Perils and possibilities of health exception laws: A narrative review.

Forty-seven of the 203 countries with abortion laws detailed by the Center for Reproductive Rights have a health exception (HE) clause, inconsistent in both wording and implementation, even within countries. This narrative review sought to determine the understanding and implementation of the legally permissible HE in different countries, or states, to provide clarification and guidance for strategies that will maximize permitted access to safe abortion within the law and avoid undue delays that harm the lives and health of women and their families. A multimethod approach was used. The literature search for countries with HE laws, including physical, mental, and social health, and exceptions for threat to life, rape, incest, and fetal anomaly, returned sparse results. The review of emblematic cases that had reached regional courts on the grounds of human rights violation for failure to obtain legal abortion under the country's HE clause included some examples qualifying on multiple grounds. We interviewed 15 physician advocates from 14 countries about use of the HE in their countries. Informants from Latin America interpreted the HE to refer to physical, psychological, and social health. HE laws are common but confusing, with significant opportunities to improve access through clarification and implementation. Where multiple grounds permit ending a pregnancy, the least onerous exception for the patient is the most ethical. Examples of progress in Colombia and Ghana demonstrate successful approaches to broader HE implementation.

Guideline No. 423: Female Genital Cosmetic Surgery and Procedures.

OBJECTIVE: To provide Canadian surgeons and other providers who offer female genital cosmetic surgery (FGCS) and procedures, and their referring practitioners, with evidence-based direction in response to increasing requests for, and availability of, vaginal and vulvar surgeries and procedures that fall outside the traditional realm of medically indicated reconstructions. TARGET POPULATION: Women of all ages seeking FGCS or procedures. BENEFITS, HARMS, AND COSTS: Health care providers play an important role in educating women about their anatomy and helping them appreciate individual variations. Most women requesting FGCS and procedures have normal genitalia, and up to 87% are reassured by counselling. At this time, due to lack of rigorous clinical or scientific evidence of short- and long-term efficacy and safety, FGCS and procedures for non-medical indications cannot be supported. FGCS and procedures are typically provided in the private sector, where costs are borne by the patient. EVIDENCE: Literature was retrieved through searches of MEDLINE, Scopus, and The Cochrane Library using appropriate controlled vocabulary and keywords. The selected search terms represented keywords for FGCS (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combined with female genital counselling, consent, satisfaction, follow-up, adolescent, and body dysmorphic or body dysmorphia. The search was restricted to publications after 2012 in order to update the literature since the previous guideline on this topic. Results were restricted to systematic reviews, randomized controlled trials, and observational studies. Studies were restricted to those involving humans, and no language restrictions were applied. The search was completed on May 20, 2020, and updated on November 10, 2020. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Gynaecologists, primary care providers, surgeons performing FGCS and/or procedures.

Directive clinique no 423 : Interventions chirurgicales et thérapeutiques esthétiques génitales féminines.

OBJECTIF: Fournir aux chirurgiens et autres fournisseurs de soins canadiens qui réalisent des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines, et tout praticien demandeur, des directives fondées sur des données probantes en réponse à l'augmentation des demandes et de la disponibilité des interventions chirurgicales et thérapeutiques vaginales et vulvaires sortant du cadre traditionnel de la reconstruction avec indication médicale. POPULATION CIBLE: Les femmes de tous âges qui consultent pour subir une intervention chirurgicale ou thérapeutique esthétique génitale. BéNéFICES, RISQUES ET COûTS: Les professionnels de la santé qui prodiguent des soins aux femmes jouent un rôle important en renseignant les femmes sur leur anatomie et en les aidant à prendre conscience des variations individuelles. La plupart des femmes qui demandent une intervention chirurgicale ou thérapeutique esthétique génitale féminine ont des organes génitaux normaux, et jusqu'à 87 % d'entre elles sont rassurées par des conseils. À l'heure actuelle, étant donné le manque de données probantes cliniques et scientifiques rigoureuses sur l'efficacité et l'innocuité à court et à long terme, il n'y a aucune base pour se prononcer en faveur des interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sans indication médicale. Les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines sont généralement réalisées dans le secteur privé, où les coûts sont assumés par la patiente. DONNéES PROBANTES: La littérature publiée a été rassemblée par des recherches dans les bases de données Medline, Scopus et Cochrane Library au moyen de termes et mots clés pertinents et validés. Les termes de recherche sélectionnés se composaient de mots clés sur les interventions chirurgicales ou thérapeutiques esthétiques génitales féminines (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combinés à female genital counselling, consent, satisfaction, follow-up, adolescent et body dysmorphic or body dysmorphia. La recherche a été limitée aux articles publiés après 2012 afin de mettre à jour la documentation depuis la dernière directive à ce sujet. Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Les études ont été limitées à celles menées chez l'humain seulement, et aucune restriction linguistique n'a été appliquée. La recherche a été effectuée le 20 mai 2020 et mise à jour le 10 novembre 2020. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Gynécologues, fournisseurs de soins primaires, chirurgiens réalisant des interventions chirurgicales et/ou thérapeutiques esthétiques génitales féminines. RECOMMANDATIONS.

When there are no abortion laws: A case study of Canada.

Canada decriminalized abortion, uniquely in the world, 30 years ago. We present the timeline of relevant Canadian legal, political, and policy events before and since decriminalization. We assess implications for clinical care, health service and systems decisions, health policy, and the epidemiology of abortion in the absence of criminal legislation. As the criminal abortion law was struck down, dozens of similar private member's bills, and one government bill, have been proposed, but none were passed. Key findings include that initially Canadian provinces attempted to provide restrictive regulations and legislation, all of which have been revoked and largely replaced with supportive policies that improve equitable, accessible, state-provided abortion service. Abortion rates have been stable over 30 years since decriminalization, and a falling proportion of abortions occur late in the second trimester. Canada demonstrates that abortion care can safely and effectively be regulated as a normal component of usual medical care.

Inter-pregnancy interval and pregnancy outcomes among women with delayed childbearing: protocol for a systematic review.

BACKGROUND: Women in high resource nations are increasingly delaying childbearing until their thirties. Delayed childbearing poses challenges for the spacing of a woman's pregnancies. Inter-pregnancy intervals <12 months are associated with risk for adverse pregnancy outcome, yet increased maternal age at delivery is linked with increased risk. The optimal inter-pregnancy interval for older mothers is uncertain. This systematic review will aim to assess the relation between inter-pregnancy interval and perinatal and maternal health outcomes in women who delay childbearing to age 30 and older. METHODS: We will search MEDLINE, CINAHL, and EMBASE databases for peer-reviewed articles on the effects of inter-pregnancy interval on perinatal and maternal health outcomes among women over 29 years at the time of first birth, in high-income countries. To assess the quality of studies, the Cochrane's Collaboration tool for assessing risk of bias will be used for randomized controlled trials, and the Newcastle-Ottawa tool to assess quality of case control and cross-sectional studies. The quality of the findings on each outcome will be assessed across studies, using the GRADE approach. The decision to conduct meta-analyses will be based on the concordance in definitions used for inter-pregnancy intervals, age groups studied, or outcomes measured among selected studies. We will report odds ratios and/or relative risks and/or risk differences for different inter-pregnancy intervals and perinatal and maternal outcomes as well as pregnancy complications. DISCUSSION: This systematic review will summarize existing data on the relation between inter-pregnancy interval and perinatal and maternal health outcomes among women who delay childbearing to age 30 and older. Findings will inform clinical best practices to assist mothers over age 30 to space their pregnancies appropriately. SYSTEMATIC REVIEW REGISTRATION: Prospero CRD42015019057.

Drivers of maternity care in high-income countries: can health systems support woman-centred care?

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

A systematic review of pediatric cognitive rehabilitation in the elementary and middle school systems.

BACKGROUND: Cognitive Rehabilitation Therapy (CRT) is efficacious in remediating cognitive deficits, and has been demonstrated to be effective in a school setting. OBJECTIVE: The purpose of this paper is to review the literature on pediatric CRT as it relates to successful re-integration of TBI survivors into the school system and community. METHODS: This systematic review of the literature suggests that social re-integration strategies which incorporate problem-solving, reasoning, self-awareness, and positive social skills within a developmental framework are the most effective techniques for Pediatric CRT. RESULTS: Children and adolescents with cognitive impairments benefit from a holistic approach to rehabilitation which incorporates developmental, social, and emotional considerations, as well as, cognitive rehabilitation techniques. CONCLUSIONS: This systematic review identifies several avenues for effective therapeutic interventions for school aged TBI survivors. Many are supported by laboratory based efficacy studies. Future research should investigate optimal ages for particular treatments, as well as, the effectiveness of treatments across different social settings.

Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents.

OBJECTIVE: To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global women's health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum. METHODS: We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents. RESULTS: Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001). CONCLUSION: Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

Objective: Pour devenir des praticiens compétents sur le plan culturel étant en mesure de prodiguer des soins aux populations vulnérables et de défendre leur cause, les résidents doivent recevoir une formation abordant les priorités de la santé à l'échelle mondiale. Dans le domaine de l'obstétrique-gynécologie, nous ne disposons que de peu de renseignements au sujet de la formation en santé des femmes à l'échelle mondiale (SFEM) qu'offrent les programmes de résidence et de l'intérêt envers ce type de formation que l'on y constate. Nous souhaitions déterminer ce qui suit en ce qui concerne les programmes canadiens de résidence en obstétrique-gynécologie : (1) la situation actuelle pour ce qui est de l'enseignement de la SFEM et du soutien disponible à cet égard; (2) l'importance de la SFEM pour les résidents et les directeurs de programme; et (3) le degré d'intérêt envers un curriculum national de cycle supérieur dans le domaine de la SFEM. Méthodes : Nous avons mené, à l'échelle du Canada, un sondage en ligne auprès des directeurs des programmes de résidence en obstétrique-gynécologie et des résidents de dernière année du domaine. Résultats : Parmi les 297 résidents sollicités, 101 (34,0 %) ont répondu au sondage et 76 (26 %) ont rempli le sondage en entier. Onze des 16 directeurs de programme sollicités (68,8 %) ont répondu et 10/16 (62,5 %) nous ont fourni des réponses complètes. Quatre des 11 programmes (36,4 %) comptaient un curriculum de SFEM, 2/11 (18,2 %) comptaient un budget de SFEM et 4/11 (36,4 %) comptaient un président de la SFEM. Neuf directeurs de programme sur 10 (90 %) et 68 résidents sur 79 (86,1 %) étaient d'avis qu'une compréhension des questions de SFEM est importante pour tous les stagiaires canadiens en obstétrique-gynécologie. Seulement un directeur de programme sur 10 (10 %) et 11 résidents sur 79 (13,9 %) étaient d'avis que leur programme offrait une formation suffisante sur ces questions. Parmi les résidents des programmes comptant un curriculum de SFEM, 12/19 (63,2 %) étaient d'avis que les résidents de leur programme qui n'entreprenaient pas un stage au choix international auraient tout de même l'occasion de se sensibiliser à la SFEM, par comparaison avec seulement neuf des 50 résidents (18,0 %) des programmes ne comptant pas un tel curriculum (P < 0,001). Conclusion : Les résidents et les directeurs de programme du domaine de l'obstétrique-gynécologie estiment que la formation au sujet de la SFEM est importante pour tous les stagiaires et qu'elle est actuellement insuffisante. La mise sur pied d'un module pédagogique national de cycle supérieur en SFEM suscite un vif intérêt.

The worldwide epidemic of female obesity.

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Advocacy: the role of health professional associations.

The FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health was developed on the premise that organizational capacity strengthening in eight low- and middle-income countries would result in improved ability of member associations to take a leadership role in engaging a range of stakeholders in the health sector to discuss evidence and facilitate policy change and clinical practice in maternal and newborn health. Definitions of relevant terms, principles, and a framework for an advocacy plan are presented. The term advocacy is typically not well understood by health professionals, nor generally thought to be part of their role as a clinician, researcher, or educator. "Influence" based on expertise is often more consonant with a clinician's reality, especially where advocacy is perceived as a more political process that may present a barrier in some countries. The organizational capacity development of the FIGO member associations was integral to their ability to exert influence based on evidence, both internally in their associations and with other stakeholders, including the Ministry of Health. Examples of advocacy from each of the eight LOGIC countries are provided, noting that evaluation of impact can be challenging.

Origins of the FIGO initiative to reduce the burden of unsafe abortion.

The origins of the International Federation of Gynecology and Obstetrics (FIGO) Initiative for the Prevention of Unsafe Abortion and its Consequences began in 1969 when a young British medical student encountered a young woman in Canada with complications of unsafe abortion. Through evolving understanding of the context of women's lives, including the role of family planning and access to safe abortion globally in preventing the deaths and imprisonment of women, I was able to contribute to FIGO's advocacy through a collaborative initiative with country-led action plans based on a situational analysis. Forty-six member associations rapidly agreed to participate with results of situational analyses-an unprecedented result in FIGO's history. Professor Anibal Faúndes' role has been pivotal to the success of this initiative, including the establishment of a working group of regional coordinators and collaborating agencies to oversee the implementation of action plans involving in-country partners and the Ministry of Health. Deaths from unsafe abortion and its complications are preventable.

Pediatric cognitive rehabilitation: effective treatments in a school-based environment.

BACKGROUND: Many studies have investigated the impact of pediatric Cognitive Rehabilitation Therapy (CRT) upon intellectual functioning after traumatic brain injury; however, relatively few have identified efficacious treatment in a school setting. OBJECTIVE: The purpose is to present a variety of CRT strategies that would be useful to a teacher or therapist working with students who are learning disabled or who have who have had a traumatic brain injury (TBI). METHODS: This article investigates the particular challenges in learning which result from impaired cognition, and suggests techniques for improving memory and executive functioning. RESULTS: Students who are learning disabled or who have TBI face social and emotional issues that impact their learning. Special therapeutic interventions are necessary to assist with orienting to their setting, integrating with peers, and coping with distressing emotions. CONCLUSIONS: Students with TBI can adapt and flourish in a school based setting provided that therapies and learned strategies are targeted to their specific needs.

Today's evidence, tomorrow's agenda: implementation of strategies to improve global reproductive health.

The Alliance for Women's Health deliberated on critical gaps and emerging issues related to women's health, focusing on contraception, safe abortion care, HIV, and cervical cancer prevention. Despite the health, socioeconomic, and development benefits of family planning, up to 222 million women have an unmet need for modern contraception. The number of unsafe abortions increased globally, 98% of which occurred in low-resource countries. Fragmentation of services for HIV and cervical cancer prevention and treatment fail to maximize opportunities to reach women within reproductive, maternal, and child health services. The FIGO 2012 PreCongress Workshop elaborated the role of societies of obstetricians-gynecologists in implementation of actions to increase access to modern methods of contraception to help individuals meet family planning intentions. Human rights principles underpin the imperative to ensure equitable access to a wide range of modern methods of contraception. The role of task shifting/sharing in different models of service delivery was elaborated. Actions from the International Conference on Population and Development on safe abortion care and integration of effective contraception were reaffirmed. A call was made to increase access to integrated HIV and cervical cancer prevention, screening, and management. Cross-cutting strategic approaches to accelerate progress include evidence-based information to stakeholders and continued education in these areas at all levels of training. A call was made to advocate for a budget line item for sexual and reproductive health, including family planning and engaging the demand side of family planning, while involving men to enhance uptake and continuation.