Faculty Bibliography

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.

Global health has become an increasingly important focus of education, research, and clinical service in North American universities and academic health centers. Today there are at least 49 academically based global health programs in the United States and Canada, as compared with only one in 1999. A new academic society, the Consortium of Universities for Global Health, was established in 2008 and has grown significantly. This sharp expansion reflects convergence of 3 factors: (1) rapidly growing student and faculty interest in global health; (2) growing realization-powerfully catalyzed by the acquired immune deficiency syndrome epidemic, the emergence of other new infections, climate change, and globalization-that health problems are interconnected, cross national borders, and are global in nature; and (3) rapid expansion in resources for global health. This article examines the evolution of the concept of global health and describes the driving forces that have accelerated interest in the field. It traces the development of global health programs in academic health centers in the United States. It presents a blueprint for a new school-wide global health program at Mount Sinai School of Medicine. The mission of that program, Mount Sinai Global Health, is to enhance global health as an academic field of study within the Mount Sinai community and to improve the health of people around the world. Mount Sinai Global Health is uniting and building synergies among strong, existing global health programs within Mount Sinai; it is training the next generation of physicians and health scientists to be leaders in global health; it is making novel discoveries that translate into blueprints for improving health worldwide; and it builds on Mount Sinai's long and proud tradition of providing medical and surgical care in places where need is great and resources few.

We assessed the impact of a lifestyle modification program (LMP) on weight gain in pregnancy and evaluated its effect on adverse pregnancy outcomes. A prospective matched controlled study design was employed. Inclusion criteria consisted of pregnant women with singleton gestations and body mass index (BMI) > or = 30 without underlying medical conditions. In the study group, patients were prospectively enrolled in the first trimester. Through the LMP, women participated in a comprehensive program on nutrition, exercise, and weight control in pregnancy. The control group consisted of matched patients by starting BMI, parity, and socioeconomic status during the same study period cared for at the same institution. The primary outcome evaluated was weight gain in pregnancy. Adverse pregnancy outcomes including preeclampsia, gestational diabetes, gestational hypertension, and various postpartum complications were evaluated between the two groups. Statistical analysis was performed using nonparametric methods, with p < 0.5 considered significant. Twenty-eight patients were recruited for this study and underwent the intervention. Patient compliance with the LMP was 75%, two patients were lost to follow-up, one had a preterm delivery, and four had incomplete data due to various reasons. Twenty-one patients completed their pregnancy and were available for analysis. Twenty matched control patients were identified for analysis. Study participants gained significantly less weight in their pregnancies when compared with controls (mean weight gain 17 versus 34 pounds, respectively; p = 0.008). Secondary outcomes of preeclampsia, gestational diabetes, cesarean section, as well as infant birth weight did not significantly differ between the groups. This study suggests an effective method of reducing prenatal weight gain in the obese population. This type of comprehensive intervention could be an important, cost-effective risk-reduction strategy.