Exploring the Use and Implications of AI in Sexual and Reproductive Health and Rights: Protocol for a Scoping Review.

BACKGROUND: Artificial intelligence (AI) has emerged as a transformative force across the health sector and has garnered significant attention within sexual and reproductive health and rights (SRHR) due to polarizing views on its opportunities to advance care and the heightened risks and implications it brings to people's well-being and bodily autonomy. As the fields of AI and SRHR evolve, clarity is needed to bridge our understanding of how AI is being used within this historically politicized health area and raise visibility on the critical issues that can facilitate its responsible and meaningful use. OBJECTIVE: This paper presents the protocol for a scoping review to synthesize empirical studies that focus on the intersection of AI and SRHR. The review aims to identify the characteristics of AI systems and tools applied within SRHR, regarding health domains, intended purpose, target users, AI data life cycle, and evidence on benefits and harms. METHODS: The scoping review follows the standard methodology developed by Arksey and O'Malley. We will search the following electronic databases: MEDLINE (PubMed), Scopus, Web of Science, and CINAHL. Inclusion criteria comprise the use of AI systems and tools in sexual and reproductive health and clear methodology describing either quantitative or qualitative approaches, including program descriptions. Studies will be excluded if they focus entirely on digital interventions that do not explicitly use AI systems and tools, are about robotics or nonhuman subjects, or are commentaries. We will not exclude articles based on geographic location, language, or publication date. The study will present the uses of AI across sexual and reproductive health domains, the intended purpose of the AI system and tools, and maturity within the AI life cycle. Outcome measures will be reported on the effect, accuracy, acceptability, resource use, and feasibility of studies that have deployed and evaluated AI systems and tools. Ethical and legal considerations, as well as findings from qualitative studies, will be synthesized through a narrative thematic analysis. We will use the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) format for the publication of the findings. RESULTS: The database searches resulted in 12,793 records when the searches were conducted in October 2023. Screening is underway, and the analysis is expected to be completed by July 2024. CONCLUSIONS: The findings will provide key insights on usage patterns and evidence on the use of AI in SRHR, as well as convey key ethical, safety, and legal considerations. The outcomes of this scoping review are contributing to a technical brief developed by the World Health Organization and will guide future research and practice in this highly charged area of work. TRIAL REGISTRATION: OSF Registries osf.io/ma4d9; https://osf.io/ma4d9. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/53888.

A global analysis of the determinants of maternal health and transitions in maternal mortality.

The reduction of maternal mortality and the promotion of maternal health and wellbeing are complex tasks. This Series paper analyses the distal and proximal determinants of maternal health, as well as the exposures, risk factors, and micro-correlates related to maternal mortality. This paper also examines the relationship between these determinants and the gradual shift over time from a pattern of high maternal mortality to a pattern of low maternal mortality (a phenomenon described as the maternal mortality transition). We conducted two systematic reviews of the literature and we analysed publicly available data on indicators related to the Sustainable Development Goals, specifically, estimates prepared by international organisations, including the UN and the World Bank. We considered 23 frameworks depicting maternal health and wellbeing as a multifactorial process, with superdeterminants that broadly affect women's health and wellbeing before, during, and after pregnancy. We explore the role of social determinants of maternal health, individual characteristics, and health-system features in the production of maternal health and wellbeing. This paper argues that the preventable deaths of millions of women each decade are not solely due to biomedical complications of pregnancy, childbirth, and the postnatal period, but are also tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. This paper underscores the need for broader, multipronged actions to improve maternal health and wellbeing and accelerate sustainable reductions in maternal mortality. For women who have pregnancy, childbirth, or postpartum complications, the health system provides a crucial opportunity to interrupt the chain of events that can potentially end in maternal death. Ultimately, expanding the health sector ecosystem to mitigate maternal health determinants and tailoring the configuration of health systems to counter the detrimental effects of eco-social forces, including though increased access to quality-assured commodities and services, are essential to improve maternal health and wellbeing and reduce maternal mortality.

Incompleteness and misclassification of maternal death recording: a systematic review and meta-analysis.

OBJECTIVE: To quantify the extent of incompleteness and misclassification of maternal and pregnancy related deaths, and to identify general and context-specific factors associated with incompleteness and/or misclassification of maternal death data. METHODS: We conducted a systematic review of incompleteness and/or misclassification of maternal and pregnancy-related deaths. We conducted a narrative synthesis to identify methods used to capture and classify maternal deaths, as well as general and context specific factors affecting the completeness and misclassification of maternal death recording. We conducted a meta-analysis of proportions to obtain estimates of incompleteness and misclassification of maternal death recording, overall and disaggregated by income and surveillance system types. FINDINGS: Of 2872 title-abstracts identified, 29 were eligible for inclusions in the qualitative synthesis, and 20 in the meta-analysis. Included studies relied principally on record linkage and review for identifying deaths, and on review of medical records and verbal autopsies to correctly classify cause of death. Deaths to women towards the extremes of the reproductive age range, those not classified by a medical examiner or a coroner, and those from minority ethnic groups in their setting were more likely misclassified or unrecorded. In the meta-analysis, we found maternal death recording to be incomplete by 34% (95% CI: 28-48), with 60% sensitivity (95% CI: 31-81.). Overall, we found maternal mortality was under-estimated by 39% (95% CI: 30-48) due to incompleteness and/or misclassification. Reporting of deaths away from the intrapartum, due to indirect causes or occurring at home were less complete than their counterparts. There was substantial between and within group variability across most results. CONCLUSION: Maternal deaths were under-estimated in almost all contexts, but the extent varied across settings. Countries should aim towards establishing Civil Registration and Vital Statistics systems where they are not instituted. Efforts to improve the completeness and accuracy of maternal cause of death recording, such as Confidential Enquiries into Maternal Deaths, are needed even where CRVS is considered to be well-functioning.

Scaling up a monitoring and evaluation framework for sexual, reproductive, maternal, newborn, child, and adolescent health services and outcomes in humanitarian settings: A global initiative.

Background: Reliable and rigorously collected sexual, reproductive, maternal, newborn, child, and adolescent (SRMNCAH) data from humanitarian settings are often sparse and variable in quality across different settings due to the lack of a standardised set of indicators across the different agencies working in humanitarian settings. This paper aims to summarise a WHO-led global initiative to develop and scale up an SRMNCAH monitoring and evaluation framework for humanitarian settings. Methods: This research revolved around three phases. The first and the last phase involved global consultations with lead international agencies active in SRMNCAH in humanitarian settings. The second phase tested the feasibility of the proposed indicators in Afghanistan, Bangladesh, the Democratic Republic of the Congo, and Jordan, using different qualitative research methods (interviews with 92 key informants, 26 focus group discussions with 142 key stakeholders, facility assessments and observations at 25 health facilities or sites). Results: Among the 73 proposed indicators, 47 were selected as core indicators and 26 as additional indicators. Generally, there were no major issues in collecting the proposed indicators, except for those indicators that relied on death reviews or population-level data. Service availability and morbidity indicators were encouraged. Abortion and SGBV indicators were challenging to collect due to political and sociocultural reasons. The HIV and PMTCT indicators were considered as core indicators, despite potential sensitivity in some settings. Existing data collection and reporting systems across the four assessed humanitarian settings were generally fragmented and inconsistent, mainly attributed to the lack of coordination among different agencies. Interpretation: Implementing agencies need to collaborate effectively to scale up this agreed-upon set of SRMNCAH framework to enhance accountability and transparency in humanitarian settings.

Digitalization of routine health information systems: Bangladesh, Indonesia, Pakistan.

Objective: To describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements. Methods: We designed a formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application. Findings: Researchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers. Conclusion: Lessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains.

Reclassifying contraceptives as over-the-counter medicines to improve access.

Self-care interventions include over-the-counter contraceptives, which enable individuals to make informed, autonomous decisions about fertility management. As there is a substantial unmet need for contraception in many countries, increasing access by establishing sound, affordable and effective regulation of over-the-counter contraceptives could help reduce unintended pregnancies and improve maternal health. We performed a review of 30 globally diverse countries: (i) to assess national regulatory procedures for changing oral contraceptives, emergency contraceptives and injectable contraceptives from prescription-only to over-the-counter products; and (ii) to determine whether national lists of over-the-counter medicines included contraceptives. Of the 30 countries, 13 (43%) had formal regulatory procedures in place for changing prescription-only medicines to over-the-counter medicines, 11 (36%) had national lists of over-the-counter medicines, and four (13%) included contraceptives on those lists. Changing from prescription-only to over-the-counter medicines presents challenges for national medicines regulatory authorities and manufacturers, involving, for example, reporting side-effects, quality control and the often poorly-defined process of switching to over-the-counter products. To facilitate the over-the-counter availability of contraceptives, countries should consider adopting a formal regulatory procedure for reclassifying prescription-only contraceptives as over-the-counter contraceptives. Although the availability of over-the-counter contraceptives can increase users' independence and anonymity and improve access, there may also be disadvantages, such as higher out-of-pocket costs and the need for accurate self-assessment. Basic remedial actions to improve, harmonize and standardize regulatory procedures for the reclassification of contraceptives are proposed with the aim of enabling national medicines regulatory authorities to manage the switch to over-the-counter contraceptives and to control their quality.

Les soins autoadministrés incluent les contraceptifs en vente libre, qui permettent aux individus de prendre des décisions réfléchies et autonomes concernant le contrôle de la fécondité. Vu le besoin criant de contraception dans de nombreux pays, faciliter l'accès en proposant des méthodes de régulation sûres, efficaces et abordables par le biais de contraceptifs en vente libre pourrait contribuer à diminuer le nombre de grossesses non désirées et à améliorer la santé maternelle. Nous avons passé en revue 30 pays aux profils variés: (i) pour évaluer les procédures réglementaires nationales visant à modifier le statut des contraceptifs oraux, d'urgence et injectables afin qu'ils soient en vente libre au lieu d'être considérés comme des médicaments sur ordonnance; et (ii) pour déterminer si les contraceptifs figuraient sur les listes nationales de médicaments en vente libre. Sur les 30 pays observés, 13 (43%) avaient mis en place des procédures réglementaires officielles en vue de modifier le statut des contraceptifs, 11 (36%) possédaient des listes nationales de médicaments en vente libre et quatre (13%) y avaient inscrit les contraceptifs. Le passage du statut de médicament sur ordonnance à celui de médicament en vente libre représente un défi pour les autorités nationales de réglementation pharmaceutique et les fabricants, notamment en matière de déclaration des effets secondaires, de contrôle de la qualité et en raison d'un processus souvent mal défini. S'ils souhaitent favoriser la disponibilité des contraceptifs en vente libre, les pays devraient envisager l'adoption d'une procédure réglementaire officielle destinée à reclassifier les contraceptifs sur ordonnance en contraceptifs en vente libre. Bien que cette disponibilité puisse accroître l'autonomie et l'anonymat des usagers et améliorer l'accès à la contraception, elle présente également des désavantages car elle entraîne une hausse des frais non remboursés et requiert une autoévaluation correcte. Le présent document formule des mesures correctrices élémentaires servant à améliorer, harmoniser et normaliser les procédures réglementaires de reclassification des contraceptifs. Objectif: permettre aux autorités nationales de réglementation pharmaceutique de superviser le passage au statut de médicament en vente libre et de contrôler la qualité.

Las intervenciones de cuidado personal incluyen los anticonceptivos de venta libre, que permiten a las personas tomar decisiones informadas y autónomas sobre la gestión de la fertilidad. Dado que en muchos países existe una importante necesidad insatisfecha de anticoncepción, aumentar el acceso mediante el establecimiento de una normativa sólida, asequible y eficaz de los anticonceptivos de venta libre podría ayudar a reducir los embarazos no deseados y mejorar la salud materna. Se realizó una revisión de 30 países de todo el mundo: (i) para evaluar los procedimientos normativos nacionales relativos al cambio de los anticonceptivos orales, los anticonceptivos de urgencia y los anticonceptivos inyectables de medicamentos de venta con receta a productos de venta libre; y (ii) para determinar si las listas nacionales de medicamentos de venta libre incluían los anticonceptivos. De los 30 países, 13 (43 %) contaban con procedimientos normativos formales para el cambio de medicamentos de venta con receta a medicamentos de venta libre, 11 (36 %) tenían listas nacionales de medicamentos de venta libre, y cuatro (13 %) incluían los anticonceptivos en esas listas. El cambio de los medicamentos de venta con receta a los de venta libre supone un desafío para las autoridades nacionales de regulación de medicamentos y para los fabricantes, ya que implica, por ejemplo, la notificación de los efectos secundarios, el control de calidad y el proceso, que suele estar mal definido, de pasar a los productos de venta libre. Para facilitar la disponibilidad de los anticonceptivos sin receta, los países deberían considerar la adopción de un procedimiento normativo formal para reclasificar los anticonceptivos de venta con receta como anticonceptivos de venta sin receta. Aunque la disponibilidad de los anticonceptivos de venta libre puede aumentar la independencia y el anonimato de los usuarios y mejorar el acceso, también puede haber desventajas, como los mayores costos de bolsillo y la necesidad de una autoevaluación precisa. Se proponen acciones correctivas básicas para mejorar, armonizar y estandarizar los procedimientos normativos para la reclasificación de los anticonceptivos, con el objetivo de que las autoridades nacionales de regulación de medicamentos puedan gestionar el cambio a los anticonceptivos sin receta y controlar su calidad.

Maternal mortality linked to COVID-19 in Latin America: Results from a multi-country collaborative database of 447 deaths.

Background: This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database. Methods: This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges. Findings: We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight. Interpretation: This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays. Funding: Latin American Center for Perinatology, Women and Reproductive Health.

Antecedentes: Este estudio tuvo el objetivo de describir las características clínicas de las muertes maternas asociadas a COVID-19 registradas en una base de datos latinoamericana multipaís. Métodos: Se implementó un estudio observacional descriptivo en el que participaron ochos países Latinoamericanos desde el 1ero de marzo 2020 al 29 de noviembre 2021. La información se obtuvo del Sistema Informático Perinatal del Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva. Presentamos las variables categóricas como frecuencias y porcentajes y las variables continuas en medianas con rangos inter cuartiles. Resultados: Identificamos un total de 447 muertes. La mediana de edad materna fue de 31 años. 86·4% de las mujeres se infectaron ante del parto, siendo la mayoría de los casos detectados en el tercer trimestre del embarazo (60·3%). Los síntomas más frecuentes en la primera consulta y la admisión fueron disnea (73·0%), fiebre (69·0%), y tos (59·0%). Se reportaron disfunciones orgánicas en 90·4% de las mujeres durante la admisión. Un total de 64·8% de las mujeres fueron ingresadas a cuidados críticos por una mediana de ocho días de estadía. En la mayoría de los casos la muerte ocurrió durante el puerperio, con una media de siete días entre el parto y su ocurrencia. El parto prematuro fue la complicación perinatal más frecuente (76·9%) y 59·9% tuvo bajo peso al nacer. Interpretación: Este estudio describe las características de las muertes maternas durante la pandemia por COVID-19 a partir de una base colaborativa multipaís. Se observaron barreras para el acceso a cuidados intensivos. Los tomadores de decisión deberían trabajar en el fortalecimiento de la conciencia de gravedad, y en estrategias de referencia para evitar potenciales demoras. Financiamiento: Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva.

Transitioning to Digital Systems: The Role of World Health Organization's Digital Adaptation Kits in Operationalizing Recommendations and Interoperability Standards.

INTRODUCTION: The transition from paper to digital systems requires quality assurance of the underlying content and application of data standards for interoperability. The World Health Organization (WHO) developed digital adaptation kits (DAKs) as an operational and software-neutral mechanism to translate WHO guidelines into a standardized format that can be more easily incorporated into digital systems. METHODS: WHO convened health program area and digital leads, reviewed existing approaches for requirements gathering, mapped to established standards, and incorporated research findings to define DAK components. RESULTS: For each health domain area, the DAKs distill WHO guidelines to specify the health interventions, personas, user scenarios, business process workflows, core data elements mapped to terminology codes, decision-support logic, program indicators, and functional and nonfunctional requirements. DISCUSSION: DAKs aim to catalyze quality of care and facilitate data use and interoperability as part of WHO's vision of SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines. Efforts will be needed to strengthen a collaborative approach for the uptake of DAKs within the local digital ecosystem and national health policies.

Estimating misclassification errors in the reporting of maternal mortality in national civil registration vital statistics systems: A Bayesian hierarchical bivariate random walk model to estimate sensitivity and specificity for multiple countries and years with missing data.

Civil registration vital statistics (CRVS) systems provide data on maternal mortality that can be used for monitoring trends and to inform policies and programs. However, CRVS maternal mortality data may be subject to substantial reporting errors due to misclassification of maternal deaths. Information on misclassification is available for selected countries and periods only. We developed a Bayesian hierarchical bivariate random walk model to estimate sensitivity and specificity for multiple populations and years and used the model to estimate misclassification errors in the reporting of maternal mortality in CRVS systems. The proposed Bayesian misclassification (BMis) model captures differences in sensitivity and specificity across populations and over time, allows for extrapolations to periods with missing data, and includes an exact likelihood function for data provided in aggregated form. Validation exercises using maternal mortality data suggest that BMis is reasonably well calibrated and improves upon the CRVS-adjustment approach used until 2018 by the UN Maternal Mortality Inter-Agency Group (UN-MMEIG) to account for bias in CRVS data resulting from misclassification error. Since 2019, BMis is used by the UN-MMEIG to account for misclassification errors when estimating maternal mortality using CRVS data.

The ARMADILLO text message intervention to improve the sexual and reproductive health knowledge of adolescents in Peru: Results of a randomized controlled trial.

BACKGROUND: The ARMADILLO Study determined whether adolescents able to access SRH information on-demand via SMS were better able to reject contraception-related myths and misconceptions as compared with adolescents receiving pushed SMS or no intervention. TRIAL DESIGN: This trial was an unblinded, three-arm, parallel-group, individual RCT with a 1:1:1 allocation. Trial registration: ISRCTN85156148. METHODS: This study was conducted in Lima, Peru among participants ages 13-17 years. Eligible participants were randomized into one of three arms: Arm 1: access to ARMADILLO's SMS information on-demand; Arm 2 access to ARMADILLO SMS information pushed to their phone; Arm 3 control (no SMS). The intervention period lasted seven weeks. At baseline, endline, and follow-up (eight weeks following endline), participants were assessed on a variety of contraception-related myths and misconceptions. An index of myths-believed was generated. The primary outcome assessed the subject-specific change in the mean score between baseline and endline. Knowledge retention from endline to follow-up was also assessed, as was a 'content exposure' outcome, which assessed change in participants' knowledge based on relevant SMS received. RESULTS: In total, 712 participants were randomized to the three arms: 659 completed an endline assessment and were included in the primary analysis. Arm 2 participants believed fewer myths at endline compared with control arm participants (estimated subject-specific mean difference of -3.69% [-6.17%, -1.21%], p = 0.004). There was no significant difference between participants in Arm 1 vs. the control Arm, or between participants in Arm 1 vs. Arm 2. A further decrease in myths believed between endline and follow-up (knowledge retention) was observed in all arms; however, there was no difference between arms. The content exposure analysis saw significant reductions in myths believed for Arm 1 (estimated subject-specific mean difference of -9.47% [-14.83%, -4.11%], p = .001) and Arm 2 (-5.93% [-8.57%, -3.29%], p < .001) as compared with the control arm; however Arm 1's reduced sample size (n = 28) is a severe limitation. DISCUSSION: The ARMADILLO SMS content has a significant (but small) effect on participants' contraception-related knowledge. Standalone, adolescent SRH digital health interventions may affect only modest change. Instead, digital is probably best used a complementary channel to expand the reach of existing validated SRH information and service programs.

Busting contraception myths and misconceptions among youth in Kwale County, Kenya: results of a digital health randomised control trial.

OBJECTIVES: The objective of this randomised controlled trial in Kenya was to assess the effect of delivering sexual and reproductive health (SRH) information via text message to young people on their ability to reject contraception-related myths and misconceptions. DESIGN AND SETTING: A three-arm, unblinded randomised controlled trial with a ratio of 1:1:1 in Kwale County, Kenya. PARTICIPANTS AND INTERVENTIONS: A total of 740 youth aged 18-24 years were randomised. Intervention arm participants could access informational SRH text messages on-demand. Contact arm participants received once weekly texts instructing them to study on an SRH topic on their own. Control arm participants received standard care. The intervention period was 7 weeks. PRIMARY OUTCOME: We assessed change myths believed at baseline and endline using an index of 10 contraception-related myths. We assessed change across arms using difference of difference analysis. RESULTS: Across arms, <5% of participants did not have any formal education, <10% were living alone, about 50% were single and >80% had never given birth. Between baseline and endline, there was a statistically significant drop in the average absolute number of myths and misconceptions believed by intervention arm (11.1%, 95% CI 17.1% to 5.2%), contact arm (14.4%, 95% CI 20.5% to 8.4%) and control arm (11.3%, 95% CI 17.4% to 5.2%) participants. However, we observed no statistically significant difference in the magnitude of change across arms. CONCLUSIONS: We are unable to conclusively state that the text message intervention was better than text message 'contact' or no intervention at all. Digital health likely has potential for improving SRH-related outcomes when used as part of multifaceted interventions. Additional studies with physical and geographical separation of different arms is warranted. TRIAL REGISTRATION NUMBER: ISRCTN85156148.

Development of an international sexual and reproductive health survey instrument: results from a pilot WHO/HRP consultative Delphi process.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardised measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low- and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonise a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a brief sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries.

Exploring the feasibility of establishing a core set of sexual, reproductive, maternal, newborn, child and adolescent health indicators in humanitarian settings: a multimethods, multicountry qualitative study protocol.

INTRODUCTION: In 2019, over 70 million people were forcibly displaced worldwide. Women and girls comprise nearly half of this population and are at heightened risk of negative sexual and reproductive health outcomes. With the collapse of health systems, reduced resources and increased vulnerabilities from displacement, there is a need to strengthen current practices and ensure the delivery of comprehensive sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services. Recognising the need for consistency in data collection, analysis and use, the WHO developed a list of core SRMNCAH monitoring and evaluation indicators for services and outcomes in humanitarian settings. This research will explore the feasibility of collecting this core set of SRMNCAH indicators in displacement contexts. METHODS AND ANALYSIS: We will undertake a multimethods qualitative study in seven humanitarian settings: Afghanistan, Albania, Bangladesh, Cameroon, the Democratic Republic of the Congo, Iraq and Jordan. We selected sites that reflect diversity in geographic region, sociocultural characteristics, primary location(s) of displaced persons and nature and phase of the crisis. Our study consists of four components: key informant interviews, facility assessments, observational sessions at select facilities and focus group discussions with front-line healthcare personnel. We will analyse our data using descriptive statistics and for content and themes. We will begin by analysing data from each setting separately and will then combine these data to explore concordant and discordant results, triangulate findings and develop global recommendations. ETHICS AND DISSEMINATION: The University of Ottawa's Research Ethics Board and the Research Project Review Panel (RP 2) of the World Health Organization-Department of Sexual and Reproductive Health as well as local IRBs of PIs' research institutions reviewed and approved this protocol. We intend to disseminate findings through workshops at the WHO country, regional and headquarter levels, as well as through local, national and international conferences, workshops, peer-reviewed publications, and reports.

Mental health of adolescents associated with sexual and reproductive outcomes: a systematic review.

OBJECTIVE: To systematically review the literature on the mental health of adolescents associated with sexual and reproductive outcomes, and compare the mental health outcomes with that of other age groups. METHODS: We searched seven databases for relevant peer-reviewed articles published between 1 January 2010 and 25 April 2019. Our inclusion criteria required that the study included age-disaggregated data on adolescents, and focused and assessed mental health outcomes associated with pregnancy or sexually transmitted infections. We extracted data on the specific health event, the mental health outcome and the method of measuring this, and comparisons with other age groups. FINDINGS: After initially screening 10 818 articles by title and abstract, we included 96 articles in our review. We observed that a wide-ranging prevalence of mental ill-health has been reported for adolescents. However, most studies of mental health during pregnancy did not identify an increased risk of depression or other mental disorders among adolescents compared with other age groups. In contrast, the majority of studies conducted during the postpartum period identified an increased risk of depression in adolescents compared with other age groups. Three studies reported on mental health outcomes following abortion, with varying results. We found no studies of the effect of sexually transmitted infections on mental health among adolescents. CONCLUSION: We recommend that sexual and reproductive health services should be accessible to adolescents to address their needs and help to prevent any adverse mental health outcomes.

Cost-Effectiveness of Interventions to Improve Maternal, Newborn and Child Health Outcomes: A WHO-CHOICE Analysis for Eastern Sub-Saharan Africa and South-East Asia.

BACKGROUND: Information on cost-effectiveness allows policy-makers to evaluate if they are using currently available resources effectively and efficiently. Our objective is to examine the cost-effectiveness of health interventions to improve maternal, newborn and child health (MNCH) outcomes, to provide global evidence relative to the context of two geographic regions. METHODS: We consider interventions across the life course from adolescence to pregnancy and for children up to 5 years old. Interventions included are those that fall within the areas of immunization, child healthcare, nutrition, reproductive health, and maternal/newborn health, and for which it is possible to model impact on MNCH mortality outcomes using the Lives Saved Tool (LiST). Generalized cost-effectiveness analysis (GCEA) was used to derive average cost-effectiveness ratios (ACERs) for individual interventions and combinations (packages). Costs were assessed from the health system perspective and reported in international dollars. Health outcomes were estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. The model was run for 2 regions: Eastern sub-Saharan Africa (SSA-E) and South-East Asia (SEA). RESULTS: The World Health Organization (WHO) recommended interventions to improve MNCH are generally considered cost-effective, with the majority of interventions demonstrating ACERs below I$100/HLY saved in the chosen settings (low-and middle-income countries [LMICs]). Best performing interventions are consistent across the two regions, and include family planning, neonatal resuscitation, management of pneumonia and neonatal infection, vitamin A supplementation, and measles vaccine. ACERs below I$100 can be found across all delivery platforms, from community to hospital level. The combination of interventions into packages (such as antenatal care) produces favorable ACERs. CONCLUSION: Within each region there are interventions which represent very good value for money. There are opportunities to gear investments towards high-impact interventions and packages for MNCH outcomes. Cost-effectiveness tools can be used at national level to inform investment cases and overall priority setting processes.