Intimate partner violence during pregnancy and its association with birth asphyxia in hospitals of Tigray region, Ethiopia.

BACKGROUND: Birth asphyxia is the main cause of neonatal mortality and morbidity worldwide. Some studies indicate intimate partner violence during pregnancy is a risk factor for birth asphyxia. In Ethiopia, intimate partner violence during pregnancy is reported to be high. Despite this high prevalence, there is a lack of data about the association of birth asphyxia and intimate partner violence. The aim of this study was to assess the prevalence of intimate partner violence during pregnancy and its associated factors with birth asphyxia in health facilities in the Tigray region of northern Ethiopia. METHODS: This was an institutional-based cross-sectional study conducted at select health facilities in the Tigray region of Ethiopia. Random sampling technique was employed to select health facilities and systematic sampling was used to select 648 study participants. Data was entered by using Epi info version 3.5.1 and was analyzed using SPSS version 20. Bivariate and multivariate analysis was done to assess the association between exposure to intimate partner violence during pregnancy and birth asphyxia after adjusting for possible confounders. RESULTS: The prevalence of intimate partner violence during pregnancy was 47(7.3%). Eighty two (12.7%) babies were delivered with birth asphyxia. Intimate partner violence during pregnancy had a significant association with birth asphyxia, AOR (95% CI) = 4.4(2-9.8). In addition to this, other factors that were associated with birth asphyxia include place of residence [ AOR (95% CI) = 2.7(1.55-4.8)], age > 19 [AOR (95% CI) = 2.9(1.29-6.5)], age 20-35 [AOR (95% CI) = 3.1(1.06-9.3)], gestational age < 37 weeks [AOR(95% CI) = 7.2(3.5-14.8)] and low birth weight [AOR(95% CI) = 3.9(2.1-7.3)]. CONCLUSIONS: The prevalence of birth asphyxia in this study is high and is further increased by intimate partner violence during pregnancy. Health care providers and policy makers should take measures aimed at preventing intimate partner violence during pregnancy to reduce harm to the mother and adverse birth outcomes.

Reliability and validity of the Sidaamu Afoo version of the pelvic organ prolapse symptom score questionnaire.

BACKGROUND: Both for clinical and research purposes, it is critical that clinicians and researchers use a tool that is trans-culturally adapted and tested for its psychometric properties. The English version of the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire was developed in 2000. Since then it has been translated into other languages and verified. However, the tool has not been adapted for use in Sidaamu Afoo language in the Sidama Region of Ethiopia. OBJECTIVE: This study aimed to translate and adapt the Pelvic Organ Prolapse Symptom Score questionnaire into Sidaamu Afoo and evaluate its psychometric properties. METHODS: A total of 100 women with symptomatic prolapse completed version-2 of the POP-SS questionnaire during the first round of interviews, and 61 of them completed the questionnaire during the second round of interviews (to establish the test-retest reliability). We adapted the scale translation process recommended by Beaton and his colleagues. The content validity was assessed using the content validity index and the construct validity was done based on exploratory factor analysis using the principal component analysis model. The criterion validity was evaluated by using the Kruskal-Wallis test based on stages of the prolapse established via pelvic examination. The internal consistency reliability of the scale was assessed using Cronbach's alpha value, and test-retest reliability was evaluated using the intraclass correlation coefficient. RESULTS: The questionnaire was successfully translated to Sidaamu Afoo, and achieved a good content validity index (0.88), high internal consistency (Cronbach's alpha of 0.79), and test-retest reliability (an intraclass correlation coefficient of 0.83). The exploratory factor analysis revealed two factors based on an eigenvalue of 1. The two factors explained 70.6% of the common variance, and each item loaded well (0.61 to 0.92) to its corresponding factor. There is a significant difference in the median score of prolapse symptoms across different stages of prolapse (Kruskal-Wallis χ2, 17.5, p < 0.001). CONCLUSION: The Sidaamu Afoo version of the POP-SS tool is valid and reliable. Further studies that involve a balanced number of women in each stage of prolapse are needed to avoid the ceiling and floor effects.

Rectovaginal Fistula Management in Low-Resource Settings.

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.

Network-Based Differences in the Vaginal and Bladder Microbial Communities Between Women With and Without Urgency Urinary Incontinence.

Background: Little is known about the relationship of proximal urogenital microbiomes in the bladder and the vagina and how this contributes to bladder health. In this study, we use a microbial ecology and network framework to understand the dynamics of interactions/co-occurrences of bacteria in the bladder and vagina in women with and without urgency urinary incontinence (UUI). Methods: We collected vaginal swabs and catheterized urine specimens from 20 women with UUI (cases) and 30 women without UUI (controls). We sequenced the V4 region of the bacterial 16S rRNA gene and evaluated using alpha and beta diversity metrics. We used microbial network analysis to detect interactions in the microbiome and the betweenness centrality measure to identify central bacteria in the microbial network. Bacteria exhibiting maximum betweenness centrality are considered central to the microbe-wide networks and likely maintain the overall microbial network structure. Results: There were no significant differences in the vaginal or bladder microbiomes between cases and controls using alpha and beta diversity. Silhouette metric analysis identified two distinct microbiome clusters in both the bladder and vagina. One cluster was dominated by Lactobacillus genus while the other was more diverse. Network-based analyses demonstrated that vaginal and bladder microbial networks were different between cases and controls. In the vagina, there were similar numbers of genera and subgroup clusters in each network for cases and controls. However, cases tend to have more unique bacterial co-occurrences. While Bacteroides and Lactobacillus were the central bacteria with the highest betweenness centrality in controls, Aerococcus had the highest centrality in cases and correlated with bacteria commonly associated with bacterial vaginosis. In the bladder, cases have less than half as many network clusters compared to controls. Lactobacillus was the central bacteria in both groups but associated with several known uropathogens in cases. The number of shared bacterial genera between the bladder and the vagina differed between cases and controls, with cases having larger overlap (43%) compared to controls (29%). Conclusion: Our study shows overlaps in microbial communities of bladder and vagina, with higher overlap in cases. We also identified differences in the bacteria that are central to the overall community structure.

The Impact of Local Estrogen on the Urogenital Microbiome in Genitourinary Syndrome of Menopause: A Randomized-Controlled Trial.

IMPORTANCE: The postmenopausal urinary bladder microbiome is not well defined. OBJECTIVES: The aims of this study were to characterize the effect of vaginal estrogen on the vaginal and urinary bladder microbiome in postmenopausal women and describe any clinical associations with the symptoms of genitourinary syndrome of menopause. STUDY DESIGN: This was a participant-masked, randomized controlled trial comparing the effect of a 12-week course of an estrogen-containing vaginal ring to a placebo vaginal ring. Standardized evaluations were performed at baseline and 12 weeks. Vaginal samples were obtained for pH, vaginal maturation index, and microbiome analysis. Concomitant catheterized urine samples were obtained for microbiome analysis. 16S ribosomal RNA gene sequencing was performed to characterize the resident microbial communities, with Lactobacillus relative abundance as the primary outcome variable. Genitourinary syndrome of menopause symptoms was measured using validated questionnaires (Pelvic Floor Distress Inventory-Short Form, Female Sexual Function Index, Vulvovaginal Symptoms Questionnaire). RESULTS: Of the 39 postmenopausal women randomized, baseline characteristics were similar between arms, with a mean age of 62 years and mean vaginal pH of 5.0. Using intention-to-treat analysis, there were no significant changes in vaginal or urinary Lactobacillus relative abundance. Two participants in each arm removed their ring prior to the end of the study. Eighty percent of participants experienced at least 1 bothersome genitourinary syndrome of menopause symptom. Vulvovaginal dryness and urinary frequency were most common at baseline, whereas painful intercourse and urinary urgency were most common at the final visit, none of which were statistically significant. CONCLUSIONS: Our study did not show a significant change in the bacterial composition of the vaginal or urinary bladder microbiome after either vaginal ring in this relatively asymptomatic postmenopausal population.

Characterizing persistent urinary incontinence after successful fistula closure: the Uganda experience.

BACKGROUND: Obstetric fistula is a devastating childbirth injury. Despite successful closure of the fistula, 16% to 55% of women suffer from persistent urinary incontinence after surgery. OBJECTIVE: This study assessed the type and severity of persistent incontinence after successful fistula closure and its impact on the quality of life of Ugandan women post-fistula treatment. STUDY DESIGN: This cross-sectional study enrolled women with a history of obstetric fistula repair who continued to have persistent urinary incontinence (cases, N=36) and women without incontinence (controls, N=52) after successful fistula closure. Data were collected in central and eastern Uganda between 2017 and 2019. All the participants completed a semistructured questionnaire. Cases underwent a clinical evaluation and a 2-hour pad test and completed a series of incontinence questionnaires, including two novel tools designed to assess the severity of incontinence in low-literacy populations. RESULTS: Cases were more likely to have acquired a fistula during their first delivery (63% vs 37%, P=.02), were younger when they developed a fistula (20.3±5.8 vs 24.8±7.5 years old, P=.003), and were more likely to have had >2 fistula surgeries (67% vs 2%, P≤.001). Cases reported a much higher rate of planned home birth for their index pregnancy compared to controls (44% vs 11%), though only 14% of cases and 12% of controls actually delivered at home. Cases reported higher rates of pain with intercourse (36% vs 18%, P=.05), but recent sexual activity status (intercourse within the previous six months) was not significantly different between the groups (47% vs 62%, P=.18). Among cases, 67% reported stress incontinence, 47% reported urgency incontinence, and 47% reported mixed incontinence. The cough stress test was successfully done with 92% of the cases, and of these, almost all (97%) had a positive cough stress test. More than half (53%) rated their incontinence as "very severe," which was consistent with objective findings. The 24-hour voiding diary indicated both high urinary frequency (average 14) and very frequent leakage episodes (average 20). Two-hour pad-tests indicated that 86% of cases had >4 g change in pad weight within 2 hours. Women with more severe incontinence reported a more negative impact on their quality of life. The mean score of the International Consultation on Incontinence Questionnaire-Quality of Life was 62.77±12.76 (range, 28-76, median=67), with a higher score indicating a greater impact on the quality of life. There was also a high mental health burden, with both cases and controls reporting high rates of suicidal ideation at any point since developing fistula (36% vs 31%, P=.67). CONCLUSION: Women with obstetric fistulas continue to suffer from severe persistent urinary incontinence even after successful fistula closure. Both stress and urgency incontinence are highly prevalent in this population. Worsening severity of incontinence is associated with a greater negative impact on the quality of life.

Emerging Frontline Leaders' Voices in Response to COVID-19 Crisis.

BACKGROUND: The COVID-19 pandemic has significantly affected healthcare institutions, introducing new challenges for nurse leaders and their colleagues. However, little is known about how the pandemic has specifically affected the lives of these leaders and what methods and strategies they are using to overcome pandemic-related challenges. OBJECTIVES: The aim of this study was to examine the effect of the 2019 pandemic on emerging healthcare leaders and highlight methods and strategies they used to overcome pandemic-related challenges. METHODS: The participants in this study represent a diverse group of interprofessional healthcare faculty enrolled in a transformational leadership course (Paths to Leadership) when the pandemic first appeared. Three months into the pandemic, the leadership cohort was invited to participate in this qualitative study, exploring four questions: Q1: How have you transformed your working styles in response to the pandemic? Q2: How have you adjusted your personal life in response to the pandemic? Q3: How have you used leadership skills learned from Paths to Leadership during the pandemic? Q4: What lessons have you learned from the pandemic? Participant narratives were analyzed by a team of nurse researchers using conventional qualitative content analysis. RESULTS: Themes for Q1 (working styles) included shifted from face-to-face to telework, faced novel disease and decisions, worked more from home, and challenged to maintain contact with professional peers and team. Themes for Q2 (personal life) included accommodate adults working and children learning from home, looked for and found the positive, and continue to struggle. Themes for Q3 (leadership skills) included reflective practice, listening, holding, and reframing. Finally, themes for Q4 (pandemic lessons) included leadership, human connection, be prepared, taking care of ourselves, and connecting with nature. DISCUSSION: The 2019 pandemic brought hardships and opportunities to faculty members enrolled in an interprofessional transformational leadership course. In conjunction with this course, the pandemic provided a unique opportunity for participants to apply newly acquired relationship building, positive organizational psychology, and reframing skills during a time of crisis. Nursing leaders, whose educational offerings may be immediately "put to the test," may find our lessons learned helpful as they develop strategies to cope with unanticipated future challenges.

Population based cohort study of fetal deaths, and neonatal and perinatal mortality at term within a Somali diaspora.

BACKGROUND: Somali women deliver at greater gestational age with limited information on the associated perinatal mortality. Our objective is to compare perinatal mortality among Somali women with the population rates. METHODS: This is a retrospective cohort study from all births that occurred in Minnesota between 2011 and 2017. Information was obtained from certificates of birth, and neonatal and fetal death. Data was abstracted from 470,550 non-anomalous births ≥37 and ≤ 42 weeks of gestation. The study population included U.S. born White, U.S. born Black, women born in Somalia or self-identified as Somali, and women who identified as Hispanic regardless of place of birth (377,426). We excluded births < 37 weeks and > 42 weeks, > 1 fetus, age < 18 or > 45 years, or women of other ethnicities. The exposure was documented ethnicity or place of birth, and the outcomes were live birth, fetal death, neonatal death prior to 28 days, and perinatal mortality rates. These were calculated using binomial proportions with 95% confidence intervals and compared using odds ratios adjusted (aOR) for diabetes, hypertension and maternal body mass index. RESULTS: The aOR [95%CI] for stillbirth rate in the Somali cohort was greater than for U.S. born White (2.05 [1.49-2.83]) and Hispanic women (1.90 [1.30-2.79]), but similar to U.S. born Black women (0.88 [0.57-1.34]). Neonatal death rates were greater than for U.S. born White (1.84 [1.36-2.48], U.S. born Black women (1.47 [1.04-2.06]) and Hispanic women (1.47 [1.05-2.06]). This did not change after analysis was restricted to those with spontaneous onset of labor. When analyzed by week, at 42 weeks Somali aOR for neonatal death was the same as for U.S. born White women, but compared against U.S. born Black and Hispanic women, was significantly lower. CONCLUSIONS: The later mean gestational age at delivery among women of Somali ethnicity is associated with greater overall risk for stillbirth and neonatal death rates at term, except compared against U.S. born Black women with whom stillbirth rates were not different. At 42 weeks, Somali neonatal mortality decreased and was comparable to that of the U.S. born White population and was lower than that of the other minorities.

Pain Management and Its Possible Implementation Research in North Ethiopia: A before and after Study.

BACKGROUND: Though there is an effective intervention, pain after surgical intervention is undermanaged worldwide. A systematic implementation is required to increase the utilization of available evidence-based intervention to manage the inevitable pain after surgery. The aim of this research project is to develop a scalable model for managing pain after cesarean section by implementing the World Health Organization's (WHO) pain management guidelines through a combination of implementation research and quality improvement methods. METHODS: We implemented the World Health Organization (WHO) pain management guidelines using effective implementation strategies. First, we conducted a formative qualitative exploration to identify enablers and obstacles. In addition, we took base-line assessment on pain management implementation process and outcome using a checklist prepared from the guideline and an adapted American Pain Outcome assessment tool version 2010, respectively. Then, we integrated the guidelines into the existing practice by using collaborative iterative learning strategy. We analyzed the data by Statistical Packages for Social Sciences (SPSS) version 21. We compared the before and after data using chi-squared and Fischer's exact test. A change in any measurement was considered as significant at p value 0.05. RESULT: We collected data from 106 mothers before and 110 mothers after intervention implementation. We successfully integrated pain as a fifth vital sign in more than 87% (p value <0.001) of patient, and fidelity was approximately 59% (p value <0.001). In addition, we significantly improved pain outcome measures after the implementation of the intervention. Conclusion and Recommendations. A systematic approach to implement pain management guidelines was successful. We recommend the ward sustain these gains and that hospital, the region, and the nation to replicate the success.

Characteristics of persistent urinary incontinence after successful fistula closure in Ethiopian women.

INTRODUCTION AND HYPOTHESIS: Obstetric fistulas have devastating consequences for women. Although surgical repair is largely successful in closing the defect, many women with successful fistula closure report persistent urinary incontinence. Our study is aimed at characterizing incontinence after successful fistula repair and its impact on quality of life. METHODS: This cross-sectional study enrolled women with a history of successful obstetric fistula closure with (n = 51; cases) or without (n = 50; controls) persistent urinary incontinence. Data were collected in Mekelle, Ethiopia, between 2016 and 2018. All cases underwent clinical evaluation and completed questionnaires characterizing the type, severity, and impact of incontinence. RESULTS: Cases were significantly more likely to have acquired their fistula at an earlier age and with their first vaginal delivery compared with controls. Almost all cases reported both stress (98%) and urgency (94%) incontinence, and half reported constant urinary leakage (49%) despite successful fistula closure. Of cases who completed urodynamic evaluation (n = 22), all had genuine stress incontinence and none had detrusor overactivity. All cases reported moderate to severe (80.4%) or very severe (19.6%) incontinence (measured by ICIQ-SF) and this had a moderate to severe negative impact on their quality of life (as measured by ICIQ-QoL). Although history of suicidal ideation was not significantly different between the groups, among those with suicidal ideation, cases were more likely to report having made a plan and/or attempted to commit suicide. CONCLUSIONS: When urinary incontinence persists after successful fistula closure, it tends to be severe and of mixed etiology and has a significant negative impact on quality of life and mental health.

Surgical Management of Pelvic Organ Prolapse in Ethiopian Women: What Is the Preferred Approach?

OBJECTIVES: The aim of this study was to determine the most effective approach to surgical repair of pelvic organ prolapse for Ethiopian women and to characterize this population. METHODS: This is a prospective cohort study of women presenting for prolapse repair. Demographics and assessments of prolapse were obtained preoperatively. Information surrounding the surgical encounter was collected. The same anatomic and symptomatic measures were ascertained postoperatively. Information regarding surgical complications was collected. RESULTS: Two hundred thirty-three women with stage III or IV prolapse underwent surgical prolapse repair between March 2015 and November 2017. Seventy-eight of these women participated with a median length of follow-up of 255 days. All of the sacrocolpopexy patients (n = 21) and 56 of 57 vaginal repair patients had follow-up anatomic data. Anatomic failure as defined by Pelvic Organ Prolapse-Quantification (Ba, C, or Bp > 0) occurred in 0% (0/21) of sacrocolpopexy patients and 34% (19/56) of vaginal repair patients (P = 0.005). Symptomatic failure, as defined by self-reported recurrence of vaginal bulge, occurred in 0% (0/21) of sacrocolpopexy patients and 23% (13/56) of vaginal repair patients (P = 0.015). A global assessment of improvement (worse, same, or improved) revealed that 100% (21/21) of sacrocolpopexy patients reported improvement, whereas 91% (50/55) of vaginal repair patients reported improvement, 7% (4/55) reported being the same, and 2% (1/55) reported being worse. There were 2 intraoperative complications and 3 postoperative complications. There were no cases of mesh erosion. CONCLUSIONS: Although both vaginal and abdominal routes of prolapse surgery seem to be safe, an abdominal approach with mesh augmentation may be the preferred surgical repair in Ethiopian women.

Capacity building in female pelvic medicine and reconstructive surgery: Global Health Partnership beyond fistula care in Ethiopia.

OBJECTIVE: Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it. METHODS: Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia. RESULTS: This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum. CONCLUSION: We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

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.

Complex Female Pelvic Pain: A Case Series From a Multidisciplinary Clinic in Urogynecology and Physiatry.

OBJECTIVE: The internal pelvic floor muscles that support the pelvic viscera lie within the external pelvic structures, which support posture and locomotion. The presence of pain in the hip, groin, leg, abdomen, and/or back in patients with pelvic pain suggests that external pelvic sites may act as pain generators that contribute to chronic pelvic pain (CPP). The aim of this study was to report musculoskeletal diagnoses resulting from including a physiatry evaluation as part of a Multidisciplinary Pelvic Pain Clinic for women with complex chronic pain. METHODS: This retrospective case series was conducted by chart review of all women attending the clinic from February 2016 through March 2018. Variable definitions were created for each demographic and clinical characteristic and used to guide a structured review of the chart. Descriptive statistical analysis was performed. RESULTS: Ninety-six percent of the 68 women (mean age, 51 years) had CPP of 6 months' duration or longer. Levator ani tenderness was present in 81% and obturator internus tenderness in 81%. Seventy-one percent of women had failed pelvic physical therapy. Musculoskeletal diagnoses included osteoarthritis, tendinopathies, enthesopathies, osteitis pubis, ischiofemoral impingement, Paget disease, and other systemic conditions. CONCLUSIONS: Musculoskeletal abnormalities were common in this highly selected cohort of complex CPP cases with external pelvic symptoms. The imaging findings and specific diagnoses allowed targeted therapy beyond generalized physical therapy for CPP. The expertise of urogynecologists and physical therapists who evaluate the internal pelvic muscles and viscera combined with the physiatrist's expertise in musculoskeletal assessment and imaging provides an expanded, collaborative approach for managing these patients.

Community profiling of the urinary microbiota: considerations for low-biomass samples.

Many studies have shown that the urinary tract harbours its own microbial community known as the urinary microbiota, which have been implicated in urinary tract disorders. This observation contradicts the long-held notion that urine is a sterile biofluid in the absence of acute infection of the urinary tract. In light of this new discovery, many basic questions that are crucial for understanding the role of the urinary microbiota in human health and disease remain unanswered. Given that the urinary microbiota is an emerging area of study, optimized techniques and protocols to identify microorganisms in the urinary tract are still being established. However, the low microbial biomass and close proximity to higher microbial biomass environments (for example, the vagina) present distinct methodological challenges for microbial community profiling of the urinary microbiota. A clear understanding of the unique technical considerations for obtaining and analysing low microbial biomass samples, as well the influence of key elements of experimental design and computational analysis on downstream interpretation, will improve our ability to interpret and compare results across methods and studies and is relevant for studies profiling the urinary microbiota and other sites of low microbial abundance.

Maternal IL-6 during pregnancy can be estimated from newborn brain connectivity and predicts future working memory in offspring.

Several lines of evidence support the link between maternal inflammation during pregnancy and increased likelihood of neurodevelopmental and psychiatric disorders in offspring. This longitudinal study seeks to advance understanding regarding implications of systemic maternal inflammation during pregnancy, indexed by plasma interleukin-6 (IL-6) concentrations, for large-scale brain system development and emerging executive function skills in offspring. We assessed maternal IL-6 during pregnancy, functional magnetic resonance imaging acquired in neonates, and working memory (an important component of executive function) at 2 years of age. Functional connectivity within and between multiple neonatal brain networks can be modeled to estimate maternal IL-6 concentrations during pregnancy. Brain regions heavily weighted in these models overlap substantially with those supporting working memory in a large meta-analysis. Maternal IL-6 also directly accounts for a portion of the variance of working memory at 2 years of age. Findings highlight the association of maternal inflammation during pregnancy with the developing functional architecture of the brain and emerging executive function.

Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center.

INTRODUCTION AND HYPOTHESIS: The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure. METHODS: The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as "easy," "of intermediate complexity," or "difficult" based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression. RESULTS: The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success ("closed and dry") was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for "easy" cases, 68% for "intermediate" cases, and 57% success for "difficult" cases. Success decreased with increasing numbers of previous attempts at surgical repair. CONCLUSIONS: These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.

Does the Urinary Microbiome Play a Role in Urgency Urinary Incontinence and Its Severity?

OBJECTIVES: Traditionally, the urinary tract has been thought to be sterile in the absence of a clinically identifiable infection. However, recent evidence suggests that the urinary tract harbors a variety of bacterial species, known collectively as the urinary microbiome, even when clinical cultures are negative. Whether these bacteria promote urinary health or contribute to urinary tract disease remains unknown. Emerging evidence indicates that a shift in the urinary microbiome may play an important role in urgency urinary incontinence (UUI). The goal of this prospective pilot study was to determine how the urinary microbiome is different between women with and without UUI. We also sought to identify if characteristics of the urinary microbiome are associated with UUI severity. METHODS: We collected urine from clinically well-characterized women with UUI (n = 10) and normal bladder function (n = 10) using a transurethral catheter to avoid bacterial contamination from external tissue. To characterize the resident microbial community, we amplified the bacterial 16S rRNA gene by PCR and performed sequencing using Illumina MiSeq. Sequences were processed using the workflow package QIIME. We identified bacteria that had differential relative abundance between UUI and controls using DESeq2 to fit generalized linear models based on the negative binomial distribution. We also identified relationships between the diversity of the urinary microbiome and severity of UUI symptoms with Pearson's correlation coefficient. RESULTS: We successfully extracted and sequenced bacterial DNA from 95% of the urine samples and identified that there is a polymicrobial community in the female bladder in both healthy controls and women with UUI. We found the relative abundance of 14 bacteria significantly differed between control and UUI samples. Furthermore, we established that an increase in UUI symptom severity is associated with a decrease in microbial diversity in women with UUI. CONCLUSIONS: Our study provides further characterization of the urinary microbiome in both healthy controls and extensively phenotyped women with UUI. Our results also suggest that the urinary microbiome may play an important role in the pathophysiology of UUI and that the loss of microbial diversity may be associated with clinical severity.

Obesity and Pelvic Floor Dysfunction: Battling the Bulge.

IMPORTANCE: Pelvic floor disorders (PFDs) comprise a broad spectrum of clinical conditions, including urinary incontinence, pelvic organ prolapse, fecal incontinence, and defecatory dysfunction. These disorders are common conditions that generate significant medical, emotional, social, and economic issues for many women. Obese women are disproportionately affected compared with their normal-weight peers, with more than half of women with a body mass index of greater than 35 kg/m(2) reporting a PFD, compared with only 32% in women with a normal body mass index. Despite this prevalence, little research is available to help guide and tailor treatment in obese populations. OBJECTIVE: This review outlines current knowledge regarding the relative contribution of obesity to PFDs, as well as its effect on treatment implications. EVIDENCE ACQUISITION: Literature relating to the incidence and treatment of PFDs in obese populations was reviewed. RESULTS: Both nonsurgical and surgical weight loss improves all PFDs. Obese women benefit from pelvic floor training, biofeedback, and pharmacologic treatments of urinary and fecal incontinence. Surgical treatments of stress urinary incontinence note increased operative times and perhaps slightly lower cure rates, but overall good treatment success in obese women. No increased risks of complications or treatment failure were noted in obese women treated for prolapse surgically, and pessaries work well for both prolapse and stress urinary incontinence in obese women. CONCLUSIONS/RELEVANCE: Although literature regarding treatment of PFDs in obese women is limited, the available evidence demonstrates good treatment outcomes in obese populations. Further research into how to best counsel and optimize treatment of obese patients is essential as the obesity epidemic continues.