EviSIP: using evidence to change practice through mentorship - an innovative experience for reproductive health in the Latin American and Caribbean regions

Maternal mortality is unacceptably high in our region. In 2015, the Latin American Center for Perinatology and Women´s Reproductive Health (CLAP) created a regional network of institutions including 16 countries, committed to improving epidemiological surveillance and healthcare of women in a situation of abortion or near miss event, using a common platform, the Perinatal Information System (SIP). The objective of the current pilot project was to test a new method of study called EviSIP (Evidence from SIP), a method of generating information on maternal near miss and abortion for the region. We describe the implementation of this initiative in reproductive healthcare facilities using SIP. Junior researchers/clinicians from these countries were included, along with expert researchers in reproductive health from across the world. Articles were produced with data on maternal near miss and abortion gathered from the SIP of each participating sentinel center; and recommendations from experts. EviSIP was the first joint workspace to discuss patient outcomes after treatment of abortion or near miss cases, with data analysis of each Sentinel Center; discuss and analyze data among centers, at a country and regional level; discuss the main outcomes and their impact on changing procedures and policies; strengthen the operational research capacity of the centers; develop and encourage the publication of scientific articles. The EviSIP initiative also promoted training of healthcare professionals in research. EviSIP provided a unique opportunity to train for research and mentorship and was pivotal to the production of scientific knowledge of reproductive health in the region. (AU)

La mortalidad materna es inaceptablemente alta en nuestra región. En 2015, el Centro Latinoamericano de Perinatología y Salud Reproductiva de la Mujer (CLAP) creó una red regional de instituciones que incluye 16 países, comprometidas con mejorar la vigilancia epidemiológica y la atención de la salud de las mujeres en situación de aborto o cuasi accidente, utilizando un método común. plataforma, el Sistema de Información Perinatal (SIP). El objetivo del proyecto piloto actual era probar un nuevo método de estudio llamado EviSIP (Evidence from SIP), un método para generar información sobre el cuasi accidente y el aborto materno en la región. Describimos la implementación de esta iniciativa en instalaciones de salud reproductiva utilizando SIP. Se incluyeron investigadores / médicos jóvenes de estos países, junto con investigadores expertos en salud reproductiva de todo el mundo. Se elaboraron artículos con datos sobre casi accidentes maternos y abortos recopilados del SIP de cada centro centinela participante; y recomendaciones de expertos. EviSIP fue el primer espacio de trabajo conjunto para discutir los resultados de los pacientes después del tratamiento de un aborto o casos de casi accidentes, con análisis de datos de cada Centro Sentinel; discutir y analizar datos entre centros, a nivel nacional y regional; discutir los principales resultados y su impacto en el cambio de procedimientos y políticas; fortalecer la capacidad de investigación operativa de los centros; Desarrollar y fomentar la publicación de artículos científicos. La iniciativa EviSIP también promovió la formación de los profesionales sanitarios en investigación. EviSIP brindó una oportunidad única para capacitarse en investigación y tutoría y fue fundamental para la producción de conocimiento científico sobre salud reproductiva en la región. (AU)

Lessons about the reliability of congenital syphilis and vertical HIV transmission data learned from case reviews in Uruguay: a cross-sectional study

Background: In Uruguay it is mandatory to review all cases of positive HIV or reactive syphilis tests in pregnancy and peripartum. We compared the rates of mother-to-child transmission of syphilis and HIV detected by case reviews to those obtained from the usual surveillance system and described the characteristic of vertical transmission cases. Methods: This is a cross-sectional study performed with secondary data obtained from official government sources, for all the country cases of maternal to child transmission of HIV and syphilis from 2012 to 2017, with descriptive analyses. For congenital syphilis analyses, the following pregnancy characteristics were investigated: number of antenatal checks, gestational age at pregnancy diagnosis, gestational age at syphilis test and diagnosis, adequate treatment, and treatment of partners. Sociodemographic characteristics included type of health care (public/private), maternal age, distribution of ethnic minorities, maximum educational attainment, presence of partner, planned pregnancy, drug and alcohol use, domestic violence, previous maternal diagnosis of syphilis, and previous children with congenital syphilis. Results: Coverage of syphilis case reviews increased from 82% in 2014 to 97.4% in 2017. For HIV, this coverage reached 100% in 2017 and elimination of mother to child transmission was achieved. A marked decline in congenital syphilis was noted in the public health care sector, especially in the capital Montevideo, whereas the private sector has remained below the elimination target. Variables related with congenital syphilis in exposed children were late pregnancy diagnosis, < 5 antenatal checks, delayed diagnosis of gestational syphilis, lower rate of correct treatment for gestational syphilis, untreated partner, low maternal schooling, unplanned pregnancy, history of syphilis, and having other children with syphilis. Conclusion: The use of case reviews provided knowledge regarding the accurate number of mother-to-child transmission cases and the evolution of elimination of mother to child transmission in the country. The results suggest that rates must be adjusted, providing an opportunity to improve the reliability of surveillance data, and point the need to address specific gaps in order to improve the quality of care during pregnancy, delivery, and the neonatal period. (AU)

En Uruguay es obligatorio revisar todos los casos de VIH positivo o pruebas de sífilis reactiva en el embarazo y el periparto. Comparamos las tasas de transmisión maternoinfantil de la sífilis y el VIH detectadas por revisiones de casos con las obtenidas del sistema de vigilancia habitual y describimos la característica de los casos de transmisión vertical. Métodos: Se trata de un estudio transversal realizado con datos secundarios obtenidos de fuentes gubernamentales oficiales, para todos los casos de transmisión maternoinfantil de VIH y sífilis del país de 2012 a 2017, con análisis descriptivos. Para los análisis de sífilis congénita, se investigaron las siguientes características del embarazo: número de controles prenatales, edad gestacional al momento del diagnóstico del embarazo, edad gestacional al momento de la prueba y diagnóstico de la sífilis, tratamiento adecuado y tratamiento de las parejas. Las características sociodemográficas incluyeron tipo de atención de salud (pública / privada), edad materna, distribución de minorías étnicas, máximo nivel educativo, presencia de pareja, embarazo planificado, consumo de drogas y alcohol, violencia doméstica, diagnóstico materno previo de sífilis e hijos anteriores con sífilis congénita. Resultados: La cobertura de las revisiones de casos de sífilis aumentó de 82% en 2014 a 97,4% en 2017. Para el VIH, esta cobertura alcanzó el 100% en 2017 y se logró la eliminación de la transmisión maternoinfantil. Se observó una marcada disminución de la sífilis congénita en el sector de la salud pública, especialmente en la capital Montevideo, mientras que el sector privado se ha mantenido por debajo de la meta de eliminación. Las variables relacionadas con la sífilis congénita en niños expuestos fueron: diagnóstico tardío de embarazo, <5 controles prenatales, diagnóstico tardío de sífilis gestacional, menor tasa de tratamiento correcto para sífilis gestacional, pareja no tratada, baja escolaridad materna, embarazo no planeado, antecedentes de sífilis y otros niños con sífilis. Conclusión: El uso de revisiones de casos proporcionó conocimiento sobre el número exacto de casos de transmisión de madre a hijo y la evolución de la eliminación de la transmisión de madre a hijo en el país. Los resultados sugieren que las tasas deben ajustarse, brindando la oportunidad de mejorar la confiabilidad de los datos de vigilancia y señalan la necesidad de abordar brechas específicas para mejorar la calidad de la atención durante el embarazo, el parto y el período neonatal. (AU)

Neonatal Near Miss: the need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system

In Latin American, there is currently a regional action with the main purposes of putting the concept of severe neonatal morbidity in practice and formulating proposals for interventions. A general overview of neonatal health conditions, including morbidity and mortality, is provided to update regional knowledge on the topic. An example of the development and implementation of the concept of maternal near miss is also provided, followed by results from a systematic review covering all previously published studies on Neonatal Near Miss. Finally, some proposals for building a common concept on the topic and for launching a prospective surveillance study are presented. A Neonatal Near Miss is a neonate who had a severe morbidity (organ dysfunction or failure) but who survived this condition within the first 27 days of life. The pragmatic criteria recommended to be used are as follows: birth weight below 1700 g, Apgar score below 7 at 5 minutes of life and gestational age below 33 weeks. As a proxy for organ dysfunction, the following management criteria are also confirmed: parenteral therapeutic antibiotics; nasal continuous positive airway pressure; any intubation during the first 27 days of life; phototherapy within the first 24 h of life; cardiopulmonary resuscitation; the use of vasoactive drugs, anticonvulsants, surfactants, blood products and steroids for refractory hypoglycemia and any surgical procedure. Although this study starts from a regional perspective, this topic is clearly globally relevant. All nations, especially low and middle-income countries, could benefit from the proposed standardization. (AU)

Maternal and congenital syphilis in selected Latin America and Caribbean countries: a multi-country analysis using data from the Perinatal Information System

Background: Maternal syphilis has an important impact on reproductive health. In 2010, World Health Organization (WHO)/Pan American Health Organization (PAHO) member countries approved the Strategy and Plan of Action for Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in the Americas by 2015. This paper aims to describe epidemiological and programmatic characteristics related to maternal and congenital syphilis in selected countries of Latin America and Caribbean for the period 2010­12. Methods: The report is based on a multi-country, quantitative and qualitative analysis from data collected from several sources, representing a compilation of country reports from nine countries as part of the 2012 mid-term evaluation of the Strategy. Data was collected based on standardised procedures at country level. Results: Results are variable among countries. All countries have a strategic national plan to eliminate congenital syphilis, with some distinct characteristics for each country. Protocols and guidelines for the management and treatment of maternal and congenital syphilis in all countries were updated between 2011 and 2013. A high rate of missing information for all countries for some indicators was noticed. Conclusions: The main limitation of the analyses is the huge amount of missing data. Countries must continue to be supported to build capacity for collecting high-quality data on intervention coverage and inequities, and to use it as a basis for decisions about how best to reach women and children with interventions. A high level political commitment is necessary to put into practice the Regional Initiative to Eliminate Congenital Syphilis, with the support of Health Ministries. (AU)