Use of Traditional Botanical Medicines During Pregnancy in Rural Rwanda.

OBJECTIVE: To evaluate the perceptions of healthcare and traditional medicine providers regarding the type, indications, side effects, and prevalence of traditional medicine use amongst pregnant women in a rural Rwandan population. METHODS: Six focus groups with physicians, nurses, and community health workers and four individual in-depth interviews with traditional medicine providers were held. Qualitative data was gathered using a structured questionnaire querying perceptions of the type, indications, side effects, and prevalence of use of traditional medicines in pregnancy. RESULTS: The healthcare provider groups perceived a high prevalence of traditional botanical medicine use by pregnant women (50-80%). All three groups reported similar indications for use of the medicines and the socioeconomic status of the pregnant women who use them. The traditional medicine providers and the healthcare providers both perceived that the most commonly used medicine is a mixture of many plants, called Inkuri. The most serious side effect reported was abnormally bright green meconium with a poor neonatal respiratory drive. Thirty-five traditional medicines were identified that are used during pregnancy. CONCLUSION: Perceptions of high prevalence of use of traditional medicines during pregnancy with possible negative perinatal outcomes exist in areas of rural Rwanda.

Global health training in US obstetrics and gynaecology residency programmes: perspectives of students, residents and programme directors.

BACKGROUND: Benefits of exposure to global health training during medical education are well documented and residents' demand for this training is increasing. Despite this, it is offered by few US obstetrics and gynaecology (OBGYN) residency training programmes. OBJECTIVES: To evaluate interest, perceived importance, predictors of global health interest and barriers to offering global health training among prospective OBGYN residents, current OBGYN residents and US OGBYN residency directors. METHODS: We designed two questionnaires using Likert scale questions to assess perceived importance of global health training. The first was distributed to current and prospective OBGYN residents interviewing at a US residency programme during 2012-2013. The second questionnaire distributed to US OBGYN programme directors assessed for existing global health programmes and global health training barriers. A composite Global Health Interest/Importance score was tabulated from the Likert scores. Multivariable linear regression was performed to assess for predictors of Global Health Interest/Importance. RESULTS: A total of 159 trainees (77%; 129 prospective OBGYN residents and 30 residents) and 69 (28%) programme directors completed the questionnaires. Median Global Health Interest/Importance score was 7 (IQR 4-9). Prior volunteer experience was predictive of a 5-point increase in Global Health Interest/Importance score (95% CI -0.19 to 9.85; p=0.02). The most commonly cited barriers were cost and time. CONCLUSION: Interest and perceived importance of global health training in US OBGYN residency programmes is evident among trainees and programme directors; however, significant financial and time barriers prevent many programmes from offering opportunities to their trainees. Prior volunteer experience predicts global health interest.

Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study.

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.

Improved obstetric safety through programmatic collaboration.

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network.

OBJECTIVE: To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation. STUDY DESIGN: The authors reviewed paper prenatal records (historical control arm and contemporaneous control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed to assess adequacy of documentation; the prenatal record was assigned a score (range, -1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio-that controlled for which elements of care were indicated for a patient-were calculated and compared between the study arm versus historical control arm and then the study arm versus contemporaneous control arm. RESULTS: The median PQI raw score was significantly lower in the study arm compared with historical control arm; however, the PQI ratios were similar between these groups. The PQI raw score was similar in both the study arm and contemporaneous control arm; however the PQI ratio was significantly higher in the study arm when compared with the contemporaneous control arm. CONCLUSION: Implementation of this prenatal EMR did not have a significant impact on completeness of documentation when compared with a standardized paper prenatal record. Adequacy of documentation seems to be related to the type of practice.

Clinical utility of chromosomal microarray analysis in prenatal diagnosis: report of first 6 months in clinical practice.

OBJECTIVE: We studied the clinical utility of chromosomal microarray analysis (CMA) in prenatal diagnosis in a clinical setting in New York City. METHODS: Our center began offering CMA to pregnant women undergoing invasive diagnostic procedures for an abnormal structural finding on ultrasound, maternal age of 35 years or older, or elevated risk on aneuploidy screening, beginning March 2012. Our first six months experience is reported. RESULTS: Benign familial variants were the most common finding (16/22 fetuses). Variants of uncertain significance were frequent, especially when fathers were not available for testing (4/22 fetuses). Most patients undertook CMA as part of evaluation of an ultrasound anomaly (52%). One patient terminated a pregnancy based on an ultrasound finding in the setting of a benign familial variant on CMA, and a second terminated a pregnancy based on a copy number variant identified on CMA. CONCLUSION: For CMA to be maximally useful in prenatal diagnosis, parental DNA samples as well as robust datasets to provide predictive phenotypic information are required. The most common reason for undertaking CMA was to evaluate an ultrasound anomaly, and benign familial variants were a common finding. Genetic services are required to provide pre- and post-test genetic counseling and help families interpret results.

Enhanced physician prompts in prenatal electronic medical records impact documentation on smoking cessation.

OBJECTIVE: Smoking cessation during pregnancy is a modifiable intervention that can improve maternal and neonatal outcomes. Encouraging smoking cessation is an assessed measure of the Meaningful Use incentives to ensure best practices with the increased use of the electronic medical record (EMR). Physician EMR prompts have been used shown to be successful with preventive care but there is a paucity of data evaluating prompts within obstetrics. The objective of this study is to determine the effectiveness of enhanced smoking cessation prompts in a prenatal EMR. METHODS: A retrospective cohort study of an enhanced smoking cessation prompting system within our prenatal EMR was performed. Pregnant women who reported tobacco use at first prenatal visit were included. The number of times a smoking cessation method was offered and documented, the number of documented attempts at smoking cessation, and the final number of cigarettes smoked were compared pre and post the enhancement of the smoking cessation prompting system. RESULTS: 95 patients were included (48 pre-enhancement; 47 post-enhancement). Post-enhancement, the documentation of smoking cessation method offered increased (0 vs. 1, p = 0.03) and documentation of smoking cessation attempts increased (1 vs. 2, p = 0.006). There was no change in the final number of cigarettes smoked (p = 0.9). CONCLUSIONS: Enhanced prompting systems increase documentation related to smoking cessation with no change in number of cigarettes smoked. In the era of Meaningful Use guidelines which focus on documentation in the EMR, continued research must be done to assure that software enhancements and improved documentation truly result in improved patient care.

Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training.

OBJECTIVE: To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. STUDY DESIGN: Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life support pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. RESULTS: Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). CONCLUSION: Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.

Resident training for eclampsia and magnesium toxicity management: simulation or traditional lecture?

OBJECTIVE: To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education. STUDY DESIGN: Statified by year, residents (n = 38) were randomly assigned to 3 educational intervention groups: Simulation→Lecture, Simulation, and Lecture. Postintervention simulations were performed for all and scored using standardized lists. Maternal, fetal, eclampsia management, and magnesium toxcity scores were assigned. Mann-Whitney U, Wilcoxon rank sum and χ(2) tests were used for analysis. RESULTS: Postintervention maternal (16 and 15 vs 12; P < .05) and eclampsia (19 vs 16; P < .05) scores were significantly better in simulation based compared with lecture groups. Postintervention magnesium toxcitiy and fetal scores were not different among groups. Lecture added to simulation did not lead to incremental benefit when eclampsia scores were compared between Simulation→Lecture and Simulation (19 vs 19; P = nonsignificant). CONCLUSION: Simulation training is superior to traditional lecture alone for teaching crucial skills for the optimal management of both eclampsia and magnesium toxicity, 2 life-threatening obstetric emergencies.

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia.

OBJECTIVE: The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC. STUDY DESIGN: This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program. RESULTS: Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively. CONCLUSION: Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

A life course perspective on women's reproductive health and the outcome of pregnancy.

The previous century was characterized by tremendous advances in reducing maternal mortality and morbidity, as well as dramatic improvements in perinatal outcomes for fetus and newborn. However, there has now developed a plateauing or even a worsening in some of the commonly tracked indicators of reproductive health. In this section, leading policy experts focus on redefining how the health system approaches the task of continuing to improve the reproductive outcomes of women and their offspring. They analyze key underlying fundamentals and offer their individual suggestions for new initiatives to reverse these disturbing negative trends.

Using simulation training to improve shoulder dystocia documentation.

OBJECTIVE: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience. METHODS: Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations. RESULTS: Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25-63 years (mean+/-standard deviation 37.0+/-9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5+/-8.1). Documentation scores were significantly improved after training. Attendings' baseline documentation scores were 8.5+/-2.2 and improved to 9.4+/-2.3, P=.03. Residents' documentation scores also improved (9.0+/-2.1 compared with 10.6+/-2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores). CONCLUSION: Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation. LEVEL OF EVIDENCE: II.

Improving shoulder dystocia management among resident and attending physicians using simulations.

OBJECTIVE: The objective of the study was to determine whether a simulation-based educational program would improve residents' and attending physicians' performance in a simulated shoulder dystocia. STUDY DESIGN: Seventy-one obstetricians participated in an unanticipated simulated shoulder dystocia, an educational debriefing session, and a subsequent shoulder dystocia simulation. Each simulation was scored, based on standardized checklists for 4 technical maneuvers and 6 communication tasks, by 2 physician observers. Paired Student t tests were used for analysis. RESULTS: Forty-three attendings and 28 residents participated. Residents showed significant improvement in mean maneuver (3.3 +/- 0.9 vs 3.9 +/- 0.4, P = .001) and communication (3.5 +/- 1.2 vs 4.9 +/- 1.0, P < .0001) scores after simulation training. Attending physicians' communication (3.6 +/- 1.6 vs 4.9 +/- 1.1, P < .0001) scores were significantly improved after training. CONCLUSION: Our program improved physician performance in the management of simulated shoulder dystocia deliveries. Obstetric emergency simulation training can improve physicians' communication skills, at all levels of training, and should be incorporated into labor and delivery quality improvement measures.

Reducing errors and risk in a prenatal network with an electronic medical record.

In 2002 the Institute of Medicine called for implementation of information technologies in health care settings to improve quality of care and reduce the incidence of medical errors. Nowhere is this need more critical than in obstetrics. In recent years numerous electronic prenatal medical records have become available. To date there has been little literature to identify what constitutes the important features in these systems, nor research into whether these systems actually improve the quality of care or the outcome of pregnancies. In this article we will elucidate some of the features that we feel are critical if we are to achieve these goals. Some of these features are: (1) availability across a computer network so that providers can access the record in a variety of settings, (2) simplicity of the user interface to ensure provider compliance with the system, (3) an intelligent system to encourage completeness of documentation in the medical record, (4) a problem-oriented obstetric chart so that no issue is overlooked and each is adequately addressed, and (5) administrative features to allow evaluation to ensure improved quality of care. These features together, we believe, will help to minimize medical errors, improve patient outcomes and reduce liability exposure.

The contribution of birth defects to preterm birth and low birth weight.

OBJECTIVE: To assess the impact of birth defects on preterm birth and low birth weight. METHODS: Data from a large, prospective multi-center trial, the First and Second Trimester Evaluation of Risk (FASTER) Trial, were examined. All live births at more than 24 weeks of gestation with data on outcome and confounders were divided into two comparison groups: 1) those with a chromosomal or structural abnormality (birth defect) and 2) those with no abnormality detected in chromosomes or anatomy. Propensity scores were used to balance the groups, account for confounding, and reduce the bias of a large number of potential confounding factors in the assessment of the impact of a birth defect on outcome. Multiple logistic regression analysis was applied. RESULTS: A singleton liveborn infant with a birth defect was 2.7 times more likely to be delivered preterm before 37 weeks of gestation (95% confidence interval [CI] 2.3-3.2), 7.0 times more likely to be delivered preterm before 34 weeks (95% CI 5.5-8.9), and 11.5 times more likely to be delivered very preterm before 32 weeks (95% CI 8.7-15.2). A singleton liveborn with a birth defect was 3.6 times more likely to have low birth weight at less than 2,500 g (95% CI 3.0-4.3) and 11.3 times more likely to be very low birth weight at less than 1,500 g (95% CI 8.5-15.1). CONCLUSION: Birth defects are associated with preterm birth and low birth weight after controlling for multiple confounding factors, including shared risk factors and pregnancy complications, using propensity scoring adjustment in multivariable regression analysis. The independent effects of risk factors on perinatal outcomes such as preterm birth and low birth weight, usually complicated by numerous confounding factors, may benefit from the application of this methodology, which can be used to minimize bias and account for confounding. Furthermore, this suggests that clinical and public health interventions aimed at preventing birth defects may have added benefits in preventing preterm birth and low birth weight. LEVEL OF EVIDENCE: II.

Tenure of academic chairs in obstetrics and gynecology: a 25-year perspective.

OBJECTIVE: To assist in predicting future leadership needs, this longitudinal study examines turnover and net retention rates among chairs at university obstetrics and gynecology departments between 1981 and 2005. METHODS: A database of appointment dates and tenure of chairs at each of 125 Association of American Medical Colleges-approved United States medical schools was collated using membership listings from the Association of Professors of Gynecology and Obstetrics and from the Council of University Chairs in Obstetrics and Gynecology. Complete data from 118 departments were confirmed by selective correspondence at individual departments and further review by the investigators. RESULTS: A total of 260 individuals (232 men, 28 women) became new chairs between 1981 and 2005. The annual turnover rate increased gradually from 6.0% to 12.7%. Five-year net retention rates remained steady between 1982 and 1997 but dropped after 1997 (85.6% compared with 63.2%; P=.03). A chair's tenure ranged widely (1 to 23 years; median 8 years), regardless of gender or school type, size, or location. Approximately one half of interim chairs became permanent chairs, usually at their own institution. The number of new women chairs increased from none in 1981 to 17 (15.2% of total chairs) in 2005. CONCLUSION: Academic chair positions in obstetrics and gynecology experienced a doubling in annual turnover rates, while retention rates declined. The proportion of chairs occupied by women increased progressively. LEVEL OF EVIDENCE: II-2.

Research agenda for preterm birth: recommendations from the March of Dimes.

Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.

Quad screen as a predictor of adverse pregnancy outcome.

OBJECTIVE: To estimate the effect of second-trimester levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), unconjugated estriol (uE3), and inhibin A (the quad screen) on obstetric complications by using a large, prospectively collected database (the FASTER database). METHODS: The FASTER trial was a multicenter study that evaluated first- and second-trimester screening programs for aneuploidy in women with singleton pregnancies. As part of this trial, patients had a quad screen drawn at 15-18 6/7 weeks. We analyzed the data to identify associations between the quad screen markers and preterm birth, intrauterine growth restriction, preeclampsia, and fetal loss. Our analysis was performed by evaluating the performance characteristics of quad screen markers individually and in combination. Crude and adjusted effects were estimated by multivariable logistic regression analysis. Patients with fetal anomalies were excluded from the analysis. RESULTS: We analyzed data from 33,145 pregnancies. We identified numerous associations between the markers and the adverse outcomes. There was a relatively low, but often significant, risk of having an adverse pregnancy complication if a patient had a single abnormal marker. However, the risk of having an adverse outcome increased significantly if a patient had 2 or more abnormal markers. The sensitivity and positive predictive values using combinations of markers is relatively low, although superior to using individual markers. CONCLUSION: These data suggest that components of the quad screen may prove useful in predicting adverse obstetric outcomes. We also showed that the total number and specific combinations of abnormal markers are most useful in predicting the risk of adverse perinatal outcome.

Using an electronic medical record to improve communication within a prenatal care network.

OBJECTIVE: In 2002, the Institute of Medicine called for the introduction of information technologies in health care settings to improve quality of care. We conducted a review of hospital charts of women who delivered before and after the implementation of an intranet-based computerized prenatal record in an inner-city practice. Our objective was to assess whether the use of this record improved communication among the outpatient office, the ultrasonography unit, and the labor floor. METHODS: The charts of patients who delivered in August 2002 and August 2003 and received their prenatal care at the Comprehensive Family Care Center at Montefiore Medical Center were analyzed. Data collected included the presence of a copy of the prenatal record in the hospital chart, the date of the last documented prenatal visit, and documentation of any prenatal ultrasonograms performed. RESULTS: Forty-three charts in each group were available for review. The prenatal chart was absent in 16% of the charts of patients from August 2002 compared with only 2% in August 2003 charts (P < .05). Among charts with prenatal records available, the median length of time between the last documented prenatal visit and delivery was significantly longer for August 2002 patients compared with August 2003 patients (36 compared with 4 days, respectively, P < .001). All patients received prenatal ultrasonograms, but documentation of the ultrasonogram was missing from 16% of the August 2002 charts compared with none of the August 2003 charts (P = .01). CONCLUSION: The use of a paperless, hospital intranet-based prenatal chart significantly improves communication among providers.