Improving the Rate of Delayed Cord Clamping in Preterm Infants: A Quality Improvement Project.

OBJECTIVE: Delayed cord clamping (DCC) provides many benefits for preterm infants. The aim of this quality improvement project was to increase the rate of DCC by 25% within 12 months for neonates <34 weeks' gestation born at a tertiary care hospital. METHOD: A multidisciplinary team investigated key drivers and developed targeted interventions to improve DCC rates. The primary outcome measure was the rate of DCC for infants <34 weeks' gestation. Process measures were adherence to the DCC protocol and the rate of births with an experienced neonatology provider present at the bedside. Balancing measures included the degree of neonatal resuscitation, initial infant temperature, and maternal blood loss. Data were collected from chart review and a perinatal research database and then analyzed on control charts. The preintervention period was from July 2019 to June 2020 and the postintervention period was from July 2020 to December 2021. RESULTS: 322 inborn neonates born at <34 weeks' met inclusion criteria (137 preintervention and 185 postintervention). The rate of DCC increased by 63%, from a baseline of 40% to 65% (P <.001), with sustained improvement over 18 months. Significant improvement occurred for all process measures without a significant change in balancing measures. CONCLUSION: Using core quality improvement methodology, a multidisciplinary team implemented a series of targeted interventions which was associated with an increased rate of DCC in early preterm infants.

Perceived stress and COVID-19-related stressors: the moderating role of social support during pregnancy.

Recent evidence on perceived stress during the COVID-19 pandemic shows that birthing people experienced stress from pandemic-related stressors. While psychosocial stress is a significant predictor of adverse birth outcomes, social support can reduce stress levels during pregnancy. This study examined social support moderation of relationships between COVID-19-related stressors and perceived stress during pregnancy. The analysis included data from publicly insured pregnant participants who were enrolled in a randomized control trial of two enhanced prenatal care models in Fresno, California, and completed a third-trimester questionnaire between April and August 2020 (n = 77). Multivariate linear regression was used to estimate the associations between perceived stress and COVID-19-related stressors and social support moderation. COVID-19-related stressors related to childcare and tension at home remained significantly associated with perceived stress adjusting for sociodemographic characteristics and other COVID-19-related stressors. Social support moderated the relationship between perceived stress and loss of childcare (ß = 2.4, 95 percent CI = 0.5-4.3, p = .014). Overall, social support moderated the association between COVID-19 stressors and perceived stress. While social support is commonly conceptualized as protective, the finding of greater stress around childcare among individuals reporting greater social support suggests complexity for leveraging these support networks during the pandemic.

Perinatal outcomes and 2017 ACC/AHA blood pressure categories.

OBJECTIVE: To evaluate the association of blood pressure category < 20 weeks according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) criteria with adverse perinatal outcomes. STUDY DESIGN: A retrospective cohort study of singleton deliveries between 1/2014 and 10/2017 was undertaken. Blood pressure category assigned by 2017 ACC/AHA criteria applied to blood pressures prior to 20 weeks gestation: normal (systolic < 120 and diastolic < 80), elevated blood pressure (systolic 120-129 and diastolic < 80 mmHg), stage 1 hypertension (systolic 130-139 and/or diastolic 80-89), stage 2 hypertension (prior diagnosis of chronic hypertension or systolic ≥ 140 or diastolic ≥ 90 mmHg). MAIN OUTCOME MEASURES: The primary outcome was preeclampsia. Secondary outcomes included preterm birth and postpartum readmission. Chi-square, ANOVA and Kruskal-Wallis tests and multivariable Poisson regression were used for analysis. RESULTS: Of the 6,067 eligible pregnancies, 3,855 (63.5%) had normotensive blood pressure, 1,224 (20.2%) elevated blood pressure, 624 (10.3%) stage 1 hypertension, and 364 (6.0%) stage 2 hypertension. Compared to 4.6% prevalence of preeclampsia among normotensive pregnancies, higher categories were associated with higher preeclampsia prevalence: elevated blood pressure (10.7%, adjusted relative risk (aRR) 2.2, 95% confidence interval (CI) 1.8-2.6), stage 1 hypertension (15.1%, aRR 2.7, 95% CI 2.2-3.4) and stage 2 hypertension (38.7%, aRR 6.2, 95% CI 5.1-7.4). Non-normal categories were also associated with a higher risk of preterm birth and postpartum readmission. CONCLUSION: Patients with elevated blood pressure and stage 1 and 2 hypertension at < 20 weeks are at increased risk of adverse obstetric perinatal outcomes.

The association of COVID-19 infection in pregnancy with preterm birth: A retrospective cohort study in California.

INTRODUCTION: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited. METHODS: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB. FINDINGS: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity. INTERPRETATION: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons. FUNDING: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

Patient and provider perspectives on preterm birth risk assessment and communication.

OBJECTIVE: To describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication. METHODS: We conducted eight focus groups with obstetric patients (n = 35) and 16 qualitative interviews with obstetric providers. Grounded theory was used to identify and analyze themes. RESULTS: Patients' knowledge about preterm birth varied greatly. Similar benefits and risks of preterm birth risk counseling were discussed by patients and providers with notable exceptions: patients cited preparedness as a benefit and providers cited maternal blame, patient alienation, and estimate uncertainty as potential risks. Most patients expressed a desire to know their personalized preterm birth risk during pregnancy. Providers differed in whether they offer universal versus selective, and quantitative versus qualitative, preterm birth risk counseling. Many providers expressed concern about discussing social and structural risk factors for preterm birth. CONCLUSION: While many patients desired knowing their personalized preterm birth risk, prenatal care providers' disclosure practices vary because of uncertainty of estimates, concerns about negative consequences and challenges of addressing systemic inequities and social determinants of health. PRACTICE IMPLICATIONS: Given the existing asymmetry of information about preterm birth risk, providers should consider patient preferences regarding and potential benefits and risks of such disclosure in their practice.

Identifying risk factors for perinatal death at Tororo District Hospital, Uganda: a case-control study.

BACKGROUND: Sub-Saharan Africa faces a disproportionate burden of perinatal deaths globally. However, data to inform targeted interventions on an institutional level is lacking, especially in rural settings. The objective of this study is to identify risk factors for perinatal death at a resource-limited hospital in Uganda. METHODS: This is a retrospective case-control study at a district hospital in eastern Uganda using birth registry data. Cases were admissions with stillbirths at or beyond 24 weeks or neonatal deaths within 28 days of birth. Controls were admissions that resulted in deliveries immediately preceding and following each case. We compared demographic and obstetric factors between cases and controls to identify risk factors for perinatal death. Subgroup analysis of type of perinatal death was also performed. Chi square, Fisher's exact, t-test, and Wilcoxon-Mann-Whitney rank sum tests were utilized for bivariate analysis, and multiple logistic regression for multivariate analysis. RESULTS: From January 2014 to December 2014, there were 185 cases of perinatal death, of which 36% (n = 69) were macerated stillbirths, 40% (n = 76) were fresh stillbirths, and 25% (n = 47) were neonatal deaths. The rate of perinatal death among all deliveries at the institution was 35.5 per 1000 deliveries. Factors associated with increased odds perinatal death included: prematurity (adjusted odds ratio (aOR) 19.7, 95% confidence interval (CI) 7.2-49.2), breech presentation (aOR 7.0, CI 1.4-35.5), multiple gestation (aOR 4.0, CI 1.1-13.9), cesarean delivery (aOR 3.8, CI 2.3-6.4) and low birth weight (aOR 2.5, CI 1.1-5.3). Analysis by subtype of perinatal death revealed distinct associations with the aforementioned risk factors, in particular for antepartum hemorrhage, which was only associated with fresh stillbirths (aOR 6.7, CI 1.6-28.8), and low birth weight. CONCLUSIONS: The rate of perinatal death at our rural hospital site was higher than national targets, and these deaths were associated with prematurity, low birth weight, breech presentation, multiple gestation, and cesarean delivery. This data and the approach utilized to acquire it can be leveraged to inform targeted interventions to reduce the rate of stillbirths and neonatal deaths in similar low resource settings.

Evaluation of a Mobile Health Approach to Tuberculosis Contact Tracing in Botswana.

Tuberculosis (TB) contact tracing is typically conducted in resource-limited settings with paper forms, but this approach may be limited by inefficiencies in data collection, storage, and retrieval and poor data quality. In Botswana, we developed, piloted, and evaluated a mobile health (mHealth) approach to TB contact tracing that replaced the paper form-based approach for a period of six months. For both approaches, we compared the time required to complete TB contact tracing and the quality of data collected. For the mHealth approach, we also administered the Computer System Usability Questionnaire to 2 health care workers who used the new approach, and we identified and addressed operational considerations for implementation. Compared to the paper form-based approach, the mHealth approach reduced the median time required to complete TB contact tracing and improved data quality. The mHealth approach also had favorable overall rating, system usefulness, information quality, and interface quality scores on the Computer System Usability Questionnaire. Overall, the mHealth approach to TB contact tracing improved on the paper form-based approach used in Botswana. This new approach may similarly benefit TB contact tracing efforts in other resource-limited settings.

Evaluating the potential impact of a mobile telemedicine system on coordination of specialty care for patients with complicated oral lesions in Botswana.

Mobile telemedicine involves the use of mobile device (e.g., cell phones, tablets) technology to exchange information to assist in the provision of patient care. Throughout the world, mobile telemedicine initiatives are increasing in number and in scale, but literature on their impact on patient outcomes in low-resource areas is limited. This study explores the potential impact of a mobile oral telemedicine system on the oral health specialty referral system in Botswana. Analysis of 26 eligible cases from June 2012 to July 2013 reveals high diagnosis concordance between dental officers and oral health specialists at 91.3% (21/23) but significant management plan discordance at 64.0% (16/25), over two-thirds of which involved the specialists disagreeing with the referring clinicians about the need for a visit to a specialist. These findings suggest mobile telemedicine can optimize the use of insights and skills of specialists remotely in regions where they are scarce.

Oncogenic viral prevalence in invasive vulvar cancer specimens from human immunodeficiency virus-positive and -negative women in Botswana.

OBJECTIVE: The primary aim of this study was to describe the prevalence of select oncogenic viruses within vulvar squamous cell carcinoma (VSCC) and their association with human immunodeficiency virus (HIV) status in women in Botswana, where the national HIV prevalence is the third highest in the world. METHODS: A cross-sectional study of biopsy-confirmed VSCC specimens and corresponding clinical data was conducted in Gaborone, Botswana. Polymerase chain reaction (PCR) and immunohistochemistry (IHC) viral testing were done for Epstein-Barr virus, human papillomavirus (HPV) strains, and Kaposi sarcoma herpesvirus, and PCR viral testing alone was done for John Cunningham virus. RESULTS: Human papillomavirus prevalence by PCR was 100% (35/35) among tested samples. Human papillomavirus type 16 was the most prevalent HPV strain (82.9% by PCR, 94.7% by either PCR or IHC). Kaposi sarcoma herpesvirus prevalence by PCR had a significant association with HIV status (P = 0.013), but not by IHC (P = 0.650). CONCLUSIONS: The high burden of HPV, specifically HPV16, in vulvar squamous cell cancer in Botswana suggests a distinct HPV profile that differs from other studied populations, which provides increased motivation for HPV vaccination efforts. Oncogenic viruses Kaposi sarcoma herpesvirus and Epstein-Barr virus were also more prevalent in our study population, although their potential role in vulvar squamous cell cancer pathology is unclear.

A mobile health approach to tuberculosis contact tracing in resource-limited settings.

Tuberculosis remains a leading cause of morbidity and mortality worldwide. In 2011, there were 8.7 million new cases and 1.4 million deaths from the disease, with >95% of these deaths taking place in low- and middle-income countries [1]. Contact tracing prevents the spread of tuberculosis by identifying and screening a case's contacts and referring symptomatic individuals to health care providers. Traditionally, contact tracing has been conducted with paper forms, which can lead to considerable inefficiencies in data collection, storage, and retrieval. These inefficiencies are problematic as tuberculosis can continue to spread if disruption of disease transmission is delayed. Mobile health approaches to tuberculosis contact tracing remain largely unaddressed and limited to management and monitoring of multidrug-resistant tuberculosis [2].To address these limitations, a mobile health application that digitizes and automates contact tracing was developed. This poster presents work currently underway to evaluate this new approach in Botswana, which has the tenth highest incidence rate of tuberculosis in the world [3]. Operational considerations for implementing a mobile health approach to contact tracing in resource-limited settings are also presented.

Evaluating the impact of a mobile oral telemedicine system on medical management and clinical outcomes of patients with complicated oral lesions in Botswana.

Mobile telemedicine, which involves the use of cellular phone telecommunications to facilitate exchange of information between parties in different locations to assist in the management of patients, has become increasingly popular, particularly in resource-limited settings. In Botswana, small studies of mobile telemedicine programs suggest access to these services positively affect patients, but these programs' impact is difficult to capture given limitations of baseline and comparative data. Our observational study uses each patient receiving mobile oral telemedicine services in Botswana as his/her own control to assess the impact of these services on his/her diagnosis and management plan. At month 5 of 12 total, preliminary analysis of eligible cases (n = 27) reveals management plan discordance between clinicians submitting cases and the specialist was 68.0% (17/25), suggesting that telemedicine can result in significant changes in management of patients.