Client-reported quality of facility-managed medication abortion compared with pharmacy-sourced self-managed abortion in Bangladesh.

OBJECTIVE: We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. METHODS: We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. RESULTS: Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). CONCLUSIONS: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

Association of maternal age 35 years and over and prenatal care utilization, preterm birth, and low birth weight, Mexico 2008-2019.

OBJECTIVE: To evaluate prenatal care utilization, low birth weight, and preterm birth among women aged 35 years and older in Mexico from 2008 to 2019. METHODS: We conducted a historical cohort study of all singleton live births in Mexico from 2008 to 2019. Outcomes were inadequate prenatal care, preterm birth, and low birth weight. We compared outcomes among women aged 35-39, 40-44, and 45-49 years with births to women aged 20-34 years. We used logistic regression to account for individual, health system, and contextual confounders. RESULTS: We included a total of 19 526 922 births; 2 325 725 (11.9%) were to women aged 35 years and older. Women aged 45-49 years had the lowest levels of education, were more likely to be uninsured, and came from highly marginalized municipalities while those aged 35-39 years had the highest levels of education and insurance and came from the least marginalized municipalities. The odds of inadequate prenatal care (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI] 1.09-1.15), preterm birth (aOR 2.05; 95% CI 1.97-2.13), and low birth weight (aOR 2.03; 95% CI 1.95-2.12) were highest for women aged 45-49 years, compared with women aged 20-34 years. The odds of adverse perinatal outcomes increased progressively with age, but the odds of inadequate prenatal care (aOR 0.77; 95% CI 0.76-0.77) were lowest for women aged 35-39 years, when compared with women aged 20-34 years. CONCLUSION: Women who deliver at 35 years and over are a heterogeneous group in Mexico. Being 35 years old and older is associated with increases in preterm birth and low birth weight neonates. Women who give birth between 45 and 49 years may be especially vulnerable.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia.

Introduction: Disrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia. Study Design: We conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives. Results: Participants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion. Conclusions: Participants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

Adolescent Reproductive Health Outcomes Among Mexican-Origin Women on Both Sides of the U.S.-Mexico Border.

PURPOSE: Much reproductive health research on the Latina population overlooks heterogeneity by national origin, nativity, and age and also ignores how U.S.-based populations differ from those in "sending" nations. The purpose of this study is to describe a history of adolescent birth, age at first sex, and contraceptive use at first sex in the Mexican-origin population in both the United States and Mexico. METHODS: We developed a binational dataset merging two comparable nationally representative cross-sectional surveys in the United States and Mexico and used covariate balancing propensity scores to balance the age structure of our four samples: U.S.-born Latinas of Mexican origin, foreign-born Latinas of Mexican origin, U.S.-born non-Latina Whites, and Mexican women residing in Mexico. We used a negative binomial regression and calculated the predicted probability of experiencing at least one adolescent birth for each ethnicity/nativity group, stratified by 5-year age group. We also described age and contraceptive use at first sex. RESULTS: Foreign-born Latinas of Mexican origin and Mexicans in Mexico had similar adjusted probabilities of reporting an adolescent birth (30.1% and 29.9%, respectively), which were higher than those of Mexican-Americans (26.2%) and U.S.-born non-Latina Whites (11.6%). History of an adolescent birth is declining across all four groups among younger ages. Differences do not appear to be driven by the timing of first sex but by contraceptive use, which is increasing among younger age groups. DISCUSSION: Access to and use of effective contraception rather than timing of initiation of sexual activity is a key determinant of U.S. Latina and Mexican adolescent births.

Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients.

OBJECTIVE: To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings. METHODS: We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. RESULTS: Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). CONCLUSION: ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

Effects of simvastatin on white matter integrity in healthy middle-aged adults.

BACKGROUND: The brain is the most cholesterol-rich organ and myelin contains 70% of total brain cholesterol. Statins are potent cholesterol-lowing medications used by millions of adults for prevention of vascular disease, yet the effect of statins on cholesterol-rich brain white matter (WM) is largely unknown. METHODS: We used longitudinal neuroimaging data acquired from 73 healthy, cognitively unimpaired, statin-naïve, middle-aged adults during an 18-month randomized controlled trial of simvastatin 40 mg daily (n = 35) or matching placebo (n = 38). ANCOVA models (covariates: age, sex, APOE-ɛ4) tested the effect of treatment group on percent change in WM, gray matter (GM), and WM hyperintensity (WMH) neuroimaging measures at each study visit. Mediation analysis tested the indirect effects of simvastatin on WM microstructure through change in serum total cholesterol levels. RESULTS: At 18 months, the simvastatin group showed a significant preservation in global WM fractional anisotropy (ß = 0.88%, 95% CI 0.27 to 1.50, P = 0.005), radial diffusivity (ß = -1.10%, 95% CI -2.13 to -0.06, P = 0.039), and WM volume (ß = 0.72%, 95% CI 0.13 to 1.32, P = 0.018) relative to the placebo group. There was no significant effect of simvastatin on GM or WMH volume. Change in serum total cholesterol mediated approximately 30% of the effect of simvastatin on WM microstructure. CONCLUSIONS: Simvastatin treatment in healthy, middle-aged adults resulted in preserved WM microstructure and volume at 18 months. The partial mediation by serum cholesterol reduction suggests both peripheral and central mechanisms. Future studies are needed to determine whether these effects persist and translate to cognitive outcomes. TRIAL REGISTRATION: NCT00939822 (ClinicalTrials.gov).

Provider Perspectives on Persistent Urinary Incontinence Following Obstetric Fistula Repair in Ethiopia.

Each year an estimated 50,000 to 100,000 women worldwide are affected by obstetric fistula. This devastating but preventable maternal morbidity leaves women incontinent, stigmatized, isolated, and often with a still birth. While fistula rates in Ethiopia have declined in recent years, estimates range from 7 to 40 percent of women suffer from persistent urinary incontinence after successful closure of their fistula. Few studies have focused on the unique experiences and challenges that providers face treating fistula patients, particularly those who experience persistent urinary incontinence. The goal of this research is to characterize the fistula provider's accounts of how to manage, support, and understand their patient's experience. Semi-structured interviews were conducted with a purposive sample of fistula care providers in Mekelle and Addis Ababa, Ethiopia. The main themes that emerged were a perceived exacerbated impact on quality of life for women with persistent urinary incontinence; a "double hit" of isolation from both their community and from other recovered fistula patients; how the church both influences how patients internalize their injury and provides them with hope and support; and the need for comprehensive and compassionate fistula care. Understanding how providers perceive and relate to their patients provides valuable insight to the unique challenges of treating this population and may better inform treatment programmes to address the gap between patient needs and current fistula care models.

Do Maternal Knowledge and Attitudes towards Childhood Immunizations in Rural Uganda Correlate with Complete Childhood Vaccination?

Improving childhood vaccination coverage and timeliness is a key health policy objective in many developing countries such as Uganda. Of the many factors known to influence uptake of childhood immunizations in under resourced settings, parents' understanding and perception of childhood immunizations has largely been overlooked. The aims of this study were to survey mothers' knowledge and attitudes towards childhood immunizations and then determine if these variables correlate with the timely vaccination coverage of their children. From September to December 2013, we conducted a cross-sectional survey of 1,000 parous women in rural Sheema district in southwest Uganda. The survey collected socio-demographic data and knowledge and attitudes towards childhood immunizations. For the women with at least one child between the age of one month and five years who also had a vaccination card available for the child (N = 302), the vaccination status of this child was assessed. 88% of these children received age-appropriate, on-time immunizations. 93.5% of the women were able to state that childhood immunizations protect children from diseases. The women not able to point this out were significantly more likely to have an under-vaccinated child (PR 1.354: 95% CI 1.018-1.802). When asked why vaccination rates may be low in their community, the two most common responses were "fearful of side effects" and "ignorance/disinterest/laziness" (44% each). The factors influencing caregivers' demand for childhood immunizations vary widely between, and also within, developing countries. Research that elucidates local knowledge and attitudes, like this study, allows for decisions and policy pertaining to vaccination programs to be more effective at improving child vaccination rates.

VA mental health clinician experiences and attitudes toward OpenNotes.

OBJECTIVE: To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online. METHOD: A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. RESULTS: Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. CONCLUSION: As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes.

The effects of ramipril in individuals at risk for Alzheimer's disease: results of a pilot clinical trial.

Research shows that certain antihypertensives taken during midlife confer Alzheimer's disease (AD) related benefits in later life. We conducted a clinical trial to evaluate the extent to which the angiotensin converting enzyme inhibitor (ACE-I), ramipril, affects AD biomarkers including cerebrospinal fluid (CSF) amyloid-ß (Aß) levels and ACE activity, arterial function, and cognition in participants with a parental history of AD. This four month randomized, double-blind, placebo-controlled, pilot clinical trial evaluated the effects of ramipril, a blood-brain-barrier crossing ACE-I, in cognitively healthy individuals with mild, or Stage I hypertension. Fourteen participants were stratified by gender and apolipoprotein E ε4 (APOE ε4) status and randomized to receive 5 mg of ramipril or matching placebo daily. Participants were assessed at baseline and month 4 on measures of CSF Aß(1-42) and ACE activity, arterial function, and cognition. Participants were middle-aged (mean 54 y) and highly educated (mean 15.4 y), and included 50% men and 50% APOE ε4 carriers. While results did not show a treatment effect on CSF Aß(1-42) (p = 0.836), data revealed that ramipril can inhibit CSF ACE activity (p = 0.009) and improve blood pressure, however, there were no differences between groups in arterial function or cognition. In this study, ramipril therapy inhibited CSF ACE activity and improved blood pressure, but did not influence CSF Aß1-42. While larger trials are needed to confirm our CSF Aß results, it is possible that prior research reporting benefits of ACE-I during midlife may be attributed to alternative mechanisms including improvements in cerebral blood flow or the prevention of angiotensin II-mediated inhibition of acetylcholine.