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Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation. A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period. There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%. Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations. • Women who experience pelvic organ prolapse report discomfort and associated urinary, bowel, and sexual problems with considerable costs and negative impact on quality of life. Pessary self-management (SM) may offer benefits to women and to the health service without increased risk when compared with clinic-based care (CBC). • With pessary SM women receive training to be able to remove and reinsert the pessary themselves at home, thus, by design, offering more personal control and less physical contact with healthcare staff. The aim of the economic evaluation in this study was to investigate health service resources required and cost-effectiveness of pessary SM when compared with CBC at 18 months, from a health sector perspective. • Pessary SM for prolapse is cost-effective when compared with CBC. Decision analytic modeling showed that SM remained a cost-effective option for durations longer than the 18 month trial. SM is an approach that can be used for non-surgical management of prolapse without negatively affecting women's quality of life, which can release scarce resources in a health system under pressure. [ABSTRACT FROM AUTHOR]

Global migration has seen an increase in female genital mutilation/cutting (FGM/C) cases observed in countries where it is not part of the cultural norm. This shift has led to many healthcare professionals (HCPs) reporting a lack of knowledge and skills necessary to support the needs of women with FGM/C. To explore the experiences and needs of women with FGM/C accessing women's health services in South Australia. Women with FGM/C were recruited through purposive and snowball sampling to participate in one-to-one semi-structured interviews. The voice recorded interviews were transcribed verbatim, coded, and analysed using Braun and Clarke's reflexive thematic analysis to determine themes. Ten migrant and refugee women living in South Australia, were interviewed. Four themes and 13-subthemes were identified. The main themes were, 1) the healthcare experience, 2) cultural values shape the healthcare experience, 3) speaking up about female genital cutting and 4) working together to improve healthcare experiences. Women's cultural needs, not their health needs, play a fundamental role on how women experienced healthcare services. When women's cultural values and traditions are acknowledged by HCPs, they are more likely to trust and feel confident to engage with services and seek medical support. Areas identified for improvement included access to the right interpreters, having more time during appointments, opportunities for continuity of care and the inclusion of family in care and treatment decisions. Women with FGM/C have specific health and cultural needs that can be met through education and provision of woman-centred care. [ABSTRACT FROM AUTHOR]

Appreciating user differences in contraceptive sources is essential for improving contraceptive access and safeguarding an equitable and sustainable future. Therefore, this study explored whether urban residence and individual wealth are associated with where women access contraception (e.g., government, private, or nongovernmental organization provider) and assessed whether these associations are modified by the income level in the respondents' country of residence. We analyzed the cross-sectional data of Demographic Health Surveys conducted between 2009 and 2020 in 25 countries. The final data set included 25,081 young women aged between 15 and 24 years who are using contraceptives. Multinomial logistic regression models were established to assess the associations of our outcome variable, namely, various contraceptive sources, with our main independent variables, namely, urban residence and wealth index. We also assessed the potential effect modification by country income level on the above associations. We observed obvious urban–rural and rich–poor disparities in odds of using contraceptive sources. Generally, living in urban residences and being wealthy were positively associated with all sources of contraceptives. However, these associations were mostly modified by country income level. People living in urban residences utilized more private sources, especially in low-income (beta coefficient, B = 0.973) and upper–middle-income countries (B = 1.361). Young women in urban areas across all analyzed countries were also more likely to use contraceptives from other sources (B = 0.267). In addition, women from poor households were less likely to use private sources (B = −1.166) and other sources (B = −0.547). Even though young women may prefer private sources of contraceptives due to their confidentiality and flexible hours, these sources carry more benefits for rich and urban young women than for poor and rural women. The differential accessibility and affordability may account for the observed urban–rural and rich–poor disparities in using contraceptive sources, respectively, and the income level of a country is likely to modify such disparities. [ABSTRACT FROM AUTHOR]

Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman et al.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways—that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings—and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement. [ABSTRACT FROM AUTHOR]

Healthcare providers are obliged to reduce the risk of harm to patients using their services. Robust risk management embraces a blame-free reporting culture and learning from clinical errors whilst adopting a proactive approach to the measurement of patient safety indicators. A good safety culture within an organisation provides assurance to service users, staff, and the public, that there is commitment to provision of high quality safe and effective care. Risk management is everybody's responsibility. Therefore, all clinicians must possess an understanding of risk management processes. This review outlines the key elements of risk management within gynaecology and explains how risks are identified, assessed, quantified and managed. Examples from within the gynaecological setting and the challenges and the emergent risks posed by the COVID19 pandemic, are also discussed. [ABSTRACT FROM AUTHOR]

The objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services. We used 2018–2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3–6 months and 12–14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access. Insurance changes primarily occurred by 3–6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p <.001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.7; p <.01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.9; p <.05). The majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3–6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services. [ABSTRACT FROM AUTHOR]

Intimate partner violence is a lead cause of ill health and premature death among Australian women. Abused women are likely to present to Emergency Departments. Routine screening provides opportunities to identify and respond to intimate partner violence. A six-month screening feasibility study was conducted in two rural and one urban NSW Emergency Departments. Surveys with participating nurses, medical officers and social workers, as well as focus groups with nurses and social workers were conducted at each site to understand their experience. Survey respondents (n = 198) agreed it was appropriate (87%) and acceptable (91%) to screen for intimate partner violence in Emergency Departments. Overall 62% of respondents suggested screening had positive impacts on womens' care. Focus group discussions with 39 nurses and social workers identified enablers of screening as: ease of use of the screening tool; availability of social work response within one hour (as per the study protocol); and executive support. Barriers were: high patient volume; lack of integration with existing processes; lack of privacy and brevity of training. Screening in Emergency Departments was strongly supported by health practitioners who responded to the survey. Work is needed to address competing demands, integration of screening processes, and staff training. [ABSTRACT FROM AUTHOR]

Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics. We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States. Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later. Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care. [ABSTRACT FROM AUTHOR]

• High maternal and infant mortality rates in Malawi mean many adults experience maternal and infant deaths in their family. • Exposure to maternal and infant deaths may affect women's future use of maternal health services, yet we lack empirical evidence. • Following a sister's maternal death, women have higher odds of using antenatal care for a subsequent pregnancy. • Following a firstborn's neonatal death, women have higher odds of delivering their subsequent birth at a formal health facility. • Although the significant linkages are sparse, the findings consistently challenge the notion that death exposures lower use of health services. In developing contexts, where formal health services are still expanding, understanding what factors discourage individuals from using health services is critical to advance population health. A long theorized, but rarely investigated, conjecture is that in high-mortality contexts, exposure to death can beget fatalism, or even foster distrust of formal healthcare, locking families into cycles of low use of health services. A counter perspective, however, suggests exposure to death can encourage individuals' health vigilance, corresponding with their higher use of health services. We test these competing ideas by analyzing the associations between women's intimate exposure to death in the context of pregnancy and delivery via (1) a sister's maternal death and (2) an infant child's neonatal death, and their subsequent use of maternal health services. We focus on the context of Malawi, a setting that features high maternal and infant mortality rates, similar to those observed across much of sub-Saharan Africa, as well as persistent gaps in service use. Specifically, we use Malawi Demographic and Health Survey (2015–16) data to examine if a sister's maternal death or a child's neonatal death corresponds with a woman's odds of attending full antenatal care during a subsequent pregnancy or delivering the pregnancy at a formal health facility. Given the qualitatively distinct nature of losing one's only or first child, we also assess if the effect of a child's neonatal death varies by birth order. The results show that maternal and neonate death exposures correspond generally with women's higher use of maternal health services, challenging the notion that exposure to death fosters fatalism or distrust. Although the results vary in significance, the nuanced findings highlight women's vigilance in the face of health threats, emphasizing their resilience amid a high burden of familial loss. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to understand perceptions of long-acting reversible contraception (LARC) among incarcerated women. We compared survey responses specific to IUDs and implants between a convenience sample of incarcerated women to a sample of women attending a local ob/gyn clinic.Study Design: We conducted a cross-sectional survey among two groups: (1) incarcerated women receiving medical care at the state correctional facility, and (2) women receiving care at an ob/gyn clinic in the same community. The anonymous survey included questions about demographic variables, current and past contraceptive use, and perception of IUDs and implants.Results: Almost half of the total sample stated that they might consider an IUD or implant for contraception. Incarcerated women tended to be less likely to give an affirmative answer to current or future use of an IUD or implant (29% vs 39%, p = 0.19). Concerns about pain and side effects were similar between the groups, but more incarcerated women cited concerns about device removal (72% vs 57%, p = 0.02) and the level of training of the provider inserting the device (68% vs 53%, p = 0.02). Incarcerated women interested in using the IUD or implant were more comfortable with device placement in the community than in the correctional setting (42% to 30%, p < 0.001).Conclusions: Incarcerated women have concerns about LARC that may be specific to their experience of incarceration. Providers working with incarcerated women should consider these when counseling patients on contraceptive choices. Options for post-release follow-up care and device removal should be included in this discussion.Implications: Incarcerated women should receive comprehensive reproductive health care, including contraceptive services if desired. However, incarceration itself may introduce fundamental concerns regarding contraception and these concerns need to be better understood to balance the provision of services with the potential for reproductive coercion. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the cost-effectiveness of 2 contraceptive counseling strategies in Colombia for women living with human immunodeficiency virus (HIV). The first integrates (1) reproductive health and HIV services (integrated model [IM]), and the second (2) offers these services separately (non-IM). Cost-effectiveness analysis from the third-party payer perspective (Colombian healthcare system). A decision analysis tree was used over a 24-month time horizon at a 3% discount rate, considering only direct costs. The outcome was the number of averted HIV perinatal transmission infections. We performed a discrete sensibility analysis and a probabilistic second-order sensitivity analysis with 10 000 iterations (Monte Carlo simulation). Compared with the non-IM, the IM prevented 3% additional HIV perinatal transmission infections, with an incremental cost-effectiveness of US dollar 525 and the highest net monetary benefit at the proposed willingness to pay. In the probabilistic sensitivity analysis, we found a substantial amount of parameter uncertainty that challenges the evidence in favor of the cost-effectiveness of the IM strategy. This study opens the possibility of integrating reproductive health and HIV services for women living with HIV in Colombia. In addition, it raises the necessity to produce additional good quality local empirical evidence to inform better and support the estimation of the economic efficiency of such a model in the country. • Women living with human immunodeficiency virus (WHIV) have 3 times higher unmet contraceptive necessities than women without this condition, leading to more unplanned pregnancies and increasing the risk of human immunodeficiency virus (HIV) perinatal transmission. • Every woman has the right to decide about her reproductive life. For WHIV who do not want or are not ready at the time, pregnancy increases their risk of perinatal transmission and maternal mortality because of higher attrition rates from prenatal services and poor antiretroviral adherence. • In generalized epidemic settings, such as in Africa, evidence shows that the integration of sexual and reproductive health with HIV services for WHIV with counseling and the availability of modern contraceptive methods reduces unplanned pregnancies and HIV perinatal transmission. The evidence in Latin America is scarce, and most countries continue to use a nonintegrated strategy with stable HIV perinatal transmission rates. • This study opens the possibility for integrating these services in Colombia, a concentrated epidemic setting, to inform local stakeholders of the benefits of this strategy and serves as an input for health policy decisions in similar Latin American countries. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to evaluate the role of public-sector family planning program impact scores and other country-level factors on LARC use among young women aged 15 to 24.Study Design: We conducted this research using a large population database covering several decades' worth of multi-wave cross-sectional samples of the demographic health survey (DHS) and the World Bank website data. We carried out a multi-level analysis on data from 1990 to 2019 from 22 Sub-Saharan African countries, with 163,242 participants.Results: We found LARC use was at 3.1% of all young women under study. Sierra Leone, 2019 survey had the highest LARC use at 21,961 per 100,000. A 10% increase in public-sector family planning program impact scores was positively associated with LARC use with odds ratio of 1.44, 95% CI, 1.43-1.45). We also noted that a 1% increase in HIV prevalence was associated with a reduced odds ratio of LARC use at 0.75 (95% CI, 0.70-0.81).Conclusions: Findings from this study provide empirical evidence highlighting the importance of country-level factors in influencing LARC use among young women in sub-Saharan Africa IMPLICATIONS: For young women in Africa, policymakers need to increase their effort on national family planning programs especially in the public sector. Broader societal level interventions to improve LARC use are required. Specific interventions must address the complexities of HIV prevention and LARC use to benefit young women living in countries with a high HIV prevalence. [ABSTRACT FROM AUTHOR]

The 2021 Women's Preventive Services Initiative Well-Woman Chart outlines a framework for incorporating preventive health services recommended by the Women's Preventive Services Initiative, the US Preventive Services Task Force, and Bright Futures based on age, health status, and risk factors. Following the previous guidelines for preventive care, this document failed to offer recommendations or guidelines for infertility screening and fertility counseling in the course of well-woman care. Healthcare providers may be less likely to address fertility with their patients in the absence of clear, evidence-based recommendations, potentially resulting in underinformed reproductive choices and compromised reproductive potential. Given the devastating consequences of infertility and unintended childlessness, we, herein, propose that infertility screening and fertility counseling should become an integral part of well-woman care and that organizations, such as the Women's Preventive Services Initiative, put forth guidelines to assist providers in addressing fertility throughout a woman's reproductive lifespan. [ABSTRACT FROM AUTHOR]

Reproductive surgery remains an important treatment option for some women with subfertility secondary to tubal disease. This review offers a comprehensive update on current evidence and guidance. Accurate investigation of the cause, site, extent is first paramount, with fertility-preserving surgical procedures reserved for women with mild tubal disease and no confounding subfertility factors. For severe tubal disease, including hydrosalpinx, a shift towards assisted reproductive technology (ART) is more often recommended, with tubal surgery instead offering a valuable adjunct to enhance reproductive success. Decisions regarding management of tubal disease are complex and require a patient-specific approach. Only surgeons with appropriate laparoscopic surgical expertize should perform tubal surgery; training the next generation of reproductive surgeons remains imperative. [ABSTRACT FROM AUTHOR]

To evaluate the correlation between clinical and hormonal parameters and comorbidity burden in Caucasian women presenting for fertility treatment. Monocentric cross-sectional study including a cohort of 3163 Caucasian women seeking medical care for fertility treatment. All patients underwent centralized laboratory testing for hormonal assessment. Complete clinical and laboratory data from the entire cohort were retrospectively analysed. Comorbidity burden score was assessed by the Charlson Comorbidity Index (CCI; categorized as 0 versus 1 versus ≥2). Descriptive statistics and regression models tested the associations between clinical and laboratory parameters and CCI. Among the entire cohort of patients, a CCI = 0 was found in 2977 women (94.1%), and CCI = 1 and CCI ≥2 were found in 113 (3.6%) and 73 (2.3%) patients, respectively. Age (P = 0.009), gravidity (P = 0.001), anti-Müllerian hormone (AMH, P < 0.001) and TSH (P = 0.003) values were significantly different among CCI groups. In regression models, age at presentation and AMH emerged as independent indicators of CCI ≥ 1. Age at presentation <36 years (odds ratio [OR] 1.742, 95% confidence interval [CI] 1.284–2.364) and an AMH concentration ≤2.3 ng/ml (OR 1.864, 95% CI 1.29–2.69) were the most informative cut-off values for CCI ≥ 1 in the study population. A younger age at presentation and lower AMH concentrations are significant independent indicators of decreased general health in women requiring clinical evaluation for fertility treatment. As observed for sperm parameters in men, AMH might serve as a proxy of women's general health status. [ABSTRACT FROM AUTHOR]

In the context of a shifting health care landscape, better understanding of the factors that motivate women to seek services from specialized family planning clinics like Planned Parenthood (PP) can provide insights about potential changes in the role of specialized family planning clinics. We surveyed 725 women seeking services at two PP health centers in Louisiana and Kentucky from March 2016 to May 2017. We examined differences in care-seeking between women who had varying levels of access including those who did and did not have insurance instability or a regular source of care (RSOC) besides the clinic. More than 60% of women attending the health centers did not have a regular source of care and nearly 40% experienced instability in insurance. Women who experienced insurance instability and a lack of a regular source of care more frequently sought primary preventive services such as pap tests and well-woman care at PP than women with better access. For women with better access, PP health centers also served important roles for those seeking contraceptive and sexually transmitted infection–related services. The most frequent reasons for choosing PP were that it was faster to get an appointment, wanting to go to the PP clinic more than other clinics, and the confidentiality of services. Our analysis suggests that PP health centers in Southern states still provide vital services for women with and without other sources of care and are critical for women needing access to timely services for preventive and sexually transmitted infection–related care. [ABSTRACT FROM AUTHOR]

Background Sexual health among service women remains understudied, yet is related to health and quality of life. This study examined if the associations between recent combat and sexual assault with sexual health difficulties were mediated by mental disorders and identified factors associated with sexual health difficulties among service women. Methods Data from two time points (2013 and 2016) of the Millennium Cohort Study, a large military cohort, were used. The outcome was self-reported sexual health difficulties. Mediation analyses examined probable posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) as intermediate variables between recent combat and sexual assault with the sexual health difficulties. Multivariable logistic regression modeling was used to examine the association of demographic, military, historical mental health, life stressors, and physical health factors with sexual health difficulties. Results Of the 6,524 service women, 13.5% endorsed experiencing sexual health difficulties. Recent combat and sexual assault were significantly associated with sexual health difficulties. Probable PTSD mediated the associations of recent combat and sexual assault with sexual health difficulties; probable MDD did not mediate these relationships. Other significant factors associated with sexual health difficulties included enlisted rank, historical mental disorders, childhood trauma, and disabling injury. Limitations Use of self-reported data, outcome not assessed using a standardized measure and future studies may benefit from examining other mediators. Conclusion Our findings that combat and sexual assault may have negative effects on service women's sexual health suggest that treatment options and insurance coverage for sexual health problems should be expanded. [ABSTRACT FROM AUTHOR]

• A wide range of HPV types were commonly detected among 18–35 year old women. • Prevalence of HPV6/11/16/18 was very low and influenced by vaccination status only. • Prevalence of non-vaccine types was influenced by known risk factors for infection. • Vaccinated women are benefiting from cross-protection against HPV types 31/33/45. • HPV vaccination has changed the epidemiology of HPV infection in Australian women. In Australia, high and widespread uptake of the quadrivalent human papillomavirus (HPV) vaccine has led to substantial population-level reductions in the prevalence of quadrivalent vaccine targeted HPV genotypes 6/11/16/18 in women aged ≤ 35 years. We assessed risk factors for HPV detection among 18–35 year old women, 9–12 years after vaccine program introduction. Women attending health services between 2015 and 2018 provided a self-collected vaginal specimen for HPV genotyping (Roche Linear Array) and completed a questionnaire. HPV vaccination status was validated against the National Register. Adjusted odds ratios (aORs) and 95% confidence intervals (CI) were calculated for factors associated with HPV detection. Among 1564 women (median age 24 years; IQR 21–27 years), Register-confirmed ≥ 1-dose vaccine coverage was highest at 69.3% and 68.1% among women aged 18–21 and 22–24 years respectively, decreasing to 42.9% among those aged 30–35 years. Overall prevalence of quadrivalent vaccine-targeted HPV types was very low (2.0%; 95% CI: 1.4–2.8%) and influenced only by vaccination status (5.5% among unvaccinated compared with 0.7% among vaccinated women; aOR = 0.13 (95% CI: 0.05–0.30)). Prevalence of remaining HPV types, at 40.4% (95% CI: 38.0–42.9%), was influenced by established risk factors for HPV infection; younger age-group (p-trend < 0.001), more recent (p < 0.001) and lifetime sexual partners (p-trend < 0.001), but not vaccination status. Prevalence of HPV31/33/45, which shared risk factors with that of non-vaccine targeted HPV types, was also lower among vaccinated (4%) compared with unvaccinated (7%) women (aOR = 0.51; 95% CI: 0.29–0.89), indicative of cross-protection. Vaccination has changed the epidemiology of HPV infection in Australian women, having markedly reduced the prevalence of vaccine-targeted types, including amongst women with known risk factors for infection. Vaccinated women appear to be benefiting from modest cross-protection against types 31/33/45 afforded by the quadrivalent HPV vaccine. These results reinforce the importance of HPV vaccination. [ABSTRACT FROM AUTHOR]

Transgender and nonbinary (TNB) individuals assigned female sex at birth experience discrimination, misgendering, problems with insurance, and denial of services when accessing health care. This study aimed to understand the experiences of TNB young adults in accessing "women's" health care—a form of care that is structurally gendered that few studies have investigated. In 2015, we conducted in-depth interviews with 20 TNB young (ages 18–29) adults assigned female sex at birth. We thematically analyzed the data. Participants described feelings of comfort and trust—and lack thereof—at every step of the health care–seeking process, including scheduling, checking in, waiting, and interactions with clinicians and other staff. Gendered language served as a constant stressor; participants—especially nonbinary participants—noted few opportunities to provide their correct pronouns and names. Participants relayed negative experiences associated with waiting rooms in "women's" health care spaces, where TNB patients are forced to disclose their identity simply through their presence or owing to actions of staff that out them. These concerns deterred some from seeking care, with most expressing discomfort or anxiety that caused them to feel unsafe. Participants described "women's" health care providers making assumptions about their anatomy, reproductive desires, sexual orientation, and sexual practices, as well as inappropriately and harmfully emphasizing their bodies and TNB identities during health care interactions. Clinician competence and humility engendered participants' feelings of safety and undergirded their interest in engaging with "women's" health care. A lack of patient-centered, TNB-competent care in structurally gendered health settings exacerbates health care and health inequities for TNB young adults. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) increased health insurance coverage throughout the United States and improved care delivery for some services. We assess whether ACA implementation and Medicaid expansion were followed by greater receipt of recommended preventive services among women and girls in a large network of community health centers. Using electronic health record data from 354 community health centers in 14 states (10 expansion, 4 nonexpansion), we used generalized estimating equations and difference-in-difference methods to compare receipt of six recommended preventive services (cervical cancer screening, human papilloma virus vaccination, chlamydia screening, influenza vaccination, human immunodeficiency virus screening, and blood pressure screening) among active female patients ages 11 to 65 (N = 711,121) before and after ACA implementation and between states that expanded versus did not expand Medicaid. Except for blood pressure screening, receipt of all examined preventive services increased after ACA implementation in both Medicaid expansion and nonexpansion states. Influenza vaccination and blood pressure screening increased more in expansion states (adjusted absolute prevalence difference-in-difference, 1.55; 95% confidence interval, 0.51–2.60; and 1.98; 95% confidence interval, 0.91–3.05, respectively). Chlamydia screening increased more in nonexpansion states (adjusted absolute prevalence difference-in-difference: −4.21; 95% confidence interval, −6.98 to −1.45). Increases in cervical cancer screening, human immunodeficiency virus screening, and human papilloma virus vaccination did not differ significantly between expansion and nonexpansion states. Among female patients at community health centers, receipt of recommended preventive care improved after ACA implementation in both Medicaid expansion and nonexpansion states, although the overall rates remained low. Continued support is needed to overcome barriers to preventive care in this population. [ABSTRACT FROM AUTHOR]

While most women remain healthy after giving birth to their baby, others experience complications that require medical attention or readmission to hospital. However, data on maternal attendance for medical care postpartum or readmission to hospital are not collected or reported routinely in many countries so the extent of health problems experienced remain unknown. Collecting data on the proportion of women who seek medical care in the early postpartum period may deepen understanding of risk factors, the consequences for women, their families and the maternity care system and, ultimately, help identify preventative strategies and processes.Objective: To identify the factors associated with maternal rehospitalisation, attendance at emergency rooms or visits to general practitioners, the three main sources of medical services postpartum in Ireland, within the first three months postpartum.Study Design: A prospective cohort study, embedded in a larger maternal health and morbidity study, with 1668 nulliparous women recruited from two maternity hospitals in Ireland. Univariate and multivariable logistic regression analyses were used to explore associations with postpartum rehospitalisation, emergency room attendance and general practitioner visits within the first three months postpartum, for maternal health-related reasons.Results: Four percent (n = 66) of women were rehospitalised, 10% (n = 166) attended an emergency room, and 13.6% (n = 223) attended their general practitioner three or more times, regarding their own health. Women aged 24 years or less were more likely to attend their doctor (p = 0.02, AOR 2.13, 95% CI 1.08-4.21) compared to women aged 25-29 years, the reference category. Women who were obese or very obese were also more likely to attend their doctor three or more times (p = 0.01, AOR 1.79, 95% CI 1.15-2.79) and also more likely to attend an emergency room (p = 0.04, AOR 1.69, 95% CI 1.02-2.80) within three months postpartum, for their own health reasons.Conclusion: Findings indicate that considerable proportions of women seek medical care from various healthcare sources postpartum. These medical visits are not routinely reported and point to the need for interventions regarding the care, management and services available to first-time mothers birthing in Ireland, with specific attention on preventative postpartum health. [ABSTRACT FROM AUTHOR]

To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females. Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months. Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages. The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement. [ABSTRACT FROM AUTHOR]

Objective: Prior qualitative research with women incarcerated at Rikers Island Jail asked women to anticipate their future contraceptive needs and pregnancy desires upon re-entering the community. We conduct this follow-up study to understand better the actual contraceptive needs and pregnancy desires experienced by women after incarceration.Study Design: We conducted semi-structured in-depth interviews in New York City in 2014 with 10 women incarcerated within the past three years. We coded transcripts using an iterative process, identified emerging themes, and stopped recruitment after reaching thematic saturation.Results: Most participants desired to wait to become pregnant until they had stable housing, income, and employment. A few faced systemic barriers to obtaining contraception, including the process of re-applying for insurance and obtaining medical appointments. For many, incarceration disrupted their use of contraception, insurance status, and relationship with trusted medical providers. Most women lacked trust in the new health professionals they encountered after incarceration.Conclusions: Incarceration disrupted medical care in general, and contraceptive care in particular. Assistance should be provided to re-apply for insurance, make appointments, and support women to see trusted health professionals.Implications: Incarceration further disenfranchises an already marginalized community through disrupting access to medical care and constrains women's reproductive autonomy long after return to the community. [ABSTRACT FROM AUTHOR]

In the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings. Semistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans' experiences with VA specialty care providers, including their perceptions of gender bias. Four major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved. This study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases. [ABSTRACT FROM AUTHOR]

Objective: To assess the availability of and practices around postabortion contraceptive services in health facilities, and document women's acceptance of postabortion contraception in six Indian states.Study Design: We conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women.Results: Although some contraceptive methods and information were available at a majority of facilities (75-97%), the range of methods was lacking and the information provided to women varied considerably by state. 8-26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method.Conclusion: The limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed.Implications: Some 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to estimate the prevalence of dyspareunia and stress urinary incontinence (SUI) during pregnancy and after delivery, in addition to evaluating possible associated risk factors.Study Design: A cross-sectional study was conducted in 2016 with the target population being women who had given birth within the previous 12 months (n = 6436) in Galicia (Spain). Information was collected regarding the mother's status 6 months before pregnancy, during pregnancy, at the time of delivery, and at the time of the survey. The prevalence of SUI and dyspareunia were estimated and regression models were performed to identify variables associated with both pathologies.Results: The prevalence of SUI and dyspareunia after delivery were 20.4 % (CI95 %: 19.2-22.0) and 23.4 % (22.3-24.8), respectively. The presence of dyspareunia during pregnancy (adjusted prevalence ratio PR 2.1), breastfeeding (PR 1.2), and having a history of episiotomy (PR 1.3) were all variables associated with the presence of dyspareunia after delivery. SUI after delivery was related to the mother's history of SUI before pregnancy (PR 2.4) and during pregnancy (PR 2.0), as well as having undergone vaginal delivery (PR 2.0).Conclusion: Knowing which factors are associated with the manifestation of SUI and dyspareunia in women after delivery is useful for identifying susceptible or "at risk" patients. These variables should be included in the clinical history of every pregnant woman. [ABSTRACT FROM AUTHOR]

The last nationwide evaluation of abortion education in undergraduate medical schools was conducted by Espey et al. more than 15 years ago. To better understand what medical schools are teaching medical students about abortion care, we conducted a brief assessment of abortion education and training at U.S. medical schools. In April 2019, the study team emailed a three-item survey to the obstetrics and gynecology clerkship directors at Association of American Medical Colleges-accredited U.S. allopathic medical schools (n = 143). The multiple-choice survey assessed the availability and type of reproductive health education students had during their preclinical and clinical experiences. Ninety-one (64%) medical schools responded. Fifty-four (59%) schools reported abortion education as part of their preclinical curriculum, with 26 (29%) dedicating at least one lecture to abortion education. Sixty-seven (74%) institutions provided a clinical abortion experience for students, with 24 (26%) indicating students had to arrange participation on their own. Nine programs (10%) reported offering no formal abortion education. While the availability of abortion education has increased since the last nationwide survey in 2005, discrepancies in the education offered persist, and many medical students remain without access to this training. Although abortion plays an essential role in women's health services, discrepancies in training opportunities limit abortion education in U.S. medical schools. Gaps in the education of medical students may have downstream effects on the availability of doctors who are trained in providing medically-safe abortions. [ABSTRACT FROM AUTHOR]

Medical distrust is often conceived of as a problem of misinformation or ignorance. In this paper, I depart from this framework, attributing distrust instead to epistemic divergence between lay people and experts. Using data from a contraceptive side effects Facebook group and in-depth physician interviews, I find that providers employ a "body-as-subject" lens informed by population-health goals, while group members employ a "body-as-agent" lens that privileges individuality and bodily autonomy. Provider epistemologies are privileged, creating epistemic injustice and harm for patients. Ultimately, this erodes trust in providers and the medical community more broadly. • OBGYNs take a population-centered approach to contraceptive counseling. • Dissatisfied IUD-users privilege individuality and bodily autonomy. • Failure to recognize lay epistemologies leads to epistemic injustice. • Epistemic injustice produces psychological, relational, and physical harms. • Ultimately, population-centered counseling erodes patient trust. [ABSTRACT FROM AUTHOR]

Research on the effects of unintended childbearing has been limited in its ability to disentangle the direct effects of childbearing from common selection factors that predispose women to both unintended childbearing and lower educational attainment. Using data from a 5-year prospective cohort study of 876 individuals seeking abortion care, some of whom were denied care because they presented beyond a facility's gestational age limit, we used discrete time survival models to estimate the hazard of graduating and dropping out among those enrolled in high school, college, or other type of school (n = 280). We also examined cluster-adjusted bivariable differences in degrees completed by receipt versus denial of a wanted abortion. Participants denied an abortion who parented were equally likely to be in school as compared with women who received a wanted abortion (33 vs. 28%; p =.19); however, they were more likely to be seeking a high school diploma (40 vs. 24%; p =.05) than a higher degree. In adjusted models, there were no differences in the hazard of graduating (adjusted hazard ratio, 0.76; 95% confidence interval, 0.36–1.61) or dropping out (adjusted hazard ratio, 1.12; 95% confidence interval, 0.67–1.88) between those who were denied versus received an abortion. Among graduates, participants denied a wanted abortion less often completed a postsecondary degree (27%) compared with those who received a wanted abortion (71%; p =.002). Unintended childbirth was not associated with graduating or dropping out in this population, a finding that is at least partially explained by differences in degrees sought at the time of abortion seeking. [ABSTRACT FROM AUTHOR]

To describe the characteristics, health service utilization, and clinical outcomes of Ontario residents who are not covered by the Ontario Health Insurance Plan and receive services from Ontario midwives. Retrospective cohort study. Ontario, Canada. All midwifery courses of care resulting in births between April 1, 2012 to March 31, 2015 and captured in the BORN perinatal registry. Within this cohort we compared midwifery clients without publicly funded health insurance to those covered by the Ontario Health Insurance Plan (OHIP). Of 55, 634 midwifery clients assessed in Ontario, 92.8% were insured by OHIP and 7.2% were not insured. Among uninsured clients, 66.3% attended a prenatal visit during the first trimester compared to 92.8% of insured women, with uninsured clients presenting with fewer pre-existing conditions. A higher proportion of uninsured clients (33.9%) planned to birth at home and 28.7% of clients' actual place birth was in the home, compared to 19.6% and 16.6% of insured clients respectively. Rates of both spontaneous labour and spontaneous vaginal birth were higher among uninsured clients (82.1% and 81.1%, respectively), compared to insured clients (77.3% and 78.1%, respectively). Clinical outcomes were generally similar, with postpartum hemorrhage (3.4%), preterm birth (5%), and small-for-gestational age (2.1%) slightly more common among uninsured clients compared to insured clients (2.9%, 4.4%, and 1.7%, respectively). Rates of most complications were lower for uninsured clients. Overall, uninsured clients used less services compared to insured clients and had good clinical outcomes under midwifery care in Ontario. Findings of this study support the policy decision in Ontario to fund midwifery care for uninsured clients and suggest that uninsured clients are well suited for midwifery care. Funding midwives to serve uninsured clients is appropriate and may improve uninsured clients access to care. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system.Study Design: We analyzed data from a national telephone-based survey of 2302 women ages 18-44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans.Results: Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04-2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31-2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20-6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17-5.50).Conclusions: While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA.Implications: This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access. [ABSTRACT FROM AUTHOR]

Although bariatric surgery is a durable treatment for patients with severe obesity, it does not directly address behavioural and psychological factors that potentially contribute to weight regain post-surgery. Psychological interventions, such as cognitive behavioural therapy (CBT), can be challenging to access due to physical limitations and practical barriers. Telephone-based CBT (Tele-CBT) can improve eating psychopathology and psychological distress before and after surgery. Given the frequent occurrence/recurrence of problematic eating-related and psychological issues many patients face 1-year post-surgery, this open-trial pilot study aimed to evaluate the effectiveness of Tele-CBT delivered 1-year post-surgery as an adjunctive treatment to the usual standard of bariatric care. Patients (n = 43) received six 1-h Tele-CBT sessions delivered weekly beginning at 1-year post-surgery. Patients completed questionnaire packages before and after the intervention to assess changes in binge eating (BES), emotional eating (EES), depression (PHQ-9), and anxiety (GAD-7). Thirty-two patients completed Tele-CBT yielding a 74.4% completion rate. Participants reported significant improvements on the Binge Eating Scale (t (31) = 3.794, p = 0.001), Emotional Eating Scale (t (31) = 3.508, p = 0.001), Patient Health Questionnaire-9 Item Scale (z = −2.371, p = 0.018), and Generalised Anxiety Disorder-7 Item Scale (z = −3.546, p < 0.001) immediately following Tele-CBT. The results demonstrate that Tele-CBT delivered 1-year post-surgery may improve binge eating, emotional eating, depression, and anxiety. Additional research is warranted to examine whether these changes translate into long-term improvements in bariatric surgery outcomes. [ABSTRACT FROM AUTHOR]

• Mass screening of functional status in older people helps detect and monitor geriatric risk factors. • A national geriatric screening program motivates the elderly to follow a healthy life-style. • A nationwide geriatric screening program helps in reducing premature death among older adults. This study aimed to assess the health benefits of a geriatric screening program comprising of physical function tests, screening questionnaires for depression and cognitive impairment, and bone mineral density measurements for women as a part of the National Screening Program for Transitional Ages (NSPTA). We compared the all-cause mortality between subjects who did and did not participate in the screening program. This was a nationwide longitudinal study with a 5-year follow-up based on a 10% sample of the National Health Insurance beneficiaries aged 60 years and older. Mortality records were obtained from the qualification dataset in the elderly cohort database of 2005–2013 provided by the National Health Insurance Service. A Cox proportional hazards model was used to analyze the mortality risk. We sampled 11,986 subjects each in the screened (intervention) and non-screened (control) groups after exact matching using propensity score. After adjusting for demographic and socioeconomic characteristics (age, sex, household income, smoking, alcohol drinking, physical activity, body mass index, and the Charlson Comorbidity Index), all-cause mortality rates were found to be significantly lower (a) in the intervention group compared to the control group (hazard ratio = 0.73; 95% confidence interval: 0.65, 0.82) and (b) among women compared to men (hazard ratio = 0.50; 95% confidence interval: 0.44, 0.56). Lower hazard ratios were also observed among those with a higher body mass index, fewer comorbidities, and higher income. A nationwide geriatric screening program might be helpful in reducing the incidence of premature deaths among older people. [ABSTRACT FROM AUTHOR]

Cervical cancer is a preventable disease. HPV infection has been linked to more than 90% of cervical cancers. A vaccine to prevent the acquisition of HPV has been available since 2006. The purpose of this study was to investigate women's perceptions of cervical cancer prevention, including HPV vaccination. A reproductive justice framework guided data collection and analysis. In 2016, researchers conducted 70 in-depth, semi-structured qualitative interviews with women aged 19–78 years in South Carolina. A purposive sampling approach was employed to maximize requisite variety based on social, economic, and environmental axes of inequality. Participants self-identified as white (53%), African American (33%), and Hispanic (9%). Data analysis included an inductive constant comparative method to identify patterns and themes across the interviews. Misinformation about the prevalence and risk of HPV and cervical cancer led to "othering" of women with HPV-related diagnoses based on the flawed assumption of not being at risk. Participants described a lack of knowledge about the effectiveness and safety of the HPV vaccine. Social norms influenced participants' perceptions of HPV vaccination and cervical cancer, including concerns about sexual activity and intergenerational communication. Participants' social construction of identity, including race/ethnicity, socioeconomic position, ability, age, gender, sexual orientation, and immigration status, impacted their perceptions of cervical cancer screening and the HPV vaccine. In particular, participants believed that the HPV vaccine was "only for girls" and identified gender norms that limited uptake. Participants described barriers to accessing health care and cervical cancer screening, including cost, health insurance, and life changes (e.g., pregnancy, relocating). Many participants experienced an abnormal Papanicolaou test and described follow-up care, including biopsies and treatment for cervical dysplasia. Findings from this study offer insight into women's identity and perceptions of cervical cancer prevention. Results provide practical recommendations to increase women's agency in the development of successful public health interventions. • Misinformation about the prevalence and risk of HPV and cervical cancer was common. • Medicalization, including the frequency of abnormal Pap tests, disempowered women. • Social norms influenced concerns about sexual activity and stigma. • Participants' identity impacted perceptions of cervical cancer prevention. [ABSTRACT FROM AUTHOR]

Objective: To utilize Time-Driven Activity-Based Costing to quantify costs of managing recurrent urinary tract infections (RUTI) in women.Methods: RUTI was defined as ≥2 UTIs in 6 months or ≥3 UTIs in 12 months. A care-delivery value chain outlined RUTI management (visits, urine studies, and imaging) for acute UTI followed by a form of long-term prevention. Prevention strategies included conservative therapy (Cranberry tablets, d-mannose, or lactobacillus); Estrogen therapy if postmenopausal; Antibiotic use (self-start, postcoital, or continuous regimens); or intravenous antibiotics in case of drug-resistance or intolerance. Costs of each resource were largely obtained from the Medicare Physician Fee Schedule, GoodRx and local pharmacy pricing, and institutional expenses. The capacity cost rate was defined as cost of resources per minute of care. Individual costs were summed to estimate overall expense of initial RUTI workup and annual cost for each long-term prevention strategy.Results: Cost of acute RUTI workup ranged from $390 to $730. Acute antibiotics cost ranged from $10 for oral trimethoprim-sulfamethoxazole to $3970 for intravenous Ertapenem. Annually, mean cost of conservative therapy ranged from $50 for d-mannose to $1290 for vaginal estradiol ring, and antibiotic use for self-start $40, postcoital $60, and continuous $190. Capacity cost rate ranged from $0.003/min for urine culture to $80/min for estrogen ring.Conclusion: Using Time-Driven Activity-Based Costing, costs of RUTI management were efficiently determined. This offers new perspectives for patient counseling and long-term decision making. [ABSTRACT FROM AUTHOR]

Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans' experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences. We conducted 32 qualitative interviews among women veterans ages 18–44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified. Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making. Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA. [ABSTRACT FROM AUTHOR]

Abstract Arrested girls in the United States (US) are often diverted from detention through referrals to juvenile specialty courts (e.g., juvenile drug court), community-based diversion programs, or pre-adjudicated probation services. Limited research suggests that sexual and reproductive health needs for diverted, or court-involved, non-incarcerated (CINI) girls are similar to that of their detained counterparts. Despite the US justice system's emphasis on diverting youth from detention, research and programmatic efforts to improve sexual and reproductive health outcomes has primarily focused on detained girls. Policy and programming for CINI girls is scant and thus warrants further attention. This report details the immediate sexual and reproductive health needs of CINI girls. We discuss implications of current health care policies and practices for this population and conclude with recommendations for research focused on improving access to sexual and reproductive health care. [ABSTRACT FROM AUTHOR]

Abstract Background Abnormal uterine bleeding (AUB) is a common women's health complaint. However, the quality of primary care (PC) management of AUB is unknown. Our objective was to develop quality indicators for Veterans Health Administration (VA) PC assessment and management of AUB. Methods We drafted candidate indicators based on comprehensive review of the scientific literature, including published consensus guidelines. Then, we convened a national panel of nine experts including PC providers, obstetrician-gynecologists, VA policy stakeholders, and quality measurement experts, and used a modified Delphi panel process. First, panelists individually rated 19 candidate indicators, using 9-point scales, on three metrics: consistency with established guidelines, importance to women's health, and reliability of measurement from VA electronic health records. Panelists then discussed the indicators. Finally, panelists re-rated revised indicators using the same metrics. Indicators were selected if final median ratings were ≥7 on each 9-point scale, without dispersion in ratings. Results Eighteen indicators were selected. Three focused on assessing need for emergency care (e.g., profuse bleeding or pregnancy). Three addressed ascertaining key aspects of the medical history (e.g., endometrial cancer risk). Two addressed performing a physical examination (e.g., pelvic examination). Six addressed indications for diagnostic studies and specialty care referrals, (e.g., transvaginal ultrasound examination). Four addressed initiation of treatment and counseling (e.g., hormone therapy). Conclusions We developed quality indicators for PC assessment and management of AUB that span reproductive and postmenopausal life phases. Applying these indicators in VA and other health systems with integrated electronic health records can assess need for, and effects of, AUB quality improvement programs. [ABSTRACT FROM AUTHOR]

Abstract Purpose The purpose of the study was to evaluate the association between a nationwide introduction of robotic minimally invasive surgery (RMIS) and survival in women with early-stage endometrial cancer. Materials and methods Prospective data on consecutive women with early-stage endometrial cancer who underwent surgery during January 2005 to June 2015 in Denmark were identified in the nationwide Danish Gynaecological Cancer Database. Data were linked with national registries regarding comorbidity, education, income and death. The cohort was divided according to the time they underwent surgery: Group 1 before RMIS introduction in their respective region and Group 2 after RMIS introduction. Five-year overall survival was compared by multivariate Cox proportional hazards models stratified by histopathological risk between Groups 1 and 2 and between surgical modalities within Group 2: total abdominal hysterectomy (TAH), laparoscopic minimally invasive surgery (LMIS) and RMIS. Results Women in Group 1 (N = 3091) had significantly lower overall survival compared with those in Group 2 (N = 2563; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.05–1.42). Age, smoking, socioeconomic status, American Society of Anaesthesiologists (ASA) score, comorbidity and histopathological risk influenced the overall survival. Following RMIS adoption, TAH was associated with higher mortality compared with LMIS and RMIS (HR, 1.42; 95% CI 1.02–1.97 and HR, 1.70; 95% CI 1.31–2.19 for LMIS and RMIS, respectively). There was no significant survival difference between RMIS and LMIS (HR, 1.19; 95% CI 0.85–1.68). Conclusion The national introduction of robotic surgery for early-stage endometrial cancer was associated with improved survival irrespective of age, body mass index, ASA score, comorbidity, smoking, socioeconomic status and histopathological risk. Highlights • A national adoption of minimally invasive surgery for endometrial cancer is associated with improved survival. • Minimally invasive techniques yield similar survival in endometrial cancer. • Survival benefit was found independent of histopathological risk group. [ABSTRACT FROM AUTHOR]

Abstract The potential health consequences of limiting access to safe abortion make it imperative to understand how conscience-based refusal to provide legally permitted services is understood and carried out by healthcare practitioners. This in-depth study of conscientious objection to abortion provision in Zambia is based on qualitative interviews (N = 51) with practitioners working across the health system who object and do not object to providing abortion services in accordance with their cadre. Interviews were conducted in September 2015. Regardless of whether practitioners self-identified as providers or non-providers of abortion services, they presented similar religiously-informed understandings of abortion as a morally-challenging practice that is, or is not, shifted from iniquity to acceptability based on the reasons for which it has been requested or the likelihood of unsafe abortion if services are not provided. These contextual factors presented a series of tipping points for participants, rather than a single justification for providing abortion. Subsequently both groups reported that their decisions about providing services were complex and changeable, rather than clear one-time resolutions. This shaped their practices, both in terms of whether or not they provided services, and when and how they delivered them. Practitioners self-identifying as non-providers, and those self-identifying as providers, reported provision, counselling, and referral practices likely to lessen women's access to safe legal abortion. In this way, conscientious objection in practice could be understood as a continuum of behaviours rather than a binary position. Our results suggest that data on prevalence of claims to conscientious objector status may underestimate the impact of practitioners' religious, moral and ethical beliefs on abortion accessibility. In Zambia, eliminating practitioners' right to conscientious objection alone or conducting rights-based advocacy may therefore not significantly increase access to safe abortion. Highlights • Objectors and providers share conscience-based narratives about abortion • Both report provision, counselling and referral practices that lessen abortion access • Practitioners' decision-making about abortion provision was on-going and non-linear • Conceptualisation of conscientious objection should include how care is delivered • Conscience-based practices of all cadre influence access to abortion services [ABSTRACT FROM AUTHOR]

Abstract Cash transfer programmes form an integral part of nutrition, health, and social protection policies worldwide, but the mechanisms through which they achieve their health and nutritional impacts are incompletely understood. We present results from a process evaluation of a combined participatory women's groups and cash transfer programme to improve low birth weight in rural Nepal. We explored the ways in which context, implementation, and mechanism of the intervention affected beneficiary women's agency over cash transfers. Informed by a grounded theory framework, we conducted and analysed semi-structured interviews with 22 beneficiary women, 15 of their mothers-in-law, 3 of their elder sisters-in-law and 20 husbands, as well as a focus group discussion with 7 supervisors of the women's group intervention. Our study reveals how women's group facilitators, their supervisors and community members developed a shared dynamic around persuading and compelling recipients of unconditional cash transfers into spending them according to criteria developed by the group. We found these dynamics effectively constituted 'soft conditions' on beneficiary spending which restricted women's ability to make decisions over their cash transfers, but also increased their likelihood of spending them on their own pregnancy. Our findings demonstrate the importance of understanding how programmes are implemented and responded to in order to understand their implications for beneficiary agency and empowerment. Highlights • We studied a combined participatory women's group and cash transfer intervention. • Group facilitators and community members created social pressure over transfer use. • These social pressures effectively constituted 'soft conditions' on cash transfer use. • Participatory women's groups can promote beneficiary spending on health & nutrition. [ABSTRACT FROM AUTHOR]

Abstract Background The Veterans Health Administration (VHA) faces challenges in providing comprehensive, gender-sensitive care for women. National policies have led to important advancements, but local leadership also plays a vital role in implementing changes and operationalizing national priorities. In this article, we explore the notions of ideal women veterans' health care articulated by women's health leaders at local VHA facilities and regional networks, with the goal of identifying elements that could inform practice and policy. Methods We conducted semistructured interviews with 86 local and regional women's health leaders at 12 VHA medical centers across four regions. At the conclusion of interviews about women's primary care, participants were asked to imagine "ideal care" for women veterans. Interviews were transcribed and coded using a hybrid inductive/deductive approach. Results In describing ideal care, participants commonly touched on whether women veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women veterans; the physical appearance of facilities; fostering active interest in women's health across providers and staff; and the relative priority of women's health at the VHA. Conclusions Policy and practice changes to care for women veterans must be mindful of key stakeholders' vision for that care. Specific features of that vision include clinic construction that anticipates a growing patient population, providing childcare and expanded reproductive health services, ensuring adequate support staff, expanding mechanisms to incorporate women veterans' input, and fostering a culture oriented towards women's health at the organizational level. [ABSTRACT FROM AUTHOR]

Abstract This study documents the perceptions and experiences of immigrant women and men in the US related to female genital cutting (FGC). This paper examines the effects of migration on these perceptions, with the goal of optimizing health services and informing public policy to support women who have undergone FGC. This qualitative study consisted of individual interviews conducted from 2014 to 2015 with 42 women and men living in Boston, Massachusetts, who immigrated from a variety of communities where FGC has been practiced. Most participants felt strongly against the continuation of the practice, describing a change in their personal and community viewpoints over time, which they attributed to education, religion and immigration. The men in our study collectively took a stand against FGC and believed that they had a particular duty to raise awareness in their families and their communities about its physical and emotional harms. Our study provides strong support for the inclusion of men, religious leaders, and immigrants in FGC-related efforts. Our unique preliminary exploration of the role of members of the diaspora provides some support for initiatives that would involve emigrants in the effort to curb FGC in their home countries. Changing views in the diaspora could play a significant role in affecting opinions and practices in contexts where FGC is prevalent. Finally, our findings do not support the fear that "vacation cutting" might be common among US immigrants. We should therefore exercise caution in our promotion of legislation and clinical practices that target this fear. Highlights • Unique qualitative study of immigrant men and women from various ethnicities on FGC. • Migration journeys and education provide strong catalysts for rejection of FGC. • Argues for the involvement of religious leaders and men in advocacy efforts against FGC. • Offers a novel exploration of the effect of the diaspora on FGC practices back home. • Undermines the theory that vacation cutting is prevalent among US immigrants. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of information on the prevalence of dietary supplement use in breast cancer survivors. Only a few studies have examined the impact of dietary supplements, particularly antioxidants, on breast cancer prognosis and the results are inconclusive. Objective: We examined pre- and postdiagnosis use of supplements in postmenopausal breast cancer survivors in Germany and investigated associations between postdiagnosis use of antioxidants and other supplements, and prognosis (total and breast cancer mortality, and recurrence-free survival) both overall and in women who received chemotherapy and radiation therapy. Design: Data from 2223 postmenopausal women diagnosed with nonmetastatic breast cancer from the population-based Mamma Carcinoma Risk Factor Investigation (MARIE) study were used. Women were interviewed at recruitment in 2002–2005 and again in 2009 and followed-up until 30 June 2015. Multivariate Cox regression analysis was used to estimate HRs and corresponding 95% CIs. Results: Pre- and postdiagnosis supplement use was reported by 36% and 45% of the women, respectively. There were 240 deaths (134 from breast cancer) and 200 breast cancer recurrences after a median follow-up time of 6.0 y after the 2009 re-interview. After adjusting for relevant confounders, concurrent antioxidant use with chemotherapy or radiation therapy among 1940 women was associated with increased risk of total mortality (HR: 1.64; 95% CI: 1.01, 2.66) and worsened recurrence-free survival (HR: 1.84; 95% CI: 1.26, 2.68). Overall postdiagnosis supplement use was not associated with breast cancer prognosis. Conclusions: Antioxidant use during chemotherapy or radiation therapy was associated with worsened breast cancer prognosis in postmenopausal women. There was no overall association between postdiagnosis supplement use and breast cancer prognosis. Results from our study align with the current recommendation to possibly avoid the use of antioxidants during chemotherapy or radiation therapy. [ABSTRACT FROM AUTHOR]

Evaluate and compare the impact of a resilience-based intervention on emotional regulation, grit and life satisfaction among female Egyptian and Saudi nursing students. Nursing students should experience a comprehensive learning environment since they are mind-body-spirit creatures. Therefore, nursing education should emphasize growing students' physical, social, emotional and spiritual well-being in addition to their knowledge, skills and attitudes. This study followed a parallel arm randomized controlled trial design. Study participants were randomly assigned to the intervention or control groups in a (1:1) ratio. It was conducted between January 2023 and the end of April 2023. Students were randomly allocated to the eight-week resilience intervention (n= 60) or a control (n= 60) group (half of the students in each group were from each country). The intervention group received a pamphlet and attended eight weekly 15-person sessions on resilience, grit (perseverance), emotional regulation and self-care. The Emotion Regulation Questionnaire, the Short Grit Scale and the Satisfaction with Life Scales were administered pre- and immediately post-intervention. Between pre- and post-intervention, there were significant improvements in grit (from 41.374.27 to 51.235.22 among Egyptian students with an effect size of 0.663 and from 42.974.30 to 54.103.87 among Saudi students with an effect size of 0.800), as well as mean emotional regulation (from 36.635.11 to 55.707.51 among Egyptian students with an effect size of 0.818 and from 44.606.87 to 61. With a substantial effect size of 0.850 (p0.001), Egyptian nursing students experienced a more significant rise in mean life satisfaction than Saudi nursing students (18.336.54 to 29.305.14). Resilience-based interventions enhanced emotional regulation, grit and life satisfaction in Egyptian and Saudi female nursing students. Grit, resilience and emotional regulation should be incorporated into nurse training to equip female students with the necessary values and protective factors to succeed in their studies. Given the unique challenges and stressors that female nursing students may face, nursing programs and institutions must provide resources and support services to help students manage stress and build resilience. [ABSTRACT FROM AUTHOR]

Pregnancy, childbearing and motherhood means a huge bodily and emotionally change in women's lives. This can be challenging for everyone, but even more so for women with a physical disability. Charcot-Marie-Tooth disease (CMT) is a rare, hereditary neuromuscular disease which affects the peripheral motor and sensory nerves, leading to muscular weakness and sensory deficits creating challenges in different daily functions. Pregnancy may exacerbate this. The purpose of the study was thus to provide new knowledge about how women with CMT experience pregnancy, childbearing and the period with a newborn, and about their experiences with physiotherapy related to these aspects. The study was anchored in a hermeneutical and phenomenological tradition, with qualitative semi-structured individual interviews applied as research method. Three women with genetically confirmed CMT 1A and one woman with a clinical CMT-diagnosis were strategically recruited. The interviews were transcribed in NVivo, and data was analysed through systematic text condensation. Perception of the pregnancy was in essence positive for the women, but bodily changes in the form of weight gain and changes in the form of the body exacerbated their regular functional challenges. They experienced worsening in balance and reduced sensibility in hands and feet during pregnancy and after birth, resulting in practical difficulties with night care, bathing, lifting and carrying the baby. Adequate help and assistance with their issues led to a sense of achievement. The mothers found physiotherapy useful if it was specific and individualized, but the health care professionals' lack of knowledge about CMT seems to affect what kind of community services is offered. This can cause frustration and a feeling of bigger responsibility at these women. Help to find balance between physical activity and rest strengthened their coping strategies. The findings highlight the need for dissemination of knowledge about CMT-related challenges with pregnancy to physiotherapists and other health care professionals, and can be useful in developing health care services for these women. [ABSTRACT FROM AUTHOR]

Abstract Although the reasons for immigrating to the U.S. vary by Latino groups, many Latinos cite economic or political motivations for their migration. Once in the United States, Latino immigrants may face many challenges, including discrimination and blocked opportunities for social mobility, and difficulties in obtaining health services and quality health care. The purpose of this study was to explore how changes in social mobility from the country of origin to the U.S. may relate to Latina women's health care interactions. We examined whether self-reported social mobility among 419 Latina women immigrants is associated with satisfaction with health care. We also examined the association among social mobility and self-rated health, quality of care, and medical mistrust. Upward social mobility was associated with greater number of years lived in the U.S., and downward social mobility was associated with more years of education. Those who reported no changes in social class (stable social mobility) were older and were the most satisfied with their medical care. Multiple regression analyses indicated that downward social mobility was associated with less satisfaction with care when controlling for demographic covariates, quality of care, and medical mistrust. Results suggest that perceived social mobility may differentially predict Latina immigrants' satisfaction with the health care system, including their trust in U.S. medical institutions. We conclude that perceived social mobility is an important element in exploring the experiences of immigrant Latinas with health care in the United States. Highlights • This is a unique analysis of social mobility among Dominican immigrant women. • Downward social mobility was associated with lower satisfaction with health care. • Downward social mobility was (weakly) associated with poor mental health. • Upward and stable social mobility were not associated with better health outcomes. [ABSTRACT FROM AUTHOR]

Abstract Access to affordable daycare might improve population mental health. However, evidence is sparse and restricted to middle- and high-income country settings. We conducted a cluster-randomized controlled trial in one low-income setting, rural Rajasthan, India. Communities lacking daycare facilities were identified (n = 160) and randomly selected for assistance in setting up a community-based daycare program (n = 80) or not (n = 80). Women eligible for the daycare program living in these communities completed structured interviews before the intervention (participation rate = 89%) and approximately one year after rollout of the intervention (participation rate = 96%), resulting in a final analytic sample of 3041. Mental distress was measured with the Hindi version of the 12-item General Health Questionnaire (score range: 0–12). We modeled the relation between access to daycare and number of mental distress symptoms (GHQ-12 score) with negative binomial regression using an intention-to-treat approach, which groups women according to if they lived in communities randomized to affordable daycare. We also evaluated the effect of access to daycare on secondary outcomes that may be related to mental distress, including women's work burden, agency, and intimate partner violence (IPV). We found that access to daycare resulted in modest reductions in symptoms of mental distress (mean difference = 0.21, 95% CI: −0.43, 0.02). We found some evidence that daycare reduced IPV, but virtually no change in women's work burden or agency. Our results provide some indication that access to affordable daycare might be one policy lever to improve population mental health. Highlights • We assessed the effect of access to daycare using an intention-to-treat approach. • 41% of women living in communities randomized to daycare utilized services. • Access to daycare resulted in modest reductions in women's mental distress. • Access to daycare resulted in modest reductions in intimate partner violence. • Access to daycare did not lead to meaningful changes in agency or work amount. [ABSTRACT FROM AUTHOR]

In-session affiliation among members is a hypothesized mechanism of action of group therapy for women with substance use disorders (SUDs). We evaluated group affiliation as an independent predictor of SUD treatment outcome in women (n = 100), 18 years or older diagnosed with substance dependence, who were randomized to the single-gender Women's Recovery Group (WRG) or mixed-gender group therapy (Group Drug Counseling; GDC). Affiliative statements made by members in both groups were measured for 39 women in each treatment arm. We studied the relationship between frequency of affiliative statements categorized in quintiles and the trajectory of days of any drug use during 3 months treatment and 6 months post-treatment using a Poisson regression model with estimation via generalized estimating equations. Furthermore, we investigated whether the effect of affiliation on substance use was moderated by group therapy type. The relationship between amount of affiliation and substance use reduction was non-linear. At the end of the treatment phase (3 months), women who experienced the highest level of affiliation (>65 affiliative statements on average) were found to reduce substance use by about 1.75 days more (p-value = 0.02) than women who experienced the lowest level of affiliation (<26). The effects of affiliation persisted 6 months post-treatment and were moderated by therapy group, whereby women enrolled in the single-gender WRG appeared to benefit more from affiliation post-treatment. Training therapists to facilitate verbal affiliation may provide added therapeutic benefit to group therapy for women with SUDs. [ABSTRACT FROM AUTHOR]