Embedding research capacity strengthening in multi-country studies in low-and middle-income countries: learnings from sexual and reproductive health research.

Research capacity strengthening (RCS) can empower individuals, institutions, networks, or countries to define and prioritize problems systematically; develop and scientifically evaluate appropriate solutions; and reinforce or improve capacities to translate knowledge into policy and practice. However, how to embed RCS into multi-country studies focusing on sexual and reproductive health and rights (SRHR) is largely undocumented. We used findings from a qualitative study, from a review of the literature, and from a validation exercise from a panel of experts from research institutions that work on SRHR RCS. We provide a framework for embedded RCS; suggest a set of seven concrete actions that research project planners, designers, implementers, and funders can utilise to guide embedded RCS activities in low- and middle-income countries; and present a practical checklist for planning and assessing embedded RCS in research projects.

Paper ContextMain findings: Building on findings from a primary qualitative study, a literature review, and a consultation with experts on capacity strengthening in LMICs, we propose a systematic approach to embedded RCS.Added knowledge: We present a framework for embedding RCS in multi-country studies and propose seven action points and a checklist for the implementation of RCS in multi-country research projects with considerations for sexual and reproductive health and rights research.Global health impact for policy and action: An easy-to-use checklist can enable global health researchers and policymakers to ensure RCS is an integral component of multi-country research.

Effectiveness and safety of COVID-19 vaccines on maternal and perinatal outcomes: a systematic review and meta-analysis.

OBJECTIVE: To assess the effects of COVID-19 vaccines in women before or during pregnancy on SARS-CoV-2 infection-related, pregnancy, offspring and reactogenicity outcomes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Major databases between December 2019 and January 2023. STUDY SELECTION: Nine pairs of reviewers contributed to study selection. We included test-negative designs, comparative cohorts and randomised trials on effects of COVID-19 vaccines on infection-related and pregnancy outcomes. Non-comparative cohort studies reporting reactogenicity outcomes were also included. QUALITY ASSESSMENT, DATA EXTRACTION AND ANALYSIS: Two reviewers independently assessed study quality and extracted data. We undertook random-effects meta-analysis and reported findings as HRs, risk ratios (RRs), ORs or rates with 95% CIs. RESULTS: Sixty-seven studies (1 813 947 women) were included. Overall, in test-negative design studies, pregnant women fully vaccinated with any COVID-19 vaccine had 61% reduced odds of SARS-CoV-2 infection during pregnancy (OR 0.39, 95% CI 0.21 to 0.75; 4 studies, 23 927 women; I2=87.2%) and 94% reduced odds of hospital admission (OR 0.06, 95% CI 0.01 to 0.71; 2 studies, 868 women; I2=92%). In adjusted cohort studies, the risk of hypertensive disorders in pregnancy was reduced by 12% (RR 0.88, 95% CI 0.82 to 0.92; 2 studies; 115 085 women), while caesarean section was reduced by 9% (OR 0.91, 95% CI 0.85 to 0.98; 6 studies; 30 192 women). We observed an 8% reduction in the risk of neonatal intensive care unit admission (RR 0.92, 95% CI 0.87 to 0.97; 2 studies; 54 569 women) in babies born to vaccinated versus not vaccinated women. In general, vaccination during pregnancy was not associated with increased risk of adverse pregnancy or perinatal outcomes. Pain at the injection site was the most common side effect reported (77%, 95% CI 52% to 94%; 11 studies; 27 195 women). CONCLUSION: COVID-19 vaccines are effective in preventing SARS-CoV-2 infection and related complications in pregnant women. PROSPERO REGISTRATION NUMBER: CRD42020178076.

Immigrant women's and families' views and experiences of routine postnatal care: findings from a qualitative evidence synthesis.

BACKGROUND: Uptake of postnatal care (PNC) is low and inequitable in many countries, and immigrant women may experience additional challenges to access and effective use. As part of a larger study examining the views of women, partners, and families on routine PNC, we analysed a subset of data on the specific experiences of immigrant women and families. METHODS: This is a subanalysis of a larger qualitative evidence synthesis. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews and grey literature for studies published until December 2019 with extractable qualitative data with no language restrictions. For this analysis, we focused on papers related to immigrant women and families. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and quality assessment were carried out using a study-specific extraction form and established quality assessment tools. Study findings were identified using thematic analysis. Findings are presented by confidence in the finding, applying the GRADE-CERQual approach. FINDINGS: We included 44 papers, out of 602 full-texts, representing 11 countries where women and families sought PNC after immigrating. All but one included immigrants to high-income countries. Four themes were identified: resources and access, differences from home country, support needs, and experiences of care. High confidence study findings included: language and communication challenges; uncertainty about navigating system supports including transportation; high mental health, emotional, and informational needs; the impact of personal resources and social support; and the quality of interaction with healthcare providers. These findings highlight the importance of care experiences beyond clinical care. More research is also needed on the experiences of families migrating between low-income countries. CONCLUSIONS: Immigrant families experience many challenges in getting routine PNC, especially related to language, culture, and communication. Some challenges may be mitigated by improving comprehensive and accessible information on available services, as well as holistic social support. TRIAL REGISTRATION NUMBER: CRD42019139183.

Aetiology and use of antibiotics in pregnancy-related infections: results of the WHO Global Maternal Sepsis Study (GLOSS), 1-week inception cohort.

BACKGROUND: Pregnancy-related infections are important contributors to maternal sepsis and mortality. We aimed to describe clinical, microbiological characteristics and use of antibiotics by source of infection and country income, among hospitalized women with suspected or confirmed pregnancy-related infections. METHODS: We used data from WHO Global Maternal Sepsis Study (GLOSS) on maternal infections in hospitalized women, in 52 low-middle- and high-income countries conducted between November 28th and December 4th, 2017, to describe the frequencies and medians of maternal demographic, obstetric, and clinical characteristics and outcomes, methods of infection diagnosis and causative pathogens, of single source pregnancy-related infection, other than breast, and initial use of therapeutic antibiotics. We included 1456 women. RESULTS: We found infections of the genital (n = 745/1456, 51.2%) and the urinary tracts (UTI) (n = 531/1456, 36.5%) to be the most frequent. UTI (n = 339/531, 63.8%) and post-caesarean skin and soft tissue infections (SSTI) (n = 99/180, 55.0%) were the sources with more culture samples taken and microbiological confirmations. Escherichia coli was the major uropathogen (n = 103/118, 87.3%) and Staphylococcus aureus (n = 21/44, 47.7%) was the commonest pathogen in SSTI. For 13.1% (n = 191) of women, antibiotics were not prescribed on the same day of infection suspicion. Cephalosporins (n = 283/531, 53.3%) were the commonest antibiotic class prescribed for UTI, while metronidazole (n = 303/925, 32.8%) was the most prescribed for all other sources. Ceftriaxone with metronidazole was the commonest combination for the genital tract (n = 98/745, 13.2%) and SSTI (n = 22/180, 12.2%). Metronidazole (n = 137/235, 58.3%) was the most prescribed antibiotic in low-income countries while cephalosporins and co-amoxiclav (n = 129/186, 69.4%) were more commonly prescribed in high-income countries. CONCLUSIONS: Differences in antibiotics used across countries could be due to availability, local guidelines, prescribing culture, cost, and access to microbiology laboratory, despite having found similar sources and pathogens as previous studies. Better dissemination of recommendations in line with antimicrobial stewardship programmes might improve antibiotic prescription.

Support, networks, and relationships: Findings from a mixed-methods evaluation of a mentorship programme for early career women researchers in sexual and reproductive health and rights.

Low research output among women researchers in health research has been linked to inadequate mentorship opportunities for early career women researchers and particularly in sexual and reproductive health and rights (SRHR) field. Mentorship has been recognized as a contributor to strengthening research capacity and as beneficial for both mentors and mentees. Women researchers oftentimes experience negative impacts of organizational and structural gender inequities related to formal and informal mentoring. In 2020, the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction at WHO launched a mentorship programme for early career SRHR women researchers from low- and middle-income countries. The programme sought to provide professional skill-building, promote and share networking opportunities, and offer support in navigating personal and professional life. We conducted a convergent parallel mixed-methods evaluation of the 2020 pilot programme, which included 26 participants, through an online survey and semi-structured in-depth interviews (IDIs). Data collection occurred between March and May 2022. Nineteen responded to the online survey (12 mentees, 7 mentors) and 11 IDIs (7 mentees, 4 mentors) were completed. Based on a preliminary framework, we used deductive and inductive methods to identify six themes: views on mentorship; reasons for applying and expectations of participation in the programme; preferred aspects of programme implementation; challenges with the programme implementation; perceived lasting benefits of the programme; and recommendations for improvement. All participants found the initial training useful, most discussed work-life prioritization throughout the mentorship relationship, and most planned to continue with the relationship. There appear to be ample benefits to mentorship, especially when planned and implemented in a structured manner. These attributes can be particularly beneficial when they are conceived as a two-way relationship of mutual learning and support, and especially for women at the start of their research careers as they navigate structural gender inequities.

Remote training for strengthening capacity in sexual and reproductive health and rights research: a systematic review.

BACKGROUND: Training has been used to develop research skills among sexual and reproductive health and rights (SRHR) researchers. Remote education may accelerate transfer of skills and reduce barriers to strengthening research capacity. This systematic review aimed to assess the effectiveness of remote training on SRHR research and describe enablers and barriers of effective remote training. METHODS: PubMed, Embase, and Scielo were searched up to December 2022 for studies that evaluated in any language online research training programmes either on a SRHR topic or tailored for professionals working in SRHR published since 1990. Characteristics of included studies, the programmes they evaluated, the programme's effectiveness, and reported barriers and enablers to remote learning were extracted. Three researchers synthesized and described findings on effectiveness, impact and outcomes mapping them against the Kirkpatrick model. Additionally, thematic analysis from qualitative data was conducted to identify themes relating to the barriers and enablers of remote learning. RESULTS: Of 1,510 articles retrieved, six studies that included 2,058 remote learners met the inclusion criteria. Five out of six studies described empirical improvements in participant research knowledge/skills and three studies reported improvements in attitudes/self-efficacy towards research. Follow-up surveys from four studies revealed frequent application of new research skills and improved opportunities for career advancement and publication following online trainings. Cited barriers to effective online SRHR research training included time management challenges and participants' competing professional obligations; limited opportunities for interaction; and lack of support from home institutions. Cited enablers included well-structured and clear courses, learning objectives and expectations with participants; ensuring a manageable workload; facilitating interactions with mentors and hands-on experience; and selecting programme topics relevant to participants' jobs. CONCLUSION: Remote SRHR training can lead to improvements in research knowledge, skills, and attitudes, particularly when course learning objectives, structure, and expectations are outlined clearly, and ongoing mentorship is provided.

Factors that influence the uptake of postnatal care from the perspective of fathers, partners and other family members: a qualitative evidence synthesis.

BACKGROUND: Postnatal care (PNC) is a key component of maternity provision and presents opportunities for healthcare providers to optimise the health and well-being of women and newborns. However, PNC is often undervalued by parents, family members and healthcare providers. As part of a larger qualitative review exploring the factors that influence PNC uptake by relevant stakeholders, we examined a subset of studies highlighting the views of fathers, partners and family members of postpartum women. METHODS: We undertook a qualitative evidence synthesis using a framework synthesis approach. We searched multiple databases and included studies with extractable qualitative data focusing on PNC utilisation. We identified and labelled a subset of articles reflecting the views of fathers, partners and other family members. Data abstraction and quality assessment were carried out using a bespoke data extraction form and established quality assessment tools. The framework was developed a priori based on previous research on the topic and adapted accordingly. Findings were assessed for confidence using the GRADE-CERQual approach and are presented by country income group. RESULTS: Of 12 678 papers identified from the original search, 109 were tagged as 'family members views' and, of these, 30 were eligible for this review. Twenty-nine incorporated fathers' views, 7 included the views of grandmothers or mothers-in-law, 4 incorporated other family member views and 1 included comothers. Four themes emerged: access and availability; adapting to fatherhood; sociocultural influences and experiences of care. These findings highlight the significant role played by fathers and family members on the uptake of PNC by women as well as the distinct concerns and needs of fathers during the early postnatal period. CONCLUSION: To optimise access to postnatal care, health providers should adopt a more inclusive approach incorporating flexible contact opportunities, the availability of more 'family-friendly' information and access to psychosocial support services for both parents.

Factors that influence the uptake of postnatal care among adolescent girls: a qualitative evidence synthesis.

BACKGROUND: Adolescent pregnancy is associated with increased risk of maternal and child morbidity and mortality globally. Access to safe, appropriate and affordable antenatal, childbirth and postnatal care (PNC) is essential in mitigating this risk. PNC is an often undervalued, underused, and understudied component of the continuum of maternal health services; however, it provides an important opportunity for adolescent girls to have access to health information and resources as they navigate the transition to motherhood and/or recovery from childbirth. This qualitative evidence synthesis seeks to highlight the experiences and perspectives of adolescent girls and their partners in accessing and using routine PNC. METHODS: Papers were selected from a primary review on PNC where a global search of databases was conducted to identify studies with qualitative data focused on PNC utilisation. Within this primary review, a subset of studies focused on adolescents was tagged for subanalysis. A data extraction form drawing on an a priori framework was used to extract data from each study. Review findings were grouped across studies and mapped onto relevant themes, which were then adapted, as appropriate, to best reflect emergent themes from included studies. RESULTS: Of 662 papers identified for full text review, 15 were included in this review on adolescents' experiences. Fourteen review findings were mapped onto four themes including: resources and access, social norms, experiences of care, and tailored support needs. CONCLUSION: Improving uptake of PNC by adolescent girls requires multipronged approaches in improving availability of and access to adolescent-sensitive maternal health services and reducing feelings of shame and stigma in the postpartum period. Much should be done to address structural barriers to access, but tangible steps to improving the quality and responsiveness of available services can be taken immediately. PROSPERO REGISTRATION NUMBER: CRD42019139183.

Fortalecimiento de la investigación local para abordar la salud y los derechos sexuales y reproductivos de las personas migrantes de Venezuela y América Central

[EXTRACTO] La evidencia que surge de este número especial destaca las necesidades específicas de las personas migrantes latinoamericanas respecto a la respuesta de los sistemas de salud a la salud sexual y reproductiva y las enfermedades infecciosas. Si bien hay políticas relacionadas con la salud de las personas migrantes y refugiadas, y se observan esfuerzos para fortalecer los sistemas de salud en los países de acogida, las personas migrantes de América Latina aún enfrentan una gran cantidad de dificultades al recurrir a los sistemas de salud para atender sus necesidades de SDSR. La pandemia de COVID-19 exacerbó aún más estos desafíos. Se necesitan políticas de SDSR que puedan llevarse a la práctica para poder responder adecuadamente a las necesidades de las personas migrantes.

Strengthening locally led research to respond to the sexual and reproductive health and rights of migrants from Venezuela and Central America

[EXTRACT] The evidence emerging from this special issue highlights the specific needs of Latin American migrants with regards to health system response to sexual and reproductive health and infectious diseases. While policies relating to the health of ref- ugees and migrants and efforts to strengthen health systems in host countries exist, migrants in Latin America still face a myr- iad of challenges when navigating health systems in addressing their SRHR needs. The COVID-19 pandemic further exacer- bated these challenges. Specific SRHR actionable policies are needed to ensure the needs of migrants are fully met.

Supporting early-career women researchers: lessons from a global mentorship programme.

Mentorship is an important contributor to strengthening research capacity among health researchers. Formal mentorship programmes, targeting women mentees can help mitigate some of the gendered power dynamics and can also help early career researchers learn from others' experiences of navigating these challenges. In 2020, the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction at the World Health Organization launched a mentorship programme geared towards early career women researchers. This paper describes the process of designing and implementing a mentorship programme for early career women sexual and reproductive health and rights researchers from low- and middle-income countries including valuable lessons learned vis-à-vis existing evidence. Some of these findings have been incorporated into iterations of the programme launched in 2022. Critical points include: ensuring considerations for language and geographical distribution; allowing mentees to participate in the matching process; providing training and opportunities to network and learn from other participants; offering the support and structure for developing these relationships. Providing women researchers with the tools - through mentorship - to navigate the unique challenges they face in their career journeys, can have a lasting impact on research capacity. Countries and institutions committed to strengthening research capacity need to focus on the holistic growth and motivation of individuals in a way that ensures gender equality.

Fortalecimiento de la investigación local para abordar la salud y los derechos sexuales y reproductivos de las personas migrantes de Venezuela y América Central / Strengthening locally led research to respond to the sexual and reproductive health and rights of migrants from Venezuela and Central America

es

Strengthening locally led research to respond to the sexual and reproductive health and rights of migrants from Venezuela and Central America

en

Issues related to pregnancy, pregnancy prevention and abortion in the context of the COVID-19 pandemic: a WHO qualitative study protocol.

INTRODUCTION: WHO has generated standardised clinical and epidemiological research protocols to address key public health questions for SARS-CoV-2 (COVID-19) pandemic. We present a standardised protocol with the aim to fill a gap in understanding the needs, attitudes and practices related to sexual and reproductive health in the context of COVID-19 pandemic, focusing on pregnancy, pregnancy prevention and abortion. METHODS AND ANALYSIS PLAN: This protocol is a prospective qualitative research, using semi-structured interviews with at least 15 pregnant women at different gestational ages and after delivery, 6 months apart from the first interview. At least 10 partners, 10 non-pregnant women and 5 healthcare professionals will be interviewed once during the course of the research. Higher number of subjects may be needed if a saturation is not achieved with these numbers. Data collection will be performed in a standardised way by skilled trained interviewers using written notes or audio-record of the interview. The data will be explored using the thematic content analysis and the researchers will look for broad patterns, generalisations or theories from these categories. ETHICS AND DISSEMINATION: The current protocol was first technically assessed and approved by the WHO scientific committee and then approved by its ethics review committee as a guidance document. It is expected that each country/setting implementing such a generic protocol adapted to their conditions also obtain local ethical approval. Comments for the user's consideration are provided the document, as the user may need to modify methods slightly because of the local context in which this study will be carried out.

Factors that influence uptake of routine postnatal care: Findings on women's perspectives from a qualitative evidence synthesis.

BACKGROUND: Effective postnatal care is important for optimal care of women and newborns-to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. METHODS: We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. FINDINGS: Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care. CONCLUSIONS: Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings. REGISTRATION: This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Health systems analysis and evaluation of the barriers to availability, utilisation and readiness of sexual and reproductive health services in COVID-19-affected areas: a WHO mixed-methods study protocol.

INTRODUCTION: COVID-19 has led to an unprecedented increase in demand on health systems to care for people infected, necessitating the allocation of significant resources, especially medical resources, towards the response. This, compounded by the restrictions on movement instituted may have led to disruptions in the provision of essential services, including sexual and reproductive health (SRH) services. This study aims to assess the availability of contraception, comprehensive abortion care, sexually transmitted infection prevention and treatment and sexual and gender-based violence care and support services in local health facilities during COVID-19 pandemic. This is a standardised generic protocol designed for use across different global settings. METHODS AND ANALYSIS: This study adopts both quantitative and qualitative methods to assess health facilities' SRH service availability and readiness, and clients' and providers' perceptions of the availability and readiness of these services in COVID-19-affected areas. The study has two levels: (1) perceptions of clients (and the partners) and healthcare providers, using qualitative methods, and (2) assessment of infrastructure availability and readiness to provide SRH services through reviews, facility service statistics for clients and a qualitative survey for healthcare provider perspectives. The health system assessment will use a cross-sectional panel survey design with two data collection points to capture changes in SRH services availability as a result of the COVID-19 epidemic. Data will be collected using focus group discussions, in-depth interviews and a health facility assessment survey. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (protocol ID CERC.0103). Each study site is required to obtain the necessary ethical and regulatory approvals that are required in each specific country.

SARS-CoV-2 positivity in offspring and timing of mother-to-child transmission: living systematic review and meta-analysis.

OBJECTIVES: To assess the rates of SARS-CoV-2 positivity in babies born to mothers with SARS-CoV-2 infection, the timing of mother-to-child transmission and perinatal outcomes, and factors associated with SARS-CoV-2 status in offspring. DESIGN: Living systematic review and meta-analysis. DATA SOURCES: Major databases between 1 December 2019 and 3 August 2021. STUDY SELECTION: Cohort studies of pregnant and recently pregnant women (including after abortion or miscarriage) who sought hospital care for any reason and had a diagnosis of SARS-CoV-2 infection, and also provided data on offspring SARS-CoV-2 status and risk factors for positivity. Case series and case reports were also included to assess the timing and likelihood of mother-to-child transmission in SARS-CoV-2 positive babies. DATA EXTRACTION: Two reviewers independently extracted data and assessed study quality. A random effects model was used to synthesise data for rates, with associations reported using odds ratios and 95% confidence intervals. Narrative syntheses were performed when meta-analysis was inappropriate. The World Health Organization classification was used to categorise the timing of mother-to-child transmission (in utero, intrapartum, early postnatal). RESULTS: 472 studies (206 cohort studies, 266 case series and case reports; 28 952 mothers, 18 237 babies) were included. Overall, 1.8% (95% confidence interval 1.2% to 2.5%; 140 studies) of the 14 271 babies born to mothers with SARS-CoV-2 infection tested positive for the virus with reverse transcriptase polymerase chain reaction (RT-PCR). Of the 592 SARS-CoV-2 positive babies with data on the timing of exposure and type and timing of tests, 14 had confirmed mother-to-child transmission: seven in utero (448 assessed), two intrapartum (18 assessed), and five during the early postnatal period (70 assessed). Of the 800 SARS-CoV-2 positive babies with outcome data, 20 were stillbirths, 23 were neonatal deaths, and eight were early pregnancy losses; 749 babies were alive at the end of follow-up. Severe maternal covid-19 (odds ratio 2.4, 95% confidence interval 1.3 to 4.4), maternal death (14.1, 4.1 to 48.0), maternal admission to an intensive care unit (3.5, 1.7 to 6.9), and maternal postnatal infection (5.0, 1.2 to 20.1) were associated with SARS-CoV-2 positivity in offspring. Positivity rates using RT-PCR varied between regions, ranging from 0.1% (95% confidence interval 0.0% to 0.3%) in studies from North America to 5.7% (3.2% to 8.7%) in studies from Latin America and the Caribbean. CONCLUSION: SARS-CoV-2 positivity rates were found to be low in babies born to mothers with SARS-CoV-2 infection. Evidence suggests confirmed vertical transmission of SARS-CoV-2, although this is likely to be rare. Severity of maternal covid-19 appears to be associated with SARS-CoV-2 positivity in offspring. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178076. READERS' NOTE: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication.

Cognitive testing of a survey instrument to assess sexual practices, behaviours, and health outcomes: a multi-country study protocol.

BACKGROUND: Population level data on sexual practices, behaviours and health-related outcomes can ensure that responsive, relevant health services are available for all people of all ages. However, while billions of dollars have been invested in attempting to improve sexual and reproductive health (including HIV) outcomes, far less is understood about associated sexual practices and behaviours. Therefore, the World Health Organization embarked on a global consultative process to develop a short survey instrument to assess sexual health practices, behaviours and health outcomes. In order for the resulting draft survey instrument to be published as a 'global' standard instrument, it is important to first determine that the proposed measures are globally comprehensible and applicable. This paper describes a multi-country study protocol to assess the interpretability and comparability of the survey instrument in a number of diverse countries. METHODS: This study will use cognitive interviewing, a qualitative data collection method that uses semi-structured interviews to explore how participants process and respond to survey instruments. We aim to include study sites in up to 20 countries. The study procedures consist of: (1) localizing the instrument using forward and back-translation; (2) using a series of cognitive interviews to understand how participants engage with each survey question; (3) revising the core instrument based on interview findings; and (4) conducting an optional second round of cognitive interviews. Data generated from interviews will be summarised into a predeveloped analysis matrix. The entire process (a 'wave' of data collection) will be completed simultaneously by 5+ countries, with a total of three waves. This stepwise approach facilitates iterative improvements and sharing across countries. DISCUSSION: An important output from this research will be a revised survey instrument, which when subsequently published, can contribute to improving the comparability across contexts of measures of sexual practices, behaviours and health-related outcomes. Site-specific results of the feasibility of conducting this research may help shift perceptions of who and what can be included in sexual health-related research.