Implementing Innovations in Global Women's, Children's, and Adolescents' Health: Realizing the Potential for Implementation Science.

The launch of the United Nations Sustainable Development Goals and the new Secretary General's Global Strategy for Women's, Children's, and Adolescents' Health are a window of opportunity for improving the health and well-being of women, children, and adolescents in the United States and around the world. Realizing the full potential of this historic moment will require that we improve our ability to successfully implement life-saving and life-enhancing innovations, particularly in low-resource settings. Implementation science, a new and rapidly evolving field that addresses the "how-to" component of providing sustainable quality services at scale, can make an important contribution on this front. A synthesis of the implementation science evidence indicates that three interrelated factors are required for successful, sustainable outcomes at scale: 1) effective innovations, 2) effective implementation, and 3) enabling contexts. Implementation science addresses the interaction among these factors to help make innovations more usable, to build ongoing capacity to assure the effective implementation of these innovations, and to ensure enabling contexts to sustain their full and effective use in practice. Improving access to quality services will require transforming health care systems and, therefore, much of the focus of implementation science in global health is on improving the ability of health systems to serve as enabling contexts. The field of implementation science is inherently interdisciplinary and academe will need to respond by facilitating collaboration among scientists from relevant disciplines, including evaluation, improvement, and systems sciences. Platforms and programs to facilitate collaborations among researchers, practitioners, policymakers, and funders are likewise essential.

Obstetrics and Gynecology Resident Interest and Participation in Global Health.

OBJECTIVE: To evaluate obstetrics and gynecology resident interest and participation in global health experiences and elucidate factors associated with resident expectation for involvement. METHODS: A voluntary, anonymous survey was administered to U.S. obstetrics and gynecology residents before the 2015 Council on Resident Education in Obstetrics and Gynecology in-training examination. The 23-item survey gathered demographic data and queried resident interest and participation in global health. Factors associated with resident expectation for participation in global health were analyzed by Pearson χ tests. RESULTS: Of the 5,005 eligible examinees administered the survey, 4,929 completed at least a portion of the survey for a response rate of 98.5%. Global health was rated as "somewhat important" or "very important" by 96.3% (3,761/3,904) of residents. "Educational opportunity" (69.2%) and "humanitarian effort" (17.7%) were cited as the two most important aspects of a global health experience. Residents with prior global health experience rated the importance of global health more highly and had an increased expectation for future participation. Global health electives were arranged by residency programs for 18.0% (747/4,155) of respondents, by residents themselves as an elective for 44.0% (1,828/4,155), and as a noncredit experience during vacation time for 36.4% (1,514/4,155) of respondents. Female gender, nonpartnered status, no children, prior global health experience, and intention to incorporate global health in future practice were associated with expectations for a global health experience. CONCLUSION: Most obstetrics and gynecology residents rate a global health experience as somewhat or very important, and participation before or during residency increases the perceived importance of global health and the likelihood of expectation for future participation. A majority of residents report arranging their own elective or using vacation time to participate, suggesting that residency programs have limited structured opportunities.

Preventing maternal and newborn deaths globally: using innovation and science to address challenges in implementing life-saving interventions.

We have made important progress toward achieving Millennium Development Goals 4 and 5, with an estimated 47% decrease in maternal deaths and 28% decrease in newborn deaths globally since 1990. However, rapidly accelerating this progress is vital because far too many maternal and newborn deaths still occur each day. Fortunately, there are major initiatives underway to enhance global efforts in preventing these deaths, including the United Nations Secretary General's Global Strategy for Women's and Children's Health. We know why maternal and newborn deaths occur, where they occur, and how they occur, and we have highly effective interventions for preventing them. Nearly all (99%) maternal and newborn deaths occur in developing countries where the implementation of life-saving interventions has been a major challenge. Determining how best to meet this challenge will require more intensive interrelated efforts that include not only science-driven guidance on effective interventions, but also strategies and plans for implementing these interventions. Implementation science, defined as "the study of methods to promote the integration of research findings and evidence into healthcare policy and practice," will be key as will innovations in both technologies and implementation processes. We will need to develop conceptual and operational frameworks that link innovation and implementation science to implementation challenges for the Global Strategy. Likewise, we will need to expand and strengthen close cooperation between those with responsibilities for implementation and those with responsibilities for developing and supporting science-driven interventions. Realizing the potential for the Global Strategy will require commitment, coordination, collaboration, and communication-and the women and newborns we serve deserve no less.

Accelerating science-driven solutions to challenges in global reproductive health: a new framework for moving forward.

Recommendations shaping policies, programs, and practices in global health should be based on the best available science, but how best to achieve this objective is less clear. We describe a new approach developed by the United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction within the World Health Organization Department of Reproductive Health and Research for addressing key challenges in global reproductive health. This approach leads to new recommendations for accelerating solutions to priority needs in the field and continued improvements in the science base-including the implementation science base-for meeting these needs. The key components of this new cycle for science-driven solutions include: 1) identifying priority needs of the field; 2) creating guidance that meets the needs of the field; 3) identifying research gaps and establishing and funding research priorities; 4) research synthesis and updating of the guidance in a timely fashion; and 5) supporting utilization in countries through systematic introduction of science-driven solutions. There is a synergistic effect when the contributions of the individual components of this cycle are linked. Strong institutional support is required for this collective effort, as is the creation of a team of researchers, practitioners, donors, and implementing agencies with shared responsibilities for its success. This new approach has already made important contributions toward addressing key challenges in family planning and maternal and perinatal health. We believe that it will help bridge the gap between knowledge and action for reproductive health and for global health more broadly.

Maternal influences on nausea and vomiting in early pregnancy.

Symptoms of nausea and vomiting in early pregnancy (NVP) are common among pregnant women, but whether some women are more likely than others to experience these symptoms has not been well established. We examined potential risk factors for NVP symptom severity, timing of onset, and duration. We included 2,407 newly pregnant women who participated in a prospective cohort study on early pregnancy health between 2000 and 2004 in three U.S. cities. Data on NVP and other health information were collected through telephone interviews, early gestation ultrasound, and medical record abstractions. Generalized linear models were used to model possible risk factors for each NVP characteristic. Eighty-nine percent of women had NVP; for 99% of these, symptoms started in the first trimester. None of the characteristics examined were associated with having NVP. Among those with NVP, increasing risk of delayed symptoms onset was associated with advancing maternal age; increased risks were also seen among non-Hispanic Black [Risk ratio (RR) = 4.3, 95% confidence interval (CI): 1.6,11.6] and Hispanic women (RR = 2.3, 95% CI:0.4,11.5). NVP symptoms for multigravidae were more likely to last beyond the first trimester with each additional pregnancy. Most pregnant women experienced NVP. Nearly all of them, regardless of characteristics examined, had symptoms beginning in the first trimester. Maternal age, race/ethnicity, and gravidity were associated with delayed onset and symptoms that persisted into the second trimester.

Severity and duration of nausea and vomiting symptoms in pregnancy and spontaneous abortion.

BACKGROUND: Earlier studies have shown an inverse association between the presence of nausea and vomiting in pregnancy (NVP) and spontaneous abortion (SAB), but no study to date has examined the effects of symptom duration on the risk of SAB. METHODS: We examined NVP symptom severity and duration in relation to the occurrence of SAB. Data were collected from 2407 pregnant women in three US cities between 2000 and 2004 through interviews, ultrasound assessments and medical records abstractions. Discrete-time continuation ratio logistic survival models were used to examine the association between NVP and pregnancy loss. RESULTS: Lack of NVP symptoms was associated with increased risk for SAB [adjusted odds ratio (OR) = 3.2, 95% confidence interval (CI): (2.4, 4.3)], compared with having any symptoms. Reduced risks for SAB were found across most maternal age groups for those with NVP for at least half of their pregnancy, but the effects were much stronger in the oldest maternal age group [OR = 0.2, 95% CI: (0.1, 0.8)]. CONCLUSIONS: The absence of NVP symptoms is associated with an increased risk of early pregnancy loss. As symptom duration decreases, the likelihood of early loss increases, especially among women in the oldest maternal age group.

Adaptation of the World Health Organization's medical eligibility criteria for contraceptive use for use in the United States.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recently adapted global guidance on contraceptive use from the World Health Organization (WHO) to create the United States Medical Eligibility Criteria for Contraceptive Use (MEC). This guidance includes recommendations for use of specific contraceptive methods by people with certain characteristics or medical conditions. STUDY DESIGN: CDC determined the need and scope for the adaptation, conducted 12 systematic reviews of the scientific evidence and convened a meeting of health professionals to discuss recommendations based on the evidence. RESULTS: The vast majority of the US guidance is the same as the WHO guidance and addresses over 160 characteristics or medical conditions. Modifications were made to WHO recommendations for six medical conditions, and recommendations were developed for six new medical conditions. CONCLUSION: The US MEC is intended to serve as a source of clinical guidance for providers as they counsel clients about contraceptive method choices.

Assisted reproductive technologies in developing countries: are we caring yet?

An attitude shift toward ART in developing countries has resulted in attempts exploring low-cost ART suitable to limited resource settings. This is a positive and needed development. Future steps should consider national infertility needs, position of infertility services within comprehensive reproductive health programs, ART surveillance, and equitable access.

Sterilization.

Worldwide, sterilization (tubal sterilization and vasectomy) is used by more people than any other method of contraception. All techniques of tubal sterilization in widespread use in the United States have low risks of surgical complications. Although tubal sterilization is highly effective, the risk of pregnancy varies by age and method of occlusion. Pregnancies can occur many years after the procedure, and when they do, the risk of ectopic gestation is high. There is now strong evidence against the existence of a post-tubal ligation syndrome of menstrual abnormalities. Although women who have undergone tubal sterilization are more likely than other women to undergo hysterectomy subsequently, there is no known biologic basis for this relationship. Although sterilization is intended to be permanent, expressions of regret and requests for reversal are not uncommon and are much more likely to occur among women sterilized at young ages. Tubal sterilization has little or no effect on sexual function for most women. Vasectomy is less likely than tubal sterilization to result in serious complications. Minor complications, however, are not uncommon. Vasectomy does not increase the risk of heart disease, and available evidence argues against an increase in the risk of prostate cancer, testicular cancer, or overall mortality. Whether a postvasectomy pain syndrome exists remains controversial. Although the long-term effectiveness of vasectomy is less well-studied than that for tubal sterilization, it seems likely to be at least as effective. Intrauterine devices and progestin implants are long-acting, highly effective alternatives to sterilization.

Oral contraceptives and the risk of death from breast cancer.

OBJECTIVE: To examine the relationship between the use of oral contraceptives and the risk of death from breast cancer. METHODS: We used interview data from the Cancer and Steroid Hormone Study, linked to cancer registry data from the Surveillance, Epidemiology, and End Results Program, to examine the 15-year survival and prior use of oral contraceptives among 4,292 women aged 20 to 54 years when diagnosed with breast cancer from December 1, 1980, to December 31, 1982. Cox proportional hazard models were used to estimate the relative rate of death from breast cancer by oral contraceptive use. RESULTS: Duration of oral contraceptive use, time since first use, age at first use, and use of specific pill formulations were not associated with survival. For time since last use, the risk of death from breast cancer decreased significantly with increasing time since last use of oral contraceptives, but a consistent gradient effect was not observed. Adjusted hazard ratios ranged from 0.86 to 1.41 and were 1.00 or less for all recency categories except during 13 to 24 months before diagnosis; none was statistically significant. Women who were currently using oral contraceptives had an adjusted hazard ratio of 0.90 (0.68, 1.19). CONCLUSION: Overall, oral contraceptive use had neither a harmful nor a beneficial effect on breast cancer mortality. The differences between pill users and nonusers were slight, and the risk estimates were usually reduced with confidence limits that nearly always included 1.0.

Neoplasia with use of intrauterine devices.

BACKGROUND: One of the mechanisms by which intrauterine devices (IUDs) prevent pregnancy is the creation of a sterile inflammatory response in the endometrium. Additionally, hormone-releasing IUDs or intrauterine systems (IUSs) release progestins or progesterone into the uterus. Both of these mechanisms may affect users' risk for neoplasia. STUDY DESIGN: We searched the PubMed database for studies on IUD use and risk for neoplasia conducted between 1960 and September 2006 and published in all languages. We excluded case reports and case series. For the association between ever using an IUD and risk for endometrial cancer, we conducted a meta-analysis using a Bayesian random-effects model to account for between-study heterogeneity. RESULTS: We found no evidence of increased risk for neoplasia with IUD use. Nine case-control studies and one cohort study found reduced risks for endometrial cancer with having ever used an IUD (pooled adjusted odds ratio=0.6, 95% confidence interval=0.4-0.7). No trend in associations was observed with characteristics of IUD use, type of IUD and histologic type of cancer. Four case-control studies found no association between IUD use and risk for cervical cancer. One study found no increased incidence of breast cancer among levonorgestrel-releasing IUS users as compared with the general population in Finland. Finally, three studies found no association between IUD use and occurrence of hydatidiform moles or malignant sequelae. CONCLUSIONS: Use of an IUD does not appear to increase the risk for neoplasia. While nearly all studies found that IUD use was associated with a decreased risk for endometrial cancer, it remains unclear whether this association is causal.