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1.
Curr Opin Anaesthesiol ; 33(6): 793-799, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002958

RESUMO

PURPOSE OF REVIEW: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.


Assuntos
Analgesia Obstétrica/tendências , Anestesia Obstétrica/tendências , Anestesiologistas/psicologia , Parto Obstétrico/tendências , Mortalidade Materna/tendências , Hemorragia Pós-Parto/prevenção & controle , Analgesia Obstétrica/efeitos adversos , Analgesia Obstétrica/métodos , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/métodos , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Feminino , Humanos , Serviços de Saúde Materna/normas , Erros Médicos/prevenção & controle , Gravidez , Complicações na Gravidez , Estados Unidos
3.
Obstet Gynecol ; 136(4): 645-653, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925616

RESUMO

OBJECTIVE: To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation). METHODS: Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend. RESULTS: From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08). CONCLUSION: After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.


Assuntos
Prevenção de Acidentes , Uso Indevido de Medicamentos , Revisão por Pares/normas , Complicações na Gravidez , Transtornos Puerperais/mortalidade , Suicídio , Adulto , Comitês Consultivos/estatística & dados numéricos , Uso Indevido de Medicamentos/mortalidade , Uso Indevido de Medicamentos/prevenção & controle , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Humanos , Mortalidade Materna/tendências , Mortalidade , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/prevenção & controle , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos , Utah/epidemiologia
4.
Obstet Gynecol ; 136(4): 657-662, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925626

RESUMO

The maternal mortality ratio in the United States is increasing; understanding the significance of this change and developing effective responses requires a granular analysis of the contributing factors that a well-informed maternal mortality review committee can provide. Data collection and analysis, clinical factors, preventability, social determinants of health, and racial inequities combine to affect this outcome, and each factor must be considered individually and in combination to recommend a robust response. Obstetrician-gynecologists formed the State of Michigan's Maternal Mortality Review Committee (the Committee) in 1950 to identify gaps in care that needed to be systematically addressed at the time. In the early years, the Committee witnessed a reduction in the number of maternal deaths; over time, prioritization of maternal mortality decreased, yet the Committee witnessed changing patterns of death, varied data collection and evaluation processes, delayed reviews, and unimplemented recommendations. The calculation of the maternal mortality ratio was not informed by the outcomes of Committee reviews. Today, the Committee, with increased support from the Michigan Department of Health & Human Services, can clearly identify and report preventable pregnancy-related mortality along with its causes and is close to achieving a near real-time surveillance system that allows the development of timely clinical and policy recommendations and interventions. The Committee's adaptations in response to the rise in maternal mortality have resulted in several lessons learned that may be helpful for currently operating committees and in the formation of new ones.


Assuntos
Uso Indevido de Medicamentos , Mortalidade Materna/tendências , Complicações na Gravidez , Serviços Preventivos de Saúde , Melhoria de Qualidade , Suicídio , Adulto , Comitês Consultivos/normas , Comitês Consultivos/estatística & dados numéricos , Uso Indevido de Medicamentos/mortalidade , Uso Indevido de Medicamentos/prevenção & controle , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Michigan/epidemiologia , Mortalidade , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/prevenção & controle , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/normas , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/tendências , Determinantes Sociais da Saúde/etnologia , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos
6.
Aust N Z J Obstet Gynaecol ; 60(5): 640-659, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32779193

RESUMO

BACKGROUND: Since its emergence in December 2019, COVID-19 has spread to over 210 countries, with an estimated mortality rate of 3-4%. Little is understood about its effects during pregnancy. AIMS: To describe the current understanding of COVID-19 illness in pregnant women, to describe obstetric outcomes and to identify gaps in the existing knowledge. METHODS: Medline Ovid, EMBASE, World Health Organization COVID-19 research database and Cochrane COVID-19 in pregnancy spreadsheet were accessed on 18/4, 18/5 and 23/5 2020. Articles were screened via Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following were excluded: reviews, opinion pieces, guidelines, articles pertaining solely to other viruses, single case reports. RESULTS: Sixty articles were included in this review. Some pregnant participants may have been included in multiple publications, as admission dates overlap for reports from the same hospital. However, a total of 1287 confirmed SARS-CoV-2 positive pregnant cases are reported. Where universal testing was undertaken, asymptomatic infection occurred in 43.5-92% of cases. In the cohort studies, severe and critical COVID-19 illness rates approximated those of the non-pregnant population. Eight maternal deaths, six neonatal deaths, seven stillbirths and five miscarriages were reported. Nineteen neonates were SARS-CoV-2 positive, confirmed by reverse transcription polymerase chain reaction of nasopharyngeal swabs. [Correction added on 2 September 2020, after first online publication: the number of neonates indicated in the preceding sentence has been corrected from 'Thirteen' to 'Nineteen'.] CONCLUSIONS: Where universal screening was conducted, SARS-CoV-2 infection in pregnancy was often asymptomatic. Severe and critical disease rates approximate those in the general population. Vertical transmission is possible; however, it is unclear whether SARS-CoV-2 positive neonates were infected in utero, intrapartum or postpartum. Future work should assess risks of congenital syndromes and adverse perinatal outcomes where infection occurs in early and mid-pregnancy.


Assuntos
Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/transmissão , Mortalidade Infantil/tendências , Pandemias/prevenção & controle , Pneumonia Viral/transmissão , Complicações Infecciosas na Gravidez/diagnóstico , Aborto Espontâneo/epidemiologia , Adulto , Austrália , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Bases de Dados Factuais , Parto Obstétrico/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Controle de Infecções/métodos , Mortalidade Materna/tendências , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Trimestres da Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Organização Mundial da Saúde , Adulto Jovem
8.
BMC Public Health ; 20(1): 1093, 2020 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-32652971

RESUMO

BACKGROUND: The Chinese government has been strengthening the primary care system since the launch of the New Healthcare System Reform in 2009. Among all endeavors, the most obvious and significant improvement lays in maternal and child health. This study was designed to explore the association of primary care physician supply with maternal and child health outcomes in China, and provide policy suggestions to the law makers. METHODS: Six-year panel dataset of 31 provinces in China from 2012 to 2017 was used to conduct the longitudinal ecological study. Linear fixed effects regression model was applied to explore the association of primary care physician supply with the metrics of maternal and child health outcomes while controlling for specialty care physician supply and socio-economic covariates. Stratified analysis was used to test whether this association varies across different regions in China. RESULTS: The number of primary care physicians per 10,000 population increased from 15.56 (95% CI: 13.66 to 17.47) to 16.08 (95% CI: 13.86 to 18.29) from 2012 to 2017. The increase of one primary care physician per 10,000 population was associated with 5.26 reduction in maternal mortality per 100,000 live births (95% CI: - 6.745 to - 3.774), 0.106% (95% CI: - 0.189 to - 0.023) decrease in low birth weight, and 0.419 decline (95% CI: - 0.564 to - 0.273) in perinatal mortality per 1000 live births while other variables were held constant. The association was particularly prominent in the less-developed western China compared to the developed eastern and central China. CONCLUSION: The sufficient supply of primary care physician was associated with improved maternal and child health outcomes in China, especially in the less-developed western region. Policies on effective and proportional allocation of resources should be made and conducted to strengthen primary care system and eliminate geographical disparities.


Assuntos
Saúde da Criança/estatística & dados numéricos , Serviços de Saúde Materna/organização & administração , Médicos de Atenção Primária/organização & administração , Atenção Primária à Saúde/organização & administração , Adulto , Criança , Serviços de Saúde da Criança/organização & administração , China/epidemiologia , Feminino , Reforma dos Serviços de Saúde , Humanos , Recém-Nascido , Mortalidade Materna/tendências , Gravidez
9.
Curr Opin Anaesthesiol ; 33(4): 612-617, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32628411

RESUMO

PURPOSE OF REVIEW: Internationally there has been increased interest in maternal morbidity; both as a strategy to reduce maternal deaths and also because of the significant impact on a woman's life as a result of suffering from maternal morbidity. The present review will evaluate the current knowledge of, and strategies to reduce maternal morbidity. RECENT FINDINGS: The study of maternal morbidity and how to reduce it has been hampered for many years by the lack of a standard approach to measurement and evaluation. The World Health Organization has attempted to standardize the approach to maternal morbidity with the development of a new definition that recognizes the multiple dimensions of maternal morbidity, including external factors such as socioeconomic factors. This approach will assist with a more accurate evaluation of maternal morbidity. Maternal morbidity arises from many and varied causes. Many of these are amenable to quality improvement with an associated reduction in maternal morbidity. SUMMARY: There have been significant advances in the understanding of maternal morbidity: incidence causes and management. Future research should aim to establish accurate rates for maternal morbidity and further develop ways for healthcare professionals, including anaesthesia care providers, to reduce it.


Assuntos
Mortalidade Materna/tendências , Feminino , Previsões , Humanos , Gravidez , Fatores Socioeconômicos , Organização Mundial da Saúde
11.
PLoS One ; 15(7): e0235954, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32702067

RESUMO

OBJECTIVE: The objective of this study was to better understand how the lack of emergency child and obstetric care can be related to maternal and neonatal mortality levels. METHODS: We performed spatiotemporal geospatial analyses using data from Brazilian municipalities. An emergency service accessibility index was derived using the two-step floating catchment area (2SFCA) for 951 hospitals. Mortality data from 2000 to 2015 was used to characterize space-time trends. The data was overlapped using a spatial clusters analysis to identify regions with lack of emergency access and high mortality trends. RESULTS: From 2000 to 2015 Brazil the overall neonatal mortality rate varied from 11,42 to 11,71 by 1000 live births. The maternal mortality presented a slightly decrease from 2,98 to 2,88 by 100 thousand inhabitants. For neonatal mortality the Northeast and North regions presented the highest percentage of up trending. For maternal mortality the North region exhibited the higher volume of up trending. The accessibility index obtained highlighted large portions of the rural areas of the country without any coverage of obstetric or neonatal beds. CONCLUSIONS: The analyses highlighted regions with problems of mortality and access to maternal and newborn emergency services. This sequence of steps can be applied to other low and medium income countries as health situation analysis tool. SIGNIFICANCE STATEMENT: Low and middle income countries have greater disparities in access to emergency child and obstetric care. There is a lack of approaches capable to support analysis considering a spatiotemporal perspective for emergency care. Studies using Geographic Information System analysis for maternal and child care, are increasing in frequency. This approach can identify emergency child and obstetric care saturated or deprived regions. The sequence of steps designed here can help researchers, and policy makers to better design strategies aiming to improve emergency child and obstetric care.


Assuntos
Serviços Médicos de Emergência , Brasil , Bases de Dados Factuais , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Hospitais , Humanos , Lactente , Mortalidade Infantil/tendências , Mortalidade Materna/tendências , Análise Espacial
12.
Lancet Glob Health ; 8(7): e965-e972, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32562652

RESUMO

BACKGROUND: Although an increasing number of pregnant women in resource-limited areas deliver in health-care facilities, maternal mortality remains high in these settings. Inadequate diagnosis and management of common life-threatening conditions is an important determinant of maternal mortality. We analysed the clinicopathological discrepancies in a series of maternal deaths from Mozambique and assessed changes over 10 years in the diagnostic process. We aimed to provide data on clinical diagnostic accuracy to be used for improving quality of care and reducing maternal mortality. METHODS: We did a retrospective analysis of clinicopathological discrepancies in 91 maternal deaths occurring from Nov 1, 2013, to March 31, 2015 (17 month-long period), at a tertiary-level hospital in Mozambique, using complete diagnostic autopsies as the gold standard to ascertain cause of death. We estimated the performance of the clinical diagnosis and classified clinicopathological discrepancies as major and minor errors. We compared the findings of this analysis with those of a similar study done in the same setting 10 years earlier. FINDINGS: We identified a clinicopathological discrepancy in 35 (38%) of 91 women. All diagnostic errors observed were classified as major discrepancies. The sensitivity of the clinical diagnosis for puerperal infections was 17% and the positive predictive value was 50%. The sensitivity for non-obstetric infections was 48%. The sensitivity for eclampsia was 100% but the positive predictive value was 33%. Over the 10-year period, the performance of clinical diagnosis did not improve, and worsened for some diagnoses, such as puerperal infection. INTERPRETATION: Decreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care. FUNDING: Bill & Melinda Gates Foundation and Instituto de Salud Carlos III.


Assuntos
Mortalidade Hospitalar/tendências , Mortalidade Materna/tendências , Qualidade da Assistência à Saúde , Centros de Atenção Terciária/estatística & dados numéricos , Adolescente , Adulto , Autopsia , Feminino , Humanos , Moçambique/epidemiologia , Gravidez , Estudos Retrospectivos , Adulto Jovem
13.
Natl Vital Stat Rep ; 69(1): 1-25, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32510312

RESUMO

Objectives-This report quantifies the impact of the inclusion of a pregnancy status checkbox item on the U.S. Standard Certificate of Death on the number of deaths classified as maternal. Maternal mortality rates calculated with and without using the checkbox information for deaths in 2015 and 2016 are presented. Methods-This report is based on cause-of-death information from 2015 and 2016 death certificates collected through the National Vital Statistics System. Records originally assigned to a specified range of ICD-10 codes (i.e., A34, O00-O99) when using information from the checkbox item were recoded without using the checkbox item. Ratios of deaths assigned as maternal deaths using checkbox item information to deaths assigned without checkbox item information were calculated to quantify the impact of the pregnancy status checkbox item on the classification of maternal deaths for 47 states and the District of Columbia. Maternal mortality rates for all jurisdictions calculated using cause-of-death information entered on the certificate with and without the checkbox were compared overall and by characteristics of the decedent. Results-Use of information from the checkbox, along with information from the cause-of-death section of the certificate, identified 1,527 deaths as maternal compared with 498 without the checkbox in 2015 and 2016 (ratio = 3.07), with the impact varying by characteristics of the decedent such as age at death. The ratio for women under age 25 was 2.15 (204 compared with 95 deaths) but was 14.14 (523 compared with 37 deaths) for women aged 40-54. Without the adoption of the checkbox item, maternal mortality rates in both 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births compared with 8.9 in 2002. With the checkbox, the maternal mortality rate would be reported as 20.9 and 21.8 deaths per 100,000 live births in 2015 and 2016.


Assuntos
Atestado de Óbito , Morte Materna/estatística & dados numéricos , Mortalidade Materna/tendências , Adulto , Causas de Morte , Feminino , Humanos , Classificação Internacional de Doenças , Pessoa de Meia-Idade , Gravidez , Estados Unidos/epidemiologia , Estatísticas Vitais , Adulto Jovem
14.
Natl Vital Stat Rep ; 69(2): 1-18, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32510319

RESUMO

This report describes changes in how the National Center for Health Statistics (NCHS) will code, publish, and release maternal mortality data and presents official 2018 maternal mortality estimates using a new coding method. Due to the incremental implementation of the pregnancy status checkbox item on the 2003 revised U.S. Standard Certificate of Death, NCHS last published an official estimate of the U.S. maternal mortality rate in 2007. As of 2018, implementation of the revised certificate, including its pregnancy checkbox, is complete for all 50 states (noting that California implemented a different checkbox than that on the U.S. Standard Certificate of Death), allowing NCHS to resume the routine publication of maternal mortality statistics. However, an evaluation of data quality indicated some errors with the reporting of maternal deaths (deaths within 42 days of pregnancy) following adoption of the checkbox, including overreporting of maternal deaths among older women. Therefore, NCHS has adopted a new method (to be called the 2018 method) for coding maternal deaths to mitigate these probable errors. The 2018 method involves further restricting application of the pregnancy checkbox to decedents aged 10-44 years from the previous age group of 10-54. In addition, the 2018 method restricts assignment of maternal codes to the underlying cause alone when the checkbox is the only indication of pregnancy on the death certificate, and such coding would be applied only to decedents aged 10-44 based solely on the checkbox when no other pregnancy information is provided in the cause-of-death statement. Based on the new method, a total of 658 deaths were identified in 2018 as maternal deaths. The maternal mortality rate for 2018 was 17.4 deaths per 100,000 live births, and the rate for non-Hispanic black women (37.1) was 2.5 to 3.1 times the rates for non-Hispanic white (14.7) and Hispanic (11.8) women. Rates also increased with age. Maternal mortality rates calculated without using information obtained from the checkbox are also presented for 2002, 2015, 2016, 2017, and 2018 to provide comparisons over time using a comparable coding approach across all states.


Assuntos
Atestado de Óbito , Mortalidade Materna/tendências , National Center for Health Statistics, U.S. , Adolescente , Adulto , Causas de Morte , Criança , Feminino , Humanos , Disseminação de Informação , Pessoa de Meia-Idade , Gravidez , Publicações , Estados Unidos/epidemiologia , Adulto Jovem
15.
Obstet Gynecol ; 135(6): 1362-1366, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459428

RESUMO

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.


Assuntos
Política de Saúde , Mortalidade Materna/tendências , Saúde Reprodutiva , Brasil/epidemiologia , Etiópia/epidemiologia , Feminino , Saúde Global/tendências , Objetivos , Humanos , Nepal/epidemiologia , Gravidez , Reino Unido/epidemiologia , Estados Unidos/epidemiologia
16.
BMC Public Health ; 20(1): 758, 2020 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-32448202

RESUMO

BACKGROUND: The maternal mortality ratio (MMR) is an important indicator of maternal health and socioeconomic development. Although China has experienced a large decline in MMR, substantial disparities across regions are still apparent. This study aims to explore causes of socioeconomic related inequality in MMR at the province-level in China from 2004 to 2016. METHODS: We collected data from various issues of the China Health Statistics Yearbook, China Statistics Yearbook, and China Population and Employment Statistics Yearbook to construct a longitudinal sample of all provinces in China. We first examined determinants of the MMR using province fixed-effect models, accounted for socioeconomic condition, health resource allocation, and access to health care. We then used the concentration index (CI) to measure MMR inequality and employed the direct decomposition method to estimate the marginal impact of the determinants on the inequality index. Importance of the determinants were compared based on logworth values. RESULTS: During our study period, economically more deprived provinces experienced higher MMR than better-off ones. There was no evidence of improved socioeconomic related inequality in MMR. Illiteracy proportion was positively associated with the MMR (p < 0.01). In contrast, prenatal check-up rate (p = 0.05), hospital delivery rate (p < 0.01) and rate of delivery attended by professionals (p = 0.02) were negatively associated with the MMR. We also find that higher maternal health profile creation rate (p < 0.01) was associated with a pro-poor change of MMR inequality. CONCLUSION: Access to healthcare was the most important factor in explaining the persistent MMR inequality in China, followed by socioeconomic condition. We do not find evidence that health resource allocation was a contributing factor.


Assuntos
Mortalidade Materna/tendências , Fatores Socioeconômicos , Algoritmos , China/epidemiologia , Bases de Dados Factuais , Feminino , Produto Interno Bruto/estatística & dados numéricos , Recursos em Saúde/estatística & dados numéricos , Humanos , Saúde Materna , Gravidez
17.
PLoS Med ; 17(5): e1003114, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32413025

RESUMO

BACKGROUND: As one of its Millennium Development Goals (MDGs), China has achieved a dramatic reduction in the maternal mortality ratio (MMR), although a distinct spatial heterogeneity still persists. Evidence of the quantitative effects of determinants on MMR in China is limited. A better understanding of the spatiotemporal heterogeneity and quantifying determinants of the MMR would support evidence-based policymaking to sustainably reduce the MMR in China and other developing areas worldwide. METHODS AND FINDINGS: We used data on MMR collected by the National Maternal and Child Health Surveillance System (NMCHSS) at the county level in China from 2010 to 2013. We employed a Bayesian space-time model to investigate the spatiotemporal trends in the MMR from 2010 to 2013. We used Bayesian multivariable regression and GeoDetector models to address 3 main ecological determinants of the MMR, including per capita income (PCI), the proportion of pregnant women who delivered in hospitals (PPWDH), and the proportion of pregnant women who had at least 5 check-ups (PPWFC). Among the 2,205 counties, there were 925 (42.0%) hotspot counties, located mostly in China's western and southwestern regions, with a higher MMR, and 764 (34.6%) coldspot counties with a lower MMR than the national level. China's westernmost regions, including Tibet and western Xinjiang, experienced a weak downward trend over the study period. Nationwide, medical intervention was the major determinant of the change in MMR. The MMR decreased by 1.787 (95% confidence interval [CI]: 1.424-2.142, p < 0.001) per 100,000 live births when PPWDH increased by 1% and decreased by 0.623 (95% CI 0.436-0.798, p < 0.001) per 100,000 live births when PPWFC increased by 1%. The major determinants for the MMR in China's western and southwestern regions were PCI and PPWFC, while that in China's eastern and southern coastlands was PCI. The MMR in western and southwestern regions decreased nonsignificantly by 1.111 (95% CI -1.485-3.655, p = 0.20) per 100,000 live births when PCI in these regions increased by 1,000 Chinese Yuan and decreased by 1.686 (95% CI 1.275-2.090, p < 0.001) when PPWFC increased by 1%. Additionally, the western and southwestern regions showed the strongest interactive effects between different factors, in which the corresponding explanatory power of any 2 interacting factors reached up to greater than 80.0% (p < 0.001) for the MMR. Limitations of this study include a relatively short study period and lack of full coverage of eastern coastlands with especially low MMR. CONCLUSIONS: Although China has accomplished a 75% reduction in the MMR, spatial heterogeneity still exists. In this study, we have identified 925 (hotspot) high-risk counties, mostly located in western and southwestern regions, and among which 332 counties are experiencing a slower pace of decrease than the national downward trend. Nationally, medical intervention is the major determinant. The major determinants for the MMR in western and southwestern regions, which are developing areas, are PCI and PPWFC, while that in China's developed areas is PCI. The interactive influence of any two of the three factors, PCI, PPWDH, and PPWFC, in western and southwestern regions was up to and in excess of 80% (p < 0.001).


Assuntos
Renda/estatística & dados numéricos , Nascimento Vivo/epidemiologia , Mortalidade Materna/tendências , Intervenção Coronária Percutânea/mortalidade , Teorema de Bayes , China/epidemiologia , Feminino , Humanos , Gravidez , Fatores Socioeconômicos , Adulto Jovem
19.
PLoS One ; 15(5): e0232364, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32379768

RESUMO

BACKGROUND: In Côte d'Ivoire, induced abortion is legally restricted unless a pregnancy threatens a woman's life. Yet the limited available evidence suggests abortion is common and that unsafe abortion is contributing to the country's high maternal mortality. Our study aimed to estimate the one-year incidence of induced abortion in Côte d'Ivoire using both direct and indirect methodologies, determine the safety of reported abortions, and identify the women most likely to experience a recent induced abortion or an unsafe abortion. METHODS: In 2018, we conducted a nationally representative, population-based survey of women age 15 to 49 in Côte d'Ivoire. Women reported their own abortion experiences and those of their closest female confidante. We estimated the one-year incidence of induced abortion, and the safety of the abortions women experienced. Using bivariate and multivariate regression, we separately assessed sociodemographic characteristics associated with having had a recent abortion or an unsafe abortion. RESULTS: Overall, 2,738 women participated in the survey, approximately two-thirds of whom reported on the abortion experiences of their closest female friend. Based on respondent data, the one-year incidence of induced abortion was 27.9 (95% CI 18.6-37.1) per 1,000 women of reproductive age, while the confidante incidence was higher at 40.7 (95% CI 33.3-48.1) per 1,000. Among respondents, 62.4% of abortions were most unsafe, while 78.5% of confidante abortions were most unsafe. Adolescents, less educated women, and the poorest women had the most unsafe abortions. CONCLUSION: This study provides the first national estimates of induced abortion incidence and safety in Côte d'Ivoire, using a population-based approach to explore social determinants of abortion and unsafe abortion. Consistent with other research, our results suggest that legal restrictions on abortion in Côte d'Ivoire are not preventing women from having abortions, but rather pushing women to use unsafe, potentially dangerous abortion methods. Efforts to reduce the harms of unsafe abortion are urgently needed.


Assuntos
Aborto Induzido/estatística & dados numéricos , Aborto Induzido/tendências , Aborto Legal/estatística & dados numéricos , Aborto Espontâneo/epidemiologia , Adolescente , Adulto , Costa do Marfim/epidemiologia , Feminino , Humanos , Incidência , Mortalidade Materna/tendências , Pessoa de Meia-Idade , Pobreza , Gravidez , Fatores Socioeconômicos
20.
Medicina (B Aires) ; 80(2): 117-126, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32282316

RESUMO

We reviewed the medical records of women with maternal death reported from August 2003 to December 2015 in the Posadas Hospital (Buenos Aires Province, Argentina), and calculated indexes, trends and years of potential life lost. A total of 52 cases fulfilled the criteria of maternal death. The information provided by death certificates was meager. Two deaths were incidental: one occurred post-caesarean section and was caused by fat embolism following liquid silicone breast injection, and the other was the consequence of femicide which involved also the 24-week fetus. Of the remaining 50 cases, 11 were late deaths (> 42 days postpartum). In 39 women, death occurred during pregnancy, childbirth, or puerperium up to 42 days: 20 were due to direct obstetric causes, and 18 to indirect, non-obstetric causes, the cause of the remaining death was not determined. The most frequent cause was septic abortion. Direct maternal deaths had had more than twice pregnancies, thrice caesarean sections, and orphaned twice as children as indirect deaths. Death caused by placenta accreta was directly related to the number of previous caesarean sections. Throughout the period, maternal mortality index varied between 25 y 150 (mean: 72) per 100 000 live births with ascending trend and 1576 years of potential life were lost. The study exposes the need to improve the death registration system and, most importantly, strengthen prevention and assistance measures to reduce maternal mortality in the area of influence of our hospital.


Assuntos
Causas de Morte , Mortalidade Materna , Adolescente , Adulto , Argentina/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Mortalidade Materna/tendências , Registros Médicos/normas , Pessoa de Meia-Idade , Placenta Acreta , Gravidez , Estudos Retrospectivos , Adulto Jovem
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