use of the implant by 12 months, and resulted in a trend toward reduced short interval pregnancy in the intervention clusters as compared to control clusters.

Identifying Prevalence and Risk Factors for Intimate Partner Violence in Pregnant Women in Rural Guatemala.

BACKGROUND: Victims of intimate partner violence (IPV) during pregnancy experience significant physical and mental health consequences and adverse birth outcomes. Our objective was to describe the prevalence of IPV, and risk factors associated with IPV in pregnant, rural Guatemalan women. METHODS: This retrospective cohort study was completed using quality improvement data gathered during routine prenatal health visits to women of Trifinio, Guatemala, by the Madres Sanas maternal health program from 2018 through 2020. Chi-square and t-tests were used to determine if there were differences in characteristics between women who self-reported experiencing IPV and those who did not. If differences occurred (p < 0.2), those covariates were included in a multivariable logistic regression to determine sociodemographic risk associated with IPV. RESULTS: 583 women were enrolled with Madres Sanas between October 10, 2018, and October 1, 2020, and reported on IPV. Nineteen (3.26%) women reported experiencing IPV. The highest prevalence of IPV (7.6%) occurred in the sub-group of women who experienced food insecurity during the past year. The sole covariate of all sociodemographic and health characteristics which differed significantly between women who reported experiencing and not experiencing IPV was food insecurity. A regression model found that those who had worried about ability to buy food in the past year had a 3.19-fold increase in the odds that they experienced IPV (95% CI 1.072, 9.486, p-value 0.037). CONCLUSION: Among this convenience sample of women, the prevalence of IPV was 3.26%. Food insecurity was associated with increased odds of experiencing IPV, highlighting an opportunity for interventions.

Use of Postpartum Birth Control in Rural Women in Southwest Guatemala: Analysis of a Quality-Improvement Database.

OBJECTIVE: Our objective was to observe the prevalence of postpartum contraceptive use in a population of rural women in Southwest Guatemala by type, and to determine characteristics associated with long-acting reversible contraceptive (LARC) use and sterilization. METHODS: We conducted a secondary analysis of prospectively collected quality improvement data from a cohort of postpartum women. We compared women intending to use or already using contraception to those not intending to utilize a method; bivariate comparisons were used to determine if there were differences in characteristics between these groups. If differences occurred (p < 0.2), those covariates were included in multivariable regression analyses to determine characteristics associated with use, and then specifically with LARC use and sterilization. RESULTS: In a cohort of 424 women who were surveyed between 2015-2017, the average age was 23 years old, and the prevalence of use or plan to use postpartum contraception was 87.5%. Women with a parity of 2 - 3 were 10% more likely to use any form of postpartum birth control (RR 1.1, CI [1.01, 1.2]) compared to primiparous women. Women who were married were also more likely to use a postpartum method (RR > 10, CI [>10,>10]). The prevalence of LARC use was low (4.0%), and women were more likely to choose this method if they were employed (RR 3.5 CI [1.1, 11.3]).Regarding sterilization, women with a parity of greater than one compared to primiparous women had an increased likelihood of sterilization (RR 3.6 CI [2.5,4.9]); each year a woman aged was associated with a 10% increased likelihood of postpartum sterilization (RR 1.1 CI [1.01,1.08]). Women were also more likely to choose sterilization if delivered by a skilled birth attendant (RR 1.8 CI [1.1,2.9]) or by cesarean birth (RR 2.1 CI [1.4,3.1]). CONCLUSION: In this cohort, married women of higher parity were more likely to use postpartum contraception, with employed women more likely to use a LARC method. Older women of higher parity who were delivered by a skilled attendant by cesarean birth were the most likely to pursue sterilization.

Delivery of home-based postpartum contraception in rural Guatemalan women: a cluster-randomized trial protocol.

BACKGROUND: Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth. METHODS: This study is a cluster-randomized trial of communities in rural Guatemala where women receive ante- and postnatal care through a community-based nursing program. When nurses visit women for their postpartum visit in the intervention clusters, instead of providing only routine care that includes postpartum contraceptive education and counseling, the nurses will also bring a range of barrier, short-acting, and long-acting contraceptives that will be offered and administered in the home setting, after routine clinical care is provided. DISCUSSION: A barrier to postpartum contraception is access to medications and devices. Our study removes some access barriers (distance, time, cost) by providing contraception in the home. We also trained community nurses to place implants, which are a type of long-acting reversible contraceptive method that was previously only available in the closest town which is about an hour away by vehicular travel. Therefore, our study examines how home-based delivery of routinely available contraceptives and the less routinely available implant may be associated with increased uptake of postpartum contraception within 3 months of childbirth. The potential implications of this study include that nurses may be able to be trained to safely provide contraceptives, including placing implants, in the home setting, and provision of home-based contraception may be an effective way of delivering an evidence-based intervention for preventing unintended and closely spaced pregnancies in the postpartum period. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04005391. Retrospectively registered on 1 July 2019.

High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening.

BACKGROUND: Congenital microcephaly is the result of a disturbance in early brain development and can have multiple etiologies. Establishing background prevalence of microcephaly in Zika virus (ZIKV)-affected areas is important for improving identification of ZIKV-affected newborns. However, to date, there is limited consistent guidance for the accurate identification of microcephaly in infants of unknown gestational age, a common concern in low- and middle-income countries. METHODS: Occipital frontal head circumference (OFC) obtained from infants (0-13 days) of unknown gestational age at enrollment in a pregnancy registry in rural Guatemala from August 2014 to March 2016 were retrospectively reviewed. Trained community health nurses recorded anthropometry in an online database. In April 2015, ZIKV was identified in this population. Gestational age was approximated in 2 ways: presumed term and estimated using z-score of zero for height on modified Fenton growth curves. After which, z-scores for OFC and weight were obtained. Microcephaly and microcephaly background prevalence were estimated using 7 established microcephaly case definitions from national and international organizations and 3 proposed definitions using Fenton growth curves. Independent associations with microcephaly and OFC, including relationship with date of birth, were assessed with prevalence ratios and linear regression. RESULTS: For 296 infants, the mean OFC was 33.1 cm (range, 29.5 to 37 cm) and the mean OFC z-score was -0.68. Depending on case definition, 13 to 125 infants were classified as having microcephaly (background prevalence 439 to 4,223 per 10,000 live births), and 1 to 9 infants were classified as having severe microcephaly (<-3 standard deviation [SD]) (34 to 304 per 10,000 live births). Five (1.7%) infants met all the microcephaly case definitions. Weight ≤-1 SD (prevalence rate [PR], 3.77; 95% confidence interval [CI]: 1.6 to 8.8; P=.002) and small for gestational age (PR, 4.68; 95% CI, 1.8 to 12.3; P=.002) were associated with microcephaly. Date of birth was not associated with OFC z-score or OFC after adjusting for gestational age and gender. CONCLUSIONS: Estimated background microcephaly is high in rural Guatemala compared with reported rates in Latin America prior to ZIKV epidemic, which has important implications for neonatal screening programs for congenital ZIKV infection. Fenton growth curves offer a standardized approach to the identification of microcephaly in infants of unknown gestational age.

Explaining the pathway from familial and peer social support to disordered eating: Is body dissatisfaction the link for male and female adolescents?

OBJECTIVE: This study examined if familial and peer social support longitudinally predicted disordered eating for late adolescents in the transitional first year of college, and if body dissatisfaction mediated this relation. Gender differences between support types and disordered eating, and body dissatisfaction as a mediator, were also examined. PARTICIPANTS/METHODS: 651 late adolescent males and females (Mage=18.47) completed measures of social support at the end of the first semester of college and of disordered eating and body image approximately five months later, at the end of the first year. RESULTS: Lower levels of familial social support prospectively predicted greater disordered eating, but not greater body dissatisfaction, and lower levels of peer social support prospectively predicted greater body dissatisfaction but not greater disordered eating, above and beyond the other type of social support type, prior levels of body dissatisfaction, disordered eating, and BMI. Body dissatisfaction did not mediate the relation between familial social support and disordered eating; however, it did significantly mediate the non-significant relation between peer social support and disordered eating, which was further moderated by gender. CONCLUSION: These findings suggest that parental social support remains a significant predictor of disordered eating for late adolescents even after they transition to college, and has a stronger relation to disordered eating than peer support. In contrast, peer social support seems to be especially linked to feelings of body dissatisfaction and may be an avenue for intervention of this type of negative self-perception that is a risk factor for later disordered eating.

Group prenatal care for women with gestational diabetes (.).

OBJECTIVE: We aimed to determine if group prenatal care affects the progression to A2 gestational diabetes mellitus (GDM) when compared with conventional care for women with GDM. METHODS: Prospective observational cohort of women diagnosed with GDM who attended group visits compared with a historical control group of women who received conventional obstetrical care in the year prior but would have met inclusion criteria for group care. The primary outcome was progression to A2 GDM. Secondary outcomes included antepartum, intrapartum and postpartum maternal outcomes and neonatal outcomes. RESULTS: A total of 165 subjects were included: 62 in group care and 103 in conventional care. Compared with patients with conventional care, group subjects were more likely to attend a postpartum visit (92% versus 66%; p = 0.002) and were almost 4 times more likely to receive recommended diabetes screening postpartum (OR 3.9, CI 1.8-8.6). Group subjects were much less likely to progress to A2 GDM (OR 0.15, CI 0.07-0.30). There were no differences in neonatal outcomes. CONCLUSIONS: Group prenatal care for women with diabetes is associated with decreased progression to A2 GDM and improved postpartum follow-up for appropriate diabetes screening without significantly affecting obstetrical or neonatal outcomes.