Evaluation of Implicit Bias Training in Continuing Medical and Nursing Education to Address Racial Bias in Maternity Health Care Settings.

OBJECTIVES: Implicit bias can affect clinical decisions that influence the care received by patients whose ancestors had been subjected to unfair medical and social practices. However, literature describing the effects of implicit bias training as part of continuing medical and nursing education is scarce. We conducted a longitudinal evaluation of a training for maternal health care clinical and nonclinical staff. METHODS: A total of 80 staff members at 2 clinical sites in Cleveland, Ohio, participated in the training and evaluation in 2020 and 2021. We used a mixed-methods evaluation to capture changes in knowledge, awareness of bias, and application of strategies to reduce biased behavior by conducting pre- and posttraining surveys immediately after training and interviews at 3 and 6 months posttraining. We conducted univariate and bivariate analyses of the surveys and recorded, transcribed, and analyzed interviews for themes. RESULTS: Using a threshold of answering 3 of 5 knowledge questions correctly, 50 of 80 (62.5%) trainees who engaged in the evaluation passed the pretraining knowledge questions and 67 (83.8%) passed the posttraining knowledge questions. Of the 80 participants, 75 (93.8%) were women. Interviewees (n = 11) said that low staff-to-patient ratios, lack of racial and ethnic diversity in leadership, inadequate training on implicit bias, and lack of institutional consequences for poor behavior exacerbated bias in maternity care. Interviewees reported having heightened awareness of bias and feeling more empowered after the training to advocate for themselves and patients to prevent and mitigate bias in the hospital. CONCLUSION: Additional study describing the effect of implicit bias training as part of continuing medical education should be conducted, and administrative and management changes should also be made to prevent bias and improve quality of care.

Public health priorities for gastroschisis: Summary of a meeting sponsored by the Centers for Disease Control and Prevention and the March of Dimes.

BACKGROUND: Gastroschisis has increased worldwide over several decades; however, there are significant gaps in understanding risk factors for development of the defect, particularly those that might be modifiable. Despite advances in survival, little is known about longer-term outcomes for affected individuals. METHODS: On April 27- and 28, 2023, the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention (CDC) and March of Dimes sponsored a meeting entitled "Public Health Priorities for Gastroschisis". The meeting goals were to review current knowledge on gastroschisis, discuss research gaps, and identify future priorities for public health surveillance, research, and action related to gastroschisis. Meeting participants encompassed a broad range of expertise and experience, including public health, clinical care of individuals with gastroschisis, affected individuals and families, and representatives from professional organizations and federal agencies. RESULTS: Several goals were identified for future public health surveillance and research, including focused theory-driven research on risk factors and increased study of longer-term effects of gastroschisis through improved surveillance. Certain public health actions were identified, that which could improve the care of affected individuals, including increased education of providers and enhanced resources for patients and families. CONCLUSIONS: These efforts may lead to an improved understanding of pathogenesis, risk factors, and outcomes and to improved care throughout the lifespan.

Implementing the Better Starts For All Pilot Mobile and Telehealth Intervention in Ohio Appalachia: Improving Access to Maternal Healthcare.

INTRODUCTION: Women in Ohio Appalachia experience greater maternal health disparities relative to the general U.S. population, resulting in poorer health outcomes. This paper describes the Ohio Better Starts for All (BSFA) program that provides mobile maternal health services in rural Ohio. METHODS: This three-year intervention was delivered through a community-clinical partnership in Ohio Appalachia. The program's preliminary evaluation and opportunities were informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS: Over six months, 86 patients were referred to the BSFA program, 54 (62.8 %) were seen by the maternal care team, and 14 out of 19 scheduled clinic days were held. Five clinics were canceled due to inclement weather, mobile unit breakdown, or provider COVID-19 infection. DISCUSSION: Maternal care providers must provide equitable care to patients, with particular attention to those who face substantial challenges accessing obstetric services. The BSFA program offers one promising solution to help women overcome barriers to accessing care.

Doula support among brazilian women who attended the senses of birth health education intervention - a cross sectional analysis.

BACKGROUND: While maternal health is a priority in international goals, maternal health outcomes remain poor in many regions of the world. In Brazil, maternal mortality has decreased over the past decades, but the country's maternal mortality ratio is higher than over half of all countries at 59 deaths per 100,000 live births. The Brazilian maternal health care model facilitates high rates of medical interventions during labor and childbirth; 56% of births are by cesarean birth. Doula support is considered a potential strategy to reduce medically unnecessary interventions during childbirth that contribute to maternal mortality. METHODS: The cross-sectional study analyses associations with use of doula support and normal birth among Brazilian women who participated in a health education intervention named the Senses of Birth (SoB). The SoB intervention, implemented in five cities from 2015 to 2017, was developed to educate about normal birth and to evidence-based practices (EBP) reduce medically in childbirth. Chi-Square tests were performed to identify the relationship between doula support during childbirth and sociodemographic characteristics, childbirth information, perceived knowledge, and use of EBPs during labor. Logistic regression was performed to identify associations in adjusted analysis. RESULTS: Controlling for covariates, doula support was associated with vaginal delivery (OR 2.47, 95% CI: 1.37-4.45.) Findings also suggest that women who had doula support were more likely to use non-pharmacological pain relief methods during labor (OR 9.68, 95% CI: 2.67-34.61), deliver in a public hospital (OR 2.02, 95% CI: 1.09-3.72), and be low and mid-level income compared to women with high income. CONCLUSION: This study's findings suggest that doula support is significantly associated with vaginal birth. The results may be useful for advocating for changes to the childbirth care model in Brazil. Incorporating EBPs, such as doula support, for all women who desire may improve maternal and child outcomes.

Investing in the Next Generation of Maternal and Child Health Leaders: The APHA Maternal and Child Health Section Student Fellows Program.

PURPOSE: Practical experience in maternal and child health (MCH) settings is critical for professional development and learning. In 2002, the Maternal and Child Health (MCH) Section of the American Public Health Association (APHA) formalized its inclusion of students in section activities through the establishment of the Student Fellows Program. The Program provides graduate-level students opportunities to learn about MCH and APHA, build professional networks, and develop leadership skills. DESCRIPTION: Since its inception, 18 cohorts of Fellows have benefited. This paper presents findings describing the Program from both written records about Fellow projects and activities recorded in past MCH Section communications as well as an online survey that was distributed to former and current Fellows to assess their perceptions and the benefits of the Student Fellows Program. ASSESSMENT: Eighteen cohorts of Fellows have engaged with Section committees and working groups in diverse ways, including MCH-related research, policy, advocacy, and education. An online survey distributed to 151 participants was answered by 79 to document their perceptions of the Student Fellows Program. Of them, 56 (71%) indicated that the Program was important for their career development, 44 (55%) reported being current members of the APHA MCH Section, and 21 (27%) reported serving in a leadership position in the Section. The Fellows highlighted that networking, mentorship and leadership development were key benefits of the Student Fellows Program. CONCLUSION: After several years of involving students in its programs, the APHA MCH Section established the Student Fellows Program in 2002. The Fellows Program has been important for developing the next generation of MCH leaders. The findings suggest that this Program supports long-term interest and commitment to the field of MCH and contributed to the formation of leadership skills and behaviors of Fellows.

A Review of the Maternal and Child Health APHA Policy Statements, 1970-2019.

INTRODUCTION: The American Public Health Association (APHA) policy statements are written by members and approved by the APHA Governing Council. Policy statements inform APHA's position on key public health issues. Maternal and child health (MCH) is a broad discipline focused on health issues concerning women, children, youth, and families. APHA's MCH policies from the last 50 years were reviewed in celebration of the 100th anniversary of the MCH Section of APHA. METHODS: A cross-sectional design was utilized to identify MCH-related statements within the larger APHA policy statement database from 1970 to 2019 (N = 1,110). The policy statements were coded as primary MCH (main focus was MCH) or secondary MCH (mentioned MCH subpopulations as vulnerable population). The primary MCH themes were also identified. RESULTS: 545 (49%) of the APHA policy statements were related to MCH, including 226 (20%) coded as primary MCH and 319 (29%) secondary MCH. The primary MCH policy statements had a main focus on the following subpopulations: women (44%), children (33%), adolescents/young adults (15%), infants (12%), families (5%), and men (2%). Major themes included reproductive health/family planning, school health, children's health, pregnancy/childbirth, and breastfeeding/nutrition. CONCLUSIONS: MCH policy statements remained an important part of APHA's policy and advocacy focus over time as indicated through the continuous high number and proportion of MCH policy statements. The historical overview of MCH policy provides insight into critical policy issues confronting the MCH field over the decades and provides guidance for future policy initiatives including a need for increased emphasis on diverse MCH populations. SIGNIFICANCE: This analysis provides a 50 year overview of MCH themes as viewed by the policy statements published by APHA, the largest public health professional organization in the United States. These policy statements represent the cutting edge of MCH policy efforts and were written to influence national, state, and local public health policy. APHA policy statements should continue to address these important MCH topics in the future with an increased emphasis on diverse MCH populations. APHA policy making is a valuable national professional activity for the MCH field with the goal of improving the health for MCH communities.

Factors associated with experiencing lifetime intimate partner violence among pregnant displaced women living in refugee camps in Erbil, Iraq.

According to the World Health Organization, intimate partner violence (IPV) affects 35% of women worldwide and 40% of pregnant women, often resulting in maternal and infant death and harm. Displaced persons are at higher risk of abuse compared to the general population. While few studies have explored IPV in Iraq, research from Erbil, Iraq showed nearly 60% of women reported experiencing IPV in their lifetime. No publications examining IPV among displaced women in Iraq exist. Considering the severe impacts of IPV in pregnancy and the associated risks for IPV among women in refugee camps, this paper presents the first analysis of prevalence and factors associated with lifetime IPV among displaced pregnant women in two Iraqi refugee camps. Thirteen percent of women reported experiencing any abuse and experiencing IPV was associated with receiving fewer years of schooling (p = 0.04), not having a private doctor (p = 0.002), attending the first prenatal visit during the third trimester (p = 0.03), feeling pressure to have a child (p = 0.003), knowing someone who was physically injured by their husband (p = 0.05), experiencing suicidal ideation (p = 0.02), and being worried about harming one's baby (p = 0.02). Policy and programme recommendations for screening and prevention of IPV in resource-limited settings are provided.

A Call to Transform Maternal and Child Health Mentorship to Build Inclusivity, Honor Diversity of Experiences, and Tackle the Root of Health Disparities.

INTRODUCTION: Mentorship should be a transformative experience that propels mentees from one point in their career to another and drives personal growth. Within the field of maternal and child health (MCH), it is considered a critical professional duty. However, MCH has yet to explicitly embrace mentorship practice as a means to address workforce challenges including turnover, knowledge loss, and undue burden on the part of historically oppressed individuals and communities to overturn oppressive systems. CALL TO ACTION: We advocate for public calls for diversity and equity to be met with strategic enhancement of the practice of MCH mentorship. Transformative MCH mentorship should be used to promote positive identity formation, understanding of self in context, efficacy, and sustained commitment to working with MCH populations in ways that are inclusive and prevent the perpetration of the problematic power dynamics that lead to inequitable outcomes. RECOMMENDATIONS: We present recommendations to strengthen MCH mentorship practice. At the individual level, there should be a refreshment of norms and expectations, where mentorship is seen as a uniquely flexible opportunity for mutual learning. At the organizational level, embedding mentorship in all aspects of practice helps establish and sustain a culture of belonging. This transformative organizational culture can attract and retain future generations of professionals that are not only more representative of the populations that MCH programs support but are prepared to authentically elevate the needs and strengths of those populations. These suggestions incorporate best practices from other fields and include ideas for the MCH field in particular.

Antenatal Depression Symptoms Among Pregnant Women Seeking Health Services in Erbil, Iraq.

INTRODUCTION: Maternal depression, which includes depression in the prenatal and postpartum periods, is estimated to affect between 10 and 20% of women globally but the rate is higher in the Middle East. Research focused on maternal depression in Iraq is limited to one study focused on postpartum depression. This paper identifies the prevalence and factors associated with antenatal depression among pregnant Iraqi women. METHODS: Women seeking maternal health services at primary health centers were invited to participate. Data were collected by trained midwifery students in Erbil, Iraq. Responses to the PHQ-2 PRIME-MD depression questions were used to identify depressive symptoms. Chi-square and logistic regression analyses were used to analyze findings. RESULTS: Of the 179 participants, 86 (48%) reported depressive symptoms. In bivariate analysis, antenatal depression was associated with gestational age (p = 0.03), first prenatal visit in the second trimester (p = 0.003), loss of appetite (p = 0.003), not having help at home (p = 0.03), and use of prenatal vitamins (p = 0.002). Gravida approached significance (p = 0.07). In adjusted analysis, women reporting loss of appetite were more likely to report depressive symptoms (OR = 3.09, 95% CI: 1.47-6.51). DISCUSSION: Consistent with other research from the region, nearly half the women reported depressive symptoms. Because lack of appetite is associated with depressive symptoms, women reporting loss of appetite should be prioritized for depression screening in time-constrained settings.

Anxiety and depression among women living with HIV in Kazakhstan.

An increase in new HIV infections among women in Kazakhstan has motivated efforts to improve access to comprehensive health services. This study estimates anxiety and depression frequency among women seeking HIV services. A cross-sectional survey was administered to women seen at the Almaty AIDS Center. Bivariable analyses (e.g., Chi-square, means with 95% confidence intervals) were performed to assess the relationship between anxiety (score of 10 or more on the Generalized Anxiety Disorder-7 Scale (GAD-7)), major depression (Patient Health Questionnaire 8 (PHQ-8)), and comorbid anxiety and major depression with sociodemographic characteristics, health functioning, and medication history. Of the 410 participants, 62 (15.1%) had a GAD-7 ≥ 10; 52 (12.7%) met major depression criteria; 35 (8.5%) met both criteria, and 79 (19.3%) met GAD-7, major depression, or both criteria. Women reporting depression or anxiety were more likely to lack food security (p < 0.01), not finish secondary school (p < 0.01), speak Russian at home (p < 0.01), perceive their health to be poor (p < 0.01), and report poorer physical and mental health functioning (p < 0.05). No medications approved for the treatment of anxiety or depression were reported. The considerable number of women reporting major depression and anxiety symptoms suggests a need for improving access to mental health care.

Mentoring in Global Health: Formative Evaluation of Tuberculosis Research Training Programs in Ethiopia and Georgia.

Mentoring is a critical component of career development for research scientists and is related to mentee success both in terms of career selection and advancement. However, there are limited data on the role of mentoring in low- and middle-income countries (LMICs). Cross-cultural mentorship programs have the potential to foster the transfer of knowledge and the development of capacity to resource-poor settings. This formative evaluation explores the cultural context of mentoring in the countries of Georgia and Ethiopia. Results were used to build culturally relevant mentor training programs for two Global Infectious Disease Research Training Programs focused on tuberculosis funded by the Fogarty International Center at the US National Institutes of Health. Four focus group discussions were conducted with research trainees and mentors to explore the perceptions of mentorship, identify obstacles for successful mentoring, and generate recommendations to strengthen mentoring in each program situated in a LMIC. Data revealed the barriers to mentoring in Ethiopia and Georgia included gaps in knowledge about mentoring roles and responsibilities, lack of knowledge about the responsibilities of the trainee in a mentoring relationship, and the need to set clear expectations between mentors and trainees. All of the focus group participants desired formal mentor training. These data informed six key components of the development and implementation of the mentor training programs in both countries. The topics included the following: a foundation in mentoring, establishing expectations between mentees and mentors, increasing interactions between mentees and mentors, additional mentor training, a case study curriculum, and methods of evaluating mentoring relationships.

Factors associated with linkage to care for HIV patients in Tajikistan.

There is a growing human immunodeficiency virus (HIV) epidemic in Tajikistan. This paper presents factors associated with linkage to HIV care among people aged 15 years and older in Tajikistan. This retrospective cross-sectional study used the Tajikistan Ministry of Health HIV registry data from patients diagnosed with HIV at age 15 years or older from 2000 to 2016. Chi squared tests and logistic regression models tested factors associated with linkage to care. A multivariable logistic regression model examined effect modifications. While linkage to care had an overall increase from 2000 to 2016, the odds of linkage were lower among certain sub-groups including among people in Dushanbe, men, people engaging in sex work, injection drug users, and older people. Regional differences exist with linkage to care, occurring least frequently in Dushanbe. While access to care and quality of care have increased significantly over time, findings suggest that linkage to care is low, especially in the capital city where many services are provided. Evaluation focusing on acceptability of HIV services should be undertaken to understand why certain people do not link with services. Additional research about the types of barriers to linking with HIV care is needed to increase linkage to HIV care.

Association between antiretroviral therapy and antitubercular drug resistance in TB treatment outcome among Kazakh TB/HIV co-infected patients.

OBJECTIVES: Drug-resistant tuberculosis (TB) poses a serious threat to public health in Kazakhstan. This paper presents findings related to TB treatment outcome and drug resistance status among people co-infected with human immunodeficiency virus (HIV) and TB in Kazakhstan. METHODS: A cohort study using data provided by the Kazakhstan Ministry of Health's National Tuberculosis Program for 2014 and 2015 was performed. The χ2 test and logistical regression were performed to understand factors associated with drug-resistant TB status and TB treatment outcome. RESULTS: In the bivariate analysis, drug-resistant TB status was significantly associated with year of TB diagnosis (P=0.001) and viral load (P=0.03). TB treatment outcome was significantly associated with age at diagnosis (p=0.01), antiretroviral (ARV) treatment (P<0.0001) and drug-resistant TB status (P=0.02). In the adjusted analysis, drug-resistant TB status was associated with an increased likelihood of successful completion of treatment with a successful outcome compared with treatment failure (odds ratio=6.94, 95% confidence interval 1.39-34.44). CONCLUSIONS: These results suggest that having drug-resistant TB is associated with a higher likelihood of completing treatment with successful outcome, even when controlling for receipt of ARV therapy.

SWOT analysis of program design and implementation: a case study on the reduction of maternal mortality in Afghanistan.

This case study analyzes the design and implementation of the Basic Package of Health Services (BPHS) in Afghanistan by synthesizing the literature with a focus on maternal health services. The authors are a group of graduate students in the Brandeis University International Health Policy and Management Program and Sustainable International Development Program who used the experience in Afghanistan to analyze an example of successfully implementing policy; two of the authors are Afghan physicians with direct experience in implementing the BPHS. Data is drawn from a literature review, and a unique aspect of the case study is the application of the business-oriented SWOT analysis to the design and implementation of the program that successfully targeted lowering maternal mortality in Afghanistan. It provides a useful example of how SWOT analysis can be used to consider the reasons for, or likelihood of, successful or unsuccessful design and implementation of a policy or program. Copyright © 2015 John Wiley & Sons, Ltd.