BackgroundCervical cancer disparities persist among minoritized women due to infrequent screening and poor follow-up. Structural and psychosocial barriers to following up with colposcopy are problematic for minoritized women. Evidence-based interventions using patient navigation and tailored telephone counseling, including the Tailored Communication for Cervical Cancer Risk (TC3), have modestly improved colposcopy attendance. However, the efficacious TC3 intervention is human resource-intense and could have greater reach if adapted for mobile health, which increases convenience and access to health information. ObjectiveThis study aimed to describe feedback from clinic staff members involved in colposcopy processes and patients referred for colposcopy regarding adaptions to the TC3 phone-based intervention to text messaging, which addresses barriers among those referred for colposcopy after abnormal screening results. MethodsSemistructured depth qualitative interviews were conducted over Zoom [Zoom Communications, Inc] or telephone with a purposive sample of 22 clinic staff members (including clinicians and support staff members) and 34 patients referred for colposcopy from 3 academic obstetrics and gynecology (OB-GYN) clinics that serve predominantly low-income, minoritized patients in different urban locations in New Jersey and Pennsylvania. Participants were asked about colposcopy attendance barriers and perspectives on a proposed text message intervention to provide tailored education and support in the time between abnormal cervical screening and colposcopy. The analytic team discussed interviews, wrote summaries, and consensus-coded transcripts, analyzing output for emergent findings and crystallizing themes. ResultsClinic staff members and patients had mixed feelings about a text-only intervention. They overwhelmingly perceived a need to provide patients with appointment reminders and information about abnormal cervical screening results and colposcopy purpose and procedure. Both groups also thought messages emphasizing that human papillomavirus is common and cervical cancer can be prevented with follow-up could enhance attendance. However, some had concerns about the privacy of text messages and text fatigue. Both groups thought that talking to clinic staff members was needed in certain instances; they proposed connecting patients experiencing complex psychosocial or structural barriers to staff members for additional information, psychological support, and help with scheduling around work and finding childcare and transportation solutions. They also identified inadequate scheduling and reminder systems as barriers. From this feedback, we revised our text message content and intervention design, adding a health coaching component to support patients with complex barriers and concerns. ConclusionsClinic staff members and patient perspectives are critical for designing appropriate and relevant interventions. These groups conveyed that text message-only interventions may be useful for patients with lesser barriers who may benefit from reminders, basic educational information, and scheduling support. However, multimodal interventions may be necessary for patients with complex barriers to colposcopy attendance, which we intend to evaluate in a subsequent trial.

OBJECTIVE:Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy. METHODS:We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti. RESULTS:We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion. CONCLUSION:Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments. PRACTICE IMPLICATIONS:Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.

Abstract Objective In 2015, a multidisciplinary consensus bundle of recommendations for the anticipation and management of postpartum hemorrhage was published. Our goal was to evaluate the successes and failures of our institutional bundle implementation process. Study Design An interdisciplinary committee was created to facilitate bundle implementation. All components of the bundle were addressed with cross-disciplinary teaching between stakeholders on the obstetrics units. Tools were built in the electronic medical record to facilitate bundle components of risk stratification, quantitative blood loss calculation, and stage-based hemorrhage management. Bundle components were individually evaluated for acceptability and sustainability. Overall rates of hemorrhage and transfusion from the periods 1 year before and after bundle implementation were also evaluated. Results Readiness bundle components were successfully implemented, although simulation drills demonstrated limited sustainability. Recognition components were mixed: risk stratification was successfully and sustainably implemented while quantitative blood loss met resistance and was ultimately discontinued as it did not clinically perform superiorly to estimated blood loss. Among response and reporting elements, patient level support and team debriefing were noted as particular deficiencies in our program. Conclusion The postpartum hemorrhage patient safety bundle provided concrete individual elements, which overall improved the success of a stratified program implementation. Multiple deficiencies in acceptability and sustainability were uncovered during our process, particularly concerns about quantitative blood loss implementation and team communication skills. Key Points Supply readiness and protocol development were “quick wins.” Culture change elements included recognition, response, and communication. Dedicated champions and electronic medical record tools improved sustainability. Poor acceptability and lack of improved outcomes led to element failure.

To determine the performance characteristics of AmnioTectTM to detect premature rupture of membranes (PROM) by distinguishing amniotic fluid from urine, among pregnant women experiencing leaking or perineal moisture. Prospective multicenter observational study comparing self-assessment with blinded investigator assessment using AmnioTect TMin women presenting for PROM evaluation between December 2016 to October 2017. Eligible women were asked to wear and interpret the AmnioTect TMaccording to instructions for use. The same pad was independently evaluated by a blinded health care provider (HCP) and both the patient and HCP assessments were compared to standard clinical PROM evaluation by sterile speculum exam. The presence of amniotic fluid and the diagnosis of PROM was established when pooling was observed along with either positive nitrazine and/or positive ferning test. The primary outcome was to compare patient use of AmnioTectTM to clinical diagnosis and secondarily to compare patient to HCP interpretation. A total of 244 women were recruited, but only 240 were analyzed with complete results. The mean age was 27.7 years (SD: 5.46), with a range 18.2 - 40.9. The mean gestational age at enrollment was 36.7 weeks, with a range of 18.9 - 41.4 weeks. Only 3 patients were < 24 weeks and 16 (6.6%) patients were < 28 weeks. The cohort was racially and educationally diverse. Only 36% of the cohort had > high school education and 58% had either completed or had some high school education. The prevalence of confirmed PROM was 45% (108/240). The patient interpreted AmnioTectTMas positive in 103/108 yielding a sensitivity of 95.4% and a specificity of 96.2% (127/132). The overall concordance between the HCP reading the AmnioTectTMresult and that of the patient was 99.6% (239/240). The PPV: 95.4% (103/108) and the NPV: 96.2 (127/132). The performance characteristics of AmnioTectTMcompare favorably when interpreted by a patient or a HCP. AmnioTectTMserves as a good screening for the outpatient detection of PROM.

INTRODUCTION: The rate of cesarean section (CS) delivery, has been generally increasing worldwide. Although the US has been cited for this increasing rate, the trend is more pronounced in areas of China, which has drawn substantial efforts from the Chinese government and health care professionals to try to reduce the CS rate to the WHO recommended level. This abstract will review the major causes associated with high cesarean rate in China and explore effective interventions addressing the issue. METHODS: A literature review was conducted in WHO world reports, Chinese government statistics, PubMed and Chinese databases WANFANG and VIP using the key terms “cesarean section”, “intrapartum management”, “psychological intervention”. RESULTS: The leading medical indications of CS in China were fetal distress, cephalopelvic disproportion, malpresentation, previous cesarean delivery, elderly primigravida and suspected macrosomia, which were comparable to the US data. Notably, cesarean delivery also occurred in 10-38.4% of the total CS number, largely resulting from sociological and psychological reasons, such as best outcome for one child family. Interventions to reduce CS in China include 1) Government and regional health commissions implementing incentives and regulations to set target CS rate limits for hospitals; 2) Prenatal patient education, focusing on understanding the course and mode of delivery; 3) Full intrapartum accompaniment by an experienced nurse or midwife. CONCLUSION: Reducing cesarean deliveries beyond medical necessity is a multifactorial, challenging task, faced by many countries, and is not limited to the US. China also is implementing initiatives to stem the high cesarean delivery rate.

From 2011 to 2015, a total of 67 patients were referred for IUD insertion guided with transabdominal sonography (TAS). Fifty-six of the 67 patients had successful IUD insertion under TAS guidance. The clinical indications for referral included fibroids, uterine position, previous history of IUD expulsion, and limited tolerance of pelvic examination. Reasons for failed TAS-guided IUD insertion included patient discomfort, cervical stenosis, and inability to remove and replace an existing device. Ultrasound guidance could help broaden the patient population that may benefit from the therapeutic value of an IUD.

INTRODUCTION: Reproductive risk assessment, STI prevention and contraception counseling represent an emerging challenge in the transgender population. Despite increased awareness of transgender healthcare needs, provider templates of care based on evidence based data that address the reproductive healthcare needs of transgender individuals are limited. METHODS: We performed a literature search using Pub Med, Scopus and Google Scholar between 2010-2016. Search terms used included transgender, pregnancy, contraception, and STI. Of the six relevant articles, three were cross sectional surveys and three were retrospective cohort studies. RESULTS: Among transgender youth, contraception use did not differ between those at risk for pregnancy vs those not at risk. As expected, sexual activity was associated with higher STI risk. Positive HIV status did not differ in transmen compared to transwomen: overall HIV prevalence was higher in the trans vs non-trans population. Unprotected sex may be a factor with STI. In one study, 88% of transmen reported using no protection. Further, pregnancy appears to be desired in select transmen, as one study noted that 68% in their cohort had a planned gestation while 32% had an unplanned one. CONCLUSION: There are limited data to formulate guidelines regarding pregnancy, STI counseling and contraceptive management of transgender individuals. Both pregnancy risk/desire exists in this population and should be a counseling topic. In addition, contraceptive and STI counseling is essential during all clinical encounters. For those at risk for HPV coinfection continued gynecological surveillance should be part of their preventive health management.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

Objective: As more postreproductive women opt to pursue pregnancy with advanced assisted reproductive technologies (ART), the menopausal practitioner will become more involved in counseling, screening, and referral of premenopausal, perimenopausal, and postmenopausal women for these services. This review was conducted with the aim of (1) evaluating ART screening practices as they pertain to postreproductive women, and (2) reviewing the outcomes of ART using oocyte donation in postreproductive women.Methods: A total of 950 unique records were found on PubMed, Clinical Key, and Google Scholar. Of these, 252 records were screened for relevance based on their titles and abstracts. With further review of these 252 records, 93 full-text articles were assessed for eligibility, and 63 were excluded based on relevance to our study. Finally, 30 studies were included in our qualitative synthesis.Results: Despite the increasing use of ART in postreproductive women, there are limited guidelines for determining candidacy with regard to maternal health, the most comprehensive of which are the guidelines from the American Society for Reproductive Medicine (ASRM). Although the American Society for Reproductive Medicine guidelines state that healthy women over 50 who are prepared for parenthood are candidates for ART through oocyte donation, they note that older women should be counseled as to the increased obstetric risk associated with advanced maternal age. With aging, particularly for those women who are menopausal and postmenopausal, the woman and her fetus, however, are at risk of increased morbidity and mortality as compared with younger, healthy pregnant women. Because national trends suggest that women are delaying childbearing, the cohort of postreproductive women looking toward ART using donor oocytes as a fertility option will expand and menopausal practitioners will often participate in the ART counseling of these women.Conclusions: Because maternal and fetal morbidity and mortality increase in postmenopausal women who become pregnant through ART, practitioners caring for this cohort should provide input into developing standardized, comprehensive guidelines for this population so that screening is consistent for all older women seeking this intervention and risks are objectively outlined and considered.

INTRODUCTION: Over the past two decades women have increased their presence in male dominated sports (football-5x, wrestling-14x, baseball and weightlifting-4x in high school athletics). Studies suggest that high intensity vs lower intensity exercise pose specific endocrine and metabolic risks to the female athlete, which gynecologists should address during office visits. METHODS: A PubMed review of articles and web reports was conducted on adverse medical consequences occurring to female athletes engaged in high intensity activities. RESULTS: Weight fluctuations, such as in wrestling or weight lifting, commonly occur. Low energy intake from high protein, low carbohydrate diets for required muscle mass retention and growth may lead to increased risks of developing exercise-related delayed menarche, menstrual dysfunction (ExMD), poor bone health, muscle damage and changes in muscle repair processes, lipid and leptin changes and other adverse endocrine and metabolic changes. Additionally, ExMD has been linked to health consequences such as cardiovascular dysfunction, endothelial dysfunction, and abnormal metabolic hormonal profile. Of greatest immediate concern is the potential muscle damage and alterations in the muscle repair process caused by low estrogen levels, which can hinder athletes from obtaining their highest level of sports performance. CONCLUSION: With several adverse consequences to female athletes resulting from high intensity sports, gynecologists should inquiry about sports participation to determine the type of sport (whether it is high impact, non-contact, etc.) dietary restrictions, body mass, menstrual issues, previous fracture and use of performance-enhancing drugs, hormones and anabolic steroids.

Background: Occurrence and consequence of cord blood (CB) vitamin D insufficiency/deficiency has not been adequately explored despite rising concern regarding this topic in pediatrics. This study was designed to determine the rate, maternal risk factors, and clinical outcomes in infants in association with vitamin D insufficient/deficient status at birth.Methods: American Academy of Pediatrics (AAP) defined levels (ng/mL) were utilized to categorize the vitamin D status in CB samples as deficient (5-15), insufficient (16-20), and sufficient (21-100). We used descriptive statistics and multiple regression models to identify the rate and factors associated with vitamin D deficiency/insufficiency and related outcomes in the enrolled mother-infant pairs.Results: This prospective study was conducted at a single center on postpartum women and their infants. Vitamin D deficiency and insufficiency was recorded in 38.9 and 29.8% respectively of the 265 CB samples. Deficient CB vitamin D levels in infants were associated with maternal Black, Hispanic, or Asian race/ethnicity, younger age, and increased number of pregnancies. The likelihood for infants to be born with an insufficient vitamin D level increases with younger maternal age and the number of pregnancies as well as Asian ethnicity. We did not find an association between the vitamin D status at birth and pre-discharge clinical characteristics of the neonates.Conclusions: The likelihood for an infant to be born with vitamin D deficiency/insufficiency is relatively high and is related mainly to younger maternal age, gravidity, and non-White race/ethnicity. Our findings raise a question regarding the adequacy of the AAP recommended vitamin D supplementation requirements without knowing the infant's vitamin D status at birth.

Cystic fibrosis (CF), which was once considered a fatal childhood illness, is now manageable with advances in treatment. Progressive damage to the lung and intestinal systems are caused by the cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation. The most commonly known gynecologic complications of cystic fibrosis involve infertility, namely amenorrhea, ovarian dysfunction and chronic anovulation. The majority of these endocrine disorders affect reproductive-aged females. Recent research suggests CFTR is expressed in the fallopian tubes, cervix and endometrium. Females with cystic fibrosis have been noted to have multicystic ovaries, much like those observed in Polycystic Ovarian Syndrome (PCOS). Reproductive tract effects of the CFTR mutation are believed to be present as early as the initiation of puberty, providing a mechanism for ovarian cyst formation. This case will demonstrate the importance of recognizing ovarian pathology as a cause for acute onset abdominal pain in the adolescent female CF patient.

OBJECTIVE:To evaluate the effectiveness of a breastfeeding promotion program in the Women, Infant and Children (WIC) Supplemental Nutrition Program participants.STUDY DESIGN:This randomized clinical trial included 52 women in the intervention group who received one-to-one pre- and postnatal breastfeeding education and support from a lactation consultant. Women (n = 52) randomized to controls received standard breastfeeding services. Data regarding their infants' feeding (classified as exclusive, partial, and bottle) during the first 7 days, 1, 2, and 3 months of age were compared. Additionally, the mothers were surveyed to assess their knowledge, attitude, and beliefs regarding breastfeeding.RESULTS:Among the 104 enrolled women, 91 (87.5%) were Hispanic. Almost all the pregnant women had planned to breastfeed their infants. Although the majority of women reported breastfeeding their infants, 45.6% in the intervention group and 28.9% of controls practiced exclusive breastfeeding during the first 7 days. By 3 months, the rate of exclusive breastfeeding in the intervention and control groups had dropped to 13.9% and 10.5%, respectively. Parity, mode of delivery, previous experience with breastfeeding, rooming in, and return to work did not significantly affect the exclusive breastfeeding rate. Maternal knowledge, attitude, and beliefs regarding breastfeeding were comparable between the study groups at the baseline stage as well as 3 months postpartum.CONCLUSIONS:Participation in the proposed breastfeeding promotion program by the low-income mothers was associated with an insignificant increase in the exclusive breastfeeding rate during the first 3 postpartum months.

OBJECTIVE: A study was conducted to develop a short, easy to administer screening tool useful for stratifying women with unexplained menorrhagia for hemostatic testing for underlying bleeding disorders. STUDY DESIGN: One hundred forty-six women with a physician diagnosis of menorrhagia underwent comprehensive hemostatic testing for the diagnosis of bleeding disorders, including von Willebrand disease, platelet dysfunction, and coagulation factor deficiencies. A 12 page questionnaire of bleeding symptoms was administered. Bleeding symptoms with high predictive values for laboratory hemostatic abnormalities were combined and used as single variables to calculate sensitivity, specificity, and positive and negative predictive values in order to develop a short screening tool to identify females for testing and evaluation. RESULTS: A combination of 8 questions in 4 categories resulted in a sensitivity of 82% (95% CI 75-90) for bleeding disorders. Adding a pictorial blood assessment chart score > 100 increased the sensitivity of the screening tool to 95% ( 95% CI 91-99). CONCLUSION: These results demonstrate the feasibility of a simple questionnaire based screening tool to identify females for testing and evaluation for bleeding disorders.

OBJECTIVE:Women need products that protect against both pregnancy and sexually transmitted infections, including human immunodeficiency virus (HIV). The acid buffering gel is a nondetergent spermicide that may provide this dual protection by reinforcing normal vaginal acidity to inactivate both sperm and acid-sensitive sexually transmitted pathogens. The objective of this study was to assess the gel's contraceptive effects, safety, and acceptability. METHODS:We conducted a multicenter, randomized, double-masked, noninferiority study at 11 centers, comparing 621 women who used an acid buffering gel plus diaphragm with 300 women who used a nonoxynol-9 spermicide plus diaphragm for 6 months. A double-masked study extension followed 234 women for an additional 6 months of use. RESULTS:The 6-month pregnancy rate per hundred women was 10.1% (95% confidence interval [CI] 7.1-13.1%) for acid buffering gel and 12.3 (95% CI 7.7-16.9) for nonoxynol-9 spermicide users. The difference in rates was -2.2% with a 95% CI -7.7 to 3.3%. Consistent and correct use 6-month pregnancy rates were 4.7% for acid buffering gel and 6.1% for nonoxynol-9 spermicide users, calculated from those cycles where diary entries indicated such use. Adverse events and acceptability were similar between the two groups. Pregnancy probabilities were similar between groups participating in the 12-month study extension. CONCLUSION:An acid buffering gel used with a diaphragm is a safe, acceptable contraceptive with efficacy comparable to that of a common commercial spermicide with diaphragm. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00065858 LEVEL OF EVIDENCE:I.

Menorrhagia is a common clinical problem among reproductive age women and 5% of women in the US seek medical attention annually for menorrhagia. Recent studies suggest that underlying bleeding disorders, particularly Von Willebrand disease and platelet dysfunction, are prevalent in women presenting with menorrhagia. However referral for comprehensive hemostatic evaluation of the substantial numbers of women with otherwise unexplained menorrhagia is problematic given the complexity, availability, and cost of hemostatic testing and the lack of effective point of care screening tests for this population. In the present study, we evaluated 146 women (ages 13–55 yrs) with unexplained menorrhagia in order to develop a simple screening tool for stratifying women for referral for comprehensive hemostatic evaluation and testing. Women with a physician diagnosis of menorrhagia were studied on days 3–9 of their menstrual cycle. ASA, NSAIDS, herbals and other potentially platelet function impairing medications were discontinued at least 14 days prior to study and estrogen based treatment was discontinued for at least 1 menstrual cycle. Women underwent comprehensive hemostatic testing including VWF, platelet aggregation and ATP release, and factor assays. A 12 page questionnaire was developed based on significant bleeding symptoms in a CDC study of women with known VWD (Drews CD, Dilley AB, Lally C, Beckman MG, Evatt B. J Am Med Womens Assoc 2002; 57:217–218) and was administered to study subjects. A combination of 8 questions in 4 categories, including history of duration/extent of menorrhagia, anemia treatment, excessive bleeding with hemostatic challenges, and family diagnosis, resulted in a sensitivity of 81% (95% CI 74–89) and positive predictive value 71% (95% CI 63–71) for hemostatic abnormalities. Adding a pictorial blood assessment chart score > 100 increased the sensitivity of the screening tool to 93% (95% CI 89–98). The data suggest that a simple 8 question screening tool with implementation of a pictorial blood assessment chart may be useful for physicians evaluating women presenting with menorrhagia to help determine which women to refer for comprehensive hemostastic testing and evaluation.