Respectful Maternity Care in the United States-Characterizing Inequities Experienced by Birthing People.

OBJECTIVE:  The purpose of this study is to understand experiences of respectful maternity care (RMC) from the perspective of birthing people in the United States from 2013 to 2018. METHODS:  We conducted an online cross-sectional survey of United States birthing people ages 18-50 in April 2018 using SurveyMonkey Audience. Quantitative survey data consisted of demographics and responses to RMC indicators. Qualitative data consisted of comments from individuals regarding their birth experiences. RESULTS:  1036 birthing people participated in the survey. Most births (95%) occurred in hospitals. 16.3% of Black or African American participants reported discrimination compared to 5.5% of participants who did not identify as Black or African American (p < 0.001). Participants who speak a language other than English were also more likely to report discrimination. 19.5% of all respondents felt neglected during their birth experience. Most prevalent experiences of disrespect and mistreatment were related to neglect (most commonly in postpartum phase of care), poor interpersonal communication, lack of respect for patient wishes, negative experience with breastfeeding services, peripartum complications, and discrimination. CONCLUSION FOR PRACTICE: Birthing people in the United States experience many forms of mistreatment, particularly those who identify as Black or African American or speak a language other than English. Patients described experiencing neglect most commonly after birth-an opportunity to improve the provision of RMC postpartum. Strategies to improve quality of maternal health care in the United States should include the provision of RMC as part of a larger effort to reduce inequities in maternal health experiences and outcomes.

Prevalence and Risk Factors of Trichomonas vaginalis Among Female Sexual Workers in Nairobi, Kenya.

BACKGROUND: Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection (STI) worldwide. Trichomonas vaginalis infection is associated with an increased risk of pelvic inflammatory disease, human immunodeficiency virus transmission, and preterm birth in women. Data on the prevalence and risk factors for TV infection in sub-Saharan African countries remain scarce. METHODS: A total of 350 Kenyan female sex workers, aged 18 to 50 years, participated in a 2-year longitudinal study of the acquisition of STIs, including TV infection. Every 3 months, cervical and vaginal brush samples were collected for STI testing. At baseline, a sociodemographic and behavior questionnaire was administered. Testing for TV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Mycoplasma genitalium, and high-risk human papillomavirus was performed using APTIMA assays. RESULTS: The TV baseline prevalence was 9.2% (95% confidence interval [95% CI], 6.3-12.7%) and 2-year cumulative TV incidence was 8.1 per 1000 person months (6.9-9.3). Risk factors for higher TV prevalence at baseline were CT infection (adjusted prevalence ratio [PR], 8.53; 95% CI, 3.35-21.71), human immunodeficiency virus seropositivity (PR, 3.01; 95% CI, 1.45, 6.24) and greater than 4 years of sex work (PR, 2.66; 95% CI, 1.07-6.60). Risk factors for elevated 2-year TV incidence were CT (hazard ratio [HR], 4.28; 95% CI, 1.36-13.50), high-risk human papillomavirus infection (HR, 1.91; 95% CI, 1.06-3.45) and history of smoking (HR, 2.66; 95% CI, 1.24-5.73). DISCUSSION: CT infection was positively associated with both prevalent and 2-year incident TV infections.

Impact of funded global health electives on career development of residents in a U.S. obstetrics and gynecology program: a cross-sectional survey.

BACKGROUND: The aims of this study were to identify factors influencing participation in global health electives during residency and to understand the career impact of global health electives on alumni of an Obstetrics and Gynecology (OB/GYN) residency program. METHODS: This was a cross-sectional, web-based survey of alumni of a residency program in the United States. RESULTS: The response rate was 49%. Out of 73 respondents, 29 (39.7%) had completed a global health elective. Availability of funds and flexibility of elective time were the main enabling factors for participating in global health electives. Most participants of global health electives in residency reported a positive impact on their competence in domestic and global women's health and on their career choices. Completing a global health elective in residency was associated with career work in global health and/or local health disparities (OR 4.62 (95% CI: 1.20-17.87)). CONCLUSION: Global health electives are important in the career development of residents. To foster OB/GYNs that continue global health and health disparities work, OB/GYN programs should give trainees the opportunity to participate in funded global health electives.

Providing support to pregnant women and new mothers through moderated WhatsApp groups: a feasibility study.

BACKGROUND: Group-based health services can improve maternal and newborn health outcomes. Group antenatal care and participatory learning and action cycles (PLA) with women's groups have been cited by the WHO as health systems interventions that can lead to improvements in adherence to care and health outcomes in pregnancy and the postpartum period. METHODS: We used a mixed-methods approach to assess the feasibility of a light touch group-based support intervention using the WhatsApp text-messaging platform. Pregnant women were enrolled at Jacaranda Health (JH), a maternity center in peri-urban Kiambu County, Kenya. Their phone numbers were added to WhatsApp groups consisting of participants with similar estimated due dates. The WhatsApp group administrator was a JH employee. Acceptability, demand, implementation, and practicality of this service were evaluated through in-depth interviews (IDIs), surveys, chart review, and analysis of group chats. Limited analysis of program efficacy (ANC visits, any PNC, and post-partum family planning uptake) was assessed by comparing participant data collected through chart review using a concurrent comparison of the general JH patient population. RESULTS: Fifty women (88%) of 57 eligible women who were approached to participate enrolled in the study. Five WhatsApp groups were created. A total of 983 messages were exchanged over 38 weeks. No harms or negative interactions were reported. Participants reported several benefits. Participants had differing expectations of the level of the group administrator's activity in the groups. ANC and PNC attendance were in line with the hospital's metrics for the rest of JH's patient population. Higher rates of postpartum long acting reversible contraception (LARC) uptake were observed among participants relative to the general patient population. CONCLUSIONS: A moderated mobile-based support group service for pregnant women and new mothers is safe and feasible. Additional research using experimental designs to strengthen evidence of the effectiveness of the support intervention is warranted.

INTERGROWTH-21st Gestational Dating and Fetal and Newborn Growth Standards in Peri-Urban Nairobi, Kenya: Quasi-Experimental Implementation Study Protocol.

BACKGROUND: The burden of preterm birth, fetal growth impairment, and associated neonatal deaths disproportionately falls on low- and middle-income countries where modern obstetric tools are not available to date pregnancies and monitor fetal growth accurately. The INTERGROWTH-21st gestational dating, fetal growth monitoring, and newborn size at birth standards make this possible. OBJECTIVE: To scale up the INTERGROWTH-21st standards, it is essential to assess the feasibility and acceptability of their implementation and their effect on clinical decision-making in a low-resource clinical setting. METHODS: This study protocol describes a pre-post, quasi-experimental implementation study of the standards at Jacaranda Health, a maternity hospital in peri-urban Nairobi, Kenya. All women with viable fetuses receiving antenatal and delivery services, their resulting newborns, and the clinicians caring for them from March 2016 to March 2018 are included. The study comprises a 12-month preimplementation phase, a 12-month implementation phase, and a 5-month post-implementation phase to be completed in August 2018. Quantitative clinical and qualitative data collected during the preimplementation and implementation phases will be assessed. A clinician survey was administered eight months into the implementation phase, month 20 of the study. Implementation outcomes include quantitative and qualitative analyses of feasibility, acceptability, adoption, appropriateness, fidelity, and penetration of the standards. Clinical outcomes include appropriateness of referral and effect of the standards on clinical care and decision-making. Descriptive analyses will be conducted, and comparisons will be made between pre- and postimplementation outcomes. Qualitative data will be analyzed using thematic coding and compared across time. The study was approved by the Amref Ethics and Scientific Review Committee (Kenya) and the Harvard University Institutional Review Board. Study results will be shared with stakeholders through conferences, seminars, publications, and knowledge management platforms. RESULTS: From October 2016 to February 2017, over 90% of all full-time Jacaranda clinicians (26/28) received at least one of the three aspects of the INTERGROWTH-21st training: gestational dating ultrasound, fetal growth monitoring ultrasound, and neonatal anthropometry standards. Following the training, implementation and evaluation of the standards in Jacaranda Health's clinical workflow will take place from March 2017 through March 5, 2018. Data analysis will be finalized, and results will be shared by August 2018. CONCLUSIONS: The findings of this study will have major implications on the national and global scale up of the INTERGROWTH-21st standards and on the process of scaling up global standards in general, particularly in limited-resource settings. REGISTERED REPORT IDENTIFIER: RR1-10.2196/10293.

Striving for Respectful Maternity Care Everywhere.

Purpose The mistreatment of women during childbirth in health facilities is a growing area of research and public attention. Description In many countries, disrespect and abuse from maternal health providers discourage women from seeking childbirth with a skilled birth attendant, which can lead to poor maternal and neonatal outcomes. This commentary highlights examples from three countries-Kenya, Mexico and the United States-and presents different forms of mistreatment during childbirth, which range from physical abuse to non-consented care to discriminatory practices. Assessment Building on the momentum from the United Nations Sustainable Development Goals, the International Federation of Gynecology and Obstetrics, and the Global and Maternal Neonatal Health Conference, the global community has placed respectful maternity care at the forefront of the maternal and neonatal health agenda. Conclusion Research efforts must focus on context-specific patient satisfaction during childbirth to identify areas for quality improvement.

Clinician attendance and delivery practices at hospital-based vaginal deliveries in Western Kenya.

OBJECTIVE: To characterize delivery practices and factors associated with respectful, evidence-based care at a referral hospital in Western Kenya. METHODS: An exploratory observational study used a standardized birth-observation form to record information on patient characteristics and healthcare practitioner behaviors during uncomplicated vaginal deliveries between June 30, 2014 and July 17, 2014. All deliveries were monitored for whether healthcare staff performed six specific evidence-based practices (three maternal and three neonatal practices). RESULTS: In total, 75 vaginal deliveries were observed. In 48 (64%) deliveries, nursing students were the only practitioners present. The mean number of evidence-based practices performed at each delivery was 3.58. The number of evidence-based practices performed by junior practitioners was higher when a nurse educator was assessing their performance (4.47 vs 3.36, P<0.001). Lower mean respectful-care scores were recorded when delivery teams comprised three or more practitioners (1.38; 95% confidence interval 0.93-1.84 vs 2.74; 95% confidence interval 2.16-3.31, P=0.002). CONCLUSION: The present study found low rates of evidence-based practice and respectful maternity care; this could serve as a deterrent for women seeking care at the study facility. These findings emphasize the need for a comprehensive approach in increasing the quality of patient care to improve maternal and newborn health outcomes.

Clinical characteristics associated with Mycoplasma genitalium among female sex workers in Nairobi, Kenya.

The prevalence of Mycoplasma genitalium is high in vulnerable populations of women in low-resource settings. However, the epidemiology of infection in these populations is not well established. To determine the prevalence of Mycoplasma genitalium and its association with cervical cytology and other correlates, we recruited 350 female sex workers (FSW) who were 18 to 50 years old in Nairobi, Kenya, for a cross-sectional study. A questionnaire was administered at baseline to obtain information on sociodemographics and sexual behaviors. Women underwent a pelvic exam, during which a physician collected cervical-exfoliation samples for conventional cytology and sexually transmitted infection (STI) testing. Samples were tested for M. genitalium and other STI organisms (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis) and the E6/E7 mRNA of human papillomavirus (HPV) by Aptima nucleic amplification assays. The prevalence of M. genitalium was 12.9%. FSW who engaged in sexual intercourse during menses were less likely to have M. genitalium infection than those who did not (odds ratio [OR], 0.3; 95% confidence interval [95% CI], 0.1, 0.9). M. genitalium was also less prevalent among FSW who had worked in prostitution for >5 years (6.2%) than among those who had worked for <3 years (17.6%) (OR, 0.3; 95% CI, 0.1, 0.8). FSW who reported more frequent condom use were more likely to be infected with M. genitalium than those who reported less frequent use (OR, 3.8; 95% CI, 1.2, 11.6). These correlates differ from those found in M. genitalium studies conducted with FSW from West Africa and China. Further longitudinal analyses assessing associations with persistent M. genitalium infection are needed.

High-risk human papillomavirus messenger RNA testing in physician- and self-collected specimens for cervical lesion detection in high-risk women, Kenya.

BACKGROUND: Little is known about the performance of physician-versus self-collected specimens for high-risk human papillomavirus (hrHPV) messenger RNA (mRNA) testing or risk factors for hrHPV mRNA positivity in physician- versus self-collected specimens. We compared the performance of hrHPV mRNA testing of physician- and self-collected specimens for detecting cytological high-grade squamous intraepithelial lesions or more severe (≥HSIL) and examined risk factors for hrHPV mRNA positivity in female sex workers in Nairobi. METHODS: From 2009 to 2011, 344 female sex workers participated in this cross-sectional study. Women self-collected a cervicovaginal specimen. A physician conducted a pelvic examination to obtain a cervical specimen. Physician- and self-collected specimens were tested for hrHPV mRNA and sexually transmitted infections using APTIMA nucleic acid amplification assays (Hologic/Gen-Probe Incorporated, San Diego, CA). Cervical cytology was conducted using physician-collected specimens and classified according to the Bethesda criteria. RESULTS: Overall hrHPV mRNA prevalence was similar in physician- and self-collected specimens (30% vs. 29%). Prevalence of ≥HSIL was 4% (n = 15). Overall sensitivity of hrHPV testing for detecting ≥HSIL was similar in physician-collected (86%; 95% CI, 62%-98%; 13 cases detected) and self-collected specimens (79%; 95% CI, 55%-95%; 12 cases detected). Overall specificity of hrHPV mRNA for ≥HSIL was similar in both physician-collected (73%; 95% CI, 68%-79%) and self-collected (75%; 95% CI, 70%-79%) specimens. High-risk HPV mRNA positivity in both physician- and self-collected specimens seemed higher in women who were younger (<30 years), had Trichomonas vaginalis or Mycoplasma genitalium infections, or had more than 8 years of educational attainment. CONCLUSIONS: Self-collected specimens for hrHPV mRNA testing seemed to have similar sensitivity and specificity as physician-collected specimens for the detection of ≥HSIL among high-risk women.