Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors.

BACKGROUND: The health and economic benefits of paid parental leave have been well-documented. In 2016, the American College of Obstetricians and Gynecologists released a policy statement about recommended parental leave for trainees; however, data on adoption of said guidelines are nonexistent, and published data on parental leave policies in obstetrics-gynecology are outdated. The objective of our study was to understand existing parental leave policies in obstetrics-gynecology training programs and to evaluate program director opinions on these policies and on parenting in residency. OBJECTIVE: A Web-based survey regarding parental leave policies and coverage practices was sent to all program directors of accredited US obstetrics-gynecology residency programs. STUDY DESIGN: Cross-sectional Web-based survey. RESULTS: Sixty-five percent (163/250) of program directors completed the survey. Most program directors (71%) were either not aware of or not familiar with the recommendations of the American College of Obstetricians and Gynecologists 2016 policy statement on parental leave. Nearly all responding programs (98%) had arranged parental leave for ≥1 residents in the past 5 years. Formal leave policies for childbearing and nonchildbearing parents exist at 83% and 55% of programs, respectively. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive. Coverage for residents on leave is most often provided by co-residents (98.7%), usually without compensation or schedule rearrangement to reduce work hours at another time (45.4%). Most program directors (82.8%) believed that becoming a parent negatively affected resident performance, and approximately one-half of the program directors believed that having a child in residency decreased well-being (50.9%), although 19.0% believed that it increased resident well-being. Qualitative responses were mixed and highlighted the complex challenges and competing priorities related to parental leave. CONCLUSION: Most residency programs are not aligned with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Complex issues regarding conflicting policies, burden to covering co-residents, and impaired training were raised.

Making Room at the Table for Obstetrics, Midwifery, and a Culture of Normalcy Within Maternity Care.

The principle of avoiding the worst possible outcomes guided the enormous successes of modern obstetrics in reducing the morbidity and mortality of childbirth. The challenges of improving the quality of childbirth today has prompted health care providers, policymakers, and patients to ask whether this principle is in fact preventing us from supporting the normal processes of childbirth, resulting in undue intervention and potentially causing harm. In this commentary, we suggest that recognizing the strengths of the medical model of childbirth does not preclude looking outside of it to meet the maternity care needs of the majority of healthy, low-risk women. Obstetricians have the good fortune to have a partner in their work among midwives, who hail from a long tradition of incorporating a perspective of "normalcy" in the care of childbearing women. Given the many evidence-based practices demonstrating the strengths of midwifery to actualize patient-centered, low-intervention birth, we advocate for the explicit establishment of professional standards for team-based physician-midwife care. More than merely introducing midwives into a physician-dominated setting, this means elevating the contributions of midwives and meaningfully incorporating a culture of normalcy to standardize practices such as intermittent auscultation, continuous birth support, nonpharmacologic pain management, and positional flexibility in labor. The literature suggests that a woman's health care provider is the most powerful determinant of her birth outcomes; striking the balance between averting poor outcomes and normalcy compels us to make room at the table for both obstetricians and midwives.

Using medical students to enhance curricular integration of cross-cultural content.

We hypothesized that an interested medical student group would be helpful in reviewing tutorial cases and giving relevant feedback on the curricular integration of cross-cultural content using case triggers in a preclinical gastrointestinal pathophysiology course. Self-selected student leaders (n = 9) reviewed pre-existing problem-based learning tutorial cases (n = 3) with cross-cultural triggers, and provided narrative feedback to course faculty. The cases were modified and used for the entire class in the following 2 years. Participating course students' comments and teaching faculty feedback were also noted. Outcomes were a change in case content, student global evaluations of the course, and self-reported faculty comfort with teaching the cases. All three tutorial cases were reviewed by a separate group of 2-3 students. Major and minor revisions were made to each case based on the student feedback. These cases were used in 2007 and 2008 and were the major change to the course during that time. Overall course evaluation scores improved significantly from 2006 to 2008 (p = 0.000). Tutors (n = 22 in 2007; n = 23 in 2008) expressed relief during tutor meetings that students had reviewed the cases. A general framework for eliciting student feedback on problem-based cases was developed. Student feedback, consisting of self-selected students' case reviews and solicited course and tutor comments, added value to a curricular reform to improve the integration of cross-cultural content into a problem-based learning curriculum. Our study underscores the fundamental link between teachers and students as partners in curricular development.

Lessons learned from use of highly active antiretroviral therapy in Africa.

BACKGROUND: Because antiretrovirals are becoming increasingly available in developing countries, we reviewed the findings of studies that have documented highly active antiretroviral therapy (HAART) use in Africa to identify lessons learned. With the World Health Organization (WHO) guidelines used as a frame of reference, we assessed the feasibility of implementing such programs in Africa. Moreover, clinical and laboratory outcomes were compiled to determine the effectiveness of HAART programs. METHODS: We searched academic databases and recent conference abstracts for studies, and we included all studies that documented patients receiving HAART in Africa. In particular, we examined studies for such program features as type of regimen and frequency of monitoring, in addition to evaluations of patient outcomes. RESULTS: Twenty-eight articles and abstracts involving studies from 14 African countries were reviewed. Overall, 6052 patients (96.4%) were receiving HAART, mainly consisting of 2 nucleoside reverse-transcriptase inhibitors (NRTIs) and 1 nonnucleoside reverse-transcriptase inhibitor. All studies reported an increase in mean and median CD4 cell counts, and a median of 73% of patients achieved undetectable viral loads by the end of the study period. Monitoring of CD4 cell count and viral load at 6-month intervals was completed by all studies. The median weight gained was 5.0 kg, and the median mortality rate was 7.4% (range, 0%-27%). Six studies reported that 68%-99% of patients took >95% of medications. Five studies measured drug resistance; most cases of resistance involved NRTIs. CONCLUSIONS: Many studies reported positive health outcomes, including high levels of treatment adherence that were comparable to those of industrialized countries. Regimens and monitoring means based on WHO guidelines were implemented--and at times, exceeded--in all studies reviewed. We found compelling evidence that HAART can be feasibly administered in resource-limited settings.