Faculty Bibliography

OBJECTIVE:Guatemala has one of the highest rates of maternal mortality in Central America. A total of 60% of births in Guatemala are attended by traditional Mayan birth attendants, or comadronas. Their prevalence in these communities makes them a valuable resource to bridge home births with safe prenatal care. The objective of this study was to evaluate a low-cost prenatal care training program for Guatemalan comadronas with the goal of improving maternal health outcomes in the region. METHODS:In this retrospective longitudinal cohort study, we examined the knowledge retention of comadronas enrolled in a 12-month prenatal care training program known as the School of PowHER (SOP). Recruited from the Lake Atitlán region of Guatemala by Saving Mothers, 501(c)(3) and the Guatemalan Ministry of Health, comadronas participated in a four-month didactic curriculum followed by a nine-month clinical curriculum. Pre- and post-tests were administered to assess learning outcomes over the study's duration (2014-2022), and test results were evaluated to assess the effectiveness of the SOP. RESULTS:A total of 123 women were recruited and enrolled in all eight graduating classes of the SOP from 2014, 2016-2019, and 2021-2022. An average, statistically significant improvement in didactic and clinical pre- and post-test scores was found across all years analyzed. CONCLUSION/CONCLUSIONS:The SOP is a low-cost, culturally appropriate, community-based model that empowers comadronas through knowledge and skill acquisition to improve local maternal health outcomes. This program proves effective at not only teaching comadronas prenatal health information and clinical skills, but also at promoting long-term retention of these skills.

INTRODUCTION/BACKGROUND:While there has been notable global advancement in reducing maternal mortality rates (MMRs) in Latin America, the rates among indigenous women remain alarmingly high. This disparity persists in Guatemala, where indigenous women face a two-fold higher MMR compared to their non-indigenous counterparts. Most of the obstetrical care is performed by traditional Mayan birth attendants (TBAs), also known as comadronas, who have minimal formalized clinical training in obstetrical care. Considering there was no national comprehensive training program for TBAs, a unique training program was established in 2014. This program, the School of PowHER (Providing Outreach in Women's Health and Educational Resources), aims to ensure sustainable education led by TBAs for TBAs in rural Guatemala with the ultimate goal of helping TBAs provide basic antenatal care and learn how to identify and refer high-risk pregnancies. The aim of this proposed study is to examine the cultural appropriateness and sensitivity of the training program through a mixed-methods approach. METHODS: We utilized a mixed-methods strategy, combining quantitative and qualitative methodologies. The quantitative aspect involved a 14-item written survey using a three-point Likert scale for responses, while the qualitative part utilized a semi-structured interview guide to conduct a focus group discussion. RESULTS: The survey (n=33) showed that 32 comadronas found the curriculum applicable (97%) and comprehensible (97%). However, only 26 comadronas (79%) were comfortable with anatomy terminology. Opinions on teaching tools varied: 13 comadronas (39%) felt they were always representative, 13 comadronas (39%) sometimes, and seven comadronas (21%) never. Group discussions echoed this lack of representation. In the learning environment, 32 comadronas felt welcomed (97%) and 31 felt understood (94%), but five comadronas (15%) were not comfortable asking questions. Thirty-one comadronas (94%) believed training made pregnant women trust comadronas more. Group interviews highlighted increased confidence, better care, and perceived lower maternal mortality. CONCLUSION/CONCLUSIONS:This study found the program to be culturally sensitive and effective. Group interviews highlighted increased confidence, improved patient care, and perceived reductions in maternal mortality. Feedback emphasized the need for more culturally relevant materials, resources, and collaboration with the Ministry of Health. This program's community-centered approach could serve as a model for similar initiatives in low- and middle-income countries addressing high maternal mortality rates, despite language and access challenges.

OBJECTIVES/OBJECTIVE:Unused/expired medicines that are improperly disposed of can enter soil and water supply and have negative implications for public health. This study aimed to assess patients' knowledge and understanding of medication disposal practices and their willingness to participate in a medication takeback programme. METHODS:A self-administered questionnaire comprising of 26 questions based on demographics, knowledge, beliefs, practices and concerns was utilized in this study. The study was conducted over 12 weeks at outpatient pharmacy sites located in the four Regional Health Authorities in Trinidad. Statistical Package for the Social Sciences (SPSS) version 24 was used for statistical analysis. KEY FINDINGS/RESULTS:A total of 547 persons completed the questionnaire. Knowledge of the dangers of improper medication disposal was highest in those aged 18-25 years (P = 0.007) and having secondary/tertiary level education (P = 0.002). Disposal of unused/expired medication via household thrash (86.1%) was the most commonly encountered practice. Only 14.1% (n = 77) of respondents asked the pharmacist for advice on best disposal practice, although 47.3% (n = 259) thought that the pharmacist should be the main source of advice for information on medication disposal practices. There was a willingness to participate in a medicine takeback programme from 82% (n = 449) of the respondents, and the majority (67.5%) (n = 303) would prefer it if medication takeback programmes were implemented at private community pharmacies. CONCLUSIONS:Patients in Trinidad utilized household garbage as their main disposal method. There is a need to implement a medication takeback programme and educate the public on proper medication disposal.

There have long been noted significant health disparities related to cancer in populations comprised of low-income and minority individuals, including those with gynecologic cancers. Compliance with appointments related to cancer care is critical to ensuring timely diagnosis, treatment, and detection of disease progression. At a public safety net hospital in New York City, the rate of clinic absenteeism in gynecologic oncology clinic was noted to be nearly 20%. This prospective, survey-based study catalogued reasons for clinic absenteeism and noted that the most common reason an appointment was missed was the patient being unaware it existed. Next most common reasons were medical conflicts and family obligations. Patients at this clinic would benefit from a clinic navigator to assist with scheduling appointments, remind patients of upcoming appointments, and resolve conflicting medical appointments.

OBJECTIVE/UNASSIGNED:To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases. MATERIAL AND METHODS/UNASSIGNED:This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded. RESULTS/UNASSIGNED:Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy. CONCLUSION/UNASSIGNED:differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.

The COVID-19 pandemic is challenging health systems across the world. The potential for devastating consequences in resource-limited low- and middle-income countries (LMICs) is just beginning to be understood. In the majority of LMICs, maternal healthcare is focused outside a health center through the use of community health workers and birth attendants. These essential workers provide the majority of maternal health care around the globe and are ill prepared for the highly transmissible nature of this novel virus and its consequences for their communities. Little attention has been focused on their training and responsiveness during this pandemic.

BACKGROUND:Childhood anxiety prevents optimal diabetes management yet may be underrecognized by guardians. OBJECTIVE:We aimed to investigate associations among anxiety, diabetes treatment adherence, and diabetes symptom control through child and guardian report. METHODS:Cross-sectional pilot study surveying a convenience sample of children (ages 2-21) in a pediatric endocrinology clinic. Behavior Assessment System for Children, Second Edition 2, Self-Care Inventory Report, and Pediatric Quality of Life measured anxiety, diabetes treatment adherence, and diabetes symptom control. Analyses were performed with Spearman correlations. RESULTS: = -0.38, P = 0.02]). Child- and guardian-reported anxiety were positively correlated (rho = 0.426, P = 0.017)-particularly for children aged >12 (rho = 0.686, P = 0.003)-although not significantly for children ≤ 12 (rho = 0.201, P = 0.473). CONCLUSION:Anxiety in children with type 1 diabetes varies with the domain of diabetes management (treatment adherence vs. symptom control) and reporting source (child vs. guardian). Children aged ≤12 exhibited a stronger relationship between higher anxiety and worse diabetes management with worse treatment adherence and symptom control in the presence of higher anxiety. Guardians of younger children were less effective at recognizing symptoms. Challenges identifying anxiety and its detrimental effects on diabetes management suggest routine screening of anxiety in pediatric endocrinology clinics is especially salient.

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.