Preserving and advocating for essential care for women during the coronavirus disease 2019 pandemic

Reproductive justice advocacy efforts among genetic counselors and family planning providers

Throughout all areas of medical practice, genetic counselors (GCs) occupy a key position in promoting patients' personal autonomy while facilitating informed medical decision-making. This professional position aligns with the concept of reproductive justice. Previous literature has attempted to define reproductive advocacy in medicine as well as the potential intersection of genetic counseling and reproductive justice advocacy work, yet limited data exist regarding GCs' perceptions of their role and involvement in reproductive justice advocacy work. This study aimed to identify the perceptions and actions of GCs regarding reproductive justice advocacy measures, as well as explore motivating factors influencing their attitudes and behaviors. Family planning providers, who tend to prioritize reproductive justice and advocacy, were surveyed to be a comparison group. We distributed an anonymous online survey within the National Society of Genetic Counselors (NSGC) and the Society of Family Planning (SFP) consisting of a 10-item personality inventory and Likert scale questions exploring characteristics and behaviors regarding reproductive justice advocacy. Results from 252 eligible respondents were analyzed using descriptive statistics, Chi-square, and Mann-Whitney U analyses. NSGC members are significantly less involved in several areas of reproductive justice advocacy, including regular participation in advocacy efforts when compared to SFP members (p = 0.04). The most cited barrier to NSGC members' participation was feeling unsure how to become involved, a significant difference compared to SFP members (p = 0.01). Findings from this study, undertaken in the final days of Roe v. Wade, suggest that GCs want to be more involved in reproductive justice advocacy but are uncertain where to begin. Intersociety collaboration and intra-society promotion of grassroots reproductive justice efforts may reduce this perceived barrier and others like it.

Surgical abortion service reorganization in response to the COVID-19 pandemic: a unique experience of attending second trimester D&E procedures under spinal anesthesia as emergency procedures

Background

The COVID-19 pandemic created a massive shift in how health care systems interact with COVID testing for patients. To avoid delay in accessing second trimester surgical abortion at our hospital (St. Paul's Hospital Millennium Medical College) during this pandemic, dilation and evacuation (D&E) procedures were attended as emergency cases, instead of as elective surgical procedures, which then required adherence to the universal preoperative COVID-19 testing protocol. This study aimed at documenting the experience of this unique abortion service adjustment in response to the COVID-19 pandemic.

Methods

This was a retrospective descriptive study conducted at St. Paul's Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia, from April 1, 2021 to July 31, 2021. We reviewed second trimester surgical abortion cases managed with D& E procedures, performed under spinal anesthesia using the emergency COVID-19 pre-operative testing protocol. Data were analyzed using SPSS version 23 and simple descriptive statistics were applied. Percentages and proportions were used to present the results.

Results

Nineteen cases of second trimester D&E cases were reviewed. The median gestational age of the abortion clients was 21.57 weeks. Eight of 19 cases had cervical preparation with overnight intra-cervical Foley catheter placement while the rest 11 (57.9%) cases had their cervical preparation with Laminaria. The median time interval from initial evaluation of the abortion client to time of doing D& E procedure was 21.83 h.

Conclusion

Surgical abortion service reorganization enabled abortion clients to access dilation and evacuation procedures within 24 h of their initial presentation. This prevented significant delays in accessing abortion care that could otherwise have occurred as a result of adhering to the preoperative COVID-19 testing protocols applied to elective surgeries.

Contraceptive services in Oregon's state-funded network during the COVID-19 pandemic

OBJECTIVES

To understand how changes to in-person health care during the COVID pandemic impacted contraceptive use in Oregon's state-funded network.

STUDY DESIGN

A retrospective cohort of 245,600 visits (virtual and in-person) among 70,295 women presenting to publicly funded family planning clinics in Oregon between January 2019 and June 2021. Data were abstracted from clinic records and restricted to visits of patients identifying as female, 12-51 years old, not using sterilization as a method. Contraception was grouped by effectiveness Tier (Tier 1: intrauterine device, implants; Tier 2: progestin injectable, pill/patch/ring). Multivariable logistic regression predicted the use of contraception by stage of the COVID pandemic which corresponded to service availability (prepandemic, acute: nonemergency services halted, subacute: restricted services), patient demographics, including insurance type, and clinic and geospatial characteristics.

RESULTS

Overall during the acute stage, people with visits were more likely to leave with a method of contraception odds ratios (OR) 1.39 (95% confidence interval [CI] 1.24-1.57); however, it was significantly less likely to be a Tier 1 method (OR 0.82, 95% CI 0.74-0.91) as compared to prepandemic. This finding was particularly marked in rural areas (OR 0.69 [96% CI 0.58-0.83]) and among the publicly insured (OR 0.87 [95% CI 0.80-0.94]).

CONCLUSIONS

Demand for contraception increased during the acute phase of the COVID pandemic, and shifts in method mix from Tier 1 to Tier 2 methods occurred. Disparities in contraceptive access persisted for those in rural locations or with public insurance.

IMPLICATIONS

Lessons learned from the COVID-19 pandemic are critical to informing our future emergency response. The need for family planning services increased during the public health emergency.

Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine

OBJECTIVE

Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine.

METHODS

We used the Maine Health Data Organization's All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020-September 2020, April 2020-March 2021) as compared with the reference period (October 2015-March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs.

RESULTS

The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated.

CONCLUSION

Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.

Terrorist Attacks against Health Care Targets that Provide Abortion Services

INTRODUCTION

Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020.

METHODS

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics.

RESULTS

In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage.

CONCLUSION

Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.

The impact of COVID-19 lockdown on abortion care: a time series analysis of data from Marie Stopes Nepal

The COVID-19 pandemic significantly impacted sexual and reproductive health and rights. Nepal implemented a nationwide lockdown in March 2020, limiting population movement and service access. The 36 clinics run by Marie Stopes Nepal (MSN) closed for varying periods at the beginning of lockdown. This study assesses the impact of lockdown and associated clinic closures on abortion services within MSN's network. An interrupted time-series analysis of clinic-level MSN data compared abortion service use in the pre-closure and post-reopening periods, focusing on the following outcomes: number of abortion care visits, proportion of abortion-related visits, gestational age at time of abortion care and demographics of patients accessing abortion care. Subsequent meta-analyses combined clinic-level results to generate outcome-specific pooled effect estimates. As MSN clinics reopened, during ongoing wider lockdown, weekly visits for abortion care decreased by 37% on average, but abortion increased as a proportion of services post-reopening (OR: 1.53) compared with pre-closure, with no evidence of a change in the proportion of higher gestation abortions. The demographic profile of abortion care clients was altered, with post-reopening clients more likely to have completed primary education (OR: 1.54) and be aged 25 years or older (OR: 1.31) compared with pre-closure clients. COVID-19 lockdown and associated clinic closures reduced the absolute number of abortion services provided within MSN's network, impacting the composition of service provision. Reductions in safe abortion and wider SRH access will have wide-ranging consequences, curtailing crucial reproductive rights. Policy-makers must ensure ongoing abortion access to protect rights and ensure access.

Competing health risks associated with the COVID-19 pandemic and early response: A scoping review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1st to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

The association between the COVID-19 pandemic and postpartum care provision

BACKGROUND

The COVID-19 pandemic led to a rapid transformation in the healthcare system to mitigate viral exposure. In the perinatal context, one change included altering the prenatal visit cadence and increasing the utilization of telehealth methods. Whether this approach had inadvertent negative implications for postpartum care, including postpartum depression screening and contraceptive utilization, is unknown.

OBJECTIVE

This study aimed to examine whether preventative health service utilization, including postpartum depression screening and contraceptive utilization, differed during the COVID-19 pandemic when compared with the prepandemic period.

STUDY DESIGN

This retrospective cohort study included all pregnant patients who received prenatal care at 1 of 5 academic obstetrical practices and who delivered at Northwestern Memorial Hospital either before (delivery from September 1, 2018, to January 1, 2019) or during (delivery from February 1, 2020, to May 15, 2020) the COVID-19 pandemic. Completion of postpartum depression screening was assessed by reviewing standardized fields in the documentation associated with the screening in the electronic health record system. The method of contraception used was ascertained from the postpartum clinical documentation. Patients were classified as initiating long-acting reversible contraception use if they received NEXPLANON (etonogestrel implant) or an intrauterine device during the hospitalization for delivery or within 3 months following delivery. Bivariable and multivariable analyses were performed.

RESULTS

Of the 2375 pregnant patients included in this study, 1120 (47%) delivered during the COVID-19 pandemic. Pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to have undergone postpartum depression screening (45.5% vs 86.2%; P<.01); this association persisted after adjusting for potential confounders (adjusted odds ratio, 0.13; 95% confidence interval, 0.11–0.16). Pregnant patients who delivered during the COVID-19 pandemic also were significantly less likely to initiate long-acting reversible contraception use within 3 months of delivery (13.5% vs 19.6%; adjusted odds ratio, 0.67; 95% confidence interval, 0.53–0.84).

CONCLUSION

The onset of the COVID-19 pandemic was associated with a decrease in the completion of postpartum depression screenings and fewer patients initiating long-acting reversible contraception use overall. These results can inform adaptations in healthcare delivery in the midst of the ongoing COVID-19 pandemic.

Addressing long-acting reversible contraception access, bias, and coercion: supporting adolescent and young adult reproductive autonomy

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare.

RECENT FINDINGS

Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services.

SUMMARY

Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.

Impact of COVID-19 Pandemic on the Clinical Activities in Obstetrics and Gynecology: A National Survey in China

Objective: Few studies have quantified the influence of coronavirus disease 2019 (COVID-19) pandemic on medical providers. This is the first national study to investigate the impact of the pandemic on physicians practicing obstetrics and gynecology in China.

Methods: A two-stage, stratified, cluster sampling method was performed based on the city categories (category 1, fewer than 10,000 beds; category 2, 10,000–30,000; and category 3, more than 30,000) and public hospital levels (primary, secondary, and tertiary). Physicians practicing obstetrics and gynecology reported the relevant changes in their general clinical activities and changes in the management of specific diseases or conditions occurring during the periods that they were most strongly affected. These changes were compared by municipal and hospital characteristics.

Results: Questionnaires were collected from a representative sample of 11,806 physicians actively practicing obstetrics and gynecology in 779 hospitals from 157 cities of 31 provinces. Except emergency visits and online consultations, category 3 cities, tertiary hospitals and general hospitals had greater reductions in overall clinical activities than category 1 cities, primary hospitals and specialized hospitals (all adjusted p < 0.05), respectively. The differences also existed in the management of specific diseases and conditions, especially for less urgent conditions, including cervical cancer screening, instructions regarding contraception and miscarriage, and assisted reproduction (all p < 0.05).

Conclusions: During the COVID-19 pandemic, the clinical obstetrics and gynecology activities in China markedly decreased, with significant differences across municipal and hospital characteristics.

Trial Registration: This study was registered with ClinicalTrials.gov on July 27, 2020 (NCT04491201).

Abortion and the COVID-19 pandemic: insights for Latin America

The COVID-19 pandemic may accentuate existing problems, hindering access to legal abortion, with a consequent increase in unsafe abortions. This scenario may be even worse in low- and middle-income countries, especially in Latin America, where abortion laws are already restrictive and access to services is already hampered. Our objective was to understand how different countries, with an emphasis on Latin Americans, have dealt with legal abortion services in the context of the COVID-19. Thus, we conducted a narrative review on abortion and COVID-19. The 75 articles included, plus other relevant references, indicate that the pandemic affects sexual and reproductive health services by amplifying existing problems and restricting access to reproductive rights, such as legal abortion. This impact may be even stronger in low- and middle-income countries, especially in Latin America, where access to legal abortion is normally restricted. The revision of sources in this article underlines the urgent need to maintain legal abortion services, both from women's perspective, in support of their reproductive rights, but also from that of the international commitment to achieving the Millennium Development Goals. Thereby, Latin American countries must place reproductive rights as a priority on their agendas and adapt legislation to accommodate alternative models of abortion care. Furthermore, our results underscore the need for clear information on the functioning of sexual and reproductive health services as essential for understanding the impact of the pandemic on legal abortion and to identify the groups most affected by the changes.

Exploring the Impact of Restricted Partners' Visiting Policies on Non-Infected Mothers' Mental Health and Breastfeeding Rates during the COVID-19 Pandemic

Changes in perinatal care occurring during the coronavirus disease 2019 (COVID-19) pandemic may negatively affect mothers' mental health and breastfeeding. This study, performed between April and May 2020, aimed to investigate the effect of restricted partners' visiting policies on non-infected mother's anxiety symptoms, the perceived postpartum support, and the breastfeeding outcomes at discharge. A cross-sectional study was conducted in a neonatal tertiary referral center in northern Italy during Italy's lockdown. We enrolled mothers with a negative nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), adequate oral and written comprehension of the Italian language, and absence of underlying maternal or neonatal clinical conditions. Maternal anxiety levels were assessed through the State-Trait Anxiety Inventory-Form Y (STAI-Y). Maternal perception of staff's support was evaluated by the Nurse Parent Support Tool (NPST). A STATE-A (concurrent emotional state after a specific situation) score ≥ 40 was considered indicative of clinically significant symptoms of anxiety. A total of 109 mothers completed the study. Mean STATE-A score was ≥40 in 42% of mothers, and median NPST score was 4.23. Mothers separated from their partner had a mean STATE-A score ≥ 40 in a higher percentage of cases than those who were not (51% vs. 30%, p = 0.03) and a lower perception of caregiver support. A NPST score ≤4.23, partner 's absence during the hospital stay and primiparity were independently associated with a STATE-A score ≥ 40. Breastfeeding rates at discharge were not influenced by maternal anxiety levels and partner's restricted policies. Instead, they were influenced by mode of delivery, a well-known risk factor, and pre-pandemic intention to breastfeed. Our study demonstrates the positive impact of a partner's presence on maternal mental health and perception of caregiver support.

The impact of COVID-19 on abortion access: Insights from the European Union and the United Kingdom

Government policies on abortion are a longstanding topic of heated political debates. The COVID-19 pandemic shook health systems to the core adding further to the complexity of this topic, as imposed national lockdowns and movement restrictions affected access to timely abortion for millions of women across the globe. In this paper, we examine how countries within the European Union and the United Kingdom responded to challenges brought by the COVID-19 crisis in terms of access to abortion. By combining information from various sources, we have explored different responses according to two dimensions: changes in policy and protocols, and reported difficulties in access. Our analysis shows significant differences across the observed regions and salient debates around abortion. While some countries made efforts to maintain and facilitate abortion care during the pandemic through the introduction or expansion of use of telemedicine and early medical abortion, others attempted to restrict it further. The situation was also diverse in the countries where governments did not change policies or protocols. Based on our data analysis, we provide a framework that can help policy makers improve abortion access.

Outcomes for 298 breastfed neonates whose mothers received ketamine and diazepam for postpartum tubal ligation in a resource-limited setting

Background

Anesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established.

Methods

Medical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy.

Results

Of 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13–3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11–3.13, p = 0.017).

Conclusions

In resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.