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PurposeOut-of-school adolescent girls (OoSGs) can lack education on menstrual, sexual, reproductive, and mental health (SRMH) and be more vulnerable to SRMH harms. Targeted interventions could reduce these risks. We assessed interventions and their effectiveness among OoSGs globally.MethodsSix online databases were searched for interventional studies targeting SRMH problems in OoSGs. Two coders independently abstracted data from each eligible study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We summarized results using forest plots.ResultsA total of 1,244 studies were screened; eight studies with sufficient information on SRMH outcomes were included (9,084 OoSGs, range 100–3,026 per study, overall study quality low-to-moderate). Six were educational programmes, and two were cash interventions; no study was directed at mental health. Participants were recruited through village census, outreach workers, and work locations. Some improvements were seen in indicators of SRMH knowledge (four studies), attitudes (one study), and risky sexual behaviors (four studies); however, no reduction was seen in human immunodeficiency virus or herpes simplex virus-2 incidence (two studies).DiscussionThis review suggests that programmes can improve OosG’s SRMH knowledge, attitudes, and practices and can be delivered in low resource contexts. Effective interventions are needed to support OoSGs, including interventions focusing on SRMH support incorporating elements of cash-transfer, and comprehensive sexual education, and to aid local policy and programming.

Introduction Rheumatic heart disease (RHD) is underdiagnosed globally resulting in missed treatment opportunities and adverse clinical outcomes. We describe the protocol for a study which aims to co-design, implement and conduct an evaluation of a task-sharing approach to echocardiographic active case finding for early detection and management of RHD in high-risk settings in Australia and Timor-Leste.Methods and analysis Echocardiograms will be obtained by trained local staff using hand-held echocardiographic devices employing the ‘Single Parasternal Long Axis view with a Sweep of the Heart’ (SPLASH) technique and interpreted by experts remote from the site of acquisition. Approximately 1500 children and pregnant women will be screened across high-risk communities in Australia and Timor-Leste over an 18-month period. The study will use a type II effectiveness-implementation hybrid design. A tailored package of implementation strategies will be co-designed with communities and health services and mapped onto a Theory of Change framework. The clinical effectiveness will be assessed as the change in the proportion of the target population that are prescribed secondary prophylaxis for RHD by the end of the study compared with baseline. The implementation will be assessed as the adoption, penetration, sustainability, fidelity and cost of the programme with a mixed-methods theory-based and economic evaluation. Data will include numbers of normal, abnormal and uninterpretable SPLASH echocardiograms obtained, numbers of participants progressing through the cascade of care, interviews with staff and programme costs.Ethics and dissemination Ethical approval has been obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, Darwin (HREC-2022-4479), the Western Australian Aboriginal Health Ethics Committee (HREC-1237) and the Instituto Nasional Saude Publika Timor-Leste Ethics and Technical Committee (03-UEPD/INSP-TL/V/2023). Informed consent is required to be enrolled. Study findings will be disseminated in the communities involved and submitted for publication.Trial registration number NCT06002243.

Breech presentation is a risk factor for poor birth outcomes. Guidance for safest mode of delivery in breech presenting full term pregnancies is available but there is a lack of evidence on the optimal mode of delivery in breech presenting preterm spontaneous births. The aim of this study is to evaluate the causal effect of mode of delivery on extended perinatal death (EPD) in this population using a trial emulation. Randomized experiments are the gold standard for estimating causal effects; however, previous attempts to conduct them in this context has resulted in recruitment challenges. Causal inference methods provide a framework for drawing causal conclusions from observational data. A trial emulation aims to overcome limitations common to observational studies by specifying core components of a randomized trial using observational data. Our trial emulation uses national Scottish health data to identify an eligible study sample and adjust for confounding characteristics between groups undergoing caesarean and vaginal deliveries to simulate randomized assignment of mode of delivery. We were able to estimate the per-protocol impact of caesarean delivery on EPD. Our data, containing all recorded potentially eligible births in Scotland between 1997 and 2019, was provided by eDRIS in a trusted research environment. After applying our eligibility criteria, our data contained 3,457 birth records, (2,361 c-section and 1,096 vaginal deliveries). There were 212 EPDs (1.7% (39) of c-sections and 16% (173) of vaginal deliveries). Our preliminary results suggest that caesarean delivery reduces the odds of EPD by 73% among breech presenting spontaneous preterm births.

Abstract Background Maternal morbidity and mortality related to infection is an international public health concern, but detection and assessment is often difficult as part of routine maternity care in many low- and middle-income countries due to lack of easily accessible diagnostics. Front-line healthcare providers are key for the early identification and management of the unwell woman who may have infection. We sought to investigate the knowledge, attitudes, and perceptions of the use of screening tools to detect infectious maternal morbidity during and after pregnancy as part of routine antenatal and postnatal care. Enabling factors, barriers, and potential management options for the use of early warning scores were explored. Methods Key informant interviews (n = 10) and two focus group discussions (n = 14) were conducted with healthcare providers and managers (total = 24) working in one large tertiary public hospital in Blantyre, Malawi. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. Results Most healthcare providers are aware of the importance of the early detection of infection and would seek to better identify women with infection if resources were available to do so. In current practice, an early warning score was used in the high dependency unit only. Routine screening was not in place in the antenatal or postnatal departments. Barriers to implementing routine screening included lack of trained staff and time, lack of thermometers, and difficulties with the interpretation of the early warning scores. A locally adapted early warning screening tool was considered an enabler to implementing routine screening for infectious morbidity. Local ownership and clinical leadership were considered essential for successful and sustainable implementation for clinical change. Conclusions Although healthcare providers considered infection during and after pregnancy and childbirth a danger sign and significant morbidity, standardised screening for infectious maternal morbidity was not part of routine antenatal or postnatal care. The establishment of such a service requires the availability of free and easy to access rapid diagnostic testing, training in interpretation of results, as well as affordable targeted treatment. The implementation of early warning scores and processes developed in high-income countries need careful consideration and validation when applied to women accessing care in low resource settings.

Plasmodium vivax malaria is a neglected disease, particularly during pregnancy. Severe vivax malaria is associated with inflammatory responses but in pregnancy immune alterations make it uncertain as to what cytokine signatures predominate, and how the type and quantity of blood immune mediators influence delivery outcomes. We measured the plasma concentrations of a set of thirty-one biomarkers, comprising cytokines, chemokines and growth factors, in 987 plasma samples from a cohort of 572 pregnant women from five malaria-endemic tropical countries and related these concentrations to delivery outcomes (birth weight and hemoglobin levels) and malaria infection. Samples were collected at recruitment (first antenatal visit) and at delivery (periphery, cord and placenta). At recruitment, we found that P. vivax-infected pregnant women had higher plasma concentrations of proinflammatory (IL-6, IL-1β, CCL4, CCL2, CXCL10) and TH1-related cytokines (mainly IL-12) than uninfected women. This biomarker signature was essentially lost at delivery and was not associated with birth weight nor hemoglobin levels. Antiinflammatory cytokines (IL-10) were positively associated with infection and poor delivery outcomes. CCL11 was the only biomarker to show a negative association with P. vivax infection and its concentration at recruitment was positively associated with hemoglobin levels at delivery. Birth weight was negatively associated with peripheral IL-4 levels at delivery. Our multi-biomarker multicenter study is the first comprehensive one to characterize the immunological signature of P. vivax infection in pregnancy thus far. In conclusion, data show that while TH1 and pro-inflammatory responses are dominant during P. vivax infection in pregnancy, antiinflammatory cytokines may compensate excessive inflammation avoiding poor delivery outcomes, and skewness toward a TH2 response may trigger worse delivery outcomes. CCL11, a chemokine largely neglected in the field of malaria, emerges as an important marker of exposure or mediator in this condition.

Abstract Background Determining gestational age in resource-poor settings is challenging because of limited availability of ultrasound technology and late first presentation to antenatal clinic. Last menstrual period (LMP), symphysio-pubis fundal height (SFH) and Ballard Score (BS) at delivery are therefore often used. We assessed the accuracy of LMP, SFH, and BS to estimate gestational age at delivery and preterm birth compared to ultrasound (US) using a large dataset derived from a randomized controlled trial in pregnant malaria patients in four African countries. Methods Mean and median gestational age for US, LMP, SFH and BS were calculated for the entire study population and stratified by country. Correlation coefficients were calculated using Pearson’s rho, and Bland Altman plots were used to calculate mean differences in findings with 95% limit of agreements. Sensitivity, specificity, positive predictive value and negative predictive value were calculated considering US as reference method to identify term and preterm babies. Results A total of 1630 women with P. falciparum infection and a gestational age > 24 weeks determined by ultrasound at enrolment were included in the analysis. The mean gestational age at delivery using US was 38.7 weeks (95%CI: 38.6–38.8), by LMP, 38.4 weeks (95%CI: 38.0–38.9), by SFH, 38.3 weeks (95%CI: 38.2–38.5), and by BS 38.0 weeks (95%CI: 37.9–38.1) (p

Abstract Background Plasmodium falciparum in pregnancy results in substantial poor health outcomes for both mother and child, particularly in young, primigravid mothers who are at greatest risk of placental malaria (PM) infection. Complications of PM include maternal anaemia, low birth weight and preterm delivery, which contribute to maternal and infant morbidity and mortality in coastal Papua New Guinea (PNG). Methods Placental biopsies were examined from 1451 pregnant women who were enrolled in a malaria prevention study at 14–26 weeks gestation. Clinical and demographic information were collected at first antenatal clinic visits and women were followed until delivery. Placental biopsies were collected and examined for PM using histology. The presence of infected erythrocytes and/or the malaria pigment in monocytes or fibrin was used to determine the type of placental infection. Results Of 1451 placentas examined, PM infection was detected in 269 (18.5%), of which 54 (3.7%) were acute, 55 (3.8%) chronic, and 160 (11.0%) were past infections. Risk factors for PM included residing in rural areas (adjusted odds ratio (AOR) 3.65, 95% CI 1.76–7.51; p ≤ 0.001), being primigravid (AOR 2.45, 95% CI 1.26–4.77; p = 0.008) and having symptomatic malaria during pregnancy (AOR 2.05, 95% CI 1.16–3.62; p = 0.013). After adjustment for covariates, compared to uninfected women, acute infections (AOR 1.97, 95% CI 0.98–3.95; p = 0.056) were associated with low birth weight babies, whereas chronic infections were associated with preterm delivery (AOR 3.92, 95% CI 1.64–9.38; p = 0.002) and anaemia (AOR 2.22, 95% CI 1.02–4.84; p = 0.045). Conclusions Among pregnant PNG women receiving at least one dose of intermittent preventive treatment in pregnancy and using insecticide-treated bed nets, active PM infections were associated with adverse outcomes. Improved malaria prevention is required to optimize pregnancy outcomes.

Summary: Background: Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes. Methods: In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845. Findings: Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59–84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72–46·72 (median $23·3, 145 brands). Interpretation: Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products. Funding: UK Medical Research Council, Department for International Development, and Wellcome Trust.