Publications by Year: 2022

INTRODUCTION: The WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia.

METHODS AND ANALYSIS: ENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron-folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of <23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at <72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy.

ETHICS AND DISSEMINATION: ENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders.

REGISTRATION NUMBER: ISRCTN15116516.

OBJECTIVE: The WHO Safe Childbirth Checklist (SCC) is a promising initiative for safety in childbirth care, but the evidence about its impact on clinical outcomes is limited. This study analysed the impact of SCC on essential birth practices (EBPs), obstetric complications and adverse events (AEs) in hospitals of different profiles.

DESIGN: Quasi-experimental, time-series study and pre/post intervention.

SETTING: Two hospitals in North-East Brazil, one at a tertiary level (H1) and another at a secondary level (H2).

PARTICIPANTS: 1440 women and their newborns, excluding those with congenital malformations.

INTERVENTIONS: The implementation of the SCC involved its cross-cultural adaptation, raising awareness with videos and posters, learning sessions about the SCC and auditing and feedback on adherence indicators.

PRIMARY AND SECONDARY OUTCOME MEASURES: Simple and composite indicators related to seven EBPs, 3 complications and 10 AEs were monitored for 1 year, every 2 weeks, totalling 1440 observed deliveries.

RESULTS: The checklist was adopted in 83.3% (n=300) of deliveries in H1 and in 33.6% (n=121) in H2. The hospital with the highest adoption rate for SCC (H1) showed greater adherence to EBPs (improvement of 50.9%;p<0.001) and greater reduction in clinical outcome indicators compared with its baseline: percentage of deliveries with severe complications (reduction of 30.8%;p=0.005); Adverse Outcome Index (reduction of 25.6%;p=0.049); Weighted Adverse Outcome Score (reduction of 39.5%;p<0.001); Severity Index (reduction of 18.4%;p<0.001). In H2, whose adherence to the SCC was lower, there was an improvement of 24.7% compared with before SCC implementation in the composite indicator of EBPs (p=0.002) and a reduction of 49.2% in severe complications (p=0.027), but there was no significant reduction in AEs.

CONCLUSIONS: A multifaceted SCC-based intervention can be effective in improving adherence to EBPs and clinical outcomes in childbirth. The context and adherence to the SCC seem to modulate its impact, working better in a hospital of higher complexity.

Maderas Rainforest Conservancy (MRC) was incorporated as a conservation nonprofit organization in 2008, and manages two sites where biological field courses have been offered since the 1990s: La Suerte Biological Research Station in Costa Rica, and Ometepe Biological Research Station in Nicaragua. MRC employs a One Health approach to conservation education, and can serve as a model for other biological field sites. The Nicaraguan Molina family, who owns the sites, partnered with primatologist Paul Garber in 1994 to develop a primate field course aimed at introducing university students to field research. Through using their land to further conservation education and research, the Molina family has preserved the forest and engaged the local communities near their sites. Eight graduate theses and 46 refereed publications have been completed since 2010 based on research undertaken at MRC sites. While primate field courses have been offered at least once annually since 1994 and remain popular, a range of other ecological courses are now additionally offered. MRC operates from a One Health perspective, engaging in forest restoration and ecological monitoring projects, and has gradually expanded community outreach initiatives. MRC now conducts regular medical and veterinary missions in the communities surrounding the research stations which provide health care to local people and limit the population growth of domestic animals, thereby increasing the survival of wild animals. MRC is also active in ESL-teaching and conservation education, and funds Proyecto Jade, which empowers local women to make and sell organic jewelry. Through these programs, MRC works to help the local communities live more sustainably with the environment around them. MRC's support of research, commitment to education, medical and veterinary missions, and outreach initiatives to the local community all work together for the well-being of both the people and the environment, thus exemplifying the One Health perspective.

Medical librarians collaborate with physicians and other healthcare professionals to improve the quality and accessibility of medical information, which includes assembling the best evidence to advance health equality through teaching and research. This column brings together brief cases highlighting the experiences and perspectives of medical librarians, educators, and healthcare professionals using their organizational, pedagogical, and information-analysis skills to advance health equality indexing.

BACKGROUND: We assessed understanding of the obstetric consent form between patients with English and Spanish language preference.

METHODS: This observational study included pregnant patients who identified as Hispanic/Latinx with English or Spanish language preference (defined as what language the patient prefers to receive healthcare information) and prenatal care providers at a large academic medical center from 2018 to 2021. Patient demographics, language preference, literacy, numeracy, acculturation, comprehension of the obstetric consent, and provider explanations were collected.

RESULTS: We report descriptive statistics and thematic analysis with an inductive approach from 30 patients with English preference, 10 with Spanish preference, and 23 providers. The English group demonstrated 72% median correct responses about the consent form; the Spanish group demonstrated 61% median correct responses. Regardless of language, the participants demonstrated limited understanding of certain topics, such as risks of cesarean birth.

DISCUSSION: Overall comprehension of key information in an obstetric consent form was low, with differences in language groups, which highlights opportunities for improvements in communication across language barriers. Innovations in the communication of critical pregnancy information for patients with limited English proficiency need to be developed and tested.

In Mexico, over the last decade, more non-physician medical professionals have been participating in birth care according to recent federal regulations. So far, very few sites have been able to implement birth care models where midwives and obstetric nurses participate. We describe the experience of a group of intern obstetric nurses participating in a model that provides respectful birth care to rural populations, managed by an international NGO in partnership with the Ministry of Health of Chiapas, Mexico. We conducted a case study including individual interviews and focus group discussions with obstetric nurse interns participating in the Compañeros En Salud programme over four years from 2016 to 2019. We applied targeted content analysis to the qualitative data. There were 28 participants from 4 groups of interns. Informants expressed their opinions in four areas: (a) training as a LEO, (b) training experience at CES, (c) LEO role in health care delivery; and (d) LEOs' perspectives about respectful maternity care. Interns identified gaps in their training including a higher load of theoretical content vs practical experience, as well as little supervision of clinical care in public hospitals. Their adaptation to the health services model has increased over time, and recent classes acknowledge the difficulties that earlier ones had to confront, including the challenging interactions with hospital staff. Interns have incorporated the value of respectful birth care and their role to protect this right in rural populations. Findings could be useful to call for the expansion of the model in public birth centres.

INTRODUCTION: Reproductive injustices such as forced sterilization, preventable maternal morbidity and mortality, restricted access to family planning services, and policy-driven environmental violence undermine reproductive autonomy and health outcomes, with disproportionate impact on historically marginalized communities. However, curricula focused on reproductive justice (RJ) are lacking in medical education.

METHODS: We designed a novel, interactive, case-based RJ curriculum for postclerkship medical students. This curriculum was created using published guidelines on best practices for incorporating RJ in medical education. The session included a prerecorded video on the history of RJ, an article, and four interactive cases. Students engaged in a 2-hour small-group session, discussing key learning points of each case. We evaluated the curriculum's impact with a pre- and postsurvey and focus group.

RESULTS: Sixty-eight students participated in this RJ curriculum in October 2020 and March 2021. Forty-one percent of them completed the presurvey, and 46% completed the postsurvey. Twenty-two percent completed both surveys. Ninety percent of respondents agreed that RJ was relevant to their future practice, and 87% agreed that participating in this session would impact their clinical practice. Most respondents (81%) agreed that more RJ content is needed. Focus group participants appreciated the case-based, interactive format and the intersectionality within the cases.

DISCUSSION: This interactive curriculum is an innovative and effective way to teach medical students about RJ and its relevance to clinical practice. Walking alongside patients as they accessed reproductive health care in a case-based curriculum improved students' comfort and self-reported knowledge on several RJ topics.

Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to inequities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative design workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston.