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Background: Pregnancy related hypertension is a leading cause of preventable maternal morbidity and mortality in the US, with consistently higher rates affecting racial minorities. Many complications are preventable with timely treatment, in alignment with the Alliance for Innovation on Maternal Health's Patient Safety Bundle ("Bundle"). The Bundle has been implemented successfully in inpatient settings, but 30% of preeclampsia-related morbidity occurs in outpatient settings in North Carolina. To address this, we have integrated community engagement and implementation science approaches to identify facilitators and barriers to Bundle implementation, which supports its adaptation for outpatient settings and identifies implementation strategies to be tested in a subsequent study. Methods: Eleven key informant interviews were conducted across three clinics to assess the implementation needs for effectively utilizing the Bundle. The interview guide was created using the Consolidated Framework for Implementation Research domains to identify facilitators and barriers to implementation. Additionally, three focus group discussions with patient participants were conducted to understand lived experiences and perceptions of respectful care. A coalition of community partners, patients, providers, those with lived experience, and the research team reviewed materials from the formative study design to dissemination and planning for future study. Results: Barriers included inadequate provider-patient interaction time, patients' lack of transportation to access care, limited protocols to inform/assess/treat/escalate patients, and workforce capacity (staff training and turnover). Facilitators included staff recognition of the importance of treating preeclampsia, champion buy-in of the Bundle's ability to improve outcomes, co-location of pharmacies for immediate treatment, and staff capacity. Respectful care principles were repeatedly identified as a facilitator for Bundle implementation, specifically for patient awareness of preeclampsia complications and treatment adherence. Conclusions: Findings highlight the importance of community-engaged approaches. Further, clinic staff regarded Bundle implementation as crucial for the outpatient setting. Identified barriers suggest that strategies should address systemic social supports (i.e., transportation, childcare) and improve access to and use of home blood pressure monitoring. Identified facilitators support improving communication, increasing clinic champion engagement, enabling systems for identifying at-risk patients, and training staff on accurate blood pressure measurement. Successful Bundle implementation requires addressing systemic barriers to delivering respectful care, such as limited time with patients. [ABSTRACT FROM AUTHOR]

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement. [ABSTRACT FROM PUBLISHER]

Background. It has been shown in the NeoALTTO trial that a neoadjuvant regimen containing paclitaxel, lapatinib and trastuzumab is superior to regimens which include only one of the HER2 antagonists with paclitaxel. In light of these results, we modelled the potential cost-effectiveness of adjuvant lapatinib for patients with HER2-positive early-stage breast cancer. Material and methods. We constructed a Markov state-transition model with three different health states: disease free, relapse, and death. We assumed an 18-week course of lapatinib was added to the TCH arm of the BCIRG 006 trial. Since no efficacy data are available for combining adjuvant lapatinib with trastuzumab, we ran the model assuming five different hypothetical hazard ratios for disease free survival when lapatinib is added to TCH (TCH was used as the control group). The hazard ratios were 0.9, 0.8, 0.7, 0.6, and 0.5. Outcomes are given in quality-adjusted life-years (QALYs). Both costs and QALYs were discounted at the 4% rate. We calculated the cost per QALY from the perspective of the Irish health care system. Probabilistic sensitivity analysis and one-way sensitivity were performed and confidence intervals were bootstrapped. Results. The incremental cost-effectiveness ratios (ICERs) for the five hazard ratios are €53 089/QALY, €27 893/QALY, €18 463/QALY, €13 527/QALY and €10 490/QALY, respectively. Using the €45 000/QALY threshold, an adjuvant lapatinib regimen is cost-effective at the 0.8 hazard ratio. Adjuvant lapatinib becomes cost-effective at the 0.879 hazard ratio where the ICER is €44 825/QALY. Conclusion. In the Irish setting, an adjuvant lapatinib regimen would be considered cost-effective for patients with HER2-positive early-stage breast cancer for four of the five hypothesised hazard ratios. Data from both adjuvant and neoadjuvant trials suggest that the hazard ratio required to achieve cost-effectiveness for adjuvant lapatinib is both possible and plausible. [ABSTRACT FROM AUTHOR]