Maternal Mortality in the United States Compared With Ethiopia, Nepal, Brazil, and the United Kingdom: Contrasts in Reproductive Health Policies

Usefulness of the Hospital Information System for maternal mortality surveillance in Brazil

OBJECTIVE

To evaluate the capability of hospital records in the Hospital Information System (SIH) to add valuable and complementary information to the Mortality Information System (SIM) in studies on maternal mortality. We calculated and compared the maternal mortality ratio from the SIH and SIM databases, by age group and region, to highlight differences between groups and assess the coverage of maternal deaths using SIH compared with SIM.

METHODS

Obstetric hospitalizations were defined based on three sources (codes ICD-10 in diagnoses; procedures; billing information). Hospital and SIM mortality ratios were calculated by dividing maternal deaths in hospitals affiliated to the Unified Brazilian Health System (SUS) per live births (SINASC) in the same hospitals.

RESULTS

In 2019, we identified 2,497,957 obstetric admissions, 0.04% (946) with in-hospital mortality as outcome. The presence of three criteria identified 98% of obstetric hospitalizations and 83% of obstetric hospitalizations with death as outcome. The comparison of mortality ratios between SIH (45.5 MMR; 95%CI 42.7 - 48.5) and SIM (49.7 MMR; 95%CI 46.7 - 52.8) was not statistically significant (p-value: 0.053).

CONCLUSION

The analysis of SIH was able to provide additional information for the monitoring and surveillance of maternal health in Brazil. Although there are differences between the mortality rates, the SIH, as a complementary information system to the SIM, may be valid in studies on maternal mortality and morbidity.

The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers

The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.

Roe 2022: It's Not 1972

The recent U.S. Supreme Court decision cannot take obstetricians and gynecologists back to 1972, because abortion practice, training, and research have made 50 years of progress. During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health. Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence.

Mid forceps did not cause "compromised babies" - "compromise" caused forceps: an approach toward safely lowering the cesarean delivery rate

OBJECTIVE

Over 5 decades, Cesarean Delivery rates (CDR) have risen 6-fold while vaginal operative deliveries [VODs] decreased from >20% to ∼3%. Poor outcomes (HIE and cerebral palsy) haven't improved. Potentiating the virtual abandonment of forceps (F), particularly midforceps (Mid), were allegations about various poor neonatal outcomes. Here, we evaluate VOD and CDR outcomes controlling for prior fetal risk metrics (PR) ascertained an hour before birth.

METHODS

Our 45-year-old database from a labor research unit of moderate/high risk laboring patients (288 NSVDs, 120 Lows, 30 Mids, and 32 CDs) had multiple fetal scalp samples for base excess (BE), pH, cord blood gases (CB), and umbilical artery bloods. ANOVA established relationships between birth methods and outcomes (Cord blood BE and pH and 1 and 5 min Apgar scores); correlations, and two-step multiple regression assessed PR for delivery method and neonatal outcomes. The main outcome measures were correlations of outcome measures with fetal scalp sample BE and pH up to an hour before delivery and fetal reserve index scores scored concurrently.

RESULTS

NSVDs had the best immediate neonatal outcomes with significantly higher CB pH and BE as compared to forceps and CDs. However, controlling for PR revealed: (1) PR at 1 h before delivery correlated with delivery mode, i.e. the decrements in outcomes were already present before the delivery was performed; and (2) The presumed deleterious effects of interventional deliveries, per se, were significantly reduced, and (3) Fetal Reserve Index predicted neonatal outcomes better than fetal scalp sample BE, pH, or delivery mode.

CONCLUSION

The historical belief that MF deliveries caused poorer outcomes than NSVDs seems mostly backwards. Appreciating PR's impact on delivery routes, and when appropriate, properly performing VODs could safely reduce CDR. If our approach lowered CDR by only ∼2%, in the United States about 80,000 CDs might be avoided, saving ∼$750 Million yearly. In the post pandemic world, safely apportioning medical expenses will be even more critical than previously.