Faculty Bibliography

In low-and-middle-income countries (LMICs), traditional birth attendant (TBA) training programs are increasing, yet reports are limited on how those programs affect the prenatal clinical abilities of trained TBAs. This study aims to assess the impact of clinical training on TBAs before and after a maternal health-training program. A prospective observational study was conducted in rural Guatemala from March to December 2017. Thirteen participants conducted 116 prenatal home visits. Data acquisition occurred before any prenatal clinical training had occurred, at the completion of the 14-week training program, and at six months post program completion. The paired t-test and McNemar’s test was used and statistical analyses were performed with R Version 3.3.1. There was a statistically significant improvement in prenatal clinical skills before and after the completion of the training program. The mean percentage of prenatal skills done correctly before any training occurred was 25.8%, 62.3% at the completion of the training program (p-value = 0.0001), and 71.0% after six months of continued training (p-value = 0.034). This study highlights the feasibility of prenatal skill improvement through a standardized and continuous clinical training program for TBAs. The improvement of TBA prenatal clinical skills could benefit indigenous women in rural Guatemala and other LMICs.

BACKGROUND:Despite expansion of interest among American medical students in global health (GH), academic medical centers face multiple obstacles to the development of structured GH curricula and career guidance. To meet these demands we sought to provide a systematic analysis of the accounts of GH experts. METHODS:We developed a collaborative, interview-based, qualitative analysis of GH experiences across six career-related themes that are relevant to medical students interested in GH: justification, medical education, economics, research prospects, law and ethics, and work-life balance. Seven GH faculty members were interviewed for 30-90 minutes using sample questions as guidelines. We applied a grounded theory approach to analyze the interview transcripts to discover an emerging theory pertinent to GH trainees. FINDINGS/RESULTS:Regarding justification, 4 respondents defined GH as work with the underserved irrespective of geographic location; 5 respondents found sustainability imperative; and all respondents believe GH creates better physicians. Respondents identified many physician competencies developed through GH medical education, with 5 respondents agreeing that work with underserved populations has transformative potential. Concerning economics, 3 respondents acknowledged GH's popularity among trainees, resulting in increased training opportunities, and 2 respondents emphasized an associated deficiency in program quality. All respondents described career models across specialties. Four respondents noted funding challenges when discussing research prospects. Within the theme of laws and ethics, 4 respondents perceived inadequate accountability, and 6 respondents identified ways to create accountability. Finally, 6 respondents recognized family demands can compromise one's GH career and thus work-life balance. CONCLUSION/CONCLUSIONS:Despite diverse perspectives on the meaning and sustainability of GH work, this analysis provides a nascent framework that may inform curricular development for GH trainees. Suggestions are offered for elaborating this framework to fully exploit the transformative potential of GH training in medical education.

In low- and middle-income countries (LMICs), where the rates of maternal mortality continue to be inappropriately high, there has been recognition of the importance of training traditional birth attendants (TBAs) to help improve outcomes during pregnancy and childbirth. In Guatemala, there is no national comprehensive training program in place despite the fact that the majority of women rely on TBAs during pregnancy and childbirth. This community case study presents a unique education program led by TBAs for TBAs in rural Guatemala. Discussion of this training program focuses on programming implementation, curriculum development, sustainable methodology, and how an educational partnership with the current national health-care system can increase access to health care for women in LMICs. Recent modifications to this training model are also discussed including how a change in the clinical curriculum is further integrating TBAs into the national health infrastructure. The training program has demonstrated that Guatemalan TBAs are able to improve their basic obstetrical knowledge, are capable of identifying and referring early complications of pregnancy and labor, and can deliver basic prenatal care that would otherwise not be provided. This training model is helping transform the role of the TBA from a sole cultural practitioner to a validated health-care provider within the health-care infrastructure of Guatemala and has the potential to do the same in other LMICs.

Abstract Objective: To assess the impact of a group lifestyle intervention on gestational weight gain in a cohort of obese pregnant women. Methods: A cohort study comparing 60 pregnant women enrolled in an educational intervention, to controls from the same institution who receive routine prenatal care. Subjects were matched to controls by pre-pregnancy BMI, parity and ethnicity. Subjects participated in group and individual counseling sessions focused on diet, exercise and weight goals. The primary outcome was gestational weight gain. Results: A greater number of patients in the intervention group met the Institute of Medicine weight gain recommendations (35 vs 24, p= .0446) Mean gestational weight gain of participants was lower than the control group but this was not statistically significant. Number of sessions attended was associated with a decrease in total weight gained. Conclusion: Educational interventions targeting obese pregnant women may be an effective way to limit gestational weight gain. Participation in educational sessions likely influences total weight gain.

Objectives: The prevalence of human papillomavirus among women in Guatemala approaches 40% and the prevalence of abnormal cervical cytology is 8%. However, the estimated population coverage of cervical cancer screening is <10%, highlighting an important gap in health care. Our objective was to determine which screening methods were used in rural Guatemala and the sensitivity of the methods for cervical cancer detection. Methods: All cervical cancer screening records from hospitals and clinics that offer surveillance in Santiago Atitlan, Guatemala, were reviewed from 1/2012 to 11/2012. Results: In Atitlan, cervical cancer screening is provided by three institutions that differ in method, availability, and cost: a private hospital, a public government-funded community health center, and a health outreach organization via mobile clinics. Of the 202women who underwent Papanicolaou screening (Pap) at the private hospital, there were no cases of abnormal cytology. Of the 128 women who underwent Pap at the outreach mobile clinics, there was one result of cervical intraepithelial neoplasia 3 and one cervical carcinoma. Of the 41women who underwent visual inspection with ascetic acid (VIA) at the public community health center, there was one abnormal result. Conclusions: Among the 330 women who underwent cervical cancer screening via Pap, only two had abnormal results (0.6%), which is discordant with the reported national rate of abnormal cervical cytology. Our data suggest a low sensitivity for screening with Pap in this region. These findings support other studies suggesting that although Pap testing has effectively decreased cervical cancer rates in developed countries, developing countries may lack the infrastructure required to maintain a successful Pap screening program. Further exploration is necessary to determine the etiology of this low sensitivity, focusing on the quality of laboratories, training of providers, access to supplies, means of transporting specimens, and patient tracking systems. (Table presented)

Cervical cancer is a leading cause of death among women in the developing world. Conventional cytology-based cervical cancer screening programs have been largely ineffectual at reducing the cervical cancer burden in low-resource settings. In response, alternative strategies have been tested, such as visual inspection with acetic acid (VIA) screening and human papillomavirus (HPV) DNA-based testing. This manuscript reviews literature addressing the programmatic approaches to implementing cervical cancer screening programs in low-resource settings, highlighting the challenges, barriers, and successes related to the use of cytology, VIA, and HPV-DNA based screening programs.