The shift to telehealth during the COVID-19 pandemic worsened digital health disparities, particularly for people experiencing homelessness who lack access to mobile devices. This pilot evaluation was designed to assess the preliminary impact of a novel emergency department (ED)-based phone distribution program. We conducted a mixed-methods observational pre–post-study evaluating the impact of a mobile phone distribution program at two urban EDs in Toronto, Canada, from November 2019 to May 2022. The quantitative component consisted of a retrospective cohort analysis of 309 patients, comparing healthcare utilization three months before and three months after phone distribution. The qualitative component involved 12 semi-structured interviews exploring participant experiences. The primary outcome was attendance at scheduled specialist appointments and the secondary outcome was ED utilization. Among the 309 participants, 67.6

Introduction SARS-CoV-2 is now endemic and expected to remain a health threat, with new variants continuing to emerge and the potential for vaccines to become less effective. While effective vaccines and natural immunity have significantly reduced hospitalisations and the need for critical care, outpatient treatment options remain limited, and real-world evidence on their clinical and cost-effectiveness is lacking. In this paper, we present the design of the Canadian Adaptive Platform Trial of Treatments for COVID in Community Settings (CanTreatCOVID). By evaluating multiple treatment options in a pragmatic adaptive platform trial, this study will generate high-quality, generalisable evidence to inform clinical guidelines and healthcare decision-making.Methods and analysis CanTreatCOVID is an open-label, individually randomised, multicentre, national adaptive platform trial designed to evaluate the clinical and cost-effectiveness of therapeutics for non-hospitalised SARS-CoV-2 patients across Canada. Eligible participants must present with symptomatic SARS-CoV-2 infection, confirmed by PCR or rapid antigen testing (RAT), within 5 days of symptom onset. The trial targets two groups that are expected to be at higher risk of more severe disease: (1) individuals aged 50 years and older and (2) those aged 18–49 years with one or more comorbidities. CanTreatCOVID uses numerous approaches to recruit participants to the study, including a multifaceted public communication strategy and outreach through primary care, outpatient clinics and emergency departments. Participants are randomised to receive either usual care, including supportive and symptom-based management, or an investigational therapeutic selected by the Canadian COVID-19 Outpatient Therapeutics Committee. The first therapeutic arm evaluates nirmatrelvir/ritonavir (Paxlovid), administered two times per day for 5 days. The second therapeutic arm investigates a combination antioxidant therapy (selenium 300 µg, zinc 40 mg, lycopene 45 mg and vitamin C 1.5 g), administered for 10 days. The primary outcome is all-cause hospitalisation or death within 28 days of randomisation.Ethics and dissemination The CanTreatCOVID master protocol and subprotocols have been approved by Health Canada and local research ethics boards in the participating provinces across Canada. The results of the study will be disseminated to policy-makers, presented at conferences and published in peer-reviewed journals to ensure that findings are accessible to the broader scientific and medical communities. This study was approved by the Unity Health Toronto Research Ethics Board (#22-179) and Clinical Trials Ontario (Project ID 4133).Trial registration number NCT05614349

Non-insured individuals face unique challenges when accessing emergency department (ED) care in Canada. This qualitative study explores the firsthand experiences of non-insured patients within the ED to understand how we can improve the system of care. This community-based research was conducted in collaboration with a community health center which has multiple service locations in Toronto, Ontario. 24 non-insured participants were recruited using a maximal variation sampling technique for semi-structured individual interviews. Participants must have received care as a patient in an ED in the last 3 years. We analyzed the data using Braun and Clarke’s thematic analysis framework. Interview participants felt unwanted and powerless, and faced health system navigation and access challenges. Subthemes include the anxiety of uncertainty regarding how to pay for ED care as well as concerns regarding insurance eligibility, healthcare access points, and language. Non-insured participants experienced stigma and discrimination; delayed care due to a lack of healthcare coverage; and difficulties with the ED registration and triage processes. The study also identified multiple instances where participants had positive experiences with clinicians and devised creative solutions to tackle challenges by engaging informal community networks and self-advocacy. Ways to improve the ED care of non-insured patients include providing ED care for all regardless of their healthcare coverage status, ameliorating clerical training, outlining clearer policies regarding payments, improving health system navigation, and fostering connections to community organizations. Many of the challenges that non-insured patients face may be applicable to other equity-deserving patient groups. By listening to and learning from the experiences of non-insured patients, a more equitable ED system can be built for this marginalized population.

Background: Workplace violence (WPV) in healthcare, particularly in emergency departments (EDs), is a growing and complex issue that significantly impacts healthcare providers (HCPs). Following the COVID-19 pandemic, the rates of WPV have increased globally, contributing to increased burnout, reduced morale, and heightened challenges in staff retention within EDs. Objective: This study aimed to explore HCPs' perspectives on WPV in EDs. The insights gathered were intended to inform targeted interventions in a quality improvement initiative focused on addressing WPV in our healthcare institutions. Methods: A qualitative study involving semi-structured interviews was conducted with 52 HCPs across two urban EDs at a multi-site academic health center. Participants from various roles and shifts shared experiences related to safety, leadership, training, and security. Interviews were recorded, transcribed, anonymized, and thematically analyzed to identify key themes surrounding WPV in EDs. Results: The thematic analysis identified four main themes, including (1) Violence is Part of the Job, (2) Leadership Dynamics regarding WPV, (3) Disconnect Among ED Staff During WPV Response, and (4) Enhancing Systems and Culture for Effective WPV Management. These themes provide a comprehensive view of HCPs' experiences and offer actionable recommendations for healthcare organizations seeking to address WPV. Conclusions: The study provides valuable qualitative insights into WPV in EDs, emphasizing the importance of addressing cultural, structural, and procedural gaps. These findings can guide the development of more supportive and effective strategies to create a safer environment for ED staff. Further rounds of interviews are planned post-intervention to assess changes in HCPs' perceptions and experiences.

OBJECTIVES:People experiencing homelessness and marginalization face considerable barriers to accessing healthcare services. Increased reliance on technology within healthcare has exacerbated these inequities. We evaluated a hospital-based prescription phone program aimed to reduce digital health inequities and improve access to services among marginalized patients in Emergency Departments. We examined the perceived outcomes of the program and the contextual barriers and facilitators affecting outcomes. METHODS:We conducted a constructivist qualitative program evaluation at two urban, academic hospitals in Toronto, Ontario. We interviewed 12 healthcare workers about their perspectives on program implementation and outcomes and analyzed the interview data using reflexive thematic analysis. RESULTS:Our analyses generated five interrelated program outcomes: building trust with patients, facilitating independence in healthcare, bridging sectors of care, enabling equitable care for marginalized populations, and mitigating moral distress among healthcare workers. Participants expressed that phone provision is critical for adequately serving patients who face barriers to accessing health and social services, and for supporting healthcare workers who often lack resources to adequately serve these patients. We identified key contextual enablers and challenges that may influence program outcomes and future implementation efforts. CONCLUSIONS:Our findings suggest that providing phones to marginalized patient populations may address digital and social health inequities; however, building trusting relationships with patients, understanding the unique needs of these populations, and operating within a biopsychosocial model of health are key to program success.

Background People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer. Methods Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients ( n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers ( n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data. Results Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department. Conclusions The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

Introduction While effective vaccines and natural immunity have significantly reduced hospitalizations and the need for critical care, SARS-CoV-2 is now endemic and is expected to continue to pose a threat to health. New variants are expected to continue to emerge, and vaccines may become less effective. Effective and affordable therapeutics for SARS-CoV-2 that can be easily used in community settings are needed to accelerate recovery, reduce hospitalizations and mortality, and mitigate the development of post-acute sequelae of SARS-CoV-2, also known as “long COVID.” In this paper we present the design of the Canadian Adaptive Platform Trial of Treatments for COVID in Community Settings (CanTreatCOVID). Methods and analysis CanTreatCOVID is an open-label, individually randomized, multi-centre, national adaptive platform trial designed to evaluate the clinical and cost-effectiveness of therapeutics for non-hospitalized SARS-CoV-2 patients across Canada. Eligible participants must present with symptomatic SARS-CoV-2 infection, confirmed by PCR or rapid antigen testing (RAT), within 5 days of symptom onset. The trial targets two groups that are expected to be at higher risk of more severe disease: (1) individuals aged 50 years and older, and (2) those aged 18-49 years with one or more comorbidities. CanTreatCOVID uses numerous approaches to recruit participants to the study, including a multi-faceted public communication strategy and outreach through primary care, out-patient clinics, and emergency departments. Participants are randomized to receive either usual care, including supportive and symptom-based management, or an investigational therapeutic selected by the Canadian COVID-19 Outpatient Therapeutics Committee. The first therapeutic arm evaluates nirmatrelvir/ritonavir (Paxlovid™), administered twice daily for 5 days. The second therapeutic arm investigates a combination antioxidant therapy (selenium 300 µg, zinc 40 mg, lycopene 45 mg, and vitamin C 1.5 g), administered for 10 days. The primary outcome is all-cause hospitalization or death within 28 days of randomization. Ethics and dissemination The CanTreatCOVID master protocol and sub-protocols have been approved by Health Canada and local research ethics boards in the participating provinces across Canada. The results of the study will be disseminated to policymakers, presented at conferences, and published in peer-reviewed journals to ensure that findings are accessible to the broader scientific and medical communities. Trial registration number: [NCT05614349][1] Strengths and Limitations Box 1. The CanTreatCOVID community-focused design allows enrollment without in-person visits. 2. The adaptive platform trial structure provides flexibility to add promising therapies and remove ineffective ones, which is critical in a rapidly changing pandemic environment 3. CanTreatCOVID gathers real-world data on outpatient COVID-19 care 4. The open-label design avoids logistical challenges associated with placebo controls in large-scale trials, though it may introduce bias related to subjective outcomes 5. The reliance on self-reported adherence to study medications could lead to variability ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT05614349 ### Funding Statement CanTreatCOVID trial is funded by the Canadian Institutes of Health Research (CIHR) and Health Canada (Grant # FRN 183092 and PPE 190332), with the first trial therapeutic, nirmatrelvir/ritonavir (Paxlovid ™), provided by the Public Health Agency of Canada. Andrew Pinto is supported as a Clinician-Scientist by the Department of Family and Community Medicine, Faculty of Medicine at the University of Toronto and at St. Michael’s Hospital, the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and a CIHR Applied Public Health Chair in Upstream Prevention. The opinions, results, and conclusions reported in this article are those of the authors and are independent of any funding sources. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The CanTreatCOVID master protocol and sub-protocols have been approved by Health Canada and local research ethics boards in the participating provinces across Canada. All participants provide informed consent, which can be completed online, via email, or verbally via telephone. An independent Data Monitoring and Safety Committee (DMSC) oversees safety data, review interim analyses provided by the Statistical Analysis Committee (SAC), and communicate recommendations to the Trial Steering Committee (TSC). The TSC provides guidance and oversight to the Trial Management Group (TMG). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT05614349&atom=%2Fmedrxiv%2Fearly%2F2024%2F11%2F27%2F2024.11.25.24317904.atom

PurposeSickle cell disease (SCD) is an inherited blood disorder with a natural course punctuated by acute complications including painful vaso-occlusive episodes. The objectives were: (1) to determine what proportion of patients with SCD receive opioids within 30 min of triage as recommended by the current clinical recommendations and quality standard; and (2) to identify facilitators to timely opioid administration for patients with SCD.MethodsThis was a retrospective observational study. The primary outcome was the proportion of visits in which patients received opioid analgesia within 30 min of triage. Secondary outcomes were time in minutes from triage to any analgesic administration and time from triage to first opioid administration. Patient demographics and ED encounter characteristics were included as potential associated variables.ResultsThere were 236 patient visits (by 103 patients) that met inclusion criteria. Patients received opioid analgesia within 30 min of triage in only 5.2% of visits. The median time from triage to opioid analgesia was 80 (IQR = 49.0, 125.5) minutes. Using an order set and receiving opioid analgesia prior to physician assessment were both associated with shorter times to opioid analgesia.ConclusionExisting recommendations are that opioid analgesia be provided within 30 min of triage for patients with SCD and VOEs. Our data show this target is rarely met, even in a department in which SCD VOEs are a common presenting concern. The association of earlier opioid analgesia with order set use and administration prior to physician assessment highlights potential avenues for improving time to analgesia. ObjectifLa drepanocytose (ou l'anemie falciforme) est une maladie hereditaire du sang dont l'evolution naturelle est ponctuee de complications aigues, notamment des episodes vaso-occlusifs douloureux. Les objectifs etaient : (1) de determiner quelle proportion de patients atteints de drepanocytose recoivent des opioides dans les 30 minutes suivant le triage, comme le recommandent les recommandations cliniques et la norme de qualite actuelles ; et (2) d'identifier les facteurs facilitant l'administration rapide d'opioides aux patients atteints de drepanocytose.MethodesIl s'agissait d'une etude observationnelle retrospective. Le critere de jugement principal etait la proportion de visites au cours desquelles les patients ont recu une analgesie opioide dans les 30 minutes suivant le triage. Les criteres de jugement secondaires etaient le temps en minutes ecoule entre le triage et l'administration de tout analgesique et le temps ecoule entre le triage et la premiere administration d'opioides. Les caracteristiques demographiques des patients et les caracteristiques des rencontres aux urgences ont ete incluses comme variables potentiellement associees.ResultatsIl y a eu 236 visites de patients (par 103 patients) qui repondaient aux criteres d'inclusion. Les patients ont recu une analgesie opioide dans les 30 minutes suivant le triage dans seulement 5,2 % des visites. Le temps median ecoule entre le triage et l'analgesie opioide etait de 80 (IQR = 49,0, 125,5) minutes. L'utilisation d'un ensemble de commandes et la reception d'une analgesie opioide avant l'evaluation du medecin etaient toutes deux associees a des temps plus courts d'analgesie opioide.ConclusionsLes recommandations existantes sont que l'analgesie opioide soit fournie dans les 30 minutes suivant le triage pour les patients atteints de drepanocytose et d'EVO. Nos donnees montrent que cet objectif est rarement atteint, meme dans un service ou les EVO de la drepanocytose sont une preoccupation courante. L'association d'une analgesie opioide plus precoce avec l'utilisation d'un ensemble de commandes et l'administration avant l'evaluation du medecin met en evidence des pistes potentielles pour ameliorer le temps d'analgesie.

Background: Emergency Department (ED) patients experiencing disadvantage (e.g., homelessness, addictions) can have limited access to cellular phones. This barrier can affect access to follow-up health care, connecting with community resources, and communicating with friends and family. PHONE-CONNECT is an intervention providing free cellular phones and prepaid plans to patients who do not have them. This intervention allows ED-based health care workers, such as social workers, nurses and physicians, to facilitate follow-up care with patients in their transition from hospital to community. Objective: To explore how the intervention affects health care workers in the emergency department, including those facilitating implementation. Methods: We used valid and reliable implementation science outcome measures - Acceptability, Appropriateness, and Feasibility of Intervention Measures - informed by a Realist Evaluation approach to explore how, why, and for whom the intervention works best. Staff trained in data collection deployed anonymous in-person and online surveys across 3 academic ED's in Toronto, Ontario. Respondents were registered nurses, medical doctors, social workers, and peer-based staff. Survey questions focused on implementation, and perceived impact of the intervention. Questions were scored on a 5-point Likert scale ranging from Completely disagree [1] to Completely Agree [5]. Data were analyzed using descriptive statistics and aggregate scores were calculated in Microsoft Excel. Results: 142 survey responses were collected between August and September 2022. Respondents agree that the intervention is acceptable (84.5%), appropriate (83.9%), and feasible (80.4%). A subset of 46 respondents facilitating the intervention reported that it improves their ability to meet the health (92.9%) and social needs of patients (91.4%); facilitate follow-up care (91.9%) and disposition planning while in the ED (88.1%); and improves the quality of care provided (90.5%). Distributing phones was reported to be worth the cumulative time and effort (91.7%), and was felt to reduce experiences of moral distress (82.4%) and burnout (69%). Conclusion: PHONE-CONNECT is feasible, acceptable, and appropriate in the ED. It empowers physicians and health care workers to provide high quality care, while reducing moral distress and burnout. Novel ED-based interventions are efficacious ways to bridge gaps in care experienced by patients in their transition from hospital to community. Though challenging with this population, future work exploring patient experiences will help optimize outcomes and further streamline the process of phone delivery and utilization.

Innovation Concept: Advocacy is a key competency of Canadian residency education, yet physicians seldom engage with supra-clinical advocacy efforts upon completion of training. Emergency medicine (EM) residency training may not equip graduates with the knowledge and skills required to engage as physician-advocates in their communities. Focused writing workshops may increase the confidence and ability of EM trainees to engage as health advocates. Methods: Following a literature review, simulated newsroom workshops were developed by two EM physicians with graduate-level journalism training and workplace experience. Participants were invited to participate in an audio-recorded focus-group and to submit their opinion editorial. Twelve participants registered for the workshops and six attended both sessions and the focus group; four submitted written work. Focus group transcripts and written work were qualitatively analysed to understand acceptability, feasibility, and how students might engage as future health advocates. Curriculum, Tool, or Material: The simulated newsroom consisted of participants acting as journalists and the expert facilitator acting as a news editor. The first workshop provided a framework for news judgement in a didactic session, followed by interactive exercises including: prioritization of news pitches, a simulated editorial meeting, and analysis of published news articles. The participants then drafted their own pitches for in situ feedback from peers and facilitators. Two-weeks later, participants brought their completed articles for peer and expert review before submitting their final article. Conclusion: The innovation bolstered resident physician confidence in advocacy through the popular press, and provided demonstrable skills in opinion writing. Participants felt challenged to develop compelling narratives and differentiate this form of advocacy communication from academic writing or prior media training. Participants valued the workshop as a voluntary component of residency education led by peer experts. Through their writing, residents demonstrated an understanding of structural factors that impact patient health and health systems. Future engagement as physician advocates may be tempered by fears of professional repercussions for public engagement; the impact of physician advocacy on population health outcomes is not yet known.

Homelessness is an emergencyOn any given night, about 35,000 people experience homelessness in Canada [1].Homelessness is associated with substantially higher mortality, with rates up to eight times higher for men [2] and 32 times higher for women compared to people of similar age (Table 1) [3].Despite this risk, homelessness remains underrecognized.As first responders in public health crises and working at a critical intersection of health systems, emergency department (ED) care providers are in a unique position to intervene.ED visits are often related to acute exacerbations of chronic health conditions or medical complications of being homeless

Background Non-insured individuals have different healthcare needs from the general Canadian population and face unique barriers when accessing emergency department (ED) care. This qualitative study aims to better understand the system of emergency care for non-insured individuals from the perspective of healthcare providers. Methods The study uses a critical realist framework to explore structural factors that facilitate or impede access to care for non-insured individuals. Semi-structured interviews were conducted with 13 interdisciplinary healthcare professionals with experience working with non-insured populations in the ED and in community health centres. Data were analyzed with the use of Braun and Clark's thematic analysis framework and organized into themes through an iterative process until thematic saturation was reached. Results Healthcare providers face distinct challenges when providing care for non-insured patients including patients presenting with increased illness complexity and providers having to navigate systemic barriers. Interview participants noted stigma and bias, lack of privacy, unclear care pathways, and access to post-ED care as challenges facing non-insured patients. Suggestions to improve the ED experience for non-insured patients include improved staff training, clearer policies, and consistency between hospitals. Most of all, healthcare providers believed that the most effective way to improve the care of non-insured patients would be to make permanent the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic. Conclusion Interviews with healthcare professionals have highlighted that marginalized populations, including non-insured individuals, face multiple barriers when accessing the ED, especially during the COVID-19 pandemic. At the same time, the temporary extension of health coverage to non-insured patients enacted during the COVID-19 pandemic has likely improved patients' healthcare experience, which we will explore directly with non-insured patients in a future study. In this post-COVID world, we now have an opportunity to learn from our experiences and build a more equitable ED system together.

Vulnerable populations have been identified as having higher infection rates and poorer COVID-19–related outcomes, likely due to their inability to readily access primary care, follow public health directives, and adhere to self-isolation guidelines. As a response to the COVID-19 pandemic, many health care services have adopted new digital solutions, which rely on phone and internet connectivity. However, persons who are digitally inaccessible, such as those experiencing poverty or homelessness, are often unable to use these services. In response to this newly highlighted social disparity known as “digital health inequity,” emergency physicians at the University Health Network in Toronto, Canada, initiated a program called PHONE-CONNECT (Phones for Healthier Ontarians iN EDs – COvid NEeds met by Cellular Telephone). This novel approach attempts to improve patients’ access to health care, information, and social services, as well as improve their ability to adhere to public health directives (social isolation and contact tracing). Although similar programs addressing the same emerging issues have been recently described in the media, this is the first time phones have been provided as a health care intervention in an emergency department. This innovative emergency department point-of-care intervention may have a significant impact on improving health outcomes for vulnerable people during the COVID-19 pandemic and beyond.

Background Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program. Methods This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses ( N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories. Results Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers. Conclusions Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

Disruptions in health service delivery due to the COVID-19 pandemic have had a devastating effect on maternal, neonatal, and child health (MNCH) with rises in maternal and neonatal deaths expected.1Riley T Sully E Ahmed Z Biddlecom A Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries.Int Perspect on Sex Reprod Health. 2020; 46: 73-76Crossref PubMed Scopus (276) Google Scholar Post-partum haemorrhage is the leading cause of maternal mortality in low-income countries and is likely to increase because of estimates of, at best, a 10% reduction in MNCH services.1Riley T Sully E Ahmed Z Biddlecom A Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries.Int Perspect on Sex Reprod Health. 2020; 46: 73-76Crossref PubMed Scopus (276) Google Scholar Misoprostol is a safe and cost-effective alternative uterotonic that is used when oxytocin is not available. It is heat stable, available in tablet form, and can be distributed by a community health worker, traditional birth attendant, or taken by the woman herself after birth.2Smith JM Gubin R Holston MM Fullerton J Prata N Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date.BMC Pregnancy Childbirth. 2013; 13: 44Crossref PubMed Scopus (61) Google Scholar In November, 2020, WHO recommended the advance distribution of misoprostol at antenatal visits for the prevention of post-partum haemorrhage for women who give birth at home and cannot access a skilled birth attendant.3WHOWHO recommendation on advance misoprostol distribution to pregnant women for prevention of postpartum haemorrhage.https://www.who.int/publications/i/item/9789240013902Date: Nov 4, 2020Date accessed: November 26, 2020Google Scholar Advance distribution of misoprostol for the prevention of post-partum haemorrhage in contexts where women cannot access a health facility because of disruptions in essential health services, such as the COVID-19 pandemic, is now a crucial consideration. Misoprostol has previously been distributed in humanitarian emergencies where access to health services was difficult. During the 2014–16 Ebola outbreak in Liberia, misoprostol was included in clean birth kits and distributed by trained community health workers.4West and Central Africa Regional OfficeUN Population FundInstitutional analysis of the UNFPA response to Ebola Crisis: in Guinea, Liberia and Sierra Leone and readiness assessment of sexual and reproductive, maternal, neonatal and adolescent health services.https://wcaro.unfpa.org/sites/default/files/pub-pdf/UNFPA-WCARO-Ebola-Crisis.pdfDate accessed: November 26, 2020Google Scholar, 5Adams P Nepal's renegade strategy to save mothers 2015.https://foreignpolicy.com/2015/05/15/nepals-renegade-strategy-to-save-mothers-earthquake-misoprostol/Date: May 15, 2015Date accessed: December 2, 2020Google Scholar, 6Ministry of Health and Social WelfareGovernment of LiberiaLiberia Ebola virus disease clinical management manual.https://reliefweb.int/report/liberia/liberia-ebola-virus-disease-clinical-management-manualDate: Dec 31, 2014Date accessed: November 26, 2020Google Scholar Nepal, one of the first countries to scale up the use of misoprostol for the prevention of post-partum haemorrhage in the community, continued to make use of this strategy during the 2015 earthquake.5Adams P Nepal's renegade strategy to save mothers 2015.https://foreignpolicy.com/2015/05/15/nepals-renegade-strategy-to-save-mothers-earthquake-misoprostol/Date: May 15, 2015Date accessed: December 2, 2020Google Scholar, 7Department of Health ServicesMinistry of HealthGovernment of NepalAnnual report Department of Health Services 2072/73 (2015/2016).https://dohs.gov.np/wp-content/uploads/2017/06/DoHS_Annual_Report_2072_73.pdfDate: February 2017Date accessed: December 8, 2020Google Scholar Scaling-up misoprostol for the prevention of post-partum haemorrhage in the community in Nepal has again reaped benefits during the COVID-19 pandemic. Facility-based births were reduced by half (49·9%) during Nepal's COVID-19 lockdown (between March 21 and May 30, 2020).8Ashish KC Gurung R Kinney MV et al.Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study.Lancet Glob Health. 2020; 8: e1273-e1281Summary Full Text Full Text PDF PubMed Scopus (272) Google Scholar In May, 2020, the Nepalese Ministry of Health and Population approved the distribution of misoprostol to all women who cannot reach a health facility to give birth and were 8 months pregnant.9Department of Health ServicesMinistry of Health and PopulationGovernment of NepalInterim Guidance for RMNCH services in COVID 19 pandemic.https://app.adpc.net/sites/default/files/public/publications/attachments/Guidance_for_RMNCH_services_08-02-2077.pdfDate: May 21, 2020Date accessed: December 6, 2020Google Scholar This was expedited because women were facing difficulties in accessing maternal health services because of the lockdown and their reluctance to give birth at the health facility. The examples during the Ebola outbreak in Liberia and recently in Nepal highlight that misoprostol can be distributed in complex emergencies where health systems have been disrupted. In both contexts, a cadre of trained community health workers assisted with distribution. Ministries of Health and partners, including Jhpiego in Liberia and One Heart Worldwide in Nepal, were able to quickly adapt and distribute misoprostol to women within the community. This ability to mobilise misoprostol was partly due to political support, previous experience, and evidence for the distribution at community level for post-partum haemorrhage prevention.2Smith JM Gubin R Holston MM Fullerton J Prata N Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date.BMC Pregnancy Childbirth. 2013; 13: 44Crossref PubMed Scopus (61) Google Scholar In both countries, misoprostol for post-partum haemorrhage was on the National Essential Medicines List and part of the essential MNCH drugs, alongside oxytocin. In the case of the Ebola outbreak in Liberia, available guidelines and recommendations by WHO and UNICEF probably accelerated its use. The 2020 WHO guidelines affirm that misoprostol can be distributed in advance to women in humanitarian contexts with considerations to integration with other response strategies and the values and preferences of women in emergency situations.3WHOWHO recommendation on advance misoprostol distribution to pregnant women for prevention of postpartum haemorrhage.https://www.who.int/publications/i/item/9789240013902Date: Nov 4, 2020Date accessed: November 26, 2020Google Scholar The Minimum Initial Services Package for Sexual and Reproductive Health is a response strategy that can be used to increase access to misoprostol for post-partum haemorrhage in humanitarian crises. The Inter-Agency Working Group on Reproductive Health in Crises also recommends pre-positioning supplies of misoprostol for the prevention of post-partum haemorrhage and training and equipping community providers during COVID-19 in settings where health facilities are inaccessible.10Sub-Working Group on Minimum Initial Service PackageInter-Agency Working GroupMISP considerations checklist for implementation during COVID-19.https://iawg.net/resources/misp-considerations-checklist-for-implementation-during-covid-19Date accessed: December 8, 2020Google Scholar COVID-19 has shown that innovative mitigation strategies are needed to resume gains made in MNCH. Governments and policy makers need to update their national guidelines to ensure that misoprostol for post-partum haemorrhage prevention can be distributed at the community level, at least until the pandemic improves. Community health workers and traditional birth attendants play a crucial role in bridging the service delivery gap and can provide clean delivery kits that include misoprostol to prevent post-partum haemorrhage. Now is the opportunity to ensure that all women in need can protect themselves against post-partum haemorrhage and reduce the risk of dying in childbirth. Misoprostol can prevent post-partum haemorrhage and save women's lives. What are we waiting for? The authors would like to thank Hannah Tappis, Alison Greer, and Sandra Krause from the Inter-Agency Working Group on Reproductive Health in Crises for their inputs on the Minimum Initial Services Package for Sexual and Reproductive Health. We declare no competing interests.