Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan.

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

An integrated newborn care kit (iNCK) to save newborn lives and improve health outcomes in Gilgit Baltistan (GB), Pakistan: study protocol for a cluster randomized controlled trial.

BACKGROUND: Ongoing high neonatal mortality rates (NMRs) represent a global challenge. In 2021, of the 5 million deaths reported worldwide for children under five years of age, 47% were newborns. Pakistan has one of the five highest national NMRs in the world, with an estimated 39 neonatal deaths per 1,000 live births. Reducing newborn deaths requires sustainable, evidence-based, and cost-effective interventions that can be integrated within existing community healthcare infrastructure across regions with high NMR. METHODS: This pragmatic, community-based, parallel-arm, open-label, cluster randomized controlled trial aims to estimate the effect of Lady Health Workers (LHWs) providing an integrated newborn care kit (iNCK) with educational instructions to pregnant women in their third trimester, compared to the local standard of care in Gilgit-Baltistan, Pakistan, on neonatal mortality and other newborn and maternal health outcomes. The iNCK contains a clean birth kit, 4% chlorhexidine topical gel, sunflower oil emollient, a ThermoSpot™ temperature monitoring sticker, a fleece blanket, a click-to-heat reusable warmer, three 200 µg misoprostol tablets, and a pictorial instruction guide and diary. LHWs are also provided with a handheld scale to weigh the newborn. The primary study outcome is neonatal mortality, defined as a newborn death in the first 28 days of life. DISCUSSION: This study will generate policy-relevant knowledge on the effectiveness of integrating evidence-based maternal and newborn interventions and delivering them directly to pregnant women via existing community health infrastructure, for reducing neonatal mortality and morbidity, in a remote, mountainous area with a high NMR. TRIAL REGISTRATION: NCT04798833, March 15, 2021.

Prevalence of Rheumatic Heart Disease and Other Cardiac Conditions in Low-Risk Pregnancies in Kenya: A Prospective Echocardiography Screening Study.

Background: Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking. Objectives: Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients. Methods: We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample. Results: The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0-14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6-36.7). Mean screening time was seven minutes (SD 1.7, range: 4-17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6-23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate. Conclusions: The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

"No, You Need to Explain What You Are Doing": Obstetric Care Experiences and Preferences of Adolescent Mothers With a History of Childhood Trauma.

STUDY OBJECTIVE: To understand the pregnancy and childbirth experiences and preferences of adolescent mothers with a history of childhood trauma in order to develop trauma-informed care practice recommendations for this unique group. DESIGN: Mixed methods convergent parallel design involving completion of the Adverse Childhood Experiences (ACE) questionnaire, a survey of care experiences and preferences during pregnancy and delivery, and a one-on-one interview. SETTING: hHospital-based medical home program for pregnant and parenting adolescents. PARTICIPANTS: Adolescent and young adult mothers aged 12-22 years, receiving care between June 2018 and June 2019. RESULTS: A total of 29 adolescent mothers completed the questionnaire, out of a potential 38 in the program (76.3% participation). Five went on to complete an interview. The average age was 17.9 years (standard deviation 1.8 years). The mean ACE score was 5.1 out of 10, indicating childhood exposure to an average of 5 different types of potential trauma. A total of 19 participants (65.5%) reported being triggered during pregnancy or postpartum. Trauma memories were elicited during vaginal examinations in the clinic (27.6%) and in the hospital (27.6%), abdominal examinations (13.8%), measurement of vital signs (17.2%), and labor (17.2%). Ten participants (34.5%) felt that the providers delivering their baby knew how to help them cope with trauma memories. Themes that emerged included the following: acknowledgment of trauma by provider, avoiding re-telling of story, building a relationship with provider, choice and control in care, and providing coping strategies. CONCLUSION: A majority of adolescent mothers in our sample experienced trauma memories during pregnancy and postpartum medical interactions. Priorities for trauma-informed care in this population are described.

Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study.

BACKGROUND: The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. METHODS: The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10-19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. RESULTS: There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. CONCLUSIONS: A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.

The impact of a global health elective on CanMEDS competencies and future practice.

BACKGROUND: There is evidence that participating in global health electives generates positive educational outcomes and personal benefits for medical trainees. The objective of this study was to examine the effect and impact that a global health elective has on CanMEDS competencies and anticipated future practice. RESULTS: The medical expert, collaborator, leader, scholar, and professional CanMEDS competencies were self-perceived to be strongly impacted through this elective. A total of 94% of participants indicated it increased their strengths as a medical expert and leader, 82% indicated a major impact on the scholar competency, 88% of participants reported a strong impact as a professional, and 76% of participants indicated that it strongly impacted them as a collaborator. The majority of participants continue to have involvement in global health, and 88% of respondents found this elective to be influential on their current practice and beliefs. CONCLUSIONS: These results suggest that individuals who participated in this global health elective perceived value in their experience. These findings support our hypothesis that participation in this global health elective would generate self-perceived positive impacts. Global health electives may provide an opportunity for physicians to expand on their CanMEDS competencies and become more proficient in caring for diverse patient populations.

A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.

Use of Audio Computer-Assisted Self-Interviews to Gather Information on Risk Behaviors in a Population of Pregnant Adolescents.

In a prospective study comparing the use of the Audio Computer-Assisted Self-Interview (ACASI) with a traditional clinical interview in 40 pregnant adolescents, there was significantly greater disclosure of violence with the ACASI method. Better identification of high-risk behaviors may help to optimize care and programing for pregnant adolescents.

The Who, What, Why and When of Gynaecological Referrals for Refugee Women.

Refugees have health needs relating to unstable living situations and poor access to care. We examined the nature of health problems requiring gynaecological referrals for refugee women in Toronto. A retrospective cohort design was used to examine gynaecologic referrals of women at a refugee clinic between December, 2011 and June, 2016. The primary outcome measure was the indications for gynaecological referral. 125 out of 1040 women received a gynaecologic referral for 131 unique concerns. The most common referrals were for abnormal uterine bleeding and cervical dysplasia. Fibroids were prevalent amongst African patients, while referrals for LARCs/sterilization were absent from Middle Eastern patients. 26% of patients referred had a sexual violence history. Refugee women exhibit gynaecologic needs similar to the broader population. Needs vary by geographic origins. As global conflicts shift, so too will this population's needs. High rates of sexual violence history reflect the need for further understanding and intervention.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents.

OBJECTIVE: To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global women's health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum. METHODS: We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents. RESULTS: Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001). CONCLUSION: Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

Objective: Pour devenir des praticiens compétents sur le plan culturel étant en mesure de prodiguer des soins aux populations vulnérables et de défendre leur cause, les résidents doivent recevoir une formation abordant les priorités de la santé à l'échelle mondiale. Dans le domaine de l'obstétrique-gynécologie, nous ne disposons que de peu de renseignements au sujet de la formation en santé des femmes à l'échelle mondiale (SFEM) qu'offrent les programmes de résidence et de l'intérêt envers ce type de formation que l'on y constate. Nous souhaitions déterminer ce qui suit en ce qui concerne les programmes canadiens de résidence en obstétrique-gynécologie : (1) la situation actuelle pour ce qui est de l'enseignement de la SFEM et du soutien disponible à cet égard; (2) l'importance de la SFEM pour les résidents et les directeurs de programme; et (3) le degré d'intérêt envers un curriculum national de cycle supérieur dans le domaine de la SFEM. Méthodes : Nous avons mené, à l'échelle du Canada, un sondage en ligne auprès des directeurs des programmes de résidence en obstétrique-gynécologie et des résidents de dernière année du domaine. Résultats : Parmi les 297 résidents sollicités, 101 (34,0 %) ont répondu au sondage et 76 (26 %) ont rempli le sondage en entier. Onze des 16 directeurs de programme sollicités (68,8 %) ont répondu et 10/16 (62,5 %) nous ont fourni des réponses complètes. Quatre des 11 programmes (36,4 %) comptaient un curriculum de SFEM, 2/11 (18,2 %) comptaient un budget de SFEM et 4/11 (36,4 %) comptaient un président de la SFEM. Neuf directeurs de programme sur 10 (90 %) et 68 résidents sur 79 (86,1 %) étaient d'avis qu'une compréhension des questions de SFEM est importante pour tous les stagiaires canadiens en obstétrique-gynécologie. Seulement un directeur de programme sur 10 (10 %) et 11 résidents sur 79 (13,9 %) étaient d'avis que leur programme offrait une formation suffisante sur ces questions. Parmi les résidents des programmes comptant un curriculum de SFEM, 12/19 (63,2 %) étaient d'avis que les résidents de leur programme qui n'entreprenaient pas un stage au choix international auraient tout de même l'occasion de se sensibiliser à la SFEM, par comparaison avec seulement neuf des 50 résidents (18,0 %) des programmes ne comptant pas un tel curriculum (P < 0,001). Conclusion : Les résidents et les directeurs de programme du domaine de l'obstétrique-gynécologie estiment que la formation au sujet de la SFEM est importante pour tous les stagiaires et qu'elle est actuellement insuffisante. La mise sur pied d'un module pédagogique national de cycle supérieur en SFEM suscite un vif intérêt.

Adolescent Pregnancy Guidelines.

OBJECTIVE: To describe the needs and evidence-based practice specific to care of the pregnant adolescent in Canada, including special populations. OUTCOMES: Healthy pregnancies for adolescent women in Canada, with culturally sensitive and age-appropriate care to ensure the best possible outcomes for these young women and their infants and young families, and to reduce repeat pregnancy rates. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library on May 23, 2012 using appropriate controlled vocabulary (e.g., Pregnancy in Adolescence) and key words (e.g., pregnancy, teen, youth). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to English or French language materials published in or after 1990. Searches were updated on a regular basis and incorporated in the guideline to July 6, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, national and international medical specialty societies, and clinical practice guideline collections. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS/HARMS/COSTS: These guidelines are designed to help practitioners caring for adolescent women during pregnancy in Canada and allow them to take the best care of these young women in a manner appropriate for their age, cultural backgrounds, and risk profiles. RECOMMENDATIONS: 1. Health care providers should adapt their prenatal care for adolescents and offer multidisciplinary care that is easily accessible to the adolescent early in the pregnancy, recognizing that adolescents often present to care later than their adult counterparts. A model that provides an opportunity to address all of these needs at one site may be the preferred model of care for pregnant adolescents. (II-1A) 2. Health care providers should be sensitive to the unique developmental needs of adolescents through all stages of pregnancy and during intrapartum and postpartum care. (III-B) 3. Adolescents have high-risk pregnancies and should be managed accordingly within programs that have the capacity to manage their care. The unique physical risks of adolescent pregnancy should be recognized and the care provided must address these. (II-1A) 4. Fathers and partners should be included as much as possible in pregnancy care and prenatal/infant care education. (III-B) 5. A first-trimester ultrasound is recommended not only for the usual reasons for properly dating the pregnancy, but also for assessing the increased risks of preterm birth. (I-A) 6. Counselling about all available pregnancy outcome options (abortion, adoption, and parenting) should be provided to any adolescent with a confirmed intrauterine gestation. (III-A) 7. Testing for sexually transmitted infections (STI) (II-2A) and bacterial vaginosis (III-B) should be performed routinely upon presentation for pregnancy care and again in the third trimester; STI testing should also be performed postpartum and when needed symptomatically. a. Because pregnant adolescents are inherently at increased risk for preterm labour, preterm birth, and preterm pre-labour rupture of membranes, screening and management of bacterial vaginosis is recommended. (III-B) b. After treatment for a positive test, a test of cure is needed 3 to 4 weeks after completion of treatment. Refer partner for screening and treatment. Take the opportunity to discuss condom use. (III-A) 8. Routine and repeated screening for alcohol use, substance abuse, and violence in pregnancy is recommended because of their increased rates in this population. (II-2A) 9. Routine and repeated screening for and treatment of mood disorders in pregnancy is recommended because of their increased rates in this population. The Edinburgh Postnatal Depression Scale administered in each trimester and postpartum, and more frequently if deemed necessary, is one option for such screening. (II-2A) 10. Pregnant adolescents should have a nutritional assessment, vitamins and food supplementation if needed, and access to a strategy to reduce anemia and low birth weight and to optimize weight gain in pregnancy. (II-2A) 11. Conflicting evidence supports and refutes differences in gestational hypertension in the adolescent population; therefore, the care usual for adult populations is supported for pregnant adolescents at this time. (II-2A) 12. Practitioners should consult gestational diabetes mellitus (GDM) guidelines. In theory, testing all patients is appropriate, although rates of GDM are generally lower in adolescent populations. Practitioners should be aware, however, that certain ethnic groups including Aboriginal populations are at high risk of GDM. (II-2A) 13. An ultrasound anatomical assessment at 16 to 20 weeks is recommended because of increased rates of congenital anomalies in this population. (II-2A) 14. As in other populations at risk of intrauterine growth restriction (IUGR) and low birth weight, an ultrasound to assess fetal well-being and estimated fetal weight at 32 to 34 weeks gestational age is suggested to screen for IUGR. (III-A) 15. Visits in the second or third trimester should be more frequent to address the increased risk of preterm labour and preterm birth and to assess fetal well-being. All caregivers should be aware of the signs and symptoms of preterm labour and should educate their patients to recognize them. (III-A) 16. It should be recognized that adolescents have improved vaginal delivery rates and a concomitantly lower Caesarean section rate than their adult counterparts. (II-2A) As with antenatal care, peripartum care in hospital should be multidisciplinary, involving social care, support for breastfeeding and lactation, and the involvement of children's aid services when warranted. (III-B) 17. Postpartum care should include a focus on contraceptive methods, especially long-acting reversible contraception methods, as a means to decrease the high rates of repeat pregnancy in this population; discussion of contraception should begin before delivery. (III-A) 18. Breastfeeding should be recommended and sufficient support given to this population at high risk for discontinuation. (II-2A) 19. Postpartum care programs should be available to support adolescent parents and their children, to improve the mothers' knowledge of parenting, to increase breastfeeding rates, to screen for and manage postpartum depression, to increase birth intervals, and to decrease repeated unintended pregnancy rates. (III-B) 20. Adolescent women in rural, remote, northern, and Aboriginal communities should be supported to give birth as close to home as possible. (II-2A) 21. Adolescent pregnant women who need to be evacuated from a remote community should be able to have a family member or other person accompany them to provide support and encouragement. (II-2A) 22. Culturally safe prenatal care including emotional, educational, and clinical support to assist adolescent parents in leading healthier lives should be available, especially in northern and Aboriginal communities. (II-3A) 23. Cultural beliefs around miscarriage and pregnancy issues, and special considerations in the handling of fetal remains, placental tissue, and the umbilical cord, must be respected. (III).

Objectif : Décrire les besoins des adolescentes enceintes au Canada (y compris celles qui sont issues de populations particulières) et les pratiques factuelles propres aux soins qui doivent être offerts à ces femmes. Issues : Grossesses saines chez les adolescentes au Canada; offre de soins sûrs au plan culturel et adaptés à l'âge pour assurer l'obtention des meilleures issues possibles pour ces jeunes femmes, leurs enfants et leur famille; et réduction des taux de grossesse à répétition. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PUBMED et The Cochrane Library le 23 mai 2012, au moyen d'un vocabulaire contrôlé (p. ex. « Pregnancy in Adolescence ¼) et de mots clés (p. ex. « pregnancy ¼, « teen ¼, « youth ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Les résultats ont été limités aux articles publiés en anglais ou en français à partir de 1990. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'au 6 juillet 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La présente directive clinique a été conçue pour aider les praticiens canadiens à offrir aux adolescentes enceintes des soins optimaux qui sont adaptés à leur âge, à leur contexte culturel et à leurs profils de risque. Recommandations 1. Les professionnels de la santé devraient adapter leurs services prénataux aux besoins des adolescentes et leur offrir des soins multidisciplinaires dont elles pourront facilement se prévaloir tôt dans le cadre de la grossesse, en tenant ainsi compte du fait que les adolescentes sollicitent souvent des soins plus tard que leurs homologues adultes. Un modèle de soins permettant de répondre à tous ces besoins en un seul et même endroit pourrait constituer le modèle à privilégier pour les adolescentes enceintes. (II-1A) 2. Les fournisseurs de soins devraient être sensibles aux besoins développementaux particuliers des adolescentes tout au long de la grossesse, ainsi que dans le cadre des soins intrapartum et postpartum. (III-B) 3. Chez les adolescentes, la grossesse est exposée à des risques élevés et devrait faire l'objet d'une prise en charge adaptée en conséquence dans le cadre de programmes disposant des capacités nécessaires. Les risques physiques propres à la grossesse chez une adolescente doivent être pris en considération et les soins offerts doivent s'y adapter. (II-1A) 4. La participation des pères et des partenaires aux cours prénataux (soins à prodiguer à la mère et à l'enfant) devrait être favorisée autant que possible. (III-B) 5. La tenue d'une échographie au cours du premier trimestre est recommandée non seulement aux fins de la datation adéquate de la grossesse (soit la raison habituellement invoquée pour la tenue d'une telle intervention), mais également pour l'évaluation des risques accrus d'accouchement préterme. (I-A) 6. Des services de counseling traitant de toutes les options disponibles en ce qui concerne la grossesse (avortement, adoption et parentage) devraient être offerts à toutes les adolescentes chez qui la présence d'une grossesse intra-utérine a été confirmée. (III-A) 7. Un dépistage visant les infections transmissibles sexuellement (II-2A) et la vaginose bactérienne (III-B) devrait être mené systématiquement dans le cadre de la première consultation prénatale et, une fois de plus, au cours du troisième trimestre; un dépistage visant les infections transmissibles sexuellement devrait également être mené pendant la période postpartum et lorsque la présence de symptômes en justifie la mise en œuvre. a. Puisque les adolescentes enceintes sont intrinsèquement exposées à des risques accrus de travail préterme, d'accouchement préterme et de rupture prématurée des membranes préterme, elles constituent un « groupe exposé à des risques élevés ¼ : le dépistage et la prise en charge de la vaginose bactérienne s'avèrent donc recommandée. (III-B) b. À la suite d'un traitement mis en œuvre en raison de l'obtention d'un résultat positif au dépistage, la tenue d'un test de contrôle post-traitement s'avère requise de trois à quatre semaines à la suite de la fin du traitement. L'orientation du partenaire vers des services de dépistage et de traitement s'avère également requise. Les fournisseurs de soins devraient profiter de l'occasion pour discuter de l'utilisation de condoms avec leurs patientes. (III-A) 8. La mise en œuvre systématique et répétée d'un dépistage de la consommation d'alcool, de la consommation de substances psychoactives et de la violence pendant la grossesse est recommandée, en raison de leurs taux accrus au sein de cette population. (II-2A) 9. La mise en œuvre systématique et répétée d'un dépistage et d'une prise en charge des troubles de l'humeur pendant la grossesse est recommandée, en raison des taux accrus de ces troubles au sein de cette population. L'administration de l'Échelle de dépression postnatale d'Édimbourg à chaque trimestre et pendant la période postpartum (et plus fréquemment, lorsque cela semble nécessaire) constitue une option pour la mise en œuvre d'un tel dépistage. (II-2A) 10. Les adolescentes enceintes devraient faire l'objet d'une évaluation nutritionnelle et d'une supplémentation en vitamines et en aliments (au besoin), ainsi qu'obtenir accès à une stratégie visant l'optimisation du gain pondéral pendant la grossesse et la baisse des risques d'anémie et de faible poids de naissance. (II-2A) 11. Des données contradictoires soutiennent et réfutent la présence de différences en matière d'hypertension gestationnelle au sein de la population adolescente; ainsi, nous soutenons pour l'instant l'offre, aux adolescentes enceintes, des soins qui sont habituellement offerts aux populations adultes. (II-2A) 12. Les praticiens devraient consulter les lignes directrices traitant du diabète sucré gestationnel. En théorie, le dépistage de toutes les patientes s'avère approprié, et ce, bien que les taux de diabète sucré gestationnel soient généralement moindres chez les populations adolescentes. Les praticiens devraient cependant être avisés que certains groupes ethniques (dont les populations autochtones) sont exposés à des risques élevés de diabète sucré gestationnel. (II-2A) 13. La tenue d'une échographie d'évaluation anatomique à 16-20 semaines est recommandée, en raison des taux accrus d'anomalies congénitales au sein de cette population. (II-2A) 14. Tout comme dans le cas d'autres populations exposées à des risques de retard de croissance intra-utérin et de faible poids de naissance, la tenue d'une échographie visant à évaluer le bien-être fœtal et à estimer le poids fœtal à un âge gestationnel de 32-34 semaines est suggérée pour le dépistage du retard de croissance intra-utérin. (III-A) 15. Au cours du deuxième ou du troisième trimestre, les consultations devraient être plus fréquentes pour traiter des risques accrus de travail et d'accouchement prétermes, et pour évaluer le bien-être fœtal. Tous les fournisseurs de soins devraient connaître les symptômes du travail préterme et former leurs patientes de façon à ce qu'elles puissent les reconnaître. (III-A) 16. On se doit de souligner que les adolescentes comptent des taux d'accouchement vaginal supérieurs et (de façon concomitante) des taux de césarienne inférieurs, par comparaison avec leurs homologues adultes. (II-2A) Tout comme dans le cas des soins prénataux, les soins peripartum prodigués à l'hôpital devraient être de nature multidisciplinaire, mettre en jeu le milieu social, soutenir l'allaitement et la lactation, et solliciter la participation des services de protection de l'enfance, lorsque cela s'avère justifié. (III-B) 17. Les soins postpartum devraient comprendre une composante traitant des modes de contraception (particulièrement des contraceptifs réversibles à action prolongée), dans le but d'abaisser les taux élevés de nouvelle grossesse chez les adolescentes; les discussions au sujet de la contraception devraient débuter avant l'accouchement. (III-A) 18. L'allaitement devrait être recommandé et du soutien suffisant devrait être offert à cette population exposée à des risques élevés d'abandon. (II-2A) 19. Des programmes de soins postpartum visant la hausse des connaissances parentales et des taux d'allaitement, le dépistage et la prise en charge de la dépression postpartum, le prolongement des intervalles entre les grossesses et la réduction des taux de grossesse non souhaitée à répétition devraient être offerts pour soutenir les parents adolescents et leurs enfants. (III-B) 20. Au sein des collectivités autochtones, rurales, éloignées et du Nord, les adolescentes devraient bénéficier du soutien nécessaire à la tenue de l'accouchement le plus près possible de leur foyer. (II-2A) 21. Les adolescentes enceintes qui doivent être évacuées d'une collectivité éloignée devraient pouvoir se faire accompagner par un membre de la famille (ou toute autre personne de leur choix) à des fins de soutien et d'encouragement. (II-2A) 22. Des soins prénataux sûrs au plan culturel (y compris des mesures de soutien affectif, pédagogique et clinique aidant les parents adolescents à mener une vie leur assurant la santé) doivent être offerts, et ce, particulièrement au sein des collectivités autochtones et du Nord. (II-3A) 23. Les croyancesculturelles (entourant la fausse couche et les problèmes de la grossesse) et les considérations particulières (en ce qui concerne la manipulation des restes fœtaux, des tissus placentaires et du cordon ombilical) doivent être respectées. (III).

One-year evaluation of the impact of an emergency obstetric and neonatal care training program in Western Kenya.

OBJECTIVE: To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital, Eldoret, Kenya. METHODS: A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP), and in the 3-month period (August-November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate. RESULTS: A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However, postpartum hemorrhage rates decreased, affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P=0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P<0.001). Additionally, the number of neonates with 5-minute Apgar scores of less than 5 reduced from 133 (7.7%) of 1717 to 95 (5.4%) of 1745 (P=0.006). CONCLUSION: The introduction of the AIP improved maternal outcomes. There were significant differences related to use of oxytocin and postpartum hemorrhage.

Experience implementing electronic health records in the antenatal clinic of a teaching and referral hospital in Kenya.

INTRODUCTION: Electronic health records (EHRs) are receiving a lot of attention for their potential to improve care. OBJECTIVE: To develop and implement EHRs in the antenatal clinic (ANC) of a teaching and referral hospital in Western Kenya. RESULTS: A multidisciplinary team developed a phased implementation of EHRs in the ANC as part of a CDC-funded effort to develop and implement primary care EHRs in lower level and referral facilities in Kenya comprising a clinic registration system and initial- and return-visit encounter forms that captured and reported data required for reporting. This was successfully done, the EHR fully implemented in the ANC including a reminder system to enhance adherence to care guidelines. CONCLUSIONS: It is possible to implement EHRs in a referral hospital ANC.

Effect of EMR implementation on clinic time, patient and staff satisfaction, and chart completeness in a resource-limited antenatal clinic in Kenya.

Electronic Medical Records (EMR) are thought to improve healthcare through a variety of means. However, the study of EMR implementation in resource-poor settings has been minimal. Moi Teaching and Referral Hospital (MTRH) is the second largest tertiary care centre in Kenya, hosting a busy antenatal clinic serving Eldoret and surrounding regions. The recent transition from written to electronic antenatal records at MTRH permits the opportunity to study whether this change improves quality of care, in terms of: TIME: Does the patient or healthcare worker spend the same amount of time at the encounter? SATISFACTION: Is the patient or healthcare worker more or less satisfied with the encounter? COMPLETENESS: Does the antenatal record do a better job of recording key information in the antenatal history? Our Objective wasto determine the effects of EMR implementation on an antenatal clinic in a resource-limited setting.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities.

PURPOSE: Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital. METHODS: Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003). RESULTS: Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%). CONCLUSIONS: Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.

Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya.

OBJECTIVE: To carry out a large-scale retrospective review of patients who had undergone surgical repair of obstetric fistula in Kenya to determine patient characteristics and determinants of successful surgical repair. METHODS: The patient records of 483 surgical repairs of obstetric fistula treated by a single surgeon (H.M.) between January 2005 and July 2010 at 3 medical centers in western Kenya were retrospectively reviewed. Descriptive and bivariate statistical analyses were performed. RESULTS: Young women with some primary or no education and prolonged labor at the time of first delivery were most highly correlated with obstetric fistula formation. Success of fistula closure was 86% for first-time vesicovaginal fistula (VVF) repairs and 67% for first-time VVF combined with rectovaginal fistula (RVF) repairs. Among women who had previously attempted VVF or combined VVF/RVF repairs, 73% and 50% of fistulas, respectively, were repaired successfully. First-time repair was significantly associated with surgical success compared with patients with a history of previous repair attempts (P=0.027). CONCLUSION: Among Kenyan women presenting for fistula repair, fistula most was most highly correlated with a low level of education and prolonged labor. The findings are consistent with results reported from other countries in Sub-Saharan Africa.