Abortion-related complications are difficult to measure due to lack of standardized definitions and limited available data. We describe the proportion of abortive events that result in a documented complication in Mexico’s public sector hospitals. We used ICD-10 codes from Mexico’s hospital discharge system (2018-2022), Subsistema Automatizado de Egresos Hospitalarios (SAEH), to describe abortive events admitted to hospitals: complications for excessive bleeding, infection, embolism, and unspecified; patient socio-demographic and clinical characteristics; and municipality-level structural vulnerability. We estimate complications by pregnancy duration, describe types of complications, identify characteristics associated with the presence of a complication using multuvariable regression, and calculate complication rates (proportion of abortive event that result in a complication treated in a public sector hospital per 1,000 women of reproductive age) by state in 2022. There were 399,405 abortive events that received hospital-based care in Secretaria de Salud (SS) hospitals between 2018-2022. Ninety-two percent had no complication reported. The adjusted predicted probability of a complication was higher among patients at > 13 weeks’ gestation (8.9

Understanding the circumstances of abortions later in pregnancy provides insight about the barriers and delays to timely care. Limited synthesized information is available on these circumstances, especially from low and middle incomes countries. Reviewing what is reported in the literature about the circumstances of abortion later in pregnancy and the methodological approaches used to study this is needed to reveal evidence gaps. The purpose of this study is to describe what is documented and methodological approaches used in existing literature on the circumstances and characteristics associated with seeking care for abortion later in pregnancy reported in population and facility-based studies. We conducted a scoping review of peer-reviewed research in OVID/PubMed, Embase, Scopus, SocIndex, and LILACs from 2007-2024 that described the circumstance, sociodemographic characteristics, population- or facility-based proportion of abortion later in pregnancy (≥12 weeks of gestation or "second trimester") reported in the literature. We screened 2598 records by title and/or abstract and 668 of those by full text. We included 78 studies that described the circumstances around seeking care for abortion later in pregnancy from qualitative data (12 studies); included information on associated characteristics from quantitative data (15 studies); reported a population- (17 studies) or facility-based (45 studies) proportion of abortion later in pregnancy. Prominent themes included health system challenges, late pregnancy recognition, financial challenges, and delayed decision making. Low economic status and adolescence were commonly associated characteristics. Population and facility-based studies lacked standardization when reporting durations of gestation. Facility studies reported a wide variety of populations and number of facilities. Circumstances surrounding abortions later in pregnancy include health system challenges, late pregnancy recognition, financial issues, and delayed decision-making, which intersect to compound and extend delays. More research guided by clear methods and standard definitions when reporting on population and facility-based proportions of abortions later in pregnancy is needed to reveal evidence gaps and better inform policies and programs.

Objective: To understand the local Mexican-origin Latino community’s preference for bilingual health care providers and understand the relationship between language concordant care and comprehension of a healthcare visit. Background: Language barriers in healthcare negatively impact quality of care. Language concordant care (where a health care provider speaks the patient’s language) has been shown to result in better patient comprehension than using interpreters/translators. Study Design: This is a cross sectional study in collaboration with the General Consulate of Mexico. We developed a 20-item survey that includes questions about socio-demographics, an acculturation scale, and questions regarding language concordant care experience and preferences. Participants were aged 18 or older who had a healthcare visit within the past 12 months. We used descriptive and multivariable statistics to describe our sample and test the association of language concordant care and comprehension of the healthcare visit. Results We recruited 505 participants who all completed the survey in Spanish. Overall, 93.5% reported preference for a language concordant provider and 32.9% reported receipt of such care. Of those who reported a concordant provider visit, 87% reported a regular source of care compared to 50% among those with a discordant provider (p<0.001). In multivariable analyses, patients with a concordant provider had higher odds of understanding everything their provider said (aOR = 10.53 (95% CI: 6.60-16.81). Conclusion There is a gap between the preference for language concordant providers and the receipt of this type of health care for Oregon Latinos. Increasing access to language concordant care can contribute to improving health care quality, equity, and outcomes for Latinos in Oregon.

IntroductionComplications from abortive events are difficult to measure and compare across settings due to lack of standardized definitions, limited available data, and stigma. Globally, indirect methods are used to estimate the incidence of abortion complications by using provider reports as a proxy; however, few studies rely on clinical data for abortive event complications. Several studies show that many abortion clients seek PAC for reasons other than a complication such as confirmation of a complete abortion. We describe care-seeking for abortive events and complication rates over time (2018–2022) and by state from the Mexican public hospital discharge register.MethodWe used hospital discharge data from Mexico (called SAEH). We included hospital facilities operated by national and state ministries of health; since our focus is on complications (rather than incidence), we include only hospitals, where complications are treated. We included ICD-10 codes O02-O08 and Z303. Our primary outcome is the existence of a complication and details about type of complication. Complications reported include codes for excessive bleeding, infection, embolism, and unspecified. We also identified procedure type (aspiration, curettage, misoprostol). We included additional socio-demographic and clinical information available in the discharge record. We described patient characteristics, complications, and procedure type by year (2018-2022). We calculated state-level abortion complication rates (complications per 1,000 events) and created a heat map of the rate of abortion complications by state.ResultsWe included 399,405 patients who received hospital-based care for an abortive event between 2018-2022. Patient demographic characteristics were stable over time (2018-2022). Overall, the largest age category was 20-24 years old (27%) and 2.5% of patients spoke an indigenous language. Abortive events primarily occurred at or less than 13 weeks of gestation (74% overall) and this proportion increased slightly over time from 73% in 2018 to 77% in 2022. Of all the patients who received care for abortive events, the overwhelming majority (93%) had no complication recorded and was stable over time. Of the 6-8% of patients who did experience a complication, the most common designation was “unspecified” with 6% of abortive events in 2018-2020; 5.6 % in 2021 and 3.9% in 2022. Reports of excessive bleeding, embolism, and infections were between <0.1-1% for all years. The states with higher complication rates are located primarily in the central and southern regions. The proportion of cases that were treated using curettage decreased from 55% in 2018 to 46% in 2022; the use of aspiration increased over time from 22% in 2018 to 29% in 2022, and use of misoprostol was less than 2% of cases overall.ConclusionsIn Mexico, most patients who seek care for abortive events (induced, spontaneous, or post-abortion) in Ministry of Health hospitals have no complications. Curettage remains common and misoprostol is underutilized in the hospital setting in Mexico. Conflating care-seeking and complications overestimates of the risk of abortion.

OBJECTIVES:To understand in-facility follow-up care-seeking behavior among both people who self-managed medication abortions and those who obtained facility-managed care in low-and-middle-income countries. We explore factors that contribute to meeting individual self-reported follow-up care needs, core to person-centered care. STUDY DESIGN:We conducted a qualitative, codebook thematic analysis of 67 in-depth interviews conducted with people who self-managed medication abortions or obtained facility-managed medication abortion care. We first classified individuals as having their follow-up care needs met (not seeking care when the participant felt confident that additional care was not warranted or desired or receiving care if it was desired) or not. Our a priori analytic domains came from the Anderson model of health services utilization - predisposing, enabling, or need factors (perceived and evaluated need for health services) that contributed to having follow-up care needs met or not. We also describe emergent themes within each domain. RESULTS:Most participants (n=59, 88%) had their follow-up care needs met; half (n=33, 49%) sought follow-up care in a facility. Prior birth or abortion experiences emerged as predisposing factors for having follow-up care needs met. Having accompaniment support (from activists or hotlines who provide abortion guidance outside of clinical settings), knowing what to expect, and information sources were key enabling factors for having follow-up care needs met. Need factors included flexible follow-up care guidelines. Those who did not have their follow-up care needs met described predisposing negative health system experiences; enabling factors including health system challenges, stigma from providers, and legal risk; and need factors of required follow-up care guidelines. CONCLUSIONS:Medication abortion follow-up care experiences are diverse, and individual needs can be met both in and outside of health facilities. Understanding prior experiences, enabling accompaniment support, and considering flexible follow-up care guidelines can support meeting individual follow-up care needs, which is essential to person-centered abortion care. IMPLICATIONS:Follow-up care needs, essential to ensuring access to high-quality abortion services, can be met in both self-managed and in-facility medication abortion models. Policies that require follow-up care when it is not needed or desired by the person can reinforce ideas that self-managed abortion is not safe or effective, despite existing evidence.

ObjectiveWe used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh.MethodsWe leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics.ResultsOf 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82).ConclusionsIn Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

We aimed to describe provider beliefs, opinions, and roles in self-managed abortion (SMA) provision and identify referral pathways to facility- and self-managed abortion care in India. We analyzed 33 semi-structured interviews with healthcare providers: pharmacy workers, unlicensed local providers, accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), and registered medical providers (RMPs) in India. We coded transcripts, conducted a thematic analysis, and identified mentions of referrals including the type of provider, the abortion care modality (facility- or self-managed), and the reason. Providers’ perception of SMA safety and liability concerns resulted in discouraging clients from seeking an SMA, instead promoting the use of contraceptives or facility-managed abortion. Nonetheless, participants acknowledged three areas were providers played a role in SMA provision: describing usage and potential side effects, dispensing medication, and managing pain. LPs and pharmacy workers described usage and dispensed medications, while LPs and ASHAs described potential side effects and managed pain. ANMs and RMPs did not provide direct care to SMA clients in the community. All provider types described referrals pathways to a facility-managed abortion. Despite provider concerns, SMA care and referrals occur in India. Understanding the complex dynamics of provider roles, opinions, and referral practices can inform comprehensive reproductive health policies and interventions that promote client-centered abortion care—including SMA—and address provider concerns. These findings have implications in the US as legal restrictions increase and there is a need for synergies between the health system and SMA care networks.

Objective This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion.Methods We conducted interviews with people seeking abortion aged 15–41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants.Results We identified six themes that contributed to high-quality abortion care from the clients’ perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain.Conclusions People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

Objective: We compared prenatal care utilization, preterm birth, and low birth weight neonates among women 35 years and older compared to women 20-34 years old in Mexico, 2008-2019. Methods: We used birth certificate data and conducted a historical cohort study of all singleton live births in Mexico from 2008-2019. Study outcomes were inadequate prenatal care (timing of initiation of care and number of visits), preterm birth, and low birth weight. We compared outcomes among women 35-39, 40-44, and 45-49 with births to women 20-34. We used logistic regression to account for individual and contextual confounders. Results: We included a total of N=19,526,922 births; 11.9% (n=2,325,725) were to women 35 and older. Compared to women aged 20 to 34, the oldest (45-49 years old) were more likely to reside in poorer communities, have less education, and be uninsured. The odds of inadequate prenatal care (aOR 1.12 95% CI 1.09-1.15 p<0.01), preterm birth (aOR 2.05 95% CI 1.97-2.13 p<0.01), and low birth weight (2.03 95% CI 1.95-2.12 p<0.01) were highest for women 45-49, compared to women 20-34. Patterns were similar among women 35-39 and 40-44 with the exception of lower odds of inadequate prenatal care (aOR 0.77 95% CI 0.76-0.77 p<0.01) for 35-39 compared to women 20-34. Conclusion: Women who deliver at 35 years old and over are a heterogeneous group in Mexico. Being 35 years old and older is associated with increases in preterm birth and low birth weight neonates. Women who give birth between 45-49 may be especially vulnerable.

AbstractObstetric fistula, a devastating condition that almost exclusively affects women in low- and middle-income countries (LMICs), is only one of many pelvic floor disorders related to childbirth. This chapter encourages readers to re-focus attention to the larger unattended crisis of childbirth-related pelvic floor disorders. These include pelvic organ prolapse, persistent urinary incontinence after successful repair of obstetric fistula, nonfistula-related urinary and anal incontinence, and musculoskeletal disorders of the pelvic floor. Women in LMICs are at a high risk for these conditions where access to family planning and timely obstetric care is limited; repeated trauma from multiple deliveries and prolonged obstructed labor is prevalent; and there is lack of access to timely care for pelvic floor injuries. Further, there is a massive shortage in trained health workers to address the large unmet need of pelvic floor disorders in these regions. A paradigm shift is needed in order to address this gap. In addition to specialized training in pelvic medicine and reconstructive surgery, we need to strengthen the overall health system needed to provide safe and quality care for these patients. We call upon humanitarian groups, charity organizations, health institutions, ministries of health, and national and international scientific societies to leverage their resources and expertise to promote women’s pelvic floor health globally.KeywordsObstetricsObstetric fistulaIncontinencePersistent urinary incontinencePelvic organ prolapsePelvic floorCapacity buildingEthiopia

IntroductionDisrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia.Study DesignWe conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives.ResultsParticipants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion.ConclusionsParticipants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

Objective To describe the community context of women who travel to access Mexico City’s public sector abortion programme and identify factors associated with travelling from highly marginalised settings. Methods We used data from the Interrupción Legal de Embarazo (ILE) programme (2016–2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients’ individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. Results Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). Conclusion ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

PURPOSE:Much reproductive health research on the Latina population overlooks heterogeneity by national origin, nativity, and age and also ignores how U.S.-based populations differ from those in "sending" nations. The purpose of this study is to describe a history of adolescent birth, age at first sex, and contraceptive use at first sex in the Mexican-origin population in both the United States and Mexico.METHODS:We developed a binational dataset merging two comparable nationally representative cross-sectional surveys in the United States and Mexico and used covariate balancing propensity scores to balance the age structure of our four samples: U.S.-born Latinas of Mexican origin, foreign-born Latinas of Mexican origin, U.S.-born non-Latina Whites, and Mexican women residing in Mexico. We used a negative binomial regression and calculated the predicted probability of experiencing at least one adolescent birth for each ethnicity/nativity group, stratified by 5-year age group. We also described age and contraceptive use at first sex.RESULTS:Foreign-born Latinas of Mexican origin and Mexicans in Mexico had similar adjusted probabilities of reporting an adolescent birth (30.1% and 29.9%, respectively), which were higher than those of Mexican-Americans (26.2%) and U.S.-born non-Latina Whites (11.6%). History of an adolescent birth is declining across all four groups among younger ages. Differences do not appear to be driven by the timing of first sex but by contraceptive use, which is increasing among younger age groups.DISCUSSION:Access to and use of effective contraception rather than timing of initiation of sexual activity is a key determinant of U.S. Latina and Mexican adolescent births.

Young people face social and structural barriers when accessing abortions. High-quality, sexual and reproductive healthcare is needed; however, literature on youth-informed abortion services is limited. This study assesses accounts of youth who obtained an abortion in Argentina, Bangladesh, Ethiopia, and Nigeria and provides recommendations to improve person-centered aspects of abortion quality. We analyzed 48 semi-structured interviews with clients recruited from clinics, safe abortion hotlines, and patent and proprietary medicine vendors. We coded transcripts and conducted a thematic analysis. The mean age was 21 years (range 16–24), and the majority had a first trimester, medication abortion. Prominent themes included access to information; privacy; stigma associated with age or marital status; the decision-making process; and comfort and rapport with providers. Youth-centered abortion care should anticipate the distinct needs of younger clients. Supportive providers have an important role in offering a non-judgmental service that makes young clients feel comfortable and prepared.

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.

Behavioral health integration (BHI) changes the paradigm of primary care delivery by integrating behavioral healthcare into primary care. Thus, BHI likely alters the shared experiences of both patients and providers in an interrelated manner; however, their experiences are usually evaluated separately. The purpose of this study was to analyze these shared experiences together within patient-provider pairs in integrated clinics. First, patient interviews were conducted using semi-structured interview guides and transcripts were analyzed for major themes of patient experience. Next, providers named in patient interviews were interviewed around these same themes. Thematic analysis was performed on 18 transcripts (11 patients, 7 providers). Common themes included BHI experience, pain management, feeling heard by providers, and health care experiences. Areas of alignment included positive perception of BHI, an absence of long-term care, and a desire to share decision-making. Pain management was a persistent area of conflict, and the differing experiences were consistent with a change in the psychodynamic patient-provider model. This conflict highlights a gap in BHI and a need for provider education about psychodynamic relationship models.

Introduction and hypothesis Obstetric fistulas have devastating consequences for women. Although surgical repair is largely successful in closing the defect, many women with successful fistula closure report persistent urinary incontinence. Our study is aimed at characterizing incontinence after successful fistula repair and its impact on quality of life. Methods This cross-sectional study enrolled women with a history of successful obstetric fistula closure with (n = 51; cases) or without (n = 50; controls) persistent urinary incontinence. Data were collected in Mekelle, Ethiopia, between 2016 and 2018. All cases underwent clinical evaluation and completed questionnaires characterizing the type, severity, and impact of incontinence. Results Cases were significantly more likely to have acquired their fistula at an earlier age and with their first vaginal delivery compared with controls. Almost all cases reported both stress (98%) and urgency (94%) incontinence, and half reported constant urinary leakage (49%) despite successful fistula closure. Of cases who completed urodynamic evaluation (n = 22), all had genuine stress incontinence and none had detrusor overactivity. All cases reported moderate to severe (80.4%) or very severe (19.6%) incontinence (measured by ICIQ-SF) and this had a moderate to severe negative impact on their quality of life (as measured by ICIQ-QoL). Although history of suicidal ideation was not significantly different between the groups, among those with suicidal ideation, cases were more likely to report having made a plan and/or attempted to commit suicide. Conclusions When urinary incontinence persists after successful fistula closure, it tends to be severe and of mixed etiology and has a significant negative impact on quality of life and mental health.

OBJECTIVE:Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it.METHODS:Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia.RESULTS:This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum.CONCLUSION:We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

Research on behavioral health integration (BHI) often explores outcomes for quality and cost, but less is known about impacts of integration work on key patient experience outcomes. A mixed-methods longitudinal study of BHI was conducted in 12 primary care clinics in Oregon to assess how adoption of key integration practices including integrated staffing models, integrated care trainings for providers, and integrated data sharing impacted a set of patient experience outcomes selected and prioritized by an advisory panel of active patients. Results showed that adopting key aspects of integration was not associated with improved patient experience outcomes over time. Patient interviews highlighted several potential reasons why, including an overemphasis by health systems on the structural aspects of integration versus the experiential components and potential concerns among patients about stigma and discrimination in the primary care settings where integration is focused.

In 2003, the George W. Bush administration passed the President’s Emergency Plan for AIDS Relief (PEPFAR), a US government initiative to address the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic primarily in Africa. PEPFAR’s US$18 billion budget remains the largest commitment from any nation towards a single disease and has saved countless lives. Given the historical and current political resistance to foreign aid, PEPFAR’s drastic spike in spending on HIV/AIDS raises questions over how the policy process resulted in bipartisan support. Using two policy process theories, punctuated equilibrium theory (PET) and the Narrative Policy Framework (NPF), this analysis helps explain the framing of the global HIV/AIDS epidemic and the factors that resulted in the creation of PEPFAR. The analysis of the PEPFAR policy process reveals a ‘tipping point’ in the early 2000s, when political actors, the media and advocacy coalitions benefitted from issue framing, narrative change and measures of political attention to elevate the global HIV/AIDS crisis to the public agenda. The findings highlight an increase in presidential attention, the evolution of the HIV/AIDS narrative away from stigma and the formation of powerful coalitions. Looking back on the combination of policy process factors that led to PEPFAR’s bipartisan success might lead to insights for dismantling the grand public health challenges of the present and future. This study’s findings have implications for currently stigmatised public health crises, such as the opioid epidemic.