Comparison of the nutrient composition of eggs produced in the Guatemalan highlands during the wet and dry seasons.

The potential of chicken eggs as a nutritionally complete protein and source of key micronutrients during the first 1000 days post-conception has been progressively recognized across the globe, particularly in resource-poor settings. Fluctuation of egg nutrient content by season is relatively unknown, which may influence international food composition databases and outcomes in intervention studies using egg supplementation. To better interpret the findings of The Saqmolo' Project, we conducted comprehensive nutrient analyses on eggs produced during the wet and dry seasons in the highlands of central Guatemala. We randomly collected 36 shell eggs from a local farm during both seasons, hard-boiled, and prepared them for transport to the United States, where they were pooled and assessed for their nutrient composition. Methods of the Association of Official Analytical Chemists, the American Oil Chemists Society, and the American Association of Cereal Chemists were utilized to determine total energy, moisture, ash, total protein, total fat, fatty acids, total carbohydrates, 12 vitamins, 11 minerals, and carotenoids, by season, in some instances with modifications. Differences in nutrient composition between de-shelled hard-boiled eggs collected between seasons were assessed using an analysis of variance (ANOVA) and Tukey's family error rate comparison test. Most nutrients in eggs produced in the highlands of central Guatemala differed negligibly (but statistically significantly) based on seasonality. Only vitamins A and E, folate, choline, and calcium fluctuated at clinically significant levels relative to the AI/RDA for infants 7-12 months. Total energy, protein, trans fatty acids, moisture, and vitamin D3 levels did not differ between seasons (p > .05). Further multi-year sampling is needed to examine how seasonal variation affects the nutrient composition of eggs. These data may be used to supplement existing national and regional food composition databases.

Adults' Experiences with Type 2 Diabetes in Rural Guatemala: A Qualitative Study.

BACKGROUND: Given that the diabetes burden is rising rapidly in low- and middle-income countries, it is critical to understand perspectives of people living with diabetes in these settings. This qualitative study examines perceptions of causality and treatment among adults with type 2 diabetes in rural Indigenous communities of Guatemala. METHODS: We conducted semi-structured interviews with 29 people living with type 2 diabetes from a population survey in two majority Indigenous Guatemalan towns. Data were coded inductively and themes were elucidated by consensus. RESULTS: Participants emphasized strong emotional experiences and stress as perceived causes of diabetes, as well as diet and heritability. All participants took biopharmaceutical treatments, but many also endorsed diet, exercise, herbal remedies, and naturopathic products as important remedies. CONCLUSION: Perspectives from people living with diabetes in two rural Indigenous towns in Guatemala differ from the biomedical model of disease and have implications for clinical practice and program development.

Academy of Nutrition and Dietetics Nutrition Research Network: The Saqmolo' Project Rationale and Study Protocol for a Randomized Controlled Trial Examining the Influence of Daily Complementary Feeding of Eggs on Infant Development and Growth in Guatemala.

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

Academy of Nutrition and Dietetics Nutrition Research Network: A Home Garden Intervention Improves Child Length-for-Age Z-Score and Household-Level Crop Count and Nutritional Functional Diversity in Rural Guatemala.

Home gardens may help address childhood malnutrition in low- and middle-income countries. In this quasi-experimental pilot study, the Academy of Nutrition and Dietetics, in collaboration with Maya Health Alliance, evaluated the feasibility of augmenting a standard-of-care nutrition-specific package for Maya children with length-for-age z score ≤-2 (stunting) in rural Guatemala with a nutrition-sensitive home garden intervention. Two agrarian municipalities in Guatemala were included. Families of 70 children with stunting from 1 municipality received the standard-of-care package (food supplementation, multiple micronutrient powders, monthly nutrition home visits, group nutrition classes). Families of 70 children with stunting from another municipality received the standard-of-care package plus a home garden intervention (garden materials, monthly agricultural home visits, agriculture classes). Maternal and child dietary diversity, household food insecurity, child growth, and agricultural indicators were collected at baseline and 6 months later and were analyzed using mixed linear and logistic regression models. Compared with the standard-of-care group, the garden intervention group had improved child (odds ratio [OR] 3.66, 95% CI 0.89-15.10, P = 0.07) and maternal dietary diversity (OR 2.31, 95% CI 0.80-6.65, P = 0.12) and decreased food insecurity (OR 0.38, 95% CI 0.11-1.35, P = 0.14); however, these effects were not statistically significant. Participation in gardens predicted a higher length-for-age z-score (change difference [CD] 0.22 SD, 95% CI 0.05-0.38, P = 0.009), greater crop species count (CD 2.97 crops, 95% CI 1.79-4.16, P < 0.001), and greater nutritional functional diversity (CD 0.04 points, 95% CI 0.01-0.07, P = 0.006) than standard-of-care alone. Home garden interventions are feasible in rural Guatemala and may have potential benefits for child growth when added to other nutrition-specific interventions.

Why women choose to to seek facility-level obstetrical care in rural Guatemala: A qualitative study.

OBJECTIVE: The majority of indigenous Guatemalan women give birth at home with traditional birth attendants (TBAs), and maternal mortality rates are high (Ministerio de Salud, 2017). Our objective was to better understand decision-making around whether to remain in the home or to seek facility-level care for obstetric complications. METHODS: This study was a qualitative analysis using semi-structured interviews in a Maya population in the Western Highlands of Guatemala who received prenatal care between April 2017 and December 2018. We used qualitative interviews with women who were identified as medically high-risk and needing facility-level care, offered assistance with acquiring such care, and yet declined this option. Women interviewed were connected to a primary care organization called Maya Health Alliance, through care with TBAs involved in a program utilizing a smartphone-based decision support application to identify maternal and neonatal complications of pregnancy. Interviews were analyzed using Dedoose (www.dedoose.com). Deductive and inductive analysis was performed. RESULTS: Barriers to care included a disagreement between the respondent and TBA about indications for facility care, fear of hospital care, concerns about the quality of hospital care, logistical obstacles, and lack of control; and they were more often described by respondents who had previous healthcare experiences. Therapeutic misalignment occurred more with conditions perceived to be less severe. Participants described a balancing of fears and apprehensions against concerns of low quality and disrespectful maternity care, and in the setting of emergent conditions, disregarded barriers that were often described as inhibiting non-urgent obstetric care. CONCLUSIONS: The decision to engage in medical care in this population of Maya women involves a weighing of the perception of seriousness of the medical complication against fears of facility level care and concerns of a poor quality of care.

Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation.

BACKGROUND: Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands. METHODS: We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff-namely physicians, nurses, and social workers-of the main public hospital in the pilot's catchment area (Chimaltenango). Interviews queried OCN's impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis. RESULTS: Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks. CONCLUSIONS: Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers' experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff-especially nurses-appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers' future care seeking behavior.

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

Obstetric care navigation: results of a quality improvement project to provide accompaniment to women for facility-based maternity care in rural Guatemala.

BACKGROUND: Many maternal and perinatal deaths in low-resource settings are preventable. Inadequate access to timely, quality care in maternity facilities drives poor outcomes, especially where women deliver at home with traditional birth attendants (TBA). Yet few solutions exist to support TBA-initiated referrals or address reasons patients frequently refuse facility care, such as disrespectful and abusive treatment. We hypothesised that deploying accompaniers-obstetric care navigators (OCN)-trained to provide integrated patient support would facilitate referrals from TBAs to public hospitals. METHODS: This project built on an existing collaboration with 41 TBAs who serve indigenous Maya villages in Guatemala's Western Highlands, which provided baseline data for comparison. When TBAs detected pregnancy complications, families were offered OCN referral support. Implementation was guided by bimonthly meetings of the interdisciplinary quality improvement team where the OCN role was iteratively tailored. The primary process outcomes were referral volume, proportion of births receiving facility referral, and referral success rate, which were analysed using statistical process control methods. RESULTS: Over the 12-month pilot, TBAs attended 847 births. The median referral volume rose from 14 to 27.5, meeting criteria for special cause variation, without a decline in success rate. The proportion of births receiving facility-level care increased from 24±6% to 62±20% after OCN implementation. Hypertensive disorders of pregnancy and prolonged labour were the most common referral indications. The OCN role evolved to include a number of tasks, such as expediting emergency transportation and providing doula-like labour support. CONCLUSIONS: OCN accompaniment increased the proportion of births under TBA care that received facility-level obstetric care. Results from this of obstetric care navigation suggest it is a feasible, patient-centred intervention to improve maternity care.

mHealth intervention to improve the continuum of maternal and perinatal care in rural Guatemala: a pragmatic, randomized controlled feasibility trial.

BACKGROUND/OBJECTIVE: Guatemala's indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates. METHODS: A pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume. RESULTS: Forty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22-58) compared to the later-access arm (median 20 per 100, IQR 0-30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5-50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10-9.86). CONCLUSIONS: Referral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts. TRIAL REGISTRATION: Clinicaltrials.gov NCT02348840 .

An mHealth monitoring system for traditional birth attendant-led antenatal risk assessment in rural Guatemala.

Limited funding for medical technology, low levels of education and poor infrastructure for delivering and maintaining technology severely limit medical decision support in low- and middle-income countries. Perinatal and maternal mortality is of particular concern with millions dying every year from potentially treatable conditions. Guatemala has one of the worst maternal mortality ratios, the highest incidence of intra-uterine growth restriction (IUGR), and one of the lowest gross national incomes per capita within Latin America. To address the lack of decision support in rural Guatemala, a smartphone-based system is proposed including peripheral sensors, such as a handheld Doppler for the identification of foetal compromise. Designed for use by illiterate birth attendants, the system uses pictograms, audio guidance, local and cloud processing, SMS alerts and voice calling. The initial prototype was evaluated on 22 women in highland Guatemala. Results were fed back into the refinement of the system, currently undergoing RCT evaluation.

The changing role of indigenous lay midwives in Guatemala: new frameworks for analysis.

OBJECTIVES: to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general. DESIGN/PARTICIPANTS: a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization. SETTING: Kaqchikel Maya-speaking communities in the Guatemalan highlands. FINDINGS: the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal-child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a high level. CONCLUSIONS AND IMPLICATIONS: as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal-child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.