The American Urogynecologic Society Action Plan on Diversity, Equity, and Inclusion: Developed by the Diversity, Equity, and Inclusion Task Force.

ABSTRACT: The American Urogynecologic Society (AUGS) identified diversity, equity, and inclusion as the cornerstone of excellence in governance and operations. Although efforts to increase diversity of our membership have been ongoing for years, there had not previously been an adequate investment to ensure an inclusive climate that emphasizes equity across our volunteers and programs. In June 2020, the AUGS President, Dr Shawn Menefee, and Board of Directors called for a Presidential Task Force on Diversity, Equity, and Inclusion to study the current state of our society and make recommendations for future directions. The charge was intentionally broad. In review of the literature, there was little to inform the best means to proceed aside from administering climate surveys to gauge the current culture of inclusion and bias. The task force believed that the challenge was not only to describe the problem but also to articulate solutions. We ultimately moved to rewrite the Diversity and Inclusion and Code of Conduct Statements and develop an Action Plan that would accelerate the efforts of AUGS to foster inclusion and improve equity through the existing governance structure. In this document, we describe how the task force was organized and conducted the work to develop strategies that were aligned with the AUGS mission: "As the leader in female pelvic medicine and reconstructive surgery, AUGS drives excellence in care for women through education, research, advocacy, and interdisciplinary collaboration."

Decision aids and shared decision making in urogynecology.

OBJECTIVES: To examine the efficacy and acceptability of decision aids (DAs) in counseling urogynecology patients with prolapse, stress urinary incontinence, or refractory overactive bladder. METHODS: This pilot study enrolled 33 patients into a control group that underwent usual care without a DA, followed by 33 patients into an intervention group where providers utilized a DA for counseling. Postvisit patient surveys assessed differences in treatment preference, knowledge, and in patient-physician collaboration using SURE, CollaboRATE, and Shared Decision Making (SDM) Process scales. Postvisit provider surveys assessed their perception of the usefulness and the difficulty of using a DA and visit length. Independent t tests were used for continuous variables (Knowledge and SDM Process scores) and Chi-Square for categorical variables (treatment preference, SURE, and CollaboRATE). RESULTS: The majority of eligible patients 66/71 (93%) completed the survey. The intervention group trended toward higher knowledge scores (72% vs 60%, P  = 0.06), clearer treatment preferences (85% vs 67%, P  = 0.08), higher rates of top SURE scale scores (91% vs 73%, P  = 0.11), and top CollaboRATE scores (75% vs 52%, P  = 0.07). SDM process scores were similar across groups (3.2 vs 3.2, P  = 0.96). Providers used the DA in 73% of intervention group visits and rated the visit length as "normal" in both groups (70% vs 76%, P  = 0.78). CONCLUSIONS: There were no statistically significant differences between the control group and the intervention group. The use of DAs was acceptable to providers and indicated a trend toward increased patient knowledge, treatment preference, and satisfaction. A larger study is warranted to examine the impact of DAs on decision making and patient experience.

Video Summary:http://links.lww.com/MENO/A856 .

Impact of vaginal douching products on vaginal Lactobacillus, Escherichia coli and epithelial immune responses.

We compared the effect of commercial vaginal douching products on Lactobacillus crispatus, L. jensenii, L. gasseri, L. iners, E. coli, and immortalized vaginal epithelial cells (VK2). All studied douching products (vinegar, iodine and baking soda based) induced epithelial cell death, and all inhibited growth of E. coli. Co-culture of vaginal epithelial cells with any of the lactobacilli immediately following exposure to douching products resulted in a trend to less human cell death. However, co-culture of epithelial cells with L. iners was associated with higher production of IL6 and IL8, and lower IL1RA regardless of presence or type of douching solution. Co-culture with L. crispatus or L. jensenii decreased IL6 production in the absence of douches, but increased IL6 production after exposure to vinegar. Douching products may be associated with epithelial disruption and inflammation, and may reduce the anti-inflammatory effects of beneficial lactobacilli.

Effect of commercial vaginal products on the growth of uropathogenic and commensal vaginal bacteria.

Half of postmenopausal women experience genitourinary syndrome of menopause, for which many use lubricating vaginal products. The effect of vaginal products on uropathogenic and commensal vaginal bacteria is poorly understood. We evaluated the effect of five common vaginal products (KY Jelly, Replens Silky Smooth lubricant, coconut oil, Replens Long-Lasting moisturizer or Trimo-San) on growth and viability of Escherichia coli and Lactobacillus crispatus. Bacteria were co-cultured products alone and in the presence of both vaginal epithelial cells and selected products. Bacterial growth was compared between conditions using an unpaired t-test or ANOVA, as appropriate. All products except for coconut oil significantly inhibited growth of laboratory and clinical strains of Escherichia coli (p < 0.02). Only two products (Replens Long-Lasting moisturizer and Trimo-San) significantly inhibited growth of Lactobacillus crispatus (p < 0.01), while the product Replens Silky Smooth stimulated growth (p < 0.01). Co-culture of selected products in the presence of vaginal epithelial cells eliminated the inhibitory effects of the products on E. coli. In conclusion, in vitro exposure to vaginal moisturizing and lubricating products inhibited growth of Escherichia coli, though the inhibition was mitigated by the presence of vaginal epithelial cells. Lactobacillus crispatus demonstrated less growth inhibition than Escherichia coli.

Effect of Vaginal Lactobacillus Species on Escherichia coli Growth.

OBJECTIVES: Lactobacillus probiotics have been proposed as an antibiotic-sparing prevention strategy for urinary tract infections (UTIs). Our objective was to examine the relative ability of the 4 most common vaginal Lactobacillus species to inhibit the growth of Escherichia coli, the most common cause of UTIs. METHODS: Conditioned media (CM) was created from 4 laboratory strains of Lactobacillus species: Lactobacillus crispatus, Lactobacillus jensenii, Lactobacillus gasseri, and Lactobacillus iners, and 6 clinical strains of L. crispatus. One laboratory strain of E. coli was cocultured with each CM, as well as with various acidic solutions. Three clinical strains of E. coli from women with acute cystitis were cocultured with the CM from a laboratory strain of L. crispatus. Bacterial growth was compared between experimental variants and media control using analysis of variance. RESULTS: Growth of E. coli was inhibited by CM from L. crispatus, L. jensenii, and L. gasseri, but not L. iners. The magnitude of inhibition was correlated with the pH of the individual CM and the concentration of D-lactic acid. Different acids inhibited E. coli growth in proportion to the pH of the acid solution. Similar levels of inhibition were seen when L. crispatus was incubated with clinical E. coli strains as with laboratory E. coli. CONCLUSIONS: Three of the most common vaginal Lactobacillus species inhibit E. coli growth, likely through creating a low pH environment. However, L. iners, one of the most common species found after menopause, does not. These findings might be leveraged to more effectively manage UTIs.

Urinary incontinence, depression, and economic outcomes in a cohort of women between the ages of 54 and 65 years.

OBJECTIVE: To estimate the association between urinary incontinence (UI) and probable depression, work disability, and workforce exit. METHODS: The analytic sample consisted of 4,511 women enrolled in the population-based Health and Retirement Study cohort. The analysis baseline was 1996, the year that questions about UI were added to the survey instrument, and at which time study participants were 54-65 years of age. Women were followed-up with biennial interviews until 2010-2011. Outcomes of interest were onset of probable depression, work disability, and workforce exit. Urinary incontinence was specified in different ways based on questions about experience and frequency of urine loss. We fit Cox proportional hazards regression models to the data, adjusting the estimates for baseline sociodemographic and health status variables previously found to confound the association between UI and the outcomes of interest. RESULTS: At baseline, 727 participants (survey-weighted prevalence, 16.6%; 95% confidence interval [CI] 15.4-18.0) reported any UI, of which 212 (survey-weighted prevalence, 29.2%; 95% CI 25.4-33.3) reported urine loss on more than 15 days in the past month; and 1,052 participants were categorized as having probable depression (survey-weighted prevalence, 21.6%; 95% CI 19.8-23.6). Urinary incontinence was associated with increased risks for probable depression (adjusted hazard ratio, 1.43; 95% CI 1.27-1.62) and work disability (adjusted hazard ratio, 1.21; 95% CI 1.01-1.45), but not workforce exit (adjusted hazard ratio, 1.06; 95% CI 0.93-1.21). CONCLUSION: In a population-based cohort of women between ages 54 and 65 years, UI was associated with increased risks for probable depression and work disability. Improved diagnosis and management of UI may yield significant economic and psychosocial benefits.

Community-based prenatal screening for postpartum depression in a South African township.

OBJECTIVE: To assess the feasibility of using community health workers to administer short or ultra-short screening instruments during routine community-based prenatal outreach for detecting probable depression at 12 weeks postpartum. METHODS: During pregnancy and at 12 weeks postpartum, the 10-item Edinburgh Postnatal Depression Scale (EPDS-10) was administered to 249 Xhosa-speaking black African women living in Khayelitsha, South Africa. We compared the operating characteristics of the prenatal EPDS-10, as well as 4 short and ultra-short subscales, with the criterion standard of probable postpartum depression. RESULTS: Seventy-nine (31.7%) women were assessed as having probable postpartum depression. A prenatal EPDS-10 score of 13 or higher had 0.67 sensitivity and 0.67 specificity for detecting probable postpartum depression. Briefer subscales performed similarly. CONCLUSION: Community health workers successfully conducted community-based screening for depression in a resource-limited setting using short or ultra-short screening instruments. However, overall feasibility was limited because prenatal screening failed to accurately predict probable depression during the postpartum period.

Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis.

BACKGROUND: A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings. METHODS AND FINDINGS: Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 full-text reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥ 9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity. CONCLUSIONS: The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts.

Scope of global health training in U.S. obstetrics and gynecology residency programs.

OBJECTIVE: To enumerate global health training activities in U.S. obstetrics and gynecology residency programs and to examine the worldwide distribution of programmatic activity relative to the maternal and perinatal disease burden. METHODS: Using a systematic, web-based protocol, we searched for global health training opportunities at all U.S. obstetrics and gynecology residency programs. Country-level data on disability-adjusted life-years resulting from maternal and perinatal conditions were obtained from the Global Burden of Disease study. We calculated Spearman's rank correlation coefficients to estimate the cross-country association between programmatic activity and disease burden. RESULTS: Of the 243 accredited U.S. obstetrics and gynecology residency programs, we identified 41 (17%) with one of several possible predefined categories of programmatic activity. Thirty-three residency programs offered their residents opportunities to participate in one or more elective-based rotations, eight offered extended field-based training, and 18 offered research activities. A total of 128 programmatic activities were dispersed across 64 different countries. At the country level, the number of programmatic activities had a statistically significant association with the total disease burden resulting from maternal (Spearman's ρ=0.37, 95% confidence interval [CI] 0.14-0.57) and perinatal conditions (ρ=0.34, 95% CI 0.10-0.54) but not gynecologic cancers (ρ=-0.24, 95% CI -0.46 to 0.01). CONCLUSIONS: There are few global health training opportunities for U.S. obstetrics and gynecology residents. These activities are disproportionately distributed among countries with greater burdens of disease. LEVEL OF EVIDENCE: II.

Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil.

BACKGROUND: Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk. METHODS AND FINDINGS: We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006-2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48-0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57-0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations. CONCLUSIONS: Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.

Community-level and individual-level influences of intimate partner violence on birth spacing in sub-Saharan Africa.

OBJECTIVE: To estimate the extent to which intimate partner violence (IPV), at the levels of the individual and the community, is associated with shortened interbirth intervals among women in sub-Saharan Africa. METHODS: We analyzed demographic and health survey data from 11 countries in sub-Saharan Africa. Only multiparous women were included in the analysis. Interbirth interval was the primary outcome. Personal history of IPV was measured using a modified Conflict Tactics Scale. Community prevalence of IPV was measured as the proportion of women in each village reporting a personal history of IPV. We used multilevel modeling to account for the hierarchical structure of the data, allowing us to partition the variation in birth intervals to the four different levels (births, individuals, villages, and countries). RESULTS: Among the 46,697 women in the sample, 11,730 (25.1%) reported a personal history of physical violence and 4,935 (10.6%) reported a personal history of sexual violence. In the multivariable regression model, interbirth intervals were inversely associated with personal history of physical violence (regression coefficient b=-0.60, 95% confidence interval -0.91 to -0.28) and the community prevalence of physical violence (b=-1.41, 95% confidence interval -2.41 to -0.40). Estimated associations with sexual violence were of similar statistical significance and magnitude. CONCLUSION: Both personal history of IPV and the community prevalence of IPV have independent and statistically significant associations with shorter interbirth intervals. LEVEL OF EVIDENCE: II.