Browsing by Subject "Maternal health"

Background: The landscape of childbirth has transformed over time, shifting from home births guided by midwives to a medicalized procedure predominantly in hospitals, with Cesarean sections (CS) as a significant innovation. Globally, CS rates have risen, including elective CS without medical necessity. Research conducted by the World Health Organization suggests optimal CS rates are between 10-15%, but many countries exceed this value. Initially, in 2014 Cambodia’s rate was at 6.9%, but the latest data released from the Cambodian Demographic and Health Survey has reported a significant increase of almost 18%. Factors like demographic transitions and improved health care are likely to have contributed to this rise. Understanding the decision-making process for childbirth modes is crucial, with medical opinions sometimes differing from patient preferences. This study focuses on Cambodian women, exploring the factors influencing their birth mode decisions, aiming to highlight the significance of women's perspectives in shaping childbirth practices. Methods: Fourteen in-depth, semi-structured interviews were conducted with either nulliparous, primipara, or multipara pregnant women in Phnom Penh, Cambodia. Participants met eligibility criteria such as having single pregnancies over 28 weeks of gestational age, lacking a medical indication from a physician for cesarean section, and being free from known pre-existing medical illnesses or diseases diagnosed during pregnancy. Lastly, participants were not employed as health professionals. Thematic analysis was used on twelve interview transcriptions to analyze the data. Results: Thematic analysis revealed several influential factors, including utilizing external information sources like physicians and family and/or friends, participants’ knowledge of delivery method and procedure recovery, a mode of birth preference largely based on the patient’s individual circumstances, the discussion of patient autonomy and authority to decide, and the recognition that childbirth expectations might change during labor. Conclusion: These research findings highlight that Cambodian pregnant woman processed their mode of birth based on a variety of influences and factors. This data suggests that an individual’s decision is impacted by their environment and the context of their lives. These results can help medical professionals, other maternal health providers, and policymakers better understand how Cambodian pregnant women process their mode of birth decisions.

Every day, approximately 800 women die from pregnancy-related complications. Most of these deaths are avoidable. Care from a skilled provider before, during, and after delivery has been shown to prevent a majority of maternal and neonatal deaths. However, time delays in recognizing the need to seek care, accessing health care facilities, and receiving adequate care from a provider of make the delivery of effective maternal healthcare practices very challenging. These three delays disproportionately affect women living in rural and remote regions, where awareness of maternal health problems can be low and health facilities are few and far between. In Kenya, maternal health care in these regions falls upon community health volunteers, who are unpaid and overworked.

In recent years, mobile phones have grown in popularity for improving disease prevention and management, especially in the field of maternal and child health. The intent of this study was to design and pilot a mobile phone-based patient management system intended for use by community health volunteers. Using a human-centered design framework, a system was developed to fit into the CHVs' existing workflows in order to improve the delivery of maternal and child health care at the community level. Integrating both voice and text messaging interfaces, the system was designed to provide the CHVs with a fast and easy method of recording and reporting data, a streamlined approach for tracking patient referrals to a health facility, and a reliable and effective way to report and respond to obstetric emergencies. The system was found to be highly usable based on self-report data from users, who indicated that the system saved them time and helped them complete their responsibilities as CHVs. In all, results of this pilot suggest that such a system may be useful for CHVs in monitoring the health of pregnant women over time and helping to avoid the time delays associated with maternal mortality.

Despite global improvements in maternal mortality rates, preventable maternal deaths are still an issue for many populations. Indigenous populations, especially those in Latin America, often do not utilize delivery services for a number of reasons, not the least of which are cultural beliefs, geographic challenges, and ability to pay for services. The primary objective of this study is to examine the birth location and birth attendance trends across time of Amazonian Indigenous women compared to women of Andean Highland decent. Additionally, the study aims to compare the education levels, urban status, and income levels of these populations. This analysis uses survey data from families in Amarakaeri Communal Reserve in Amazonian Peru. Bivariate analysis and multivariate logistic regression were used to examine birth location and birth attendance across time. Since 1990, Amazonian Indigenous women in the study sample are increasingly giving birth at health posts in the attendance of nurses, but most still elect to give birth at home with a relative as an attendant. From this, it is concluded that women of Amazonian Indigenous decent are increasingly seeking out skilled birth attendants, but barriers to utilization may remain. Further descriptive research is necessary to ascertain the reasons why Amazonian Indigenous women still prefer giving birth at home, and additional modeling is necessary to determine the effects of potential influencing variables, such as urban status, education levels, and income levels.

Background: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.

Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.

Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.

Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.

Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.

Keywords: Tanzania, obstetric fistula, stigma, maternal health

AbstractAbstractAbstractAbstract Abstract

Spacing the inter-pregnancy interval to more than two years reduces maternal and neonatal morbidity and mortality. Modern contraceptive use can reduce maternal morbidity and mortality by contributing to birth spacing and reducing the total fertility rate. This study is designed to understand the factors associated with appropriate birth spacing and the barriers to modern contraceptive use in Leogane, Haiti. A cross sectional survey of 552 reproductive age women in Leogane proper was performed from June to July of 2011. Univariate, multivariate, and logisitic regressions were used to analyze the data. The results demonstrate the importance of education, employment status, contraceptive use and stable relationships in influencing appropriate birth spacing. Women who spaced their births tended to have less complications compared to women who did not, however this difference was not statistically significant. Barriers to contraceptive use were cultural factors such as religion, and low socioeconomic status. However, contraceptive use was positively influenced by education and partner acceptance of contraceptives. These findings indicate that family programs focused on educating women and their partners on the benefits of contraception and birth spacing would be successful in Leogane, Haiti.

Abstract

Background. Hypertensive disorders (chronic hypertension, preeclampsia/eclampsia, preeclampsia superimposed on chronic hypertension and gestational hypertension) are present in 6% to 8% of pregnancies in the United States. The number of women of childbearing age who will develop hypertension is increasing due to the obesity epidemic and the increasing maternal age at pregnancy. In the United States, 3 to 5% of pregnant women have chronic hypertension before pregnancy or are diagnosed in the first 20 weeks of pregnancy. Chronic hypertension contributes to pregnancy related hypertension and has negative effects on maternal and infant outcomes including preterm birth and small for gestational age infants. Prenatal care is one of the most important preventative public health measures used globally and in the United States because the goal is to detect potential complications during pregnancy and provide appropriate and timely interventions. However, not all pregnant women have access to early prenatal care and adequate prenatal care. The benefits of prenatal care for maternal and infant outcomes for women with hypertensive disorders during pregnancy have not been described. Therefore, the purpose of this dissertation was to examine the influence of chronic hypertension, pregnancy induced hypertension and prenatal care on pregnancy outcomes for women and their infants.

Methods. First, a secondary data analysis of the 2009-2011 Pregnancy Risks Assessment Monitoring System (PRAMS) dataset for North Carolina (Chapter 3) was conducted to understand the effects of chronic hypertension and prenatal care on maternal and infant outcomes in pregnant women. Second, to understand whether preterm infants born to women with hypertensive disorders of pregnancy differ from those of women without hypertensive disorders in terms of illness and development characteristics, a secondary data analysis of a study of maternally administered interventions for neonates was conducted in Chapter 4.

Results. In Chapter 3, the results indicated that women with chronic hypertension have higher risks for pregnancy induced hypertension, preterm birth, and small for gestational age infants. In addition, first trimester or adequate prenatal care did not improve pregnancy outcomes for women with chronic hypertension as it did for women without chronic hypertension. In Chapter 4, preterm infants of women with hypertensive disorders are more likely to be small for gestational age than preterm infants of women without hypertensive disorders.

Conclusion. Overall results showed that preterm infants of women with hypertensive disorders are small for gestational age when compared to preterm infants of women without hypertensive disorders. Also, prenatal care has no significant impact on improving pregnancy and birth outcomes of women with chronic hypertension.

Contraceptive prevalence in Haiti remains low despite extensive foreign aid targeted at improving family planning. [1] Earlier studies have found that peer-informed learning have been successful in promoting sexual and reproductive health. [2-5] This pilot project was implemented as a three-month, community-based, educational intervention to assess the impact of peer education in increasing contraceptive knowledge among women in Fondwa, Haiti. Research investigators conducted contraceptive information trainings to pre-identified female leaders of existing women’s groups in Fondwa, who were recruited as peer educators (n=4). Later, these female leaders shared the knowledge from the training with the test participants in the women’s group (n=23) through an information session. Structured surveys measuring knowledge of contraceptives were conducted with all participants before the intervention began, at the end of the intervention, and four weeks after the intervention. The surveys measured general contraceptive knowledge, knowledge about eight selected types of modern contraceptives and contraceptive preferences and attitudes. Only test participants showed significant improvement in their general contraceptive knowledge score (p<0.001), but both test participants and peer educators showed significant improvement in overall knowledge scores for identifying the types and uses of modern contraceptive methods. Assessment for knowledge retention remained significantly higher four weeks after the intervention than prior to the intervention. Therefore, a one-time, three-hour peer-based educational intervention using existing social structures is effective, and might be valuable in a population with minimal access to education and little to no knowledge about contraceptives.

At this moment in human history, there is almost a one hundred percent chance that the readers of this dissertation have detectable levels of per- and polyfluoroalkyl substances (PFAS) in their bodies. Their “nonstick” and long-lasting properties have made PFAS attractive for widescale use in industries and commercial products. Large scale manufacturing applications combined with lack of regulatory efforts have led to ubiquitous human exposure for almost eight decades. Whereas the United States (U.S.) Environmental Protection Agency (EPA) estimates that at least 600 PFAS are in commercial use in the U.S. today, much of the existing toxicological research focuses on two “legacy” PFAS, perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA). It is well established that human exposure to PFOS and PFOA can lead to numerous adverse health outcomes, including liver and immune toxicity, thyroid disease, kidney and testicular cancers, cardiovascular disease, and reproductive and developmental effects like maternal hypertensive disorders, increased risk of miscarriage, and fetal growth restriction. Unfortunately, very little is known about the toxicity of “replacement” PFAS, including perfluorobutane sulfonic acid (PFBS), which is increasingly detected in the environment and within humans. Another troubling gap in the scientific literature is lack of understanding regarding the toxicity of PFAS mixtures, considering human exposure to PFAS does not occur in isolation. Concerningly, much of the available research has focused on toxicity of individual PFAS although humans are exposed to mixtures of PFAS in their daily lives. These deficiencies understanding the scope and mechanisms of human toxicity to alternative PFAS and PFAS mixtures poses challenges for adequate risk assessment to protect public health. This dissertation aims to improve knowledge regarding how maternal exposure to an understudied PFAS and to a PFAS mixture impacts maternal and fetal health. These endpoints are of specific interest because PFAS have been associated with adverse maternal and fetal health outcomes, including endocrine disruption, preeclampsia, preterm birth, and fetal growth restriction. Since it is widely accepted that dysregulated placentation underlies a number of adverse pregnancy outcomes for mother and offspring, the hypothesis of this dissertation is that exposure to replacement PFAS and environmental PFAS mixtures pose significant risks to maternal and fetal health during pregnancy through their effects on the development and function of the placenta. Effects of PFBS are described in chapters 2 – 4, whereas effects of an environmental PFAS mixture are described in chapter 5 – 6. In chapter 2, the transcriptomic effects of PFBS exposure are investigated on three placental trophoblastic cell types. RNA sequencing (RNA-seq) was performed on PFBS-dosed extravillous trophoblast (EVT), cytotrophoblast (CTB), and syncytiotrophoblast (STB) cells using two cellular models. Investigation of EVTs used the immortalized HTR8/SVneo line, while CTBs and STBs were examined using a novel human trophoblastic stem cell line. RNA-seq identified 75 significantly dysregulated genes in PFBS-dosed EVTs, 16 genes of which are associated with placentation and preeclampsia pathogenesis. RNA-seq identified 14 significantly dysregulated genes in PFBS-dosed STBs, in which one gene is involved in angiogenesis and has been implicated in preeclampsia pathogenesis, and five genes are involved with mitochondrial function. Interestingly, no significantly dysregulated genes were detected in PFBS-dosed CTBs. Overall, these experiments identified dysregulated expression of genes involved with cell-specific functions in both EVTs and STBs, presenting a mechanistic link between PFBS exposure, dysregulated placentation, and development of pregnancy complications like preeclampsia. While chapter two presents in vitro evidence that PFBS can disrupt placentation, chapters 3 and 4 describe the effects of PFBS exposure on maternal and fetal health, respectively, using an in vivo model of pregnancy. This approach involved a New Zealand White rabbit (Oryctolagus cuniculus) model of pregnancy, which was selected for study due to rabbit hemodynamics resembling humans during pregnancy and the structural similarities between human and rabbit placentas. Additionally, this model provided the ability to obtain blood pressure measurements and multiple biological fluid and tissue collections, in amounts sufficient for multiple assays. Dams were exposed to control, PFBS-low dose, or PFBS-high dose drinking water. One week after drinking water exposure began, dams were bred, and pregnancy confirmed via ultrasound on gestational day (GD) 15. On GD 25, dams were sacrificed, and maternal and fetal organs were evaluated and measured. Maternal health effects, investigated in chapter 3, included maternal blood pressure, weights and measures, histopathology, clinical chemistry panels, and thyroid hormone levels. At the high dose of PFBS exposure, dams exhibited significant changes in pulse pressure and renal resistive index measure, calculated from blood pressure measurements, which is suggestive of changes in arterial structure and kidney function that may result in hypertension and renal diseases. Adverse structural changes in kidney histopathology provided additional evidence of kidney toxicity from PFBS exposure. Fetal health and placental effects are described in chapter 4, which includes fetal viability, body weights and measures, histopathology, placental weight and morphology, and placental RNA sequencing. Significant changes in fetal crown-rump distance were detected in fetuses from dams receiving the high PFBS dose. Utilization of a mixed model statistical approach identified a significant interaction term between PFBS high dose and fetal sex when evaluating placental weight, suggesting a sex-specific effect on placental weight with PFBS exposure. Additionally, the fetal body weight: placental weight ratio was decreased in the PFBS high group and had a significant sex by exposure interaction term. As this measure is a common proxy for placental insufficiency, PFBS exposure may decrease placental functions that play an important role in achieving optimal fetal development. Together, these two observations demonstrate that PFBS can alter clinically relevant fetoplacental endpoints, some of which are sex-specific. Further investigation of the placenta via RNA sequencing identified one significantly dysregulated gene, AGT, in PFBS high dose placentas as compared to controls. AGT is well-characterized for its role in placentation and preeclampsia. Overall, chapters 3 and 4 present data demonstrating significant maternal and fetal outcomes, respectively, from maternal PFBS exposure in an in vivo experimental model of pregnancy. The results presented in these chapters support the hypothesis that PFBS exposure during gestation leads to adverse health outcomes, seen through maternal effects, like renal injury and hypertension, and fetal effects, like decreased growth parameters and adverse placenta function. Over the course of our lives, including those of pregnant women, PFBS exposure does not occur in isolation. Thus, chapters 5 and 6 investigate the effects of exposure to an environmentally relevant PFAS mixture. The mixture was formulated to mimic the levels of PFAS measured in the tap water of a central North Carolina community (Pittsboro, NC). This mixture includes PFBS along with nine other PFAS. The same rabbit model of pregnancy used for the work presented in chapters 3 and 4 was used to investigate maternal and fetal health outcomes from gestational exposure to this PFAS mixture. Maternal endpoints investigated in chapter 5 revealed significant increased body weight, increased kidney and liver weights, adverse kidney histopathology, and a marker of kidney dysfunction in the clinical chemistry panel in PFAS-exposed dams. Although increased blood pressure and dysregulated thyroid hormone levels observed in the PFAS-exposed group did not reach statistical significance, trends observed with these outcomes require consideration and further investigation in both future in vivo and human population studies. Chapter 6 describes adverse placental outcomes, but no observed adverse fetal health endpoints, resulting from maternal exposure to the environmentally relevant PFAS mixture. Statistical analysis via a mixed model detected a significant interaction term between PFAS exposure and sex when evaluating body weight: placental weight ratio, suggesting that female placental efficiency is disrupted by exposure to a PFAS mixture. Interestingly, a significantly higher number of placentas with abnormal gross morphology were observed in PFAS exposed dams as compared to controls, with a higher incidence in females than males in the PFAS exposed group. Finally, RNA sequencing identified 14 differentially expressed genes between control and PFAS-exposed placenta samples, nine of which have an established functional relevance to pregnancy outcomes. Overall, chapters 5 and 6 support the hypothesis that maternal exposure to an environmentally relevant mixture of PFAS leads to adverse effects on maternal and placental outcomes, although fetal effects were not detected using the measures employed. In summary, this dissertation provides fundamental evidence that PFBS and an environmentally relevant PFAS mixture can elicit adverse health outcomes on both maternal and fetal health. Many of these outcomes may be underlaid by a dysregulated placenta, but other avenues of toxicity were made apparent, including renal injury and hypertension. This research adds to the emergent literature that replacement PFAS and mixtures pose a significant concern for maternal and fetal health.