egislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

Objective To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Design Population-based natural experiment. Setting and data sources Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Main outcomes Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Independent variables Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science

It is well documented that the majority of adults, children and families in need of evidence-based behavioral health interventionsi do not receive them [1, 2] and that few robust empirically supported methods for implementing evidence-based practices (EBPs) exist. The Society for Implementation Research Collaboration (SIRC) represents a burgeoning effort to advance the innovation and rigor of implementation research and is uniquely focused on bringing together researchers and stakeholders committed to evaluating the implementation of complex evidence-based behavioral health interventions. Through its diverse activities and membership, SIRC aims to foster the promise of implementation research to better serve the behavioral health needs of the population by identifying rigorous, relevant, and efficient strategies that successfully transfer scientific evidence to clinical knowledge for use in real world settings [3]. SIRC began as a National Institute of Mental Health (NIMH)-funded conference series in 2010 (previously titled the “Seattle Implementation Research Conference”; $150,000 USD for 3 conferences in 2011, 2013, and 2015) with the recognition that there were multiple researchers and stakeholdersi working in parallel on innovative implementation science projects in behavioral health, but that formal channels for communicating and collaborating with one another were relatively unavailable. There was a significant need for a forum within which implementation researchers and stakeholders could learn from one another, refine approaches to science and practice, and develop an implementation research agenda using common measures, methods, and research principles to improve both the frequency and quality with which behavioral health treatment implementation is evaluated. SIRC’s membership growth is a testament to this identified need with more than 1000 members from 2011 to the present.ii SIRC’s primary objectives are to: (1) foster communication and collaboration across diverse groups, including implementation researchers, intermediariesi, as well as community stakeholders (SIRC uses the term “EBP champions” for these groups) – and to do so across multiple career levels (e.g., students, early career faculty, established investigators); and (2) enhance and disseminate rigorous measures and methodologies for implementing EBPs and evaluating EBP implementation efforts. These objectives are well aligned with Glasgow and colleagues’ [4] five core tenets deemed critical for advancing implementation science: collaboration, efficiency and speed, rigor and relevance, improved capacity, and cumulative knowledge. SIRC advances these objectives and tenets through in-person conferences, which bring together multidisciplinary implementation researchers and those implementing evidence-based behavioral health interventions in the community to share their work and create professional connections and collaborations

Transvaginal cervical length and tobacco use in Appalachian women: association with increased risk for spontaneous preterm birth

Currently ACOG recommends that a mid-term screening strategy may be considered to identify short cervix in low risk populations in an effort to prevent preterm birth. Vaginal progesterone is recommended for women with a cervical length ≤20 mm. Cerclage is recommended for women with prior spontaneous preterm birth who are already receiving progesterone supplementation and CL is \u3c25 mm. This study examined risk factors for spontaneous preterm birth (SPB) \u3c35 weeks among a general obstetrical population prior to these ACOG recommendations. However, cervical cerclage was a possible intervention. Study population included 1,074 patients from 1 Jan 2007-30 Jun 2008 receiving mid-trimester transvaginal ultrasounds during prenatal care at a tertiary medical center clinic. Receiver operator characteristic (ROC) curve cutoff optimal value was ≤34 mm, (n=224), corresponding to 8.9% SPB with shortened cervices compared to 1.4% in patients with normal cervices (\u3e34 mm; n=850; p\u3c0.001 (Area Under the Curve (AUC) 76.6, p\u3c0.001). Cervical lengths \u3c30 mm had 12 times the risk of SPB (p\u3c0.001) while 30-34 mm had 5 times (p=0.005). Tobacco use (≥10 cigarettes per day), p=0.030, and low BMI, p=0.034, had additive effect. Shortened cervical length during routine screening independently predicted SPB while heavy smoking with shortened cervix during pregnancy doubled risk compared to shortened cervix alone

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live bir

Barriers to Clinical Trial Participation: Comparative Study Between Rural and Urban Participants

BackgroundThe National Clinical Trials Network program conducts phase 2 or phase 3 treatment trials across all National Cancer Institute’s designated cancer centers. Participant accrual across these clinical trials is a critical factor in deciding their success. Cancer centers that cater to rural populations, such as The University of Kansas Cancer Center, have an additional responsibility to ensure rural residents have access and are well represented across these studies. ObjectiveThere are scant data available regarding the factors that act as barriers to the accrual of rural residents in these clinical trials. This study aims to use electronic screening logs that were used to gather patient data at several participating sites in The Kansas University of Cancer Center’s Catchment area. MethodsScreening log data were used to assess what clinical trial participation barriers are faced by these patients. Additionally, the differences in clinical trial participation barriers were compared between rural and urban participating sites. ResultsAnalysis revealed that the hospital location rural urban category, defined as whether the hospital was in an urban or rural setting, had a medium effect on enrolment of patients in breast cancer and lung cancer trials (Cohen d=0.7). Additionally, the hospital location category had a medium effect on the proportion of recurrent lung cancer cases at the time of screening (d=0.6). ConclusionsIn consideration of the financially hostile nature of cancer treatment as well as geographical and transportation barriers, clinical trials extended to rural communities are uniquely positioned to alleviate the burden of nonmedical costs in trial participation. However, these options can be far less feasible for patients in rural settings. Since the number of patients with cancer who are eligible for a clinical trial is already limited by the stringent eligibility criteria required of such a complex disease, improving accessibility for rural patients should be a greater focus in health policy

Table S11

Maternal mortality ratio with abortive outcome (MMRAO) by place of residence in 32 Mexican states exhibiting a more (m) or less (l) permissive abortion legislation, 2002-2011

Data from: Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women, and maternal deaths: a natural experiment in 32 Mexican states

Objective: To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Design: Population-based natural experiment. Setting and data sources: Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Main outcomes: Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Independent variables: Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. Main results: Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=−0.061 to −1.100), skilled attendance at birth (β=−0.032 to −0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=−0.566 to −0.962), clean water (β=−0.048 to −0.730), sanitation (β=−0.052 to −0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=−14.329) and MMRAO (β=−1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R2) 51–88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. Conclusions: Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states

Figure 6

Mortality ratios and the proportion of abortion-related deaths by place of residence in states with or without a constitutional amendment to protect the unborn starting at conception: focus on the Federal District. Left panels illustrate trends for MMR (top panel), MMRAO (middle top panel), iAMR (middle bottom panel), and the proportion of abortion-related deaths (bottom panel) by place of residence between 2008 and 2011 in Mexican states, grouped as with amendment” (in dark green), without amendment (in cyan), and the Federal District (in green) in terms of exhibiting or not an constitutional amendment (the Federal District of Mexico was not included in this group to be illustrated separately) to protect the unborn starting at conception (Figure S1, Supplementary Material). Right panels show average ratios and proportion of abortion-related deaths for each group (dark green, cyan, and green bars, respectively). * p<0.05 using Z-test. Abbreviations: iAMR, induced abortion mortality ratio; MMR, maternal mortality ratio; MMRAO, maternal mortality ratio with abortive outcome

Figure 1

Mortality ratios and the proportion of abortion-related deaths by place of residence in states with less and more permissive abortion legislation. Left panels illustrate trends in MMR (top panel), MMRAO (middle top panel), iAMR (middle bottom panel), and the proportion of abortion-related deaths (bottom panel) by place of residence between 2002 and 2011 in Mexican states, grouped as with less permissive (in dark green) or more permissive (in cyan) in terms of abortion legislation in their criminal code (see Material and Methods). For comparison, trends for the whole Mexican country (all states) are depicted as dotted lines. Right panels show average ratios and proportion of abortion-related deaths for each group (dark green and cyan bars, respectively), and the whole Mexican country (hollow bars). * p<0.05 using Z-test. Abbreviations: iAMR, induced abortion mortality ratio; MMR, maternal mortality ratio; MMRAO, maternal mortality ratio with an abortive outcome