Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil / Atrasos no acesso ao tratamento das complicações relacionadas ao aborto: a experiência das mulheres no Nordeste brasileiro / Retrasos en el acceso a cuidados médicos para complicaciones relacionadas con el aborto: la experiencia de mujeres en el nordeste brasileño

Abstract: Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women's health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public-sector hospitals in three capital cities in the Northeastern Brazil between August-December 2010 were interviewed; medical records were extracted (N = 2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organizing childcare, a companion or transport (17%) and fear/stigma (11%); a few did not initially recognize they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.

Resumo: Cerca de 18 milhões de abortos são realizados por ano em condições inseguras nos países de renda baixa e média, associados a numerosas consequências negativas para a saúde das mulheres. O tempo despendido pelas mulheres com complicações até chegar aos serviços onde possam receber os cuidados adequados no período pós-aborto podem influenciar o risco de morte e o grau das complicações posteriores. Foram entrevistadas todas as mulheres com 18 anos ou mais internadas devido a complicações do aborto em hospitais públicos em capitais estaduais do Nordeste brasileiro entre agosto e dezembro de 2010, e os prontuários foram analisados (N = 2.804). Quase todas as mulheres (94%) se dirigiram diretamente a um serviço de saúde, principalmente hospitais (76,6%), enquanto as outras seguiram diversos itinerários em busca de atendimento. Uma em cada quatro mulheres percorreu três ou mais hospitais. As mulheres esperavam uma média de dez horas antes de decidir buscar atendimento. 29% relatavam dificuldades no início da busca, inclusive desafios na organização dos cuidados dos filhos, com acompanhantes ou transporte (17%) e medo/estigma (11%). Uma pequena minoria (0,4%) não se deu conta inicialmente da necessidade de cuidados médicos. O tempo mediano para chegar até o serviço de saúde finalmente utilizado foi 36 horas. Mais de uma em cada quatro mulheres relatava dificuldades em conseguir internação hospitalar, inclusive tempo de espera prolongado (15%), atendimento apenas depois que todas as mulheres grávidas estivessem sido atendidas (8,9%) e espera por um leito (7,4%). Quase todas as mulheres (90%) chegavam em boas condições, mas aquelas sujeitas a esperas mais prolongadas mostraram maior probabilidade de complicações (tanto leves quanto graves). No Brasil, onde o acesso ao aborto induzido é restrito, as mulheres enfrentam muitas dificuldades para receber cuidados pós-aborto, o que contribui aos atrasos e impacta a gravidade das complicações pós-aborto.

Resumen: Cerca de 18 millones de abortos inseguros se producen en países de renta media o baja y están asociados con numerosas consecuencias adversas para la salud de la mujer. El tiempo que tardan las mujeres con complicaciones en llegar a los servicios médicos, donde puedan recibir cuidados apropiados tras un aborto, puede tener influencia en el riesgo de muerte y existencia de futuras complicaciones de salud. Todas las mujeres con 18+ años, admitidas por complicaciones durante un aborto en hospitales del sector público de tres capitales del Nordeste brasileño, entre agosto y diciembre de 2010, fueron entrevistadas; y sus historiales médicos resumidos (N = 2.804). Casi todas las mujeres (94%) fueron directamente a una institución sanitaria, en su mayoría un hospital (76,6%); el resto buscaron diferentes vías de cuidados, con una cuarta parte visitando 3+ hospitales. Las mujeres esperaron 10 horas de media antes de decidir buscar cuidados. Un 29% informó de dificultades al empezar a buscar cuidados, incluyendo el hacer frente a los desafíos para organizar el cuidado infantil, un acompañante o transporte (17%) y miedo/estigma (11%); otras en un principio no reconocieron la necesidad de cuidados (0,4%). La media de tiempo que les llevaba llegar al servicio de salud definitivo era 36 horas. Más de un cuarto de las mujeres informaron vivir dificultades estando admitidas en un hospital, incluyendo largas esperas (15%), sólo siendo atendidas tras las mujeres embarazadas (8,9%) y esperando una cama (7,4%). Casi todas las mujeres (90%) llegaron en buenas condiciones, pero aquellas con retrasos más largos eran las que estaban más expuestas a tener complicaciones (leves o graves). En Brasil, donde el acceso al aborto inducido está limitado, las mujeres se enfrentan a numerosas dificultades para recibir cuidado tras un aborto, lo que contribuye a retrasos e influye en la gravedad de las complicaciones post aborto.

Obstetric fistula in Southern Sudan: situational analysis and Key Informant Method to estimate prevalence.

BACKGROUND: Obstetric fistula is a severe condition which can have devastating consequences for a woman's life. Despite a considerable literature, very little is known about its prevalence. This project was conducted to carry out a situational analysis of fistula services in South Sudan and to pilot test the Key Informant Method (KIM) to estimate the prevalence of fistula in a region of South Sudan. METHODS: Key stakeholder interviews, document reviews and fistula surgery record reviews were undertaken. A KIM survey was conducted in a district of Western Bahr-el-Ghazal in January 2012. One hundred sixty-six community-based distributors, traditional birth attendants and village midwives were trained as key informants to identify women with fistula in the community. Women identified were subsequently examined by an obstetrician and nurse to verify whether they had a fistula. RESULTS: There were limited fistula repair services in South Sudan. Approximately 50-80 women per year attend periodic campaigns, with around half having a fistula and receiving a repair. On average a further 5 women a year received fistula repair from hospital services. Ten women with potential fistula were identified via KIM; all confirmed by the obstetrician. Of these, three were from the survey area, which had 8,865 women of reproductive age (15-49 years). This gives a minimal estimated prevalence of at least 30 fistulas per 100,000 women of reproductive age (95% CI 10-100). CONCLUSIONS: Routine fistula repair services available do not meet the population's needs. The pilot study suggests that KIM can be used to identify women with fistula in the community. Data on fistula are generally poor; the KIM methodology we used in South Sudan yielded a lower fistula prevalence than estimates reported previously in the region.

Effect of vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana: a secondary analysis from the ObaapaVitA trial.

OBJECTIVE: To determine the effect of weekly low-dose vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana. METHODS: A cluster-randomized, triple-blind, placebo-controlled trial was conducted in seven districts of the Brong Ahafo region of Ghana. Women aged 15-45 years who were capable of giving informed consent and intended to live in the trial area for at least 3 months were enrolled and randomly assigned, according to their cluster of residence, to receive oral vitamin A (7500 µg) or placebo once a week. Randomization was blocked, with two clusters in each fieldwork area allocated to vitamin A and two to placebo. Every 4 weeks, fieldworkers distributed capsules and collected data during home visits. Verbal autopsies were conducted by field supervisors and reviewed by physicians, who assigned a cause of death. Cause-specific mortality rates in both arms were compared by means of random-effects Poisson regression models to allow for the cluster randomization. Analysis was by intention-to-treat, based on cluster of residence, with women eligible for inclusion once they had consistently received the supplement or placebo capsules for 6 months. FINDINGS: The analysis was based on 581 870 woman-years and 2624 deaths. Cause-specific mortality rates were found to be similar in the two study arms. CONCLUSION: Low-dose vitamin A supplements administered weekly are of no benefit in programmes to reduce mortality in women of childbearing age.

Résumé OBJECTIF: Déterminer l'effet de la supplémentation hebdomadaire en vitamine A à faible dose sur la mortalité spécifique des femmes en âge de procréer au Ghana. MÉTHODES: Une étude randomisée, en triple aveugle, contrôlée contre placebo, a été menée dans sept districts de la région de Brong Ahafo au Ghana. Les femmes âgées de 15 à 45 ans, capables de donner un consentement éclairé et amenées à vivre dans la région de l'étude pendant au moins 3 mois, ont été incluses et il a été déterminé qu'elles recevraient une fois par semaine, au hasard selon leur groupe de résidence, de la vitamine A par voie orale (7 500 µg) ou un placebo. La randomisation a été fixée par deux groupes dans chaque zone recevant la vitamine A et deux groupes recevant le placebo. Toutes les 4 semaines, les agents de terrain distribuaient les capsules et recueillaient les données lors de visites à domicile. Des autopsies orales ont été effectuées par les superviseurs sur le terrain et analysées par des médecins, qui déterminaient la cause du décès. Les taux de mortalité spécifique dans les deux groupes ont été comparés à l'aide d'une régression de Poisson pour valider la randomisation des groupes. L'analyse, basée sur l'intention de traiter, était basée sur le groupe de résidence, pour des femmes éligibles à l'étude ayant reçu les capsules de supplément ou de placebo de manière constante pendant 6 mois. RÉSULTATS: L'analyse s'est basée sur 581 870 années-femmes et 2624 décès. Les taux de mortalité spécifique ont été jugés similaires dans les deux groupes de l'étude. CONCLUSION: Les suppléments en vitamine A à faible dose administrés hebdomadairement ne sont d'aucune utilité dans les programmes visant à réduire la mortalité chez les femmes en âge de procréer.

Resumen OBJETIVO: Determinar el efecto de la administración semanal de dosis bajas de vitamina A en la mortalidad por causas específicas de mujeres en edad reproductiva en Ghana. MÉTODOS: Se realizó un ensayo aleatorio de grupos, triple ciego y controlado por placebo en siete distritos de la región de Brong Ahafo, en Ghana. Se inscribieron mujeres de entre 15 y 45 años de edad capaces de dar su consentimiento informado y que tuvieran previsto vivir en el área de ensayo durante al menos tres meses. De acuerdo con el grupo de residencia al que habían sido asignadas de forma aleatoria, recibieron semanalmente vitamina A por vía oral (7500 µg) o placebo. La distribución aleatoria se limitó en cada área de trabajo a dos grupos a los que se les administró vitamina A y dos grupos que recibieron placebo. Cada cuatro semanas, los investigadores de campo distribuyeron cápsulas y recogieron datos durante las visitas a los hogares. Las autopsias verbales realizadas por los supervisores de campo fueron revisadas por médicos, quienes determinaron la causa de la muerte. Se compararon las tasas de mortalidad por causas específicas de ambos brazos mediante los modelos de regresión de Poisson con efectos aleatorios para facilitar la distribución aleatoria de los grupos. El análisis fue por intención de tratar, según el grupo de residencia y con mujeres que cumplieron las condiciones de inclusión una vez habían recibido de forma constante las cápsulas de suplemento o placebo durante seis meses. RESULTADOS: El análisis se basó en 581 870 años-mujer y 2624 muertes. Se descubrió que las tasas de mortalidad por causas específicas fueron similares en ambos brazos del estudio. CONCLUSIÓN: Los suplementos de dosis bajas de vitamina A administrados semanalmente no presentan ninguna ventaja en los programas para reducir la mortalidad de las mujeres en edad reproductiva.

Risk-factors for antepartum fetal deaths in the city of São Paulo, Brazil

OBJECTIVE: To assess risk factors for antepartum fetal deaths. METHODS: A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. RESULTS: Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mother's education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40 percent), hypertension (27 percent), intrauterine growth restriction (30 percent) and absence of a long-standing union (26 percent). CONCLUSIONS: Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mother's low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

OBJETIVO: Analisar os fatores de risco para óbitos fetais anteparto. METODOS: Estudo de caso-controle de base populacional realizado no Município de São Paulo, SP, de agosto de 2000 a janeiro de 2001. Os indivíduos foram selecionados a partir de uma coorte de nascimentos, obtida por meio de vinculação de declarações de nascimento e óbito. Os casos foram 164 óbitos fetais anteparto e os controles, uma amostra aleatória de 313 de sobreviventes até 28 dias. Foram realizadas entrevistas domiciliares com as mães e aplicado protocolo hospitalar. Foi empregada regressão logística para análise dos dados, baseado em modelo conceitual hierárquico. RESULTADOS: Os fatores estatisticamente significantes associados aos óbitos fetais anteparto foram: mães com união recente ou sem união; escolaridade da mãe inferior a quatro anos; nascimentos anteriores de baixo peso; mães com hipertensão, diabetes, e sangramento durante a gestação; ausência ou pré-natal inadequado presença de malformação congênita e presença de pequeno para idade gestacional. As maiores frações de risco atribuível na população foram inadequação do pré-natal (40 por cento), hipertensão (27 por cento), presença de pequeno para idade gestacional (30 por cento), e ausência de união com mais de um ano (26 por cento). CONCLUSÕES: Os fatores de risco proximais são os mais importantes para a mortalidade fetal anteparto. Entretanto, fatores distais como mães de baixa escolaridade e união recente ou ausente também desempenham importante papel. Melhorar acesso e qualidade do pré-natal pode promover impacto positivo na mortalidade fetal.

Demographic and psychosocial profile of smoking among pregnant women in Lebanon: public health implications.

OBJECTIVES: To assess the prevalence and determinants of smoking prior to and during pregnancy in Lebanon. METHODS: A cross-sectional study using two structured instruments. One instrument included information on demographic characteristics, smoking patterns in the index pregnancy and previous pregnancies, use of prenatal health services, stressful life events, and social support during pregnancy. The second was the Arabic General Health Questionnaire (GHQ-12). Women who delivered in 11 randomly selected hospitals in Beirut and its suburbs within 24 hours were asked to consent to participate in the study. The total sample interviewed was 576 women. RESULTS: The prevalence of pre-pregnancy smoking was 32% and 20% for smoking in pregnancy. Considering argileh smoking, the prevalence of tobacco use in pregnancy increased to 27% in Beirut and 25% in the suburbs. Pre-pregnancy smoking was associated with older maternal age [OR = 1.08, 95% CI (1.03, 1.14)], low and medium education [OR = 2.22, 95% CI (1.22,4.04)], increased psychiatric distress [OR = 3.11, 95% CI (1.77,5.46)], and a husband who smoked [OR = 5.00, 95% CI (2.98,8.39)]. Continued smoking during pregnancy was associated with low and medium education [OR = 3.77, 95% CI (1.31, 10.8)], younger age [OR = 1.11, 95% CI (1.02-1.20)], and a heavy pre-pregnancy smoking pattern [OR = 13.9, 95% CI (1.40,137.4)]. CONCLUSION: Policies and programs to eliminate or reduce smoking during pregnancy should be targeted toward young and less educated females and involving the spouse. Obstetricians should promote smoking cessation during pregnancy using evidence-based methods.