Sexual and reproductive health and rights of migrant women attending primary care in England: A population-based cohort study of 1.2 million individuals of reproductive age (2009-2018)

Background

Evidence on the sexual and reproductive health and rights (SRHR) of migrants is lacking globally. We describe SRHR healthcare resource use and long-acting reversible contraceptives (LARCs) prescriptions for migrant versus non-migrant women attending primary care in England (2009-2018).

Methods

This population-based observational cohort study, using Clinical Practice Research Datalink (CPRD) GOLD, included females living in England aged 15 to 49. Migration was defined using a validated codelist. Rates per 100 person years at risk (pyar) and adjusted rate ratios (RRs) were measured in migrants versus non-migrants for consultations related to all-causes, six exemplar SRHR outcomes, and LARC prescriptions. Proportions of migrants and non-migrants ever prescribed LARC were calculated.

Findings

There were 25,112,116 consultations across 1,246,353 eligible individuals. 98,214 (7.9 %) individuals were migrants. All-cause consultation rates were lower in migrants versus non-migrants (509 vs 583/100pyar;RR 0.9;95 %CI 0.9-0.9), as were consultations rates for emergency contraception (RR 0.7;95 %CI 0.7-0.7) and cervical screening (RR 0.96;95 %CI 0.95-0.97). Higher rates of consultations were found in migrants for abortion (RR 1.2;95 %CI 1.1-1.2) and management of fertility problems (RR 1.39;95 %CI 1.08-1.79). No significant difference was observed for chlamydia testing and domestic violence. Of 1,205,258 individuals eligible for contraception, the proportion of non-migrants ever prescribed LARC (12.2 %;135,047/1,107,894) was almost double that of migrants (6.91 %;6,728/97,364). Higher copper intrauterine devices prescription rates were found in migrants (RR 1.53;95 %CI 1.45-1.61), whilst hormonal LARC rates were lower for migrants: levonorgestrel intrauterine device (RR 0.63;95 %CI 0.60-0.66), subdermal implant (RR 0.72;95 %CI 0.69-0.75), and progesterone-only injection (RR 0.35;95 %CI 0.34-0.36).

Interpretation

Healthcare resource use differs between migrant and non-migrant women of reproductive age. Opportunities identified for tailored interventions include access to primary care, LARCs, emergency contraception and cervical screening. An inclusive approach to examining health needs is essential to actualise sexual and reproductive health as a human right.

Reproductive outcomes among female health care workers

OBJECTIVE

Occupational exposures may be associated with reproductive health and pregnancy outcomes. This study investigated the association between occupational exposures and reproductive health, pregnancy outcomes, and the lactation period among hospital staff.

MATERIALS AND METHODS

Seven hundred thirty-three female healthcare workers from hospitals affiliated with the Tehran University of Medical Sciences were invited to participate in this cross-sectional study. The measurement method for fertility consequences was self-report. Demographic characteristics, occupational data, medical history, and reproductive history were collected via data collection form. Finally, reproductive outcomes were evaluated in different occupational hazard categories.

RESULT

Chemical exposures (solvents) were a risk factor for stillbirth. Prolonged working hours were associated with spontaneous abortion and breastfeeding periods. Shift workers did not have a higher frequency of reproductive and pregnancy outcomes, but the breastfeeding period was significantly decreased in shift workers. Psychiatric disorders were associated with preterm labour, low birth weight, and stillbirth in sequence with nervousness, depression, and mood disturbance. Furthermore, depression affects the breastfeeding period. Moreover, we found a link between job titles and infertility. In addition, socioeconomic status was related to stillbirth and infertility.

CONCLUSION

The study revealed that chemical and ergonomic exposures have associations with some reproductive outcomes. We also conclude that shift work could adversely affect the breastfeeding period. So, implementing some organizational strategies to control adverse health effects of occupational hazards and modifying shift work and working hours for nursing mothers is recommended.

Knowledge and practice of family planning among pregnant tribal women in Southern India: an observational study

BACKGROUND

There are over 700 Scheduled Tribes (ST) living in 30 Indian states. As with other indigenous groups across the world, Indian ST have some of the poorest infant and child health outcomes of any communities in India. A child born to an ST family is 19% more likely to die in the first month of life and has a 45 percent risk of dying in their first year compared with other Indian populations. Research suggests that early conception, high fertility, and low use of family planning methods are large contributors to these disparities.

METHODS

A cross sectional survey in Kannada was conducted among 303 pregnant tribal women in Mysore, India after obtaining informed consent. Univariate and multivariable analyses were carried out to determine the demographic and psychosocial factors associated with knowledge of contraceptive methods using Stata 14.0.

RESULTS

There was widespread knowledge about female sterilization, while only 39.3% of women reported hearing about one or more forms of temporary contraception, and 36.3% knew where to get them. The largest proportion of women had heard about copper-T (33.0%), followed by oral contraceptive pills (23.8%), condoms (11.9%), and injectables (4.6%). Only 2.7% of women reported ever using any form of temporary contraception. Results from the multivariable logistic regression indicated that knowledge of at least one form of temporary contraception was linked to higher age (adjusted odds ratio[AOR]: 1.09; 95% CI: 1.02, 1.17), greater number of years of marriage (AOR: 0.90; 95% CI: 0.85, 0.96), and last birth in a government facility (AOR: 3.67; 95% CI: 1.99, 6.82).

CONCLUSIONS

The study revealed poor knowledge and utilization of temporary contraceptive methods among a tribal population in rural Mysore, India. Interventions aiming to increase knowledge of contraceptive options are important for birth spacing in this population and should target younger women and those without contact with government health facilities.

Education and reproductive health: evidence from schooling expansion in Turkey

We investigate the role of additional years of schooling mandated by a compulsory schooling expansion law in affecting reproductive preferences and safe reproductive health behaviors in Turkey-a middle-to-high-income country with gender inequity in education but overall high levels of safe reproductive health practices at the time of passing the law. Using a fuzzy regression discontinuity design, we find that the additional schooling improved several health behaviors. However, the effects on some outcomes commonly analyzed in the existing literature, such as contraceptive use or fertility, were either weak or insignificant. Overall, our findings complement the current literature on the marginal health benefits of schooling expansion and suggest that policymakers consider the institutional and cultural factors while evaluating the scope and potential non-educational benefits of such expansions.

Correlation between microbial characteristics and reproductive status of the yak uterus based on macrogenomic analysis

INTRODUCTION

This study aimed to investigate the microbial characteristics of yak uteri collected using intrauterine cotton swabs (CS) during different reproductive stages and the correlation of these microbial characteristics with reproductive status.

METHODS

We used a macrogenomic approach to analyze the functional aspects of different microorganisms in samples collected during the pre-estrus, estrus, late estrus, and diestrus stages.

RESULTS

The results revealed the presence of 1293 microbial genera and 3401 microbial species in the uteri of yaks at different reproductive stages. The dominant bacterial species varied across the different periods, with Micrococcus and Proteus being dominant during pre-estrus; Pseudomonas, Clostridium, Flavobacterium, Bacillus, and Staphylococcus during estrus; Acinetobacter, Bacillus and Proteus during late estrus; and Pseudomonas, Escherichia coli, and Proteus during diestrus.

DISCUSSION

The primary functions of these bacteria are enriched in various metabolic pathways, including carbohydrate and amino acid metabolism, intracellular transport and secretion, post-translational protein modification, and drug resistance. These findings suggest that the microbial diversity in the uterus of yaks plays a crucial role in reproductive regulation and can help prevent reproductive tract-related diseases.

"I still don't know how someone gets pregnant": determinants of poor reproductive health among young female refugees in South Africa

BACKGROUND

Studies exploring the sexual and reproductive health (SRH) of refugee women have focused primarily on first generation refugees in humanitarian and crisis settings. There is a paucity of research exploring the reproductive health of girls and young women who are born to refugee parents in a host country or who have migrated with their parents at a very young age and who have since reached sexual maturity. We conducted a qualitative study which aimed to explore the reproductive health and rights' needs and challenges amongst young refugee women in South Africa.

METHODS

The study was carried out in the city of eThekwini (Durban) in South Africa in 2021 and 2022. A total of 35 semi-structured, in person interviews were conducted amongst young refugee women between the ages of 18 and 24 years living in the city centre.

RESULTS

Twenty-five participants were 17 years or younger on arriving in South Africa, one of whom was born in South Africa. Eleven of these women had experienced one or more pregnancies while living in South Africa and all of these women had experienced at least one unintended pregnancy. Participants had poor reproductive health knowledge of the role of menstruation and how conception occurs. Economic, social, and legal insecurities intersected in complex ways as determinants of poor reproductive health outcomes. Despite availability, contraceptive use was poor and linked to lack of knowledge, myths and unwanted side effects. There were negative economic and social impacts for young refugee women experiencing early pregnancies irrespective of whether they were intended or not. Being unable to conceive or experiencing an unintended pregnancy negatively impacted sexual relationships which were entered primarily for material support. Desire for confidentiality shaped lack of access to legal termination of pregnancy in the public health sector.

CONCLUSION

Participants experienced specific vulnerabilities resulting from their position as refugees despite length of stay in South Africa. It is important to better understand these specificities in the design of programmes and policies aimed at ensuring positive health outcomes for these young women. Peer education amongst refugee communities may be an important tool in the provision of culturally acceptable SRH education.

Experiences with family planning and abortion services during the Covid-19 pandemic: a qualitative study in Bangladesh, Iran and Netherlands

OBJECTIVE

Access to family planning services is a human right that plays an essential role in society's health, particularly women's health. The COVID-19 pandemic has affected all aspects of human life including access to family planning services. Accordingly, the main goal of this study was to explore the experiences of women and service providers from the main challenges and obstacles of access to family planning services and abortion services in Bangladesh, Iran, and the Netherlands during the COVID-19 pandemic.

METHODS

In this qualitative study, the data were collected through online, telephone, or in-person semi-structured interviews with key informants. Participants selected by purposive sampling method. The participants included women aged 15 to 49 (n = 63) and service providers (n = 54) in the 3 abovementioned countries. These individuals were included from October 2020 until December 2020. Conventional thematic analysis was employed to analyze the collected data.

RESULTS

The main extracted themes were challenges (reduction of referral; disruption of access to services; insufficient knowledge; worries among staff; rising prices; and unavailability of some contraceptives), measures (time extension and visit scheduling; telephone, online, and door to door services; and support of the media) and recommendations (health facility improvements; free, online, and closer services; and ongoing trainings and awareness campaigns).

CONCLUSION

The COVID-19 pandemic has affected family planning and reproductive health services in different ways and has uncovered existing inequalities in access to these services. However, in Iran, the reported challenges were also rooted in new population policies that have further limited access to family planning and abortion services.

Family Planning Concerns Among Women With Psoriasis: A Descriptive, Cross-Sectional, Multicenter Study

BACKGROUND AND OBJECTIVE

A significant proportion of women of childbearing age have psoriasis. The aim of this study was to examine family planning concerns in this population.

MATERIAL AND METHODS

Observational, descriptive, cross-sectional, multicenter study conducted between March 2020 and October 2021. We collected sociodemographic data and analyzed responses to a family planning questionnaire administered to women aged 18 to 45 years with plaque psoriasis who were candidates for systemic treatment.

RESULTS

We studied 153 patients (mean [SD] age, 35.4 [8.0] years; mean disease duration, 16.7 years) being treated at 11 Spanish hospitals. Overall, 38.4% of women were considered to have moderate to severe psoriasis by their physicians; perceived severity ratings were significantly higher among women. Psoriasis affected the women's desire to become pregnant or led to their delaying pregnancy in 1 in 3 respondents. They were concerned that their condition might worsen if they had to discontinue or switch treatment or that the treatment might harm the baby. Approximately half of the women had not received family planning counseling from their physicians, and this was more likely to be the case among never-pregnant women. Women on biologic therapy (58.7%) had better psoriasis control and a better quality of life than women on other treatments. Their sexual health was also less affected.

CONCLUSIONS

Women with psoriasis have numerous family planning concerns, which in some cases can lead them to delay pregnancy or affect their desire to become pregnant. Dermatologists need to receive better training regarding family planning in women with psoriasis so that they can provide their patients with more and better information.

Patient-centered or population-centered? How epistemic discrepancies cause harm and sow mistrust

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.

Seroepidemiology of Treponema pallidum, Mycoplasma hominis, and Ureaplasma urealyticum in fertility treatment-seeking patients in the Emirate of Abu Dhabi, United Arab Emirates

BACKGROUND

Several genital pathogens affect fertility. The study estimated the seroprevalence of Treponema pallidum, Ureaplasma urealyticum, and Mycoplasma hominis and identify specific factors associated with exposure to at least one of these pathogens in patients seeking fertility treatment in the Emirate of Abu Dhabi, United Arab Emirates.

METHODS

A seroepidemiological survey was conducted in a major fertility clinic in the Emirate of Abu Dhabi. Serum samples were screened for eight immunoglobulins (IgG, IgM, and IgA) against T. pallidum, U. urealyticum, and M. hominis using enzyme-linked immunoassays. Factors associated with seropositivity to at least one of the pathogens were investigated.

RESULTS

The study surveyed 308 patients seeking fertility treatment (mean age: 36.1 ± 6.8 years). Most patients were female (88.0%), 24.9% had at least one chronic comorbidity, 19.3% had a previous genital infection, and 68.1% had been diagnosed with infertility for ≥ 6 months. Ig seroprevalence of T. pallidum (IgG: 3.0%, IgM: 3.2%), U. urealyticum (IgG: 2.6%, IgM: 2.0%), and M. hominis (IgG: 33.9%) was 6.4%, 4.6%, and 49.0%, respectively. Nearly one quarter (23.0%) and one decile (9.2%) of the patients exhibited evidence of ongoing infection (IgM seropositivity) or recent infection (IgA seropositivity) with M. hominis, respectively. Overall, 53.0% of the patients were seropositive for at least one of the screened immunoglobulins. Patients with an education level of secondary schooling or below (66.2%) or those who were unemployed (61.1%) had a higher seroprevalence of IgG antibodies compared with patients with college or higher-level education (48.4%) or those who were employed (48.1%) (p < 0.05).

CONCLUSION

Exposure to T. pallidum or U. urealyticum was relatively low, whereas that to M. hominis was common in the surveyed patients. Enhanced awareness and screening programmes for genital pathogens are crucial to prevent and control the transmission of infections and reduce the growing burden of infertility.

[Translated article] Family Planning Concerns Among Women With Psoriasis: A Descriptive, Cross-Sectional, Multicenter Study

BACKGROUND AND OBJECTIVE

A significant proportion of women of childbearing age have psoriasis. The aim of this study was to examine family planning concerns in this population.

MATERIAL AND METHODS

Observational, descriptive, cross-sectional, multicenter study conducted between March 2020 and October 2021. We collected sociodemographic data and analyzed responses to a family planning questionnaire administered to women aged 18 to 45 years with plaque psoriasis who were candidates for systemic treatment.

RESULTS

We studied 153 patients (mean [SD] age, 35.4 [8.0] years; mean disease duration, 16.7 years) being treated at 11 Spanish hospitals. Overall, 38.4% of women were considered to have moderate to severe psoriasis by their physicians; perceived severity ratings were significantly higher among women. Psoriasis affected the women's desire to become pregnant or led to their delaying pregnancy in 1 in 3 respondents. They were concerned that their condition might worsen if they had to discontinue or switch treatment or that the treatment might harm the baby. Approximately half of the women had not received family planning counseling from their physicians, and this was more likely to be the case among never-pregnant women. Women on biologic therapy (58.7%) had better psoriasis control and a better quality of life than women on other treatments. Their sexual health was also less affected.

CONCLUSIONS

Women with psoriasis have numerous family planning concerns, which in some cases can lead them to delay pregnancy or affect their desire to become pregnant. Dermatologists need to receive better training regarding family planning in women with psoriasis so that they can provide their patients with more and better information.

Contraception use and satisfaction among mothers with low income: Evidence from the Baby's First Years study

OBJECTIVES

Low income can lead to limited choice of and access to contraception. We examine whether an unconditional cash transfer (UCT) impacts contraceptive use, including increased satisfaction with and reduced barriers to preferred methods, for individuals with low income.

STUDY DESIGN

Baby's First Years is a randomized control study of a monthly UCT to families with low incomes. The study enrolled 1000 mothers at the time of childbirth across four US sites in 2018-2019; 400 were randomized to receive a UCT of $333/mo and 600 were randomized to receive $20/mo for the first years of their child's life. We use intent-to-treat analyses to estimate the impact of the cash transfer on contraception use, satisfaction with contraception method, and barriers to using methods of choice.

RESULTS

Over 65% of mothers reported using some type of contraception, and three-quarters reported using the method of their choice. We find no impact of the UCT on mothers' choice of, satisfaction with, or barriers to contraception. However, the cash transfer was associated with trends toward using multiple methods and greater use of short-term hormonal methods.

CONCLUSIONS

We find high levels of satisfaction with current contraceptive use among mothers of young children with low income. Receipt of monthly UCTs did not impact contraception methods, perceived barriers to use, or satisfaction. Yet, 25% were not using the method of their choice, despite the provision of cash, indicating that this cash amount alone may not be sufficient to impact contraceptive use or increase satisfaction.

IMPLICATIONS

Satisfaction with contraception use among low-income populations may be higher than previously documented. Nevertheless, provision of modest financial resources alone may not sufficiently address access, availability, and satisfaction for individuals with low-incomes of childbearing age. This suggests the importance of exploring how other nonfinancial factors influence reproductive autonomy, including contraceptive use.

How a "Something Else" Response Option for Sexual Identity Affects National Survey Estimates of Associations Between Sexual Identity, Reproductive Health, and Substance Use

This randomized experiment tested whether the inclusion of a "something else" response option for a question about sexual identity in a national health survey would significantly moderate estimated differences between sexual identity subgroups in terms of various health outcomes, including substance use and reproductive health. We conducted secondary analyses of data from five consecutive years of the National Survey of Family Growth (NSFG; 2015-2019), where two large national half-samples were randomly assigned to receive one of two different versions of a question about sexual identity (a four-category version that included a "something else" response option or a three-category version omitting this option). We focused on national estimates of differences between subgroups defined by sexual identity. Multivariable models indicated that the estimated subgroup differences changed in a statistically significant fashion when using the four-category version of the sexual identity question for several measures, including 16% of male measures (household size, past-year cigarette use, and past-year illicit drug use) and 15% of female measures (wanting a/another child, ever had a sexually transmitted disease, and past-year marijuana use). The absence of a "something else" response option for questions about sexual identity in national health surveys may cause respondents to select options that do not accurately describe their identities, and this can have a significant effect on national estimates of differences between sexual identity subgroups in terms of selected health outcomes.

Knowledge, Attitudes and Practices on Reproductive Health Among Abortion Adolescents in Vietnam

Background

Adolescent pregnancy is a global issue. The majority of these adolescents experience unintended pregnancy ending in abortion. Knowledge gaps and misconceptions about reproductive health are the main reasons for unintended pregnancy among adolescents.

Objective

This study aims to identify knowledge, attitudes, practices, and related factors of reproductive health among adolescent post-abortion or those seeking abortion at Hanoi Obstetrics and Gynecology Hospital (HOGH), a tertiary hospital in Vietnam.

Methods

Ours was a descriptive cross-sectional study of 103 adolescents who sought induced abortions between January 1, 2022 and June 30, 2023. Participants were interviewed directly via questionnaires to collect information.

Results

The mean age of participants was 16.3 years. 64.1% of the population did not have general knowledge regarding reproductive health, 42.7% of subjects displayed incorrect attitudes regarding reproductive health. As a result, lack of knowledge and incorrect attitudes led to unsafe sex. The percentage of adolescents practicing unsafe sex is incredibly high (90.3%) thus causing unintended pregnancies. Education levels and family economic status were the main factors linked to knowledge, attitudes, and practices (KAP) regarding reproductive health.

Conclusion

Most adolescents seeking abortion had poor KAP regarding reproductive health. Their KAP of reproductive health were linked to levels of education and family economic status. The findings emphasize the need to provide reproductive health care information and services for adolescents, and the need for appropriate attention from both family and society to the target group. We believe this will result in the improvement of their health and the avoidance of unfortunate consequences.

The association between exposure to polycyclic aromatic hydrocarbons and birth outcomes: A systematic review and meta-analysis of observational studies

Exposure to polycyclic aromatic hydrocarbons (PAHs) has been linked to adverse birth outcomes; however, to date, the available studies on such relations, with the exception of birth weight, has not been systematically synthesized. We conducted a systematic review and meta-analysis of the available observational studies on the association of maternal exposure to PAHs and their metabolites during pregnancy with indicators of fetal growth and gestational age at delivery. We searched Web of Science, PubMed and Scopus systematically for all relevant published papers in English until 13 January 2023. Random effects meta-analysis was applied to synthesize the association estimates. Publication bias was assessed using Egger's regression. A total of 31 articles were included in our review (n = 703,080 participants). Our quality assessment of reviewed papers showed that 19 research had excellent, nine had good, and three had fair quality. Most of the reviewed studies on exposure to PAHs and their metabolites with gestational age and preterm birth (seven studies) reported no statistically significant association. Eight studies were eligible for our meta-analysis. Results of the meta-analysis indicated that higher levels of maternal urinary 1-OHP was associated with lower birth weight, birth length and head circumference and a higher risk of low birth weight (LBW). However, these associations were not statistically significant. Similarly, the combined association between maternal urinary 1-OHP and newborn's Ponderal index (PI) and Cephalization index were not statistically significant. Overall, our systematic review and meta-analysis suggested a potential adverse impact of exposure to PAHs on LBW, HC, and CC; however, further studies are required to be able to draw concrete conclusions on such associations.

[Investigation on reproductive health status of women workers in different positions in oilfield enterprises]

Objective: The status and influencing factors of reproductive health (including menstrual period and gynecological diseases) of female workers in different positions of oilfield enterprises were analyzed. Methods: From January to December 2020, a total of 979 female workers in an oil field were selected as research objects by the judgment sampling method, and the "Female Reproductive Health Survey" was used as the investigation tool to investigate the demographic characteristics, menstrual status and gynecological diseases. The influential factors were analyzed by 2-test and logistic regression analysis. Results: The prevalence of abnormal menstruation was 26.1% (256/979), dysmenorrhea 53.1% (520/979), and gynecological diseases 54.34% (532/979). The prevalence of breast disease was 23.39% (229/979), uterine disease 11.03% (108/979), cervical disease 10.32% (101/979), and HPV infection 7.97% (78/979). Age, the nature of the job and whether occupational harmful factors were clear were the influencing factors of gynecological diseases (P=0.001, 0.000, 0.007). Age, job nature, working hours and work intensity were the influencing factors of abnormal menstruation (P=0.005, 0.000, 0.000, 0.010) . Conclusion: The reproductive health status of female workers in different positions of oil field enterprises is not optimistic, and the reproductive health status of female workers in professional and technical positions needs to be improved.

The Carolina hysterectomy cohort (CHC): a novel case series of reproductive-aged hysterectomy patients across 10 hospitals in the US south

BACKGROUND

Hysterectomy is a common surgery among reproductive-aged U.S. patients, with rates highest among Black patients in the South. There is limited insight on causes of these racial differences. In the U.S., electronic medical records (EMR) data can offer richer detail on factors driving surgical decision-making among reproductive-aged populations than insurance claims-based data. Our objective in this cohort profile paper is to describe the Carolina Hysterectomy Cohort (CHC), a large EMR-based case-series of premenopausal hysterectomy patients in the U.S. South, supplemented with census and surgeon licensing data. To demonstrate one strength of the data, we evaluate whether patient and surgeon characteristics differ by insurance payor type.

METHODS

We used structured and abstracted EMR data to identify and characterize patients aged 18-44 years who received hysterectomies for non-cancerous conditions between 10/02/2014-12/31/2017 in a large health care system comprised of 10 hospitals in North Carolina. We used Chi-squared and Kruskal Wallis tests to compare whether patients' socio-demographic and relevant clinical characteristics, and surgeon characteristics differed by patient insurance payor (public, private, uninsured).

RESULTS

Of 1857 patients (including 55% non-Hispanic White, 30% non-Hispanic Black, 9% Hispanic), 75% were privately-insured, 17% were publicly-insured, and 7% were uninsured. Menorrhagia was more prevalent among the publicly-insured (74% vs 68% overall). Fibroids were more prevalent among the privately-insured (62%) and the uninsured (68%). Most privately insured patients were treated at non-academic hospitals (65%) whereas most publicly insured and uninsured patients were treated at academic centers (66 and 86%, respectively). Publicly insured and uninsured patients had higher median bleeding (public: 7.0, uninsured: 9.0, private: 5.0) and pain (public: 6.0, uninsured: 6.0, private: 3.0) symptom scores than the privately insured. There were no statistical differences in surgeon characteristics by payor groups.

CONCLUSION

This novel study design, a large EMR-based case series of hysterectomies linked to physician licensing data and manually abstracted data from unstructured clinical notes, enabled identification and characterization of a diverse reproductive-aged patient population more comprehensively than claims data would allow. In subsequent phases of this research, the CHC will leverage these rich clinical data to investigate multilevel drivers of hysterectomy in an ethnoracially, economically, and clinically diverse series of hysterectomy patients.

The social determinants of mental health disorders among women with infertility: a systematic review

INTRODUCTION

Infertility is associated with mental health disorders in women, even if a successful pregnancy resolves infertility. However, the link between social determinants of health (SDoH) and mental health in women with infertility is not well understood. We aimed to investigate the determinants thoroughly so that mental health screening and services can be tailored to suit women with infertility who are vulnerable to mental health disorders.

METHODOLOGY

All observational studies that included women participants of reproductive age with infertility and assessed social determinants associated with mental health disorders were searched using a combination of keywords from MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science databases and published in English. Two reviewers conducted screening, data extraction, quality assessment and risk of bias. The protocol was registered on PROSPERO (number CRD42022343962).

RESULTS

The systematic review included 32 studies out of 3405 screened articles from January 1st 2010 to 16th October 2023. Compared to women without infertility, the prevalence of mental health disorders, including anxiety, depression, psychological distress, and stress, is high among women with infertility, with the severity being influenced by social determinants-those with higher education, employment, higher personal or family income, private health insurance, higher social support, stronger religious beliefs, and higher spiritual well-being reported better mental health outcomes.

CONCLUSION

The study highlights the need for early detection, tailored interventions, and integrated and comprehensive support systems to address the mental health needs of women with infertility and improve their well-being.

Explaining Iranian midwives' experiences of providing healthcare services during the COVID-19 pandemic: a qualitative study

BACKGROUND

COVID-19 has changed and challenged the way health and maternity care is provided. Midwives are among the first and most influential maternity care providers during the COVID-19 pandemic; however, there is inadequate information about their experiences in providing healthcare services, particularly in Iran. The present study was conducted to explain the midwives' experiences of providing healthcare services during the COVID-19 pandemic in Gorgan.

METHODS

The present study was conducted qualitatively through the inductive content analysis method in 2022. Data were collected through semi-structured interviews. A total of 21 individuals were selected as participants using a purposeful method and the maximum diversity strategy.

RESULTS

Data analysis led to the emergence of 377 codes, 12 subcategories, and 3 main categories, including, the laborious occupational challenges for midwives during the pandemic, identifying and creating new opportunities for the development of the midwifery profession, and the lack of perceived organizational and social support.

CONCLUSIONS

During the COVID-19 pandemic, midwives experienced various challenges in providing healthcare services, yet sacrificed themselves to perform their duties and provide quality care incessantly. The COVID-19 pandemic was a combination of laborious occupational challenges and individual and professional growth opportunities for midwives in Iran. Strong and managed organizational support is essential to overcome the crisis, maintain the workforce, and empower them to deal with future crises.

Patient perspectives of using reproductive autonomy to measure quality of care: a qualitative study

BACKGROUND

Current measures of reproductive health care quality, such as rates of "unintended" pregnancies, neglect to incorporate patients' desires and center their reproductive autonomy. This study explores patients' perspectives on and receptivity to alternative metrics for measuring quality of such care.

METHODS

An online research recruitment firm identified eligible participants living in New York, ages 18-45, self-identifying as women, and having visited a primary care provider in the last year. We conducted five virtual focus groups and eight in-depth interviews with participants (N = 30) in 2021. Semi-structured guides queried on ideal clinic interactions when preventing or attempting pregnancy and their perspectives on how to measure the quality of such encounters, including receptivity to using our definition of reproductive autonomy to develop one such metric: "whether the patient got the reproductive health service or counseling that they wanted to get, while having all the information about and access to their options, and not feeling forced into anything." We employed an inductive thematic analysis.

RESULTS

Participants wanted care that was non-judgmental, respectful, and responsive to their needs and preferences. For pregnancy prevention, many preferred unbiased information about contraceptive options to help make their own decisions. For pregnancy, many desired comprehensive information and more provider support. There was considerable support for using reproductive autonomy to measure quality of care.

CONCLUSIONS

Patients had distinct desires in their preferred approach to discussions about preventing versus attempting pregnancy. Quality of reproductive health care should be measured from the patient's perspective. Given participants' demonstrated support, future research is needed to develop and test a new metric that assesses patients' perceptions of reproductive autonomy during clinical encounters.

A training program for obstetrics point-of-care ultrasound to 514 rural healthcare providers in Kenya

BACKGROUND

Ultrasound is a crucial and effective diagnostic tool in medicine. Recent advancements in technology have led to increased use of point-of-care ultrasound (POCUS). Access to ultrasound equipment and training programs in low-and middle-income countries (LMICs) is limited. Despite the World Health Organization (WHO) recommendations for universal antenatal ultrasounds, POCUS for reproductive health applications has not been widely used in LMICs. We describe here the feasibility of implementation of a training of obstetrics point-of-care ultrasound (OB POCUS) for high-risk conditions in rural public healthcare facilities in Kenya with partnership from Butterfly Network, Global Ultrasound Institute, and Kenyatta University.

METHODS

As part of the initiation of a large-scale implementation study of OB POCUS, clinician trainees were recruited from rural Kenyan hospitals for participation in a series of five-day POCUS workshops held between September and December 2022. Trainers provided brief didactic lessons followed by hands-on training with live models and at regional clinical sites for 5 OB POCUS applications. Instructor-observed assessment of students' scanning and image interpretation occurred over the training period. Assessment of knowledge and confidence was performed via an online pre-test and post-test as well as Objective Structured Clinical Examination (OSCE) was administered at course completion.

RESULTS

Five hundred and fourteen mid-level Health Care Providers (HCPs) in Kenya were trained over a three-month period through in-person didactic sessions, bedside instruction, and clinical practice over a 5-day period with a trainer: trainee ratio of approximately 1:5. Out of the 514 trained HCPs, 468 were from 8 rural counties with poor maternal and neonatal outcomes, while the remaining 46 were from nearby facilities. OB POCUS topics covered included: malpresentation, multiple gestation, fetal cardiac activity, abnormalities of the placenta and amniotic fluid volume. There was marked improvement in the post training test scores compared to the pretest scores.

CONCLUSION

Our implementation description serves as a guide for successful rapid dissemination of OB POCUS training for mid-level providers. Our experience demonstrates the feasibility of a short intensive POCUS training to rapidly establish specific POCUS skills in efforts to rapidly scale POCUS access and services. There is a widespread need for expanding access to ultrasound in pregnancy through accessible OB POCUS training programs. An implementation study is currently underway to assess the patient and systems-level impact of the training.

"I feel like it gives me what I need to know": A qualitative study on adolescent perceptions of two contraceptive decision aids

OBJECTIVES

We sought to understand how adolescents perceive two commonly used contraceptive decision aids and which elements adolescents identified as most important to them.

STUDY DESIGN

We conducted a cross-sectional qualitative study of adolescents' perceptions of two decision aids, Your Birth Control Choices designed by the Reproductive Health Access Project and Birth Control: What's Important to You? designed by Power to Decide for Bedsider.org. We conducted semistructured interviews with 20 adolescents (aged 15-19 years) who were assigned female sex at birth and attended a single clinic in North Carolina. Interview questions addressed the decision aids' aesthetic design, informational content, inclusivity, and comprehensibility. We transcribed and analyzed interviews using Dedoose software. We developed a codebook using a combination of a priori and inductive codes followed by content analysis to identify themes.

RESULTS

All participants agreed that both decision aids could be helpful with contraceptive decision-making and with patient-provider discussions. However, some phrasing and descriptions of contraceptive methods were confusing. Participants preferred realistic imagery, clear explanations of side effects, and details on method use. Participants expressed a preference for the information contained in the detailed Reproductive Health Access Project decision aid, while most favored the aesthetic design and layout of the Bedsider decision aid.

CONCLUSIONS

Although adolescents expressed sentiments of increased knowledge and empowerment after reviewing the decision aids, this study suggests neither decision aid completely meets adolescent needs and preferences. Additional adaptations are necessary to create adolescent-centered contraceptive decision aids.

IMPLICATIONS

Adolescents in this study found two contraceptive decision aids as useful adjuncts to conversations with providers. The decision aids improved contraceptive knowledge and may facilitate decision-making. However, neither of the studied decision aids fully met the perceived needs of adolescents. Future adaptations or designs should include additional adolescent-centered content.

Pandemic-related stressors and mental health among women with a live birth in 2020

The objective of this analysis was to assess the associations between pandemic-related stressors and feeling more anxious/depressed, among women with a live birth. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 maternal experiences supplement, implemented in 29 U.S. jurisdictions from October 2020-June 2021, among women with a live birth during April-December 2020. We examined stressors by type (economic, housing, childcare, food insecurity, partner, COVID-19 illness) and score (number of stressor types experienced [none, 1-2, 3-4, or 5-6]). Outcomes were feeling 1) more anxious and 2) more depressed than usual due to the pandemic. We calculated adjusted prevalence ratios estimating associations between stressors and outcomes. Among 12,525 respondents, half reported feeling more anxious and 28% more depressed than usual. The prevalence of stressor types was 50% economic, 41% childcare, 18% partner, 17% food insecurity, 12% housing, and 10% COVID-19 illness. Respondents who experienced partner stressors (anxious aPR: 1.81, 95% CI: 1.73-1.90; depressed aPR: 3.01, 95% CI: 2.78-3.25) and food insecurity (anxious aPR: 1.79, 95% CI: 1.71-1.88; depressed aPR: 2.32, 95% CI: 2.13-2.53) had the largest associations with feeling more anxious and depressed than usual. As stressor scores increased, so did the aPRs for feeling more anxious and more depressed due to the pandemic. COVID-19 stressors, not COVID-19 illness, were found to be significantly associated with feeling more anxious and depressed. Pregnant and postpartum women might benefit from access to supports and services to address pandemic-related stressors/social-determinants and feelings of anxiety and depression.

Service trends among non-obstetrics/gynecology providers in the U.S.: Long-acting reversible contraception insertions, removals, and re-insertions

This study evaluates trends in long-acting reversible contraception (LARC) services among obstetrician/gynecologists (OB/GYNs) and non-OB/GYNs in the U.S. during 2012-2018. Using public and private insurance claims from the Symphony Health database, we calculated the percentage of LARC insertions, removals, and reinsertions performed by OB/GYNs and non-OB/GYNs. We then assessed time trends with linear regression. The proportion of LARC services that were performed by non-OBGYNs increased modestly between 2012 and 2018. Increases were similar for insertions, removals, and reinsertions. Further research is needed to understand trends in LARC service provision within primary care to better tailor medical training and policy interventions.

Through Their Eyes: Youth Perspectives on Sexual and Reproductive Health Barriers and Facilitators in Baltimore, Maryland

PURPOSE

Youth face barriers to sexual and reproductive health (SRH). Few states require the delivery of comprehensive sex education in schools, and youth report challenges with accessing clinical care. We sought to identify youth's perceived barriers and facilitators to SRH in their communities.

METHODS

We utilized photovoice, a community-based participatory research methodology. Youth were recruited from high schools in Baltimore, Maryland. Participants were given a tutorial on Photovoice methodology and photography. In groups of 5-7 participants, youth brainstormed questions relevant to their perspective of SRH. Three months were allocated to taking photographs. Participants wrote brief narratives to accompany their photographs, and group level assessment was used for participants to comment on others' photographs. Participants discussed the narratives and comments, created themes, and generated action steps to address barriers to SRH. Further thematic analysis was conducted using NVivo.

RESULTS

There were 30 participants aged 14-19 years with 26 self-identifying as female and four nonbinary. Self-identified race/ethnicity included 50% Black/African American, 30% Asian American, and 20% White or Hispanic/Latino. Four domains emerged: desire for societal-level change, community-level change, peer-level change, and positive examples of SRH within their communities (e.g., gender-inclusive spaces and free menstrual products).

DISCUSSION

Youth photographs shed light on a strong desire for an improved school environment, in terms of safety, cleanliness, gender-inclusivity, menstrual product access, and SRH education.

Sexual and Reproductive Health Concerns in Adults With Cloacal Anomalies: A Qualitative Study

STUDY OBJECTIVE

Long-term gynecologic data are lacking to inform the care of patients with cloacal malformations. We seek to examine perceived sexual and reproductive health challenges of patients born with cloacal anomalies and characterize the experiences of patients as adults.

DESIGN AND SETTING

Virtual semi-structured focus groups and single-participant interviews were conducted using an online video platform. Retrospective chart review was performed to abstract available demographics and surgical history.

PARTICIPANTS

Adult patients were contacted from a database of 143 patients born with cloaca who had been seen at or referred to a tertiary care pediatric colorectal center. Participants were recruited until data collection reached thematic saturation. Twenty patients aged 18-53 years participated in 5 focus groups and 3 single-participant interviews. The hospital IRB determined the research activities to be exempt from IRB review and oversight.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Interviews and focus groups were transcribed and analyzed using the constant comparative method to identify themes regarding sexual and reproductive health and compared with medical and surgical history abstracted from chart review.

RESULTS

Participants reported many perceived barriers to intercourse and intimacy including bowel and bladder continence management. All participants reported discussion of pregnancy and fertility with healthcare providers as important. Other common themes included concerns about independence and transitioning from pediatric to adult providers.

CONCLUSION

Anorectal malformations are associated with sexual and reproductive health concerns. Patients seek guidance on family building, intimacy, and transition to adult care. Future quantitative study of these topics is needed to develop best practices for counseling and clinical management of these patients.

LEVEL OF EVIDENCE

Level VI.

TYPE OF STUDY

Prognosis Study.

Zinc and α-tocopherol protect the antral follicles and endogenous antioxidants of female albino rats (Rattus norvegicus) against lead toxicity

BACKGROUND

Lead impairs female reproductive health because it can induce oxidative stress. Zinc as an antioxidant produces an enzyme system that helps neutralize free radicals. α-Tocopherol has an antagonistic effect that reduces oxidative stress. This study aimed to demonstrate the effects of zinc (Zn) and α-tocopherol on the ovarian endogenous antioxidants and antral follicles of albino rats (Rattus norvegicus) exposed to lead acetate (Pb(C2H3O2)2).

METHODS

Twenty-five female Wistar rats were divided into five groups, namely groups K (control), P0, P1, P2, and P3. Following exposure and treatment for 21 days with different combinations, the albino rats were necropsied, and their ovaries were removed for subsequent histopathological preparations and endogenous antioxidant analysis. Observations were made on the ovary, including an antral follicle count and diameter calculations. Analysis of the superoxide dismutase (SOD) levels (560 nm wavelength) and malondialdehyde MDA-TBA (532 nm wavelength) were performed by a spectrophotometer. The data were analyzed using a one-way ANOVA and least significant difference (LSD) test with the SPSS V24 software.

RESULTS

The highest SOD enzyme expression in the albino rat ovaries was in P0 (17.23 ± 5.34), and the lowest was in P3 (4.21 ± 0.76). The lowest MDA level was observed in the control group (K) and P3 compared to the other groups. The highest average antral follicle count and diameter were found in the albino rats exposed to 1.5 mg/kg BW lead acetate, and treated with 0.54 mg/kg BW zinc sulfate and 100 mg/kg BW α-tocopherol (group P3) compared to the other groups. The mechanisms of action of zinc and α-tocopherol work synergistically to decrease free radicals and ovarian damage.

CONCLUSION

The results showed that a combination of 0.54 mg/kg BW zinc (Zn) and 100 mg/kg BW α-tocopherol can maintain the number and diameter of the antral follicles and reduce ovarian SOD expression and MDA levels in albino rats exposed to lead acetate.

Gaps in Adhering to Pap Testing Recommendations and Related Barriers in a Sample of Young Adults in the US

Given ongoing gaps in adherence to Pap testing recommendations, this study examined: 1) adherence to Pap test screening recommendations; and 2) barriers to Pap test screening among those who were nonadherent, using constructs from the Andersen model. We analyzed Spring 2022 survey data among 541 US young adults who reported having a cervix (n = 541; mean age = 27.73, 42.1% heterosexual, 57.9% sexual minority, 86.0% woman, 3.7% transgender man, 68.2% White, 31.8% racial/ethnic minority). Multivariable logistic regression examined sociodemographic correlates of nonadherence to Pap testing recommendations (i.e., no Pap testing in the past 3 years). Among those who were nonadherent, barriers to Pap testing were assessed. 68.6% (n = 371) were defined as adherent and 31.4% (n = 170) nonadherent. Multivariable regression findings indicated significant differences by race/ethnicity such that Asians (vs. Whites) were more likely to be nonadherent (OR = 2.41, CI = 1.11, 3.70, p = .021); no other differences in relation to race/ethnicity or sexual/gender identity were found. The most commonly reported barriers were: "I have not gotten around to it" (42.9%), "getting a Pap test is just not a priority for me" (30.6%), "fear/worry" (28.2%), "dislike/don't like having procedures done" (27.1%), "my healthcare provider has never mentioned it" (21.2%), "haven't had sex so I don't consider myself at high risk" (20.6%), and "COVID-19 pandemic prevented me" (15.3%). Pap testing is underutilized among young adults in the US, particularly Asians. Multilevel interventions must address barriers within the healthcare system (e.g., provider recommendation), external environment (e.g., societal factors), and individual realm (e.g., perceptions).

Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings

PURPOSE OF REVIEW

Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition.

RECENT FINDINGS

Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

Sperm chromatin structure assay (SCSA®) and flow cytometry-assisted TUNEL assay provide a concordant assessment of sperm DNA fragmentation as a function of age in a large cohort of approximately 10,000 patients

BACKGROUND

Sperm DNA integrity is increasingly seen as a critical characteristic determining reproductive success, both in natural reproduction and in assisted reproductive technologies (ART). Despite this awareness, sperm DNA and nuclear integrity tests are still not part of routine examinations for either infertile men or fertile men wishing to assess their reproductive capacity. This is not due to the unavailability of DNA and sperm nuclear integrity tests. On the contrary, several relevant but distinct tests are available and have been used in many clinical trials, which has led to conflicting results and confusion. The reasons for this are mainly the lack of standardization between different clinics and between the tests themselves. In addition, the small number of samples analyzed in these trials has often weakened the value of the analyses performed. In the present work, we used a large cohort of semen samples, covering a wide age range, which were simultaneously evaluated for sperm DNA fragmentation (SDF) using two of the most frequently used SDF assays, namely the TUNEL assay and the sperm chromatin structure assay (SCSA®). At the same time, as standard seminal parameters (sperm motility, sperm morphology, sperm count) were available for these samples, correlations between age, SDF and conventional seminal parameters were analyzed.

RESULTS

We show that the SCSA® and TUNEL assessments of SDF produce concordant data. However, the SDF assessed by TUNEL is systematically lower than that assessed by SCSA®. Regardless of the test used, the SDF increases steadily during aging, while the HDS parameter (High DNA stainability assessed via SCSA®) remains unchanged. In the cohort analyzed, conventional sperm parameters do not seem to discriminate with aging. Only sperm volume and motility were significantly lower in the oldest age group analyzed [50-59 years of age].

CONCLUSIONS

In the large cohort analyzed, SDF is an age-dependent parameter, increasing linearly with aging. The SCSA® assessment of SDF and the flow cytometry-assisted TUNEL assessment are well correlated, although TUNEL is less sensitive than SCSA®. This difference in sensitivity should be taken into account in the final assessment of the true level of fragmentation of the sperm nucleus of a given sample. The classical sperm parameters (motility, morphology, sperm count) do not change dramatically with age, making them inadequate to assess the fertility potential of an individual.

The self-care situation analysis of reproductive-aged women in Tehran: a survey study

BACKGROUND

Along with a global increase in the prevalence of infectious and non-communicable diseases, self-care with an emphasis on reproductive health Self-care has received special attention. Given the importance of women's health, assessment of their self-care status using a valid and reliable tool seems to be necessary to determine the needs for future women's reproductive health promotion interventions. The present study aimed to assess the women's self-care at reproductive age in Tehran, to determine women's health needs based on global guidelines for women's health.

METHODS

This was a descriptive cross-sectional study on 1051 women of reproductive age, living in Tehran. The Subjects were recruited using a multi-stage sampling method. The women completed a socio-demographic and valid and reliable questionnaire to assess their self-care status. The data were analyzed using SPSS 24 and by Pearson, Spearman, ANOVA, and regression tests.

RESULTS

The mean score of self-care was 49.57 ± 23.50% in the reproductive-aged women. The lowest scores were related to psychosocial health (32.12 ± 29.93%) and reproductive-sexual health (49.74 ± 27.99%) respectively. There were significant positive correlations between the self-care and women's education level (r = 0.180; p < 0.01), and husband's education level (r = 0.272; p < 0.01), while there was a negative significant correlation between the self-care and the family size (r = - 0.135; p < 0.01).

CONCLUSION

The findings showed inadequate self-care among reproductive-aged women in Tehran. The most important challenge in their self-care behaviors was related to psychosocial and reproductive-sexual health. It seems to provide a package for promoting women's self-care in four areas of physical, psychosocial, reproductive-sexual health, and screening tests, with an emphasis on the first two priorities, namely psychosocial and reproductive health necessary in Tehran.

"It's Not a Top Priority": A Qualitative Analysis of Provider Views on Barriers to Reproductive Healthcare Provision for Homeless Women in the United States

Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women's needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.

Attitudes towards induced abortion among gynecologists in Kurdistan region of Iraq

BACKGROUND

Unsafe abortion is a major contributor to maternal morbidity and mortality in countries where induced abortion is restricted. In Kurdistan Region of Iraq, induced abortion is strictly forbidden except for life-threatening situations, increasing the risk of seeking unsafe abortions. Attitudes among healthcare professionals who directly encounter cases and consequences of induced abortion can be studied to improve women's access to safe abortion. This study aimed to examine attitudes towards induced abortion among gynecologists in Kurdistan Region of Iraq.

METHODS

This cross-sectional facility-based study was conducted in the first quarter of 2022 in Kurdistan Region of Iraq in the cities of Erbil, Sulaymaniyah, and Duhok. Convenient sampling was used to invite 330 gynecologists to participate, with 171 ultimately completing the questionnaire, giving a response rate of 53%. Questionaries using the Taylor and Whitehead abortion attitude scale were sent in person or digitally. The data was then analyzed using Chi-square and Fisher's exact tests to determine the independence of attitudes and associations between attitudes and sociodemographic factors.

RESULTS

Among 171 gynecologists, 25% of the gynecologists agreed that induced abortion is unacceptable under any circumstances. Most (71%) disagreed that a woman has the right to choose to have an induced abortion. Around 51% considered induced abortion murder, and 41% agreed that induced abortion goes against all morals. Around 57% disagreed with the legalization of induced abortion, while 43% agreed. Gynecologists who were unmarried (P = 0.025), under the age of 40 (P = 0.044), and with less than 10 years of clinical experience (P = 0.043) were more likely to support the legalization of induced abortion in Kurdistan Region. None of the variables was found to be independently associated with attitudes towards abortion legalization.

CONCLUSIONS

Despite some younger gynecologists having more favorable attitudes towards induced abortion, most gynecologists in Kurdistan Region had less favorable views. Most gynecologists were willing to provide post-abortion care regardless of their legal status. We recommend conducting more studies to investigate the consequences of current abortion legislation among women in need of induced abortion in Kurdistan Region of Iraq.

Male contraception: narrative review of ongoing research

BACKGROUND

Since the release of the combined oral contraceptive pill in 1960, women have shouldered the burden of contraception and family planning. Over 60 years later, this is still the case as the only practical, effective contraceptive options available to men are condoms and vasectomy. However, there are now a variety of promising hormonal and non-hormonal male contraceptive options being studied. The purpose of this narrative review is to provide clinicians and laypeople with focused, up-to-date descriptions of novel strategies and targets for male contraception. We include a cautiously optimistic discussion of benefits and potential drawbacks, highlighting several methods in preclinical and clinical stages of development.

RESULTS

As of June 2023, two hormonal male contraceptive methods are undergoing phase II clinical trials for safety and efficacy. A large-scale, international phase IIb trial investigating efficacy of transdermal segesterone acetate (Nestorone) plus testosterone gel has enrolled over 460 couples with completion estimated for late 2024. A second hormonal method, dimethandrolone undecanoate, is in two clinical trials focusing on safety, pharmacodynamics, suppression of spermatogenesis and hormones; the first of these two is estimated for completion in December 2024. There are also several non-hormonal methods with strong potential in preclinical stages of development.

CONCLUSIONS

There exist several hurdles to novel male contraception. Therapeutic development takes decades of time, meticulous work, and financial investment, but with so many strong candidates it is our hope that there will soon be several safe, effective, and reversible contraceptive options available to male patients.

Associations between area-level arsenic exposure and adverse birth outcomes: An Echo-wide cohort analysis

BACKGROUND

Drinking water is a common source of exposure to inorganic arsenic. In the US, the Safe Drinking Water Act (SDWA) was enacted to protect consumers from exposure to contaminants, including arsenic, in public water systems (PWS). The reproductive effects of preconception and prenatal arsenic exposure in regions with low to moderate arsenic concentrations are not well understood.

OBJECTIVES

This study examined associations between preconception and prenatal exposure to arsenic violations in water, measured via residence in a county with an arsenic violation in a regulated PWS during pregnancy, and five birth outcomes: birth weight, gestational age at birth, preterm birth, small for gestational age (SGA), and large for gestational age (LGA).

METHODS

Data for arsenic violations in PWS, defined as concentrations exceeding 10 parts per billion, were obtained from the Safe Drinking Water Information System. Participants of the Environmental influences on Child Health Outcomes Cohort Study were matched to arsenic violations by time and location based on residential history data. Multivariable, mixed effects regression models were used to assess the relationship between preconception and prenatal exposure to arsenic violations in drinking water and birth outcomes.

RESULTS

Compared to unexposed infants, continuous exposure to arsenic from three months prior to conception through birth was associated with 88.8 g higher mean birth weight (95% CI: 8.2, 169.5), after adjusting for individual-level confounders. No statistically significant associations were observed between any preconception or prenatal violations exposure and gestational age at birth, preterm birth, SGA, or LGA.

CONCLUSIONS

Our study did not identify associations between preconception and prenatal arsenic exposure, defined by drinking water exceedances, and adverse birth outcomes. Exposure to arsenic violations in drinking water was associated with higher birth weight. Future studies would benefit from more precise geodata of water system service areas, direct household drinking water measurements, and exposure biomarkers.

Birth preparedness and complication readiness: Evaluating the "know-do" gap among women receiving antenatal care in Benin City, Nigeria

Across several African countries, birth preparedness and complication readiness (BPACR) among pregnant women is poor. The practice of BPACR, though improving in recent years, is not commensurate with the knowledge available to pregnant women. Maternal health indices remain sub-optimal. This study evaluates the determinants of this "know-do' gap among women receiving antenatal care at a secondary health facility in Benin City, Nigeria. A cross-sectional study involving 427 pregnant women was conducted between October and December 2020 using a structured interviewer-administered questionnaire. The prevalence of knowledge and practice were described, and the determinants of BPACR practice evaluated using bivariable (chi-square) analysis and multivariable ordinal logistic regression with post-estimation predictive margins analysis. About 77% of respondents had good birth preparedness practice. Multivariable regression revealed that respondents with poor knowledge and moderate knowledge of components of BPACR had statistically significant lower odds (OR:0.05 (95% CI: 0.02-0.13) and 0.10 (95% CI: 0.03-0.30) times, respectively) for greater practice of BPACR when compared to those with good knowledge. Respondents with poor knowledge of danger signs had statistically significant lower odds (OR: 0.08 (95% CI: 0.03-0.26) for greater practice of BPACR when compared to those with good knowledge. But predictive margins analyses demonstrates that knowledge, though critical to practice, is insufficient to optimize practice. The optimum number of danger signs women need to know to improve practice may be between eight to ten. Beyond this number, practice may not change significantly. Other predictors of BPACR practice include income level, parity, gravidity, and residential settings. The number of antenatal clinic visits had no statistically significant correlation with BPACR practice. Interventions to facilitate practice at the community level may be helpful to improve outcomes and bridge the know-do gap with respect to BPACR within the study context.

Looking Back, Visioning Forward: Preconception Health in the US 2005 to 2023

Preconception health has always been about preventative health care, ensuring the overall wellbeing of people of reproductive age before they have children. However, just as public health and health care have shifted to prioritize equity and include ideas about how social determinants of health influence health outcomes, the field of preconception health has experienced a similar transition. The purpose of this paper is to provide an overview of the evolution of preconception health in the United States after 2005, highlighting the key tensions that have shaped the field. We provide an overview of the early history of the movement and describe how four phases of ideological tensions overtime have led to changes across seven categories of preconception health: definitions and frameworks, surveillance and measurement, messaging and education, strategic convenings and collaborations, clinical practice, and reproductive life planning. We also describe the historic and emerging challenges that affect preconception care, including limited sustained investment and ongoing threats to reproductive health. The vision of preconception health care we outline has been created by a diversity of voices calling for wellness, equity, and reproductive justice to be the foundation to all preconception health work. This requires a focus on preconception health education that prioritizes bodily autonomy, not just pregnancy intentions; national surveillance and data measures that center equity; attention to mental health and overall well-being; and the inclusion of transgender and non-binary people of reproductive age.

Metagenomic analysis reveals a dynamic microbiome with diversified adaptive functions that respond to ovulation regulation in the mouse endometrium

Understanding the microflora inhabiting the reproductive tract is important for a better understanding of female physiology and reproductive health. The endometrial fluid from mice in three reproductive stages (A: Unproductive mice; B: Postovulatory mice; C: Postpartum mice) was extracted for microbial DNA extraction and sequencing. Phenotypic and functional analyses of endometrial microbial enrichment was undertaken using LefSe. The results showed 95 genera and 134 species of microorganisms in the uteri of mice. There were differentially distributed genera, among which Lactobacillus, Enterococcus, and Streptococcus were more abundant in the endometrial fluid of mice in the unproductive group. That of mice in the postovulatory group was colonized with Salmonella enterica and Campylobacter and was mainly enriched in metabolic pathways and steroid biosynthesis. The presence of Chlamydia, Enterococcus, Pseudomonadales, Acinetobacter, and Clostridium in the endometrial fluid of postpartum mice, in addition to the enrichment of the endocrine system and the Apelin and FoxO signaling pathways, resulted in a higher number of pathogenic pathways than in the other two groups. The results showed that the microbial diversity characteristics in the endometrium of mice in different reproductive states differed and that they could be involved in the regulation of animal reproduction through metabolic pathways and steroid biosynthesis, suggesting that reproductive diseases induced by microbial diversity alterations in the regulation of animal reproduction cannot be ignored.

Socio-cultural Norms and Gender Equality of Ethnic Minorities in Vietnam

BACKGROUND

Thirty years ago, Vietnam was a poor low-income country; since then, it has accomplished remarkable achievements in socio-economic development, not least in its high rate of poverty reduction. But cultural stereotypes remain a root cause of inequality for women and girls, forming a barrier to accessing opportunities in education, health care, and in receiving equal treatment.

METHODOLOGY

This paper used a variety of methods, including a literature review of cultural stereotypes and gender equality and a survey of gender equality for ethnic minorities covering 2894 households by IFGS in 2019. It analyzed the correlation between different variables, including gender, ethnicity, family type, parents' perception about opportunities for ethnic minority girls for schooling, health care, and equality of treatment. In addition, this article uses material from qualitative data collected from 15 in-depth interviews and life stories.

RESULTS

Traditional gender stereotypes are a major obstacle to achieving gender equality for women and girls. Customs and cultural practices ground prejudices against women and girls in the perception of numerous ethnic minorities in Vietnam. Being perceived as the breadwinner for their family, ethnic women have to participate in the labor force, in addition to taking care of other family members. Furthermore, they lack opportunities to communicate outside their small community. Therefore, in some ethnic minorities, there is a high rate of girls experiencing child marriage, and early pregnancies are more likely; this significantly affects their development and results in negative consequences for nutrition and maternal and child health care. In addition, girls who have an early marriage to satisfy their parents' desire have to drop out of school and limit their social interactions. Different causes, such as limited awareness, attachment to traditional beliefs, and parents' prejudice (that schooling is prioritized for boys), have locked adolescent girls into a vicious circle of child marriage and school dropout. This is also the reason for the high illiteracy rate of ethnic minority women in Vietnam.

CONCLUSIONS

Traditional stereotyped gender perceptions have become major barriers to the development of ethnic minority girls and women in Vietnam. Child marriage and teenage pregnancy stem from the notion that girls do not need to be educated, but should join the workforce as early as possible and take care of their families; the result is a wide range of negative consequences, including keeping girls away from school and social interaction. Ethnic minority women have a high rate of illiteracy and social communication constraints, leading to their poor access to health care services. The spiral of gender inequality toward ethnic minority girls and women in Vietnam is still ongoing as parents' perceptions have not changed. Ethnic minority girls and women continue to be marginalized by the barriers of gender stereotypes and traditional culture.

Sexual and reproductive health problems among women with mental illness attending tertiary care psychiatric outpatient clinic in India: A cross-sectional study

Objectives

Sexual and reproductive health (SRH) is a vital concern among women with mental illness (WMI) due to the increased risk for unplanned pregnancy, sexually transmitted infections (STIs), and poor obstetric outcomes. Objective of the study was to explore the current use of family planning (FP) methods, symptoms of STIs and sexual dysfunction among WMI.

Materials and Methods

This descriptive study involved 404 WMI of reproductive age (18-49 years) attending tertiary care psychiatric outpatient clinics in India. During face-to-face interviews, centers for disease control and prevention (CDC)-reproductive health assessment toolkit-FP questionnaire, STI questionnaire and Female sexual function index (FSFI) were used to collect the data.

Results

Of 404 WMI, 261(64.6%) were users, and 137 (33.9%) were non-users of FP methods. About 6(1.5%) WMI did not respond FP methods question. Female sterilization was the highest among the users, 244(93%). Among non-users, 100 (73%) were unaware of choosing the effective method of FP. Most of the WMI, 377(93.3%), were unaware of STIs. The symptoms of STI reported include unusual genital discharge 62(15.3%) and genital ulcers/ sores 58(14.4 %). Most of them, 76(63.3%), were not on any treatment. The most common reason for not taking treatment was feeling ashamed 70(92.1%). Female sexual dysfunction was reported in 176(43.6%). Most of the WMI had difficulties in the arousal domain 288(71.3%), followed by low desire 233(57.7%) and dissatisfaction 186(46%).

Conclusion

Most WMI underwent sterilization. Non-users of FP methods were not aware of choosing the effective method. Awareness about STIs was poor, and feeling ashamed was the primary reason for not availing of medical help. Nearly half of the WMI reported sexual dysfunction, among which arousal difficulties, low desire and dissatisfaction were common. Health professionals need to increase awareness about FP methods and symptoms of STIs among WMIs. Women require appropriate counselling regarding SRH and treatment for sexual dysfunction.

Advancing Access to Care through Digital Health: Perspectives from Youth on a Novel Platform to Increase Access to Sexual and Reproductive Health Care and Education for Adolescents and Young Adults

STUDY OBJECTIVE

Youth account for half of new sexually transmitted infections (STIs) in the United States annually. Barriers to STI prevention include a lack of accurate sexual and reproductive health (SRH) education and low STI testing. We sought to obtain youth feedback on a digital health platform prototype designed to address these barriers.

METHODS

The platform prototype included SRH content, free STI testing and treatment, and anonymous question submission. Five focus group discussions, each lasting 45-60 minutes with 5-6 youth living in a high-prevalence STI region (Baltimore, Maryland), were conducted. Thematic analysis was conducted.

RESULTS

There were 28 participants with a mean age of 15.9 years (range 14-19), among whom 89% self-identified as female, 57% Black/African American, 29% Asian American, 14% White, and 7% Hispanic/Latino. Youth felt that the prototype platform was comprehensive and understandable. They suggested adding peer reviews to increase trustworthiness.

CONCLUSION

Youth reported that the platform (violetproject.org) was an acceptable tool for SRH education and STI testing. Participants expressed enthusiasm and willingness to use the platform as a reliable SRH educational tool to combat medical misinformation on the Internet and a non-clinic-based source of STI testing. This platform could fill gaps in access to SRH care and education for youth.

Developing the sexual and reproductive health knowledge scale in emergencies

OBJECTIVE

This study aims to develop the The Sexual and Reproductive Health Knowledge Scale in Emergencies (SRHKE) to evaluate the sexual and reproductive health knowledge of nurses in exceptional circumstances and cases.

METHOD

This methodological study was conducted with a total of 311 nurses from two hospitals in the Western Black Sea Region of Turkey between December 2021 and May 2022. The data were collected using a descriptive information form and SRHKE. The content validity, construct validity, and internal consistency of the scale were tested.

RESULTS

The scale had a four-factor structure, and these factors explained 65% of the total variance in the measured variable. It had high internal consistency (Cronbach's alpha coefficient values were 0.826 for the 1st factor, 0.814 for the 2nd factor, 0.788 for the 3rd factor, 0.723 for the 4th factor, and 0.896 for the total scale). The item-total score correlation values of the scale ranged from 0.479 to 0.659. Pearson's correlation coefficients calculated for the evaluation of construct validity ranged from 0.519 to 0.749 (p < 0.005).

CONCLUSION

SRHKE has high validity and reliability. The scale can be used by nurses in Turkish society to determine their levels of sexual and reproductive health knowledge in emergencies.

Association of Social Determinants of Health, Race and Ethnicity, and Age of Menarche among US Women Over 2 Decades

INTRODUCTION

Age of menarche (AOM), or the first menstrual cycle, is one indicator of female puberty. The timing of AOM can be influenced by social determinants of health (SDOH). This study examined associations between SDOH and AOM over the past 2 decades in the United States.

METHODS

US National Health and Nutrition Examination Survey data (1999 to early 2020) were analyzed. Multinomial logistic regression analyses examined associations between AOM (early [11.99 years and younger], typical [12-13 years], and late [13.01 years and older]) and race/ethnicity, insurance coverage, education, family income-to-poverty ratio, money management, and home status.

RESULTS

AOM remained consistent over the past 2 decades (mean 12.50 years, SE 0.02) for the aggregate sample. Females identifying as Hispanic (excluding Mexican Americans) were 63% more likely (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.13-2.36) to report early menarche. Those identifying as other/multiracial were 46% more likely to report late menarche (aOR 1.46, 95% CI 1.13-1.89) vs non-Hispanic Whites. Financial and home status instability was associated with early menarche (aOR 1.46, 95% CI 1.17-1.83; aOR 1.25, 95% CI 1.05-1.48). Less than 9th-grade education was associated with late menarche (aOR 1.47, 95% CI 1.14-1.89).

CONCLUSION

Although the average AOM has remained stable in the United States over the past 20 years, identifying as Hispanic (excluding Mexican Americans) and financial/home instability are associated with early AOM, and lower education levels are associated with late AOM. Identifying programming and policy options targeting SDOH may help improve current and future reproductive health.

Exploring the prevalence of abortion and its characteristics in Perú

OBJECTIVES

Our paper presents the analysis of a nationwide survey that explored induced abortion among women using a ballot-box technique. Our objective was to determine the prevalence of abortion and the main characteristics of the procedure.

STUDY DESIGN

We conducted surveys in households with 2400 women aged 18-49 from urban areas nationwide, between October 15 and 29, 2018. Data collection was overseen by the Instituto de Opinión Pública de la Universidad Católica del Perú. We performed a probabilistic, multistage, and socioeconomic level-stratified sampling. Our study used the "ballot-box technique" to ensure anonymity and reduce the risk of social desirability.

RESULTS

We visited 15,433 houses nationwide. Among those households where surveys could not be conducted, it was due to abandoned or inaccessible property, unwilling to participate, absent members, out of quota, or inconclusive survey. On average, 19.0% of Peruvian women at all socioeconomic levels reported having had at least one abortion in their lifetime. Induced abortion is reported at all socioeconomic levels and reported age of the abortion is concentrated between 19 and 29 years old. In 57.7% of cases, women sought healthcare personnel for their last induced abortion. Among them, procedure abortion (45.3%) stands out over medical abortions (34.0%). Thirty-three percent of women who reported having had at least one induced abortion in their lifetime were admitted to a hospital after their last abortion.

CONCLUSIONS

The illegality of abortion has not prevented its occurrence in Peru. Our results suggest that, in Peru, legal restrictions on induced abortion create an unfavorable context for women's health, exposing them to services whose safety is not guaranteed. Efforts should be made to increase awareness and education about contraception and family planning methods to prevent unwanted pregnancies and reduce the need for abortion.

IMPLICATIONS

These findings should be considered in public policy discussions regarding abortion, since they might have a great impact for better decision making. They demonstrate that legal restrictions have not prevented the occurrence of abortion but has only created unsafe conditions around it.

Systems analysis reveals differential expression of endocervical genes in African women randomized to DMPA-IM, LNG implant or cu-IUD

Although effective contraceptives are crucial for preventing unintended pregnancies, evidence suggests that their use may perturb the female genital tract (FGT). A comparative analysis of the effects of the most common contraceptives on the FGT have not been evaluated in a randomized clinical trial setting. Here, we evaluated the effect of three long-acting contraceptive methods: depot medroxyprogesterone acetate(DMPA-IM), levonorgestrel(LNG) implant, and a copper intrauterine device (Cu-IUD), on the endocervical host transcriptome in 188 women from the Evidence for Contraceptive Options and HIV Outcomes Trial (ECHO) trial. Cu-IUD usage showed the most extensive transcriptomic changes, and was associated with inflammatory and anti-viral host responses. DMPA-IM usage was enriched for pathways associated with T cell responses. LNG implant had the mildest effect on endocervical gene expression, and was associated with growth factor signaling. These data provide a mechanistic basis for the diverse influence that varying contraceptives have on the FGT.

Current Progress in Stem Cell Therapy for Male Infertility

Infertility has become one of the most common issues worldwide, which has negatively affected society and infertile couples. Meanwhile, male infertility is responsible for about 50% of infertility. Accordingly, a great number of researchers have focused on its treatment during the last few years; however, current therapies such as assisted reproductive technology (ART) are not effective enough in treating male infertility. Because of their self-renewal and differentiation capabilities and unlimited sources, stem cells have recently raised great hope in the treatment of reproductive system disorders. Stem cells are undifferentiated cells that can induce different numbers of specific cells, such as male and female gametes, demonstrating their potential application in the treatment of infertility. The present review aimed at identifying the causes and potential factors that influence male fertility. Besides, we highlighted the recent studies that investigated the efficiency of stem cells such as spermatogonial stem cells (SSCs), embryonic stem cells (ESCs), very small embryonic-like stem cells (VSELs), induced pluripotent stem cells (iPSCs), and mesenchymal stem cells (MSCs) in the treatment of various types of male infertility.

Infertility Burden Across Indian States: Insights from a Nationally Representative Survey Conducted During 2019-21

Background

Infertility is an escalating global concern, impacting approximately one-sixth of the reproductive age population worldwide. Employing data from the National Family Health Survey-5 (NFHS-5, 2019-21), this study assessed the prevalence of primary infertility at both national and state levels in India.

Methods

The data of the study was extracted from the National Family Health Survey and Individual file (women file) of the fifth round of NFHS encompassing a sample of 491,484 currently married women in the age group of 15-49 years.

Results

The findings showed that the prevalence of infertility is 18.7 per 1,000 women among those married for at least five years and currently in union. This prevalence increases as the duration of marriage decreases. On a state-level analysis, regions such as Goa, Lakshadweep, and Chhattisgarh exhibit the highest burdens.

Conclusion

These findings underscore the growing challenge posed by primary infertility in India, calling for targeted interventions and policy measures. The establishment of a national infertility surveillance system is of pivotal importance in addressing this pressing public health issue.

Meaning of having to cope with voluntary termination of late pregnancy in women undergoing the procedure in healthcare institutions of two Colombian cities

Objectives

As part of sexual and reproductive health, abortion is a woman’s right in Colombia. However, not all the members of Colombian society recognize this right. The aim of this work is to understand the transformation of meanings after having to cope with voluntary termination of late pregnancy in women living in Colombia, as well as their interaction with family and friends and the health system.

Material and methods

Hermeneutic research undertaken within a constructivist paradigm and analyzed from a feminist perspective using grounded theory techniques: coding, categorization and constant comparison. Nineteen semi-structured interviews were conducted among 18 women living in Colombia who underwent voluntary termination of late pregnancy defined as more than 20 weeks of gestation, accompanied by feticide and labor induction, in two Colombian cities between 2016 and 2020. Besides, two focus groups were conducted, one with some of the interviewees and another with feminist experts in order to cross-reference the information derived from the research process and delve deeper into the findings.

Results

Women attached a negative and opposite meaning to voluntary termination of pregnancy, but once they found themselves in a situation that forced them to put an end to gestation, they transgressed their own meanings and those of society to find justifications to help them uphold their decision. This confrontation brought them to a place of profound and intimate reflection and led them to transform their lives.

Conclusions

Meanings regarding abortion in women who undergo late pregnancy termination are usually contrary to this right in sexual and reproductive health. After the event, these meanings become transformed through a process of conscious reflection as women come face-to-face with their own meanings and those of society.

Knowledge and practices of preconception care among rural Japanese women: findings from a mixed methods investigation

BACKGROUND

Preconception care is not widespread in Japan and there is a pressing need to improve the practice. The present study assessed the knowledge and behavior of preconception care among women to seek effective intervention. Our research questions were: 1) How much do women know about preconception care? 2) How much are they practicing preconception care and what are the information sources of their behavior? 3) Do the women's preconception care behavior associated with accurate knowledge?

METHODS

The research was conducted in a rural town in central Japan. Using an exploratory sequential mixed methods design, we undertook interviews, developed a survey based on the qualitative results, and then conducted a survey. The interviews explored how preconception care was perceived and practiced in women of childbearing age. The survey was designed to investigate the knowledge of preconception care among women with and without pregnancy experience, their practice behavior of preconception care, and whether the behavior is associated with knowledge.

RESULTS

The participants were 13 for the interview and 232 for the survey. They had limited access to preconception care recommendations and advice for specific actions was given by obstetricians and gynecologists after pregnancy. There was a large gap in knowledge about preconception care between parous and nulliparous women, especially about the need for folic acid supplementation. Practices that were manageable in their daily lives, such as cessation of smoking and alcohol, diet, and weight management, were considered common sense. In contrast, recommended practices that require medical attention, such as screening for sexually transmitted diseases and cervical cancer, tended to be less accurately known and practiced. Participants' sources of information about preconception care were the Internet, family and friends and mass media.

CONCLUSION

In rural Japan, women of childbearing age lack knowledge about preconception care, especially before their first pregnancy. Primary care providers should try outreach to schools and women's groups in the community, promote information sharing among family and close friends, and utilize information technology to enhance the knowledge and practice of preconception care.