The struggle over legal abortion access in the United States is a religious controversy, not a scientific debate. Religious activists who believe that meaningful individual life (i.e., "personhood") begins at a specific "moment-of-conception" are attempting to pass laws that force this view upon all pregnant persons, irrespective of their medical circumstances, individual preferences, or personal religious beliefs. This paper argues that such actions promote a constitutionally prohibited "establishment of religion." Abortion policy in a secular state must be based upon scientifically accurate biology, not unprovable theological presuppositions. The scientific facts regarding human pregnancy do not support the position that personhood begins with fertilization-at which point a pregnancy does not yet even exist. Abortion policy should regard the embryo/fetus as part of the pregnant individual's body until delivery. We argue that individual "personhood" only begins when the latent potentialities of the fetal nervous system are actualized in the newborn after delivery. The paper argues that instantiating non-scientific beliefs concerning embryonic/fetal "personhood" into the law as the basis for abortion policy establishes a state-sponsored religion. The protection of religious liberty requires that abortion be decriminalized. Abortion should be treated like any other medical procedure and regulated similarly. To protect both religious freedom and sound medical practice, individual legal personhood should be recognized as beginning only at birth.

BACKGROUND:Inadequate menstrual hygiene management can result in physical, social, psychological, and educational challenges for schoolgirls. To address these issues, researchers have conducted intervention studies, but the impact on school attendance has varied. This review has systematically collected and evaluated evidence about the effects of menstrual hygiene interventions on schoolgirls. METHOD:A systematic search of the literature was done and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA statement). Both peer-reviewed journals and gray literature were searched using PubMed and Google Scholar. The search included individual, or cluster randomized controlled trials, and quasi-experimental studies, and covered the period from the date of indexing until January 3, 2023. RESULT:A review of sixteen trial studies showed that menstrual hygiene interventions have a positive effect on schoolgirls' school attendance, performance, and dropout rates, as well as on their menstrual knowledge, attitudes, practices, and emotional well-being. There was a low to medium risk of bias in most of the studies. Additionally, the literature overlooked the impact of interventions that involve parental and male engagement, interventions correcting community misperceptions about menstruation, and the impact of infrastructure improvements on water, sanitation, and hygiene. CONCLUSION:Interventions aimed at improving menstrual hygiene management can enhance schoolgirls' educational outcomes, and can improve their menstrual knowledge, attitudes, and practices by helping them manage their periods more effectively. Most interventions have focused on the provision of menstrual products and menstrual education but have neglected improvements in the physical environment at home and school and the social norms surrounding menstruation. Trial studies should take a holistic approach that considers the total socio-cultural environment in which menstrual hygiene management takes place, thus enabling stakeholders and policymakers to develop sustainable, long-term solutions to these problems.

Background Menstrual hygiene management is a critical aspect of adolescent health. However, access to adequate menstrual hygiene products and sanitation facilities is severely restricted during times of war. There is a dearth of information about the menstrual hygiene needs of adolescent girls during humanitarian crises. This study investigated the menstrual hygiene management needs of the internally displaced adolescent girls in the war-torn region of Tigray, Ethiopia.Methods A qualitative study was conducted in three centers for internally displaced people in Mekelle, Tigray Region. Four focus-group discussions and six in-depth interviews were conducted using the local language among 39 adolescent girls aged 13-19 years. The collected data were recorded, transcribed, translated, and analyzed using the ATLAS.ti-7.5.18 software through a qualitative thematic analysis approach.Results Six primary themes were identified: 1) shortage of menstrual pads; 2) poor accommodation of latrine facilities; 3) silence around menstruation; 4) exchange of menstrual pads for life-saving commodities, 5) lack of privacy; 6) menstruation is a "curse" for adolescent girls living in displaced people's camps. The study highlights the significant challenges faced by internally displaced adolescent girls in managing their menstrual hygiene while living in camps for internally displaced people. Lack of access to adequate menstrual hygiene management supplies often leads them to use rags or worn-out clothing instead of menstrual pads.Conclusion Access to adequate menstrual hygiene products and sanitation facilities is severely limited among displaced adolescent girls in Tigray. The findings emphasize the urgent need to address menstrual hygiene issues during emergencies. Supplying essential items such as sanitary pads, soap, water, sanitation infrastructure, and improved information on menstrual hygiene management should be prioritized.

BACKGROUND:In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.METHODS:An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.RESULTS:There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].CONCLUSIONS:The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

Haemodialysis is extremely limited in low-income countries. Access to haemodialysis is further curtailed in areas of active conflict and political instability. Haemodialysis in the Tigray region of Ethiopia has been dramatically affected by the ongoing civil war. Rapid assessment from the data available at Ayder Hospital’s haemodialysis unit registry, 2015–2021, shows that enrollment of patients in the haemodialysis service has plummeted since the war broke out. Patient flow has decreased by 37.3% from the previous yearly average. This is in contrary to the assumption that enrollment would increase because patients could not travel to haemodialysis services in the rest of the country due to the complete blockade. Compared to the prewar period, the mortality rate has doubled in the first year after the war broke out, i.e., 28 deaths out of 110 haemodialysis recipients in 2020 vs. 43 deaths out of 81 haemodialysis recipients in the year 2021. These untoward outcomes reflect the persistent interruption of haemodialysis supplies, lack of transportation to the hospital, lack of financial resources, and the unavailability of basic medications due to the war and the ongoing economic and humanitarian blockade of Tigray in Northern Ethiopia. In the setting of this medical catastrophe, the international community should mobilize to advocate for resumption of life-saving haemodialysis treatment in Ethiopia’s Tigray region and put pressure on the Ethiopian government to allow the passage of life-saving medicines, essential medical equipment, and consumables for haemodialysis into Tigray.

Abstract This article reviews the infectious complications of abortion (both spontaneous and induced) and the management of this condition. The key points are: (1) Making abortion illegal does not reduce its incidence or prevalence; rather, it only makes abortions unsafe, increasing the likelihood of infectious complications. (2) Timely recognition of developing sepsis in the pregnant patient is critical. This requires constant vigilance and a high index of suspicion. (3) Rapid intravenous administration of broad-spectrum antibiotics targeted to the likely intrauterine source of infection as soon as sepsis is diagnosed is critical to prevent severe sepsis, septic shock, and multisystem organ failure. (4) The mainstay of treatment is prompt evacuation of any residual products of conception from within the uterine cavity under broad-spectrum antibiotic cover targeting the likely intrauterine source of infection. (5) Prompt engagement of specialists in both critical care and obstetrics-gynecology is necessary to optimize outcomes in patients with septic abortion.

The unprovoked Russian invasion of Ukraine that began in February 2022 has caused worldwide anger and international condemnation. The European and North American response to these events has been swift and dramatic. An equally devastating war broke out in the Tigray Region of northern Ethiopia over 18 months ago, but this conflict has been largely neglected by the international community. We are saddened to realise that this may be because African lives are being destroyed in Tigray, not European ones, as in Ukraine. We are obstetricians and gynaecologists at Ayder Comprehensive Specialized Hospital in Mekelle, the capital of Tigray Region. Our institution is the second largest hospital in Ethiopia and serves as the tertiary care referral centre for a catchment area of 9 million people. The consequences of this war have been especially tragic for girls and women. As obstetricians and gynaecologists, these are our patients. In early November 2020, war broke out in Tigray. The city of Mekelle, where our hospital is located, was captured by federal troops within a month of the onset of the war, whereas the rest of Tigray Region continued to experience significant fighting (Figure 1). The specific political events that led to the outbreak of the war have become irrelevant to the continuing human consequences of the conflict, which are severe and worsening. Civilians have been massacred, crops destroyed, livestock slaughtered and schools looted.1,2 Health centres, clinics and hospitals throughout Tigray were systematically targeted for destruction, in contravention of the Geneva Conventions and the internationally accepted laws of war.2,3 Some 70 000 Tigrayans have fled across the western border to Sudan as refugees. Two million Tigrayans have become displaced internally, many fleeing to Mekelle. Nearly 90% of the population of Tigray now live in conditions of food insecurity.4 Some 400 000 people face starvation. Global acute malnutrition among children now affects 28% of the paediatric population, and is worsening under conflict conditions.4 Tigrayan girls and women were targeted specifically by military personnel in this conflict. Thousands of women were brutally raped. There are multiple reports of gang rapes that lasted for days, sometimes ending in the deliberate mutilation of the victims. We have seen and cared for these women. The international press has widely reported on such cases, which have been confirmed by ontheground investigations and victim interviews carried out by nonpartisan international humanitarian organisations such as Amnesty International and Human Rights Watch.5– 7 In one of the most extensive investigations to date, Amnesty International stated: ‘The patterns of sexual violence emerging from survivors’ accounts indicate that the violations have been part Accepted: 12 May 2022 | Published Online 1 June 2022

In Brief The 2012 death in Ireland of Savita Halappanavar from an inappropriately managed spontaneous abortion may be a harbinger of what now awaits pregnant Americans.

BACKGROUND: Obstetric fistula is a devastating childbirth injury. Despite successful closure of the fistula, 16% to 55% of women suffer from persistent urinary incontinence after surgery. OBJECTIVE: This study assessed the type and severity of persistent incontinence after successful fistula closure and its impact on the quality of life of Ugandan women post-fistula treatment. STUDY DESIGN: This cross-sectional study enrolled women with a history of obstetric fistula repair who continued to have persistent urinary incontinence (cases, N= 36) and women without incontinence (controls, N= 52) after successful fistula closure. Data were collected in central and eastern Uganda between 2017 and 2019. All the participants completed a semistructured questionnaire. Cases underwent a clinical evaluation and a 2-hour pad test and completed a series of incontinence questionnaires, including two novel tools designed to assess the severity of incontinence in lowliteracy populations. RESULTS: Cases were more likely to have acquired a fistula during their first delivery (63% vs 37%, P=.02), were younger when they developed a fistula (20.3 +/- 5.8 vs 24.8 +/- 7.5 years old, P=.003), and were more likely to have had >2 fistula surgeries (67% vs 2%, P <=.001). Cases reported a much higher rate of planned home birth for their index pregnancy compared to controls (44% vs 11%), though only 14% of cases and 12% of controls actually delivered at home. Cases reported higher rates of pain with intercourse (36% vs 18%, P=.05), but recent sexual activity status (intercourse within the previous six months) was not significantly different between the groups (47% vs 62%, P=.18). Among cases, 67% reported stress incontinence, 47% reported urgency incontinence, and 47% reported mixed incontinence. The cough stress test was successfully done with 92% of the cases, and of these, almost all (97%) had a positive cough stress test. More than half (53%) rated their incontinence as "very severe," which was consistent with objective findings. The 24-hour voiding diary indicated both high urinary frequency (average 14) and very frequent leakage episodes (average 20). Two-hour pad-tests indicated that 86% of cases had >4 g change in pad weight within 2 hours. Women with more severe incontinence reported a more negative impact on their quality of life. The mean score of the International Consultation on Incontinence Questionnaire-Quality of Life was 62.77 +/- 12.76 (range, 28-76, median=67), with a higher score indicating a greater impact on the quality of life. There was also a high mental health burden, with both cases and controls reporting high rates of suicidal ideation at any point since developing fistula (36% vs 31%, P=.67). CONCLUSION: Women with obstetric fistulas continue to suffer from severe persistent urinary incontinence even after successful fistula closure. Both stress and urgency incontinence are highly prevalent in this population. Worsening severity of incontinence is associated with a greater negative impact on the quality of life.

ABSTRACT:In November 2020, the federal government of Ethiopia invaded its northern region of Tigray, in collusion with the Government of Eritrea and ethnic Amhara militias. The invading forces pillaged the schools, destroyed the transportation infrastructure, burned crops and killed livestock, and looted the health care system. Thousands of civilians were killed, often in extrajudicial executions. Thousands of Tigrayan women were raped. Tens of thousands of Tigrayans fled to Sudan as refugees. Hundreds of thousands face famine and millions more have been internally displaced. The region is under a total communications blackout. The banking system has collapsed. The federal government has harassed external aid workers and imposed a de facto blockade on all medicines and famine relief. A man-made humanitarian catastrophe unlike any in recent memory is unfolding. The world medical community must speak up. The madness must stop.

We discuss a variety of contemporary issues relating to obstetric fistula. These include definitions of these injuries, the etiologic mechanisms by which fistulas occur, the role of specialist fistula centers in diagnosis and management, the classification of fistulas, and the assessment of surgical outcomes. We also review the growing need for complex reconstructive surgical procedures, follow-up challenges, and the transition to a fistula-free world in which other pathologies (such as pelvic organ prolapse) will be of increasing importance. Finally, we discuss the need to develop responsive systems of maternal health care that treat women with competence, compassion, respect, and fairness.

INTRODUCTION AND HYPOTHESIS:American gynecologist J. Marion Sims (1813-1883) is known for developing the first consistently successful operation for the repair of vesico-vaginal fistula, for inventing the Sims vaginal speculum, and for popularizing the left lateral decubitus position for gynecological examination and treatment.METHODS AND RESULTS:This article reviews the history of the Sims vaginal speculum, charting its evolution from a bent pewter spoon to the lever speculum and finally to its now-familiar form as the two-bladed Sims speculum.CONCLUSION:The article also reviews the origins of the Sims position, correcting popular misconceptions concerning both the position and the speculum and advocating for greater familiarity with the use of both of these valuable tools by practicing clinicians.

L. Lewis Wall comments on the surgical operations conducted by Dr J Marion Sims and the ethics surrounding his work

Objective To evaluate the effect on school attendance of a menstrual hygiene intervention that distributes educational booklets to school children and menstrual hygiene kits to schoolgirls in northern Ethiopia. Methods Attendance was tracked for 8839 students in grades 7-12 during the 2015-2016 academic year when the intervention was implemented. Negative binomial regression was used to test whether student sex predicted post-intervention school absences when controlling for grade-level and pre-intervention absences. Similar attendance data were analyzed for 3569 students in grades 7, 9, and 11 for the 2014-2015 academic year as a historical comparison. Results Over 12 211 educational booklets were distributed to students and 5991 menstrual hygiene kits were distributed to schoolgirls. After the intervention, girls had 24% fewer school absences than boys. Sex was not a predictor of absences during a similar time-period in the prior school year. Conclusion This is one of the first large studies to show a positive relationship between a menstrual hygiene intervention and girls' school attendance. These positive results suggest such interventions should be expanded to other schools in northern Ethiopia. Future research should explore whether similar interventions can also decrease the rate at which girls drop out of school around menarche.

J. Marion Sims (1813–1883) is often regarded as the founder of modern surgical gynecology. Widely known and respected during his lifetime, he was honored after death with a statue erected in New York City’s Bryant Park. It was later relocated to Central Park, where it remained until 2018, when it was removed after persistent public protests over its presence. The controversy arose over perceptions of Sims’s most famous achievement: the development of the first reliable surgical cure for vesico-vaginal fistula, a catastrophic complication of prolonged obstructed labor, which was common in the nineteenth century. Sims developed his surgical technique by operating on a group of enslaved African–American women with fistulas between 1846 and 1849. Modern attacks on Sims are based more on a presentist revulsion over the institution of slavery than on a clear understanding of what Sims actually did within the context of his time and place. Modern critics attack his “experimental” surgeries, the patients’ lack of “informed consent,” and Sims’s failure to use anesthesia during fistula surgery. None of these criticisms takes into consideration the appalling nature of the injuries these women had received, the suffering their condition caused them, the lack of any effective “standard-of-care” treatment for fistulas at that time, the social and legal constraints facing doctors who treated slaves, or the uncertain and problematic early history of anesthesiology. Although “retrospective indignation” may be emotionally satisfying, it does not illuminate the past nor help us understand difficult decision-making in surgery, whatever the time or place.

See Related Article on p.444Adequate menstrual hygiene management has been defined as, "Women and adolescent girls are using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water to wash the body as required, and having access to facilities to dispose of used menstrual management materials" [[1]Sommer M. Sahin M. Overcoming the taboo: Advancing the global agenda for menstrual hygiene management for schoolgirls.Am J Pub Health. 2013; 103: 1556-1559Crossref PubMed Scopus (95) Google Scholar]. Most girls and women in the U.S. take this for granted. See Related Article on p.444 In this issue of the Journal of Adolescent Health, Anne Sebert Kuhlmann et al. provide a brief but compelling look at students' lack of access to menstrual hygiene products at a public secondary school serving a low-income population in St. Louis, Missouri [[2]Sebert Kuhlmann A. Key R. Billingsley C. et al.Students' menstrual hygiene needs and school attendance in an urban St. Louis, Missouri, district.J Adolesc Health. 2020; 67: 444-446Google Scholar]. The authors found that nearly half of the students surveyed had needed menstrual supplies during the previous school year but had been unable to afford them. Almost one fifth of students had missed at least 1 day of school because of lack of access to menstrual hygiene products, and this problem was substantially more common among ninth graders than among more advanced students. A previous study from the same group looking at low-income women in the St. Louis area [[3]Sebert Kuhlmann A. Peters B.E. Danjoint D. et al.Unmet menstrual hygiene needs among low-income women.Obstet Gynecol. 2019; 133: 238-244Crossref PubMed Scopus (23) Google Scholar] found similar levels of need among adults, with nearly two-thirds unable to afford needed menstrual hygiene supplies during the previous year and with one-fifth experiencing this on a monthly basis. An abundance of studies demonstrates the lack of biological knowledge about menstruation and menstrual hygiene management among adolescents around the world [4Koff E. Rierdan J. Early adolescent girls' understanding of menstruation.Women Health. 1995; 22: 1-21Crossref PubMed Scopus (51) Google Scholar, 5Farage M.A. Miller K.W. Davis A. Cultural aspects of menstruation and menstrual hygiene in adolescents.Expert Rev Obstet Gynecol. 2011; 6: 127-139Crossref Scopus (15) Google Scholar, 6Cooper S.C. Koch P.B. "Nobody told me nothin": Communication about menstruation among low-income African-American women.Women Health. 2007; 46: 57-78Crossref PubMed Scopus (38) Google Scholar, 7Sommer M. Ackatia-Armah N. Connolly S. et al.A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia, and Ethiopia.Compare. 2015; 45: 589-609Crossref Scopus (54) Google Scholar]. Significant problems with access to menstrual hygiene supplies have been documented among girls and women in middle- and low-income countries [[8]Sebert Kuhlmann A. Henry K. Wall L.L. Menstrual hygiene management in resource-poor countries.Obstet Gynecol Surv. 2017; 72: 356-376Crossref Scopus (27) Google Scholar,[9]Sumpter C. Torondel B. A systematic review of the health and social effects of menstrual hygiene management.PLoS One. 2013; 8: e62004Crossref PubMed Scopus (131) Google Scholar], but there is almost no awareness that this same problem exists in affluent countries such as the U.S.; the issue has not received adequate attention from researchers and public policy advocates [[10]Cotropia C.A. Menstruation management in United States schools and implications for attendance, academic performance, and health.Women's Reprod Health. 2019; 6: 289-305Crossref Google Scholar]. Lack of access to adequate menstrual hygiene in American schools is a neglected issue with important health and social implications. There are numerous compelling arguments for addressing this problem. The first argument is that because menstruation is a normal human physiological process with associated hygienic and sanitary requirements, it should not be the basis for discriminatory treatment. Menstrual hygiene falls into the same category as urinary or defecatory hygiene requirements, which we expect to be met reliably and comfortably in public spaces. We expect schools and other public facilities to provide spaces to meet these needs, providing soap and water for washing and toilet paper for cleaning the appropriate body parts. To suggest that we should use our personal resources and carry a roll of toilet paper with us every day would generate public outrage. We have long demanded reasonable access to toilet facilities at work and in public spaces; why should menstruation be regarded differently than other similar physiological processes? When attempts were made to capitalize on normal human physiology by introducing pay toilets, people rebelled at the inconvenience of fumbling for coins in moments of physiological desperation and the sheer effrontery of the financial demand of paying to meet a basic human biological need [[11]Montano E. The 'bring your own tampon' policy: Why menstrual hygiene products should be provided for free in restrooms.U Miami L Rev. 2018; 73: 370-411Google Scholar]. Furthermore, half of the population are menstruators, and half are not. A sound legal argument holds that failure to provide sanitary products to menstruators in the same way that toilet paper and similar supplies are routinely provided to the public at large is a denial of equal protection of the law to the menstruating population. A sister argument to this "equal protection" contention is that such discrimination violates the basic human right to be treated with dignity [[11]Montano E. The 'bring your own tampon' policy: Why menstrual hygiene products should be provided for free in restrooms.U Miami L Rev. 2018; 73: 370-411Google Scholar]. There is ample documentation of the shame and embarrassment that is created for adolescents around the world who experience an unexpected menstrual hygiene accident at school [12Somer M. Sutherland C. Chandra-Mouli V. Putting menarche and girls into the global population health agenda.Reprod Health. 2015; 12: 24Crossref Scopus (43) Google Scholar, 13Herbert A.C. Ramirez A.M. Lee G. et al.Puberty experiences of low-income girls in the United States: A systematic review of qualitative literature from 2000 to 2014.J Adolesc Health. 2017; 60: 363-379Abstract Full Text Full Text PDF Scopus (21) Google Scholar, 14Wall L.L. Teklay K. Desta A. et al.Tending the 'monthly flower:' A qualitative study of menstrual beliefs in Tigray, Ethiopia.BMC Women's Health. 2018; 18: 183Crossref Scopus (6) Google Scholar]. Such events are clearly injurious to the psychosocial well-being of adolescent girls. Injuries of this kind could be prevented by easy, free access to menstrual hygiene supplies in educational institutions. When girls and women lack access to adequate menstrual management materials, they are forced to improvise, often using paper towels, toilet paper, old rags, socks, strips of cloth, infant diapers, and other unsatisfactory methods. These stresses affect not only students at school but also women in the workplace [[15]Sommer M. Chandraratna S. Cavill S. et al.Managing menstruation in the workplace: An overlooked issue in low- and middle-income countries.Int J Equity Health. 2016; 15: 86Crossref PubMed Scopus (40) Google Scholar]. Women in the military face particular challenges, especially when they are deployed in rugged environments or combat zones [[16]Czerwinski B.S. Wardell D.W. Yoder L.H. et al.Variations in feminine hygiene practices of military women in deployed and noncombat environments.Mil Med. 2001; 166: 152-158Crossref PubMed Scopus (23) Google Scholar,[17]Trego L.L. Military women's menstrual experiences and interest in menstrual suppression during deployment.JOGNN 2007. 2007; 36: 342-347Google Scholar]. Lack of proper menstrual hygiene is increasingly associated with higher rates of genitourinary infections, which have their own important health consequences [[18]Janoowalla H. Keppler H. Asanti D. et al.The impact of menstrual hygiene management on adolescent health: The effect of Go! pads on rate of urinary tract infection in adolescent females in Kibogora, Rwanda.Int J Gynecol Obstet. 2020; 148: 87-95Crossref Scopus (6) Google Scholar,[19]Das P. Baker K.K. Dutta A. et al.Menstrual hygiene practices, WASH access and the risk of rrogenital infection in women from Odisha, India.PLoS One. 2015; 10: e0130777Crossref PubMed Scopus (81) Google Scholar]. Students are required to attend school by law. Their education is of critical importance for their future progress as citizens and their success in later life. The time has come to make sure that all girls in school—and all menstruators everywhere—have unimpeded access to menstrual hygiene products adequate to their needs. Earlier this year, the parliament of Scotland passed legislation to provide free menstrual hygiene products to all women of all ages in their country—the first in the world to do so [[20]Yeginsu C. Scotland set to be first country to provide free pads and tampons. New York Times, February 27, 2020Google Scholar]. Similar initiatives are presently growing in Canada, Australia, New Zealand, and elsewhere. We should join them. Students' Menstrual Hygiene Needs and School Attendance in an Urban St. Louis, Missouri, DistrictJournal of Adolescent HealthVol. 67Issue 3PreviewTo assess the menstrual hygiene needs and related school absences among female students in an urban St. Louis, MO district. Full-Text PDF

Over the past 40 years, American medicine has become corporatized. Medical care has become permeated by a business philosophy whose primary concern is increasing shareholder value rather than providing optimal care for patients. Patient-physician relationships have eroded as the health care system has turned its attention toward electronic medical records (rather than face-to-face interactions with patients), toward quantifiable ("billable") metrics, and toward calculating the relative value units delivered by various health care "providers." An emphasis on clinical efficiency has diminished the depth of patient-physician contacts and has tended to promote quick, superficial interactions. Patients in pain are often overmedicated rather than listened to and understood. Suffering (which is at bottom a problem about the meaning of illness) has lost its place as a major medical concern. It is often easier to write a prescription for a powerful narcotic than to probe the details of a patient's life. This unfortunate tendency to seek quick, pill-based solutions to pain has been reinforced by the pharmaceutical industry, which has promoted this simple but profitable approach through the aggressive marketing of oxycodone and related medications. Both patients and physicians have lost out in the process. We need to reconstruct a health care system that gives pain its due but places that pain in the larger context of a patient's suffering. This can only be done by restoring clinicians to their preeminent place in medicine. We must strive to be healers, not simply providers.