CNN-Based LCD Transcription of Blood Pressure From a Mobile Phone Camera

Routine blood pressure (BP) measurement in pregnancy is commonly performed using automated oscillometric devices. Since no wireless oscillometric BP device has been validated in preeclamptic populations, a simple approach for capturing readings from such devices is needed, especially in low-resource settings where transmission of BP data from the field to central locations is an important mechanism for triage. To this end, a total of 8192 BP readings were captured from the Liquid Crystal Display (LCD) screen of a standard Omron M7 self-inflating BP cuff using a cellphone camera. A cohort of 49 lay midwives captured these data from 1697 pregnant women carrying singletons between 6 weeks and 40 weeks gestational age in rural Guatemala during routine screening. Images exhibited a wide variability in their appearance due to variations in orientation and parallax; environmental factors such as lighting, shadows; and image acquisition factors such as motion blur and problems with focus. Images were independently labeled for readability and quality by three annotators (BP range: 34–203 mm Hg) and disagreements were resolved. Methods to preprocess and automatically segment the LCD images into diastolic BP, systolic BP and heart rate using a contour-based technique were developed. A deep convolutional neural network was then trained to convert the LCD images into numerical values using a multi-digit recognition approach. On readable low- and high-quality images, this proposed approach achieved a 91% classification accuracy and mean absolute error of 3.19 mm Hg for systolic BP and 91% accuracy and mean absolute error of 0.94 mm Hg for diastolic BP. These error values are within the FDA guidelines for BP monitoring when poor quality images are excluded. The performance of the proposed approach was shown to be greatly superior to state-of-the-art open-source tools (Tesseract and the Google Vision API). The algorithm was developed such that it could be deployed on a phone and work without connectivity to a network.

Working with lay midwives to improve the detection of neonatal complications in rural Guatemala

BackgroundGlobally most neonatal deaths occur within the first week of life and in low-income and middle-income countries. Strengthening health system linkages for frontline providers—such as lay midwives providing home-based obstetrical care—may improve neonatal outcomes in these settings. Here, we conducted a quality improvement study to increase the detection of neonatal complications by lay midwives in rural Guatemala, thereby increasing referrals to a higher level of care.MethodsA quality improvement team in Guatemala reviewed drivers of neonatal health services provided by lay midwives. Improvement interventions included training on neonatal warning signs, optimised mobile health technology to standardise assessments and financial incentives for providers. The primary quality outcome was the rate of neonatal referral to a higher level of care.ResultsFrom September 2017 to September 2018, participating midwives attended 869 home deliveries and referred 80 neonates to a higher level of care. A proportion control chart, using the preintervention period from January to September 2017 as the baseline, showed an increase in the referral rate of all births from 1.5% to 9.9%. Special cause was obtained in January 2018 and sustained except for May 2018. The proportion of neonates receiving assessments by midwives in the first week of life increased to >90%. A trend toward an increasing number of days between neonatal deaths did not attain special cause.ConclusionsStructured improvement interventions, including mobile health decision support and financial incentives, significantly increased the detection of neonatal complications and referral of neonates to higher levels of care by lay midwives operating in rural home-based settings in Guatemala. The results show the value of improving the integration of lay midwives and other first responders into neonatal systems of care in low-resource settings.

Senales de Peligo: Guatemalan Lay Midwives’ Perceptions of Responding to Obstetrical Complications

Introduction: The Guatemalan maternal mortality rate is among the highest in Latin Americans, and lay midwives (LMs) attend home births. The study’s purpose was to explore LMs’ knowledge of, attitudes toward, and practices regarding obstetrical complications and emergencies. Method: In the remote Peten region, a descriptive ethnographic study held focus group discussions before education programs to teach/boost LMs’ awareness about obstetrical complications. The long-table approach of analyses developed a matrix of common themes. Results: Nearly 200 LMs participated in 11 groups. Six themes emerged: LMs attribute their knowledge to God, recognize signs of obstetrical danger, want more training and equipment, encounter resistance from a patriarchal culture, feel fear and despair in addressing obstetrical complications/emergencies, and experience arduous logistics in emergency hospital transfers. Discussion: Contrary to published literature, LMs were able to verbalize basic knowledge of obstetrical complications. Information learned can guide future, action-research studies to address the maternal mortality rate in resource-poor settings.

Working with the State

Beyond their work as maternity care practitioners lay midwives fulfilled a crucial role in public health and this chapter describes their value as an extension of the state board of health. From their authoritative position in the community midwife clubs were extremely influential in organizing vaccination drives and education campaigns. The chapter discusses the state’s reliance on midwives to gather vital statistics, and the importance and consequences of submitting a birth certificate after each delivery.

Changing Childbirth Customs

The shift towards macro-centered maternity care was not merely about improved safety in childbirth, a more complex situation is unravelled in chapter 13. Hopes for progress and inclusion and equality of access stimulated black women’s agency for change and micro level childbirth customs were adjusted accordingly. The implementation of Medicaid solidified the shift leaving licensed lay midwives in the distant past, figuratively speaking.

Licensing and the “New Laws”

This chapter introduces the supervision and licensing of lay midwives implemented with the passage of the Sheppard-Towner Maternity and Infancy Protection Act in 1921. It details the ways in which the midwives adapted to the increasing local, state and federal public health mandates, and how they interacted with county health officers, nurses, and physicians. Dr. Felix J. Underwood of the Mississippi State Board of Health was an early pioneer of midwifery supervision and his development of midwife club meetings and the midwife manual are used in this chapter to illustrate the state and county initiatives to improve maternal health.

Lay Midwives “Retire”

The elimination of midwifery was finally achieved when many states across the South passed legislation prohibiting lay midwifery practice. Chapter 14 uses the personal experience of lay midwives to explore various methods employed by state boards of health to control the activity of midwives and enforce retirement. As the evidence shows, the economic marketplace of childbirth became a factor in some physicians’ interactions with lay midwives; for others commitment and mutual respect rescinded state legislation for a while. For some lay midwives their duty to serve eclipsed any legal restriction.