Publications

BACKGROUND: Current guidelines suggest that cholecystectomy during the third trimester of pregnancy is safe for both the woman and the fetus. However, no population-based study has examined this issue. The aim of this analysis was to compare the results of cholecystectomy during the third trimester of pregnancy with outcomes in women operated on in the early postpartum period in a large population.

METHODS: The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Women undergoing cholecystectomy during the third trimester of pregnancy (n = 403) were compared with those having this procedure in the 3 months post partum (n = 17,490). Patient demographics as well as maternal delivery and cholecystectomy-related outcomes were compared by standard statistics as well as after adjustments for age, race, comorbidities, insurance status, and hospital setting.

RESULTS: Women who underwent cholecystectomy during the third trimester were older (27 vs 25 years; p < 0.001), but did not differ in race or insurance status. Cholecystectomy during pregnancy was more likely to require hospitalization (85% vs 63%; p < 0.001) and more likely to be performed open (13% vs 2%; p < 0.001). Composite maternal outcomes (odds ratio 1.88; p < 0.001), including preterm delivery (odds ratio 2.05; p < 0.001) as well as length of hospital stay (+0.83 days; p < 0.001) and readmissions (odds ratio 2.05; p = 0.002), were all significantly increased when cholecystectomy was performed during pregnancy.

CONCLUSIONS: Maternal delivery and procedure-related outcomes were worse when cholecystectomy was performed during the third trimester of pregnancy. Preterm delivery, which is associated with multiple adverse infant outcomes, was increased in third-trimester women. Whenever possible, cholecystectomy should be delayed until the postpartum period.

Maternal morbidity and mortality, important indicators of healthcare quality both nationally and internationally, have gained increasing public attention in the United States (U.S.). The U.S. has the highest rate of maternal mortality among high-income countries; notably, this rate has more than doubled since 1990. Black women in the U.S. die at three to four times the rate of white women from pregnancy-related complications, one of the widest of all racial disparities in women's health. Medical complications, including cardiovascular disease and hypertensive disorders in pregnancy, remain leading contributors to disparities in maternal outcomes including pregnancy-related deaths. However, an under-explored opportunity for improvement is the failure to transition from obstetrical to primary care, which limits optimizing postpartum health. Health system approaches, community-based interventions, and policy solutions that facilitate transitions of care may be critical to eliminating persistent disparities in maternal outcomes.

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487-2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068-1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936-991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.

The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.

BACKGROUND: Community health centers (CHCs) and federally qualified health centers (FQHCs) are critical health care access points for medically underserved areas in the United States. They also provide opportunities for residents to learn about health system challenges, including workforce shortages, social determinants of health, and health equity.

OBJECTIVE: We sought to describe current obstetrics and gynecology (OB-GYN) resident engagement and training in community health settings.

METHODS: We conducted a website review and survey to identify the prevalence and types of OB-GYN resident exposure to CHCs, including FQHCs. We reviewed 241 program websites to identify community health electives or rotations. We then surveyed program administrators regarding departmental affiliations with CHCs, types of resident involvement, and barriers to resident rotations at CHCs.

RESULTS: The website review revealed that 18% (44 of 241) of programs offered a community health rotation. Of the 241 programs surveyed, 78 program administrators responded (32%). Forty-three programs (55%) had at least 1 affiliated CHC, and 34 programs (44%) allowed residents to rotate at a CHC. The most common barrier to resident rotations at a CHC was inadequate resident coverage of hospital-based clinical responsibilities. Respondents reported that among 782 graduating residents in the 2016-2017 and 2017-2018 academic years, 76 (10%) planned to pursue a position at a CHC.

CONCLUSIONS: According to their websites, a small percentage of US OB-GYN residency programs offered a CHC rotation. Of programs responding to a survey on the topic, less than half offered CHC rotations and less than 1 in 10 residents planned to work in CHCs after graduation.

We live in a world of incredible linguistic diversity; nearly 7000 languages are spoken globally and at least 350 are spoken in the United States. Language-concordant care enhances trust between patients and physicians, optimizes health outcomes, and advances health equity for diverse populations. However, historical and contemporary trauma have impaired trust between communities of color, including immigrants with limited English proficiency, and physicians in the U.S. Threats to informed consent among patients with limited English proficiency persist today. Language concordance has been shown to improve care and serves as a window to broader social determinants of health that disproportionately yield worse health outcomes among patients with limited English proficiency. Language concordance is also relevant for medical students engaged in health care around the world. Global health experiences among medical and dental students have quadrupled in the last 30 years. Yet, language proficiency and skills to address cultural aspects of clinical care, research and education are lacking in pre-departure trainings. We call on medical schools to increase opportunities for medical language courses and integrate them into the curriculum with evidence-based teaching strategies, content about health equity, and standardized language assessments. The languages offered should reflect the needs of the patient population both where the medical school is located and where the school is engaged globally. Key content areas should include how to conduct a history and physical exam; relevant health inequities that commonly affect patients who speak different languages; cultural sensitivity and humility, particularly around beliefs and practices that affect health and wellbeing; and how to work in language-discordant encounters with interpreters and other modalities. Rigorous language assessment is necessary to ensure equity in communication before allowing students or physicians to use their language skills in clinical encounters. Lastly, global health activities in medical schools should assess for language needs and competency prior to departure. By professionalizing language competency in medical schools, we can improve patients' trust in individual physicians and the profession as a whole; improve patient safety and health outcomes; and advance health equity for those we care for and collaborate with in the U.S. and around the world.

OBJECTIVE: To design an Obstetrics and Gynecology (OBGYN) residency elective in global health that meets ACGME standards and simultaneously promotes health equity.

DESIGN: A 4-week elective was established for US residents in a high-volume African district hospital that served as a site for OBGYN rotations for the national internship training program. Clear clinical, operative, and teaching requirements were delineated for US OBGYN residents. Resident formal didactic outputs were incorporated into the intern OBGYN curriculum. The program was evaluated through assessment of resident experience and contribution to local training, as well as assessment of intern competency in OBGYN.

SETTING: Scottish Livingstone Hospital, a public district hospital in Molepolole, Botswana.

PARTICIPANTS: Second- to fourth-year OBGYN residents from US training programs, working with Batswana medical interns under on-site faculty supervision.

RESULTS: From May 2016 to June 2018, 18 residents from 9 US OBGYN residency programs participated in the elective. Under supervision, US residents performed 116 major and 77 minor gynecologic surgeries, and teach-assisted Batswana interns and medical officers in 76 cesarean deliveries. Residents led or contributed significantly to 25 didactic education sessions as part of the formal intern OBGYN curriculum. During this period, 24 Batswana interns rotated through the hospital's department of OBGYN, and all 24 trainees met required OBGYN competencies prior to completing their internship.

CONCLUSIONS: Matching US resident demand for global health experiences to equitable global health programming while maintaining ACGME training guidelines poses a challenge to OBGYN residency training programs. This elective provides a model OBGYN global health elective that addresses host-identified needs, broadens residents' skills, and meets standards for postgraduate OBGYN training. Purposeful global health electives for US residents embedded in longitudinal programs provide an opportunity for residents to contribute to broader global health efforts that promote health equity.

BACKGROUND: One international and three local organizations developed the Santa Ana Women's Health Partnership (SAWHP) to address cervical cancer in Santa Ana Huista, Huehuetenango, Guatemala. This paper describes the structure, outcomes, and lessons learned from our community partnership and program.

METHODS: The community partnership developed a singlevisit approach (SVA) program that guided medically underserved women through screening and treatment of cervical cancer.

LESSONS LEARNED: The program promoted acceptability of SVA among rural women by engaging local female leaders and improving access to screening services. The program's approach focused on maximizing access and generated interest beyond the coverage area. Distrust among the community partners and weak financial management contributed to the program's cessation after 4 years.

CONCLUSIONS: The SAWHP design may guide future implementation of cervical cancer screening programs to reach medically underserved women. Open, ongoing dialogue among leaders in each partner institution is paramount to success.