Low HIV testing rates among US women who report anal sex and other HIV sexual risk behaviors, 2011-2015.

OBJECTIVE: In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with preexposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex. STUDY DESIGN: We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant US women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including ≥2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis. RESULTS: Overall, 7.9 million of 42.4 million sexually active, nonpregnant US women (18.7%) reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse, and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs 15.9%; P < .001). HIV testing in the past year was higher for women with other risk behaviors compared with anal sex, ranging from 35.8% to 47.2%. CONCLUSION: Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women's health and well-being but that can be offered only based on HIV testing results. Women's health care providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

Detection of early-stage changes in people with chronic diseases: A telehome monitoring-based telenursing feasibility study.

Chronic diseases, such as chronic obstructive pulmonary disease, amyotrophic lateral sclerosis, and diabetes mellitus, require long-term management, which daily telenurse monitoring can provide. The aim of the present feasibility study was to determine if using a telenursing protocol with home monitoring during a 12 week implementation could also identify early signs of deterioration and factors correlated with participants' change in status, while attaining patient acceptance and satisfaction. The purposive sample of 43 participants provided 4533 combined days of monitoring. Outcome feasibility indicators were the range of triggering protocol alerts (70~100%) and diagnoses with exacerbations (20~29.3%). Highly correlated were participants' activity limitation and palpitations with chronic obstructive pulmonary disease, activity limitation and ineffective sputum clearance with amyotrophic lateral sclerosis, and fatigue with diabetes. Acceptance and adherence were high with daily monitoring, including "feelings of safety," and "understanding own condition". Telenursing with home monitoring indicated a trend to accurately detect early-stage changes. Participant acceptance was acceptable. It would be feasible to conduct a randomized, controlled trial using this model with some modifications.

Prevalence and risk factors of intimate partner violence among pregnant women in Japan.

Intimate partner violence (IPV) during pregnancy can result in adverse outcomes for both mothers and their infants. This cross-sectional study examined the prevalence and risk factors of IPV associated with abuse during pregnancy via a self-administered questionnaire completed by 302 healthy pregnant women. Demographic information was also collected from medical records to analyze risk factors for abuse. Of the 302 women, 48 (15.9%) were identified as experiencing IPV. The identified risk factors were age over 30, multipara, previous abortion experience, and male partner aged under 30.

Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence. METHODS: We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019. RESULTS: Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices. CONCLUSION: South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.

Voluntary medical male circumcision reduces the risk of male HIV acquisition. Programmes to provide circumcisions for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Estimates of circumcision coverage are needed for planning and delivering circumcisions to meet targets and evaluate their impacts on HIV incidence. We developed a model to integrate date from both household surveys and health systems on the number of circumcisions conducted, and applied it to understand how the practices and coverage of circumcision are changing in South Africa. National circumcision coverage increased considerably between 2008 and 2019, however, there remains a substantial subnational variation across districts and age groups. Further progress is needed to reach national and international targets.

Immigrants' experiences of maternity care in Japan.

Language and cultural differences can negatively impact immigrant women's birth experience. However, little is known about their experiences in Japan's highly homogenous culture. This cross-sectional study used survey data from a purposive sampling of immigrant women from 16 hospitals in several Japanese prefectures. Meeting the criteria and recruited to this study were 804 participants consisting of 236 immigrant women: Chinese (n = 83), Brazilian (n = 62), Filipino (n = 43), South Korean (n = 29) and from variety of English speaking nations (n = 19) and 568 Japanese women. The questionnaire was prepared in six languages: Japanese (kana syllables), Chinese, English, Korean, Portuguese, and Tagalog (Filipino). Associations among quality of maternity care, Japanese literacy level, loneliness and care satisfaction were explored using analysis of variance and multiple linear regression. The valid and reliable instruments used were Quality of Care for Pregnancy, Delivery and Postpartum Questionnaire, Rapid Estimate of Adult Literacy in Medicine Japanese version, the revised UCLA Loneliness Scale-Japanese version and Care satisfaction. Care was evaluated across prenatal, labor and delivery and post-partum periods. Immigrant women scored higher than Japanese women for both positive and negative aspects. When loneliness was strongly felt, care satisfaction was lower. Some competence of Japanese literacy was more likely to obstruct positive communication with healthcare providers, and was associated with loneliness. Immigrant women rated overall care as satisfactory. Japanese literacy decreased communication with healthcare providers, and was associated with loneliness presumably because some literacy unreasonably increased health care providers' expectations of a higher level of communication.

Development and applicability of a dignity-centred palliative care programme for people with idiopathic pulmonary fibrosis: A qualitative-driven mixed methods study.

AIMS: This study evaluated the acceptability of a dignity-centred palliative care programme for people with idiopathic pulmonary fibrosis by converging perceptions of living with idiopathic pulmonary fibrosis qualitative data and quantitative data. DESIGN: The qualitative-driven mixed methods research addressed the study aim by using a convergent design. This single arm, non-randomized study used purposive sampling. METHODS: Interviews with 12 stable outpatients with IPF provided qualitative data. Their quantitative data were from six scales: self-esteem, health-related quality of life, anxiety, depression, dyspnoea, cough and programme satisfaction. Intervention was three educational modules: symptom management, enhancing daily activities and life reviews. RESULTS: Semi-structured interviews yielded eight categories. Self-esteem was not statistically significantly changed. Dyspnoea symptoms improved significantly. Participants (n = 9) holding positive attitudes for living with idiopathic pulmonary fibrosis, had improved lifestyle behaviour and improved or maintained self-esteem. The meta-inference regarding idiopathic pulmonary fibrosis perceptions were related to changes in self-esteem.

Continuous interprofessional collaboration for women with gestational diabetes mellitus: A cross-sectional survey in Japan.

AIM: This study aimed to identify the current situation of interprofessional collaboration for gestational diabetes mellitus (GDM) management in Japan including the professionals involved, the collaboration methods employed, and the barriers perceived by nurses and midwives. METHODS: This nationwide cross-sectional survey of 1,046 total hospitals facilitating childbirth in Japan used an original 60-item questionnaire to investigate GDM management practice through interprofessional collaboration. The questionnaire required one responder to be a midwife or nurse who was familiar with the management practices for GDM women in their respective hospitals. Quantitative data were analyzed using descriptive statistics, and framework analysis was conducted for qualitative data collected by open-ended questions. RESULTS: All 308 respondents (response rate 29.4%) were included. The professionals included in interprofessional collaboration were limited, and the only strategy used for interprofessional collaboration by a majority (91.5%) of hospitals was medical charts. There were 50.8% of hospitals that provided postpartum GDM follow-ups and 54.5% of hospitals that did not engage in external collaboration for GDM management. The barriers to interprofessional collaboration extracted were seven categories and 23 subcategories, which were aligned within the following units of analysis: individual, team, organization, and community. CONCLUSIONS: This survey shows that interprofessional collaboration, including support for GDM postpartum follow-up in Japan remains insufficient. Furthermore, nurses and midwives perceive numerous barriers to interprofessional collaboration for continuous GDM management at the individual, team, organizational and community levels.

Quality-of-life predictors for men undergoing infertility treatment in Japan.

AIM: To dentify the predictors of the quality of life (QOL) of infertile men who are undergoing infertility treatments in Japan and to create a QOL prediction model, with the main variables aimed at providing more adequate support to male patients. METHODS: This cross-sectional study used the quantitative data that were collected from 321 returned self-report questionnaires that had been distributed to the men of 411 couples who were undergoing fertility treatment. The following four scales were used to measure the main outcomes: FertiQoL, psychological distress, spousal support, and workplace support. The data were analyzed by descriptive statistics, multiple regression analyses, and structural equation modeling. RESULTS: The number of returned questionnaires was 321 (78.1%). The QOL that was measured by FertiQoL was significantly lower in those men who were diagnosed with male factor infertility than in the other male patients. The two significant predictors of QOL were: spousal support and the infertility period. The structural equation modeling revealed that the same factors were related to QOL. CONCLUSIONS: Male factor infertility, less spousal support, and a longer period of infertility were associated with a poorer QOL of those men who were undergoing infertility treatment. These results suggest that focusing on infertility causes, the length of the infertility period, and the couples' partnership during treatment is needed to provide full support to men who have been diagnosed with infertility.

HIV Diagnoses and the HIV Care Continuum Among Women and Girls Aged ≥13 Years-39 States and the District of Columbia, 2015-2016.

BACKGROUND: In 2017, 19% of new HIV diagnoses in the United States were in women. HIV acquisition can be prevented with pre-exposure prophylaxis, and HIV transmission with viral suppression. HIV viral suppression is achieved by linking women to care and supporting adherence to antiretroviral medications. The national HIV prevention goal for viral suppression is 80%. SETTING: United States. METHODS: We analyzed data reported by 40 US jurisdictions to the Centers for Disease Control and Prevention's National HIV Surveillance System to determine the number and rate of HIV diagnoses per 100,000 women in 2016. We also determined the percentages of women with diagnosed HIV who were linked to care within 1 and 3 months, received HIV care, were retained in HIV care, and were virally suppressed in 2015. Findings were stratified by demographic characteristics and HIV transmission category. RESULTS: In 2016, 6407 women were diagnosed with HIV. Black women had a rate of 783.7 per 100,000, Hispanic/Latino women 182.7, and white women 43.6. In 2015, 190,735 women were living with diagnosed HIV. Viral suppression increased with age, ranging from 46.5% among women aged 13-24 years to 62.3% among women aged ≥45 years. Black women had the lowest rate of viral suppression (55.5%). No age group of women achieved 80% viral suppression. CONCLUSIONS: Pre-exposure prophylaxis implementation for women at high risk for HIV infection can help to decrease new infections. Women living with HIV would benefit from interventions that support linkage to HIV care and antiretroviral medication adherence to increase viral suppression.

Preparation and Application of a New Bacterial Biosensor for the Presumptive Detection of Gunshot Residue.

MicRoboCop is a biosensor that has been designed for a unique application in forensic chemistry. MicRoboCop is a system made up of three devices that, when used together, can indicate the presence of gunshot residue (GSR) by producing a fluorescence signal in the presence of three key analytes (antimony, lead, and organic components of GSR). The protocol describes the synthesis of the biosensors using Escherichia coli (E. coli), and the analytical chemistry methods used to evaluate the selectivity and sensitivity of the sensors. The functioning of the system is demonstrated by using GSR collected from the inside of a spent cartridge casing. Once prepared, the biosensors can be stored until needed and can be used as a test for these key analytes. A positive response from all three analytes provides a presumptive positive test for GSR, while each individual device has applications for detecting the analytes in other samples (e.g., a detector for lead contamination in drinking water). The main limitation of the system is the time required for a positive signal; future work may involve studying different organisms to optimize the response time.

Factors Affecting Pre-Exposure Prophylaxis Implementation for Women in the United States: A Systematic Review.

Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective pill that HIV-negative individuals can take once daily to prevent HIV infection. Although PrEP is a private, user-controlled method that empowers women to protect themselves without relying on a partner's behavior, women's PrEP use has been extremely low. We systematically reviewed the literature to identify and summarize factors that may be affecting PrEP implementation for women in the United States. We conducted a search of the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database (MEDLINE, EMBASE, and CINAHL) and PubMed to identify peer-reviewed studies published between January 2000 and April 2018 that reported U.S. women's or health care providers' PrEP knowledge or awareness, willingness to use or prescribe, attitudes, barriers and facilitators to use or prescription, or PrEP adherence and discontinuation influences. Thirty-nine studies (26 women, 13 providers) met the eligibility criteria. In these studies, 0%-33% of women had heard of PrEP. Between 51% and 97% of women were willing to try PrEP, and 60%-92% of providers were willing to prescribe PrEP to women. Implementation barriers included access, cost, stigma, and medical distrust. Three studies addressed adherence or discontinuation. PrEP knowledge is low among women and providers. However, women and providers generally have positive views when aware of PrEP, including a willingness to use or prescribe PrEP to women. Most of the implementation barriers highlighted in studies were social or structural factors (e.g., access). Additional studies are needed to address research gaps, including studies of PrEP adherence and discontinuation.

Fast, comprehensive two-dimensional liquid chromatography.

The absolute need to improve the separating power of liquid chromatography, especially for multi-constituent biological samples, is becoming increasingly evident. In response, over the past few years, there has been a great deal of interest in the development of two-dimensional liquid chromatography (2DLC). Just as 1DLC is preferred to 1DGC based on its compatibility with biological materials we believe that ultimately 2DLC will be preferred to the much more highly developed 2DGC for such samples. The huge advantage of 2D chromatographic techniques over 1D methods is inherent in the tremendous potential increase in peak capacity (resolving power). This is especially true of comprehensive 2D chromatography wherein it is possible, under ideal conditions, to obtain a total peak capacity equal to the product of the peak capacities of the first and second dimension separations. However, the very long timescale (typically several hours to tens of hours) of comprehensive 2DLC is clearly its chief drawback. Recent advances in the use of higher temperatures to speed up isocratic and gradient elution liquid chromatography have been used to decrease the time needed to do the second dimension LC separation of 2DLC to about 20s for a full gradient elution run. Thus, fast, high temperature LC is becoming a very promising technique. Peak capacities of over 2000 and rates of peak capacity production of nearly 1 peak/s have been achieved. In consequence, many real samples showing more than 200 peaks with signal to noise ratios of better than 10:1 have been run in total times of under 30 min. This report is not intended to be a comprehensive review of 2DLC, but is deliberately focused on the issues involved in doing fast 2DLC by means of elevating the column temperature; however, many issues of broader applicability will be discussed.

Development of an in vitro incubation procedure for screening of CYP2D6 intrinsic clearance.

The in vitro intrinsic clearances (CL(int)) for the metabolism of p-methoxymethamphetamine (PMMA) and fluoxetine by the CYP2D6 enzyme were calculated using a steady-state (SS) approach and a new general enzyme (GE) method, which measures the formation of product and the depletion of substrate as a function of time. For PMMA, the SS experiment resulted in a CL(int) of 2.7+/-0.2 microL pmol 2D6(-1)min(-1) and the GE experiment resulted in a CL(int) of 3.0+/-0.6 microL pmol 2D6(-1)min(-1). For fluoxetine, the SS experiment resulted in a CL(int) of 0.33+/-0.17 microL pmol 2D6(-1)min(-1) and the GE experiment resulted in a CL(int) of 0.188+/-0.013 microL pmol 2D6(-1)min(-1). We used two kinetic modeling techniques that can accommodate atypical kinetic models. We also show that the addition of fluoxetine results in a 10-fold decrease in the observed intrinsic clearance of PMMA, confirming that fluoxetine is a potent inhibitor of the liver enzyme CYP2D6.

Factors contributing to postpartum blood-loss in low-risk mothers through expectant management in Japanese birth centres.

OBJECTIVE: To describe aspects of expectant midwifery care for low-risk women conducted in midwifery-managed birth centres during the first two critical hours after delivery and to compare differences between midwifery care, client factors and postpartum blood loss volume. METHOD: As a secondary analysis from a larger study, this descriptive retrospective study examined data from birth records of 4051 women who birthed from 2001 to 2006 at nine (21%) of the 43 midwifery centres in Tokyo. Nonparametric and parametric analyses identified factors related to increased blood loss. Interviews to establish sequence of midwifery care were conducted. FINDINGS: The midwifery centres provided care based on expectant management principles from birth to after expulsion of the placenta. Approximately 63.3% of women were within the normal limits of blood loss volume under 500g. A minority of women (12.9%) experienced blood loss between 500 and 800g and 4% had blood loss exceeding 1000g. Blood loss volume tended to increase with infant birth weight and duration of delivery. The total blood loss volume was significantly higher for primiparas than for multiparas during the critical two hours after delivery and for immediately after delivery, yet blood loss volume was significantly higher for multiparas than for primiparas during the first hour after delivery. Preventive uterine massage and umbilical cord clamping after placenta expulsion resulted in statistically significant less blood loss. Identified were two patterns of midwifery care based on expectant management principles from birth to after expulsion of the placenta. The practice of expectant management was not a significant factor for increased postpartum blood loss. CONCLUSION: These results detail specific midwifery practices and highlight the clinical significance of expectant management with low risk pregnant women experiencing a normal delivery.

Fast gradient elution reversed-phase liquid chromatography with diode-array detection as a high-throughput screening method for drugs of abuse. II. Data analysis.

In Part I of this work, we developed a method for the detection of drugs of abuse in biological samples based on fast gradient elution liquid-chromatography coupled with diode array spectroscopic detection (LC-DAD). In this part of the work, we apply the chemometric method of target factor analysis (TFA) to the chromatograms. This algorithm identifies the target compounds present in chromatograms based on a spectral library, resolves nearly co-eluting components, and differentiates between drugs with similar spectra. The ability to resolve highly overlapped peaks using the spectral data afforded by the DAD is what distinguishes the present method from conventional library searching methods. Our library has a mean list length (MLL) of 1.255 and a discriminating power of 0.997 when both retention index and spectral factors are considered. The algorithm compares a library of 47 different compounds of toxicological relevance to unknown samples and identifies which compounds are present based on spectral and retention index matching. The application of a corrected retention index for identification rather than raw retention times compensates for long-term and column-to-column retention time shifts and allows for the use of a single library of spectral and retention data. Training data sets were used to establish the search and identification parameters of the method. A validation data set of 70 chromatograms was used to calculate the sensitivity (correct identification of positives) and specificity (correct identification of negatives) of the method, which were found to be 92% and 94%, respectively.

Nursing care delivery in Japanese psychiatric units.

Japan has the largest number of psychiatric beds per population in the world. At the same time, little research had been done to describe nursing care delivered in psychiatric units. To describe contents of nursing care, the framework for care classification and measuring methods must be examined. The purpose of this study was to develop a nursing intervention classification and examine the correlation between amount of care and patients' mental states. Data were collected from 39 patient care records from 4 randomly selected psychiatric hospitals. Patients' function and condition were evaluated by their doctors using the Global Assessment of Functioning (GAF) and the Brief Psychiatric Rating Scale (BPRS). Six care categories were extracted: basic activities of daily living, psychological support/interpersonal skills, medical support, monitoring, family support and miscellaneous. By examining three cases with this classification, there were significant correlations between the GAF and BPRS scores and amount of care for two acutely ill psychotic patients.

Apologizing: trying to get it right.

It is hardly possible to go through a day without "stepping on someone's toes." By practicing the steps described in this article, you can strengthen your ability to engage in an apology process that is powerful and healing. Being truthful and courageous about your own part of a situation opens the door for others around you to do likewise. People will experience you as a person who has integrity. Receiving an apology from another person allows you to complete the process by forgiving.

Caring for patients with malignant pleural mesothelioma in Japan: evaluation of a Palliative Care Educational Program.

PURPOSE: This study evaluated the effect of an Educational PROGRAM on Palliative Care for MPM for Nurses in Japan. PROGRAM: The 5-h program consisted of lectures and care planning group work. MATERIALS AND METHODS: This study used a pretest-posttest design with a single cohort of nurses and included a Difficulties in Palliative Care for Patients with MPM (DPCMPM) Scale with 15 items. The pre- and posttest scores were compared using a t-test. RESULTS: We included 27 female nurses with a mean of 14.4 years of nursing experience. In 12 of 15 DPCMPM items, the posttest difficulty scores were lower than the pretest scores. Participants highly evaluated the program for validity, clarity, clinical usefulness, and the facilitators. The Palliative Care for MPM Handbook for Nurses was developed as an educational tool for clinical settings. CONCLUSIONS: The Educational PROGRAM on Palliative Care for MPM for Nurses was effective in reducing nursing difficulties.

A qualitative analysis of beginning mindfulness experiences for women with post-traumatic stress disorder and a history of intimate partner violence.

This article presents the beginning mindfulness experiences of low income, minority women with a history of intimate partner violence. Ten women participated in a Mindfulness-Based Stress Reduction group, three interviews and a focus group over 15 months. Using an interpretive phenomenological analysis approach, we derived the following themes: struggles to practice meditation; a vision of growing and helping; personal improvements, and interpersonal improvements. We share recommendations for clinical practice.

Rural Indonesia women's traditional beliefs about antenatal care.

BACKGROUND: The Indonesia Maternal Mortality Rate (MMR) of 420/100.00 live births remains among the highest in East Asia while coverage of births assisted by skilled providers is still low. Traditional beliefs have been a key factor associated with the choice between midwives or traditional birth attendants (TBA) and the low number of antenatal care visits in rural West Sumatra. METHODS: We conducted three focus groups with 16 women from rural West Java to describe their perception regarding issues related to traditional beliefs. Focus group discussions provided data for the content analysis. RESULTS: The majority of the 16 women interviewed was from Village Dago, West Java and had only an elementary school education. Their ages ranged from 19 to 40 years. Most were multiparous housewives with an income of IDR 918.750 per month, which was lower than the monthly income in West Java (IDR. 1.172.060). Emerging from the focus group discussion were four main themes regarding their pregnancy and traditional beliefs: 1) pregnancy was a normal cycle in women's life (pregnancy is a natural phenomena, not a sickness; no recognition of danger signs during pregnancy and death of baby or mother during pregnancy was brought about by God's will); 2) women followed the traditional beliefs (positive motivation to follow the traditional beliefs and fear of not following the traditional beliefs); 3) relying on TBA called paraji rather than midwife (parajis are kind, tolerant and patient and have more experience than midwives; more accessibility than midwives and encouragement of natural birth) and 4) midwives are more secure than paraji; (they use a medical standard of care). CONCLUSIONS: Women's beliefs grounded in religion and tradition permeated the village culture making it difficult to counter their long held health practices with practices based on recent advances in health care. Use of TBA in this village was still dominant and women believed that following traditional beliefs led to a healthy pregnancy therefore, they also followed all relatives' suggestions. Understanding the complexities of local culture is the first step to improving women's awareness of how to preserve their pregnancy and prevent complications.