Delays in obtaining hospital care and abortion-related complications within a context of illegality.

Abortion, particularly when illegal, highlights inequities in different populations. Although abortion-related mortality is lower compared to other obstetric causes, abortion complications tend to be more lethal. Delays in seeking and obtaining care are determinants of negative outcomes. This study, nested within the GravSus-NE, analyzed healthcare delays and their association with abortion-related complications in three cities of northeastern Brazil (Salvador, Recife and São Luís). Nineteen public maternity hospitals were involved. All eligible women ≥18 years old hospitalized between August and December 2010 were evaluated. Descriptive, stratified and multivariate analyses were performed. Youden's index was used to determine delay. One model was created with all the women and another with those admitted in good clinical conditions, thus determining complications that occurred during hospitalization and their associated factors. Of 2,371 women, most (62.3%) were ≤30 years old (median 27 years) and 89.6% reported being black or brown-skinned. Most (90.5%) were admitted in good condition, 4.0% in fair condition and 5.5% in poor/very poor condition. Median time between admission and uterine evacuation was 7.9 hours. After a cut-off time of 10 hours, the development of complications increased considerably. Black women and those admitted during nightshifts were more likely to experience a wait time ≥10 hours. Delays were associated with severe complications (OR 1.97; 95%CI: 1.55-2.51), including in the women admitted in good condition (OR 2,56; 95%CI: 1.85-3.55), and even following adjustment for gestational age and reported abortion type (spontaneous/induced). These findings corroborate the literature, highlighting the social vulnerability of women hospitalized within Brazil's public healthcare system in a situation of abortion. The study strongpoints include having objectively measured the time between admission and uterine evacuation and having established a cut-off time defining delay based on conceptual and epidemiological criteria. Further studies should evaluate other settings and new measurement tools for effectively preventing life-threatening complications.

How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states.

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.