Caring for Muslim Patients: A Primer for the Obstetrician Gynecologist

Studies show that Muslim American patients experience discrimination and feel uncomfortable seeking appropriate health care for various reasons. Obstetrician-gynecologists should be educated regarding Islamic perspectives on topics such as modesty, sexual health, contraception, abortion, infertility, and fasting during pregnancy. Understanding the barriers Muslim patients face and improving cultural humility will improve the quality of sexual and reproductive care delivered to Muslim patients.

Ramadan Fasting and Pregnancy: An Evidence-Based Guide for the Obstetrician

Pregnant Muslim women may be religiously exempt from fasting during the Islamic month of Ramadan, especially if there is concern for undue hardship or harm to maternal or fetal health. However, several studies demonstrate that most women still choose to fast during pregnancy and avoid discussing fasting with their providers. A targeted literature review of published studies on fasting during Ramadan and pregnancy/maternal and fetal outcomes was performed. We generally found little to no clinically significant effect of fasting on neonatal birthweight or preterm delivery. Conflicting data exist on fasting and mode of delivery. Fasting during Ramadan has been mainly associated with signs and symptoms of maternal fatigue and dehydration, with a minimal decrease in weight gain. There is conflicting data regarding the association with gestational diabetes mellitus and insufficient data on maternal hypertension. Fasting may affect some antenatal fetal testing indices-including non-stress tests, lower amniotic fluid levels, and lower biophysical profile scores. Current literature on the long-term effects of fasting on offspring suggests possible adverse effects, but more data is required. The quality of evidence was negatively impacted by the variation in defining "fasting during Ramadan" in pregnancy; study size and design; and potential confounders. Therefore, in counseling patients, obstetricians should be prepared to discuss the nuances in the existing data while demonstrating cultural and religious awareness and sensitivity to foster a trusting relationship between patient and provider. We provide a framework for obstetricians and other prenatal care providers to aid in that effort and supplemental materials to encourage patients to seek clinical advice on fasting. Providers should engage patients in a shared decision-making process and offer them a nuanced a review of the evidence (including limitations) and individualized recommendations based on clinical experience and patient history. Finally, should certain patients choose to fast while pregnant, providers should offer medical recommendations, closer observation, and support to reduce harm and hardship while fasting.

Perspectives of women of refugee background on healthcare needs in a major urban metropolitan community in the US: A qualitative needs assessment

The objective of this study was to describe the healthcare needs and experiences of women of refugee background in Chicago-home to one of the largest and most diverse refugee populations in the United States. We used a phenomenological study design with a desire-centered rather than damage-centered approach to conduct a series of focus group discussions with 24 women of refugee background in their native languages in Chicago, Illinois between December 2018 and February 2019. Convenience sampling was used to recruit women of refugee background at least 18 years of age living in the Chicago metropolitan area who attended educational women's health workshops at local refugee community centers. An inductive approach to the analysis was used to code transcripts and generate themes. Our study identified four major healthcare priorities for women of refugee background in a major metropolitan area: (1) central and centralised healthcare, (2) continuity of care, (3) trauma-informed care and (4) community engagement and partnerships. The healthcare priorities identified by the participants in this study should inform existing and future healthcare models and clinics providing care for women of refugee background in urban and sub-urban contexts across the United States.

Female Genital Cutting: An Evidence-based Review for the OBGYN of Long-term Sequelae and Management Options

Female genital cutting (FGC) is a persisting global practice that increases patients' risk for experiencing long-term health sequelae. Existing meta-analysis evidence strongly supports an association between FGC and the development of long-term dyspareunia, urinary tract infections, and sexual dysfunction as well as increased risk obstetrically of prolonged labor, cesarean section, perineal lacerations, and episiotomy. Surgical defibulation is recommended in patients with type III FGC to decrease obstetric and gynecologic morbidity. Existing evidence does not seem to definitively support clitoral reconstructive surgery. More research is needed to study conservative treatment and management approaches to long-term sequelae of FGC.

Perspectives on induced abortion among Palestinian women: religion, culture and access in the occupied Palestinian territories

Induced abortion is an important public health issue in the occupied Palestinian territories (OPT), where it is illegal in most cases. This study was designed to elicit the views of Palestinian women on induced abortion given the unique religious, ethical and social challenges in the OPT. Sixty Palestinian women were interviewed on their perceptions of the religious implications, social consequences and accessibility of induced abortions in the OPT at Al-Makassed Islamic Charitable Hospital in East Jerusalem. Themes arising from the interviews included: the centrality of religion in affecting women's choices and views on abortion; the importance of community norms in regulating perspectives on elective abortion; and the impact of the unique medico-legal situation of the OPT on access to abortion under occupation. Limitations to safe abortion access included: legal restrictions; significant social consequences from the discovery of an abortion by one's community or family; and different levels of access to abortion depending on whether a woman lived in East Jerusalem, the West Bank, or Gaza. This knowledge should be incorporated to work towards a legal and medical framework in Palestine that would allow for safe abortions for women in need.

Attitudes of Palestinian medical students on the geopolitical barriers to accessing hospitals for clinical training: a qualitative study

Background

The movement of Palestinians in the occupied Palestinian territories is restricted by bureaucratic and physical obstacles. To date, no studies have examined the barriers that Palestinian medical students face in accessing hospitals for clinical training. The objectives of this study were to characterize these barriers and understand how they affect Palestinian students’ medical education and quality of life.

Methods

Convenience sampling was used to recruit 4th-6th year medical students from Al-Quds University to participate in focus group discussions. A total of 36 students participated in the discussions. Transcripts of the discussions were coded to identify major themes.

Results

Palestinian medical students expressed facing numerous challenges during their clinical training. Students emphasized the difficulties of obtaining permits to train at Jerusalem hospitals, including arbitrary permit rejections and long wait times. Significant delays, searches, and mistreatment at checkpoints during their commute to hospitals were particularly burdensome. The majority of students who participated in the focus groups felt that their education and quality of life had been strongly negatively affected by their experience trying to access hospital training sites.

Conclusions

Our findings suggest that medical students living and studying in the occupied Palestinian territories receive sub-optimal training due to ambiguous permit rules, barriers at checkpoints, and the psychological burden of the process. These results highlight the impact that military occupation has on the education and quality of life of Palestinian medical students in a setting in which there is regular violence and many health indicators are already poor.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-016-0067-8) contains supplementary material, which is available to authorized users.

A comparative study of outcomes for endoscopic diverticulotomy versus external diverticulectomy

OBJECTIVES

Current literature on the treatment of Zenker's diverticulum (ZD) favors the use of various endoscopic procedures over external surgical techniques for patients, arguing that endoscopic approaches reduce intraoperative time and anesthesia, length of hospital stay, and days until oral diet is restarted. However, such techniques often have higher symptomatic recurrence rates and require further interventions. Because of our experience with both endoscopic diverticulotomy (ENDO) and external diverticulectomy (EXT) using the GIA-stapler, we sought to compare these 2 procedures in terms of in-hospital parameters, complications, return to normal diet, and rates of symptom recurrence.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary care hospital.

SUBJECTS

Patients with Zenker's diverticulum who underwent surgical repair.

METHODS

Retrospective analysis of 67 patients seen at Brigham and Women's Hospital between 1990 and 2012 with Zenker's diverticulum who underwent either an endoscopic Zenker's procedure (36) or an external stapler-assisted diverticulectomy with cricopharyngeal myotomy (31).

RESULTS

Although the external stapler-assisted procedure for ZD does carry a longer intraoperative time and a slightly longer hospital stay than the endoscopic approach, it provides similar days until initiation of an oral diet and a similar incidence of postoperative complications. Further, it is superior to the endoscopic approach when one considers its much lower rate of symptomatic recurrence and need for revision procedures.

CONCLUSION

We argue that the external stapler-assisted diverticulectomy with cricopharyngeal myotomy should be considered as a viable treatment in patients who need definitive, single-session treatment for ZD, especially to prevent life-threatening aspiration pneumonia.

A pathway to insulin independence in newborns and infants with diabetes

Permanent neonatal diabetes was previously assumed to require insulin injection or infusion for life. Recently, permanent neonatal diabetes resulting from mutations in the two protein subunits of the adenosine triphosphate-sensitive potassium channel (Kir6.2 and SUR1) has proven to be successfully treatable with high doses of sulfonylureas rather than insulin. Many patients with these mutations first develop hyperglycemia in the nursery or intensive care unit. The awareness of the neonatolgist of this entity can have dramatic effects on the long-term care and quality of life of these patients and their families. In this study, we present the experience of our center, highlighting aspects relevant to neonatal diagnosis and treatment.