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1.
Rev. méd. panacea ; 8(2): 82-86, mayo-ago. 2019.
Artigo em Espanhol | LILACS | ID: biblio-1016008

RESUMO

Introducción: En los últimos veinte años se han desarrollado esfuerzos por reducir la morbimortalidad perinatal a través de la mejora en los servicios que se ofertan al binomio madre-niño. Objetivo: Determinar las características maternas, fetales y neonatales de riesgo asociadas a mortalidad neonatal Materiales y métodos: Búsqueda bibliográfica, a través de los motores de búsqueda de Pubmed, Sciencedirect, Redalyc, Cochrane, Researchgate, Tripdatabase, Google Scholar y Elsevier, de artículos publicados con una antigüedad no mayor de 5 años, en idioma español como inglés. Discusión: Durante las últimas dos décadas existen esfuerzos por reducir la mortalidad y morbilidad neonatal a través de la mejora en la atención médica, identificando y reduciendo los factores de riesgo. Ante ello, la comunidad científica ha diseñado diversos estudios para determinar los factores maternos y neonatales asociados a la morbi-mortalidad neonatal. Conclusiones: La morbi-mortalidad neonatal es multifactorial y dependerá, en gran manera, de las características de las poblaciones estudiadas. (AU)


Introduction: In the last twenty years, efforts have been made to reduce perinatal morbidity and mortality through the improvement of the services offered to the mother-child binomial. Objective: To determine the maternal, fetal and neonatal risk characteristics associated with neonatal mortality Methodology: Bibliographic search of published articles, through the search engines of Pubmed, Sciencedirect, Redalyc, Cochrane, Researchgate, Tripdatabase, Google Scholar, and Elsevier, with no more than 5 years old, in Spanish and English. Discussion: During the last two decades, there has been efforts to reduce neonatal mortality and morbidity through improvement in medical care, identifying and reducing risk factors. Given this, the scientific community has designed several studies to determine the maternal and neonatal factors associated with neonatal morbidity and mortality. Conclusions: Neonatal morbidity and mortality is multifactorial and will depend, to a large extent, on the characteristics of the studied populations. (AU)


Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Fatores de Risco , Morbidade , Mortalidade Perinatal
3.
Horiz. méd. (Impresa) ; 19(2): 19-27, Jun. 2019. tab, graf
Artigo em Espanhol | LILACS, LIPECS | ID: biblio-1006973

RESUMO

Objetivo: Identificar la "Brecha de Oportunidad" mediante el método BABIES con el empleo de tasas de mortalidad perinatal. Materiales y métodos: Se realizó un estudio descriptivo transversal con la Base de datos de Vigilancia Epidemiológica Perinatal y Neonatal. Se determinó las tasas de mortalidad perinatal por distritos y por áreas de posible intervención según método BABIES. Resultados: La tasa de mortalidad más baja se encontró en el distrito de Independencia (6,1 por 100 nacimientos vivos en 2014, y 5,9 en 2015, respectivamente). El área prioritaria de intervención en el distrito de Comas fue salud materna, y en Carabayllo, Cuidado durante el embarazo. Conclusiones: El método BABIES permite identificar la Brecha de Oportunidad para poder dirigir intervenciones a nivel local.


Objective: To identify the "opportunity gap" with the BABIES method using perinatal mortality rates.Materials and methods: A descriptive cross-sectional study was performed with the Perinatal and Neonatal Epidemiological Surveillance Database. Perinatal mortality rates by districts and by areas of possible intervention were determined according to the BABIES method. Results: The district of Independencia had the lowest mortality rate, with 6.1 and 5.9 per 100 live births in the years 2014 and 2015, respectively. The priority area of intervention in the district of Comas was "maternal health" and in Carabayllo, "care during pregnancy". Conclusions: The BABIES method allows us to identify the "opportunity gap" which can guide us to perform interventions at the local level.


Assuntos
Recém-Nascido , Mortalidade Perinatal , Recém-Nascido , Saúde Materna
4.
Ceska Gynekol ; 84(2): 129-139, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31238683

RESUMO

OBJECTIVE: Analysis of maternal morbidity and mortality in Slovak Republic in the years 2007-2015. DESIGN: Prospective epidemiological perinatological nation-wide. SETTINGS: 1st Department of Gynaecology and Obstetrics Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. METHODS: The analysis of selected maternal morbidity and mortality data prospective collected in the years 2007-2015. RESULTS: Cesarean section rate progressively increased from 24.1% in the year 2007 up to 30.8% in the year 2013 and up to year 2015 decreased to 30.2%. Vacuum-extraction frequency was 1.3% in the year 2007 and to the year 2015 increased up to 1.6%. Forceps frequency was the same in the year 2007 and 2015: 0.6%. In the years 2008-2015 frequency of perineal tears 3th and 4th degree increased from 0.44% to 0.68% and frequency of episiotomies decreased from 74.7% to 57.2%. In the years 2012-2015 incidence of total severe acute maternal morbidity per 1,000 births was 5.85, peripartum hysterectomy 0.78, severe postpartum bleeding 2.03, transport to anaesthesiology department/intensive care unit 1.26, eclampsia 0.2, HELLP syndrome 0.6, abnormal placental invasion 0.38, uterine rupture 0.45, severe sepsis in pregnancy and puerperium 0.14 and frequency of nonfatal amniotic fluid embolism was 2/100,000 maternities. Total maternal mortality ratio in this period was 11.5 and pregnancy-related deaths ratio 9.9 per 100,000 live births. CONCLUSION: The highest cesarean section rate in Slovakia, 30.8 %, was in the year 2013, but in the next years slowly decreased. Frequency of episiotomies decreased in followed period too. Incidence of severe acute maternal morbidity was 5.85 per 1,000 births. Maternal mortality ratio in Slovakia was one of the highest in European Union and not corresponding with good level of perinatal mortality. Improving of cesarean section rate and episiotomy, incidence of severe acute maternal morbidity and maternal mortality still need to be improved in Slovak Republic.


Assuntos
Cesárea/estatística & dados numéricos , Eclampsia/epidemiologia , Histerectomia/estatística & dados numéricos , Mortalidade Materna , Ruptura Uterina/epidemiologia , Adulto , Episiotomia/estatística & dados numéricos , Feminino , Humanos , Incidência , Morbidade , Mortalidade Perinatal , Períneo/lesões , Período Pós-Parto , Gravidez , Estudos Prospectivos , Eslováquia/epidemiologia , Vácuo-Extração/estatística & dados numéricos
5.
BMC Public Health ; 19(1): 811, 2019 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-31234805

RESUMO

BACKGROUND: The perinatal mortality rate (PMR) in Nigeria rose by approximately 5% from 39 to 41 deaths per 1000 total births between 2008 and 2013, indicating a reversal in earlier gains. This study sought to identify factors associated with increased PMR. METHODS: Nationally representative data including 31,121 pregnancies of 7 months or longer obtained from the 2013 Nigeria Demographic and Health Survey were used to investigate the community-, socio-economic-, proximate- and environmental-level factors related to perinatal mortality (PM). Generalized linear latent and mixed models with the logit link and binomial family that adjusted for clustering and sampling weights was employed for the analyses. RESULTS: Babies born to obese women (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI]: 1.13-1.89) and babies whose mothers perceived their body size after birth to be smaller than the average size (aOR = 1.92, 95% CI: 1.61-2.30) showed greater odds of PM. Babies delivered through caesarean section were more likely to die (aOR = 2.85, 95% CI: 2.02-4.02) than those born through vaginal delivery. Other factors that significantly increased PM included age of the women (≥40 years), living in rural areas, gender (being male) and a fourth or higher birth order with a birth interval ≤ 2 years. CONCLUSIONS: Newborn and maternal care interventions are needed, especially for rural communities, that aim at counselling women that are obese. Promoting well-timed caesarean delivery, Kangaroo mother care of small-for-gestational-age babies, child spacing, timely referral for ailing babies and adequate medical check-up for older pregnant women may substantially reduce PM in Nigeria.


Assuntos
Parto Obstétrico/mortalidade , Morte Perinatal/etiologia , Mortalidade Perinatal/tendências , Complicações na Gravidez/mortalidade , Adulto , Intervalo entre Nascimentos , Cesárea/mortalidade , Demografia , Feminino , Inquéritos Epidemiológicos , Humanos , Recém-Nascido , Modelos Lineares , Masculino , Serviços de Saúde Materna , Mães/estatística & dados numéricos , Nigéria , Obesidade/mortalidade , Razão de Chances , Gravidez , Adulto Jovem
6.
Int J Gynaecol Obstet ; 146(1): 126-131, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31058318

RESUMO

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.


Assuntos
Saúde Global/normas , Saúde Materna/normas , Cuidado Pré-Natal/organização & administração , Feminino , Humanos , Mortalidade Materna , Tocologia/organização & administração , Mortalidade Perinatal , Gravidez , Desenvolvimento Sustentável , Nações Unidas
7.
Medicine (Baltimore) ; 98(20): e15470, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096442

RESUMO

BACKGROUND: Growing evidence suggests that interpregnancy weight change (IPWC) is a risk factor for perinatal outcomes, since it may increase the probability of gestational complications including gestational diabetes or cesarean delivery. Additionally, IPWC may affect neonatal outcomes increasing the prevalence of newborns small for gestational age or preterm birth. However, the association between IPWC and perinatal outcomes has not systematically synthesized thus far. This study protocol aims to provide a clear, transparent and standardized procedure for systematically reviewing the association between IPWC and perinatal outcomes. METHODS AND ANALYSIS: This systematic review and meta-analyses protocol is based on the preferred reporting items for systematic review and meta-analysis protocols and the Cochrane Collaboration Handbook. MEDLINE, EMBASE, the Cochrane Library, and Web of Science will be systematically searched from their inception. No limits will be defined by study design, as such different tools to assess risk of bias will be used:Odd ratios and their corresponding 95% confidence intervals will be reported to evaluate associations between IPWC and perinatal outcomes. RESULTS: The results of this study will be published in a peer-reviewed journal. CONCLUSION: This systematic review and meta-analysis will systematically synthesize the evidence regarding the association between IPWC and perinatal outcomes. Data will be extracted from published articles and findings will be published in peer-reviewed journals. Ethical approval and informed consent will not be required due to the nature of the study. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018100449.


Assuntos
Peso Corporal/fisiologia , Ganho de Peso na Gestação/fisiologia , Complicações na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Índice de Massa Corporal , Estudos de Casos e Controles , Estudos Transversais , Diabetes Gestacional/epidemiologia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Estudos Observacionais como Assunto , Mortalidade Perinatal , Gravidez , Complicações na Gravidez/fisiopatologia , Fatores de Risco
8.
Cochrane Database Syst Rev ; 5: CD009613, 2019 05 23.
Artigo em Inglês | MEDLINE | ID: mdl-31120549

RESUMO

BACKGROUND: There are a number of ways of monitoring blood glucose in women with diabetes during pregnancy, with self-monitoring of blood glucose (SMBG) recommended as a key component of the management plan. No existing systematic reviews consider the benefits/effectiveness of different techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear. This review is an update of a review that was first published in 2014 and subsequently updated in 2017. OBJECTIVES: To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2018), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM), automated telemedicine monitoring or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also eligible for inclusion. RCTs using a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: This review update includes a total of 12 trials (863) women (792 women with type 1 diabetes and 152 women with type 2 diabetes). The trials took place in Europe, the USA and Canada. Three of the 12 included studies are at low risk of bias, eight studies are at moderate risk of bias, and one study is at high risk of bias. Four trials reported that they were provided with the continuous glucose monitors free of charge or at a reduced cost by the manufacturer.Continuous glucose monitoring (CGM) versus intermittent glucose monitoring, (four studies, 609 women)CGM may reduce hypertensive disorders of pregnancy (pre-eclampsia and pregnancy-induced hypertension) (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.85; 2 studies, 384 women; low-quality evidence), although it should be noted that only two of the four relevant studies reported data for this composite outcome. Conversely, this did not translate into a clear reduction for pre-eclampsia (RR 0.65, 95% CI 0.39 to 1.08; 4 studies, 609 women, moderate-quality evidence). There was also no clear reduction in caesarean section (average RR 0.94, 95% CI 0.75 to 1.18; 3 studies, 427 women; I2 = 41%; moderate-quality evidence) or large-for-gestational age (average RR 0.84, 95% CI 0.57 to 1.26; 3 studies, 421 women; I2 = 70%; low-quality evidence) with CGM. There was not enough evidence to assess perinatal mortality (RR 0.82, 95% CI 0.05 to 12.61, 71 infants, 1 study; low-quality evidence), or mortality or morbidity composite (RR 0.80, 95% CI 0.61 to 1.06; 1 study, 200 women) as the evidence was based on single studies of low quality. CGM appears to reduce neonatal hypoglycaemia (RR 0.66, 95% CI 0.48 to 0.93; 3 studies, 428 infants). Neurosensory disability was not reported.Other methods of glucose monitoringFor the following five comparisons, self-monitoring versus a different type of self-monitoring (two studies, 43 women); self-monitoring at home versus hospitalisation (one study, 100 women), pre-prandial versus post-prandial glucose monitoring (one study, 61 women), automated telemedicine monitoring versus conventional system (three studies, 84 women), and constant CGM versus intermittent CGM (one study, 25 women), it is uncertain whether any of the interventions has any impact on any of our GRADE outcomes (hypertensive disorders of pregnancy, caesarean section, large-for-gestational age) because the quality of the evidence was found to be very low. This was due to evidence largely being derived from single trials, with design limitations and limitations with imprecision (wide CIs, small sample sizes, and few events). There was not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Other important outcomes, such as neurosensory disability, were not reported in any of these comparisons. AUTHORS' CONCLUSIONS: Two new studies (406 women) have been incorporated to one of the comparisons for this update. Although the evidence suggests that CGM in comparison to intermittent glucose monitoring may reduce hypertensive disorders of pregnancy, this did not translate into a clear reduction for pre-eclampsia, and so this result should be viewed with caution. No differences were observed for other primary outcomes for this comparison. The evidence base for the effectiveness of other monitoring techniques analysed in the other five comparisons is weak and based on mainly single studies with very low-quality evidence. Additional evidence from large well-designed randomised trials is required to inform choices of other glucose monitoring techniques and to confirm the effectiveness of CGM.


Assuntos
Automonitorização da Glicemia/métodos , Glicemia/metabolismo , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 2/sangue , Adulto , Canadá , Europa (Continente) , Feminino , Humanos , Hipertensão/prevenção & controle , Hipoglicemia/induzido quimicamente , Recém-Nascido , Mortalidade Perinatal , Pré-Eclâmpsia/prevenção & controle , Gravidez , Estados Unidos
9.
J Dairy Sci ; 102(7): 6404-6417, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31056325

RESUMO

In the Netherlands, the mortality rate of ear-tagged calves <1 yr is one of the indicators that is continuously monitored in census data and is defined as the number of deceased calves relative to the number of calf-days-at-risk. In 2017, yearly calf mortality rates were published in the lay press and resulted in discussions about the calculation of this parameter among stakeholders because the same parameter appeared to be calculated in many different ways by different organizations. These diverse definitions of calf mortality answered different aims such as early detection of deviations, monitoring trends, or providing insight into herd-specific results, but were difficult to understand by stakeholders. The aim of this study was to evaluate several definitions of calf mortality for scientific validity, usefulness for policymakers, and comprehensibility by farmers. Based on expert consultations, 10 definitions for calf mortality were evaluated that assessed different age categories, time periods, and denominators. Differences in definitions appeared to have a large effect on the magnitude of mortality. For example, with the original mortality parameter, the mortality rate was 16.5% per year. When the first year of life was subdivided into 3 age categories, the mortality rate was 3.3, 4.5, and 3.1% for postnatal calves (≤14 d), preweaned calves (15-55 d), and weaned calves (56 d-1 yr), respectively. Although it was logical that these mortality rates were lower than the original, the sum of the 3 separate mortality rates was also lower than the original mortality rate. The reason was that the number of calves present in a herd and the risk of mortality are not randomly distributed over a calf's first year of life and the conditional nature of mortality rates when calculated for different age categories. Ultimately, 4 parameters to monitor calf mortality in Dutch dairy herds were chosen based on scientific value, usefulness for monitoring of trends, and comprehensibility by farmers: perinatal calf mortality risk (i.e., mortality before, during, or shortly after the moment of birth up to the moment of ear-tagging), postnatal calf mortality risk (≤14 d), preweaned calf mortality rate (15-55 d), and weaned calf mortality rate (56 d-1 yr). Slight differences in definitions of parameters can have a major effect on results, and many factors have to be taken into account when defining an important health indicator such as mortality. Our evaluation resulted in a more thorough understanding of the definitions of the selected parameters and agreement by the stakeholders to use these key indicators to monitor calf mortality.


Assuntos
Doenças dos Bovinos/mortalidade , Animais , Animais Recém-Nascidos , Bovinos , Fazendeiros , Fazendas/estatística & dados numéricos , Feminino , Humanos , Mortalidade , Países Baixos , Mortalidade Perinatal , Gravidez , Fatores de Risco
11.
Int J Gynaecol Obstet ; 146(1): 95-102, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31032903

RESUMO

OBJECTIVE: To determine associations between geographic accessibility, delivery volume, and obstetric outcomes. METHODS: Population-based cohort study of linked hospital administrative, census, and geospatial data (2006-2009) from all Canadian jurisdictions except Quebec. Perinatal mortality and major maternal morbidity/mortality were compared across categories of road distance and hospital delivery volume. RESULTS: Among 820 761 mothers delivering 827 504 neonates, travel distance had minimal effect on perinatal mortality. Compared with mothers travelling 0-9 km, the odds of adverse maternal outcomes was decreased for women travelling modest distances (20-49 km, odds ratio, 0.80 [95% confidence interval, 0.75-0.86]), and increased thereafter (50-99 km, 0.99 [0.89-1.10]; 200-299 km, 1.44 [1.10-1.87]; >400 km, 2.22 [1.06-4.63]). Relative to high-volume hospitals (>2500 deliveries/year), adverse maternal outcomes were less likely for hospitals with 1000-2499 (0.90 [0.86-0.95]), and roughly equivalent for hospitals with 200-499 (1.34 [1.22-1.48]) and 500-999 (1.27 [1.17-1.39]) deliveries/year. Odds of perinatal mortality ranged from 1.04 (0.73-1.49; 100-199 deliveries/year) to 1.50 (1.04-2.16; 50-99 deliveries/year); the pattern did not suggest causality. CONCLUSION: Maternal outcomes worsen when travel distance is greater than 200 km, and improve when delivery volume exceeds 1000 deliveries per year.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Mortalidade Materna , Mortalidade Perinatal , Adulto , Canadá/epidemiologia , Estudos de Coortes , Feminino , Hospitais/estatística & dados numéricos , Humanos , Recém-Nascido , Razão de Chances , Vigilância da População , Gravidez , Estudos Retrospectivos
12.
Scand J Trauma Resusc Emerg Med ; 27(1): 37, 2019 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-30953532

RESUMO

The aim of this Letter to the Editor was to report some methodological shortcomings in a recently published Article. We proved that the obtained results are subjected to the sparse data bias and presented some remedial tools such as penalization approaches. In addition, model fitting and performance aroused some controversies. In conclusion, the results of this study should be interpreted with caution and further reanalysis is necessary.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Parto Domiciliar/estatística & dados numéricos , Doenças do Recém-Nascido/mortalidade , Nascimento Prematuro/mortalidade , Medição de Risco , Feminino , Seguimentos , Humanos , Recém-Nascido , Irã (Geográfico)/epidemiologia , Mortalidade Perinatal/tendências , Gravidez , Estudos Prospectivos , Fatores de Risco
14.
Health Res Policy Syst ; 17(1): 36, 2019 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-30953520

RESUMO

OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.


Assuntos
Análise Custo-Benefício , Morte Materna/prevenção & controle , Mortalidade Materna , Morte Perinatal/prevenção & controle , Mortalidade Perinatal , Guias de Prática Clínica como Assunto , Cuidado Pré-Natal/economia , Custos e Análise de Custo , Feminino , Produto Interno Bruto , Humanos , Lactente , Gravidez , Ruanda/epidemiologia , Organização Mundial da Saúde
15.
Lancet ; 393(10184): 1973-1982, 2019 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-30929893

RESUMO

BACKGROUND: Universal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs). METHODS: For this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191. FINDINGS: We included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ2=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ2=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ2=0·62). INTERPRETATION: Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks. FUNDING: Ammalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.


Assuntos
Cesárea/efeitos adversos , Morte Materna/estatística & dados numéricos , Mortalidade Materna , Mortalidade Perinatal , África ao Sul do Saara/epidemiologia , Feminino , Humanos , Recém-Nascido , Morte Perinatal , Gravidez , Prevalência , Fatores Socioeconômicos
17.
BMC Health Serv Res ; 19(1): 166, 2019 Mar 14.
Artigo em Inglês | MEDLINE | ID: mdl-30871523

RESUMO

BACKGROUND: Nepal formulated a range of policies related to maternal and neonatal survival, especially after the year 2000. Nevertheless, Nepal's perinatal mortality remains high, particularly in disadvantaged regions. Policy analysis can uncover the underlying values, strategies and policy formulation processes that shape the potential to reduce in-country health inequities. This paper provides a critical account of the main policy documents relevant to perinatal survival in Nepal. METHODS: Six key policy documents covering the period 2000-2015 were reviewed using an adapted framework and were analyzed through qualitative content analysis. RESULTS: The analysis shows that the policies focused mainly on the system: improvement in provision of birthing facilities; targeting staff (Skilled Birth Attendants) and health service users by providing cash incentives to staff for bringing patients to services, and to users (pregnant women) to attend health institutions. Despite a growing focus on saving women and newborn babies, there is a poor policy focus and direction on preventing stillbirth. The policy documents were found to emphasize tensions between birthing at home and at health institutions on the one hand, and between strategies to provide culturally appropriate, woman-centered care in communities and medically orientated services on the other. Policies acknowledge the need to provide and address woman-centered care, equity, social inclusion, and a rights-based approach, and identify the community based approach as the mode of service delivery. Over and above this, all policy documents are aimed at the national level, and there is no specific policy direction for the separate ecological, cultural or geographic regions such as the mountainous region, which continues to exhibit higher mortality rates and has different cultural and demographic characteristics to the rest of Nepal. CONCLUSIONS: To better address the continuing high perinatal mortality rates, particularly in disadvantaged areas, national health policies should pay more attention to the inequity in healthcare access and in perinatal outcomes by integrating both stillbirth prevention and neonatal survival as policy agenda items. To ensure effective translation of policy into practice, it is imperative to tailor the strategies according to acknowledged policy values such as rights, inclusion and socio-cultural identity.


Assuntos
Assistência à Saúde Culturalmente Competente/organização & administração , Assistência Perinatal/organização & administração , Cuidado Pré-Natal/organização & administração , Feminino , Política de Saúde , Acesso aos Serviços de Saúde/organização & administração , Humanos , Recém-Nascido , Tocologia/organização & administração , Nepal , Enfermeiras Obstétricas/provisão & distribução , Assistência Centrada no Paciente/organização & administração , Mortalidade Perinatal , Formulação de Políticas , Gravidez
18.
Paediatr Perinat Epidemiol ; 33(2): 116-118, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30920009
19.
Glob Health Action ; 12(1): 1581466, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30849300

RESUMO

BACKGROUND: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. OBJECTIVE: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. METHODS: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. DISCUSSION: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices.


Assuntos
Serviços de Saúde Materna/organização & administração , Melhoria de Qualidade/organização & administração , Comportamento Cooperativo , Prática Clínica Baseada em Evidências , Feminino , Humanos , Índia , Recém-Nascido , Relações Interinstitucionais , Serviços de Saúde Materna/normas , Mortalidade Materna/tendências , Mortalidade Perinatal/tendências , Gravidez
20.
Cochrane Database Syst Rev ; 3: CD004905, 2019 03 14.
Artigo em Inglês | MEDLINE | ID: mdl-30873598

RESUMO

BACKGROUND: Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- and middle-income countries. They are exacerbated in pregnancy due to the increased demands of the developing fetus, leading to potentially adverse effects on the mother and baby. A consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane Review in 2017, evidence from several trials has become available. The findings of this review will be critical to inform policy on micronutrient supplementation in pregnancy. OBJECTIVES: To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes. SEARCH METHODS: For this 2018 update, on 23 February 2018 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We also contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA: All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on pregnancy outcomes were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but excluded quasi-randomised trials. Trial reports that were published as abstracts were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We identified 21 trials (involving 142,496 women) as eligible for inclusion in this review, but only 20 trials (involving 141,849 women) contributed data. Of these 20 trials, 19 were conducted in low- and middle-income countries and compared MMN supplements with iron and folic acid to iron, with or without folic acid. One trial conducted in the UK compared MMN supplementation with placebo. In total, eight trials were cluster-randomised.MMN with iron and folic acid versus iron, with or without folic acid (19 trials)MMN supplementation probably led to a slight reduction in preterm births (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.90 to 1.01; 18 trials, 91,425 participants; moderate-quality evidence), and babies considered small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.88 to 0.97; 17 trials; 57,348 participants; moderate-quality evidence), though the CI for the pooled effect for preterm births just crossed the line of no effect. MMN reduced the number of newborn infants identified as low birthweight (LBW) (average RR 0.88, 95% CI 0.85 to 0.91; 18 trials, 68,801 participants; high-quality evidence). We did not observe any differences between groups for perinatal mortality (average RR 1.00, 95% CI 0.90 to 1.11; 15 trials, 63,922 participants; high-quality evidence). MMN supplementation led to slightly fewer stillbirths (average RR 0.95, 95% CI 0.86 to 1.04; 17 trials, 97,927 participants; high-quality evidence) but, again, the CI for the pooled effect just crossed the line of no effect. MMN supplementation did not have an important effect on neonatal mortality (average RR 1.00, 95% CI 0.89 to 1.12; 14 trials, 80,964 participants; high-quality evidence). We observed little or no difference between groups for the other maternal and pregnancy outcomes: maternal anaemia in the third trimester (average RR 1.04, 95% CI 0.94 to 1.15; 9 trials, 5912 participants), maternal mortality (average RR 1.06, 95% CI 0.72 to 1.54; 6 trials, 106,275 participants), miscarriage (average RR 0.99, 95% CI 0.94 to 1.04; 12 trials, 100,565 participants), delivery via a caesarean section (average RR 1.13, 95% CI 0.99 to 1.29; 5 trials, 12,836 participants), and congenital anomalies (average RR 1.34, 95% CI 0.25 to 7.12; 2 trials, 1958 participants). However, MMN supplementation probably led to a reduction in very preterm births (average RR 0.81, 95% CI 0.71 to 0.93; 4 trials, 37,701 participants). We were unable to assess a number of prespecified, clinically important outcomes due to insufficient or non-available data.When we assessed primary outcomes according to GRADE criteria, the quality of evidence for the review overall was moderate to high. We graded the following outcomes as high quality: LBW, perinatal mortality, stillbirth, and neonatal mortality. The outcomes of preterm birth and SGA we graded as moderate quality; both were downgraded for funnel plot asymmetry, indicating possible publication bias.We carried out sensitivity analyses excluding trials with high levels of sample attrition (> 20%). We found that results were consistent with the main analyses for all outcomes. We explored heterogeneity through subgroup analyses by maternal height, maternal body mass index (BMI), timing of supplementation, dose of iron, and MMN supplement formulation (UNIMMAP versus non-UNIMMAP). There was a greater reduction in preterm births for women with low BMI and among those who took non-UNIMMAP supplements. We also observed subgroup differences for maternal BMI and maternal height for SGA, indicating greater impact among women with greater BMI and height. Though we found that MMN supplementation made little or no difference to perinatal mortality, the analysis demonstrated substantial statistical heterogeneity. We explored this heterogeneity using subgroup analysis and found differences for timing of supplementation, whereby higher impact was observed with later initiation of supplementation. For all other subgroup analyses, the findings were inconclusive.MMN versus placebo (1 trial)A single trial in the UK found little or no important effect of MMN supplementation on preterm births, SGA, or LBW but did find a reduction in maternal anaemia in the third trimester (RR 0.66, 95% CI 0.51 to 0.85), when compared to placebo. This trial did not measure our other outcomes. AUTHORS' CONCLUSIONS: Our findings suggest a positive impact of MMN supplementation with iron and folic acid on several birth outcomes. MMN supplementation in pregnancy led to a reduction in babies considered LBW, and probably led to a reduction in babies considered SGA. In addition, MMN probably reduced preterm births. No important benefits or harms of MMN supplementation were found for mortality outcomes (stillbirths, perinatal and neonatal mortality). These findings may provide some basis to guide the replacement of iron and folic acid supplements with MMN supplements for pregnant women residing in low- and middle-income countries.


Assuntos
Suplementos Nutricionais , Ácido Fólico/administração & dosagem , Ferro na Dieta/administração & dosagem , Micronutrientes/administração & dosagem , Complicações na Gravidez/terapia , Interações de Medicamentos , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Micronutrientes/efeitos adversos , Micronutrientes/deficiência , Mortalidade Perinatal , Gravidez , Resultado da Gravidez , Nascimento Prematuro/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto
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