Development of a new definition of maternal near miss based on organ dysfunction in Latin America and the Caribbean: A prospective multicenter cohort study.

BACKGROUND: There has been debate over whether the existing World Health Organization (WHO) criteria accurately represent the severity of maternal near misses. OBJECTIVE: This study assessed the diagnostic accuracy of two WHO clinical and laboratory organ dysfunction markers for determining the best cutoff values in a Latin American setting. METHODS: A prospective multicenter cohort study was conducted in five Latin American countries. Patients with severe maternal complications were followed up from admission to discharge. Organ dysfunction was determined using clinical and laboratory data, and participants were classified according to severe maternal outcomes. This study compares the diagnostic criteria of Latin American Centre for Perinatology, Network for Adverse Maternal Outcomes (CLAP/NAMO) to WHO standards. RESULTS: Of the 698 women studied, 15.2% had severe maternal outcomes. Most measured variables showed significant differences between individuals with and without severe outcomes (all P-values <0.05). Alternative cutoff values suggested by CLAP/NAMOs include pH ≤7.40, lactate ≥2.3 mmol/L, respiratory rate ≥ 24 bpm, oxygen saturation ≤ 96%, PaO2/FiO2 ≤ 342 mmHg, platelet count ≤189 × 109 × mm3, serum creatinine ≥0.8 mg/dL, and total bilirubin ≥0.67 mg/dL. No significant differences were found when comparing the diagnostic performance of the CLAP/NAMO criteria to that of the WHO standards. CONCLUSION: The CLAP/NAMO values were comparable to the WHO maternal near-miss criteria, indicating that the WHO standards might not be superior in this population. These findings suggest that maternal near-miss thresholds can be adapted regionally, improving the identification and management of severe maternal complications in Latin America.

Changes in reproductive, maternal, and child health in Haiti during the pre- and peri-COVID-19 pandemic / Cambios en materia de salud reproductiva, materna e infantil en los periodos pre y peripandémico de la COVID-19 en Haití / Mudanças na saúde reprodutiva, materna e infantil no Haiti antes e durante a pandemia de COVID-19

[ABSTRACT]. Objective. To assess changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti from August 2018 to September 2021, before and during the COVID-19 pandemic. Methods. A retrospective study using surveillance data from the Haitian Unique Health Information System, examining two periods: pre- and peri-COVID-19 pandemic. Health indicators at the national level in the two periods were compared using two-sample t-tests for proportions, and average absolute monthly changes were calculated using variance-weighted regression. Results. There was a statistically significant decline in the proportion of most of the indicators assessed from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were the proportions of pregnant women with four antenatal care visits, with five antenatal care visits or more, and those who received a second dose of tetanus vaccine, which decreased by over 4 percentage points during the two periods. Likewise, the proportions of children who received diphtheria, tetanus, and pertussis (DTaP), BCG, polio, pentavalent, and rotavirus vaccines also all declined by over 8 percentage points. In contrast, pneu- mococcal conjugate vaccine increased by over 4 percentage points. A statistically significant decrease was also observed in the average absolute monthly changes of several reproductive and child health indicators assessed. Conclusions. The COVID-19 pandemic may have contributed to the decline observed in several RMNCAH indicators in Haiti. However, the role played by the sociopolitical crisis and control exercised by armed groups over the population in the last three years cannot be ruled out.

[RESUMEN]. Objetivo. Evaluar los cambios en materia de salud reproductiva, materna, neonatal, infantil y adolescente que se produjeron en Haití desde agosto del 2018 hasta septiembre del 2021, antes de la pandemia de COVID-19 y durante ella. Metodología. Estudio retrospectivo basado en datos de vigilancia del sistema único de información de salud de Haití para estudiar los periodos pre y peripandémico. La comparación de los indicadores de salud a nivel nacional de estos dos periodos se realizó mediante pruebas de t de dos muestras para comparar proporciones, y se calculó el promedio de la variación mensual absoluta mediante una regresión ponderada por la varianza. Resultados. Al comparar el periodo prepandémico con el peripandémico, se observó un descenso estadísticamente significativo de la mayoría de los indicadores porcentuales evaluados. Sin embargo, los indicadores porcentuales más afectados fueron los de mujeres embarazadas con cuatro visitas de atención prenatal, con cinco visitas de atención prenatal o más, o que recibieron una segunda dosis de la vacuna contra el tétanos; estos indicadores disminuyeron en más de cuatro puntos porcentuales en el segundo periodo en comparación con el primero. Asimismo, las proporciones de niños y niñas que recibieron las vacunas contra la difteria, el tétanos y la tosferina (DTPa), contra la poliomielitis, antirrotavírica, BCG, y pentavalente también disminuyeron en más de ocho puntos porcentuales. En cambio, la proporción de niños y niñas que recibieron la vacuna antineumocócica conjugada aumentó en más de cuatro puntos porcentuales. También se observó un descenso estadísticamente significativo en el promedio de la variación mensual absoluta de varios indicadores de salud reproductiva e infantil. Conclusiones. La pandemia de COVID-19 puede haber contribuido al descenso observado en varios indica- dores relacionados con la salud reproductiva, materna, neonatal, infantil y adolescente en Haití. Sin embargo, no se puede descartar el papel que ha desempeñado en dicho descenso la crisis sociopolítica y el control ejercido por los grupos armados sobre la población en los últimos tres años.

[RESUMO]. Objetivo. Avaliar mudanças na saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti entre agosto de 2018 e setembro de 2021, antes e durante a pandemia de COVID-19. Métodos. Estudo retrospectivo usando dados de vigilância do Sistema Único de Informações de Saúde do Haiti, examinando dois períodos, antes e durante a pandemia de COVID-19. Os indicadores de saúde do país nos dois períodos foram comparados por meio de testes t de duas amostras para proporções, e as variações mensais absolutas médias foram calculadas por meio de regressão linear ponderada. Resultados. Entre o período anterior e o período durante a pandemia de COVID-19, houve uma queda estatisticamente significante na proporção da maioria dos indicadores avaliados. Os indicadores mais afetados, porém, foram as proporções de gestantes com quatro consultas de pré-natal, gestantes com cinco ou mais consultas de pré-natal e gestantes que receberam uma segunda dose de vacina antitetânica, que sofreram uma diminuição de mais de 4 pontos percentuais na comparação entre os dois períodos. Similarmente, as proporções de crianças que receberam vacinas contra difteria, tétano e pertússis (DTPa), BCG, poliomielite, pentavalente e rotavírus também diminuíram em mais de 8 pontos percentuais. Por outro lado, no caso da vacina pneumocócica conjugada houve um aumento de mais de 4 pontos percentuais. Além disso, foi observada uma redução estatisticamente significante nas variações mensais absolutas médias de vários indicadores de saúde reprodutiva e infantil avaliados. Conclusões. A pandemia de COVID-19 pode ter contribuído para a piora observada em vários indicadores de saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti. No entanto, não se pode descartar o papel desempenhado pela crise sociopolítica e pelo controle exercido por grupos armados sobre a população nos últimos três anos.

Changes in reproductive, maternal, and child health in Haiti during the pre- and peri-COVID-19 pandemic.

Objective: To assess changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti from August 2018 to September 2021, before and during the COVID-19 pandemic. Methods: A retrospective study using surveillance data from the Haitian Unique Health Information System, examining two periods: pre- and peri-COVID-19 pandemic. Health indicators at the national level in the two periods were compared using two-sample t-tests for proportions, and average absolute monthly changes were calculated using variance-weighted regression. Results: There was a statistically significant decline in the proportion of most of the indicators assessed from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were the proportions of pregnant women with four antenatal care visits, with five antenatal care visits or more, and those who received a second dose of tetanus vaccine, which decreased by over 4 percentage points during the two periods. Likewise, the proportions of children who received diphtheria, tetanus, and pertussis (DTaP), BCG, polio, pentavalent, and rotavirus vaccines also all declined by over 8 percentage points. In contrast, pneumococcal conjugate vaccine increased by over 4 percentage points. A statistically significant decrease was also observed in the average absolute monthly changes of several reproductive and child health indicators assessed. Conclusions: The COVID-19 pandemic may have contributed to the decline observed in several RMNCAH indicators in Haiti. However, the role played by the sociopolitical crisis and control exercised by armed groups over the population in the last three years cannot be ruled out.

What are the benefits of antenatal education as a maternal health promotion tool? A systematic review with meta-analysis

Introduction: Antenatal education is a low-cost intervention designed to increase the knowledge of pregnant women on pregnancy and childbirth and reduce fear related to labor pain. However, the impact of antenatal education programs on maternal outcomes is unclear. Objective: To investigate whether structured antenatal education programs affect maternal health outcomes. Methods: Electronic databases were searched from inception to November 2019, and randomized controlled trials investigating antenatal educational programs for low-risk pregnant women were included. Results: A total of 348 studies were identified; nine were included in this review. One study assessed the number of antenatal visits, while three showed that antenatal education programs significantly improved childbirth self-efficacy (outcome expectancy16.00 [95% CI 9.86-22.15] and efficacy expectancy 20.44 [95% CI=13.62-27.25]). Self-diagnosis on labor was investigated in two studies, and five demonstrated that antenatal education increased the frequency of vaginal delivery (odds ratio 1.28 [95% CI 1.01-1.63]) but not episiotomy (as observed in three studies). Conclusion: Structured antenatal education programs may increase childbirth selfefficacy and the frequency of vaginal delivery

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Changes in reproductive, maternal, and child health in Haiti during the pre- and peri-COVID-19 pandemic / Cambios en materia de salud reproductiva, materna e infantil en los periodos pre y peripandémico de la COVID-19 en Haití / Mudanças na saúde reprodutiva, materna e infantil no Haiti antes e durante a pandemia de COVID-19

ABSTRACT Objective. To assess changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti from August 2018 to September 2021, before and during the COVID-19 pandemic. Methods. A retrospective study using surveillance data from the Haitian Unique Health Information System, examining two periods: pre- and peri-COVID-19 pandemic. Health indicators at the national level in the two periods were compared using two-sample t-tests for proportions, and average absolute monthly changes were calculated using variance-weighted regression. Results. There was a statistically significant decline in the proportion of most of the indicators assessed from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were the proportions of pregnant women with four antenatal care visits, with five antenatal care visits or more, and those who received a second dose of tetanus vaccine, which decreased by over 4 percentage points during the two periods. Likewise, the proportions of children who received diphtheria, tetanus, and pertussis (DTaP), BCG, polio, pentavalent, and rotavirus vaccines also all declined by over 8 percentage points. In contrast, pneumococcal conjugate vaccine increased by over 4 percentage points. A statistically significant decrease was also observed in the average absolute monthly changes of several reproductive and child health indicators assessed. Conclusions. The COVID-19 pandemic may have contributed to the decline observed in several RMNCAH indicators in Haiti. However, the role played by the sociopolitical crisis and control exercised by armed groups over the population in the last three years cannot be ruled out.

RESUMEN Objetivo. Evaluar los cambios en materia de salud reproductiva, materna, neonatal, infantil y adolescente que se produjeron en Haití desde agosto del 2018 hasta septiembre del 2021, antes de la pandemia de COVID-19 y durante ella. Metodología. Estudio retrospectivo basado en datos de vigilancia del sistema único de información de salud de Haití para estudiar los periodos pre y peripandémico. La comparación de los indicadores de salud a nivel nacional de estos dos periodos se realizó mediante pruebas de t de dos muestras para comparar proporciones, y se calculó el promedio de la variación mensual absoluta mediante una regresión ponderada por la varianza. Resultados. Al comparar el periodo prepandémico con el peripandémico, se observó un descenso estadísticamente significativo de la mayoría de los indicadores porcentuales evaluados. Sin embargo, los indicadores porcentuales más afectados fueron los de mujeres embarazadas con cuatro visitas de atención prenatal, con cinco visitas de atención prenatal o más, o que recibieron una segunda dosis de la vacuna contra el tétanos; estos indicadores disminuyeron en más de cuatro puntos porcentuales en el segundo periodo en comparación con el primero. Asimismo, las proporciones de niños y niñas que recibieron las vacunas contra la difteria, el tétanos y la tosferina (DTPa), contra la poliomielitis, antirrotavírica, BCG, y pentavalente también disminuyeron en más de ocho puntos porcentuales. En cambio, la proporción de niños y niñas que recibieron la vacuna antineumocócica conjugada aumentó en más de cuatro puntos porcentuales. También se observó un descenso estadísticamente significativo en el promedio de la variación mensual absoluta de varios indicadores de salud reproductiva e infantil. Conclusiones. La pandemia de COVID-19 puede haber contribuido al descenso observado en varios indicadores relacionados con la salud reproductiva, materna, neonatal, infantil y adolescente en Haití. Sin embargo, no se puede descartar el papel que ha desempeñado en dicho descenso la crisis sociopolítica y el control ejercido por los grupos armados sobre la población en los últimos tres años.

RESUMO Objetivo. Avaliar mudanças na saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti entre agosto de 2018 e setembro de 2021, antes e durante a pandemia de COVID-19. Métodos. Estudo retrospectivo usando dados de vigilância do Sistema Único de Informações de Saúde do Haiti, examinando dois períodos, antes e durante a pandemia de COVID-19. Os indicadores de saúde do país nos dois períodos foram comparados por meio de testes t de duas amostras para proporções, e as variações mensais absolutas médias foram calculadas por meio de regressão linear ponderada. Resultados. Entre o período anterior e o período durante a pandemia de COVID-19, houve uma queda estatisticamente significante na proporção da maioria dos indicadores avaliados. Os indicadores mais afetados, porém, foram as proporções de gestantes com quatro consultas de pré-natal, gestantes com cinco ou mais consultas de pré-natal e gestantes que receberam uma segunda dose de vacina antitetânica, que sofreram uma diminuição de mais de 4 pontos percentuais na comparação entre os dois períodos. Similarmente, as proporções de crianças que receberam vacinas contra difteria, tétano e pertússis (DTPa), BCG, poliomielite, pentavalente e rotavírus também diminuíram em mais de 8 pontos percentuais. Por outro lado, no caso da vacina pneumocócica conjugada houve um aumento de mais de 4 pontos percentuais. Além disso, foi observada uma redução estatisticamente significante nas variações mensais absolutas médias de vários indicadores de saúde reprodutiva e infantil avaliados. Conclusões. A pandemia de COVID-19 pode ter contribuído para a piora observada em vários indicadores de saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti. No entanto, não se pode descartar o papel desempenhado pela crise sociopolítica e pelo controle exercido por grupos armados sobre a população nos últimos três anos.

The burden of stillbirths in low resource settings in Latin America: Evidence from a network using an electronic surveillance system.

OBJECTIVE: To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries (LAC). METHODS: We analysed data from the Perinatal Information System of the Latin American Center for Perinatology and Human Development (CLAP) between January 2018 and June 2021 in 8 health facilities from five LAC countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic). Maternal, pregnancy, and delivery characteristics, in addition to pregnancy outcomes were reported. Estimates of association were tested using chi-square tests, and P < 0.05 was regarded as significant. Bivariate analysis was conducted to estimate stillbirth risk. Prevalence ratios (PR) with their 95% confidence intervals (CI) for each predictor were reported. RESULTS: In total, 101,852 childbirths comprised the SIP database. For this analysis, we included 99,712 childbirths. There were 762 stillbirths during the study period; the Stillbirth ratio of 7.7/1,000 live births (ranged from 3.8 to 18.2/1,000 live births across the different maternities); 586 (76.9%) were antepartum stillbirths, 150 (19.7%) were intrapartum stillbirths and 26 (3.4%) with an ignored time of death. Stillbirth was significantly associated with women with diabetes (PRadj 2.36; 95%CI [1.25-4.46]), preeclampsia (PRadj 2.01; 95%CI [1.26-3.19]), maternal age (PRadj 1.04; 95%CI [1.02-1.05]), any medical condition (PRadj 1.48; 95%CI [1.24-1.76, and severe maternal outcome (PRadj 3.27; 95%CI [3.27-11.66]). CONCLUSIONS: Pregnancy complications and maternal morbidity were significantly associated with stillbirths. The stillbirth ratios varied across the maternity hospitals, which highlights the importance for individual surveillance. Specialized antenatal and intrapartum care remains a priority, particularly for women who are at a higher risk of stillbirth.

Prevalencia de déficit de vitamina B12 en sangre periférica de madres cursando el puerperio inmediato en el Centro Hospitalario Pereira Rossell / Prevalence of vitamin B12 deficiency in peripheral blood of mothers undergoing immediate puerperium at the Pereira Rossell Hospital Center / Prevalência de deficiência de vitamina B12 no sangue periférico de mães no puerpério imediato no Centro Hospitalar Pereira Rossell

Objetivo: evaluar la prevalencia del déficit de vitamina B12 en mujeres cursando puerperio inmediato. Material y método: estudio observacional descriptivo de captación prospectiva de la cohorte en estudio. Muestra de 133 mujeres cursando el tercer trimestre de embarazo en la maternidad del Centro Hospitalario Pereira Rossell (CHPR), Montevideo, Uruguay, entre setiembre de 2021 y octubre de 2022. Se obtuvieron muestras de sangre materna en el puerperio inmediato por punción venosa periférica. Estas muestras fueron procesadas mediante inmunoensayo de electroquimioluminiscencia. Además, se aplicó una entrevista para la evaluación de los hábitos nutricionales. Resultados: todas las pacientes reportaron tener una dieta omnívora, excepto una, que manifestó llevar una dieta vegana y recibía suplementación diaria de vitamina B12. El 75,9% de la muestra del estudio presentó un nivel socioeconómico bajo, puntuado según el cuestionario de medición de nivel socioeconómico del INSE (Índice de nivel socioeconómico, 2018 - Cámara de Empresas de Investigación Social y Mercado del Uruguay, CEISMU). Se registró una prevalencia de déficit de vitamina B12 de 39,10% (n: 52). Conclusiones: a pesar de que esta muestra de embarazadas presenta una dieta omnívora, se detectó una elevada prevalencia de déficit de vitamina B12. Dada la importancia de esta vitamina en la salud materna, fetal y neonatal, se deberían considerar políticas de salud pública de prevención de la deficiencia tanto en embarazadas como en madres lactantes.

Objective: To assess the prevalence of vitamin B12 deficiency in women during the immediate postpartum period. Method: Descriptive observational study with prospective cohort recruitment, involving a sample of 133 women in their third trimester of pregnancy at the Maternity Department of the Pereira Rossell Hospital Center (CHPR) in Montevideo, Uruguay, between September 2021 and October 2022. Maternal blood samples were obtained during the immediate postpartum period through peripheral venous puncture. These samples were processed using electrochemiluminescence (ECL) immunoassay. Additionally, a nutritional interview was conducted to assess dietary habits. Results: All patients reported following an omnivorous diet, except for one who reported following a vegan diet and received daily vitamin B12 supplementation. Seventy-five point nine percent (75.9%) of the study sample exhibited a low socioeconomic status as determined by the Socioeconomic Level Measurement Questionnaire of the INSE (Socioeconomic Level Index, 2018 - CEISMU, Uruguay). Resulting in a vitamin B12 deficiency prevalence of 39.10% (n: 52). Conclusions: Despite the fact that this sample of pregnant women maintains an omnivorous diet, a high prevalence of vitamin B12 deficiency was detected. Given the significance of vitamin B12 for maternal, fetal, and neonatal health, public health policies for preventing deficiency should be considered for both pregnant women and lactating mothers.

Objetivos: Avaliar a prevalência da deficiência de vitamina B12 em mulheres durante o pós-parto imediato. Métodos: Estudo observacional descritivo de recrutamento prospectivo da coorte em estudo; amostra com 133 mulheres no terceiro trimestre de gravidez na maternidade do Centro Hospitalar Pereira Rossell (CHPR), em Montevidéu Uruguai, entre setembro de 2021 e outubro de 2022. As amostras de sangue materno foram obtidas no pós-parto imediato por punção venosa periférica que foram processadas por imunoensaio eletroquimioluminescente. Além disso, foi realizada uma entrevista nutricional para avaliar hábitos nutricionais. Resultados: Todas as pacientes relataram ter dieta onívora, exceto uma que relatou ter dieta vegana e receber suplementação diária de vitamina B12. 75,9% da amostra apresentou baixo nível socioeconômico de acordo com o Questionário de Medição do Nível Socioeconômico do INSE (Índice de Nível Socioeconômico, 2018 - CEISMU, Uruguai). Uma prevalência de deficiência de vitamina B12 de 39,10% (n: 52) foi registrada. Conclusões: Embora esta amostra de gestantes tenha dieta onívora, uma alta prevalência de deficiência de vitamina B12 foi detectada. Dada a importância da vitamina B12 na saúde materna, fetal e neonatal, devem ser consideradas políticas de saúde pública para prevenir a deficiência tanto em mães grávidas como em lactantes.

Neonatal outcomes according to different degrees of maternal morbidity: cross-sectional evidence from the Perinatal Information System (SIP) of the CLAP network.

BACKGROUND: The burden of maternal morbidity in neonatal outcomes can vary with the adequacy of healthcare provision and tool implementation to improve monitoring. Such information is lacking in Latin American countries, where the decrease in severe maternal morbidity and maternal death remains challenging. OBJECTIVES: To determine neonatal outcomes according to maternal characteristics, including different degrees of maternal morbidity in Latin American health facilities. METHODS: This is a secondary cross-sectional analysis of the Perinatal Information System (SIP) database from eight health facilities in five Latin American and Caribbean countries. Participants were all women delivering from August 2018 to June 2021, excluding cases of abortion, multiple pregnancies and missing information on perinatal outcomes. As primary and secondary outcome measures, neonatal near miss and neonatal death were measured according to maternal/pregnancy characteristics and degrees of maternal morbidity. Estimated adjusted prevalence ratios (PRadj) with their respective 95% CIs were reported. RESULTS: In total 85,863 live births were included, with 1,250 neonatal near miss (NNM) cases and 695 identified neonatal deaths. NNM and neonatal mortality ratios were 14.6 and 8.1 per 1,000 live births, respectively. Conditions independently associated with a NNM or neonatal death were the need for neonatal resuscitation (PRadj 16.73, 95% CI [13.29-21.05]), being single (PRadj 1.45, 95% CI [1.32-1.59]), maternal near miss or death (PRadj 1.64, 95% CI [1.14-2.37]), preeclampsia (PRadj 3.02, 95% CI [1.70-5.35]), eclampsia/HELPP (PRadj 1.50, 95% CI [1.16-1.94]), maternal age (years) (PRadj 1.01, 95% CI [<1.01-1.02]), major congenital anomalies (PRadj 3.21, 95% CI [1.43-7.23]), diabetes (PRadj 1.49, 95% CI [1.11-1.98]) and cardiac disease (PRadj 1.65, 95% CI [1.14-2.37]). CONCLUSION: Maternal morbidity leads to worse neonatal outcomes, especially in women suffering maternal near miss or death. Based on SIP/PAHO database all these indicators may be helpful for routine situation monitoring in Latin America with the purpose of policy changes and improvement of maternal and neonatal health.

Surveillance of severe maternal morbidity and maternal mortality in maternity hospitals of the Latin American and Caribbean network - Red CLAP: study protocol.

The sustained reduction in maternal mortality in America underlines the need to analyse women who survived a complication that could have been fatal if appropriate and timely care had not been taken. Analysis of maternal near-miss (MNM) cases, as well as potentially life-threatening conditions (PLTC), are considered indicators for monitoring the quality of maternal care. The specific objective of this study protocol is to develop a surveillance system for PLTC, MNM and maternal mortality, as primary outcomes, in Latin American and Caribbean maternal healthcare institutions. Secondarily, the study was designed to identify factors associated with these conditions and estimate how often key evidence-based interventions were used for managing severe maternal morbidity. This is a multicenter cross-sectional study with prospective data collection. The target population consists of all women admitted to health centres participating in the network during pregnancy, childbirth, or the postpartum period. Variables describing the sequence of events that may result in a PLTC, MNM or maternal death are recorded. Relevant quality control is carried out to ensure the quality of the database and confidentiality. Centres with approximately 2,500 annual deliveries will be included to achieve a sufficient number of cases for calculation of indicators. The frequency of outcome measures for PLTC, MNM and maternal mortality and their confidence intervals and differences between groups will be calculated using the most appropriate statistical tests. Similar procedures will be performed with variables describing the use of evidence-based practices. Networking creates additional possibilities for global information management and interaction between different research groups. Lessons can be learned and shared, generating scientific knowledge to address relevant health problems throughout the region with provision of efficient data management.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System.

BACKGROUND: Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. METHODS: Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. RESULTS: Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). CONCLUSION: Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR.

Predicting severe maternal outcomes in a network of sentinel sites in Latin-American countries.

OBJECTIVE: This study aimed to determine incidences of potentially life-threatening conditions (PLTC), maternal near misses (MNM), and maternal deaths (MD) in women who gave birth in participating facilities, and to determine the probability that a pregnancy involving a PLTC would evolve into an MNM and/or an MD. METHODS: This was a multicentric observational study implemented on a maternal network from August 2018 to May 2019 in five Latin-American countries. We summarized categorical variables as frequencies and continuous variables with median, interquartile range, and standard deviations. Positive and negative likelihood ratios were calculated and multivariate predictive models were built. RESULTS: There were 33 901 deliveries and miscarriages, of which 8.0% had at least one PLTC and 0.6% had an MNM. Hypertensive disorder was the most frequent condition to evolve into a severe maternal outcome. CONCLUSION: Identifying PLTC can help to prevent MNM and MD. The inclusion of these predictors in a real-time data registration system like the Perinatal Informatic System could work as a surveillance tool for early detection, leading to a reduction in the rate of worsening conditions.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System

Background: Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. Methods: Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. Results: Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). Conclusion: Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR. (AU)

Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study.

BACKGROUND: The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database. METHODS: We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models. RESULTS: Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital. CONCLUSION: Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted.

Maternal mortality linked to COVID-19 in Latin America: Results from a multi-country collaborative database of 447 deaths.

Background: This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database. Methods: This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges. Findings: We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight. Interpretation: This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays. Funding: Latin American Center for Perinatology, Women and Reproductive Health.

Antecedentes: Este estudio tuvo el objetivo de describir las características clínicas de las muertes maternas asociadas a COVID-19 registradas en una base de datos latinoamericana multipaís. Métodos: Se implementó un estudio observacional descriptivo en el que participaron ochos países Latinoamericanos desde el 1ero de marzo 2020 al 29 de noviembre 2021. La información se obtuvo del Sistema Informático Perinatal del Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva. Presentamos las variables categóricas como frecuencias y porcentajes y las variables continuas en medianas con rangos inter cuartiles. Resultados: Identificamos un total de 447 muertes. La mediana de edad materna fue de 31 años. 86·4% de las mujeres se infectaron ante del parto, siendo la mayoría de los casos detectados en el tercer trimestre del embarazo (60·3%). Los síntomas más frecuentes en la primera consulta y la admisión fueron disnea (73·0%), fiebre (69·0%), y tos (59·0%). Se reportaron disfunciones orgánicas en 90·4% de las mujeres durante la admisión. Un total de 64·8% de las mujeres fueron ingresadas a cuidados críticos por una mediana de ocho días de estadía. En la mayoría de los casos la muerte ocurrió durante el puerperio, con una media de siete días entre el parto y su ocurrencia. El parto prematuro fue la complicación perinatal más frecuente (76·9%) y 59·9% tuvo bajo peso al nacer. Interpretación: Este estudio describe las características de las muertes maternas durante la pandemia por COVID-19 a partir de una base colaborativa multipaís. Se observaron barreras para el acceso a cuidados intensivos. Los tomadores de decisión deberían trabajar en el fortalecimiento de la conciencia de gravedad, y en estrategias de referencia para evitar potenciales demoras. Financiamiento: Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva.

Diagnostic performance of two different maternal near-miss approaches in a High Obstetric Risk Unit.

Maternal near-miss (MNM) is a maternal quality care indicator. The World Health Organization (WHO) defines it as a state in which a woman nearly dies but survives due to a complication during pregnancy, birth, or puerperium. The Latin American Federation of Obstetrics and Gynecology (FLASOG) and the Colombian National Health Institute (INS) established recommendations for the event's epidemiological surveillance; nonetheless, the operational definitions of the cases are different. This retrospective study examined the approaches of FLASOG and INS versus the WHO approach (gold standard) for the assessment of MNM in a high obstetric risk unit. Patients admitted with at least one criterion of the WHO, FLASOG, or INS approach for the definition of MNM from March 2016 to March 2017 were included. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were evaluated, as well as the Receiver Operating Characteristics (ROC) curve of the FLASOG and INS. MNM classification compared to WHO system as reference. The results highlight that the WHO classification establishes very high boundaries for some of the diagnostic criteria and the lack of standardization of the MNM criteria among the different proposals in Latin America hinders the applicability in Colombia and other countries with a similar situation.

Marijuana, tobacco, alcohol and cocaine use during pregnancy in 2013 and 2016. A self-report study in Montevideo, Uruguay. / Autodeclaración del consumo de marihuana, tabaco, alcohol y derivados de cocaína en embarazadas en 2013 y 2016, Montevideo, Uruguay.

BACKGROUND: Uruguay passed Law 19.172 on December 20, 2013, thus enabling the State to regulate the production, distribution, sale, and consumption of cannabis. OBJECTIVES: to determine the change in maternal self-report of marijuana, tobacco, alcohol, and cocaine use during pregnancy between 2013 and 2016. METHODS: cross-sectional, descriptive, analytical study between 2013 and 2016. The sample consists of pregnant woman who delivered and received immediate postpartum care at the Centro Hospitalario Pereira Rossell in Montevideo, Uruguay. The instrument was a protocolized survey that assessed outcomes such as sociodemographic level, years of formal education, data on pregnancy, childbirth, newborn, and substance use before and during pregnancy. RESULTS: the sample consisted of 577 pregnant women, 319 corresponding to interviews conducted in 2013 and 258 in 2016. Regarding alcohol intake, 76 (23.82%) women reported drinking while pregnant in 2013, whereas in 2016, 91 (35.3%) (p=.003) did so. As for tobacco, 59 (43%) quit smoking when they found out about their pregnancy in 2013, and 69 (60%) quit in 2016 (p=.008). In 2013, 41 women (12.85%) smoked marijuana until they discovered their pregnancy, and 79 (30%) did so in 2016 (p < .001). The use of cocaine and its derivatives did not change significantly between 2013 and 2016. CONCLUSIONS: between 2013 and 2016, there was a significant increase in the self-report of marijuana and alcohol consumption before and during pregnancy. The consumption of cocaine and cocaine base paste remained stable during this period. Tobacco use decreased significantly in pregnant women.

Introducción: Uruguay es el primer país en modificar la legislación sobre el consumo recreativo de cannabis, mediante la Ley 19.172 del 20 de diciembre de 2013, otorgando al Estado la potestad de regular su producción y comercialización. Objetivo: evaluar las prevalencias de la autodeclaración del consumo de marihuana, tabaco, alcohol, cocaína y derivados y su evolución temporal en embarazadas para los años 2013 y 2016. Metodología: estudio descriptivo, transversal y analítico, durante dos períodos de tiempo, en 2013 y 2016. Se incluyeron mujeres que tuvieron su parto y puerperio inmediato en el Centro Hospitalario Pereira Rossell (CHPR) de Montevideo, Uruguay. Se realizó una encuesta protocolizada sobre su nivel sociodemográfico, años de educación formal, datos del embarazo, parto, recién nacido y consumo de sustancias antes y durante la gestación. Resultados: en la investigación participaron 577 mujeres, 319 correspondientes a las entrevistas realizadas en el año 2013 y 258 en 2016. Respecto al alcohol, 76 (23,82%) mujeres declaran su consumo durante el embarazo en 2013, mientras que, en 2016, 91 (35,3%) (p=0,003). En cuanto al tabaco, 59 (43%) dejaron de fumar al enterarse del embarazo en 2013 y 69 (60%) en 2016 (p=0,008). En 2013, 41 mujeres (12,85%) fumaron marihuana hasta saber del embarazo y 79 (30%) en 2016 (p <0,001). Durante la gestación, en 2013 declararon fumar marihuana 5 mujeres (1,57%), mientras que en 2016 fueron 28 (10,85%) (p <0,001). El uso de cocaína y pasta base de cocaína (PBC) no cambió significativamente entre 2013 y 2016. Conclusiones: Entre los años 2013 y 2016 se observó un aumento significativo en la autodeclaración del consumo de marihuana y alcohol antes y durante el embarazo. El consumo de cocaína y pasta base de cocaína se mantuvo estable en ese periodo. El consumo de tabaco disminuyó significativamente en mujeres embarazadas.

A systematic review and meta-analysis of cesarean delivery and other uterine surgery as risk factors for placenta accreta.

BACKGROUND: The incidence of placenta accreta has increased in recent years and it has been suggested that the rising trend in cesarean delivery and other uterine surgery is the underlying cause. OBJECTIVE: To explore the magnitude of the effect of performing single and repeat cesarean deliveries or other uterine surgery on the incidence of placenta accreta. SEARCH STRATEGY: Relevant databases were searched for papers published before August 1, 2018, using terms including "accreta" and "cesarean." SELECTION CRITERIA: Cohort studies assessing the risk of placenta accreta according to women's history of uterine surgery. DATA COLLECTION AND ANALYSIS: Meta-analyses were performed to assess the risks associated between uterine surgery and placenta accreta, hysterectomy, and uterine rupture. The I2 statistic was used to examine between-study heterogeneity. MAIN RESULTS: The risk of placenta accreta in a second pregnancy increased for women who had undergone a cesarean in their first pregnancy compared with vaginal delivery (OR 3.02; 95% CI, 1.50-6.08). Absolute risk of placenta accreta increased with the number of previous cesareans. The risk of uterine rupture and hysterectomy was also associated with the number of cesareans. CONCLUSIONS: Risk of placenta accreta, hysterectomy, and uterine rupture increases with the number of previous cesarean deliveries. PROSPERO: CRD42016050646.