Discrete glucose profiles identified using continuous glucose monitoring data and their association with adverse pregnancy outcomes

BACKGROUND

Continuous glucose monitoring has facilitated the evaluation of dynamic changes in glucose throughout the day and their effect on fetal growth abnormalities in pregnancy. However, studies of multiple continuous glucose monitoring metrics combined and their association with other adverse pregnancy outcomes are limited.

OBJECTIVE

This study aimed to (1) use machine learning techniques to identify discrete glucose profiles based on weekly continuous glucose monitoring metrics in pregnant individuals with pregestational diabetes mellitus and (2) investigate their association with adverse pregnancy outcomes.

STUDY DESIGN

This study analyzed data from a retrospective cohort study of pregnant patients with type 1 or 2 diabetes mellitus who used Dexcom G6 continuous glucose monitoring and delivered a nonanomalous, singleton pregnancy at a tertiary center between 2019 and 2023. Continuous glucose monitoring data were collapsed into 39 weekly glycemic measures related to centrality, spread, excursions, and circadian cycle patterns. Principal component analysis and k-means clustering were used to identify 4 discrete groups, and patients were assigned to the group that best represented their continuous glucose monitoring patterns during pregnancy. Finally, the association between glucose profile groups and outcomes (preterm birth, cesarean delivery, preeclampsia, large-for-gestational-age neonate, neonatal hypoglycemia, and neonatal intensive care unit admission) was estimated using multivariate logistic regression adjusted for diabetes mellitus type, maternal age, insurance, continuous glucose monitoring use before pregnancy, and parity.

RESULTS

Of 177 included patients, 90 (50.8%) had type 1 diabetes mellitus, and 85 (48.3%) had type 2 diabetes mellitus. This study identified 4 glucose profiles: (1) well controlled; (2) suboptimally controlled with high variability, fasting hypoglycemia, and daytime hyperglycemia; (3) suboptimally controlled with minimal circadian variation; and (4) poorly controlled with peak hyperglycemia overnight. Compared with the well-controlled profile, the suboptimally controlled profile with high variability had higher odds of a large-for-gestational-age neonate (adjusted odds ratio, 3.34; 95% confidence interval, 1.15-9.89). The suboptimally controlled with minimal circadian variation profile had higher odds of preterm birth (adjusted odds ratio, 2.59; 95% confidence interval, 1.10-6.24), cesarean delivery (adjusted odds ratio, 2.76; 95% confidence interval, 1.09-7.46), and neonatal intensive care unit admission (adjusted odds ratio, 4.08; 95% confidence interval, 1.58-11.40). The poorly controlled profile with peak hyperglycemia overnight had higher odds of preeclampsia (adjusted odds ratio, 2.54; 95% confidence interval, 1.02-6.52), large-for-gestational-age neonate (adjusted odds ratio, 3.72; 95% confidence interval, 1.37-10.4), neonatal hypoglycemia (adjusted odds ratio, 3.53; 95% confidence interval, 1.37-9.71), and neonatal intensive care unit admission (adjusted odds ratio, 3.15; 95% confidence interval, 1.20-9.09).

CONCLUSION

Discrete glucose profiles of pregnant individuals with pregestational diabetes mellitus were identified through joint consideration of multiple continuous glucose monitoring metrics. Prolonged exposure to maternal hyperglycemia may be associated with a higher risk of adverse pregnancy outcomes than suboptimal glycemic control characterized by high glucose variability and intermittent hyperglycemia.

Are populations of postpartum women differentially served by community health worker programs: an observational cohort study from Zanzibar, Tanzania

BACKGROUND

Although community health worker (CHW) programs focus on improving access to healthcare, some individuals may not receive the intended quality or quantity of an intervention. The objective of this research was to examine if certain populations of pregnant women differentially experience the implementation of a community health worker-led maternal health intervention in Zanzibar.

METHODS

We included pregnant women enrolled in the Safer Deliveries (Uzazi Salama) program, which operated in 10 of 11 districts in Zanzibar, Tanzania between January 1, 2017, and June 19, 2019 (N = 33,914). The outcomes of interest were receipt of the entire postpartum intervention (three CHW visits) and time to first postpartum CHW visit (days). Visits by CHWs were done at the women's home, however, a telehealth option existed for women who were unable to be reached in-person. We conducted statistical tests to investigate the bivariate associations between our outcomes and each demographic and health characteristic. We used multivariate logistic regression to estimate the relationships between covariates and the outcomes and multivariate linear regression to estimate the association between covariates and the average time until first postpartum visit.

RESULTS

Higher parity (OR = 0.85; P = 0.014; 95%CI: 0.75-0.97), unknown or unreported HIV status (OR = 0.64; p < 0.001; 95%CI: 0.53-0.78), and receipt of phone consultations (OR = 0.77; p < 0.001; 95%CI: 0.69-0.87) were associated with a lower odds of receiving all postpartum visits. Similarly, women with an unknown or unreported HIV status (estimated mean difference of 1.81 days; p < 0.001; 95%CI: 1.03-2.59) and those who received a phone consultation (estimated mean difference of 0.83 days; p < 0.001; 95%CI: 0.43-1.23), on average, experienced delays to first visit. In addition, current delivery at a referral hospital was associated with lower odds of receiving a postpartum visit and longer time to first visit compared to delivery at home, cottage hospital, PHCU + , or district hospital. Women from all other districts received their first visit earlier than women from Kaskazini B. There were no differences in the odds of receiving the entire postpartum intervention by sociodemographic variables, including age, education, and poverty assessment indicators.

CONCLUSION

The results indicate no differences in intervention contact across wealth and education levels, suggesting that the program is effectively reaching women regardless of SES. However, women with other characteristics (e.g., higher parity, unknown or unreported HIV status) had lower odds of receiving the complete intervention. Overall, this work generates knowledge on existing disparities in intervention coverage and enables future programs to develop approaches to achieve equity in health care utilization and outcomes.

hCG trends after mifepristone and misoprostol for undesired pregnancy of unknown location

OBJECTIVES

To describe human chorionic gonadotropin (hCG) trends for patients with a pregnancy of unknown location (PUL) presenting for medication abortion by management strategy and outcome.

STUDY DESIGN

This retrospective cohort study included patients presenting for medication abortion with a PUL at ≤42 days gestation managed with either (1) immediate mifepristone with serial hCG follow-up (same-day-start) or (2) hCG testing every 48 to 72 hours ± ultrasonography to confirm pregnancy location followed by treatment (delay-for-diagnosis). The primary outcome was percent hCG change over time between presentation and diagnosis, summarized using a multivariate regression model.

RESULTS

Of the 55 same-day-start patients, none were treated for ectopic. The eight who eventually required suction curettage had median hCG percent changes (interquartile range) on days 3, 4, and 5 of +57% (-14 to 127; n = 2), +292% (226-353; n = 4), and +392% (n = 1), while the 41 successful medication abortions had declines of -64% (n = 1), -65% (-75 to -27; n = 17), and -77% (-85 to -68; n = 13). Of the 380 delay-for-diagnosis patients, the 30 ectopic pregnancies had day 3, 4, and 5 changes of +38% (-17 to 56; n = 14), +50% (17-71; n = 7), and +115% (87-177; n = 4). None of the ectopic pregnancies declined ≥50% by days 3 to 5. The hCG trend for ectopic pregnancies differed from successful medication abortions (p < 0.01), but not medication abortions with retained intrauterine pregnancies (p = 0.41).

CONCLUSIONS

Serum hCG trends can help differentiate ectopic pregnancy from successful medication abortion, but cannot distinguish between ectopic and retained intrauterine pregnancy.

IMPLICATIONS

Serial serum hCG testing is effective for confirming successful medication abortion and identifying patients requiring further follow-up among patients undergoing medication abortion for an undesired PUL.

The impact of COVID-19 and national pandemic responses on health service utilisation in seven low- and middle-income countries

BACKGROUND

The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes.

OBJECTIVE

We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses.

METHODS

We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker.

RESULTS

For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: -5.1%, -1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning.

CONCLUSIONS

Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.

The Journey of Zanzibar's Digitally Enabled Community Health Program to National Scale: Implementation Report

BACKGROUND

While high-quality primary health care services can meet 80%-90% of health needs over a person's lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced, and managed community health worker programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation.

OBJECTIVE

In this implementation report, we describe the design and rollout of Zanzibar's national, digitally enabled community health program-Jamii ni Afya.

METHODS

Since 2010, D-tree International has partnered with the Ministry of Health Zanzibar to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community health workers use a mobile app that guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources, and continuous quality improvement.

RESULTS

The Zanzibar government has documented increases in the delivery of health facilities among pregnant women and reductions in stunting among children younger than 5 years since the community health program has scaled. Key success factors included starting with the health challenge and local context rather than the technology, usage of data for decision-making, and extensive collaboration with local and global partners and funders. Lessons learned include the significant time it takes to scale and institutionalize a digital health systems innovation due to the time to generate evidence, change opinions, and build capacity.

CONCLUSIONS

Jamii ni Afya represents one of the world's first examples of a nationally scaled digitally enabled community health program. This implementation report outlines key successes and lessons learned, which may have applicability to other governments and partners working to sustainably strengthen primary health systems.

Use of Abortion Services in Massachusetts After the Dobbs Decision Among In-State vs Out-of-State Residents

This cohort study compares observed vs expected abortion counts after Dobbs in Massachusetts among in-state vs out-of-state residents.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data

INTRODUCTION

The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda.

METHODS

We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time.

RESULTS

In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected.

CONCLUSION

Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Service delivery reform for maternal and newborn health in Kakamega County, Kenya: study protocol for a prospective impact evaluation and implementation science study

Background

Maternal and neonatal mortality remain elevated in low and middle income countries, and progress is slower than needed to achieve the Sustainable Development Goals. Existing strategies appear to be insufficient. One proposed alternative strategy, Service Delivery Redesign for Maternal and Neonatal Health (SDR), centers on strengthening higher level health facilities to provide rapid, definitive care in case of delivery and post-natal complications, and then promoting delivery in these hospitals, rather than in primary care facilities. However to date, SDR has not been piloted or evaluated.

Methods

We will use a prospective, non-randomized stepped-wedge design to evaluate the effectiveness and implementation of Service Delivery Redesign for Maternal and Neonatal Health in Kakamega County, Kenya.

Discussion

This protocol describes a hybrid effectiveness/implementation evaluation study with an adaptive design. The impact evaluation (“effectiveness”) study focuses on maternal and newborn health outcomes, and will be accompanied by an implementation evaluation focused on program reach, adoption, and fidelity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13578-y.

Caregiver parenting practices, dietary diversity knowledge, and association with early childhood development outcomes among children aged 18-29 months in Zanzibar, Tanzania: a cross-sectional survey

Background

Many children in low- and middle-income countries fail to reach their cognitive potential, with experiences before age 3 critical in shaping long-term development. Zanzibar’s Jamii ni Afya program is the first national, digitally enabled community health volunteer (CHV) program promoting early childhood development (ECD) following the Nurturing Care Framework within an integrated maternal and child healthcare package. Using program baseline data, we explored home environment, caregivers’ parenting, health and nutrition knowledge and practices, and ECD outcomes in Zanzibar.

Methods

We conducted a national household survey among 499 children aged 18-29 months using two-stage cluster sampling in February 2019. The primary outcome was child development score measured using the Caregiver Reported Early Developmental Index (CREDI), with higher scores representing higher levels of child development. We analyzed CREDI scores, along with MICS questions on parenting knowledge, practices, and characteristics of the home environment. We developed multivariate regression models to assess associations between caregiver-child interactions, knowledge of dietary diversity, and ECD.

Results

Ten percent of children had overall CREDI z-scores 2 standard deviations [SD] or more below the global reference population mean, with 28% of children at risk of developmental delay with z-scores 1 SD or more below the mean. Cognitive and language domains were of highest concern (10.2 and 12.7% with z-score < − 2 SD). In 3-day recall, 75% of children engaged in ≥4 early stimulating activities with all caregivers averaging 3 total hours of play. CREDI scores were positively associated with greater frequency of caregivers’ engagement (β = 0.036, p = 0.002, 95%CI = [0.014, 0.058]), and dietary diversity knowledge (β = 0.564, p < 0.001, 95%CI = [0.281, 0.846]).

Conclusions

Our findings demonstrate a positive association between both the frequency of caregiver child interactions and knowledge of adequate dietary diversity, and ECD outcomes. This aligns with global evidence that promoting early stimulation, play and learning opportunities, and dietary diversity can improve developmental outcomes. Further study is needed to establish causal relationships and assess the impact of ECD programming in Zanzibar.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13009-y.

Association of HIV infection and antiretroviral therapy with the occurrence of an unfavorable TB treatment outcome in a rural district hospital in Eastern Cape, South Africa: A retrospective cohort study

Background

Our objective was to assess differences in TB treatment outcomes between individuals who were HIV negative, HIV positive on anti-retroviral treatment (ART) and HIV positive not on ART, at TB treatment initiation at a rural district hospital in Eastern Cape, South Africa.

Methods

This was a retrospective cohort study of individuals diagnosed with TB between January 2017 and April 2020 at a district hospital. Adults 15 years and over with reported HIV status and treatment outcome were included (N = 711). A categorical outcome with three levels was considered: unfavorable, down referral, and success. We report descriptive statistics for the association between HIV and ART status and treatment outcome using Chi-square and Fisher’s exact tests. A multinomial baseline logit model was used to estimate odds ratios for treatment outcomes.

Results

Overall, 59% of included patients were HIV positive with 75% on ART. Eighty-eight patients 12% had an unfavorable outcome. Half of all patients were down referred with an additional 37% having a successful outcome. Individuals without HIV were more likely to be down referred (versus unfavorable) compared to individuals with untreated HIV (2.90 OR, 1.36, 6.17 95% CI). There was a greater likelihood for individuals without HIV having a successful TB treatment outcome compared to individuals with untreated HIV (4.98 OR, 2.07, 11.25 95% CI).

Conclusion

The majority of individuals had positive TB treatment outcomes (down referred or success). However, people without HIV had nearly five times greater odds of having successful outcomes than those with untreated HIV.

Syndromic surveillance with monthly aggregate health systems information data for COVID-19 pandemic response in Neno, Malawi: a monitoring study

Background

In the context of diminutive COVID-19 screening and testing, syndromic surveillance can be used to identify areas with higher-than-expected SARS-CoV-2 symptoms for targeted public health interventions. We used syndromic surveillance to monitor potential SARS-CoV-2 outbreaks in 14 health facilities in the Neno district of rural Malawi.

Methods

We monitored three indicators identified as potential symptoms of SARS-CoV-2 infection: the proportion of outpatient visits for fast-breathing cases in children under 5 years (FBC<5); the proportion of suspected malaria cases confirmed as non-malaria in children under 5 years (NMC<5); and the same indicator in individuals aged 5 years and older (NMC≥5). We extracted data aggregated by month and at the health facility-level from the District Health Information System. With data from January, 2016, to February, 2020, as a baseline, we used a linear model with a negative binomial distribution to estimate expected proportions for the indicators in absence of the COVID-19 pandemic with 95% prediction intervals (PI) for March, 2020, to July, 2021. We compared the observed proportions to the expected rates, focusing on the first two waves of infections (June to July, 2020, and January to March, 2021).

Findings

The proportion of FBC<5 was consistently higher than expected, with a peak in May, 2020, when 2·5% of outpatient visits were fast breathing cases in children younger than 5 years of age (compared with the expected rate of 0·8% [95% PI 0·4–1·5]). NMC<5 was as expected throughout the study period. The NMC≥5 indicator remained as expected, except for increases in suspected cases tested negative for malaria, to 31·3% (from the expected 18·6% [95% PI 12·3–28·7]) in November, 2020, and to 32·5% (from the expected 21·7% [95% PI 14·2–32·2]) in July, 2021.

Interpretation

An increase in FBC<5 and NMC≥5 before observed COVID-19 waves might indicate SARS-CoV-2 infections that were missed before robust testing. This tendency was not seen in NMC<5, which can represent differences in symptomatology leading to decreased health-seeking behaviours for this age group. Syndromic surveillance can allow for real-time responses at facilities, including increased and focused testing and screening to identify potential SARS-CoV-2 infections.

Funding

Supported by Canadian Institutes of Health Research.

674. Evaluation of the Access Bio CareStart™ Rapid SARS-CoV-2 Antigen Test in Asymptomatic Individuals Tested at a Community Mass-testing Program in Western Massachusetts

Background

Point-of-care antigen-detecting rapid diagnostic tests (RDTs) to detect Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) represent a scalable tool for surveillance of active SARS-CoV-2 infections in the population. Data on the performance of these tests in real-world community settings will be paramount for their implementation to combat the COVID-19 pandemic.

Methods

We evaluated the performance characteristics of the CareStartTM COVID-19 Antigen Test (CareStart) in a community testing site in Holyoke, Massachusetts. We compared CareStart to a SARS-CoV-2 reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) reference, both using anterior nasal swab samples. We calculated the sensitivity, specificity, and the expected positive and negative predictive values at different SARS-CoV-2 prevalence estimates.

Results

We performed 666 total tests on 591 unique individuals. 573 (86%) were asymptomatic. There were 52 positive tests by RT-qPCR. The sensitivity of CareStart was 49.0% (95% Confidence Interval (CI): 34.8 – 63.4) and specificity was 99.5% (95% CI: 98.5 – 99.9). Among positive RT-qPCR tests, the median cycle threshold (Ct) was significantly lower in samples that tested positive on CareStart. Using a Ct less than or equal to 30 as a benchmark for positivity increased the sensitivity of the test to 64.9% (95% CI: 47.5 – 79.8).

Conclusion

Our study shows that CareStart has a high specificity and moderate sensitivity. The utility of RDTs, such as CareStart, in mass implementation should prioritize use cases in which a higher specificity is more important, such as triage tests to rule-in active infections in community surveillance programs.

Disclosures

All Authors: No reported disclosures

396. Disparities in SARS-CoV-2 Antibody Prevalence: Findings from a Citywide Serosurvey in Holyoke, Massachusetts, November 2020–January 2021

Background

Seroprevalence studies are important tools to estimate the prevalence of prior or recent SARS-CoV-2 infections. This information is critical for identifying hotspots and high-risk groups and informing public health responses to the COVID-19 pandemic. We conducted a city-level seroprevalence study in Holyoke, Massachusetts to estimate the seroprevalence of SARS-CoV-2 antibodies and risk factors for seropositivity.

Methods

We invited inhabitants of 2,000 randomly sampled addresses to participate between November 5 and December 31, 2020. Participants completed questionnaires measuring sociodemographic and health characteristics, and COVID-19 exposure history, and provided dried blood spots for measurement of SARS-CoV-2 IgG and IgM antibodies. To calculate total and group seroprevalence estimates, inverse probability of response weights were constructed based on age, gender, race/ethnicity and census tract to ensure estimates represented the city’s population.

Results

We enrolled 280 households including 472 individuals. 328 underwent antibody testing. The citywide weighted seroprevalence of SARS-CoV-2 IgG or IgM was 13.9% (95%CI 7.8 - 21.8) compared to 9.8% based on publicly reported case counts. Seroprevalence was 16.8% (95%CI 5.7 – 28.0) among individuals identifying as Hispanic compared to 8.9% (95%CI 3.0 - 14.7) among those identifying as White. Seroprevalence was 20.7% (95%CI 2.2 – 39.2) for ages 0-19; 13.8% (95%CI 5.6 – 22) for ages 20 – 44; 9.6% (95%CI 0 – 20.5) for ages 45 – 59; 4.8% (95%CI 0 – 10.2) for ages 60 – 84; and 42.9% (95%CI 0 – 100) for ages &gt;85.

Table 1. Seroprevalence by antibody positivity profile

Conclusion

The measured SARS-CoV-2 seroprevalence in Holyoke was only 13.9% during the second surge of SARS-CoV-2 in this region, far from accepted thresholds for “herd immunity” and highlighting the need for expanding vaccination. Individuals identifying as Hispanic were at high risk of prior infection. Subsequent community-level serosurveys are necessary to guide local responses to the SARS-CoV-2 pandemic.

Disclosures

All Authors: No reported disclosures

Reliability and Discriminant Validity of a Checklist for Surgical Scrubbing, Gowning and Gloving

Background:

Surgical scrubbing, gowning, and gloving is challenging for medical trainees to learn in the operating room environment. Currently, there are few reliable or valid tools to evaluate a trainee’s ability to scrub, gown and glove. The objective of this study is to test the reliability and validity of a checklist that evaluates the technique of surgical scrubbing, gowning and gloving (SGG).

Methods:

This Institutional Review Board-approved study recruited medical students, residents, and fellows from an academic, tertiary care institution. Trainees were stratified based upon prior surgical experience as novices, intermediates, or experts. Participants were instructed to scrub, gown and glove in a staged operating room while being video-recorded. Two blinded raters scored the videos according to the SGG checklist. Reliability was assessed using the intraclass correlation coefficient for total scores and Cohen’s kappa for item completion. The internal consistency and discriminant validity of the SGG checklist were assessed using Cronbach alpha and the Wilcoxon rank sum test, respectively.

Results:

56 participants were recruited (18 novices, 19 intermediates, 19 experts). The intraclass correlation coefficient demonstrated excellent inter-rater reliability for the overall checklist (0.990), and the Cohen’s kappa ranged from 0.598 to 1.00. The checklist also had excellent internal consistency (Cronbach’s alpha 0.950). A significant difference in scores was observed between all groups (p < 0.001).

Conclusion:

This checklist demonstrates a high inter-rater reliability, discriminant validity, and internal consistency. It has the potential to enhance medical education curricula.

Errors in estimated gestational ages reduce the likelihood of health facility deliveries: results from an observational cohort study in Zanzibar

Background

Most maternal health programs in low- and middle- income countries estimate gestational age to provide appropriate antenatal care at the correct times throughout the pregnancy. Although various gestational dating methods have been validated in research studies, the performance of these methods has not been evaluated on a larger scale, such as within health systems. The objective of this research was to investigate the magnitude and impact of errors in estimated delivery dates on health facility delivery among women enrolled in a maternal health program in Zanzibar.

Methods

This study included 4225 women who were enrolled in the Safer Deliveries program and delivered before May 31, 2017. The exposure of interest was error in estimated delivery date categorized as: severe overestimate, when estimated delivery date (EDD) was 36 days or more after the actual delivery date (ADD); moderate overestimate, when EDD was 15 to 35 days after ADD; accurate, when EDD was 6 days before to 14 days after ADD; and underestimate, when EDD was 7 days or more before ADD. We used Chi-squared tests to identify factors associated with errors in estimated delivery dates. We performed logistic regression to assess the impact of errors in estimated delivery dates on health facility delivery adjusting for age, district of residence, HIV status, and occurrence of past home delivery.

Results

In our data, 28% of the estimated delivery dates were a severe overestimate, 23% moderate overestimate, 41% accurate, and 8% underestimate. Compared to women with an accurate delivery date, women with a moderate or severe overestimate were significantly less likely to deliver in a health facility (OR = 0.71, 95% CI: [0.59, 0.86]; OR = 0.74, 95% CI: [0.61, 0.91]). When adjusting for multiple confounders, women with moderate overestimates were significantly less likely to deliver in a health facility (AOR = 0.76, 95% CI: [0.61, 0.93]); the result moved slightly towards null for women with severe overestimates (AOR = 0.84, 95% CI: [0.69, 1.03]).

Conclusions

The overestimation of women’s EDDs reduces the likelihood of health facility delivery. To address this, maternal health programs should improve estimation of EDD or attempt to curb the effect of these errors within their programs.