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Background: Ulipristal acetate 30 mg became available as prescription-only emergency contraception in British Columbia, Canada, in September 2015, as an addition to over-the-counter levonorgestrel emergency contraception. In this study, we determined dispensing and practice use patterns for ulipristal acetate, as well as facilitators of and barriers to emergency contraception for physicians, pharmacists and patients in BC. Methods: In the quantitative component of this mixed-methods study, we examined ulipristal acetate use from September 2015 to December 2018 using a database that captures all outpatient prescription dispensations in BC (PharmaNet) and another capturing market sales numbers for all oral emergency contraception in BC (IQVIA). We analyzed the quantitative data descriptively. We conducted semistructured interviews from August to November 2019, exploring barriers and facilitators affecting the use of ulipristal acetate. We performed iterative qualitative data collection and thematic analysis guided by Michie’s Theoretical Domains Framework. Results: Over the 3-year study period, 318 patients filled 368 prescriptions for ulipristal acetate. Use of this agent increased between 2015 and 2018. However, levonorgestrel use by sales (range 118 897–129 478 units/yr) was substantially higher than use of ulipristal acetate (range 128–389 units/yr). In the 39 interviews we conducted, from the perspectives of 12 patients, 12 community pharmacists, and 15 prescribers, we identified the following themes and respective theoretical domains as barriers to access: low awareness of ulipristal acetate (knowledge), beliefs and experiences related to shame and stigma (beliefs about consequences), and multiple health system barriers (reinforcement). Interpretation: Use of ulipristal acetate in BC was low compared with use of levonorgestrel emergency contraception; lack of knowledge, beliefs about consequences and health system barriers may be important impediments to expanding use of ulipristal acetate. These findings illuminate potential factors to explain low use of this agent and point to the need for additional strategies to support implementation.

AimThe aim of this review was to systematically review the outcome of routine anti-D administration among unsensitised rhesus (RhD)-negative individuals who have an abortion. This review is registered with Prospero.MethodsA search for all published and ongoing studies, without restrictions on language or publication status, was performed using the following databases from their inception: EBM Reviews Ovid - Cochrane Central Register of Controlled Trials, MEDLINE Ovid (Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily), Embase.com, Popline and Google Scholar. Study types included: randomised controlled trials, controlled trials, cohort and case–control studies from 1971 onwards. The population included women who undergo an abortion (induced, incomplete, spontaneous or septic abortion), medical or surgical ResultsA total of 2652 studies were screened with 105 accessed for full-text review. Two studies have been included with high bias appreciated. Both studies found few women to be sensitised in forming antibodies after an abortion. The limited studies available and heterogeneity prevent the conduction of a meta-analysis.ConclusionsRh immunoglobulin has well-documented safety. However, it is not without risks and costs, is a possible barrier to delivering efficient services, and may have limited availability in some countries. The evidence base and quality of studies are currently limited. There is unclear benefit from the recommendation for Rh testing and immunoglobulin administration in early pregnancy. More research is needed as clinical practice guidelines are varied, based on expert opinions and moving away from testing and administration at time of abortion.ImplicationsThere is limited evidence surrounding medical benefit of Rh testing and immunoglobulin administration in early pregnancy. Further research is needed to define alloimmunisation and immunoglobulin benefit to update standards of care. Additionally, other factors should be considered in forming clinical policies and guidelines such as costs, feasibility and impact on access to care for patients.

Michelle C Chan,1 Angela M Bayer,1 Joseph R Zunt,2 Magaly M Blas,1 Patricia J Garcia1 1School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru; 2Departments of Neurology and Global Health, University of Washington, Seattle, WA, USA Abstract: To solve increasingly complex global health problems, health professionals must collaborate with professionals in non-health-related fields. The Universidad Peruana Cayetano Heredia and University of Washington created the NIH-funded Kuskaya training program in response to the need for transformative global health training for talented graduates from all disciplines. Kuskaya is a 1-year, interdisciplinary training program that teaches Peruvian and US graduates critical skills related to public health research through the design and implementation of a collaborative research project in Peru. Between 2014 and 2018, the program has trained 33 fellows, of which one third were from non-health disciplines. The program is unique because it targets junior trainees from disciplines outside of the health field, the program’s curriculum is adapted to fit the fellows’ backgrounds and professional aspirations, and the structure of the program allows for collaboration within the cohort and encourages fellows to apply for additional funding and pursue advanced degrees. Lessons learned in designing the Kuskaya program include: 1) involving mentors in the fellow selection process, 2) involving fellows in existing lines of research to increase mentor involvement, 3) institutionalizing mentoring through regular works-in-progress meetings and providing mentoring materials, and 4) defining a core curriculum for all fellows while providing additional supplementary materials to meet each cohort’s needs, and evaluating their progress. Kuskaya provides an innovative model for bi-national, global health training to engage and provide a public health career pathway for all professionals. Keywords: public health, international health, program design, education

Urinary incontinence and pelvic organ prolapse are highly prevalent in women and have a significant impact on quality of life. Pessaries are devices that are used as a conservative management option. Many women use pessaries, which avoid surgical intervention with its associated morbidity and cost. However, not all women are good candidates for pessary use. The objective of this study was to determine clinical factors leading to persistent pessary use for incontinence or pelvic organ prolapse in a tertiary care centre at 12 months. Studying patient characteristics for long-term pessary use will contribute to better patient counselling, management, and health resource distribution.This study was a retrospective outpatient chart review of new pessary fittings in patients in a tertiary care urogynaecology clinic between January and June 2014. Any woman over 18 years of age fitted with a pessary at that time was included in the study. All statistical analyses were performed using IBM SPSS Statistics version. 24 (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-3).A total of 152 women were fitted with pessaries. A multivariable logistic regression analysis found that a patient's diagnosis of prolapse or incontinence (P = 0.01) and a lack of complications (P 0.0001) were statistically significant for persistent pessary use at 12 months. Patients with prolapse had 7.7 times higher odds (95% CI 1.51-39.35) of using a pessary at 12 months than did patients with incontinence. Patients without complications had 250 times higher odds (95% CI 18.52-2500) of pessary use. Patients who tried two to three pessaries had 16 times higher odds (95% CI 1.80-137.00) of persistent use than patients who trialed just one.This study has found that a lack of complications, the number of pessaries tried, and a primary diagnosis of prolapse are significant factors for continued pessary use at 12 months.

Background Multidisciplinary team care is becoming more popular for complex health issues, including pelvic floor dysfunction. Methods We conducted a retrospective review of the records of 207 patients attending a multidisciplinary pelvic floor dysfunction clinic. A telephone survey was also conducted. The outcomes investigated included conservative versus surgical management, comorbidities, number of specialists seen, and subjective patient feedback. Results The average patient was 59.9 years old and travelled an average distance of 128.6km to attend the clinic. Common clinical presentations were urge urinary incontinence (58.9%) and stress urinary incontinence (54.6%). Ninety-three of 178 patients (52.2%) presented with at least two comorbidities. At the time of data collection, 52.2% of patients had opted for surgical management, 27.5% had chosen conservative management, and the remainder remained undecided. One hundred sixty-five women participated in the telephone survey and their responses were grouped into major themes: (1) wait times, (2) multidisciplinary clinic feedback, and (3) parking, patient education, and information distribution. Conclusion Based on feedback, the majority of patients were accepting of a multidisciplinary approach to pelvic floor dysfunction and were satisfied with that approach.

Resume Objectif Offrir une mise a jour sur les traitements chirurgicaux a effraction minimale actuellement utilises pour contrer l'incontinence urinaire a l'effort chez les femmes: intervention par bandelette vaginale sans tension (TVT), intervention par bandelette transobturatrice (TOT) et autres interventions de fronde mi-uretrales. Options La discussion se limite a la prise en charge chirurgicale a effraction minimale de l'incontinence urinaire a l'effort chez les femmes. Resultats Des recherches menees dans PubMed et Cochrane Library, afin d'en tirer les articles publies en anglais avant la fin de fevrier 2008, ont permis d'identifier la litterature la plus pertinente. Les recommandations ont ete formulees en fonction des lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs. Valeurs La presente mise a jour constitue le consensus obtenu par le sous-comite sur l'urogynecologie de la Societe des obstetriciens et gynecologues du Canada. Avantages, desavantages et couts Les services de counseling portant sur la prise en charge chirurgicale de l'incontinence urinaire devraient tenir compte de tous les avantages, desavantages et couts des options chirurgicales. Recommandations 1.L'intervention par bandelette vaginale sans tension peut etre offerte a titre de solution de rechange dont l'efficacite est equivalente a celle de l'intervention de Burch, en ce qui a trait a la prise en charge chirurgicale de l'incontinence urinaire a l'effort. (I-A) 2.L'intervention par bandelette transobturatrice peut etre offerte a titre de solution de rechange a l'intervention par bandelette vaginale sans tension qui elimine les risques de lesions aux organes intra-abdominaux. Elle devrait etre offerte aux patientes en prenant bien soin de leur indiquer que son efficacite et son innocuite a long terme, par comparaison avec l'intervention par bandelette vaginale sans tension, restent a determiner. (II-B) 3.Les interventions de fronde mi-uretrales effectuees au moyen d'une seule incision sous-uretrale ne devraient etre utilisees que dans le cadre d'un essai clinique, et ce, jusqu'a ce que leur efficacite et leur innocuite soient prouvees. (III-C) 4.Malgre la simplicite sous-entendue des trousses chirurgicales preemballees destinees aux interventions mi-uretrales, l'obtention de la formation appropriee est recommandee avant l'execution de l'une ou l'autre de ces interventions chirurgicales. (III-C) Validation La presente mise a jour technique a ete approuvee par le sous-comite sur l'urogynecologie, le comite executif et le Conseil de la Societe des obstetriciens et gynecologues du Canada.

Objective: To provide an update on currently used minimally invasive surgical treatments for stress urinary incontinence in women: tension-free vaginal tape (TVT) procedure, transobturator tape (TOT) procedure, and other midurethral sling devices. Options: The discussion is limited to minimally invasive surgical management of stress urinary incontinence in women.