Effectiveness of emergency obstetric care training at the regional level in Ukraine: a non-randomized controlled trial.

BACKGROUND: Emergency obstetric care training, using Advances in Labour and Risk Management (ALARM) International Program (AIP) was implemented in Ukraine, a country with universal access to skilled perinatal and obstetric care but restricted resources. A total of 577 providers (65.5% of total) from 28 maternal clinics attended a 5-day training session focused on the five main causes of maternal mortality, with hands-on skill workshops, pre- and post- tests, and an objective structured clinical examination. The effects of this emergency obstetric care training on maternal outcomes is the subject of this paper. METHODS: A non-randomized controlled trial was conducted. The pilot areas where the training was implemented consisted of 64 maternity clinics of which 28 were considered as cases and 36 non-participating clinics were the referents. Data on maternal outcomes were collected for a 2-year span (2004-2005) prior to the trainings, which took place 2006-2007 and again after implementation of the trainings, from 2008 to 2009. Information was collected from 189,852 deliveries. Outcomes for the study were incidences of operative delivery and postpartum hemorrhage. Non-parametric statistics, meta-analyses, and difference in difference (DID) estimation were used to assess the effect of the AIP on maternal indices. RESULTS: DID analysis showed that after the training, compared to the referents, the cases had significant reduction of blood transfusions (OR: 0.56; 95%CI: 0.48-0.65), plasma transfusions (OR: 0.70; 95%CI: 0.63-0.78), and uterus explorations (OR: 0.64; 95%CI: 0.59-0.69). We observed a non-significant reduction of postpartum hemorrhage ≥1000 ml (OR: 0.92; 95%CI: 0.81-1.04; P = 0.103). Utilization of vacuum extraction for vaginal delivery increased (OR: 2.86; 95%CI: 1.80-4.57), as well as forceps assisted delivery (OR: 1.80; 95%CI: 1.00-3.25) and cesarean section (OR: 1.11; 95%CI: 1.06-1.17). There was no change in the occurrence of postpartum hysterectomy and maternal mortality. CONCLUSIONS: After one week of Emergency Obstetrics Care training of the obstetric staff in a setting with universal access to perinatal and obstetric care but restricted resources, an association with the reduction of postpartum hemorrhage related interventions was observed. The effects on the use of vacuum extraction and cesarean section were minimal. TRIAL REGISTRATION: Retrospectively registered 071212007807 from 07/12/2012.

Ukrainian medical students' attitudes to parenthood and knowledge of fertility.

OBJECTIVES: The aim of our study was to investigate Ukrainian medical students' intentions and attitudes in relation to future parenthood, and their knowledge about fertility. METHODS: A classroom survey was carried out of randomly selected groups among 3568 Russian-speaking medical students. The response rate was 88.8%; 858 were female and 407 were male; the mean age was 20.6 (standard deviation [SD] 2.4) years. RESULTS: One in four male and 16% of female respondents did not want to have children, 3.3% had children and 17% wanted one child only. Female respondents wished to have their first child when they were 24.4 (SD 2.4) years of age, and male respondents when they were 26.8 (SD 3.4) years of age. Around 60% of respondents reported there was a pronounced decline in female fertility after the age of 45 years. CONCLUSIONS: The desire to have children in the future is not apparent among medical students, especially not among men. Gaps in students' knowledge about fertility need to be addressed by sexual and reproductive education.

Results of a Dutch national and subsequent international expert meeting on interconception care.

Introduction: The potential value of preconception care and interconception care is increasingly acknowledged, but delivery is generally uncommon. Reaching women for interconception care is potentially easier than for preconception care, however the concept is still unfamiliar. Expert consensus could facilitate guidelines, policies and subsequent implementation. A national and subsequent international expert meeting were organized to discuss the term, definition, content, relevant target groups, and ways to reach target groups for interconception care.Methods: We performed a literature study to develop propositions for discussion in a national expert meeting in the Netherlands in October 2015. The outcomes of this meeting were discussed during an international congress on preconception care in Sweden in February 2016. Both meetings were recorded, transcribed and subsequently reviewed by participants.Results: The experts argued that the term, definition, and content for interconception care should be in line with preconception care. They discussed that the target group for interconception care should be "all women who have been pregnant and could be pregnant in the future and their (possible) partners". In addition, they opted that any healthcare provider having contact with the target group should reach out and make every encounter a potential opportunity to promote interconception care.Discussion: Expert discussions led to a description of the term, definition, content, and relevant target groups for interconception care. Opportunities to reach the target group were identified, but should be further developed and evaluated in policies and guidelines to determine the optimal way to deliver interconception care.

Steroid profiles in ovarian follicular fluid from regularly menstruating women and women after ovarian stimulation.

BACKGROUND: Information on the concentrations of steroids in ovarian follicular fluid (FF) from regularly menstruating (RM) women has been limited because of the absence of methods for the simultaneous quantification of multiple steroids in small volumes of FF. We studied steroid profiles in FF during the early follicular phase of the menstrual cycle and after ovarian stimulation for in vitro fertilization (IVF), and compared concentrations with published values obtained by immunoassay (IA). METHODS: We used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to measure 13 steroids in 40-microL aliquots of FF samples from 21 RM women and from 5 women after ovarian stimulation for IVF. Relationships between concentrations of steroids and their ratios (representations of the enzyme activities) were evaluated within and between subgroups. RESULTS: The concentrations of testosterone (Te), androstenedione (A4), and estradiol (E2) measured by LC-MS/MS were lower than those previously reported in studies with IAs. In RM women, androgens were the most abundant class of steroids, with A4 being the major constituent. The concentrations of 17-hydroxyprogesterone (17OHP), total androgens, and estrogens were 200- to 1000-fold greater in FF than in serum. Compared with RM women, FF samples from women undergoing ovarian stimulation had significantly higher concentrations of E2 (P = 0.021), pregnenolone (P = 0.0022), 17OHP (P = 0.0007), and cortisol (F) (P = 0.0016), and significantly higher ratios of F to cortisone (P = 0.0006), E2 to estrone (P = 0.0008), and E2 to Te (P = 0.0013). CONCLUSIONS: The data provide the first MS-based concentration values for 13 steroids in ovarian FF from RM women, from estrogen- and androgen-dominant follicles, and from women after ovarian stimulation for IVF.

Improving quality of prevention of mother-to-child HIV transmission services in Ukraine: a focus on provider communication skills and linkages to community-based non-governmental organizations.

BACKGROUND: Ukraine has the highest rate of HIV infection in Europe, with an estimated adult prevalence of 1.6 percent. The epidemic in Ukraine remains largely driven by injection drug use, and women of reproductive age are being increasingly affected. Prior research has highlighted the need to improve the quality of services for prevention of mother-to-child transmission (PMTCT) and to address other issues related to HIV counseling, testing, and care, especially in the context of antenatal and obstetric services. METHODS: From 2004 to 2007, PATH led a collaborative effort to improve the quality of PMTCT services in Ukraine. Initial assessments included focus groups with Ukrainian women and review of existing educational materials. Interventions focused on training providers to improve skills in communication and referral to community-based support; they also addressed the underlying issue of stigma. RESULTS: Observational data demonstrated that providers who participated in the training intervention delivered PMTCT counseling of a consistently higher quality than did providers who did not undergo training. Exit interviews with clients confirmed these findings. CONCLUSIONS: An intervention focused on strengthening voluntary counseling and testing for HIV, forging partnerships with local organizations, and undoing HIV-related stigma can help to improve access to and quality of PMTCT services in antenatal care clinics.

Non-genetic risk factors for early and late age at menarche in Eastern Ukrainian females.

ABSTRACT: BACKGROUND: Age at menarche is a reproductive trait, which is largely influenced by environmental factors. Each population has a set of lifestyle factors that may shift age at menarche in different direction. Populations of Eastern Slavs, particularly Ukrainians, are underrepresented in studies of reproductive health. The objective of the present research was to determine important non-genetic risk factors, which may contribute to menarcheal onset in Eastern Ukrainians. METHODS: In total 620 females aged 17-25 years participated in the cross-sectional survey. The questionnaire included lifestyle factors previously reported in other populations as those, which might affect age at menarche. The risk factors for early and late age at menarche were determined using logistic regression models. The models were validated by receiver operating curves. RESULTS: Body composition in the prepubertal stage as presented by responders seems to have the strongest association with age at menarche. Those who were shorter and thinner as compared to their peers at age six had significantly more chance to start menstruating later (OR = 1.66, 95% CI [1.01-2.73]) and reduced chance to have menarche before 12 years old (OR = 0.32, 95% CI [0.14-0.73]). Maternal smoking during pregnancy and low protein intake reported during childhood may decrease a probability of late age at menarche. CONCLUSIONS: Although overall body composition at age of six was a main trait, which was associated with menarcheal timing, more information on body measurements (e.g. waist-hip ratio) in prepubertal stage would help to establish a greater degree of accuracy on this matter.

Using the Nordic-Baltic perinatal death classification to assess perinatal care in Ukraine.

OBJECTIVE: To identify health care issues important to reduce the perinatal mortality rate (PMR) in Ukraine. STUDY DESIGN: Perinatal deaths in the Donetsk region (Ukraine) in 1997-1998 were compared with those in Denmark in 1996 by using the Nordic-Baltic classification for perinatal deaths. Clinical guidelines, use of technology and rates of interventions in the two regions were described. RESULTS: A two-fold increase in PMR was found in Ukraine compared to Denmark, mainly explained by higher rates of antenatal deaths of growth restricted fetuses, intrapartum deaths, and neonatal deaths due to asphyxia. Vacuum extraction is rarely used in Ukraine. The clinical guidelines for care differ significantly between the two regions. CONCLUSION: Appropriate use of technology and implementation of evidence-based guidelines should be a matter of high priority in the Donetsk region, Ukraine.

Steroid profiles in ovarian follicular fluid in women with and without polycystic ovary syndrome, analyzed by liquid chromatography-tandem mass spectrometry.

OBJECTIVE: To compare steroid concentrations and steroid product-to-precursor ratios in ovarian follicular fluid (FF) from women with polycystic ovary syndrome (PCOS) and from regularly menstruating women in their early follicular phase, using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Polycystic ovary syndrome involves abnormal regulation of the steroidogenic enzymes, leading to arrest of follicle development. DESIGN: Case-control study. SETTING: University hospital clinic. PATIENT(S): Follicular fluid from size-matched ovarian follicles (5-8 mm) in 27 nonstimulated women with PCOS and in 21 women without PCOS was sampled. Thirteen steroids were quantitated from 40 µL of FF, using LC-MS/MS. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Concentrations of steroids in the FF and product-to-precursor ratios (enzyme activity) were compared between the groups. RESULT(S): In women with PCOS, ovarian FF contained higher concentrations of individual and total androgens, lower individual and total estrogens (E), and a lower total E-to-androgen ratio, compared with regularly menstruating women. The product-to-precursor concentration ratios indicated higher CYP17-linked and lower CYP19-linked (aromatase) enzyme activity. Receiver operating characteristic plots indicated the early CYP17 step (17-OH5P/5P) being highly important for the prevalence of PCOS (c=0.95). CONCLUSION(S): The women with PCOS had higher ovarian CYP17-linked and lower CYP19-linked (aromatase) enzyme activity, confirming previous data. Multiple steroid assessments from minute volumes including FF from nonstimulated ovaries, using LC-MS/MS, might be useful in research, clinical endocrinology, and in IVF.

Granulosa cell aromatase enzyme activity: effects of follicular fluid from patients with polycystic ovary syndrome, using aromatase conversion and [11C]vorozole-binding assays.

The local regulation of ovarian aromatase enzyme in polycystic ovary syndrome (PCOS) was studied with aromatase conversion and [11C]vorozole-binding assays to analyze aromatase activity, substrate-enzyme affinity and number of aromatase binding sites in non-cultured human granulosa cells (GC) incubated with different sources and preparations of follicular fluid (FF). Incubation with FF from women stimulated in in vitro fertilization cycles with follicle-stimulating hormone yielded higher conversion activity than with FF from healthy women and PCOS patients, paralleled with higher substrate affinity (lower Kd) than with FF from healthy women. In PCOS women, charcoal-pretreated FF yielded higher conversion, whereas the ether-pretreated FF yielded lower conversion activity, than with untreated PCOS FF. Both preparations of FF yielded higher affinity to substrate (lower Kd values) and the ether-pretreated FF a lower number of binding sites (Bmax). It seems that steroids with the presence of proteins in PCOS FF reduced aromatase conversion activity through decreased substrate affinity, whereas FF preparations devoid of proteins reduced the aromatase conversion activity mainly through blocking of aromatase active sites. Identification of specific agents responsible for this rapid regulation of aromatase function might help to understand normal regulation of the menstrual cycle and supposed imbalances of inhibitors/activators in PCOS.