Search

Background The burden of maternal and neonatal morbidity and mortality is a global health concern with the highest burden documented after childbirth in women and babies living in sub-Saharan Africa. To date, there is limited information on the quality of postnatal care and/or whether evidence-based interventions to improve postnatal care in a way that meets the specific health needs of each mother and her baby have been lacking. There is also limited data related to how quality of care (respectful or disrespectful) influences women's decision to access postnatal care. Objective To systematically review available qualitative evidence for how quality of care (respectful or disrespectful) influences perceptions and experiences of, and decisions to, access postnatal care for women living in sub-Saharan Africa. Search strategy CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2009—2019. Grey literature was searched on Google Scholar. Selection criteria Qualitative literature in English describing women’s perceptions and experiences of the quality of care they received after childbirth and how this influenced their perceptions of and decisions to access postnatal care. Data analysis Thematic analysis was performed to extract subthemes and themes. Outcomes were themes from the qualitative data used to form a thematic synthesis. Results Fifteen studies were included with data from 985 women interviewed face-to-face across eight countries. Descriptions of respectful care included healthcare providers being kind, supportive and attentive to women’s needs. Women described preferring healthcare services where the healthcare providers communicated in a respectful and caring manner. Descriptions of disrespectful care included verbal and/or physical abuse and power imbalances between women and healthcare providers. Some women were denied postnatal care when attending a healthcare facility after giving birth at home. There is evidence to suggest that vulnerable women (adolescents; women with poor socioeconomic status; women who are HIV positive) are more likely to receive disrespectful care. Conclusions This systematic review describes how aspects of respectful and disrespectful maternity care influence women’s perceptions and experiences of, and decisions to access postnatal care services. There is a need for a renewed focus to prioritise respectful maternity care and to sustainably provide good quality postnatal care to all women and their babies in a way that meets their expectations and health needs.

Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) is a respiratory disease which causes coronavirus and has given rise to the Middle East Respiratory Syndrome (MERS), SARS-CoV in Hong Kong and SARS-CoV-2 (COVID-19). COVID-19, to date, has had the highest morbidity and mortality rates globally, thus reaching the pandemic status. Whilst research has explored the impact of pandemic on general wellbeing, there appears to be a paucity on its association with women’s mental health, with many pregnant women reporting the pandemic negatively impacted their mental health. This study aims to explore the prevalence of the impact of the COVID-19, MERS and SARS pandemics on the mental health of pregnant women. A study protocol was developed and published in PROSPERO (CRD42021235356) to explore several key objectives. A literature search was carried out and identified 316 studies. A meta-analysis was conducted to report the findings. There were no studies reporting the mental health impact due to MERS and SARS. Results showed that women who were pregnant or had just given birth displayed various symptoms of poor mental health including those relating to depression (24.9%), anxiety (32.8%), stress (29.44%), Post Traumatic Stress Disorder (PTSD) (27.93%), and sleep disorders (24.38%) during the COVID-19 pandemic. The importance of managing mental health during pregnancy and after-delivery improves the quality of life and wellbeing of mothers hence developing an evidence-based approached as part of pandemic preparedness would improve mental health during challenging times.

Background Many women seeking asylum during pregnancy and after childbirth experience significant ill-health, but detection and assessment is often difficult as part of routine maternity care. Healthcare providers are key for the early identification and management of vulnerable pregnant women who have additional psychological and social health needs. We sought to explore the experiences and health needs of women seeking asylum during pregnancy and after childbirth in Liverpool, United Kingdom. Enabling factors and barriers to access women-centred care were also explored.Methods Key informant interviews (n=10) and one focus group discussion (n=4) were conducted with women attending a pregnancy support group. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. ResultsWomen seeking asylum understand wellbeing during and after pregnancy is multifactorial and that physical health is interlinked with psychological and social factors. Many women reported that their expectations of maternity services were exceeded, but information giving, and the use of language interpreters needed to be improved. Women explained that they need more comprehensive and timely psychological and social support. The asylum-seeking process itself resulted in women feeling anxious and/or depressed with little control or choice over their future. Women were stressed regarding poor standard of accommodation, low income, dispersal and the uncertainty of their asylum application outcome.ConclusionsA multidisciplinary framework and team support, with effective referral pathways to collaborate with maternal mental health and social services, are necessary as part of routine maternity care to ensure a more comprehensive and holistic approach that addresses the needs of asylum-seeking women.

Key to bringing psychological science to bear on public policy is developing scholars' engagement and rapport with policymakers. Scholars benefit from support navigating the policy arena in ways that strengthen their independent policy engagement. This study presents findings from a randomized controlled trial of the Research-to-Policy Collaboration (RPC) model, which develops and trains a rapid response network of researchers to respond to legislative requests for scientific evidence. Researchers were surveyed on their concerns about how policymakers support or use scientific research, how they engaged with policymakers, and perceived benefits to their research. Researchers randomized to the RPC reported fewer concerns about policymakers' support and use of research, greater involvement in supporting policymakers' understanding of problems (i.e., conceptual use), and more responses to external prompts for their involvement. Subgroup analyses examined how experiences differed for those identifying as Black, Indigenous, or Person of Color (BIPOC). At baseline, BIPOC-identifying researchers perceived greater costs of policy engagement and reported less involvement in supporting conceptual or instrumental uses of research than White-identifying researchers. Subsequent to the RPC, BIPOC-identifying researchers in the intervention group were reportedly less concerned about federal support of science, more engaged in supporting conceptual uses of research, and perceived greater benefits of policy engagement for their research than BIPOC-identifying researchers in the control group. These differences were not observed among White-identifying researchers. Findings are discussed in light of disparities experienced by marginalized scholars, the ways in which resources and supports may counteract these challenges, and possible strategies to strengthen public psychology overall. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Core to the goal of scientific exploration is the opportunity to guide future decision-making. Yet, elected officials often miss opportunities to use science in their policymaking. This work reports on an experiment with the US Congress—evaluating the effects of a randomized, dual-population (i.e., researchers and congressional offices) outreach model for supporting legislative use of research evidence regarding child and family policy issues. In this experiment, we found that congressional offices randomized to the intervention reported greater value of research for understanding issues than the control group following implementation. More research use was also observed in legislation introduced by the intervention group. Further, we found that researchers randomized to the intervention advanced their own policy knowledge and engagement as well as reported benefits for their research following implementation.

Monogenic diabetes describes a long list of relatively rare causes of diabetes with a genetic basis caused by highly penetrant mutations or alterations at any one gene or locus. There are many important reasons to distinguish such causes from the more common polygenic disorders type 1 and type 2 diabetes, which are much more dependent upon environmental factors. The two main categories of monogenic diabetes are (1) neonatal diabetes, both permanent and transient, which is distinguishable by the very unusual early age of onset of diabetes in infants, and (2) maturity-onset diabetes of the young (MODY), which is characterized by onset of diabetes in adolescence or young adulthood, often with a strong family history, suggestive of an autosomal dominant pattern of inheritance, and usually with a mild disease severity, although it can be progressive. Despite continued barriers in obtaining clinical genetic testing, this remains the only means of diagnosing monogenic diabetes, which is essential for guiding clinical treatment and management decisions tailored to each genetic disorder, potentially having a profound impact on outcome and quality of life. In this chapter, we review the main causes of both neonatal diabetes and MODY, highlighting important aspects of diagnosis, management of diabetes and associated features, and long-term outcome.

Complications during pregnancy and childbirth are a leading cause of death, disability and ill-health among women of reproductive age. To achieve further global reductions in maternal mortality and improved maternal health, a more comprehensive and sustainable approach is needed that addresses the continuum of maternity care and provides holistic quality of care in ways that meet women’s health needs. To sustainably improve maternity care, there is a need to identify bottlenecks to assess the status of antenatal and postnatal care; assess maternal morbidity during and after childbirth; conduct quality improvement processes at the healthcare facility level; and emphasize a health systems approach. And there is a need for high-quality implementation research to assess “what works where and how” especially in different settings across LMICs. More evidence is needed to demonstrate how to generate replicable and scale-up sustainable intervention packages and solutions to increase their availability and improve the quality of care for mothers and babies globally. Sharing lessons learned across and between settings and with stakeholders at national and international levels should be used to proactively inform policy and practice to ensure that maternity care is safe, effective, woman-centred, timely, efficient and equitable.

ObjectivesThe study sought to explore the knowledge, attitudes and perceptions of healthcare providers and health programme managers regarding the benefits, challenges and impact of international medical volunteers’ clinical placements. Views on how to better improve the work of international medical volunteers and the volunteer organisation Voluntary Service Overseas (VSO) for the benefit of local communities were also explored.SettingsPublic healthcare facilities, VSO offices in Gulu and VSO offices in Kampala, Uganda.ParticipantsUgandan healthcare providers (n=11) and health programme managers (n=6) who had worked with or managed international medical volunteers.InterventionsData collection was conducted using key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis using NVivo identified emerging themes.ResultsBoth healthcare providers and managers reported a beneficial impact of volunteers and working with the volunteer organisation (clinical service provision, multidisciplinary teamwork, patient-centred care, implementation of audits, improved quality of care, clinical teaching and mentoring for local healthcare providers); identified challenges of working with volunteers (language barriers and unrealistic expectations) and the organisation (lack of clear communication and feedback processes); and provided recommendations to improve volunteer placements and working partnership with the organisation (more local stakeholder input and longer placements). Most healthcare providers were positive and recommended that volunteers are enabled to continue to work in such settings if resources are available to do so.ConclusionsHealthcare providers based in a low-resource setting report positive experiences and impacts of working with international medical volunteers. Currently, there is lack of local feedback processes, and the establishment of such processes that consider local stakeholder reflections requires further strengthening. These would help gain a better understanding of what is needed to ensure optimal effectiveness and sustainable impact of international medical volunteer placements.

The sustainable development goals aim to improve health and well-being for all. Our study sought to evaluate factors associated with ill-health in women during and after pregnancy. A population-based longitudinal study of women who delivered a singleton live-born baby in a 3-month period across Jamaica was conducted. Socio-demographic factors, perception of health, chronic illnesses and frequency and reasons for hospital admission were assessed during pregnancy; within 24-48 hours after birth; up to 12 months and up to 22 months after childbirth. This study presents data for women participating in all four assessments. Relationships between ill-health and maternal characteristics were estimated using log-normal regression analysis. Of 9,742 women interviewed at birth, 1,311 were assessed at all four stages, 27.7% of whom reported ill-health at least once. Hospitalization rates were 20.9% during pregnancy, 6.1% up to 12 months and 0.5% up to 22 months after childbirth. Complications related to pregnancy accounted for 69.3% of antenatal admissions. Ill-health, reported by 11% of women, was less likely with better education (RR=0.62, 95%; 0.42-0.84). Hospital admission was associated with a higher socio-economic status (RR=1.33, 95% 1.04-1.70) and delivery by Caesarean section [CS] (RR=1.57, 95%; 1.21-2.04). One in three (33.7%) women recorded ongoing chronic illnesses after childbirth. These were more likely with an increase in age and parity and was associated with delivery by elective CS (RR=1.44, 95%; 1.20-1.73). In multivariable analyses, ill-health was more likely with chronic illness (RR=2.06, 95%; CI: 1.71-2.48) and hospital admission from 12 to 22 months after childbirth (RR=1.54, 95% CI: 1.12-2.12). Ill-health during pregnancy and after childbirth represent a significant burden of disease. A standardised comprehensive approach to measuring and addressing this disease burden will ensure that women and their babies survive and thrive during and after pregnancy. \ud Keywords: indicators, maternal morbidity, pregnancy, postnatal, assessment.\ud Short Title: Maternal morbidity during pregnancy and up to 22 months after birth.\ud \ud Ethical approval: Ethical approval was granted by the University of the West Indies Ethics Committee (Mona) and the Ministry of Health's Advisory Panel on Medico - Legal Affairs, Kingston, Jamaica.\ud \ud Funding received: The JA Kids study was funded by a grant to the University of the West Indies from the Inter-American Development Bank (IDB) (Project number ATN/JF-12312-JA). Secondary data analysis at the Centre for Maternal and Newborn health in the UK was funded through a Global Health Grant (Project number OPP1033805) from the Bill and Melinda Gates Foundation and World Health Organization (WHO).

Introduction: Maturity onset diabetes of the young (MODY) may represent 2-5% of diabetes under 30-35 years. Rarely MODY may be due to mutation in the INS gene. HNF1A mutations are well described causes of MODY and may be treated with low dose sulfonylurea. Our aim was to compare clinical features and treatment of INS-MODY with HNF1A-MODY cohort population. Methods: Participants enrolled through the U.S. Monogenic Diabetes Registry, with Sanger or next-generation sequencing completed with causal mutations found in INS or HNF1A, diagnosed after 13 months of age. Those with neonatal diabetes due to INS were excluded. Results: Each group shared similar demographics (Table 1). Common presenting symptoms in each group included polyuria, polydipsia, weight loss, fatigue (Table 1). In the INS cohort, all showed residual c-peptide. None reported DKA. The majority had used insulin, though there were a variety of treatment modalities, even among those with the same mutation (Figure 1). For HNF1A cohort, over 60% had been on insulin or sulfonylurea, with 40% having discontinued insulin. Conclusion: Review of treatments in INS cohort consist of multiple agents with majority using insulin at some point. If clinical suspicion of MODY, genetic testing may help inform treatment. It appears that some variants of INS-MODY lead to a progressive disease eventually requiring insulin therapy and early insulin may improve outcomes. Disclosure M. McCauley: None. S. Korkmaz: None. L.R. Letourneau-Freiberg: None. R.N. Naylor: None. S.W. Greeley: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK104942, P30DK0205950); National Center for Advancing Translational Sciences (UL1TR002389)

Background: Infancy-onset diabetes is largely monogenic before 6 months of age, whereas autoimmune type 1 diabetes is more likely from 6-12 months of age. As the most common neonatal diabetes, patients with KATP channel mutations exhibit a spectrum of neurodevelopmental disability that is largely related to brain expression of mutated channels. It is not known how glycemic dysregulation of any type of early-onset diabetes may affect brain development. Methods: Subjects included from UChicago Monogenic Diabetes Registry with diabetes diagnosed under a year of age currently aged 4-20 years and unaffected sibling controls. Known KATP channel mutations or other rare causes affecting brain development were excluded. Measures of intellectual function (IF), executive function (EF), visual motor integration (VMI) and academic achievement (AA) were utilized (Table 1). A two-sample t-test was conducted comparing each group assuming unequal variance. Results: Comprehensive testing was completed for those with infancy-onset diabetes and siblings (Table 1). There were no significant differences on any measure, though mean scores trended lower in the affected group. Conclusion: Our findings show no difference in IF, EF, VMI, AA in children diagnosed with diabetes in infancy compared to their unaffected siblings. Our conclusions are limited due to a small sample size; differences may be subtle and require a larger sample size to be identified. Disclosure M. McCauley: None. A.M. Denson: None. L.R. Letourneau-Freiberg: None. M.N. Scott: None. S.W. Greeley: None. Funding American Diabetes Association (1-17-JDF-008 to S.A.W.G.); National Institute of Diabetes and Digestive and Kidney Diseases (R01DK104942, P30DK0205950); National Center for Advancing Translational Sciences (UL1TR002389)

Despite more than 40 y of discussion and debate regarding female genital mutilation/cutting (FGM/C), this topic remains controversial and emotive, and the practice continues. FGM/C is defined as ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons’.1 There are four main classifications of FGM/C (Table 1).1 Type III, or ‘infibulation’, is the most severe form and accounts for 10% of cases.2 It is estimated that more than 200 million girls and women worldwide are living with the effects of FGM/C.2 Of these, 44 million are

Many skilled medical professionals from high-income countries volunteer to work in poor-resource settings. There is, however, little research to assess the views and experiences of such healthcare providers. Our study sought to explore this among Voluntary Service Overseas volunteers working in Ethiopia for one year. An online survey was distributed to all returned international medical volunteers one year after their return to their base country. Most felt that they had impacted the local community in which they worked and reported a positive experience, recommending this to friends or family, but there was a small subgroup whose experience was otherwise. We believe there is a need for more comprehensive, systematic and robust monitoring in order to evaluate the outcomes of medical volunteers’ placements.

The Royal College of Obstetricians and Gynaecologists (RCOG) has a long history of advocacy for women’s health, nationally and internationally. There is a demand and interest in global women’s health among a sample of junior doctors training in obstetrics and gynaecology in the UK. There is ongoing debate regarding whether this desire should be nurtured, opportunities created and barriers addressed, both in the interest of training and as a means of addressing global health inequity. Global health work needs to be a mutually beneficial partnership for all involved, with work carried out sensitively and sustainably.

BackgroundFor every maternal death, it is estimated that 20 or 30 women have morbidity related to pregnancy or childbirth. The majority of this burden of disease is in women living in low and middle income countries. Maternal morbidity includes physical, psychological and social ill-health. There is limited data on the strength of association between these co-morbidities. In order to address all health needs that a woman may have when attending for maternity care, it is important to be able to identify all types of co-morbidities and understand how each co-morbidity influences other aspects of a woman’s health and wellbeing during and after pregnancy.MethodsWe systematically reviewed published literature, in English, describing measurement of two or more types of maternal morbidity, and/or associations between co-morbidities, during or after pregnancy and childbirth for women living in low- and middle-income countries. CINAHL plus, Global Health, Medline and Web of Science databases were searched from 2007-2018. Outcomes were descriptions, occurrence of maternal co-morbidities, and associations between these co-morbidities. Narrative analysis was conducted.Results38 papers reporting on 36 studies were included (71,229 women; 60,911 during and 10,318 after pregnancy from 17 countries). The majority of studies (26/36) were cross-sectional surveys. Self-reported physical ill-health was documented in 26 studies but there was no standardised data collection tool used. In total, physical morbidity was included in 28 studies; psychological morbidity in 32 studies and social morbidity in 27 studies; with 3 studies assessing association between all three types of morbidity and 30 studies assessing association between two types of morbidity. In four studies, clinical examination and/or basic laboratory investigations were also conducted. There is reported association between physical and psychological morbidity (four studies); and association between psychological and social morbidity (six studies). Domestic violence increases risk of physical ill-health (two studies).ConclusionsThere is a lack of standardised, comprehensive and routine measurements and tools used to assess the burden maternal morbidity and co-morbidity in women during and after pregnancy. There is emerging data to suggest strong associations between the different types of morbidity.

Background For every maternal death, 20 to 30 women are estimated to have morbidities related to pregnancy or childbirth. Much of this burden of disease is in women in low- and middle-income countries. Maternal multimorbidity can include physical, psychological and social ill-health. Limited data exist about the associations between these morbidities. In order to address all health needs that women may have when attending for maternity care, it is important to be able to identify all types of morbidities and understand how each morbidity influences other aspects of women’s health and wellbeing during pregnancy and after childbirth. Methods We systematically reviewed published literature in English, describing measurement of two or more types of maternal morbidity and/or associations between morbidities during pregnancy or after childbirth for women in low- and middle-income countries. CINAHL plus, Global Health, Medline and Web of Science databases were searched from 2007 to 2018. Outcomes were descriptions, occurrence of all maternal morbidities and associations between these morbidities. Narrative analysis was conducted. Results Included were 38 papers reporting about 36 studies (71,229 women; 60,911 during pregnancy and 10,318 after childbirth in 17 countries). Most studies (26/36) were cross-sectional surveys. Self-reported physical ill-health was documented in 26 studies, but no standardised data collection tools were used. In total, physical morbidities were included in 28 studies, psychological morbidities in 32 studies and social morbidities in 27 studies with three studies assessing associations between all three types of morbidity and 30 studies assessing associations between two types of morbidity. In four studies, clinical examination and/or basic laboratory investigations were also conducted. Associations between physical and psychological morbidities were reported in four studies and between psychological and social morbidities in six. Domestic violence increased risks of physical ill-health in two studies. Conclusions There is a lack of standardised, comprehensive and routine measurements and tools to assess the burden of maternal multimorbidity in women during pregnancy and after childbirth. Emerging data suggest significant associations between the different types of morbidity. Systematic review registration number PROSPERO CRD42018079526.

Objective The National Family Health Survey‐4 in India provided the first nationally representative estimates of hysterectomy among women aged 15–49. This paper aims to examine the national and state‐level age‐specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state‐level indicators that may explain variation across states. Design Cross‐sectional, nationally representative household survey. Setting National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016. Population The survey covered 699 686 women between the ages of 15 and 49 years. Methods Descriptive analyses and multivariate logistic regression. Main outcome measures Women who reported ever having a hysterectomy and age at hysterectomy. Results Age‐specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15‐29; 3.59% (3.45,3.74) among women aged 30‐39; and 9.20% (8.94,9.46) among women 40‐49 years. There was considerable variation in prevalence by state. Four states reported age‐specific prevalence similar to high‐income settings. Approximately two‐thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P, Tweetable abstract Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.

Background: The majority of diabetes occurring under 6 months of age is generally thought to be due to a monogenic cause. In neonatal diabetes occurring beyond 6 months, the frequency of autoimmune diabetes increases dramatically. While during this time autoimmune diabetes is more likely, there appears to be continued incidence of monogenic diabetes occurring though the first year of life. For ABCC8, KCNJ11 and INS mutations, though the majority of cases occur prior to 6 months of age, cases have been reported past 6 months of age through 12 months of age and beyond; as such, testing through 13 months can provide valuable information to physicians and families. Methods: Participants were enrolled in the University of Chicago Monogenic Diabetes Registry. Genetic testing was performed for participants without a known monogenic form of diabetes, including either 1) Sanger sequencing for KCNJ11, ABCC8, and INS or 2) next-generation sequencing panel covering all known forms of neonatal diabetes. Data were stored using REDCap. Results: One hundred ninety participants who were diagnosed between 6-13 months of age were identified. Of these, 118 have had extensive genetic testing completed and thus will be the focus of this abstract. Fifty participants were diagnosed between 6-8.9 months (mean age 7.3 months, 54% male, 72% Caucasian) and 68 cases between 9-13 months (mean age 10.78 months, 72% male, 81% Caucasian). Of 50 patients enrolled in the registry between age 6-8.9 months, 44% were found to have a monogenic cause (n =22). INS mutations were the most common cause (n=8, 36%), followed by KCNJ11 (n=5, 23%), ABCC8 (n=4, 18%), FOXP3 (n=3, 14%), and GATA4 (n=2, 9%). Of this group, 16 patients had reported antibody testing, with 4 (25%) having positive antibodies. T1D risk scores were below the 50th percentile for 49% of those tested. For 68 patients diagnosed between 9-13 months, 18% had a monogenic cause (n = 12). INS mutations were the most common cause (n=5, 42%), followed by GCK (n=4, 33%), ABCC8 (n=1, 8%), KCNJ11 (n=1, 8%), and HNF4A (n=1, 8%). Antibody testing was reported in 9 participants, of whom 3 were positive (33%). Conclusion: Though most neonatal diabetes above 6 months of age can be attributed to autoimmune diabetes, monogenic diabetes continues to occur. In examining our cohort of patients diagnosed with diabetes between 6-13 months, a substantial number have a genetic cause of diabetes (6-8.9 months 44%, 9-13 months 18%). Though more data is needed, genetic testing beyond 6 months through age 13 months continues to provide valuable clinical information.

Maternal morbidity describes complications that have a significant effect on women during and after pregnancy, and are a leading cause of ill-health among women of reproductive age, especially in low- and middle-income countries. With the introduction of the new Sustainable Development Goals, the scope of global maternal health targets has been expanded, moving from a focus on preventing maternal mortality to formulating targets and emphasising the importance of maternal health and wellbeing. This chapter introduces the new concept of maternal morbidity, suggests how this relates to maternal mortality, and summarises what is known about the burden of maternal morbidity globally and what interventions and research are needed to improve maternal health during and after pregnancy, with an emphasis on the context of low- and middle-income countries.

Background Maternal mental health is an international public health concern. Many women experience mental ill-health during and after pregnancy, but assessment is not part of routine maternity care in many low- and middle-income countries. Healthcare providers are in a position to identify and support women who experience mental health disorders during and after pregnancy. We sought to investigate the knowledge, attitudes and perceptions of routine screening for maternal mental health during and after pregnancy among healthcare providers providing routine maternity care in Accra, Ghana. Enabling factors, barriers and potential management options to routinely screen maternal mental health during and after pregnancy were explored. Methods Semi-structured key informant interviews (n = 20) and one focus group discussion (n = 4) were conducted with healthcare providers working in one public hospital in Accra, Ghana. 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 maternal mental health and would be keen to help women who experience mental ill-health during and after pregnancy, if resources were available to do so. An enabling factor was the suggestion of introducing a culturally appropriate mental health screening tool. However, compromised mental health was often considered a ‘spiritual issue’ and not routinely screened for by healthcare providers, nor requested by women. Barriers to the provision of quality maternal mental health care included lack of trained staff and lack of time. Conclusions Healthcare providers are aware of the problem of the lack of maternal mental health provision during and after pregnancy and are open to developing protocols to improve care. Currently, screening for maternal mental ill-health is not part of routine maternity care. The establishment of such a service requires the reprioritisation of workloads, further training, and a change in the attitudes and practices of healthcare providers. Education to change the attitudes of healthcare providers, women and the wider community towards mental health is needed. The development and implementation of culturally appropriate guidelines would be beneficial and result in better quality of maternity care.

Against a background of an increasing demand for surgical intervention for the treatment of FGM/C related complications Berg et al Note for typesetter: Please update reference when assigned to an issue. have conducted a systematic review of 62 studies involving 5829 women to assess the effectiveness of defibulation excision of cysts and clitoral reconstructive surgery. Berg et al report that defibulation showed a lower risk of Caesarean section and perineal tears; excision of cysts commonly resulted in resolution of symptoms; and clitoral reconstruction resulted in most women self-reporting improvements in their sexual health. However Berg et al highlight that they had little confidence in the effect estimate for all outcomes as most of the studies were observational and conclude that there is currently poor quality of evidence on the benefits and/or harm of surgical interventions to be able to counsel women appropriately. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Background Violence against women is an international public health concern and a violation of women’s rights. Domestic violence can first occur, and increase in frequency and severity, during and after pregnancy. Healthcare providers have the potential to identify and support women who experience domestic violence. We sought to investigate the knowledge and perceptions of domestic violence among doctors who provide routine antenatal and postnatal care at healthcare facilities in Pakistan. In addition, we explored possible management options from policy makers, and enabling factors of and barriers to the routine screening of domestic violence. Methods Semi-structured key informant interviews were conducted with doctors (n = 25) working in public and private hospitals and with officials involved in domestic violence policy development (n = 5) in Islamabad, Pakistan. Transcribed interviews were coded and codes grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. Results Most doctors have a good awareness of domestic violence and a desire to help women who report domestic violence during and after pregnancy. Enabling factors included doctors’ ability to build rapport and trust with women and their suggestion that further education of both healthcare providers and women would be beneficial. However, domestic violence is often perceived as a “family issue” that is not routinely discussed by healthcare providers. Lack of resources, lack of consultation time and lack of effective referral pathways or support were identified as the main barriers to the provision of quality care. Conclusions Doctors and policy advisors are aware of the problem and open to screening for domestic violence during and after pregnancy. It is suggested that the provision of a speciality trained family liaison officer or healthcare provider would be beneficial. Clear referral pathways need to be established to provide quality care for these vulnerable women in Pakistan.

Against the background of a renewed global focus on improving women's health and well-being during and after pregnancy, Kopp et al have assessed 290 women at least one year after primary surgical repair for obstetric fistula in Malawi. Following surgery 19.3% of women reported urinary incontinence and 3.5% depressive symptoms. Women who had more severe types of fistula reported poorer quality of life after surgery.

Background To explore healthcare providers’ knowledge and attitudes to the need for pain relief for women in labor. Methods A structured questionnaire (n = 200) distributed to healthcare providers working in the obstetric departments, including theatres, of three public hospitals in different settings (rural, peri-urban and urban) in Ethiopia. Descriptive analysis was performed using Excel 2013 and SPSS version 22 for associations. Results The response rate was 81.5% with 164 questionnaires completed. The majority, 79% of respondents, understood that women can feel moderate to severe pain in labor and 77% were of the opinion that labor pain should be relieved. However, common practices included only supportive measures such as breathing and relaxation exercises, back massage and support from family. The general attitude of healthcare providers is that labor is a natural process, women should be able to cope and that pain relief is not a priority for women in labor. More than half, 52% of healthcare providers had safety concerns with using pharmacological methods to relieve pain in labor. Conclusion The majority of healthcare providers understand that women suffer significant pain during labor. However, providing effective pain relief is currently not provided as part of routine intra-partum care in Ethiopia. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1237-4) contains supplementary material, which is available to authorized users.

IntroductionFor every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity.MethodsDescriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis.Results11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries.ConclusionWomen suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

CpG oligodeoxynucleotides (CpG-ODNs) affect innate and adaptive immune responses, including antigen presentation, costimulatory molecule expression, dendritic cell maturation, and induction of cytokines enhancing antibody-dependent cell-mediated cytotoxicity (ADCC). We conducted a phase 1 study evaluating 4 dose levels of a CpG-ODN (1018 ISS) with rituximab in 20 patients with relapsed non-Hodgkin lymphoma (NHL). Patients received CpG once a week for 4 weeks beginning after the second of 4 rituximab infusions. Adverse events were minimal. Quantitative polymerase chain reaction (PCR) measurements of a panel of genes inducible by CpG-ODN and interferons were performed on blood samples collected before and 24 hours after CpG. A dose-related increase was measured in the expression of several interferon–inducible genes after CpG and correlated with serum levels of 2′-5′ oligoadenylate synthetase (OAS), a validated interferon response marker. Genes induced selectively by interferon-γ (IFN-γ) were not significantly induced by CpG. In conclusion, we have defined a set of gene expression markers that provide a sensitive measure of biologic responses of patients to CpG therapy in a dose-related manner. Moreover, all the genes significantly induced by this CpG are regulated by type 1 interferons, providing insight into the dominant immune mechanisms in humans. CpG treatment resulted in no significant toxicity, providing rationale for further testing of this exciting combination immunotherapy approach to NHL.

Ten ischemic cardiac events (ICEs) were reported among 37,901 initial US Department of Health and Human Services (DHHS) smallpox vaccinees. Symptoms developed a median of 10 days after vaccination (range, 0-28 days). The median age of case patients was 56 years (range, 42-65 years), and 60% were male. Seven (70%) of the case patients had >/=3 cardiac risk factors or probable coronary artery disease before vaccination. Two women, 55 and 57 years of age, experienced acute myocardial infarction and fatal cardiac arrests. Background rates of ICEs during a 3-week period for civilian populations that were age and sex matched to DHHS vaccinees were estimated. The observed number of myocardial infarctions exceeded estimated expectations (5 vs. 2) but remained within the 95% predictive interval (PI) (0.6-5.4). New onset angina was observed significantly less frequently than estimated expectations (1 vs. 10; 95% PI, 3.5-15.7). After persons with >/=3 cardiac risk factors or known heart disease were deferred from vaccination, no ICEs were reported among an additional 6638 vaccinees.

CDC and the U.S. Food and Drug Administration rely on state and local health departments, health-care providers, and the public to report the occurrence of adverse events after vaccination to the Vaccine Adverse Event Reporting System. With such data, trends can be accurately monitored, unusual occurrences of adverse events can be detected, and the safety of vaccination intervention activities can be evaluated. On January 24, 2003, the U.S. Department of Health and Human Services (DHHS) implemented a preparedness program in which smallpox (vaccinia) vaccine was administered to federal, state, and local volunteers who might be first responders during a biologic terrorism event. As part of the DHHS Smallpox Preparedness and Response Program, CDC in consultation with experts, established surveillance case definitions for adverse events after smallpox vaccination. Adverse reactions after smallpox vaccination identified during the 1960s surveillance activities were classified on the basis of clinical description and included eczema vaccinatum; fetal vaccinia; generalized vaccinia; accidental autoinoculation, nonocular; ocular vaccinia; progressive vaccinia; erythema multiforme major; postvaccinial encephalitis or encephalomyelitis; and pyogenic infection of the vaccination site. This report provides uniform criteria used for the surveillance case definition and classification for these previously recognized adverse reactions used during the DHHS Smallpox Preparedness and Response Program. Inadvertent inoculation was changed to more precisely describe this event as inadvertent autoinoculation and contact transmission, nonocular and ocular vaccinia. Pyogenic infection also was renamed superinfection of the vaccination site or regional lymph nodes. Finally, case definitions were developed for a new cardiac adverse reaction (myo/pericarditis) and for a cardiac adverse event (dilated cardiomyopathy) and are included in this report. The smallpox vaccine surveillance case definitions presented in the report can be used in future vaccination programs to ensure uniform reporting guidelines and case classification.

BACKGROUND Gemcitabine is an effective treatment for recurrent Hodgkin disease (HD), with relatively minimal associated toxicity. The authors conducted a trial substituting this drug for dacarbazine in the standard regimen to form ABVG (doxorubicin, bleomycin, vinblastine, gemcitabine) for patients with newly diagnosed, high-risk HD. METHODS Twelve patients (median age, 34 years) with advanced-stage de novo HD were enrolled. Standard doses of doxorubicin, bleomycin, and vinblastine were given for six cycles. Cohorts of three patients were enrolled and the dose of gemcitabine was escalated to identify the maximally tolerated dose in this combination. RESULTS The maximally tolerated dose of gemcitabine was determined to be 800 mg/m2 in this combination. Five patients developed clinically significant pulmonary toxicity. Three required hospitalization during the final two cycles of treatment. Pneumonitis could not be predicted with serial diffusion capacity for carbon monoxide (DECO) evaluations, and reversed after discontinuation of bleomycin in three patients and steroid therapy in two patients. All 12 patients are alive to date, and 4 patients have experienced disease progression. CONCLUSIONS The bleomycin/gemcitabine combination should not be pursued for de novo HD due to significant pulmonary toxicity. Cancer 2003;98:978–82. © 2003 American Cancer Society. DOI 10.1002/cncr.11582