Publications

People who speak languages other than English face structural barriers in accessing the US healthcare system. With a growing number of people living in countries other than their countries of birth, the impact of language and cultural differences between patients and care teams on quality care is global. Cultural brokering presents a unique opportunity to enhance communication and trust between patients and clinicians from different cultural backgrounds during pregnancy care-a critical window for engaging families in the healthcare system. This critical review aims to synthesize literature describing cultural brokering in pregnancy care. We searched keywords relating to cultural brokering, pregnancy, and language in PubMed, Embase, and CINAHL and traced references of screened articles. Our search identified 33 articles. We found that cultural brokering is not clearly defined in the current literature. Few of the articles provided information about language concordance between cultural brokers and patients or clinicians. No article described the impact of cultural brokering on health outcomes. Facilitators of cultural brokering included: interprofessional collaboration within the care team, feeling a family connection between the cultural broker and patients, and cultivating trust between the cultural broker and clinicians. Barriers to cultural brokering included: misunderstanding the responsibilities, difficulty maintaining personal boundaries, and limited availability and accessibility of cultural brokers. We propose cultural brokering as interactions that cover four key aims: (1) language support; (2) bridging cultural differences; (3) social support and advocacy; and (4) navigation of the healthcare system. Clinicians, researchers, and policymakers should develop consistent language around cultural brokering in pregnancy care and examine the impact of cultural brokers on health outcomes.

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.

OBJECTIVE: To measure clinician continuity during pregnancy care and contextualize the findings with patient experiences of clinician continuity and their influence on trust-building.

METHODS: We conducted a convergent mixed methods study that examined the number of clinicians seen for all patients who gave birth at a large academic medical center between June 2023 and May 2024. Statistical analyses were performed across demographic subgroups with number of clinicians seen during pregnancy care as the primary outcome and the proportion of visits with the most frequently seen clinician as the secondary outcome. Multivariable Poisson regression models were used to control for covariates. Purposive sampling was used to select a subset of English- and Spanish-speaking patients for semi-structured interviews. Participants completed a short sociodemographic survey and interviews exploring perceptions of clinical continuity, factors that build or erode trust, and patients' recommendations for pregnancy care. Interviews were transcribed and analyzed using content analysis. Two researchers met to iteratively refine the codebook, discuss discrepancies, and reach consensus.

RESULTS: We identified 2395 patients with eligible visits for the retrospective cohort. Total visits ranged from two to 38 (median 13, interquartile range [IQR] 10-15) with a median of 4 clinicians seen during pregnancy (IQR 3-5). Participants in the resident practice and hospital-based maternal-fetal medicine practice saw more clinicians (7, IQR 6-9 and 5, IQR 3-7, respectively; p < 0.001). Overall, 21.0% of patients had one or more visit with the obstetrician who was present at delivery. The qualitative phase included 14 participants with a median age of 31 years (IQR 28-35). Most participants valued continuity of care; discontinuity of care was a driving factor of patient-clinician trust erosion. Participants recommended clinical continuity as a strategy to improve pregnancy care.

CONCLUSION: Clinician continuity during outpatient pregnancy care varied by clinician type, practice, clinical site, and patient factors. Participants highly valued continuity of care, which was associated with greater trust and improved care experiences.

OBJECTIVE: This study examines whether hospitals with stronger patient safety culture more consistently follow essential birth practices and have fewer adverse outcomes for mothers and newborns and whether this evidence can guide maternity care priorities in patient safety policy.

METHODS: We conducted a multicenter cross-sectional study in six public maternity hospitals in Brazil (November 2022 to February 2024). In each hospital, we measured patient safety culture using the Brazilian version of the Hospital Survey on Patient Safety Culture. From a systematic sample of 2183 births (approximately 360 per hospital), we reviewed charts to record eight essential obstetric and neonatal practices and 10 adverse outcomes. We created hospital-level composites for the practice bundle and adverse outcomes and correlated them with culture scores using Spearman coefficients (one-sided exact P-values).

RESULTS: A total of 686 professionals responded to the survey, with a mean overall culture score of 43.6% (range: 29.5%-56.4%). "Perception of safety" and "non-punitive response to errors" were consistently low, while "management expectations," "organizational learning," and "teamwork within units" were relative strengths. Adherence was high for postpartum oxytocin (93.4%), vitamin K (95.9%), and newborn identification (91.1%), and low for partogram initiation (36.4%), birth companion (48.1%), and breastfeeding within the first hour (47.5%). Culture scores aligned positively with the practice bundle (ρ = 0.77; P = 0.072) and inversely with adverse outcomes-maternal (ρ = -0.77; P = 0.072), neonatal (ρ = -0.89; P = 0.019), and total (ρ = -0.94; P = 0.005).

CONCLUSION: Findings support pairing culture-strengthening actions with clinical bundles to promote safer childbirth and prioritize maternity services in safety policy.

OBJECTIVE: To identify barriers to the implementation of the World Health Organization Safe Childbirth Checklist in two reference maternity hospitals-one for high-risk and one for routine-risk childbirths-and to develop a causal model applicable to these contexts.

METHODS: This qualitative, exploratory study was conducted in two public maternity hospitals that had been using the checklist, since its implementation in 2014. Data were collected through focus groups interviews and brainstorming sessions conducted in 2022 and 2023. Participants included healthcare professionals involved in childbirth care and members of the patient safety center. Content analysis categorized findings based on the five domains of the Consolidated Framework for Implementation Research (CFIR). A causal model was developed using a fishbone diagram to organize results by category.

RESULTS: The identified barriers were classified into four of the five CFIR domains. In the Innovation domain, the checklist itself posed challenges due to its design, complexity, and adaptability to existing workflows. In the Inner Setting, barriers included a weak patient safety culture and infrastructure limitations. The Implementation Process domain revealed deficiencies such as inadequate planning, lack of stakeholder involvement, and absence of feedback and assessment mechanisms. Unlike the high-risk maternity hospital, the Outer Setting barrier -lack of policies supporting continuing education-was identified in the routine-risk facility.

CONCLUSIONS: Implementation of the checklist in the studied maternity hospitals is hindered by structural, cultural, and adaptation challenges. Limited investment in training represents a significant obstacle, highlighting the need for professional development programs. High staff turnover and the absence of specific protocols further compromise consistent use. Addressing these barriers requires comprehensive strategies to enhance adherence to and integration of the checklist in maternal-newborn care.

While US health systems are implementing language proficiency assessments to verify skills needed to ensure meaningful language access for patients, there is no consensus on best practices for multilingual medical students who want to demonstrate language proficiency for direct patient care. Many medical students who report non-English language skills face challenges navigating when and how to appropriately use those skills in clinical interactions. We used a modified Delphi process to seek consensus from an expert panel through the National Association of Medical Spanish (NAMS) for a Qualified Multilingual Assessment (QMA) policy for medical students. The survey included five topics related to QMA logistics and five topics related to QMA implementation guidance for clinical affiliates: QMA purpose, language access standards, responsibilities of supervising physicians, guarding against implicit bias, and monitoring learning opportunities. We set 80% as the threshold for consensus and revised topics that yielded <80% consensus. We circulated the revised topics in a second survey to establish consensus. Following two rounds of surveys among expert stakeholders, we reached consensus across all topics, yielding a first-of-its-kind QMA policy that administrators may adapt for clinical learning environments and institutions with health professional trainees. This policy includes key QMA policy recommendations for medical students: selecting a QMA, QMA logistics, and QMA implementation guidance for clinical affiliates.

Urinary Tract Infections (UTIs) in pregnant women can lead to pyelonephritis and preterm birth. We assessed UTI prevalence, etiology, antimicrobial resistance, and associated risk factors among pregnant women receiving antenatal care in rural Amhara, Ethiopia. 604 pregnant women were screened for UTI at ≤ 24 weeks gestational age from August 2020 to June 2022. Urine culture, dipstick, and antibiotic sensitivity testing were completed. We conducted descriptive statistics for prevalence and logistic regression to examine UTI risk factors. UTI prevalence was 3.5% (21/604, 95%CI = 2.0%-4.9%), among which 43% were symptomatic and 57% were asymptomatic. Common uropathogens were Escherichia coli (57.1%), Klebsiella pneumoniae (14.3%), and Enterococcus faecalis (14.3%). Among all isolates, resistance was high for ampicillin (66.7%) and amoxicillin-clavulanate (40.0%). The majority of isolates (76.2%) were susceptible to nitrofurantoin, cotrimoxazole, and cefpodoxime. Maternal age > 20 years was a protective factor against UTI (OR = 0.27, 95% CI = 0.10-0.77; ref < 20 years). Urine dipstick (nitrite or leukocyte esterase) had low sensitivity (37.5%) but higher specificity (93.9%) to identify positive culture. This study emphasizes the high resistance to first-line antibiotics used in pregnancy and the need for accurate, low-cost UTI screening methods in LMICs.