Effects of a Home-Based Intervention on HIV Prevention Health Behaviors in Pregnant/Postpartum Kenyan Women: Estimating Moderating Effects of Depressive Symptoms.

We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women's HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of < 37 weeks, were randomized into standard care or three home visits (2 during pregnancy, 1 postpartum) promoting couple HIV testing and counseling (CHTC) and HIV prevention. Of 105 female participants, 37 (35.24%) reported depressive symptoms and 50 (47.62%) were HIV-positive. Three Poisson regressions with robust variance (univariable, multivariable, and multivariable with depressive symptoms/study arm interaction) were modeled for three outcomes: CHTC, infant HIV testing, health-seeking postpartum. In multivariable analysis with interaction, a moderating trend for the interaction between depressive symptoms and individual health-seeking was observed (p-value = 0.067). Women scoring ≤ 9 (n = 68) on the PHQ-8 and participating in home visits were 1.76 times more likely to participate in individual health-seeking compared to participants in standard care (ARR 1.76, 95% CI 1.17-2.66).

Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya.

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

Medical student volunteerism and interest in working with underserved and vulnerable populations.

BACKGROUND: The desire of medical students to eventually work with underserved and vulnerable populations (hereafter 'service interest'), has been shown to be shaped by individual factors including job satisfaction and financial considerations. School-level factors such as required longitudinal primary care experiences and the availability of extracurricular opportunities to work with underserved patients also affect service interest, but little is known about the impact of student volunteer activities. METHODS: This cross-sectional study gathered data from preclinical medical students via an online questionnaire. The data were linked to academic records, deidentified, and analysed using an ordinal logistic regression model with interest in caring 'primarily for underserved or vulnerable populations' as the outcome variable. RESULTS: Of 121 respondents (33% response rate), 24.8% expressed a definite interest, 55.3% expressed possible interest, and 19.9% expressed no service interest. Intent to work with the underserved was not related to age, sex, race/ethnicity, being from a rural hometown, academic qualifications prior to medical school, or anticipated debt at medical school graduation. Students with no service interest had a higher average academic performance in medical school and plans of subspecialising. When considering volunteerism prior to medical school, students in the highest and middle volunteerism tertiles had 5.68 (95% CI: 1.63, 19.81) and 4.34 (1.32, 14.32) times the odds, respectively, of having definite or possible service interest relative to those who were in the lowest volunteerism tertile, after adjusting for potential confounders. Volunteerism in a student-run clinic for the underserved during medical school was not correlated with service interest. CONCLUSIONS: Medical schools looking to enroll more students interested in working with underserved or vulnerable populations may choose to emphasise applicant premedical volunteerism record in their admissions decisions.

A conceptual framework for the impact of obesity on risk of cesarean delivery.

Cesarean deliveries accounted for 32.2% of nearly 4 million births in the United States in 2014. Obesity affects a third of reproductive-age women and is associated with worse cesarean delivery outcomes. Studies have shown that increasing maternal body mass index correlates linearly with cesarean delivery rates, but little is known about the potential mediating and moderating mechanisms. Thus, a conceptual framework for understanding how obesity correlates with risk of cesarean delivery is crucial to determining safe ways to reduce the cesarean delivery rate among obese gravidas. Based on an extensive review and synthesis of the literature, we present a conceptual framework that posits how obesity may operate through several pathways to lead to a cesarean delivery. Our framework explores the complexity of obesity as an exposure that operates through potential mediating pathways, a moderator of cesarean delivery risk, and a covariate with other cesarean delivery risk factors. Among nulliparas, obesity appears to operate through 3 main proximal mediating mechanisms to increase risk of cesarean delivery including: (1) preexisting comorbidities and obstetric complications; (2) a slower progression of first-stage labor, potentially increasing the risk of cesarean delivery secondary to failure to progress; and (3) a prolongation of pregnancy, which is associated with risk of maternal postdates. For multiparas, a fourth proximal mediator of prior uterine scar may also increase cesarean delivery risk. Distal mediating mechanisms, which operate through one of the proximal mechanisms, may include an induction of labor or planned prelabor cesarean delivery. Obesity may also moderate the likelihood of cesarean delivery by interacting with clinician-level or hospital-level factors. Future research should assess the validity of this framework and seek to understand the relative contributions of each potential pathway between obesity and cesarean delivery. This will allow for evidence-based recommendations to reduce preventable cesareans among obese women by targeting modifiable mediators and moderators of the relationship between obesity and increased risk of cesarean delivery.

Men's hopes, fears and challenges in engagement in perinatal health and the prevention of mother-to-child transmission of HIV in rural Kenya.

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review.

BACKGROUND: For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications. OBJECTIVES: To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies. METHODS: We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded. RESULTS: Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD. CONCLUSIONS: For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.

Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms.

There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = - 0.08, SE = 0.02, 95% CI [- 0.12, - 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.

Implementation of repeat HIV testing during pregnancy in Kenya: a qualitative study.

BACKGROUND: Repeat HIV testing in late pregnancy has the potential to decrease rates of mother-to-child transmission of HIV by identifying mothers who seroconvert after having tested negative for HIV in early pregnancy. Despite being national policy in Kenya, the available data suggest that implementation rates are low. METHODS: We conducted 20 in-depth semi-structured interviews with healthcare providers and managers to explore barriers and enablers to implementation of repeat HIV testing guidelines for pregnant women. Participants were from the Nyanza region of Kenya and were purposively selected to provide variation in socio-demographics and job characteristics. Interview transcripts were coded and analyzed in Dedoose software using a thematic analysis approach. Four themes were identified a priori using Ferlie and Shortell's Framework for Change and additional themes were allowed to emerge from the data. RESULTS: Participants identified barriers and enablers at the client, provider, facility, and health system levels. Key barriers at the client level from the perspective of providers included late initial presentation to antenatal care and low proportions of women completing the recommended four antenatal visits. Barriers to offering repeat HIV testing for providers included heavy workloads, time limitations, and failing to remember to check for retest eligibility. At the facility level, inconsistent volume of clients and lack of space required for confidential HIV retesting were cited as barriers. Finally, at the health system level, there were challenges relating to the HIV test kit supply chain and the design of nationally standardized antenatal patient registers. Enablers to improving the implementation of repeat HIV testing included client dissemination of the benefits of antenatal care through word-of-mouth, provider cooperation and task shifting, and it was suggested that use of an electronic health record system could provide automatic reminders for retest eligibility. CONCLUSIONS: This study highlights some important barriers to improving HIV retesting rates among pregnant women who attend antenatal clinics in the Nyanza region of Kenya at the client, provider, facility, and health system levels. To successfully implement Kenya's national repeat HIV testing guidelines during pregnancy, it is essential that these barriers be addressed and enablers capitalized on through a multi-faceted intervention program.

Diagnosis of Placental Position by Early First-Trimester Ultrasound: A Pilot Study.

OBJECTIVE: Conventional wisdom is that placental location cannot be identified before 8 weeks' gestation when the placenta first becomes hyperechogenic on ultrasound. We sought to evaluate whether placental location could be reliably diagnosed between 5 and 6 weeks' gestation. MATERIALS AND METHODS: This was a retrospective analysis of prospectively acquired data. Early placental location was diagnosed by evaluation of the embryonal and yolk sac position inside the gestational sac on transvaginal ultrasound. Placental position was described as anterior, posterior, fundal, or lateral. Early and mid-pregnancy placental locations were compared and coded as being the same, having migrated to an adjacent surface, or being on an opposite surface. RESULTS: A total of 111 patients met study criteria, providing 141 placental locations, comprising 85 singleton and reduced pregnancies and 28 dichorionic twin pregnancies. The most common placental location was anterior in both singleton and twin/triplet pregnancies. Placental location at the mid-pregnancy ultrasound was consistent with early pregnancy location in 100% of cases, with 79.5% (112/141) being on the same surface and 20.5% (29/141) having expanded onto an adjacent surface. Placental location was not associated with pregnancy outcome, although our study may have been underpowered to detect a significant difference. CONCLUSIONS: Placental location diagnosed at 5 to 6 weeks' gestation is consistent with the location on mid-pregnancy ultrasound. Excluding the presence of an ectopic, cornual, or cesarean section scar and uterine subseptation pregnancy in early first trimester would allow a more effective tailoring of pregnancy follow-up.

Development and Piloting of a Home-Based Couples Intervention During Pregnancy and Postpartum in Southwestern Kenya.

Engaging both partners of a pregnant couple can enhance prevention of mother-to-child transmission of HIV and promote family health. We developed and piloted an intervention to promote couple collaboration in health during pregnancy and postpartum in southwestern Kenya. We utilized formative data and stakeholder input to inform development of a home-based couples intervention. Next, we randomized pregnant women to intervention (n = 64) or standard care (n = 63) arms, subsequently contacting their male partners for enrollment. In the intervention arm, lay health workers conducted couple home visits, including health education, couple relationship and communication skills, and offers of couple HIV testing and counseling (CHTC) services. Follow-up questionnaires were conducted 3 months postpartum (n = 114 women, 86 men). Baseline characteristics and health behaviors were examined by study arm using t-tests, chi-square tests, and regression analyses. Of the 127 women randomized, 96 of their partners participated in the study. Of 52 enrolled couples in the intervention arm, 94% completed at least one couple home visit. Over 93% of participants receiving couple home visits were satisfied and no adverse social consequences were reported. At follow-up, intervention couples had a 2.78 relative risk of having participated in CHTC during the study period compared with standard care couples (95% confidence interval: 1.63-4.75), and significant associations were observed in other key perinatal health behaviors. This pilot study revealed that a home-based couples intervention for pregnant women and male partners is acceptable, feasible, and has the potential to enhance CHTC and perinatal health behaviors, leading to improved health outcomes.

Couple interdependence impacts HIV-related health behaviours among pregnant couples in southwestern Kenya: a qualitative analysis.

INTRODUCTION: HIV infection is frequently transmitted within stable couple partnerships. In order to prevent HIV acquisition in HIV-negative couples, as well as improve coping in couples with an HIV-positive diagnosis, it has been suggested that interventions be aimed at strengthening couple relationships, in addition to addressing individual behaviours. However, little is known about factors that influence relationships to impact joint decision-making related to HIV. METHODS: We conducted qualitative in-depth interviews with 40 pregnant women and 40 male partners in southwestern Kenya, an area of high HIV prevalence. Drawing from the interdependence model of communal coping and health behaviour change, we employed thematic analysis methods to analyze interview transcripts in Dedoose software with the aim of identifying key relationship factors that could contribute to the development of a couples-based intervention to improve health outcomes for pregnant women and their male partners. RESULTS: In accordance with the interdependence model, we found that couples with greater relationship-centred motivations described jointly engaging in more health-enhancing behaviours, such as couples HIV testing, disclosure of HIV status, and cooperation to improve medication and clinic appointment adherence. These couples often had predisposing factors such as stronger communication skills and shared children, and were less likely to face potential challenges such as polygamous marriages, wife inheritance, living separately, or financial difficulties. For HIV-negative couples, joint decision-making helped them face the health threat of acquiring HIV together. For couples with an HIV-positive diagnosis, communal coping helped reduce risk of interspousal transmission and improve long-term health prospects. Conversely, participants felt that self-centred motivations led to more concurrent sexual partnerships, reduced relationship satisfaction, and mistrust. Couples who lacked interdependence were more likely to mention experiencing violence or relationship dissolution, or having difficulty coping with HIV-related stigma. CONCLUSIONS: We found that interdependence theory may provide key insights into health-related attitudes and behaviours adopted by pregnant couples. Interventions that invest in strengthening relationships, such as couple counselling during pregnancy, may improve adoption of beneficial HIV-related health behaviours. Future research should explore adaptation of existing evidence-based couple counselling interventions to local contexts, in order to address modifiable relationship characteristics that can increase interdependence and improve HIV-related health outcomes.