Evaluating adherence to American College of Obstetricians and Gynecologists guidelines at the first obstetric visit.

OBJECTIVE: This is a prospective observational cohort study with the objective of assessing adherence to the American College of Obstetricians and Gynecologists guidelines regarding the first prenatal visit and determining what patient and provider factors are associated with high adherence in a faculty obstetric clinic at an academic medical center. METHODS: The American College of Obstetricians and Gynecologists guidelines recommend addressing 72 topics early in prenatal care. A research assistant observed the first prenatal encounter and noted which topics were discussed during the visit. Patient and clinic characteristics were also collected. The primary outcome was the percentage of topics covered at each visit. After analyzing all encounters, patient encounters that scored above the median score were compared with encounters scoring below the median using bivariate comparisons with respect to patient and clinic characteristics. A multivariable Poisson regression model with robust error variance was performed on characteristics with a p value of ⩽0.2. RESULTS: Fifty-one patient encounters met inclusion criteria and the median score for topics covered was 74%. Patients with chronic disease were more likely to have a higher percentage of topics covered (odds ratio 1.67, 95% confidence interval: 0.91-3.09). Patients who completed a prenatal questionnaire were also more likely to have a higher percentage (odds ratio 2.28, 95% confidence interval: 1.00-5.15) as well as patients who had nurse-led education integrated into their visit during (odds ratio 1.82, 95% confidence interval: 1.19-2.78). Patient satisfaction had no correlation with the number of topics covered. CONCLUSION: The number of topics to cover at the first prenatal visit has expanded creating challenges for patients and providers. Integration of prenatal questionnaires and nurse-led education has the potential to address gaps in antenatal care.

Virtual Prenatal and Postpartum Care Acceptability Among Maternity Care Providers.

INTRODUCTION: The Covid-19 pandemic and statewide stay-at-home orders abruptly impacted clinic operations necessitating the incorporation of telehealth. Uptake of telehealth is multifaceted. Clinician acceptance is critical for success. The aim of this study is to understand maternity care providers' acceptance of and barriers to providing virtual maternity care. METHODS: Providers completed a baseline and 3-month follow up survey incorporating the validated implementation outcome measures, feasibility of intervention measure (FIM), intervention appropriateness measure (IAM), and acceptability of intervention measure (AIM).Statistical analyses evaluated differences between groups in this small convenience sample to understand trends in perceptions and barriers to telehealth. While not intended to be a qualitative study, a code tree was used to evaluate open-ended responses. RESULTS: Baseline response rate 50.4% (n = 56). Follow-up retention/response-rate 68% (n = 38). Most reported no prior telehealth experience. 94% agreed with the FIM, decreasing to 92% at follow-up. 80% (prenatal) and 84% (postpartum) agreed with the IAM. Agreement with the AIM increased to 83%.Differences in the FIM and AIM found by division (p < 0.01) and years in practice (p < 0.01). Identified barriers included patient lack of essential tools, inadequate clinic support, and patients prefer in person visits. Themes that emerged included barriers, needs, and areas of success. DISCUSSION: Telehealth was found to be feasible, appropriate, and acceptable across provider types and divisions. Improving patient/provider access to quality equipment is imperative. Future research must address how and when to incorporate telehealth.

Perspectives of Obstetricians and Women with a History of Prior Cesarean Birth Regarding Subsequent Mode of Birth in Trifinio and Coatepeque, Guatemala.

BACKGROUND: The decision regarding delivery in the context of a prior cesarean birth is complex because both trial of labor after cesarean and elective repeat cesarean birth have risks and benefits. PURPOSE: Our research objective was to understand the perspective of women and obstetricians regarding factors influencing mode of birth for women with a history of prior cesarean. METHODS: In February 2020, qualitative data was collected at Coatepeque Hospital in Coatepeque, Guatemala. In-depth interviews were conducted with obstetricians and women at the Center for Human Development in the Southwest Trifinio region. Interviews were recorded, transcribed, translated, and analyzed using conceptual content analysis of key informant interviews to analyze the meaning of themes and concepts related to mode of delivery for women with a history of prior cesarean birth. RESULTS: Women described feeling conflicted about their preferences on the location and attendant of their future births, but suggested that the hospital setting, and physician providers were more capable of managing complications. Physicians felt trial of labor after cesarean was the safer option but described multiple reasons that made repeat cesarean birth the more common mode of birth. CONCLUSIONS: There is a need for innovative approaches to patient messaging and education around mode of delivery after a prior cesarean in the Southwest Region in Guatemala. Findings from this study underscore the need to improve the quality and dissemination of the educational information given, medical history collected during prenatal care, and pain control during labor. Finally, there is a need for obstetric training to support vaginal birth in the facility setting for the successful implementation of evidence-based practices around trial of labor after cesarean at Coatepeque Hospital.

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.

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.

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.

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.

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol.

BACKGROUND: As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. METHODS: We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. DISCUSSION: Completion of our study aims will allow us to describe participants' perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. TRIAL REGISTRATION: There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

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 Southwest Trifinio, Guatemala: Reach, adoption, and implementation in a cluster-randomized trial.

OBJECTIVE: The objective of this analysis was to present our secondary outcomes (reach, adoption, implementation, maintenance domains) of a prospective trial to test the efficacy of a home-based intervention to increase postpartum contraceptive uptake. STUDY DESIGN: We executed a cluster-randomized trial to determine if provision of contraception in the home setting increased uptake of postpartum methods. We collected secondary outcomes on how our implementation strategies of revising professional roles and changing service sites performed in terms of the number of people our study enrolled of all women eligible (reach), how it was accepted by the providers (adoption), what methods were used to conduct the study (implementation), and preliminary results on whether or not the intervention will be continued (maintenance). We conducted a survey and focus group discussion to assess adoption and implementation among intervention nurse staff, and a survey in a convenience sample of patients in the intervention arm to assess acceptability. RESULTS: Our primary outcome of effectiveness has been published; implant uptake was 25% in the intervention cohort compared to 3% in the control clusters. Our reach was 89%, as 208 of the 234 eligible women consented to participate. Among a convenience sample of N = 25 patients completing a survey on the intervention 12 months after enrollment, ≥ 68% (n = 17 of 25) felt the intervention was acceptable. From the nursing perspective (N = 7), only a minority of nurses felt the intervention was complicated (n = 1, 17%), and (n = 7, 100%) reported the intervention was acceptable. CONCLUSIONS: Our intervention achieved good reach (89% of the eligible population) and was acceptable to the majority of patients and providers. Practitioners interested in achieving greater reach of contraceptive interventions in their communities may consider changing service sites to convenience their clients, as our results suggest this approach was acceptable. IMPLICATIONS: The unique contribution of this paper is in its success with training nurses to insert contraceptive implants during postpartum home visits, which resulted in increased uptake of the contraceptive implant where access to the device was previously limited. Given the trial's successful feasibility and acceptability to both nurses and patients, perhaps this intervention has the potential to be adapted and scaled to other settings.

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.

A Secondary Analysis of the LILAC Study Regarding Cesarean Birth by Maternal Request in Women Living with HIV.

BACKGROUND: Latin America has the highest regional average cesarean birth rates. One potential driver is cesarean birth by maternal request (CBMR). METHODS: We analyzed of a large prospective cohort study of HIV-infected women in six Latin American countries. RESULTS: Comparisons were made between women who chose CBMR (n = 38) and women with a medical indication for cesarean (n = 683). The only variable associated with CBMR was onset of labor (AOR 0.3 [0.1,0.9], p = 0.04). CONSLUSION: Spontaneous labor reduced the likelihood of a woman living with HIV to pursue CBMR in a large Latin American cohort.

The association of timing of repeat cesarean with outcomes among a cohort of Guatemalan women with a history of prior cesarean birth.

BACKGROUND: The objective of this analysis was to observe whether maternal and perinatal/neonatal outcomes of birth vary by timing of repeat cesarean among women with a history of one prior cesarean birth in a Guatemalan cohort. METHODS: This secondary analysis was conducted using data from a prospective study conducted in communities in Chimaltenango, Guatemala through the Global Network for Women's and Children's Health Research. RESULTS: Between January 2017 and April 2020, 26,465 women delivered; 3,143 (11.9%) of those women had a singleton gestation and a history of prior cesarean delivery. 2,210 (79.9%) women with a history of prior cesarean birth had data available on mode of delivery and gave birth by repeat cesarean; 1312 (59.4%) were pre-labor cesareans while 896 (40.5%) were intrapartum cesarean births. Risk factors associated with an increased risk of intrapartum cesarean birth included hospital delivery as compared to "other" location (ARR 1.6 [1.2,2.1]) and dysfunctional labor (ARR 1.6 [1.4,1.9]). Variables associated with a reduced risk of intrapartum cesarean birth were hypertensive disease (ARR 0.7 [0.6,0.9]), schooling (ARR 0.9 [0.8,0.9]), and increasing age, which was associated with a very slight reduction in the outcome (ARR 0.99 [0.98,0.99]). Maternal and neonatal outcomes did not vary by type of cesarean birth. CONCLUSION: Outcomes of cesarean birth do not seem to vary by timing of repeat cesarean birth, with hypertensive disease increasing the likelihood of pre-labor cesarean. This information might be useful in counseling women that outcomes after failed trial of labor do not appear worse than those after pre-labor cesarean birth.

How birth outcomes among a cohort of Guatemalan women with a history of prior cesarean vary by mode or birth across different interpregnancy intervals.

OBJECTIVES: Our objectives were to analyze how pregnancy outcomes varied by cesarean birth as compared to vaginal birth across varying interpregnancy intervals (IPI) and determine if IPI modified mode of birth. METHODS: This secondary analysis used data from a prospective registry of home and hospital births in Chimaltenango, Guatemala from January 2017 through April 2020, through the Global Network for Women's and Children's Health Research. Bivariate comparisons and multivariable logistic regression were used to answer our study question, and the data was analyzed with STATA software v.15.1. RESULTS: Of 26,465 Guatemalan women enrolled in the registry, 2794 (10.6%) had a history of prior cesarean. 560 (20.1%) women delivered by vaginal birth after cesarean with the remaining 2,233 (79.9%) delivered by repeat cesarean. Repeat cesarean reduced the risk of needing a dilation and curettage compared to vaginal birth after cesarean, but this association did not vary by IPI, all p-values > p = 0.05. Repeat cesarean delivery, as compared to vaginal birth after cesarean, significantly reduced the likelihood a woman breastfeeding within one hour of birth (AOR ranged from 0.009 to 0.10), but IPI was not associated with the outcome. Regarding stillbirth, repeat cesarean birth reduced the likelihood of stillbirth as compared to vaginal birth (AOR 0.2), but again IPI was not associated with the outcome. CONCLUSION: Outcomes by mode of delivery among a Guatemalan cohort of women with a history of prior cesarean birth do not vary by IPI.

Characteristics and Outcomes Associated with Cesarean Birth as Compared to Vaginal Birth at Mizan-Tepi University Teaching Hospital, Ethiopia.

INTRODUCTION: The objective of this study was to observe characteristics and outcomes associated with cesarean birth as compared to vaginal birth. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women. Data was collected on admission, delivery, and discharge by trained physician data collectors on paper forms through chart review and patient interview. RESULTS: Data on mode of delivery was available for 993/1000 women (0.7% missing data), 23.4% of whom underwent cesarean. These women were less likely to have labored (84.5% versus 87.4%), more likely to have been transferred (62.0% versus 45.2%), more likely to have been admitted in early labor (53.0% versus 48.6%), more likely to be in labor for longer than 24 hours (10.7% versus 3.3%) and were less likely to have multiple gestation (7.7% versus 3.9%), p < 0.05. In a Poisson model, history of cesarean (aRR 2.0, p < 0.001), transfer during labor (RR 1.5, p = 0.003), labor longer than 24 hours and larger birthweight (RR 2.7, p 0.001) were associated with an increased risk of cesarean. CONCLUSION: Our analysis suggests cesarean birth is being used among women with a history of prior cesarean and in cases of labor complications (prolonged labor or transfer), but fresh stillbirth is still common in this setting.