The Association of Longer Breastfeeding Duration and Socioeconomic, Pregnancy, Childbirth and Postpartum Characteristics.

Background and Objectives: Breastmilk is the safest and most suitable food for an infant, playing the role of their first vaccine and containing all the essential nutrients for the first months of life. The World Health Organisation recommends exclusive breastfeeding for the first 6 months of life and continued breastfeeding while introducing a child to complementary foods until 2 years and beyond. According to Latvian statistics from 2022, only 27.4% of babies were breastfed for 12 months. The aim of this study was to determine the socio-economic factors and factors related to pregnancy, childbirth and postpartum that influence breastfeeding for more than 6 months in Latvia. Materials and Methods: Data were used from the cross-sectional survey "Research on factors and behaviours affecting the sexual and reproductive health of the population of Latvia", which was conducted in 2023. A study sample was randomised and stratified by gender and five age groups. The analyses in this study are based on a sample of women who had given birth at least once (n = 1407), and the dependent variable was the duration of breastfeeding their last child. Binary logistic regression was conducted to identify the associated factors. Results: The point prevalence of longer duration of breastfeeding for the last child was 47.9% (n = 674). The odds of longer breastfeeding duration were higher among mothers who did not smoke during pregnancy (vs. smokers, aOR 2.1, p < 0.001), of Latvian nationality (vs. Russian, aOR 1.3, p = 0.03), who had two childbirth (vs. one, aOR 1.5, p = 0.003), who had the highest level of education (vs. primary education, aOR 2.0, p = 0.03), started breastfeeding immediately after the birth (vs. later than the first day, aOR 1.7, p = 0.01) or on the first day (vs. later, aOR 1.6, p = 0.01). Conclusions: We documented socio-demographic pregnancy and childbirth factors associated with longer breastfeeding durations. Efforts to promote breastfeeding practices should target mothers from the most vulnerable groups.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Contraception among HIV-positive women in Latvia- knowledge, experience and factors influencing the choice.

OBJECTIVES: Latvia has one of the highest numbers of new HIV cases in the EU. The latest SRH national survey confirmed low effective contraceptive prevalence in the general population, no data were available about women living with HIV (WLHIV). The study aimed to assess knowledge on the use of different contraceptives, to identify factors in choosing contraception, to assess the availability of family planning health care services, and to investigate contraception habits. METHODS: A cross-sectional study was conducted among WLHIV aged 18-49 recruited with assistance of non-governmental organisations addressing HIV issues. Interviews in Latvian and Russian languages were based on pre-tested questionnaire. Data were processed and analysed using IBM SPSS 22.0. RESULTS: 102 WLHIV were interviewed and 99 of them met the inclusion criteria. Most women were aware of at least one effective contraceptive method yet around half of them had misconceptions about hormonal methods. Most of the women were able to evaluate the effectiveness of contraceptives. Sexually active women usually used male condoms (76.3%) although around 40% did not use them permanently especially if their partner was HIV-positive. Contraception usage after HIV infection decreased. Women mainly trusted medical professionals on information provided about contraceptives. Over 50% of women experienced situations they could not afford a visit to a gynaecologist or contraceptives. CONCLUSIONS: The survey showed a wide prevalence of misconceptions and prejudice about hormonal contraceptives. There is a need for health education including sexuality education and financial support to make effective contraception available and affordable for WLHIV.

Iron Status in Pregnant Women in Latvia: An Epidemiological, Cross-Sectional, Multicenter Study According to WHO and UK Criteria.

Background and Objectives: During pregnancy, iron deficiency anaemia is a common problem associated with health risks for both the mother and her foetus/infant. This study aimed to investigate the prevalence of iron deficiency, iron deficiency anaemia, and related dietary patterns in pregnant women in Latvia. Materials and Methods: This cross-sectional, multicentre study included pregnancy data from 974 women. The sample selection was based on the stratification principle (population of women of childbearing age in regions of Latvia). Maternal demographic details, anthropometric measurements, iron status, dietary patterns, and supplementation information were obtained from maternal files and during interviews held in eight outpatient departments of medical institutions and maternity departments. The prevalence was assessed. Chi-square tests and logistic regression were used to identify associations between iron deficiency and sociodemographic characteristics, dietary patterns, and iron supplement intake during pregnancy. The criterion used for the diagnosis of iron deficiency anaemia is a Hb level <110 g/L in the 1st and 3rd trimesters and <105 g/L during the 2nd trimester as recommended by the WHO. However, the UK guideline was used for borderline iron deficiency, which is an SF level <30 µg/L in all trimesters. Results: The observed prevalence of anaemia was 2.8% in the first trimester, 7.9% in the second trimester, and 27.0% in the third trimester. The prevalence of iron deficiency was 46.7% in the first trimester, 78.1% in the second trimester, and 91.7% in the third trimester. No associations with dietary patterns were found. Single women had 1.85 times the odds (95% CI 1.07 to 3.18) of being anaemic than married women. Conclusions: Iron deficiency affects a large proportion of pregnant women in Latvia in all trimesters, with iron deficiency anaemia affecting pregnant women in the third trimester. Monitoring and intervention should be performed in a timely and more targeted manner.

Can a mother's polycystic ovary syndrome (PCOS)-related symptoms be used to predict the future clinical profile of PCOS in her adolescent daughter? A pilot study.

OBJECTIVE: The aim of the study was to establish whether a mother's polycystic ovary syndrome (PCOS) symptoms can predict her daughter's future PCOS clinical profile. METHODS: This was a cross-sectional study of 57 adolescents who attended a paediatric gynaecology clinic between 2017 and 2019 and had an established diagnosis of PCOS according to the 2018 criteria of the European Society of Human Reproduction and Embryology. A clinical examination and pelvic ultrasound were performed and the level of total testosterone was measured. A structured questionnaire concerning PCOS symptoms was completed by the girls' mothers. RESULTS: It was found that 51% of girls with PCOS and 44% of their mothers had an elevated body mass index (BMI), and 35% of girls had an increased waist-hip ratio (>0.85). The mother's BMI significantly predicted her daughter's BMI and waist-hip ratio. It was reported that 40% of mothers had experienced menstrual irregularities, 50% hirsutism and 67% acne, and 12% had a confirmed diagnosis of PCOS. CONCLUSION: Our study population had several markers of poor metabolic health (increased BMI and waist-hip ratio) that were passed down from mother to daughter. No direct link was found between a mother's PCOS symptoms and those of her adolescent daughter. In order to establish definitive links between the symptoms of a mother and those of her daughter, a more comprehensive study should be conducted using a larger study sample. Additionally, a follow-up assessment of our studied adolescents would be appropriate to evaluate the progress of their symptoms.

Post-reproductive aged women: a lost generation in the cervical cancer screening programme.

OBJECTIVES: The aims of the study were to find out why some post-reproductive aged women did not participate in the organised cervical cancer screening programme in Latvia and to clarify factors that would motivate them to take part. METHODS: A cross-sectional study was carried out between January and July 2017 among female patients in three general practitioner (GP) practices. GP practice nurses used the Latvian national health service database to identify women aged 25-70 who had not participated in the organised programme for the last 3 years. Participants were asked to complete a specially developed questionnaire. The results were then compared between three age groups: 25-34, 35-49 and 50-70 years. RESULTS: Included in the study were 523 out of 992 women who had not attended screening; 41% were in the age group 50-70 years. Post-reproductive aged women statistically significantly more often did not take part in the programme because of lack of time (26.4%), too great a distance to the gynaecology screening clinic (10.4%), lengthy appointment waiting time (8.5%) and a belief that a smear test was unnecessary for them (8.5%); 32.1% of women in this age group indicated that if the cervical screen could be carried out by their GP it would facilitate their participation in the programme. CONCLUSION: Post-reproductive aged women in Latvia often do not attend cervical cancer screening. Analysis of personal and organisational barriers confirmed that the involvement of GPs would encourage older women to participate in the organised screening programme.

Opportunities for linking research to policy: lessons learned from implementation research in sexual and reproductive health within the ANSER network.

BACKGROUND: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work. METHODS: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes. RESULTS: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings. CONCLUSION: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

Sex Surveys in Europe: Reflections on over Four Decades of Sexual Behavior and Sexual Health Surveillance.

Sexual expression is fundamental to human existence and an important topic of enquiry in its own right. Understanding sexual behavior is also essential to establish effective sexual health prevention activities (e.g., education), services and policies, and to assess the progress of policies and action plans. Questions on sexual health are rarely included in general health surveys, and therefore dedicated population studies are required. Many countries lack both funding and sociopolitical support to conduct such surveys. A tradition of periodic population sexual health surveys exists in Europe but the methods used (e.g., in questionnaire construction, recruiting methods or interview format) vary from one survey to another. This is because the researchers within each country are confronted with conceptual, methodological, sociocultural and budgetary challenges, for which they find different solutions. These differences limit comparison across countries and pooling of estimates, but the variation in approaches provides a rich source of learning on population survey research. In this review, survey leads from 11 European countries discuss how their surveys evolved during the past four decades in response to sociohistorical and political context, and the challenges they encountered. The review discusses the solutions they identified and shows that it is possible to create well designed surveys which collect high quality data on a range of aspects of sexual health, despite the sensitivity of the topic. Herewith, we hope to support the research community in their perennial quest for political support and funding, and ongoing drive to advance methodology in future national sex surveys.

Role of Single Nucleotide Variants in the YAP1 Gene in Adolescents with Polycystic Ovary Syndrome.

BACKGROUND: Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women. It can manifest in adolescence, affecting up to 8% of adolescents. Long-term health consequences characteristic of PCOS are impaired fertility, increased risk of type 2 diabetes, metabolic disorders and cardiovascular disease. All of these sequelae are exacerbated by increased body weight, a major feature of PCOS. The protein encoded by the YAP1 gene plays a key role in one of the pivotal mechanisms that govern cellular/organismal metabolism and contributes to the pathogenesis of metabolic diseases. AIM: To compare the prevalence of single nucleotide variants (SNVs) in the YAP1 gene among adolescents with PCOS, adolescents at risk of PCOS development and healthy adolescents, and assess their association with the clinical characteristics of PCOS. RESULTS: The frequencies of the five investigated YAP1 gene SNVs (rs11225161, rs11225166, rs3858420, rs11225138 and rs79981660) were not significantly different among adolescents with PCOS, risk group patients and healthy controls. Furthermore, none of the SNVs contributed to the clinical characteristics of adolescents with PCOS and adolescents at risk of PCOS development. CONCLUSIONS: No significant associations were found between PCOS in adolescents and the five investigated SNVs in the YAP1 gene.

Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care.

INTRODUCTION: Quality of care is an important factor in reducing preventable maternal deaths, yet it is a significant challenge in many countries. Substandard and poor quality of care is the leading factor in two-thirds of maternal deaths in European countries. Our study investigated the deaths of all women of reproductive age in 2012 in Georgia. The aim was to define the underlying causes of maternal deaths and to identify the factors in women's care which contributed to the fatal outcomes. METHODS: A national Reproductive Age Mortality Survey was conducted in Georgia in 2014-15. Data from multiple sources was triangulated to identify all deaths of women of reproductive age. This was followed by verbal autopsy diagnoses. Each case of early and late maternal death was investigated through interviews and medical record reviews at the last medical facility providing care for the deceased woman. A specialist panel reviewed and assigned underlying causes of death, assessed the management of each woman's condition, and identified elements of suboptimal care. RESULTS: We identified a total of 23 maternal deaths, including 15 (65%) early and eight (35%) late deaths. The maternal mortality ratio was 26.3 per 100 000 live births. The four leading causes of early maternal deaths were: sepsis, hemorrhage, embolism, and pregnancy-induced hypertension. Embolism and sepsis were the direct causes of the eight late maternal deaths. Cancer, tuberculosis, and postpartum suicide constituted the indirect causes of death. Improvements in care which would have made a difference to the outcomes were identified in 87% of early maternal deaths and 67% of late maternal deaths due to direct obstetric causes. DISCUSSION: Delayed recognition and inappropriate management of maternal complications were common across almost all cases studied. The findings from Georgia highlight the conclusion that most maternal deaths were preventable and that improvement in obstetric care is urgently required.

Non-Classical Congenital Adrenal Hyperplasia-Causing Alleles in Adolescent Girls with PCOS and in Risk Group for PCOS Development.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women. Depending on the diagnostic criteria applied, it occurs in up to 16.6% of the general female population. Congenital adrenal hyperplasia includes a group of autosomal recessive disorders, the most common of which is non-classical congenital adrenal hyperplasia (NCAH) caused by mutations in the CYP21A2 gene. PCOS and NCAH have similar clinical manifestations (hyperandrogenemia, i.e., hirsutism, acne, alopecia, and increased androgen levels in the blood) and potential impact on long-term health (infertility, increased risk of type 2 diabetes, and cardiovascular disease. Consequently, it is thought that NCAH mutations in the heterozygous state may play a role in PCOS development and phenotypic expression. OBJECTIVE: To determine the prevalence of the most common pathogenic alleles of the CYP21A2 gene in adolescents with PCOS and adolescents at risk of PCOS development, and to compare the results with healthy adolescents matched for gynecological age. METHODS: A cross-sectional study was conducted with 55 PCOS patients, 23 risk patients (with hyperandrogenism but a normal menstrual cycle), and 49 healthy adolescents. Genetic variations in the CYP21A2 gene were analyzed using a standard Multiplex Ligation-dependent Probe Amplification test (SALSA MLPA Probemix P050-C1 CAH; MRC Holland). RESULTS: No significant differences were found among the three groups regarding the frequency of carriers of NCAH variations in the heterozygous state. It was found that the I172N carrier in the PCOS group had a significantly higher Global Acne Grading Scale score than PCOS patients without this variation (p = 0.038). Within the control group of healthy adolescents, compound heterozygous carriers (IVS2-12A > G and -113G > A) had a significantly higher body mass index than non-carriers (p = 0.036). CONCLUSION: We found no differences in the incidence of NCAH-causing variations in the heterozygous state in adolescent PCOS patients, risk adolescents (with hirsutism but normal menstruation), and healthy adolescents. Future studies of larger cohorts and rarer pathogenic CYP21A2 gene variations are required.

Role of Single Nucleotide Variants in FSHR, GNRHR, ESR2 and LHCGR Genes in Adolescents with Polycystic Ovary Syndrome.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women, affecting up to 16.6% of reproductive-age women. PCOS symptoms in adolescents comprise oligomenorrhoea/amenorrhoea and biochemical and/or clinical hyperandrogenism. Long-term health risks of PCOS patients include infertility, metabolic syndrome, type 2 diabetes and cardiovascular disease. Genetic factors have been proven to play a role in development of the syndrome and its symptoms. OBJECTIVE: To investigate single nucleotide variants (SNVs) in the GNRHR, ESR2, LHCGR and FSHR genes in adolescent patients with PCOS and their association with PCOS symptoms. METHODS: We conducted a cross-sectional study comprising of 152 adolescents: 63 patients with PCOS, 22 patients at risk of developing PCOS and 67 healthy controls. Participants were recruited from out-patients attending a gynaecologist at the Children's Clinical University Hospital, Riga, Latvia, between January 2017 and December 2020. Genomic DNA was extracted from whole blood, and SNVs in the GNRHR, ESR2, LHCGR and FSHR genes were genotyped. The distributions of SNV genotypes were compared among the three groups and genotype-phenotype associations within the PCOS group were evaluated. RESULTS: No statistically significant differences were found in the distributions of genotypes for GNRHR (rs104893837), ESR2 (rs4986938), LHCGR (rs2293275) and FSHR (rs6166, rs6165, rs2349415) among PCOS patients, risk patients and healthy controls. Within the PCOS group, ESR2 rs4986938 minor allele homozygous patients had a significantly higher level of total testosterone than major allele homozygous patients and heterozygous patients. A significantly higher total testosterone level was also observed in PCOS patients carrying the LHCGR rs2293275 minor allele compared with major allele homozygous patients. CONCLUSIONS: The SNVs ESR2 rs4986938 and LHCGR rs2293275 play a role in the phenotypic characteristics of PCOS. To fully uncover their influence on the development of PCOS and its symptoms, further studies of larger cohorts and a follow up of this study sample through to adulthood are required. Furthermore, studies of adolescent PCOS patients conducted prior to the latest European Society of Human Reproduction and Embryology (ESHRE) criteria (2018) should be re-evaluated as the study groups might include risk patients according to these updated criteria, thereby potentially significantly impacting the published results.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave.

BACKGROUND: The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses. RESULTS: Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSION: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Aspects of sexuality education in Europe - definitions, differences and developments.

OBJECTIVE: Sexuality education in Europe has been influenced by political, social and ethical movements. This paper considers some of these influences and the implementation of sexuality education in different parts of Europe. CONTENT: The aim of sexuality education is to enable young people to acquire knowledge, attitudes, skills and values to make appropriate choices in their sexual behaviour and thus experience a healthy sex life that is age-appropriate. This should prevent them from acquiring or passing on sexually transmitted infections, including human immunodeficiency virus, from causing or suffering unwanted pregnancies, and from being the perpetrator or victim of violence. It should enhance understanding and respect diversity, thus contributing to a better society. Sexuality education as such has been widely recognised as essential for sexual health, but the content and principles that form the basis of this education have changed over time and differ widely among the countries of Europe. CONCLUSION: Agreeing on common standards of sexuality education across Europe is a challenge for the 21st century.

Maternal Mortality in Georgia: Incidence, Causes and Level of Underreporting: A National Reproductive Age Mortality Study 2014.

INTRODUCTION: Accurate data on maternal mortality are essential for assessing progress towards Sustainable Development Goals (SDG).The aim of the study was to determine the incidence and causes of maternal deaths in Georgia, then explore the potential for improvement of quality of maternal health care. The study's secondary aims were to identify the level of underreporting of maternal deaths in Georgian vital statistics over 1 year (2012) and to compare these results with previous data from 2006. The study findings allow to support the country in developing evidence-based policies and tracking progress towards meeting SDG targets. METHODS: A national Reproductive Age Mortality Survey (RAMOS) was conducted in Georgia in 2014-15. Multiple data sources were used to identify deaths of women aged 15-49 years between January and December 2012. All deaths in women of reproductive age were investigated through verbal autopsy (VA) diagnoses. Deaths in women during pregnancy or one-year postpartum were further investigated by conducting interviews and medical record reviews at the last medical facility which provided health care for the woman during her fatal condition. A specialist panel reviewed these cases and assigned underlining causes of deaths. RESULTS: We found that 98% of deaths among women of reproductive age were registered by Georgia's civil registration and vital statistics system (CRVS). A total of 918 deaths met the study inclusion criteria. Thirty-six (4.1%) women died during pregnancy or within one-year postpartum. Among these 36 deaths, 23 (63.8%) were maternal deaths, 15 early (either during pregnancy or 42 days postpartum) and eight late (43-365 days postpartum) deaths (65.2% vs 34.8%). The remaining 13 of 36 deaths were coincidental deaths. Fourteen maternal deaths were reported by official statistics and nine deaths were not included in these statistics. Thus, the underreporting rate was 39%. Direct obstetric causes accounted for 73.9% (n=17) of maternal deaths, whereas 26.1% (n=6) were indirect. The leading causes of direct maternal deaths were infection (21.7%), hemorrhage (17.4%), pulmonary embolism (13.0%), and pregnancy-induced hypertension (8.7%). The RAMOS study calculated a maternal mortality ratio (early maternal deaths) of 26.3 per 100,000 live births compared with the official figure of 22.8 per 100,000 live births. DISCUSSIONS: Registration of early maternal deaths significantly improved since last survey in 2008, while indirect and late maternal deaths continue to be unrecognized, as reflected in official Georgian statistics. The difference between RAMOS study findings and officially reported maternal mortality rates is minimal, showing improvements in detection of maternal deaths by the national maternal mortality surveillance system. The greatest number of direct obstetric deaths occur in the first week postpartum, which likely reflects deficiencies in quality of care.

Consensus recommendations for cervical cancer prevention in the Czech Republic: a report of the International Conference on Human Papillomavirus in Human Pathology (Prague, 1-3 May 2008).

A comparison of cervical cancer incidence and mortality in the Czech Republic with that from other countries shows that the burden of cervical cancer here is considerably higher than in Western Europe, where screening is widespread. In May 2008, the International Conference on Human Papillomavirus in Human Pathology was convened to review the latest evidence and to formulate consensus recommendations for the reduction of cervical cancer rates. The Czech Republic is spending considerable resources on cervical cancer prevention, but these resources are being used inefficiently. The current system is characterized by a lack of coordination and monitoring that leads to the over-screening of a minority of women while the majority of the target population are under-screened or not screened at all. It was recommended that a comprehensive, organized programme be implemented, coordinated by an independent administrative body with legal and budgetary responsibility. As the laboratory infrastructure and professional technical skills required for a quality-assured organized screening programme are already in place, implementation of this programme would not require much in the way of additional resources to produce substantial cost-effective reductions in cervical cancer rates.

Placental histological inflammation and reproductive tract infections in a low risk pregnant population in Latvia.

BACKGROUND: To investigate the correlation of reproductive tract infections (RTI) and endogenous vaginal flora at first antenatal consultation with placental histological inflammation. METHODS: In a follow-up study, 154 low risk women with no miscarriage risk factors were examined for the presence of Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, Streptococcus agalactiae (GBS), Staphylococcus aureus, Enterococcus faecalis (GDS) and bacterial vaginosis (BV). At delivery, outcome data were collected and the histology of the placenta was studied. RESULTS: Some 85 (56.3%) of all pregnant women had RTI or endogenous vaginal flora. Placental histological inflammation correlated with genital tract colonisation with G. vaginalis (p =0.013), BV (p =0.031), S. aureus (p =0.04) and aerobic vaginitis (p =0.017). BV and BV-related G. vaginalis correlated with the presence of parietal and placental chorioamnionitis in 53.8 and 43.5% of cases. Genital tract colonisation with GDS and other aerobic flora in combination with inflammatory vaginitis correlated with the presence of funisitis in 33.3 and 40.0% of cases. Mycoplasmas increased the risk for intrauterine infection only when present in combination with other RTIs (p =0.023). CONCLUSION: Histological placental inflammation is associated with both BV and genital tract colonisation with aerobic bacteria, while funisitis is associated with colonisation of aerobic bacteria at first prenatal visit before the 17th gestational week.

What is the quality of the maternal near-miss case reviews in WHO European Region? Cross-sectional study in Armenia, Georgia, Latvia, Republic of Moldova and Uzbekistan.

OBJECTIVES: The maternal near-miss case review (NMCR) cycle is a type of clinical audit aiming at improving quality of maternal healthcare by discussing near-miss cases. In several countries this approach has been introduced and supported by WHO and partners since 2004, but information on the quality of its implementation is missing. This study aimed at evaluating the quality of the NMCR implementation in selected countries within WHO European Region. DESIGN: Cross-sectional study. SETTINGS: Twenty-three maternity units in Armenia, Georgia, Latvia, Moldova and Uzbekistan. ASSESSMENT TOOLS: A predefined checklist including 50 items, according to WHO methodology. Quality in the NMCR implementation was defined by summary scores ranging from 0 (totally inappropriate) to 3 (appropriate). RESULTS: Quality of the NMCR implementation was heterogeneous among different countries, and within the same country. Overall, the first part of the audit cycle (from case identification to case analysis) was fairly well performed (mean score 2.00, 95% CI 1.94 to 2.06), with the exception of the 'inclusion of users' views' (mean score 0.66, 95% CI 0.11 to 1.22), while the second part (developing recommendations, implementing them and ensuring quality) was poorly performed (mean score 0.66, 95% CI 0.11 to 1.22). Each country had at least one champion facility, where quality of the NMCR cycle was acceptable. Quality of the implementation was not associated with its duration. Gaps in implementation were of technical, organisational and attitudinal nature. CONCLUSIONS: Ensuring quality in the NMCR may be difficult but achievable. The high heterogeneity in results within the same country suggests that quality of the NMCR implementation depends, to a large extent, from hospital factors, including staff's commitment, managerial support and local coordination. Efforts should be put in preventing and mitigating common barriers that hamper successful NMCR implementation.

Provision of medical abortion by midlevel healthcare providers in Kyrgyzstan: testing an intervention to expand safe abortion services to underserved rural and periurban areas.

OBJECTIVE: To demonstrate the feasibility and safety of training midlevel healthcare providers (midwives and family nurses) to provide medical abortion and postabortion contraception in underserved areas in Kyrgyzstan. STUDY DESIGN: This was an implementation study at four referral facilities and 28 Felsher Obstetric Points in two districts to train their midwives and family nurses to deliver safe and effective abortion care with co-packaged mifepristone-misoprostol and provide contraceptives postabortion. The outcome of abortion - complete abortion, incomplete abortion or o-going pregnancy - was the primary end point measured. An international consultant trained 18 midwives and 14 family nurses (with midwifery diplomas) to provide medical abortion care. Supervising gynecologists based in the referral centers and study investigators based in Bishkek provided monthly monitoring of services and collection of patient management forms. A voluntary self-administered questionnaire at the follow-up visit documented women's acceptability of medical abortion services. All study data were cross-checked and entered into an online data management system for descriptive analysis. RESULTS: Between August 2014 and September 2015, midwives provided medical abortion to 554 women with a complete abortion rate of 97.8%, of whom 62% chose to use misoprostol at home. No women were lost to follow-up. Nearly all women (99.5%) chose a contraceptive method postabortion; 61% of women receiving services completed the acceptability form, of whom more than 99% indicated a high level of satisfaction with the service and would recommend it to a friend. CONCLUSION: This study demonstrates that trained Kyrgyz midwives and nurses can provide medical abortion safely and effectively. This locally generated evidence can be used by the Kyrgyz Ministry of Health to reduce unintended pregnancy and expand safe abortion care to women in underserved periurban and rural settings. IMPLICATIONS: Success in scaling up midwife/nurse provision of medical abortion in Kyrgyzstan will require registration of mifepristone-misoprostol, regulations permanently allowing midwife/nurse provision, strengthened procurement and distribution systems to prevent stockouts of supplies, preservice training of midwives/nurses and their involvement in district level supervision, monitoring and reporting, and support from supervisors.

Frequency of interleukin-4 (IL-4) -589 gene polymorphism and vaginal concentrations of IL-4, nitric oxide, and mannose-binding lectin in women with recurrent vulvovaginal candidiasis.

BACKGROUND: A C-->T substitution at position -589 in the interleukin-4 (IL-4) gene is associated with increased production of IL-4. Associations between this polymorphism and recurrent vulvovaginal candidiasis (RVVC), as well as vaginal concentrations of IL-4 and the anticandidal compounds nitric oxide (NO) and mannose binding lectin (MBL), were evaluated. METHODS: Vaginal samples obtained by lavage from 42 women with RVVC during the acute stage of the disease and 43 control samples were assayed by enzyme-linked immunosorbent assay for IL-4 and NO metabolites. The -589 IL-4 gene polymorphism was detected by polymerase chain reaction and endonuclease digestion. Data were analyzed by Fisher's exact test, the nonparametric Mann-Whitney and Kruskal-Wallis tests, and Spearman rank correlation. P < .05 was considered significant. RESULTS: Candida albicans was identified in 38 patients with RVVC; 3 others had infection due to Candida tropicalis, and 1 had infection due to Candida krusei. The IL-4 T,T genotype was detected in 59.5% of patients with RVVC and in 7.0% of control subjects (P < .0001). The frequency of IL-4*T was 76.2% in patients with RVVC and 23.3% in control subjects (P < .0001). The median concentration of vaginal IL-4 was elevated in patients with RVVC, compared with control subjects (P < .0001). Conversely, vaginal concentrations of NO metabolites (P = .02) and MBL (P < .0001) were reduced in patients with RVVC. There was a positive association between IL-4*T homozygosity and vaginal IL-4 levels (P < .0001) and negative associations between this genotype and vaginal NO (P = .01) and MBL (P < .0001) concentrations. CONCLUSIONS: Reduced vaginal levels of anticandidal factors in IL-4*T homozygotes may increase susceptibility to RVVC.