Browsing by Subject "Obstetrics"

Background: Prolonged and obstructed labor is a leading cause of maternal mortality and morbidity in low resource settings. To prevent prolonged labor, the Uganda Ministry of Health (MOH) recommends using the partograph to monitor mothers in labor. Published literature has reported low rates of partograph use in Uganda, as well as improved partograph use after training. This study aimed to evaluate the effectiveness of LifeNet International’s (LN) partograph training in rural health clinics in Maska, Uganda. Additionally, the study sought to identify factors potentially related to partograph use, and thus to inform future implementations to increase partograph use in these low-resource settings.

Methods: LifeNet works with rural clinics in Uganda by providing training and management strategies to improve healthcare quality for mothers during delivery. In 2017, LifeNet began collaborating with the Duke Global Health Institute (DGHI) to evaluate LN’s impacts in six clinics in Masaka District, Uganda. As part of this evaluation project, this study is evaluating the impact of LN partograph training using direct observation, medical chart data, and facility-level data collected by LN. Additionally, semi-structured interviews were conducted by a DGHI researcher. The pre-training data were collected from May 15th to July 17th, 2017 and post-training from August 23rd, 2017 to January 29th, 2018 for this study. Follow-up direct observation data are scheduled to be collected from May 21st to July 26th, 2018. Quantitative data were analyzed using Stata version 14.2. Interview transcripts were reviewed for themes of health providers’ partograph knowledge and challenges of partograph use in practices.

Results: Before the LN partograph training, an estimated 19.8% of deliveries (42 of 212 observed) in study clinics were monitored with a partograph. A diagonal line drawn on the partograph helps the clinician to recognize possible labor complications (i.e. the action line). Sixteen (38.1%) of those that used partographs reached the action lines, among which five (31.2%) had actions under taken. In the first month after the LN partograph training, partograph use increased to 46.8% and was sustained for the remainder of the observation period. The proportion of partograph use did not change over time after the training (prevalence risk ratio, PRR=1.00, 95%CI: 1.00-1.00). Among all partographs reviewed after the training (n=594), health providers gave two interventions to manage abnormal labors. Mean duration of labor and proportion of prolonged labor did not change over time (risk ratio, RR=1.00, p = 0.561; RR=1.00, p=0.757, respectively). However, mean duration of labor was significantly higher among deliveries in which a partograph was used, compared to deliveries in which no partograph was used (RR=4.39, p<0.001). Furthermore, the proportion of deliveries with prolonged labor was higher in the partograph use group compared with the group that did not use the partograph, but the difference was not statistically significant (RR=5.97, p=0.072).

Based on the interviews with clinical providers in these clinics, there seems to be some education in use of the partograph in their schooling; however, there remained some misunderstanding about partograph use and interpretation. Health providers indicated that lack of accessibility to blank partographs in clinics, heavy workload, and lack of periotic check were challenges in using partographs to monitor labor.

Conclusions: Partograph use increased following the LN training and was sustained for at least five months afterwards. This type of clinical training program may be effective in improving maternal healthcare quality in Last Mile health facilities in resource-poor settings, like Masaka, Uganda.

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.

This dissertation explores the simultaneous trends towards increasing and decreasing medical intervention in childbirth. Using the medicalization literature as a theoretical framework, I use a mixed-methods approach to explore how both the medical community and laypeople think about and plan for childbirth.

First, the midwifery and obstetrics literatures from the past 35 years are reviewed to provide a medical and scientific context for the trends seen in childbirth over this time period. Second, descriptive and logistic regression analyses of the Center for Disease Control's Natality dataset, a census of U.S. birth certificate data, provide a picture childbirth trends and an understanding of the relationship between maternal characteristics and medicalized and natural births. Third, 35 qualitative interviews were conducted with pregnant women, focusing on their plans for their children's birth. The interviews also address the factors that influence women's plans and choices for childbirth, thus providing a better understanding of the social factors that affect birth plans.

The key finding of this research is that most women would prefer to be able to have the "best of both worlds" - the ability to experience childbirth as a natural process for as long as is safe and comfortable, combined with immediate access to the medical skills and technology that can assist them and their babies in an emergency.

The quantitative analyses demonstrate that alternatives to a mainstream model of childbirth are on the rise, even while these alternatives continue to represent only a small fraction of births. The increase in midwifery use while rates of hospital births remain relatively consistent suggests that many midwife-attended births are taking place in hospitals. These data support the finding that women like the idea of a natural birth, but also want to have ready access to trained doctors, surgeons, and the best medical care available in case something goes wrong.

There can be no doubt that childbirth, on the whole, had become a highly medicalized process. However, despite the fact that women want childbirth to be recognized as a natural process, there is no true movement for the demedicalization of childbirth. That is, women are not suggesting that medical intervention be removed entirely from childbirth. Instead, there need to be more options available to women, thus enabling them to give birth in a way that is comfortable and respectful of their preferences and goals, while simultaneously maintaining ready access to additional intervention, should it be necessary.

Implications for future research in childbirth and other fields of study are discussed.

Abstract

Background: While highly preventable cervical cancer remains a leading cause of

cancer in women globally. Sub-Saharan Africa is disproportionately affected, and in

Kenya specifically, over 4,800 new cervical cancer cases are diagnosed and over 2,000

deaths occur each year. While screening for human papillomavirus (HPV) is a more

cost-effective screening strategy with the potential to increase screening uptake, there is

substantial lost to follow-up (LTFU) for treatment following a positive HPV screen. This

study aimed to identify the predictors of successful treatment acquisition and explore

the barriers and facilitators to seeking treatment among HPV positive women.

Methods: This mixed-methods study was integrated into an ongoing clusterrandomized

trial of implementation strategies in rural western Kenya. This study

randomly selected 100 HPV positive women from the original study database and

conducted a treatment acquisition behavior survey. The study sought a 50/50 ratio of

women who were treated and LTFU, but obtained data from 61 treated women and 39

LTFU women. A subset of 10 women in each group were then selected for in-depth

interviews. Analysis included descriptive statistics to compare treated and LTFU

women’s responses to the survey questionnaire. Interview transcripts were coded and

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analyzed through code-by-code comparisons of women who were treated and women

who were LTFU.

Results: Cost of transportation and distance to the health facility were the most

common challenges in seeking treatment among both treated and LTFU women. Among

women who sought treatment, 67% (n=41) reported that their peers knew their HPV test

result, whereas among LTFU women only 38% (n=15) reported that their peers knew

their HPV test result (p=0.007). There was a significant difference in knowing their peers’

HPV result between treated and LTFU women (p=0.03). Partner support was described

by treated and LTFU women similarly, in that most women reported that they relied on

their partners for transportation money, and that men not understanding the disease

may prevent them from supporting their wives in seeking treatment. Additional barriers

included fear of the treatment process, stigma within their community, logistical

barriers, and lack of information on the disease and treatment. Facilitators to treatment

seeking included peer encouragement, support and encouragement of their children,

involving men in educational sessions, bringing facilities closer and providing

transportation to the health facility.

Conclusions: Cost of transportation, distance to the treatment facility, support of

partners and children, feelings of fear and stress, stigma within the community and

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logistical barriers were reported similarly across treated and LTFU groups. The greatest

disparity between the two groups was a lack of social support among LTFU women.

Given the potential impact of involving men and women in the community in

educational sessions, and promoting treatment seeking in groups, interventions that use

these treatment facilitators are needed.

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.