Pregnancy Care Utilization, Experiences, and Outcomes Among Undocumented Immigrants in the United States: A Scoping Review

BACKGROUND

Undocumented immigrants face many barriers in accessing pregnancy care, including language differences, implicit and explicit bias, limited or no insurance coverage, and fear about accessing services. With the national spotlight on maternal health inequities, the current literature on undocumented immigrants during pregnancy requires synthesis.

OBJECTIVE

We aimed to describe the literature on pregnancy care utilization, experiences, and outcomes of undocumented individuals in the United States.

METHODS

We performed a scoping review of original research studies in the United States that described the undocumented population specifically and examined pregnancy care utilization, experiences, and outcomes. Studies underwent title, abstract, and full-text review by two investigators. Data were extracted and synthesized using descriptive statistics and content analysis.

RESULTS

A total of 5,940 articles were retrieved and 3,949 remained after de-duplication. After two investigators screened and reviewed the articles, 29 studies met inclusion criteria. The definition of undocumented individuals varied widely across studies. Of the 29 articles, 24 showed that undocumented status and anti-immigrant policies and rhetoric are associated with decreased care utilization and worse pregnancy outcomes, while inclusive health care and immigration policies are associated with increased prenatal and postnatal care utilization as well as improved pregnancy outcomes.

CONCLUSIONS

The small, heterogeneous literature on undocumented immigrants and pregnancy care is fraught with inconsistent definitions, precluding comparisons across studies. Despite areas in need of further research, the signal among published studies is that undocumented individuals experience variable access to pregnancy care, heightened fear and stress regarding their status during pregnancy, and worse outcomes compared with other groups, including documented immigrants.

Cultural brokering in pregnancy care: A critical review

People who speak languages other than English face structural barriers in accessing the US healthcare system. With a growing number of people living in countries other than their countries of birth, the impact of language and cultural differences between patients and care teams on quality care is global. Cultural brokering presents a unique opportunity to enhance communication and trust between patients and clinicians from different cultural backgrounds during pregnancy care-a critical window for engaging families in the healthcare system. This critical review aims to synthesize literature describing cultural brokering in pregnancy care. We searched keywords relating to cultural brokering, pregnancy, and language in PubMed, Embase, and CINAHL and traced references of screened articles. Our search identified 33 articles. We found that cultural brokering is not clearly defined in the current literature. Few of the articles provided information about language concordance between cultural brokers and patients or clinicians. No article described the impact of cultural brokering on health outcomes. Facilitators of cultural brokering included: interprofessional collaboration within the care team, feeling a family connection between the cultural broker and patients, and cultivating trust between the cultural broker and clinicians. Barriers to cultural brokering included: misunderstanding the responsibilities, difficulty maintaining personal boundaries, and limited availability and accessibility of cultural brokers. We propose cultural brokering as interactions that cover four key aims: (1) language support; (2) bridging cultural differences; (3) social support and advocacy; and (4) navigation of the healthcare system. Clinicians, researchers, and policymakers should develop consistent language around cultural brokering in pregnancy care and examine the impact of cultural brokers on health outcomes.

Addressing Racial/Ethnic Inequities in Maternal Health Through Community-Based Social Support Services: A Mixed Methods Study

Introduction

In the US, there are striking inequities in maternal health outcomes between racial and ethnic groups. Community-based organizations (CBOs) provide social support services that are critical in addressing the needs of clients of color during and after pregnancy.

Methods

We conducted a descriptive, cross-sectional mixed methods study of CBOs in Greater Boston that provide social support services to pregnant and postpartum clients. In May–August 2020, we administered an online survey about organizational characteristics, client population, and services offered. In July–August 2020, we conducted semi-structured interviews focused on services provided, gaps in services, and the impact of structural racism on clients. We used descriptive statistics to characterize CBOs and services and used thematic analysis to extract themes from the qualitative data.

Results

A total of 21 unique CBOs participated with 17 CBOs completing the survey and 14 participating in interviews. CBOs served between 10 and 35,000 pregnant and postpartum clients per year (median = 200), and about half (n = 8) focused their programming on pregnant and postpartum clients. The most significant gaps in social support services were housing and childcare. Respondents identified racism and lack of coordination among organizations as the two primary barriers to accessing social support.

Discussion

CBOs face multiple challenges to providing social support to pregnant and postpartum clients of color, and significant gaps exist in the types of services currently provided. Improved coordination among CBOs and advocacy efforts to develop community-informed solutions are needed to reduce barriers to social support.

Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study

BACKGROUND

Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority.

OBJECTIVE

To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection.

METHODS

We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact.

RESULTS

Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs.

CONCLUSION

Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings.

METHODS

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

RESULTS

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

CONCLUSION

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Lateral condyle fracture of the femur complicated by lateral patellar luxation in two dogs

Two cases of lateral condyle fracture of the femur associated with lateral patellar luxation in the dog are described in this paper. Lateral condyle fractures are rare and difficult to diagnose. If the fracture is not opportunely reduced, the instability of the stifle can cause lateral patellar luxation and severe degenerative joint disease.

Associations between past bullying experiences and psychosocial and academic functioning among college students

OBJECTIVES

This study examined whether childhood bullying victimization was associated with psychosocial and academic functioning at college.

PARTICIPANTS

The sample consisted of 413 first-year students from a large northeastern university.

METHODS

Students completed an online survey in February 2012 that included items assessing past bullying involvement, current psychosocial and academic functioning, and victimization experiences since arriving at college.

RESULTS

Regression analyses indicated that reports of past bullying and other peer victimization were associated with lower mental health functioning and perceptions of physical and mental health, but were not associated with perceptions of social life at college, overall college experience, or academic performance.

CONCLUSIONS

Childhood bullying victimization is associated with poorer mental and physical health among first-year college students. Colleges should consider assessing histories of bullying victimization, along with other past victimization exposures, in their service provision to students.

Carbohydrate changes in pre- and peri-implantation mouse embryos as detected by a monoclonal antibody

We have examined the tissue and embryonic distribution of an antigen on a large polysaccharide that is recognized by a monoclonal antibody, IIC3, prepared against F9 teratocarcinoma cells. By immunofluorescence the antigen is first detected on compacted morulae and early blastocysts. It is strongly expressed on the primary endoderm and trophoblast of expanded blastocysts, but then disappears from the trophoblast of attached blastocysts in vitro. The binding of the antibody is completely inhibited by D-galactose and N-acetylgalactosamine. Fluoresceinated lectins were used to study further the changes in cell surface carbohydrates on trophoblast during implantation. Ricinus I, specific for terminal galactose, binds to preimplantation stages but does not bind to the trophoblast of the attached blastocyst. On the other hand, wheat germ agglutinin, specific for N-acetylglucosamine and sialic acid, binds to all preimplantation embryos and also to attached blastocysts (embryo proper and trophoblast). Neuraminidase treatment of blastocyst outgrowths enhances binding of both IIC3 and Ricinus I to the trophoblast; conversely, the binding of wheat germ agglutinin is decreased by this treatment. The results obtained in this study show changes of cell surface carbohydrates during early mouse development and suggest that sialic acid may be masking molecules on the surface of the trophoblast at the time of implantation.

Reexpression of a T/t-complex antigen (t12) in thymocyte x embryonal carcinoma cell hybrids

Hybrids between PCC4 aza 1 teratocarcinoma cells and thymocytes from an adult +/t12 mouse are phenotypically embryonal carcinoma cells. They express the t 12 antigen and do not express detectable H-2 antigens. Normally t12 is only expressed early in development and on male germ cells. Thus, the thymocyte genome is reprogramed such that adult thymocyte H-2 antigen is turned off but the thymocyte genome participates in the embryonal cell phenotype by reexpressing an embryonic antigen long silent in the adult. The expression of the t12 embryonic antigen represents the first example of the activation of a gene in somatic cell hybrids that is expressed only temporally in development.