Adeline Boatin

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

Abstract Objective To provide an update on economic related inequalities in caesarean section rates within countries. Design Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. Setting 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time. Participants Women aged 15-49 years with a live birth during the two or three years preceding the survey. Main outcome measures Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change. Results National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries. Conclusions Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.

Wireless Fetal Heart Rate Monitoring in Inpatient Full-Term Pregnant Women: Testing Functionality and Acceptability

We tested functionality and acceptability of a wireless fetal monitoring prototype technology in pregnant women in an inpatient labor unit in the United States. Women with full-term singleton pregnancies and no evidence of active labor were asked to wear the prototype technology for 30 minutes. We assessed functionality by evaluating the ability to successfully monitor the fetal heartbeat for 30 minutes, transmit this data to Cloud storage and view the data on a web portal. Three obstetricians also rated fetal cardiotocographs on ease of readability. We assessed acceptability by administering closed and open-ended questions on perceived utility and likeability to pregnant women and clinicians interacting with the prototype technology. Thirty-two women were enrolled, 28 of whom (87.5%) successfully completed 30 minutes of fetal monitoring including transmission of cardiotocographs to the web portal. Four sessions though completed, were not successfully uploaded to the Cloud storage. Six non-study clinicians interacted with the prototype technology. The primary technical problem observed was a delay in data transmission between the prototype and the web portal, which ranged from 2 to 209 minutes. Delays were ascribed to Wi-Fi connectivity problems. Recorded cardiotocographs received a mean score of 4.2/5 (± 1.0) on ease of readability with an interclass correlation of 0.81(95%CI 0.45, 0.96). Both pregnant women and clinicians found the prototype technology likable (81.3% and 66.7% respectively), useful (96.9% and 66.7% respectively), and would either use it again or recommend its use to another pregnant woman (77.4% and 66.7% respectively). In this pilot study we found that this wireless fetal monitoring prototype technology has potential for use in a United States inpatient setting but would benefit from some technology changes. We found it to be acceptable to both pregnant women and clinicians. Further research is needed to assess feasibility of using this technology in busy inpatient settings.

Teaching by Teleconference: A Model for Distance Medical Education across Two Continents

Introduction In Uganda, an estimated 120 obstetrician/gynecologists serve a population of 30 million people demonstrating the need to train additional skilled clinician leaders in reproductive health. In 2012, a partnership was formed with the Mbarara Regional Referral Hospital (MRRH) in southwest Uganda and the Massachusetts General Hospital (MGH) in Boston, USA, in part to increase access to specialist training. This report presents an update in the development of a teaching conference between the institutions. Methods In June 2012, a didactic teleconference between the institutions was instituted. Various conferencing tools were tried: direct telephone connection, Ventrilo™ conferencing system and Skype™ via personal computer or smart phone. In Mbarara, Internet was accessed via cellular data. In Boston, Internet was accessed via hospital network or cellular data. All lectures were HIPAA compliant. PowerPoint lectures were stored in a collective Dropbox™ that could be accessed and downloaded prior to lecture dates. Results Over 30 months, 30 lectures were given. Lecturers included faculty and fellows from maternal fetal medicine, gynecology oncology, urogynecology, family planning, psychiatry and obstetric anesthesia. A patient case pertinent to the teaching topic framed the discussion. About 20 participants attended each lecture. Internet connectivity was the biggest challenge. Ultimately audio Skype via cellular data proved the most successful modality and became the method of choice. Conclusion A successful collaboration in medical education via teleconference is sustainable, low cost, and beneficial to both resource-rich and resource-poor institutions. Expertise can be shared bilaterally and internationally by individuals potentially unable travel.

Antimicrobial-resistant infections among postpartum women at a Ugandan referral hospital

Introduction Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. Methods We performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care, measured vital signs after delivery, performed structured physical exam, symptom questionnaire, and microbiologic evaluation of febrile and hypothermic women. Malaria rapid diagnostic testing, blood and urine cultures were performed aseptically and processed at Epicentre Mbarara Research Centre. Antimicrobial susceptibility and breakpoints were determined using disk diffusion per EUCAST standards. Hospital diagnoses, treatments and outcomes were abstracted from patient charts. Results Mean age was 25 years, 12% were HIV-infected, and 50% had cesarean deliveries. Approximately 5% (205/4176) with ≥1 temperature measurement recorded developed postpartum fever or hypothermia; blood and urine samples were collected from 174 (85%), and 17 others were evaluated clinically. Eighty-four (48%) had at least one confirmed source of infection: 39% (76/193) clinical postpartum endometritis, 14% (25/174) urinary tract infection (UTI), 3% (5/174) bloodstream infection. Another 3% (5/174) had malaria. Overall, 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated. Of 25 Gram-negatives isolated, 20 (80%) were multidrug-resistant and cefepime non-susceptible. Conclusions For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. Increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.

Audit and feedback using the Robson classification to reduce caesarean section rates: a systematic review

In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.

Stage of labor at admission among Ugandan women with a prior cesarean, and its impact on management and delivery outcomes

To describe stage of labor at admission among women with a prior cesarean, and examine its impact on intrapartum management and delivery mode.

Risk Factors for Vaginal Colonization and Relationship between Bacterial Vaginal Colonization and In-Hospital Outcomes in Women with Obstructed Labor in a Ugandan Regional Referral Hospital

Introduction The proportion of women with severe maternal morbidity from obstructed labor is between 2 and 12% in resource-limited settings. Maternal vaginal colonization with group B streptococcus (GBS), Escherichia coli, and Enterococcus spp. is associated with maternal and neonatal morbidity. It is unknown if vaginal colonization with these organisms in obstructed labor women is associated with poor outcomes. Objectives To determine whether vaginal colonization with GBS, E. coli, or Enterococcus is associated with increased morbidity among women with obstructed labor and to determine the risk factors for colonization and antibiotic susceptibility patterns. Methods We screened all women presenting in labor to Ugandas Mbarara Regional Referral Hospital maternity ward from April to October 2015 for obstructed labor. Those meeting criteria had vaginal swabs collected prior to Cesarean delivery and surgical antibiotic prophylaxis. Swabs were inoculated onto sterile media for routine bacterial culture and antimicrobial susceptibility testing. Results Overall, 2,168 women were screened and 276 (13%) women met criteria for obstructed labor. Vaginal swabs were collected from 272 women (99%), and 170 (64%) were colonized with a potential pathogen: 49% with E. coli, 5% with GBS, and 8% with Enterococcus. There was no difference in maternal and fetal clinical outcomes between those colonized and not colonized. The number of hours in labor was a significant independent risk factor for vaginal colonization (aOR 1.02, 95% CI 1.00–1.03, P=0.04). Overall, 38% of GBS was resistant to penicillin; 61% of E. coli was resistant to ampicillin, 4% to gentamicin, and 5% to ceftriaxone and cefepime. All enterococci were ampicillin and vancomycin susceptible. Conclusion There was no difference in maternal or neonatal morbidity between women with vaginal colonization with E. coli, GBS, and Enterococcus and those who were not colonized. Duration of labor was associated with increased risk of vaginal colonization in women with obstructed labor.

Dysfunctional labor: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data

http://dx.doi.org/10.1016/j.vaccine.2017.01.050 0264-410X/ 2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ⇑ Corresponding author. E-mail addresses: adeline_boatin@mgh.harvard.edu (A.A. Boatin), contact@ brightoncollaboration.org. 1 Present address: University of Washington, Seattle, USA. 2 Brighton Collaboration home page: http://www.brightoncollaboration.org. Adeline A. Boatin a,⇑, Linda O. Eckert , Michel Boulvain , Chad Grotegut , Barbra M. Fisher , Jay King , Marie Berg , Richard M.K. Adanu , Uma Reddy , Jason J.S. Waugh , Manish Gupta , Sonali Kochhar , Sara Kenyon, The Brighton Collaboration Dysfunctional Labor Working Group 2

The Role of Minimally Invasive Gynecologic Surgery in Sub Saharan Africa

Purpose of ReviewMinimally invasive gynecologic surgery (MIGS) is now firmly established in developed countries where there has been a trend away from traditional open surgery towards laparoscopy given proven benefits of faster recovery time and better cosmesis for patients. However, this same trend has not been observed in regions like sub Saharan Africa (SSA) where resources are limited. Lack of human and material resources, need for technological support, and challenges with training have been postulated as major limitations for wide spread introduction and expansion of MIGS in SSA. Nonetheless, a few institutions in sub Saharan Africa have been able to surmount these challenges to develop MIGS in SSA. This paper reviews the current state of minimally invasive surgery in sub Saharan Africa. We review the role and benefits of expanding minimally invasive surgery in sub Saharan Africa with a focus on management of gynecologic conditions. Finally, we review the challenges associated with MIGS in SSA and provide recommendations on the way forward.Recent FindingsThere are several published studies on the successful development of minimally invasive surgery in sub -Saharan Africa with similar benefits of shorter hospital stay, quicker recovery, and better cosmesis for patients. These studies also report the challenges with human and material resources and training.SummaryThere is a large role and need for expansion of minimally invasive surgery in sub Saharan Africa. The challenges of lack of resources, personnel, and training can be surmountable through ingenuity, modeling based on experiences from other low to middle income countries and commitment to the advancement of MIGS for the benefit of women’s health globally.