An integrated newborn care kit (iNCK) to save newborn lives and improve health outcomes in Gilgit Baltistan (GB), Pakistan: study protocol for a cluster randomized controlled trial.

BACKGROUND: Ongoing high neonatal mortality rates (NMRs) represent a global challenge. In 2021, of the 5 million deaths reported worldwide for children under five years of age, 47% were newborns. Pakistan has one of the five highest national NMRs in the world, with an estimated 39 neonatal deaths per 1,000 live births. Reducing newborn deaths requires sustainable, evidence-based, and cost-effective interventions that can be integrated within existing community healthcare infrastructure across regions with high NMR. METHODS: This pragmatic, community-based, parallel-arm, open-label, cluster randomized controlled trial aims to estimate the effect of Lady Health Workers (LHWs) providing an integrated newborn care kit (iNCK) with educational instructions to pregnant women in their third trimester, compared to the local standard of care in Gilgit-Baltistan, Pakistan, on neonatal mortality and other newborn and maternal health outcomes. The iNCK contains a clean birth kit, 4% chlorhexidine topical gel, sunflower oil emollient, a ThermoSpot™ temperature monitoring sticker, a fleece blanket, a click-to-heat reusable warmer, three 200 µg misoprostol tablets, and a pictorial instruction guide and diary. LHWs are also provided with a handheld scale to weigh the newborn. The primary study outcome is neonatal mortality, defined as a newborn death in the first 28 days of life. DISCUSSION: This study will generate policy-relevant knowledge on the effectiveness of integrating evidence-based maternal and newborn interventions and delivering them directly to pregnant women via existing community health infrastructure, for reducing neonatal mortality and morbidity, in a remote, mountainous area with a high NMR. TRIAL REGISTRATION: NCT04798833, March 15, 2021.

The impact of a global health elective on CanMEDS competencies and future practice.

BACKGROUND: There is evidence that participating in global health electives generates positive educational outcomes and personal benefits for medical trainees. The objective of this study was to examine the effect and impact that a global health elective has on CanMEDS competencies and anticipated future practice. RESULTS: The medical expert, collaborator, leader, scholar, and professional CanMEDS competencies were self-perceived to be strongly impacted through this elective. A total of 94% of participants indicated it increased their strengths as a medical expert and leader, 82% indicated a major impact on the scholar competency, 88% of participants reported a strong impact as a professional, and 76% of participants indicated that it strongly impacted them as a collaborator. The majority of participants continue to have involvement in global health, and 88% of respondents found this elective to be influential on their current practice and beliefs. CONCLUSIONS: These results suggest that individuals who participated in this global health elective perceived value in their experience. These findings support our hypothesis that participation in this global health elective would generate self-perceived positive impacts. Global health electives may provide an opportunity for physicians to expand on their CanMEDS competencies and become more proficient in caring for diverse patient populations.

Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study.

BACKGROUND: The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. METHODS: The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10-19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. RESULTS: There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. CONCLUSIONS: A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.

A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.

Use of Audio Computer-Assisted Self-Interviews to Gather Information on Risk Behaviors in a Population of Pregnant Adolescents.

In a prospective study comparing the use of the Audio Computer-Assisted Self-Interview (ACASI) with a traditional clinical interview in 40 pregnant adolescents, there was significantly greater disclosure of violence with the ACASI method. Better identification of high-risk behaviors may help to optimize care and programing for pregnant adolescents.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

Adolescent Pregnancy Guidelines.

OBJECTIVE: To describe the needs and evidence-based practice specific to care of the pregnant adolescent in Canada, including special populations. OUTCOMES: Healthy pregnancies for adolescent women in Canada, with culturally sensitive and age-appropriate care to ensure the best possible outcomes for these young women and their infants and young families, and to reduce repeat pregnancy rates. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library on May 23, 2012 using appropriate controlled vocabulary (e.g., Pregnancy in Adolescence) and key words (e.g., pregnancy, teen, youth). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to English or French language materials published in or after 1990. Searches were updated on a regular basis and incorporated in the guideline to July 6, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, national and international medical specialty societies, and clinical practice guideline collections. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS/HARMS/COSTS: These guidelines are designed to help practitioners caring for adolescent women during pregnancy in Canada and allow them to take the best care of these young women in a manner appropriate for their age, cultural backgrounds, and risk profiles. RECOMMENDATIONS: 1. Health care providers should adapt their prenatal care for adolescents and offer multidisciplinary care that is easily accessible to the adolescent early in the pregnancy, recognizing that adolescents often present to care later than their adult counterparts. A model that provides an opportunity to address all of these needs at one site may be the preferred model of care for pregnant adolescents. (II-1A) 2. Health care providers should be sensitive to the unique developmental needs of adolescents through all stages of pregnancy and during intrapartum and postpartum care. (III-B) 3. Adolescents have high-risk pregnancies and should be managed accordingly within programs that have the capacity to manage their care. The unique physical risks of adolescent pregnancy should be recognized and the care provided must address these. (II-1A) 4. Fathers and partners should be included as much as possible in pregnancy care and prenatal/infant care education. (III-B) 5. A first-trimester ultrasound is recommended not only for the usual reasons for properly dating the pregnancy, but also for assessing the increased risks of preterm birth. (I-A) 6. Counselling about all available pregnancy outcome options (abortion, adoption, and parenting) should be provided to any adolescent with a confirmed intrauterine gestation. (III-A) 7. Testing for sexually transmitted infections (STI) (II-2A) and bacterial vaginosis (III-B) should be performed routinely upon presentation for pregnancy care and again in the third trimester; STI testing should also be performed postpartum and when needed symptomatically. a. Because pregnant adolescents are inherently at increased risk for preterm labour, preterm birth, and preterm pre-labour rupture of membranes, screening and management of bacterial vaginosis is recommended. (III-B) b. After treatment for a positive test, a test of cure is needed 3 to 4 weeks after completion of treatment. Refer partner for screening and treatment. Take the opportunity to discuss condom use. (III-A) 8. Routine and repeated screening for alcohol use, substance abuse, and violence in pregnancy is recommended because of their increased rates in this population. (II-2A) 9. Routine and repeated screening for and treatment of mood disorders in pregnancy is recommended because of their increased rates in this population. The Edinburgh Postnatal Depression Scale administered in each trimester and postpartum, and more frequently if deemed necessary, is one option for such screening. (II-2A) 10. Pregnant adolescents should have a nutritional assessment, vitamins and food supplementation if needed, and access to a strategy to reduce anemia and low birth weight and to optimize weight gain in pregnancy. (II-2A) 11. Conflicting evidence supports and refutes differences in gestational hypertension in the adolescent population; therefore, the care usual for adult populations is supported for pregnant adolescents at this time. (II-2A) 12. Practitioners should consult gestational diabetes mellitus (GDM) guidelines. In theory, testing all patients is appropriate, although rates of GDM are generally lower in adolescent populations. Practitioners should be aware, however, that certain ethnic groups including Aboriginal populations are at high risk of GDM. (II-2A) 13. An ultrasound anatomical assessment at 16 to 20 weeks is recommended because of increased rates of congenital anomalies in this population. (II-2A) 14. As in other populations at risk of intrauterine growth restriction (IUGR) and low birth weight, an ultrasound to assess fetal well-being and estimated fetal weight at 32 to 34 weeks gestational age is suggested to screen for IUGR. (III-A) 15. Visits in the second or third trimester should be more frequent to address the increased risk of preterm labour and preterm birth and to assess fetal well-being. All caregivers should be aware of the signs and symptoms of preterm labour and should educate their patients to recognize them. (III-A) 16. It should be recognized that adolescents have improved vaginal delivery rates and a concomitantly lower Caesarean section rate than their adult counterparts. (II-2A) As with antenatal care, peripartum care in hospital should be multidisciplinary, involving social care, support for breastfeeding and lactation, and the involvement of children's aid services when warranted. (III-B) 17. Postpartum care should include a focus on contraceptive methods, especially long-acting reversible contraception methods, as a means to decrease the high rates of repeat pregnancy in this population; discussion of contraception should begin before delivery. (III-A) 18. Breastfeeding should be recommended and sufficient support given to this population at high risk for discontinuation. (II-2A) 19. Postpartum care programs should be available to support adolescent parents and their children, to improve the mothers' knowledge of parenting, to increase breastfeeding rates, to screen for and manage postpartum depression, to increase birth intervals, and to decrease repeated unintended pregnancy rates. (III-B) 20. Adolescent women in rural, remote, northern, and Aboriginal communities should be supported to give birth as close to home as possible. (II-2A) 21. Adolescent pregnant women who need to be evacuated from a remote community should be able to have a family member or other person accompany them to provide support and encouragement. (II-2A) 22. Culturally safe prenatal care including emotional, educational, and clinical support to assist adolescent parents in leading healthier lives should be available, especially in northern and Aboriginal communities. (II-3A) 23. Cultural beliefs around miscarriage and pregnancy issues, and special considerations in the handling of fetal remains, placental tissue, and the umbilical cord, must be respected. (III).

Objectif : Décrire les besoins des adolescentes enceintes au Canada (y compris celles qui sont issues de populations particulières) et les pratiques factuelles propres aux soins qui doivent être offerts à ces femmes. Issues : Grossesses saines chez les adolescentes au Canada; offre de soins sûrs au plan culturel et adaptés à l'âge pour assurer l'obtention des meilleures issues possibles pour ces jeunes femmes, leurs enfants et leur famille; et réduction des taux de grossesse à répétition. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PUBMED et The Cochrane Library le 23 mai 2012, au moyen d'un vocabulaire contrôlé (p. ex. « Pregnancy in Adolescence ¼) et de mots clés (p. ex. « pregnancy ¼, « teen ¼, « youth ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Les résultats ont été limités aux articles publiés en anglais ou en français à partir de 1990. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'au 6 juillet 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La présente directive clinique a été conçue pour aider les praticiens canadiens à offrir aux adolescentes enceintes des soins optimaux qui sont adaptés à leur âge, à leur contexte culturel et à leurs profils de risque. Recommandations 1. Les professionnels de la santé devraient adapter leurs services prénataux aux besoins des adolescentes et leur offrir des soins multidisciplinaires dont elles pourront facilement se prévaloir tôt dans le cadre de la grossesse, en tenant ainsi compte du fait que les adolescentes sollicitent souvent des soins plus tard que leurs homologues adultes. Un modèle de soins permettant de répondre à tous ces besoins en un seul et même endroit pourrait constituer le modèle à privilégier pour les adolescentes enceintes. (II-1A) 2. Les fournisseurs de soins devraient être sensibles aux besoins développementaux particuliers des adolescentes tout au long de la grossesse, ainsi que dans le cadre des soins intrapartum et postpartum. (III-B) 3. Chez les adolescentes, la grossesse est exposée à des risques élevés et devrait faire l'objet d'une prise en charge adaptée en conséquence dans le cadre de programmes disposant des capacités nécessaires. Les risques physiques propres à la grossesse chez une adolescente doivent être pris en considération et les soins offerts doivent s'y adapter. (II-1A) 4. La participation des pères et des partenaires aux cours prénataux (soins à prodiguer à la mère et à l'enfant) devrait être favorisée autant que possible. (III-B) 5. La tenue d'une échographie au cours du premier trimestre est recommandée non seulement aux fins de la datation adéquate de la grossesse (soit la raison habituellement invoquée pour la tenue d'une telle intervention), mais également pour l'évaluation des risques accrus d'accouchement préterme. (I-A) 6. Des services de counseling traitant de toutes les options disponibles en ce qui concerne la grossesse (avortement, adoption et parentage) devraient être offerts à toutes les adolescentes chez qui la présence d'une grossesse intra-utérine a été confirmée. (III-A) 7. Un dépistage visant les infections transmissibles sexuellement (II-2A) et la vaginose bactérienne (III-B) devrait être mené systématiquement dans le cadre de la première consultation prénatale et, une fois de plus, au cours du troisième trimestre; un dépistage visant les infections transmissibles sexuellement devrait également être mené pendant la période postpartum et lorsque la présence de symptômes en justifie la mise en œuvre. a. Puisque les adolescentes enceintes sont intrinsèquement exposées à des risques accrus de travail préterme, d'accouchement préterme et de rupture prématurée des membranes préterme, elles constituent un « groupe exposé à des risques élevés ¼ : le dépistage et la prise en charge de la vaginose bactérienne s'avèrent donc recommandée. (III-B) b. À la suite d'un traitement mis en œuvre en raison de l'obtention d'un résultat positif au dépistage, la tenue d'un test de contrôle post-traitement s'avère requise de trois à quatre semaines à la suite de la fin du traitement. L'orientation du partenaire vers des services de dépistage et de traitement s'avère également requise. Les fournisseurs de soins devraient profiter de l'occasion pour discuter de l'utilisation de condoms avec leurs patientes. (III-A) 8. La mise en œuvre systématique et répétée d'un dépistage de la consommation d'alcool, de la consommation de substances psychoactives et de la violence pendant la grossesse est recommandée, en raison de leurs taux accrus au sein de cette population. (II-2A) 9. La mise en œuvre systématique et répétée d'un dépistage et d'une prise en charge des troubles de l'humeur pendant la grossesse est recommandée, en raison des taux accrus de ces troubles au sein de cette population. L'administration de l'Échelle de dépression postnatale d'Édimbourg à chaque trimestre et pendant la période postpartum (et plus fréquemment, lorsque cela semble nécessaire) constitue une option pour la mise en œuvre d'un tel dépistage. (II-2A) 10. Les adolescentes enceintes devraient faire l'objet d'une évaluation nutritionnelle et d'une supplémentation en vitamines et en aliments (au besoin), ainsi qu'obtenir accès à une stratégie visant l'optimisation du gain pondéral pendant la grossesse et la baisse des risques d'anémie et de faible poids de naissance. (II-2A) 11. Des données contradictoires soutiennent et réfutent la présence de différences en matière d'hypertension gestationnelle au sein de la population adolescente; ainsi, nous soutenons pour l'instant l'offre, aux adolescentes enceintes, des soins qui sont habituellement offerts aux populations adultes. (II-2A) 12. Les praticiens devraient consulter les lignes directrices traitant du diabète sucré gestationnel. En théorie, le dépistage de toutes les patientes s'avère approprié, et ce, bien que les taux de diabète sucré gestationnel soient généralement moindres chez les populations adolescentes. Les praticiens devraient cependant être avisés que certains groupes ethniques (dont les populations autochtones) sont exposés à des risques élevés de diabète sucré gestationnel. (II-2A) 13. La tenue d'une échographie d'évaluation anatomique à 16-20 semaines est recommandée, en raison des taux accrus d'anomalies congénitales au sein de cette population. (II-2A) 14. Tout comme dans le cas d'autres populations exposées à des risques de retard de croissance intra-utérin et de faible poids de naissance, la tenue d'une échographie visant à évaluer le bien-être fœtal et à estimer le poids fœtal à un âge gestationnel de 32-34 semaines est suggérée pour le dépistage du retard de croissance intra-utérin. (III-A) 15. Au cours du deuxième ou du troisième trimestre, les consultations devraient être plus fréquentes pour traiter des risques accrus de travail et d'accouchement prétermes, et pour évaluer le bien-être fœtal. Tous les fournisseurs de soins devraient connaître les symptômes du travail préterme et former leurs patientes de façon à ce qu'elles puissent les reconnaître. (III-A) 16. On se doit de souligner que les adolescentes comptent des taux d'accouchement vaginal supérieurs et (de façon concomitante) des taux de césarienne inférieurs, par comparaison avec leurs homologues adultes. (II-2A) Tout comme dans le cas des soins prénataux, les soins peripartum prodigués à l'hôpital devraient être de nature multidisciplinaire, mettre en jeu le milieu social, soutenir l'allaitement et la lactation, et solliciter la participation des services de protection de l'enfance, lorsque cela s'avère justifié. (III-B) 17. Les soins postpartum devraient comprendre une composante traitant des modes de contraception (particulièrement des contraceptifs réversibles à action prolongée), dans le but d'abaisser les taux élevés de nouvelle grossesse chez les adolescentes; les discussions au sujet de la contraception devraient débuter avant l'accouchement. (III-A) 18. L'allaitement devrait être recommandé et du soutien suffisant devrait être offert à cette population exposée à des risques élevés d'abandon. (II-2A) 19. Des programmes de soins postpartum visant la hausse des connaissances parentales et des taux d'allaitement, le dépistage et la prise en charge de la dépression postpartum, le prolongement des intervalles entre les grossesses et la réduction des taux de grossesse non souhaitée à répétition devraient être offerts pour soutenir les parents adolescents et leurs enfants. (III-B) 20. Au sein des collectivités autochtones, rurales, éloignées et du Nord, les adolescentes devraient bénéficier du soutien nécessaire à la tenue de l'accouchement le plus près possible de leur foyer. (II-2A) 21. Les adolescentes enceintes qui doivent être évacuées d'une collectivité éloignée devraient pouvoir se faire accompagner par un membre de la famille (ou toute autre personne de leur choix) à des fins de soutien et d'encouragement. (II-2A) 22. Des soins prénataux sûrs au plan culturel (y compris des mesures de soutien affectif, pédagogique et clinique aidant les parents adolescents à mener une vie leur assurant la santé) doivent être offerts, et ce, particulièrement au sein des collectivités autochtones et du Nord. (II-3A) 23. Les croyancesculturelles (entourant la fausse couche et les problèmes de la grossesse) et les considérations particulières (en ce qui concerne la manipulation des restes fœtaux, des tissus placentaires et du cordon ombilical) doivent être respectées. (III).

Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents.

OBJECTIVE: To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global women's health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum. METHODS: We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents. RESULTS: Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001). CONCLUSION: Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

Objective: Pour devenir des praticiens compétents sur le plan culturel étant en mesure de prodiguer des soins aux populations vulnérables et de défendre leur cause, les résidents doivent recevoir une formation abordant les priorités de la santé à l'échelle mondiale. Dans le domaine de l'obstétrique-gynécologie, nous ne disposons que de peu de renseignements au sujet de la formation en santé des femmes à l'échelle mondiale (SFEM) qu'offrent les programmes de résidence et de l'intérêt envers ce type de formation que l'on y constate. Nous souhaitions déterminer ce qui suit en ce qui concerne les programmes canadiens de résidence en obstétrique-gynécologie : (1) la situation actuelle pour ce qui est de l'enseignement de la SFEM et du soutien disponible à cet égard; (2) l'importance de la SFEM pour les résidents et les directeurs de programme; et (3) le degré d'intérêt envers un curriculum national de cycle supérieur dans le domaine de la SFEM. Méthodes : Nous avons mené, à l'échelle du Canada, un sondage en ligne auprès des directeurs des programmes de résidence en obstétrique-gynécologie et des résidents de dernière année du domaine. Résultats : Parmi les 297 résidents sollicités, 101 (34,0 %) ont répondu au sondage et 76 (26 %) ont rempli le sondage en entier. Onze des 16 directeurs de programme sollicités (68,8 %) ont répondu et 10/16 (62,5 %) nous ont fourni des réponses complètes. Quatre des 11 programmes (36,4 %) comptaient un curriculum de SFEM, 2/11 (18,2 %) comptaient un budget de SFEM et 4/11 (36,4 %) comptaient un président de la SFEM. Neuf directeurs de programme sur 10 (90 %) et 68 résidents sur 79 (86,1 %) étaient d'avis qu'une compréhension des questions de SFEM est importante pour tous les stagiaires canadiens en obstétrique-gynécologie. Seulement un directeur de programme sur 10 (10 %) et 11 résidents sur 79 (13,9 %) étaient d'avis que leur programme offrait une formation suffisante sur ces questions. Parmi les résidents des programmes comptant un curriculum de SFEM, 12/19 (63,2 %) étaient d'avis que les résidents de leur programme qui n'entreprenaient pas un stage au choix international auraient tout de même l'occasion de se sensibiliser à la SFEM, par comparaison avec seulement neuf des 50 résidents (18,0 %) des programmes ne comptant pas un tel curriculum (P < 0,001). Conclusion : Les résidents et les directeurs de programme du domaine de l'obstétrique-gynécologie estiment que la formation au sujet de la SFEM est importante pour tous les stagiaires et qu'elle est actuellement insuffisante. La mise sur pied d'un module pédagogique national de cycle supérieur en SFEM suscite un vif intérêt.

Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan.

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

Can paediatric and adolescent gynecological care be delivered via Telehealth?

OBJECTIVE: Paediatric and adolescent gynecology (PAG) is an evolving subspecialty, with patients often having to travel large distances to access care. The goal of the present study was to assess whether Telehealth (TH) would be appropriate for PAG services in a tertiary care centre and to determine patient/family interest. METHODS: The present study was a prospective observational study of patients who attended PAG clinics over the course of one year. Patient data collected on each visit included postal code, diagnosis, availability of a local hospital with TH, patient appropriateness for TH and patient/family reasons for accepting TH. Visits were stratified by diagnosis to determine if certain conditions were more amenable to TH. RESULTS: From the total visits through the year (July 15, 2008 to July 15, 2009), 1541 (79.6%) patients were approached for participation; 8 (0.5%) declined. The final sample size was 1533 patient visits. Four hundred sixty-nine visits (30.6%) were potentially appropriate for TH based on geography. According to clinic physicians, only 51 of these 469 visits (10.9%) were appropriate for TH. The main reasons for being inappropriate were the need for physical examination (n=238, 57.0%), imaging (n=57, 13.6%), or issues regarding sexuality/privacy (n=45, 10.8%). Of the 51 appropriate visits, 28 patients/families (55.0%) expressed interest in TH. Of those not interested in TH, the main reasons included the desire for a face-to-face encounter and the need to coordinate with other health care appointments. CONCLUSION: Of the patient visits considered for TH (based on the fact that patients lived a considerable distance from the hospital), 10.9% were deemed appropriate for TH by the PAG team, but 45.0% of families/patients in this group said they would prefer a traditional clinic visit. Currently, TH appears to be appropriate for only a small subset of patients/families.

OBJECTIF : La gynécologie pour les enfants et les adolescentes (GEA) est une surspécialité en évolution, et les patientes doivent souvent parcourir de longues distances pour accéder aux soins. La présente étude visait à évaluer si la télésanté (TS) peut convenir pour prodiguer des services de GEA dans un centre de soins tertiaires et pour déterminer l'intérêt des patientes et de la famille. MÉTHODOLOGIE : La présente étude d'observation prospective portait sur des patientes qui avaient fréquenté des cliniques de GEA pendant un an. Les données sur les patientes colligées à chaque visite incluaient le code postal, le diagnostic, l'accès à un hôpital local doté de la TS, l'applicabilité des patientes à la TS et les raisons pour que la patiente et sa famille acceptent la TS. Les visites étaient stratifiées selon le diagnostic afin de déterminer si certaines maladies étaient plus acceptables pour la télésanté. RÉSULTATS : D'après le nombre total de visites tout au long de l'année (du 15 juillet 2008 au 15 juillet 2009), les chercheurs ont demandé à 1 541 patientes (79,6 %) de participer, mais huit (0,5 %) ont refusé. La dimension définitive de l'échantillon était de 1 533 visites-patients. Quatre cent soixante-neuf visites (30,6 %) avaient le potentiel de convenir à la TS d'après le facteur géographique. Selon les médecins de la clinique, seulement 51 de ces 469 visites (10,9 %) convenaient à la TS. Les principales raisons des rejets étaient la nécessité de procéder à un examen physique (n=238, 57,0 %) ou à une imagerie (n=57, 13,6 %) ou les questions relatives à la sexualité ou au respect de la vie privée (n=45, 10,8 %). Des 51 visites pertinentes, 28 patientes ou familles (55,0 %) ont exprimé leur intérêt envers la TS. Parmi les personnes qui n'y étaient pas intéressées, les principales raisons invoquées étaient le souhait d'une rencontre en personne et la nécessité de coordonner avec d'autres rendez-vous de santé. CONCLUSION : Parmi les visites de patientes envisagées pour la TS (parce que les patientes vivaient très loin de l'hôpital), 11 % étaient réputées convenir selon l'équipe de GEA, mais 45,0 % des familles et des patientes de ce groupe affirmaient préférer une visite classique en clinique. Pour l'instant, la TS semble convenir seulement à un petit sous-groupe de patientes et de familles.

Retrospective review of predisposing factors and surgical outcomes in obstetric fistula patients at a single teaching hospital in Western Kenya.

OBJECTIVE: We examined success rates and complications of obstetric fistula (OF) surgical repairs in association with patient and fistula characteristics, including sociocultural and socioeconomic determinants of health. A better understanding of these associations will help guide surgical management and prevent predisposing factors. METHODS: We reviewed the medical records of 86 patients who underwent OF repair at Moi Teaching and Referral Hospital in Kenya between 1999 and 2007. RESULTS: Women with OF presented for repair with a variety of concurrent conditions. Seventy-eight percent had laboured for at least 24 hours; 29% had undergone previous unsuccessful surgery. Of the women who presented at postoperative follow-up, 54% still complained of incontinence. Persistent incontinence was associated with larger, more complicated fistulas and having had previous failed attempts at surgical repair. CONCLUSION: The association of factors such as duration of labour with OF reflects the limited availability of obstetrical care in Western Kenya. There is a significant difference in postoperative success of fistula repair between women with large fistulas or those who had previous failed surgery and other patients. This reflects the importance of primary and secondary prevention.

"No, You Need to Explain What You Are Doing": Obstetric Care Experiences and Preferences of Adolescent Mothers With a History of Childhood Trauma.

STUDY OBJECTIVE: To understand the pregnancy and childbirth experiences and preferences of adolescent mothers with a history of childhood trauma in order to develop trauma-informed care practice recommendations for this unique group. DESIGN: Mixed methods convergent parallel design involving completion of the Adverse Childhood Experiences (ACE) questionnaire, a survey of care experiences and preferences during pregnancy and delivery, and a one-on-one interview. SETTING: hHospital-based medical home program for pregnant and parenting adolescents. PARTICIPANTS: Adolescent and young adult mothers aged 12-22 years, receiving care between June 2018 and June 2019. RESULTS: A total of 29 adolescent mothers completed the questionnaire, out of a potential 38 in the program (76.3% participation). Five went on to complete an interview. The average age was 17.9 years (standard deviation 1.8 years). The mean ACE score was 5.1 out of 10, indicating childhood exposure to an average of 5 different types of potential trauma. A total of 19 participants (65.5%) reported being triggered during pregnancy or postpartum. Trauma memories were elicited during vaginal examinations in the clinic (27.6%) and in the hospital (27.6%), abdominal examinations (13.8%), measurement of vital signs (17.2%), and labor (17.2%). Ten participants (34.5%) felt that the providers delivering their baby knew how to help them cope with trauma memories. Themes that emerged included the following: acknowledgment of trauma by provider, avoiding re-telling of story, building a relationship with provider, choice and control in care, and providing coping strategies. CONCLUSION: A majority of adolescent mothers in our sample experienced trauma memories during pregnancy and postpartum medical interactions. Priorities for trauma-informed care in this population are described.

Prevalence of Rheumatic Heart Disease and Other Cardiac Conditions in Low-Risk Pregnancies in Kenya: A Prospective Echocardiography Screening Study.

Background: Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking. Objectives: Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients. Methods: We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample. Results: The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0-14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6-36.7). Mean screening time was seven minutes (SD 1.7, range: 4-17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6-23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate. Conclusions: The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

Repeat screening for sexually transmitted infection in adolescent obstetric patients.

OBJECTIVE: To determine if repeat screening for sexually transmitted infection is appropriate for adolescent obstetric patients and to identify any risk factors associated with increased risk of contracting a sexually transmitted infection (STI) during pregnancy. METHODS: We conducted a retrospective review of the medical records of adolescent obstetric patients seen over a five-year period in the Young Prenatal Program at the Hospital for Sick Children (Toronto, Ontario). RESULTS: Between January 2003 and December 2007, 201 patients with 211 pregnancies attended the Young Prenatal Program. Of the 211 pregnancies reviewed, all patients had screening at baseline for HIV, syphilis, hepatitis B, chlamydia, gonorrhea, and trichomonas; 173 patients were screened in the third trimester, two were tested at another point in the pregnancy because of symptoms, and 161 were screened at their postpartum visit. In 53 pregnancies, STI was diagnosed either during pregnancy or postpartum. Fourteen patients had multiple sexually transmitted infections for a total of 71 infections. Thirty-four infections were diagnosed at baseline, 15 in the third trimester, two because of symptoms, and seven were diagnosed postpartum. In patients who did not develop an STI during pregnancy, the previous use of contraception (excluding condoms), being in a relationship with the baby's father, and living with their partner were identified as significant protective factors against STI. There was a trend towards significance for contracting an STI in patients with a history of abuse, in those with a higher than average number of sexual partners, and in those with a younger than average age of coitarche. CONCLUSION: Sexually transmitted infections were diagnosed in 25.1% of adolescent pregnancies (53/211) in our cohort. Of the 71 sexually transmitted infections diagnosed, 22.5% (16/71) were diagnosed on routine third trimester screening. Because of the high rates of STI and the small number of identified risk factors, routine repeat screening in the third trimester for chlamydia, gonorrhea, and trichomonas is warranted in pregnant adolescents.

Müllerian duct anomalies and mimics in children and adolescents: correlative intraoperative assessment with clinical imaging.

Müllerian duct anomalies (MDAs) are congenital entities that result from nondevelopment, defective vertical or lateral fusion, or resorption failure of the müllerian (paramesonephric) ducts. MDAs are common, although the majority are asymptomatic, and have been classified by the American Society of Reproductive Medicine according to clinical manifestations, prognosis, and treatment. Accurate diagnosis of an MDA is essential, since the management approach varies depending on the type of malformation. In females, when a müllerian duct becomes obstructed, the patient may present with an abdominal mass and dysmenorrhea. If the patient is not treated in a timely fashion, the consequences can be severe, extending even to infertility. When an MDA is suspected, ultrasonography (US) should be performed initially to delineate any abnormalities in the genital tract. However, US cannot help identify the type of MDA. In contrast, magnetic resonance imaging is a valuable technique for noninvasive evaluation of the female pelvic anatomy and accurate MDA classification. If obstruction is present, surgical correction of the MDA may be required, and further counseling of the patient with regard to reproductive possibilities becomes important. Supplemental material available at http://radiographics.rsnajnls.org/cgi/content/full/29/4/1085/DC1.

Methotrexate in the management of adolescents with ectopic pregnancies: a physician survey.

OBJECTIVE: To assess gynaecologists' management of ectopic pregnancies in adolescents. METHODS: A survey was sent to Canadian gynaecologists, including pediatric gynaecologists, by mail and email. Pediatric gynaecologists in the United States were surveyed by mail. Variations in preferences and practices in the management of ectopic pregnancy were identified, with specific focus on the use of methotrexate. Some possible determinants of alternative management were described, using both descriptive and inferential statistics. RESULTS: A total of 209 physicians responded. Of these, 89 (42.6%) had treated adolescents with ectopic pregnancies (the "treatment group"). There were no statistically significant differences in demographic characteristics of the treatment group compared with the non-treatment group, except for the proportion of adolescents in the physicians' practices and whether or not they provided care for pregnant adolescents. In the treatment group, 84.3% had used methotrexate in the management of adolescents with an ectopic pregnancy. Most physicians (57/89, 64%) stated that they do not use different criteria for managing adolescent and adult patients, although across all age categories only 21.3% to 25.8% stated that age is not a relevant factor; 43.9% and 28.8% would definitely not or probably not offer methotrexate to patients less than 13 and 14-16 years of age, respectively, and 4.8% and 6.2% would definitely not or probably not offer methotrexate to patients 17-19 and more than 19 years of age, respectively. Physicians would definitely not or probably not offer methotrexate to a patient with a history of non-compliance with contraception (48.4%) or of substance abuse (45.9%), or to a patient living alone (62.7%). CONCLUSION: Physicians do report using methotrexate in managing adolescents with ectopic pregnancies, but consider age and compliance variables in their decision-making.

Retrospective review of unintentional female genital trauma at a pediatric referral center.

UNLABELLED: Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair. METHODS: One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated. RESULTS: Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma.Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management. CONCLUSIONS: Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.

The Who, What, Why and When of Gynaecological Referrals for Refugee Women.

Refugees have health needs relating to unstable living situations and poor access to care. We examined the nature of health problems requiring gynaecological referrals for refugee women in Toronto. A retrospective cohort design was used to examine gynaecologic referrals of women at a refugee clinic between December, 2011 and June, 2016. The primary outcome measure was the indications for gynaecological referral. 125 out of 1040 women received a gynaecologic referral for 131 unique concerns. The most common referrals were for abnormal uterine bleeding and cervical dysplasia. Fibroids were prevalent amongst African patients, while referrals for LARCs/sterilization were absent from Middle Eastern patients. 26% of patients referred had a sexual violence history. Refugee women exhibit gynaecologic needs similar to the broader population. Needs vary by geographic origins. As global conflicts shift, so too will this population's needs. High rates of sexual violence history reflect the need for further understanding and intervention.