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PUB 540 The Impact of Place on Maternal and Infant Health

PUB 540 The Impact of Place on Maternal and Infant Health

Read "The Environment That Racism Built: The Impact of Place on Maternal and Infant Health,"
by Frederick (2018), located on the Center for American Progress website.
https://www.americanprogress.org/issues/race/news/2018/05/10/450703/environment-racism-
built/

Stanford Scholars Examine Racism, Social Change and How to Build a More Just Future
Read "Stanford Scholars Examine Racism, Social Change and How to Build a More Just
Future," by De Witte, from Stanford News (2020), located on the Stanford University website.

Stanford scholars examine racism, social change and how to build a more just future

CITI Training Instructions

Page 7 Grand Canyon University

2022 ©

Prepared on: May 9,
2022
Refer to the "CITI Training Instructions" to register for and complete the CITI Training
assignment assigned in this topic.

Reducing Racial Inequities in Health: Using What We Already Know to Take Action
Read "Reducing Racial Inequities in Health: Using What We Already Know to Take Action," by
Williams and Cooper, from International Journal of Environmental Research and Public Health (2019).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6406315/

Public Health Code of Ethics
Read "Public Health Code of Ethics," by the American Public Health Association (APHA), located
on the APHA website.
https://www.apha.org/-/media/files/pdf/membergroups/ethics/code_of_ethics.ashx

Scraping the Web for Public Health Gains: Ethical Considerations From a Big Data Research
Project on HIV and Incarceration
Read "Scraping the Web for Public Health Gains: Ethical Considerations From a 'Big Data'
Research Project on HIV and Incarceration," by Rennie, Buchbinder, Juengst, Brinkley-
Rubinstein, Blue, and Rosen, from Public Health Ethics (2020).
https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?
direct=true&db=a9h&AN=144947375&site=ehost-
live&scope=site&custid=s8333196&groupid=main&profile=ehost

Naming Institutionalized Racism in the Public Health Literature: A Systematic Literature
Review
Read "Naming Institutionalized Racism in the Public Health Literature: A Systematic
Literature Review," by Hardeman, Murphy, Karbeah, and Kozhimannil, from Public Health Reports
(2018).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958385/

Over the past decade, in order to accelerate progress towards achieving MDGs 4 and 5, a number of countries in the SSA region have searched for innovative strategies to encourage women to seek care at health facilities and to increase facility-based deliveries [2021]. Abolition of user fees and financial incentives are some of the promising strategies. Evaluation research suggests that under certain conditions, these strategies can increase facility-based deliveries in SSA [2223]. However, the extent of reduction in maternal and perinatal mortality as a result of the increase in facility-based deliveries is not known.

Few studies report on the impact of place of delivery on maternal and perinatal mortality in SSA, probably reflecting the pragmatic and ethical difficulties of conducting such studies [24]. To date we are unaware of any randomized control trial (RCT), which would allow causal inference. An observational study in Nigeria has found no association between perinatal mortality and place of delivery [25]. Another study on neonatal mortality that pooled studies in low and middle income countries (LMIC) found that neonatal mortality was significantly lower for facility-based deliveries compared to home deliveries (RR 0.71, 95% CI: 0.54-0.87), but this did not include stillbirths or maternal outcomes [26]. Robust evidence on the relative effectiveness of place of delivery, using health outcome measures, is needed to inform policy formulation in SSA. This information may also make it possible to assess the comparative effectiveness of alternative interventions for reducing maternal and perinatal mortality.

The aim of this paper is to estimate from secondary data how maternal and perinatal mortality in SSA is affected by place of delivery. Mortality is chosen as a health outcome because it is relatively easy to measure and therefore likely to achieve valid results [27]. Additionally, unlike neonatal mortality that only takes live births into account, perinatal mortality also includes stillbirths making it a comprehensive and suitable indicator for assessing outcomes of both intrapartum and immediate post partum care services [28].

Methods

Literature search

Using a predefined protocol, we carried out a systematic search of the literature following guidelines for meta-analysis of observational studies in Epidemiology (MOOSE) [29] and preferred reporting items for systematic reviews and meta-analysis (PRISMA) (see Additional file 1). The search was conducted between January and August 2013. A physician with support of a librarian conducted the search. Medical and social science databases and journal libraries included, but were not limited to, PubMed, EBSCO Host, Web of Science, ScienceDirect, Wiley, Cochran library and Google Scholar. We searched for studies conducted in SSA, involving pregnant women and reporting on risk of maternal and perinatal mortality/death by place of birth or delivery. Reference lists of selected publications were assessed in order to identify other potential papers of interest.

The key words used were “Maternal mortality”, “Maternal deaths”, “Perinatal mortality”, “Perinatal deaths”, risk, “Place of birth/delivery”, study, Africa and “sub-Saharan Africa”. In the selected publications, the following definitions were used. Maternal deaths were defined as all direct and indirect obstetric deaths during pregnancy, delivery, and the first 42 days after birth. Perinatal deaths were defined as pregnancy losses occurring after seven completed months of gestation (stillbirths), or deaths within the first seven days of delivery of a live born child (early neonatal deaths) weighing 1000 grams or more. Place of delivery was either facility-based (defined as birth or delivery in a formal health facility whether or not attended by a skilled medical attendant) or home (defined as birth or delivery outside of a formal health facility whether or not attended by a skilled traditional birth attendant). Studies reporting on perinatal mortality were considered eligible if they reported on pregnancy outcomes from 7 complete months until 7 days after birth. Studies reporting on maternal mortality were eligible if they reported on maternal deaths as soon as pregnancy was identified until 42 days after birth. In addition the studies had to be written in English and published between 1990 and 2013.

Data quality and extraction

Each study was subjected to a quality review using a modified Newcastle-Ottawa scale for cohort studies [30]. Key quality items assessed included representativeness of the population, population characteristics such as gestation age at enrollment and duration of pregnancy follow up, information about study design (population based cohort vs. demographic and health surveillance), ascertainment of exposure and proportion of home deliveries, and use of standard definitions for main outcome measures and denominators used (e.g. births, live births). We also extracted information that may have affected the outcomes such as frequency of data collection, proportion of refusals, loss to follow up and sample sizes.

We noted general study information (e.g. year of study publication and authors) and the primary health outcomes for the study: maternal and perinatal mortality ratio by place of delivery. As the outcomes of interest are ratios, we extracted information on relevant numerators and denominators that would enable independent calculations of these ratios. In cases where an appropriate denominator was not provided (e.g. number of live births at home), but the numerator and corresponding appropriate ratio was given, we estimated the denominator by simple proportion. We precluded studies that aimed to ascertain risk of a particular exposure (e.g. HIV infection or severe anaemia in pregnancy) or an intervention (e.g. Prevention of mother to child transmission of HIV) on perinatal/maternal mortality, with insufficient (<25%) assignment of outcomes of interest to place of delivery and where reported data could not completely fill a 2 × 2 table. Where possible, we contacted some authors either to confirm information or provide extra details. Two individuals independently extracted the information and resolved disparities by consensus.

Statistical analysis

Study quality was scored in two categories: high if more than 60% of the quality items were reported and low otherwise. For both primary health outcomes of interest, we estimated the crude odds ratio (OR) by place of delivery in each study and then calculated the weighted average of the OR across the studies using meta analytic procedures [31]. The OR from each study can be combined using a variety of analytical methods, which are classified as: a) fixed effect models which weight studies according to the amount of information they contain; or b) random-effects models, which incorporate an estimate of between-study variation in the weighting [3233]. We assessed study heterogeneity using I2 statistic, which measures the percentage of variation in OR attributable to heterogeneity between studies. The fixed effects model was used when I2 was low < 50% [34] otherwise we used random-effects model to calculate individual study OR and corresponding 95% confidence intervals (95% CI) and to pool the results across the studies.

The potential effect of place of delivery on maternal and perinatal mortality was estimated by attributable risk percentage reduction, defined as the portion of the incidence of an outcome in the exposed that is due to the exposure: [(Ie-Iu)/Ie]*100 where Ie and Iu are incidences in the exposed and unexposed groups, respectively [35]. In our analysis, this represents the incidence of mortality in the exposed (home delivery group) that would be prevented if the exposure (home deliveries) were eliminated. We used a Poisson method to calculate mortality ratios and their 95% CIs as Poisson method approximates distribution of these ratios better [36]. STATA version 12.0 (Stata Corp, College Station, Texas) was used for analysis. No ethical review was required for the study.

Results

As shown in Figure 1, a total of 1247 studies were identified through the literature search. We discarded 615 studies after appraising the titles as they contained irrelevant information or were redundant. We then screened abstracts for the remaining 632 studies before excluding 617 more studies. The reasons for exclusions were a) the studies were not population based or did not report outcomes by place of delivery (n = 594); b) the studies were evaluating impact of an interventions or risk of an exposure (n = 19); and c) the studies were duplicate publications (n = 4). We retrieved 15 studies in full, of which 6 studies were further excluded (5 prospective cohorts and 1 retrospective cohort) because the reported data for 5 studies were not sufficient to completely fill a 2 × 2 table [3741] and 1 study [42] did not have enough information on place of delivery.

Figure 1
figure 1

Flow chart showing identification, screening and inclusion of studies for meta-analysis of maternal and perinatal mortality by place of delivery in sub-Saharan Africa, 1990–2013.

Of the 9 studies that met the inclusion criteria for the analysis: 6 studies [4348] reported on perinatal mortality and the other 3 studies [364950] reported on maternal mortality. All were population based prospective cohort studies and had high quality scores. The mean study quality score for the selected studies was 10 out of 15 possible points (see Additional file 2). The most common limitations identified were lack of randomization in group allocation and lack of independent blind assessment of study outcomes. The 9 retained studies contained information on 36,772 pregnancy episodes in total. Of these 9,362 (25.5%) had information on the perinatal outcome alone. Table 1 provides further details on the characteristics of the studies included in the meta-analysis.

Table 1 Characteristics of studies included in meta-analysis of perinatal and maternal mortality by place of delivery in sub-Saharan Africa

Perinatal mortality

To estimate the protective effect of place of delivery, we first calculated the odds of perinatal mortality by place of delivery. Using a fixed effects model, Figure 2 shows that the pooled crude odds of perinatal mortality is significantly higher for home compared to facility delivery (OR 1.21, 95% CI: 1.02-1.46). As there is a high between-study heterogeneity I2 = 73.7, we also estimated the pooled effect with a random effects model [51]. The estimate from the more conservative random effects model is exactly the same, but is no longer significant, (OR 1.21, 95% CI: 0.79-1.84). The results of the individual studies are also mixed. Two studies are in favor of home delivery [4752], one is neutral [46] and three are in favor of facility-based delivery [4345].

Figure 2
figure 2

Pooled analysis of perinatal mortality by place of delivery in sub-Saharan Africa.

Next, we estimated the actual perinatal mortality ratio (PMR) by place of delivery. Table 2 shows that the overall weighted PMR is 63 (95% CI: 5473) per 1000 births. The PMR is 70 (95% CI: 57–86) and 56 (95% CI: 44–69) per 1000 births for home and facility-based deliveries, respectively. The attributable risk percentage is 21% (95% CI:-6,40).

Table 2 Weighted perinatal and maternal mortality ratios by place of delivery in sub-Saharan Africa

Maternal mortality

Figure 3 shows that the estimated pooled crude odds for maternal mortality at facility is 2.29 (95% CI: 1.58-3.31) compared to home settings. There is no variation in OR attributable to heterogeneity, I-squared = 0%. The increased odds for maternal mortality at facility are consistently high across all the three individual maternal studies and stable across both fixed and random effect models. The overall weighted maternal mortality ratio (MMR) is 727 (95% CI: 570–913) deaths per 100, 000 live births. The MMR is 599 (95% CI: 424–823) and 945 (95% CI: 658–1315) per 100,000 live births for home and facility deliveries, respectively (Table 2).

Figure 3
figure 3

Pooled analysis of maternal mortality by place of delivery in sub-Saharan Africa.

Perinatal mortality

In this study, we attempted to estimate the risk of mortality for home deliveries compared to facility-based deliveries. The study illustrates the complexity of the relationship between risk of mortality and place of delivery. At an individual level, we found evidence for an increased chance of perinatal losses following home compared to facility-based deliveries. However, opposite conclusions can statistically be reached, significant versus nonsignificant results, depending on whether we make fixed model or random effect model assumptions. It has been argued that a finding that is statistically significant with the latter but not with the former model, should be viewed with caution [5153].

We estimated the overall weighted perinatal mortality ratio in SSA to be 63 (95% CI: 54–73) deaths per 1000 births. This figure compares well with current WHO estimates of PMR (56 per 1000 births) in the region [18]. Our results imply that at best, an expected 14 perinatal deaths could be averted per 1000 births if women were delivered at a facility instead of home. This represents a 21% (95% CI:-6,40) reduction in perinatal mortality risk for the home delivery group. In 2012, 36.8 million births were estimated to have taken place in SSA of which 18.0 million (49%) were home deliveries [54]. In view of the high number of home deliveries in the SSA region, it can be argued that a 21% reduction in perinatal mortality risk might produce important public health improvements, if only a significant portion of the women who currently give birth at home could be motivated to deliver in health facilities.

Through health worker trainings and WHO policy [5], the current practice in the region is to encourage active or self referral of pregnant women, especially those with high risk factors (e.g. twin pregnancy, pregnancy induced hypertension) to deliver at health facilities. Moreover, some of the studies included in the analysis made special arrangements for facility referral of at risk pregnancies [4347]. This selection was likely to have made the facility and home delivery groups different with respect to perinatal risk factors, the latter being on average less at risk than the former. The results might therefore represent an underestimation of PMR in the home delivery group. The observation that perinatal mortality is on average high in the home delivery group, in spite of its relative low risk profile, should be of concern to policy makers, program implementers and health care providers in SSA.

PUB 540 The Impact of Place on Maternal and Infant Health

PUB 540 The Impact of Place on Maternal and Infant Health

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Maternal mortality

Regarding maternal mortality, the results show that pregnant mothers delivering in facilities have a significantly higher risk of experiencing a maternal death than women delivering at home. Several reasons could account for this surprising result. First, in settings where access to facility-based delivery is low (<40%), those seeking care at facilities may be complicated cases with higher risk of mortality [5556]. In such settings, high maternal mortality at facilities would be expected due to high risk selection, as already reported in the literature [57]. Only one [36] out of the three studies reporting on maternal mortality had a low facility delivery rate. Precluding this study from the analysis does not significantly change the results. This suggests that low facility delivery rate alone does not appear to explain the relatively high risk of mortality observed for facility-based deliveries in this study. Second, and related to the risk selection, the study by Høj et al. [50] shows a progressive increase in risk of maternal mortality from health center to hospital compared to home: (OR 1.49,95% CI: 0.73-2.76) and (OR 2.72, 95% CI:1.64-4.38) respectively. This suggests existence of a differential in terms of the complexity of case mix by level of care. This can be interpreted as an indication that referral for facility-based delivery is actually working with secondary or tertiary referral facilities treating women with more complex conditions [36], although probably the timeliness of care is not optimal to make a difference [58]. Thirdly, facility-based delivery as a strategy to reduce maternal mortality does not simply entail delivery at a health facility, but also access to an enabling environment, such as availability of health workers with midwifery training, diagnostic tools, drug supplies and access to blood bank for effective care. High risk of maternal mortality at facility may therefore reflect lack of requisite capacity for facilities to offer quality care to high-risk women [59]. A large study in the region has shown that most maternal deaths occurring at facilities are among women who receive substandard care [36]. Moreover, not all facilities-based deliveries are attended by health workers with midwifery training due to unfilled vacancies and staff absenteeism [60], supporting the assertion that poor quality of care at health facilities is likely to explain a significant portion of the observed high risk of facility-based maternal deaths. Fourthly, although hard evidence is lacking, the possibility that mothers might be harmed at facilities, due for example to poor infection control or other human errors, cannot be ruled out [55].

Strengths and limitations

The strength of our paper accrues from the deliberate choice to include studies with a homogenous design, using standard definitions of outcomes (perinatal and maternal mortality ratios), and that largely collected data prospectively and at regular intervals to minimize recall bias and increase validity of the outcome measures. Typically, estimates of perinatal and maternal mortality in African countries are derived from complex statistical modeling techniques [48] or from nationally representative demographic and health surveys that use sisterhood approach methods [61]. However, poor quality data, recall bias, and selective underreporting tend to affect such estimates [25].

Still, our study suffers from some limitations. Population-based cohort studies are costly and therefore only a few have been conducted in the SSA region. Despite the high quality of individual eligible studies, the pooled analysis is based on a limited number of studies, thus the results should be interpreted with caution. We also noted subtle operational variations in the exposures. For example, home delivery in some settings meant delivery by non-trained traditional birth attendants (TBAs) [43] while in other settings it entailed delivery by trained TBAs [52]. Despite the uniform study design, such conceptual differences can lead to clinical variations [32] and heterogeneity.

Geographical, temporal, health systems and individual patient risk profiles can also affect maternal and perinatal outcomes [58] and confound the interpretation of health outcomes by place of delivery. It is known for instance that rural areas tend to have worse perinatal and maternal health outcomes than urban areas [4]. Within the SSA region, important variations in the risk of mortality exist between sub-regions [62]. At an individual level, age, parity, and existence of other co-morbidities such as hypertension can influence both maternal and perinatal outcomes [4750]. Ideally, these factors should be controlled before making statements about the relative effectiveness of one place of delivery compared to another [55]. Inadequate number of studies and particularly the lack of patient level information from the available studies precluded the possibility of such accurate analysis in our own review.

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Introduction to the case (1
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Briefly explain and summarize
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Be sure to include the specific
patient factors that may impact
your decision making when

prescribing medication for this
patient.

9 (9%) – 10 (10%)
The response accurately, clearly,
and fully summarizes in detail the
case for the Assignment.
The response accurately and
clearly explains in detail the
specific patient factors that
impact decision making when
prescribing medication for this
patient.

8 (8%) – 8 (8%)
The response accurately
summarizes the case for the
Assignment.
The response accurately explains
the specific patient factors that
impact decision making with
prescribing medication for this
patient.

7 (7%) – 7 (7%)
The response inaccurately or
vaguely summarizes the case for
the Assignment.
The response inaccurately or

vaguely explains the specific
patient factors that impact
decision making with prescribing
medication for this patient.

0 (0%) – 6 (6%)
The response inaccurately and
vaguely summarizes the case for
the Assignment, or is missing.
The response inaccurately and
vaguely explains the specific
patient factors that impact
decision making with prescribing
medication for this patient.

Decision #1 (1–2 pages)
• Which decision did you
select?
• Why did you select this
decision? Be specific and
support your response with
clinically relevant and patient-
specific resources, including
the primary literature.
• Why did you not select the

18 (18%) – 20 (20%)
The response accurately and
clearly explains in detail the

decision selected.
The response accurately and
clearly explains in detail why the
decision was selected, with
specific clinically relevant
resources that fully support the
decision selected.

16 (16%) – 17 (17%)
The response accurately explains
the decision selected.
The response explains why the
decision was selected, with
specific clinically relevant
resources that support the
decision selected.
The response accurately explains

14 (14%) – 15 (15%)
The response inaccurately or
vaguely explains the decision
selected.
The response inaccurately or
vaguely explains why the
decision was selected, with
specific clinically relevant
resources that inaccurately or
vaguely support the decision

0 (0%) – 13 (13%)
The response inaccurately and
vaguely explains the decision
selected.
The response inaccurately and
vaguely explains why the
decision was selected, with
specific clinically relevant
resources that do not support the
decision selected, or is missing.

other two options provided in
the exercise? Be specific and
support your response with
clinically relevant and patient-
specific resources, including
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• What were you hoping to
achieve by making this
decision? Support your
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references to the Learning
Resources (including the
primary literature).
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considerations may impact
your treatment plan and
communication with patients.
Be specific and provide

examples.

The response accurately and
clearly explains in detail why the
other two responses were not
selected, with specific clinically
relevant resources that fully
support the response.
The response accurately and
clearly explains in detail the
outcome the student was hoping
to achieve with the selected
decision, with specific clinically
relevant resources that fully
support the response.
The response accurately and
clearly explains in detail how
ethical considerations impact the
treatment plan and
communication with patients.
Examples provided fully support
the decisions and responses
provided.

why the other two responses
were not selected, with specific
clinically relevant resources that
support the response.
The response accurately explains

the outcome the student was
hoping to achieve with the
selected decision, with specific
clinically relevant resources that
support the response.
The response accurately explains
how ethical considerations
impact the treatment plan and
communication with patients.
Examples provided support the
decisions and responses
provided.

selected.
The response inaccurately or
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that inaccurately or
vaguely support the response.
The response inaccurately or
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant
resources that inaccurately or
vaguely support the response.
The response inaccurately or
vaguely explains how ethical

considerations impact the
treatment plan and
communication with patients.
Examples provided may support
the decisions and responses
provided.

The response inaccurately and
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that do not support the
decision selected, or is missing.
The response inaccurately and
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant
resources that do not support the
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The response inaccurately and
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communication with patients, or
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Examples provided do not
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responses provided, or is

missing.

Decision #2 (1–2 pages)
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decision? Be specific and
support your response with
clinically relevant and patient-
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other two options provided in
the exercise? Be specific and
support your response with
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specific resources, including
the primary literature.
• What were you hoping to

18 (18%) – 20 (20%)
The response accurately and
clearly explains in detail the
decision selected.
The response accurately and
clearly explains in detail why the
decision was selected, with
specific clinically relevant
resources that fully support the

decision selected.
The response accurately and
clearly explains in detail why the
other two responses were not
selected, with specific clinically
relevant resources that fully
support the response.

16 (16%) – 17 (17%)
The response accurately explains
the decision selected.
The response explains why the
decision was selected, with
specific clinically relevant
resources that support the
decision selected.
The response accurately explains
why the other two responses
were not selected, with specific
clinically relevant resources that
support the response.
The response accurately explains
the outcome the student was

14 (14%) – 15 (15%)
The response inaccurately or
vaguely explains the decision
selected.
The response inaccurately or

vaguely explains why the
decision was selected, with
specific clinically relevant
resources that inaccurately or
vaguely support the decision
selected.
The response inaccurately or
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that inaccurately or

0 (0%) – 13 (13%)
The response inaccurately and
vaguely explains in detail the
decision selected.
The response inaccurately and
vaguely explains why the
decision was selected, with
specific clinically relevant
resources that do not support the
decision selected, or is missing.
The response inaccurately and
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that do not support the
decision selected, or is missing.

achieve by making this
decision? Support your
response with evidence and
references to the Learning
Resources (including the
primary literature).
• Explain how ethical
considerations may impact
your treatment plan and
communication with patients.
Be specific and provide
examples.

The response accurately and
clearly explains in detail the
outcome the student was hoping
to achieve with the selected
decision, with specific clinically
relevant resources that fully
support the response.
The response accurately and
clearly explains in detail how
ethical considerations impact the
treatment plan and
communication with patients.
Examples provided fully support
the decisions and responses
provided.

hoping to achieve with the
selected decision, with specific
clinically relevant resources that
support the response.
The response accurately explains
how ethical considerations
impact the treatment plan and
communication with patients.
Examples provided support the
decisions and responses
provided.

vaguely support the response.
The response inaccurately or
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant
resources that inaccurately or
vaguely support the response.
The response inaccurately or
vaguely explains how ethical
considerations impact the
treatment plan and
communication with patients.
Examples provided may support
the decisions and responses
provided.

The response inaccurately and
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant
resources that do not support the
response, or is missing.
The response inaccurately and
vaguely explains how ethical
considerations impact the
treatment plan and
communication with patients, or
is missing.
Examples provided do not
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missing.

Decision #3 (1–2 pages)
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select?
• Why did you select this
decision? Be specific and
support your response with
clinically relevant and patient-
specific resources, including
the primary literature.
• Why did you not select the
other two options provided in

the exercise? Be specific and
support your response with
clinically relevant and patient-
specific resources, including
the primary literature.
• What were you hoping to
achieve by making this
decision? Support your
response with evidence and
references to the Learning
Resources (including the
primary literature).
• Explain how ethical

18 (18%) – 20 (20%)
The response accurately and
clearly explains in detail the
decision selected.
The response accurately and
clearly explains in detail why the
decision was selected, with
specific clinically relevant
resources that fully support the
decision selected.
The response accurately and
clearly explains in detail why the
other two responses were not
selected, with specific clinically
relevant resources that fully

support the response.
The response accurately and
clearly explains in detail the
outcome the student was hoping
to achieve with the selected
decision, with specific clinically
relevant resources that fully

16 (16%) – 17 (17%)
The response accurately explains
the decision selected.
The response explains why the
decision was selected, with
specific clinically relevant
resources that support the
decision selected.
The response accurately explains
why the other two responses
were not selected, with specific
clinically relevant resources that
support the response.
The response accurately explains
the outcome the student was
hoping to achieve with the
selected decision, with specific
clinically relevant resources that
support the response.
The response accurately explains
how ethical considerations

14 (14%) – 15 (15%)
The response inaccurately or
vaguely explains the decision
selected.
The response inaccurately or
vaguely explains why the
decision was selected, with
specific clinically relevant
resources that inaccurately or
vaguely support the decision
selected.
The response inaccurately or
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that inaccurately or
vaguely support the response.
The response inaccurately or
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant

0 (0%) – 13 (13%)
The response inaccurately and
vaguely explains in detail the
decision selected.
The response inaccurately and

vaguely explains why the
decision was selected, with
specific clinically relevant
resources that do not support the
decision selected, or is missing.
The response inaccurately and
vaguely explains why the other
two responses were not selected,
with specific clinically relevant
resources that do not support the
decision selected, or is missing.
The response inaccurately and
vaguely explains the outcome the
student was hoping to achieve
with the selected decision, with
specific clinically relevant
resources that do not support the

considerations may impact
your treatment plan and
communication with patients.
Be specific and provide
examples.

support the response.
The response accurately and
clearly explains in detail how
ethical considerations impact the
treatment plan and

communication with patients.
Examples provided fully support
the decisions and responses
provided.

impact the treatment plan and
communication with patients.
Examples provided support the
decisions and responses
provided.

resources that inaccurately or
vaguely support the response.
The response inaccurately or
vaguely explains how ethical
considerations impact the
treatment plan and
communication with patients.
Examples provided may support
the decisions and responses
provided.

response, or is missing.
The response inaccurately and
vaguely explains how ethical
considerations impact the
treatment plan and
communication with patients, or
is missing.

Examples provided do not
support the decisions and
responses provided, or is
missing.

Conclusion (1 page)
• Summarize your
recommendations on the
treatment options you selected
for this patient. Be sure to
justify your recommendations
and support your response
with clinically relevant and
patient-specific resources,
including the primary literature.

14 (14%) – 15 (15%)
The response accurately and
clearly summarizes in detail the
recommendations on the
treatment options selected for
this patient.
The response accurately and
clearly explains a justification for
the recommendations provided,
including clinically relevant
resources that fully support the
recommendations provided.

12 (12%) – 13 (13%)
The response accurately
summarizes the
recommendations on the
treatment options selected for
this patient.
The response accurately explains
a justification for the
recommendation provided,
including clinically relevant
resources that support the
recommendations provided.

11 (11%) – 11 (11%)
The response inaccurately or
vaguely summarizes the
recommendations on the
treatment options selected for
this patient.
The response inaccurately or
vaguely explains a justification for
the recommendations provided,
including clinically relevant
resources that inaccurately or
vaguely support the
recommendations provided.

0 (0%) – 10 (10%)
The response inaccurately and

vaguely summarizes the
recommendations on the
treatment options selected for
this patient, or is missing.
The response inaccurately and
vaguely explains a justification for
the recommendations provided,
including clinically relevant
resources that do not support the
recommendations provided, or is
missing.

Written Expression and
Formatting – Paragraph
Development and Organization:
Paragraphs make clear points
that support well-developed
ideas, flow logically, and
demonstrate continuity of
ideas. Sentences are carefully
focused—neither long and
rambling nor short and lacking
substance. A clear and
comprehensive purpose
statement and introduction are
provided that delineate all
required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow
writing standards for flow,
continuity, and clarity.
A clear and comprehensive
purpose statement, introduction,
and conclusion are provided that
delineate all required criteria.

4 (4%) – 4 (4%)
Paragraphs and sentences follow
writing standards for flow,
continuity, and clarity 80% of the
time.
Purpose, introduction, and
conclusion of the assignment are
stated, yet they are brief and not
descriptive.

3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow
writing standards for flow,
continuity, and clarity 60%–79%
of the time.
Purpose, introduction, and
conclusion of the assignment is
vague or off topic.

0 (0%) – 3 (3%)
Paragraphs and sentences follow

writing standards for flow,
continuity, and clarity &amp;lt; 60% of
the time.
No purpose statement,
introduction, or conclusion were
provided.

Written Expression and
Formatting – English writing
standards:
Correct grammar, mechanics,
and proper punctuation

5 (5%) – 5 (5%)
Uses correct grammar, spelling,
and punctuation with no errors.

4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar,
spelling, and punctuation errors.

3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4)
grammar, spelling, and
punctuation errors.

0 (0%) – 3 (3%)
Contains many (≥ 5) grammar,
spelling, and punctuation errors

that interfere with the reader’s
understanding.

Written Expression and
Formatting – The paper follows
correct APA format for title
page, headings, font,
spacing, margins, indentations,
page numbers, parenthetical/in-
text citations, and reference
list.

5 (5%) – 5 (5%)
Uses correct APA format with no
errors.

4 (4%) – 4 (4%)
Contains a few (1 or 2) APA
format errors.

3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA
format errors.

0 (0%) – 3 (3%)
Contains many (≥ 5) APA format
errors.

Total Points: 100

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