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Gama SGND, Bittencourt SA, Theme Filha MM, Takemoto MLS, Lansky S, Frias PGD, Ayres BVDS, Domingues RMSM, Dias MAB, Esteves-Pereira AP, Nakamura-Pereira M, Leal MDC. Maternal mortality: protocol of a study integrated to the Birth in Brazil II survey. CAD SAUDE PUBLICA 2024; 40:e00107723. [PMID: 38775574 PMCID: PMC11105346 DOI: 10.1590/0102-311xpt107723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 05/25/2024] Open
Abstract
The Maternal Mortality Study conducts a hospital investigation of maternal deaths that occurred in 2020/2021 in the maternity hospitals sampled by the Birth in Brazil II survey, with the following objectives: estimate the maternal mortality underreporting; calculate a correction factor and the corrected (MMR); validate the causes of maternal mortality reported in the death certificate (DC); and analyze the factors associated with maternal mortality. The Birth in Brazil II includes approximately 24,250 puerperal women distributed in 465 public, private, and mixed hospitals with ≥ 100 live births/year in the five macroregions of Brazil. The Maternal Mortality Study data will be completed using the same Birth in Brazil II questionnaire, from the consultation of hospital records. Trained obstetricians will fill out a new DC (redone DC) from independent analysis of this questionnaire, comparing it to official data. The database of the investigated deaths will be related to the deaths listed in the Mortality Information System of the Brazilian Ministry of Health, allowing the estimation of underreporting and calculation of the corrected MMR. To calculate the reliability of the causes of death, the kappa test and prevalence-adjusted kappa with 95% confidence interval will be used. A case-control study to estimate the risk factors for maternal mortality will be developed with the investigated deaths (cases) and the controls obtained in the Birth in Brazil II survey, using conditional multiple logistic regression models. We expect this research to contribute to the correction of the underreporting of maternal mortality and to a better understanding of the determinants of the persistence of a high MMR in Brazil.
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Affiliation(s)
| | | | | | | | - Sônia Lansky
- Secretaria Municipal de Saúde de Belo Horizonte, Belo Horizonte, Brasil
| | - Paulo Germano de Frias
- Programa de Pós-graduação em Avaliação em Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brasil
| | | | | | - Marcos Augusto Bastos Dias
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Leal MDC, Esteves-Pereira AP, Bittencourt SA, Domingues RMSM, Theme Filha MM, Leite TH, Ayres BVDS, Baldisserotto ML, Nakamura-Pereira M, Moreira MEL, Gomes MADSM, Dias MAB, Takemoto MLS, Pacagnella RDC, Gama SGND. Protocol of Birth in Brazil II: National Research on Abortion, Labor and Childbirth. CAD SAUDE PUBLICA 2024; 40:e00036223. [PMID: 38695459 PMCID: PMC11057480 DOI: 10.1590/0102-311xpt036223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 05/06/2024] Open
Abstract
Brazil has made advances in obstetric care in public and private hospitals; however, weaknesses in this system still require attention. The Brazilian Ministry of Health, aware of this need, funded the second version of the Birth in Brazil survey. This study aimed to evaluate: prenatal, labor and birth, postpartum, and abortion care, comparing the results with those of Birth in Brazil I; and analyze the main determinants of perinatal morbidity and mortality; evaluate the care structure and processes of obstetrics and neonatology services in maternity hospitals; analyze the knowledge, practices, and attitudes of health professionals who provide birth and abortion care; and identify the main barriers and facilitators related to care of this nature in Brazil. With a national scope and a 2-stage probability sample: 1-hospitals and 2-women, stratified into 59 strata, 465 hospitals were selected with a total planned sample of around 24,255 women - 2,205 for abortion reasons and 22,050 for labor reasons. Data collection was conducted using six electronic instruments during hospital admission for labor or abortion, with two follow-up waves, at two and four months. In order to expand the number of cases of severe maternal morbidity, maternal and perinatal mortality, three case control studies were incorporated into Birth in Brazil II. The fieldwork began in November 2021 and is scheduled to end in 2023. It will allow a comparison between current labor and birth care results and those obtained in the first study and will evaluate the advances achieved in 10 years.
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Affiliation(s)
- Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | | | | | | | | | | | | | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Maria Elisabeth Lopes Moreira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Marcos Augusto Bastos Dias
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Torres JA, Leite TH, Fonseca TCO, Domingues RMSM, Figueiró AC, Pereira APE, Theme-Filha MM, da Silva Ayres BV, Scott O, de Cássia Sanchez R, Borem P, de Maio Osti MC, Rosa MW, Andrade AS, Filho FMP, Nakamura-Pereira M, do Carmo Leal M. An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals. Reprod Health 2024; 20:190. [PMID: 38671479 PMCID: PMC11052714 DOI: 10.1186/s12978-024-01773-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 03/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil. METHOD Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model". RESULTS PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA. CONCLUSION The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Paulo Borem
- Institute for Healthcare Improvement, Brasília, Brazil
| | | | | | | | - Fernando Maia Peixoto Filho
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
| | - Marcos Nakamura-Pereira
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
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Silva RPD, Pazin-Filho A. Rate and direct medical costs of cesarean sections among supplementary health plan holders living in the state of São Paulo, Brazil: 2015-2021. CIENCIA & SAUDE COLETIVA 2024; 29:e00512023. [PMID: 38198318 DOI: 10.1590/1413-81232024291.00512023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/06/2023] [Indexed: 01/12/2024] Open
Abstract
Brazil has the second largest cesarean section rate in the world. Differences in rates exist between the public and private health sectors. This study used data on admissions of supplementary health plan holders aged between 10 and 49 years living in the state of São Paulo admitted between 2015 and 2021 to determine cesarean section rates and costs in the private health sector. We conducted a partial economic analysis in health from a supplementary health perspective focusing on the direct medical costs of admissions. A total of 757,307 admissions were analyzed with total costs amounting to R$7.701 billion. The cesarean section rate over the period was 80%. Rates were lowest in young women (69%) and highest in the oldest age group (86%), exceeding 67% across all groups. The rate was 71% higher than in public services. The proportion of admissions with use of the intensive care unit was higher among cesarian deliveries. The median cost of a cesarean was 15% higher than that of a normal delivery and twice as high in insurance companies than healthcare cooperatives. There is an opportunity to apply policies that are widely used in public services to the private sector with the aim of reducing cesarean rates in private services, direct costs of admission, and the cost of supplementary health plans.
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Affiliation(s)
- Rildo Pinto da Silva
- Programa de Mestrado Profissional em Gestão de Organizações de Saúde, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. R. Pedreira de Freitas, Casa 2, Campus Universitário. 14049-900 Ribeirão Preto SP Brasil.
| | - Antonio Pazin-Filho
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto SP Brasil
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Junior LCM, Pinto CN, Gerencer CS, Pro ECG, de Carvalho HB. Association of maternal, fetal and labor variables with a low Apgar score in the fifth minute in term pregnancy: a case-control study. Arch Gynecol Obstet 2023; 308:1473-1483. [PMID: 36374349 PMCID: PMC9662118 DOI: 10.1007/s00404-022-06832-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To search for maternal, labor-related and fetal variables associated with low Apgar in the fifth minute in term pregnancy. METHODS A retrospective case-control study with term births was conducted in a public teaching hospital from 2013 to 2020. Cases were term births with Apgar score less than 7 in the fifth minute, and controls, the next one or two births following a case, with Apgar of 7 or more. Non-cephalic presentations, multiples and malformations were excluded. We accessed 100 cases and 190 controls. We considered significant values of p < 0.05. RESULTS Were accessed 27 variables which could be risk factors, from which 12 were associated with the outcome. We found a protective effect of prelabor cesarean for the outcome, odds ratio (OR) 0.38, p = 0.013. Consequently, we conducted two sets of analyses: in the whole group and in the group of laboring women. The values of OR were in general greater in the group of laboring women, compared with the whole group. We conducted multivariate analysis within the group of women in labor. The variables which fitted best in the model were nulliparity, male sex of the fetus, less than six prenatal visits and abnormal cardiotocography; all remained significant. An association of rupture of membranes more than 360 min with the outcome, even after controlling fpr duration of labor, was found; adjusted OR 2.45, p = 0.023. CONCLUSION Twelve variables were associated with the outcome. Prelabor cesarean had a protective effect. The time of ruptured membranes was associated with low Apgar.
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Affiliation(s)
- Luís Carlos Machado Junior
- Universidade de São Paulo/Faculdade de Medicina/Centro de Saúde Escola Samuel Barnsley Pessoa, São Paulo, Brazil.
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil.
| | - Camila Nazareth Pinto
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
| | - Caroline Sangalan Gerencer
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
| | - Elisa Caroline Giacometti Pro
- Hospital Municipal Universitário de São Bernardo do Campo, R. Alexandre Benois, 180, ap. 101, São Paulo, SP, CEP 05270 090, Brazil
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Oliveira IMGDD, Fonseca EPD, França FMG, Cortellazzi KL, Pardi V, Pereira AC, Tagliaferro EPDS. Age and Type of Delivery as Risk Indicators for Maternal Mortality. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:134-141. [PMID: 37105197 PMCID: PMC10166646 DOI: 10.1055/s-0043-1768456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE This study assessed maternal mortality (MM) and related factors in a large-sized municipality in the Southeastern region of Brazil (Campinas, São Paulo) during the period 2000-2015. METHODS This study consisted of two phases: 1. An analytical nested case-control phase that assessed the impact of individual and contextual variables on MM; and 2. an ecological phase designed to contextualize maternal deaths by means of spatial analysis. The case group consisted of all maternal deaths (n = 87) and the control group consisted of 348 women who gave birth during the same period. Data analysis included descriptive statistics, association, and multiple logistic regression (MLR) tests at p < 0.05 as well as spatial analysis. RESULTS Maternal Mortality Ratio was 37 deaths per 100.000 live births. Deaths were dispersed throughout the urban territory and no formation of cluster was observed. MLR showed that pregnant women aged ≥ 35 years old (OR = 2.63) or those with cesarean delivery (OR = 2.51) were more prone to maternal death. CONCLUSION Maternal deaths were distributed dispersedly among the different socioeconomic levels and more prone to occur among older women or those undergoing cesarean deliveries.
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Affiliation(s)
| | | | | | - Karine Laura Cortellazzi
- Department of Health Sciences and Pediatric Dentistry, Piracicaba Dental School, State University of Campinas, Piracicaba, Brazil
| | - Vanessa Pardi
- Department of Foundational Sciences, School of Dental Medicine, East Carolina University, Greenville, NC, USA
| | - Antonio Carlos Pereira
- Department of Health Sciences and Pediatric Dentistry, Piracicaba Dental School, State University of Campinas, Piracicaba, Brazil
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Abdulla F, Hossain MM, Rahman MM, Rahman MS, Rahman A. Risk factors of caesarean deliveries in urban-rural areas of Bangladesh. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1101400. [PMID: 36874261 PMCID: PMC9975760 DOI: 10.3389/frph.2023.1101400] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023] Open
Abstract
Background and aims The key interest of this research is to identify the causes of the ongoing increasing trends in caesarean section or C-section (CS) deliveries in both urban and rural areas of Bangladesh. Methods This study analyzed all Bangladesh Demographic and Health Survey (BDHS) datasets through Chi-square and z tests and the multivariable logistic regression model. Results CS deliveries were found to be more prevalent in urban than in rural areas of Bangladesh. Mothers above 19 years, above 16 years at first birth, overweight mothers, those with higher educational levels, those who received more than one antenatal care (ANC) visit, fathers having secondary/higher education degrees and employed as workers or in business, and mothers living in wealthy households in the cities of Dhaka, Khulna, Mymensingh, Rajshahi, and Rangpur divisions had a significantly higher likelihood of CS deliveries in urban areas. Contrastingly, mothers with ages between 20 and 39 years, above 20 years at first birth, normal weight/overweight mothers, those with primary to higher level of education, those in the business profession, fathers who also received primary to higher education, mothers who received more than one ANC visit, and those living in wealthy households in Dhaka, Khulna, Mymensingh, Rajshahi, and Rangpur divisions were more likely to have CS deliveries in rural areas. The 45-49 age group mothers had a five times higher likelihood of CS deliveries [odds ratio (OR): 5.39] in urban areas than in rural areas. Wealthy mothers were more likely to be CS-delivered in urban (OR: 4.84) than in rural areas (OR: 3.67). Conclusion The findings reveal a gradual upward alarming trend in CS deliveries with an unequal contribution of significant determinants in urban and rural areas of Bangladesh. Therefore, integrated community-level awareness programs are an urgent need in accordance with the findings on the risks of CS and the benefits of vaginal deliveries in this country.
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Affiliation(s)
- Faruq Abdulla
- Department of Applied Health and Nutrition, RTM Al-Kabir Technical University, Sylhet, Bangladesh
| | - Md Moyazzem Hossain
- Department of Statistics, Jahangirnagar University, Savar, Bangladesh.,School of Mathematics, Statistics & Physics, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Md Mahabubur Rahman
- Department of Statistics, Faculty of Sciences, Islamic University, Kushtia, Bangladesh
| | | | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, NSW, Australia
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Tajvar M, Hajizadeh A, Zalvand R. A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries. BMC Public Health 2022; 22:2354. [PMID: 36522731 PMCID: PMC9753301 DOI: 10.1186/s12889-022-14686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before. METHODS We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification. RESULTS In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery. CONCLUSION A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.
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Affiliation(s)
- Maryam Tajvar
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hajizadeh
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Rostam Zalvand
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Teixeira GA, Holanda NSO, Azevedo IG, Moura JR, de Carvalho JBL, Pereira SA. Factors Associated with Number of Prenatal Visits in Northeastern Brazil: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14912. [PMID: 36429631 PMCID: PMC9690730 DOI: 10.3390/ijerph192214912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
The aim of this study is to assess factors associated with the number of prenatal visits of women who delivered in a public maternity hospital in northeastern Brazil. This cross-sectional study focused on 380 puerperal women who gave birth at a public maternity hospital in northeastern Brazil. Prenatal and perinatal data were collected in the immediate postpartum period by interviewing mothers and using medical records. Chi-square/Fisher exact test compared the data, and a logistic regression model estimated the association between birth weight and number of prenatal visits. As a result, the sample was composed of 175 women with <37 weeks of gestational age and 205 women with ≥37 weeks of gestational age. Women with less than four prenatal visits were more likely to give birth to low birth weight (<2500 g) and preterm infants (<37 weeks of gestational age) than those with more than four prenatal visits (p = 0.001). The subjects with less than four prenatal visits had a 2.76-fold higher odds of giving birth to infants weighing less than 2500 g (p = 0.03; 95%CI = 1.05-7.30), without relation to maternal and gestational ages. In conclusion, women with less than four prenatal visits had higher odds of giving birth to low birth infants, independently of maternal and gestational ages, and were more likely to give birth to premature babies.
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Affiliation(s)
- Gracimary A. Teixeira
- Health Technical School, Federal University of Paraiba, João Pessoa 58051-900, PB, Brazil
| | - Norrara S. O. Holanda
- Health Sciences’ Faculty of Trairi, Federal University of Rio Grande do Norte (FACISA—UFRN), Santa Cruz 59200-000, RN, Brazil
| | - Ingrid G. Azevedo
- Department of Therapeutic Processes, Universidad Católica de Temuco, Temuco 4813302, La Araucania, Chile
| | - Julia R. Moura
- Department of Physical Therapy, Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte (UFRN), Natal 59090-000, RN, Brazil
| | - Jovanka B. L. de Carvalho
- Graduate Program in Health and Society and Graduate Program in Nursing, Federal University of Rio Grande do Norte (UFRN), Natal 59078-970, RN, Brazil
| | - Silvana A. Pereira
- Department of Physical Therapy, Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte (UFRN), Natal 59090-000, RN, Brazil
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Fernandes LMM, Mishkin KE, Lansky S. Doula support among brazilian women who attended the senses of birth health education intervention - a cross sectional analysis. BMC Pregnancy Childbirth 2022; 22:765. [PMID: 36224541 PMCID: PMC9558943 DOI: 10.1186/s12884-022-05069-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While maternal health is a priority in international goals, maternal health outcomes remain poor in many regions of the world. In Brazil, maternal mortality has decreased over the past decades, but the country's maternal mortality ratio is higher than over half of all countries at 59 deaths per 100,000 live births. The Brazilian maternal health care model facilitates high rates of medical interventions during labor and childbirth; 56% of births are by cesarean birth. Doula support is considered a potential strategy to reduce medically unnecessary interventions during childbirth that contribute to maternal mortality. METHODS The cross-sectional study analyses associations with use of doula support and normal birth among Brazilian women who participated in a health education intervention named the Senses of Birth (SoB). The SoB intervention, implemented in five cities from 2015 to 2017, was developed to educate about normal birth and to evidence-based practices (EBP) reduce medically in childbirth. Chi-Square tests were performed to identify the relationship between doula support during childbirth and sociodemographic characteristics, childbirth information, perceived knowledge, and use of EBPs during labor. Logistic regression was performed to identify associations in adjusted analysis. RESULTS Controlling for covariates, doula support was associated with vaginal delivery (OR 2.47, 95% CI: 1.37-4.45.) Findings also suggest that women who had doula support were more likely to use non-pharmacological pain relief methods during labor (OR 9.68, 95% CI: 2.67-34.61), deliver in a public hospital (OR 2.02, 95% CI: 1.09-3.72), and be low and mid-level income compared to women with high income. CONCLUSION This study's findings suggest that doula support is significantly associated with vaginal birth. The results may be useful for advocating for changes to the childbirth care model in Brazil. Incorporating EBPs, such as doula support, for all women who desire may improve maternal and child outcomes.
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Affiliation(s)
- Luísa M M Fernandes
- Instituto René Rachou, Fundação Oswaldo Cruz (FIOCRUZ), Minas Gerais, Brazil
| | | | - Sônia Lansky
- Department of Health, City Hall, Belo Horizonte, Minas Gerais, Brazil
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11
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Levin G, Yagel S, Schwartz A, Many A, Rosenbloom J, Yinon Y, Meyer R. Trial of labor after cesarean in twin gestation with no prior vaginal delivery - evidence from largest cohort reported. Int J Gynaecol Obstet 2022; 159:229-236. [PMID: 34995363 PMCID: PMC9544935 DOI: 10.1002/ijgo.14090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/07/2021] [Accepted: 01/06/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery. METHODS A retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011-2020. TOLAC success and failure groups were compared. RESULTS Of 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56-11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (<7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07-96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07-0.69, P = 0.009). CONCLUSION TOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.
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Affiliation(s)
- Gabriel Levin
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Simcha Yagel
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Anat Schwartz
- Department of Obstetrics and GynecologyTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Ariel Many
- Department of Obstetrics and GynecologyTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Joshua I. Rosenbloom
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Yoav Yinon
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Department of Obstetrics and GynecologyChaim Sheba Medical CenterRamat‐GanIsrael
| | - Raanan Meyer
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Department of Obstetrics and GynecologyChaim Sheba Medical CenterRamat‐GanIsrael
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12
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Dias BAS, Leal MDC, Esteves-Pereira AP, Nakamura-Pereira M. Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital. CAD SAUDE PUBLICA 2022; 38:e00073621. [PMID: 35857919 DOI: 10.1590/0102-311xpt073621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/14/2022] [Indexed: 11/21/2022] Open
Abstract
This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.
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Affiliation(s)
| | - Maria do Carmo Leal
- Vice-Presidência de Ensino, Informação e Comunicação, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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13
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Zaiden L, Nakamura-Pereira M, Gomes MAM, Esteves-Pereira AP, Matos CPD, Barros LDA, Takemoto MLS, Leal MDC. Obstetric interventions in a maternity hospital with a collaborative model of care: a comparative observational study. CIENCIA & SAUDE COLETIVA 2022; 27:2741-2752. [PMID: 35730843 DOI: 10.1590/1413-81232022277.20632021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/31/2021] [Indexed: 11/22/2022] Open
Abstract
Collaborative models (CM) focused on intrapartum care shared between both midwives and obstetricians have been proposed as a strategy to reduce these rates. Our aim was to compare use of evidence-based practices, obstetric interventions and c-section rates in two settings: a maternity hospital that applies a CM of care (MRJ) and data from a pool of maternity hospitals included in the Birth in Brazil Survey (NB) that do not adopt a CM. Data was abstracted from medical and administrative records in MRJ and from medical records and face-to-face interviews in NB. Differences were compared using chi-square test, with significance level set at p<0.05. MRJ showed a higher frequency of labour companionship, labour care provided by nurse midwives, non-pharmacological pain relief methods, food intake during labour, and less use of oxytocin, analgesia and amniotomy. More women also had second stage assisted by a nurse midwife and in a vertical position, as well as lower use of episiotomies and vacuum-extractor/forceps. The c-section rate was lower at MRJ. Shared care between midwives and obstetricians can be an effective strategy to improve quality of intrapartum care.
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Affiliation(s)
- Laura Zaiden
- Faculdade de Medicina de Petrópolis, Universidade Faculdades Arthur Sá Earp Neto. Av. Barão do Rio Branco 1003, Centro. 25680-120 Petrópolis RJ Brasil. .,Maternidade Escola, Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ Brasil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro RJ Brasil
| | - Maria Auxiliadora Mendes Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro RJ Brasil
| | | | - Caio Pereira de Matos
- Faculdade de Medicina de Petrópolis, Universidade Faculdades Arthur Sá Earp Neto. Av. Barão do Rio Branco 1003, Centro. 25680-120 Petrópolis RJ Brasil.
| | - Lucas de Araujo Barros
- Faculdade de Medicina de Petrópolis, Universidade Faculdades Arthur Sá Earp Neto. Av. Barão do Rio Branco 1003, Centro. 25680-120 Petrópolis RJ Brasil.
| | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fiocruz. Rio de Janeiro RJ Brasil
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14
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Dias BAS, Leal MDC, Esteves-Pereira AP, Nakamura-Pereira M. Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital. CAD SAUDE PUBLICA 2022. [DOI: 10.1590/0102-311xen073621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.
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15
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SARS-CoV-2 Infection and C-Section: A Prospective Observational Study. Viruses 2021; 13:v13112330. [PMID: 34835136 PMCID: PMC8622813 DOI: 10.3390/v13112330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
Pregnant women are particularly vulnerable to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In addition to unfavorable perinatal outcomes, there has been an increase in obstetric interventions. With this study, we aimed to clarify the reasons, using Robson's classification model, and risk factors for cesarean section (C-section) in SARS-CoV-2-infected mothers and their perinatal results. This was a prospective observational study that was carried out in 79 hospitals (Spanish Obstetric Emergency Group) with a cohort of 1704 SARS-CoV-2 PCR-positive pregnant women that were registered consecutively between 26 February and 5 November 2020. The data from 1248 pregnant women who delivered vaginally (vaginal + operative vaginal) was compared with those from 456 (26.8%) who underwent a C-section. C-section patients were older with higher rates of comorbidities, in vitro fertilization and multiple pregnancies (p < 0.05) compared with women who delivered vaginally. Moreover, C-section risk was associated with the presence of pneumonia (p < 0.001) and 41.1% of C-sections in patients with pneumonia were preterm (Robson's 10th category). However, delivery care was similar between asymptomatic and mild-moderate symptomatic patients (p = 0.228) and their predisposing factors to C-section were the presence of uterine scarring (due to a previous C-section) and the induction of labor or programmed C-section for unspecified obstetric reasons. On the other hand, higher rates of hemorrhagic events, hypertensive disorders and thrombotic events were observed in the C-section group (p < 0.001 for all three outcomes), as well as for ICU admission. These findings suggest that this type of delivery was associated with the mother's clinical conditions that required a rapid and early termination of pregnancy.
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16
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Chaudhuri S, Giri DK, Mondal A, Rani R, Janani V, Mundle M. Comparison of Fetomaternal Outcome Between Planned Vaginal Delivery and Planned Cesarean Section in Women with Eclampsia: Observational Study. J Obstet Gynaecol India 2021; 71:369-378. [PMID: 34566295 DOI: 10.1007/s13224-021-01432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objective The route of termination of pregnancy in eclampsia is not clearly established. This study aims to compare the fetomaternal outcome between planned vaginal delivery and planned cesarean section in women with eclampsia after 34 weeks of gestation. Methods This prospective observational study was conducted in the department of Obstetrics and Gynecology, Midnapore Medical College, West Bengal, India. 182 women with eclampsia carrying 34 weeks or more gestation were allocated to either cesarean(CD) or vaginal delivery (VD) group. The primary measure of outcome was severe maternal outcome. Secondary measures of outcome were perinatal mortality and morbidity. Results Of the 62 women allocated in vaginal delivery (VD) group, 60 women (32.97%) had vaginal delivery and 122 (67.03%) had undergone cesarean delivery (CD). Severe maternal outcome was more common in VD group in comparison with CD group (72.5% vs 27.5%, P < 0.00001 RR 2.64 OR 6.98). Perinatal outcome in relation to Apgar score at 5 min, still birth was better in CD group than VD group. Perinatal death was higher in VD group when compared with CD group (25.8%; vs. 8.33%; P = 0.002, RR 3.1 OR 3.83). Conclusion There is increasing trend of delivering the eclampsia mother at > 34 weeks of gestation by cesarean section instead of inducing labor and delivering vaginally. Cesarean section when chosen as method of delivery does not increase morbidity or mortality.
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Affiliation(s)
- Snehamay Chaudhuri
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal India
| | - Dipak Kumar Giri
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal India
| | - Arpita Mondal
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal India.,Barasat District Hospital, Barasat, West Bengal India
| | - Rashmi Rani
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal India
| | - Vaitheeswari Janani
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal India
| | - Malay Mundle
- Department of Community Medicine IIIMSAR, Haldia, West Bengal India
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17
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Levin G, Tsur A, Tenenbaum L, Mor N, Zamir M, Meyer R. Prediction of vaginal birth after cesarean for labor dystocia by sonographic estimated fetal weight. Int J Gynaecol Obstet 2021; 158:50-56. [PMID: 34561870 DOI: 10.1002/ijgo.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/10/2021] [Accepted: 09/23/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To estimate the association of the weight difference between the index trial of labor after cesarean (TOLAC) sonographic estimated fetal weight (sEFW) and prior delivery birth weight with TOLAC success rate among women with previous labor dystocia and no prior vaginal delivery. METHODS A retrospective cohort study including all women with prior cesarean for labor dystocia and no prior vaginal delivery undergoing TOLAC during between March 2011 and June 2020 with a sEFW within 1 week from delivery. RESULTS Overall, 168 women were included, of those 107 (63.7%) successfully delivered vaginally. The mean sEFW and mean birth weight were lower in the TOLAC success group (P = 0.010 and P = 0.013, respectively). The rate of higher sEFW in the current delivery compared with the previous delivery did not differ between study groups. The rate of higher TOLAC birth weight was lower in the TOLAC success group (odds ratio 0.30; 95% confidence interval 0.15-0.58). In multivariable regression analysis, maternal age older than 30 years, induction of labor, and higher birth weight were independently negatively associated with TOLAC success (adjusted odds ratio [95% confidence interval]: 0.27 [0.10-0.70], 0.27 [0.08-0.90], and 0.43 [0.19-0.94]; P = 0.008, P = 0.034, and P = 0.035, respectively). CONCLUSIONS sEFW characteristics did not predict the success or failure of TOLAC among women with prior labor dystocia and no previous vaginal delivery.
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Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Abraham Tsur
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lee Tenenbaum
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nizan Mor
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Zamir
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Sheba Talpiot Medical Leadership Program, Sheba Medical Center Hospital, Ramat-Gan, Israel
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18
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Quibel T, Rozenberg P, Bouyer C, Bouyer J. Variation between hospital caesarean delivery rates when Robson's classification is considered: An observational study from a French perinatal network. PLoS One 2021; 16:e0251141. [PMID: 34415907 PMCID: PMC8378683 DOI: 10.1371/journal.pone.0251141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION WHO has recommended using Robson's Ten Group Classification System (TGCS) to monitor and analyze CD rates. Its failure to take some maternal and organizational factors into account, however, could limit the interpretation of CD rate comparisons, because it may contribute to variations in hospital CD rates. OBJECTIVE To study the contribution of maternal socioeconomic and clinical characteristics and hospital organizational factors to the variation in CD rates when using Robson's ten-group classification system for CD rate comparisons. METHODS This prospective, observational, population-based study included all deliveries at a gestational age > 24 weeks at the 10 hospitals of the French MYPA perinatal network in the Paris area. CD rates were calculated for each TGCS group in each hospital. Interhospital variations in these rates were investigated with hierarchical logistic regression models to quantify the variation explained by differences in patient and hospital characteristics when the TGCS is considered. Variations in CD rates between hospitals were estimated with median odds ratios (MOR) to express interhospital variance on the standard odds ratio scale. The percentage of variation explained by TGCS and maternal and hospital characteristics was also calculated. RESULTS The global CD rate was 24.0% (interhospital range: 17-32%). CD rates within each TGCS group differed significantly between hospitals (P<0.001). CD was significantly associated with maternal age (>40 years), severe preeclampsia, and two organizational factors: hospital status (private maternities) and the deliveries per staff member per 24 hours. The MOR in the empty model was 1.27 and did not change after taking the TGCS into account. Adding maternal characteristics and hospital organizational factors lowered the MOR to 1.14 and reduced the variation between hospital CD rates by 70%. CONCLUSION Maternal characteristics and hospital factors are needed to address variation in CD rates among the TGCS groups. Therefore, comparisons of these rates that do not consider these factors should be interpreted carefully.
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Affiliation(s)
- Thibaud Quibel
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Patrick Rozenberg
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Camille Bouyer
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- Réseau de Périnatalité Maternité en Yvelines et Périnatalité Active (MYPA), Saint-Germain-en-Laye, France
| | - Jean Bouyer
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
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19
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Mascarello KC, Matijasevich A, Barros AJDD, Barros FCLFD, Santos IDSD, Labrecque JA, Silveira MF. Analysis of early and late maternal complications associated with delivery using propensity score. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2021; 24:e210027. [PMID: 34076146 DOI: 10.1590/1980-549720210027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze early and late maternal complications associated with the mode of delivery in a birth cohort in Brazil, using the propensity score technique for analysis. METHODS This is a prospective cohort study, using data from the Pelotas Birth Cohort, RS, 2004. A total of 4,189 women were included and a descriptive analysis of the data and subsequent calculation of the propensity and pairing score of vaginal delivery women and cesarean delivery women with similar scores (1,366 pairs). We then assessed the difference in outcome risk between the groups. RESULTS Women in the cesarean group had 2.9 percentage points (pp) more risk of postpartum infection, 1.13 p.p. more risk of urinary infection, 1.10 p.p. more risk of anesthetic complications and 1.24 p.p. higher risk of headache compared to vaginal delivery, but less risk of anemia (-2.43 pp) and hemorrhoids (-1.24 p.p.). The use of propensity scores is extremely useful for reducing bias and increasing accuracy in observational studies when experimental studies cannot be performed. CONCLUSION Cesarean sections have been associated with a higher prevalence of postpartum and urinary tract infections, anesthetic complications and headache and lower prevalence of anemia and hemorrhoids, so they should be performed with clear indications and when their benefits outweigh potential risks.
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Affiliation(s)
| | - Alicia Matijasevich
- Epidemiological Research Center, Post-Graduation Program in Epidemiology, Universidade Federal de Pelotas - Pelotas (RS), Brazil.,Department of Preventive Medicine, School of Medicine, Universidade de São Paulo - São Paulo (SP), Brazil
| | | | | | - Iná da Silva Dos Santos
- Epidemiological Research Center, Post-Graduation Program in Epidemiology, Universidade Federal de Pelotas - Pelotas (RS), Brazil.,Post-Graduation Program in Pediatrics and Child Heallth, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | | | - Mariângela Freitas Silveira
- Epidemiological Research Center, Post-Graduation Program in Epidemiology, Universidade Federal de Pelotas - Pelotas (RS), Brazil
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Diniz CSG, Franzon ACA, Fioretti-Foschi B, Niy DY, Pedrilio LS, Amaro E, Sato JR. Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e25016. [PMID: 33945496 PMCID: PMC8143871 DOI: 10.2196/25016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/27/2021] [Accepted: 02/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable. OBJECTIVE This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic. METHODS A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included. RESULTS The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020. CONCLUSIONS This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic. TRIAL REGISTRATION The Brazilian Clinical Trials Registry U1111-1255-8683; http://www.ensaiosclinicos.gov.br/rg/RBR-3g5f9f/. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25016.
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Affiliation(s)
- Carmen Simone Grilo Diniz
- School of Public Health, University of Sao Paulo, Sao Paulo, Brazil
- Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Ana Carolina Arruda Franzon
- Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Gender and Evidence on Maternity and Health Study Group, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil
| | - Beatriz Fioretti-Foschi
- Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Gender and Evidence on Maternity and Health Study Group, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil
| | - Denise Yoshie Niy
- Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Gender and Evidence on Maternity and Health Study Group, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Edson Amaro
- Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Big Data, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - João Ricardo Sato
- Big Data, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Center of Mathematics, Computing and Cognition, Universidade Federal do ABC, Sao Bernardo do Campo, Brazil
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21
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Ferreira Júnior AR, Brandão LCDS, Teixeira ACDMF, Cardoso AMR. Potencialidades e limitações da atuação do enfermeiro no Centro Parto Normal. ESCOLA ANNA NERY 2021. [DOI: 10.1590/2177-9465-ean-2020-0080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo Conhecer as potencialidades e limitações da atuação do enfermeiro no Centro de Parto Normal (CPN). Método abordagem qualitativa, do tipo exploratório e descritivo, realizado em 2018, com seis enfermeiras atuantes em CPN intra-hospitalar público na região metropolitana de Fortaleza, Ceará, Brasil. A coleta das informações ocorreu por meio de entrevista individual, com análise a partir dos pressupostos da sociologia das profissões, com foco nos temas: conhecimento e autonomia; credencialismo; divisão do trabalho; mercado de trabalho e quadro de valores. Resultado A atuação do enfermeiro no CPN potencializa as boas práticas para o parto e nascimento, bem como amplia a importância e visibilidade deste profissional no cuidado materno-infantil. O cuidado clínico e a gestão emergem como foco da ação do enfermeiro no CPN. No entanto, mesmo com a indução do Estado para essa atuação, ainda há a necessidade de reconhecimento das competências e autonomia do enfermeiro no cuidado obstétrico por outros profissionais. Conclusão e implicações para a prática Há desafios que precisam ser superados como a ampliação da autonomia e do respeito ao credenciamento do enfermeiro para atuação no CPN e a harmonização entre a gestão do processo de trabalho e gestão do cuidado clínico por este profissional.
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22
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Menezes MO, Takemoto MLS, Nakamura‐Pereira M, Katz L, Amorim MMR, Salgado HO, Melo A, Diniz CSG, de Sousa LAR, Magalhaes CG, Knobel R, Andreucci CB. Risk factors for adverse outcomes among pregnant and postpartum women with acute respiratory distress syndrome due to COVID-19 in Brazil. Int J Gynaecol Obstet 2020; 151:415-423. [PMID: 33011966 PMCID: PMC9087686 DOI: 10.1002/ijgo.13407] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/04/2020] [Accepted: 09/29/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate whether clinical and social risk factors are associated with negative outcomes for COVID-19 disease among Brazilian pregnant and postpartum women. METHODS A secondary analysis was conducted of the official Acute Respiratory Syndrome Surveillance System database. Pregnant and postpartum women diagnosed with COVID-19 ARDS until July 14, 2020, were included. Adverse outcomes were a composite endpoint of either death, admission to the intensive care unit (ICU), or mechanical ventilation. Risk factors were examined by multiple logistic regression. RESULTS There were 2475 cases of COVID-19 ARDS. Among them, 23.8% of women had the composite endpoint and 8.2% died. Of those who died, 5.9% were not hospitalized, 39.7% were not admitted to the ICU, 42.6% did not receive mechanical ventilation, and 25.5% did not have access to respiratory support. Multivariate analysis showed that postpartum period, age over 35 years, obesity, diabetes, black ethnicity, living in a peri-urban area, no access to Family Health Strategy, or living more than 100 km from the notification hospital were associated with an increased risk of adverse outcomes. CONCLUSION Clinical and social risk factors and barriers to access health care are associated with adverse outcomes among maternal cases of COVID-19 ARDS in Brazil.
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Affiliation(s)
| | | | - Marcos Nakamura‐Pereira
- Instituto Nacional de Saúde da Mulherda Criança e do Adolescente Fernandes FigueiraFundação Oswaldo CruzRio de JaneiroRJBrazil
| | - Leila Katz
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)RecifePEBrazil
| | | | - Heloisa O. Salgado
- Departamento de Medicina SocialFaculdade de Medicina de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrazil
| | - Adriana Melo
- Universidade Federal de Campina Grande (UFCG)Campina GrandePBBrazil
| | - Carmen S. G. Diniz
- Department of HealthLife Cycles and SocietySchool of Public HealthUniversity of São Paulo (USP)São PauloSPBrazil
| | | | | | - Roxana Knobel
- Department of Gynecology and ObstetricsUniversidade Federal de Santa Catarina (UFSC)FlorianópolisSCBrazil
| | - Carla B. Andreucci
- Department of MedicineUniversidade Federal de São Carlos (UFSCAR)São CarlosSPBrazil
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Wardhana MP, Gumilar KE, Rahmadhany P, Rosita Dewi E, Laksana MAC. INA-CBGs claim versus total hospital cost: A vaginal delivery investigation at Airlangga University Academic Hospital, Indonesia. J Public Health Res 2020; 9:1999. [PMID: 33409246 PMCID: PMC7771029 DOI: 10.4081/jphr.2020.1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Inadequate funding for vaginal delivery can be one of the barriers to reducing the maternal mortality rate. It could be therefore critical to compare the vaginal delivery cost between total hospital cost and INA-CBGs cost in national health insurance. Methods: This was a retrospective cross-sectional study conducted from October to December 2019 in Universitas Airlangga Academic Hospital. It collected data on primary diagnosis, length of stay, total hospital cost, INA-CBGs cost, and counted disparity. The data analyzed statistically using t-test independent sample (or Mann-Whitney test). Results: A total of 149 vaginal delivery claims were found, with the majority having a level II severity (79.87%) and moderate preeclampsia as a primary diagnosis (20.1%). There was a significant disparity in higher total hospital costs compared with government INA-CBGs costs (Rp. 9,238,022.09±1,265,801.88 vs 1,881,521.48±12,830.15; p<0.001). There was also an increase of LOS (p<0.001), total hospital cost (p<0.001), and cost disparity (p<0.01) in a higher severity level of vaginal delivery. Conclusion: Vaginal delivery costs in INA-CBGs scheme are underneath the actuarial value. There was also an increase in total hospital costs and a more significant disparity in the higher severity levels of vaginal delivery.
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Affiliation(s)
- Manggala Pasca Wardhana
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Airlangga, Soetomo Teaching Hospital, Surabaya.,Department of Obstetrics and Gynaecology, Universitas Airlangga Academic Hospital, Surabaya
| | - Khanisyah Erza Gumilar
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Airlangga, Soetomo Teaching Hospital, Surabaya.,Department of Obstetrics and Gynaecology, Universitas Airlangga Academic Hospital, Surabaya
| | - Prima Rahmadhany
- Department of Obstetrics and Gynaecology, Universitas Airlangga Academic Hospital, Surabaya
| | - Erni Rosita Dewi
- School of Midwifery, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Muhammad Ardian Cahya Laksana
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Airlangga, Soetomo Teaching Hospital, Surabaya.,Department of Obstetrics and Gynaecology, Universitas Airlangga Academic Hospital, Surabaya
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24
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Sk R. Does delivery in private hospitals contribute largely to Caesarean Section births? A path analysis using generalised structural equation modelling. PLoS One 2020; 15:e0239649. [PMID: 33031397 PMCID: PMC7544137 DOI: 10.1371/journal.pone.0239649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/11/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The rate of Caesarean Section (CS) deliveries has shown an alarming rise in recent years. CS is a surgical procedure used when there is apprehension of risk to the life of mother or baby in case of vaginal delivery, but its rates higher than 10-15 per cent are not justifiable. It is well recognised that a CS delivery could have a large number of adverse impacts on women and infants. Several studies, especially in developing countries, have revealed that delivery in private hospitals is one of the most contributing factors in CS deliveries. The present study conceptualises a causal pathway in which the possible risk factors, socio-economic, maternal and pregnancy-related, as well as institutional, influence the chances of CS delivery. It is hypothesised that certain factors would contribute to CS deliveries largely indirectly through the place of delivery, that is, either a public or private institution. METHODS AND FINDINGS To test the hypotheses, this study analysed 146,280 most recent live births delivered in hospitals during the five years preceding the fourth round of India's National Family Health Survey (NFHS-4), carried out during 2015-2016. The analysis, using generalised structural equation modelling (GSEM), revealed that many exogenous variables considered in the path models influence CS deliveries significantly, directly and/or indirectly through the place of delivery factor. Prominent among these are wealth index and receiving ANC services at only private hospitals; the total effects of these variables are even higher than the direct/total effect of place of delivery. CONCLUSION From this finding, it could be said that the place of delivery is a proximate determinant of a CS delivery or a mediator of other co-factors. Interventions to curb higher CS deliveries should be focused on improving the quality of public health sectors and on developing protocols for CS deliveries.
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Affiliation(s)
- Rayhan Sk
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
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25
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Geleto A, Chojenta C, Taddele T, Loxton D. Association between maternal mortality and caesarean section in Ethiopia: a national cross-sectional study. BMC Pregnancy Childbirth 2020; 20:588. [PMID: 33023536 PMCID: PMC7539527 DOI: 10.1186/s12884-020-03276-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/21/2020] [Indexed: 03/30/2024] Open
Abstract
BACKGROUND Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. METHODS Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson's correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05. RESULTS The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant. CONCLUSIONS At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.
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Affiliation(s)
- Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia.
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
| | - Tefera Taddele
- Health System and Reproductive Health Directorate, the Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
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Takemoto M, Menezes MO, Andreucci CB, Knobel R, Sousa L, Katz L, Fonseca EB, Nakamura-Pereira M, Magalhães CG, Diniz C, Melo A, Amorim M. Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis. BJOG 2020; 127:1618-1626. [PMID: 32799381 PMCID: PMC7461482 DOI: 10.1111/1471-0528.16470] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/22/2022]
Abstract
Objective To describe clinical characteristics of pregnant and postpartum women with severe COVID‐19 in Brazil and to examine risk factors for mortality. Design Cross‐sectional study based on secondary surveillance database analysis. Setting Nationwide Brazil. Population or sample 978 Brazilian pregnant and postpartum women notified as COVID‐19 Acute Respiratory Distress Syndrome (ARDS) cases with complete outcome (death or cure) up to 18 June 2020. Methods Data was abstracted from the Brazilian ARDS Surveillance System (ARDS‐SS) database. All eligible cases were included. Data on demographics, clinical characteristics, intensive care resources use and outcomes were collected. Risk factors for mortality were examined by multivariate logistic regression. Main outcome measures Case fatality rate. Results We identified 124 maternal deaths, corresponding to a case fatality rate among COVID‐19 ARDS cases in the obstetric population of 12.7%. At least one comorbidity was present in 48.4% of fatal cases compared with 24.9% in survival cases. Among women who died, 58.9% were admitted to ICU, 53.2% had invasive ventilation and 29.0% had no respiratory support. The multivariate logistic regression showed that the main risk factors for maternal death by COVID‐19 were being postpartum at onset of ARDS, obesity, diabetes and cardiovascular disease, whereas white ethnicity had a protective effect. Conclusions Negative outcomes of COVID‐19 in this population are affected by clinical characteristics but social determinants of health also seem to play a role. It is urgent to reinforce containment measures targeting the obstetric population and ensure high quality care throughout pregnancy and the postpartum period. Tweetable abstract A total of 124 COVID‐19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors. A total of 124 COVID‐19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.
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Affiliation(s)
- Mls Takemoto
- Programa de Pós-graduação em Tocoginecologia, Medical School of Botucatu, São Paulo State University (UNESP), Botucatu, Brazil
| | - M O Menezes
- Programa de Pós-graduação em Tocoginecologia, Medical School of Botucatu, São Paulo State University (UNESP), Botucatu, Brazil
| | - C B Andreucci
- Department of Medicine, Universidade Federal de São Carlos (UFSCAR), São Carlos, Brazil
| | - R Knobel
- Department of Gynecology and Obstetrics, Universidade Federal de Santa Catarina (UFSC), Florianópolis, Brazil
| | - L Sousa
- Programa de Pós-Graduação Profissional em Saúde da Mulher e da Criança, Universidade Federal do Ceará (UFC), Fortaleza, Brazil
| | - L Katz
- Programa de Pós-graduação em Saúde Materno Infantil do IMIP, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Brazil
| | - E B Fonseca
- Division of Obstetrics and Gynecology, Universidade Federal da Paraíba, João Pessoa, Brazil
| | - M Nakamura-Pereira
- Fundação Oswaldo Cruz, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Rio de Janeiro, Brazil
| | - C G Magalhães
- Department of Gynecology and Obstetrics, Medical School of Botucatu, São Paulo State University (UNESP), Botucatu, Brazil
| | - Csg Diniz
- Department of Health, Life Cycles and Society, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Aso Melo
- Departamento de Saúde da Mulher, Instituto de Pesquisa Professor Joaquim Amorim Neto, IPESQ, Campina Grande, Brazil
| | - Mmr Amorim
- Programa de Pós-graduação em Saúde Materno Infantil do IMIP, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Brazil
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Leal NP, Versiani MH, Leal MDC, Santos YRP. Social practices of labor and birth in Brazil: the speech of puerperal women. CIENCIA & SAUDE COLETIVA 2020; 26:941-950. [PMID: 33729349 DOI: 10.1590/1413-81232021263.13662020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/11/2020] [Indexed: 11/22/2022] Open
Abstract
The article analyzes the opinions of a group of women regarding the standard of care at maternity facilities attached to the Ministry of Health's Programa Rede Cegonha or Stork Network Program. The women's views were obtained from a questionnaire administered to 10,665 puerperal women between 2016 and 2017 as part of the survey Evaluation of good labor and childbirth care practices in maternity facilities covered by the Rede Cegonha, conducted by the Oswaldo Cruz Foundation and Maranhão Federal University. Consisting mainly of closed-ended questions, the questionnaire contained an optional open-ended question at the end that allowed women to talk freely about the standard of care received in the maternity facility. Of the 10,665 puerperal women interviewed, 2,069 gave their opinions. We undertook a critical reading of the opinions identifying four core themes, which were discussed in the light of the relevant literature: puerperal woman/health team relationship; puerperal women's right to information; presence of a companion; and quality of hospital services and facilities. Giving both praise and criticism, all the women reiterated the importance of improving the quality of public health services to ensure the humanization of childbirth in Brazil.
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Affiliation(s)
- Neide Pires Leal
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | - Yammê Ramos Portella Santos
- Escola Nacional de Saúde Pública, Fiocruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
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Balayla J, Lasry A, Badeghiesh A, Volodarsky-Perel A, Gil Y. Mode of delivery is an independent risk factor for maternal mortality: a case-control study. J Matern Fetal Neonatal Med 2020; 35:1962-1968. [PMID: 32498579 DOI: 10.1080/14767058.2020.1774874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background and Objectives: In contrast to the global trend, the maternal mortality ratio (MMR) in the United States has increased in recent decades. During this time, the cesarean section rate has concurrently and steadily increased. Herein, we sought to determine whether the mode of delivery is an independent risk factor for maternal in-hospital mortality.Materials and Methods: We conducted a retrospective, population-based, 1:1 matched, case-control study on all births recorded in the Health - Care Cost and Utilization Project - Nationwide Inpatient Sample between 2005 and 2014. We compared cases of maternal mortality and survival on a number of clinical characteristics. We conducted two different multivariate logistic regression analysis models, obtaining the adjusted odds ratios to determine the independent effect of mode of delivery on maternal mortality relative to surviving controls.Results: We found a total of 617 cases of maternal mortality, which corresponds to an in-hospital MMR of 6.9/100,000 in our cohort. We matched 617 controls to mortality cases by year and geographic location. Relative to surviving controls, cases of maternal mortality were older, more likely to be African American, of lesser income, more likely to use Medicaid as payment, to have prolonged admissions, and more likely to have severe obstetrical complications including preterm delivery, postpartum hemorrhage, eclampsia, peripartum cardiomyopathy, pulmonary emboli, and disseminated intravascular coagulation (DIC). Relative to unassisted vaginal delivery, adjusted logistic regression analysis reveals no excess mortality observed with assisted vaginal delivery: OR 1.35, 95% CI [0.59-3.51]. However, after adjusting for demographic and obstetrical confounders, a significant risk of maternal mortality was observed with cesarean delivery: OR 3.21, 95% CI [2.80-3.61], p-value = .0001. This risk was more pronounced amongst primary cesarean deliveries: OR 5.72, 95% CI [4.92-6.51], p-value = .0001.Conclusion: Cesarean delivery, and particularly primary cesarean delivery, is an independent risk factor for maternal in-hospital mortality. Measures taken to reduce the cesarean section rate may impact the rising maternal mortality ratio (MMR) in the United States.
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Affiliation(s)
- Jacques Balayla
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Ariane Lasry
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Alexander Volodarsky-Perel
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada.,Lady Davis Research Institute, Jewish General Hospital, Montreal, Canada
| | - Yaron Gil
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
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Sirgant D, Rességuier N, d'Ercole C, Auquier P, Tosello B, Blanc J. Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery. J Gynecol Obstet Hum Reprod 2020; 49:101764. [PMID: 32335351 DOI: 10.1016/j.jogoh.2020.101764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks). MATERIAL AND METHODS We performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death). RESULTS Among the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78-0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20-0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25-5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age < 28 weeks and SMM (aOR, 1.80; 95 % CI, 0.99-3.27, p = 0.05). CONCLUSION Lower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.
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Affiliation(s)
- Delphine Sirgant
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France
| | - Noémie Rességuier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Claude d'Ercole
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Pascal Auquier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Barthélémy Tosello
- Department of Neonatology, North Hospital, Assistance Publique des Hôpitaux de Marseille, France; Aix-Marseille Univ, CNRS, EFS, ADES, Marseille, France
| | - Julie Blanc
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France.
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Rudey EL, Leal MDC, Rego G. Cesarean section rates in Brazil: Trend analysis using the Robson classification system. Medicine (Baltimore) 2020; 99:e19880. [PMID: 32332659 PMCID: PMC7220553 DOI: 10.1097/md.0000000000019880] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/26/2022] Open
Abstract
Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it.Data were collected from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification.A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth.Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually.We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.
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da Silva Gama ZA, Medeiros WR, Saturno-Hernández PJ, de Meneses Sousa K, Mello MS, de Lima Vale É, de Souza Rosendo TMS, da Silva EMM, de Freitas MR. The WHO Safe Childbirth Checklist implementation: impact on the prescription of magnesium sulphate through a one-year longitudinal study. BMC Pregnancy Childbirth 2020; 20:154. [PMID: 32164643 PMCID: PMC7068955 DOI: 10.1186/s12884-020-2836-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preeclampsia is a relatively frequent condition during pregnancy and childbirth. The administration of magnesium sulphate as a prophylactic and treatment measure is an evidence-based practice for eclampsia; however, it is not consistently used, compromising the health of pregnant women. This study aimed to assess compliance with recommendations of the International Society for the Study of Hypertension in Pregnancy (ISSHP) for the use of MgSO4 in pregnant women with preeclampsia, before and after the implementation of the World Health Organization Safe Childbirth Checklist (SCC). METHODS This quasi-experimental study was conducted between July 2015 and July 2016 at a third-level maternity hospital in northeastern Brazil, where the SCC was implemented. Compliance (underuse and overuse of MgSO4) was assessed in biweekly samples of 30 deliveries assessed 6 months before and 6 months after SCC implementation, using indicators based on international guidelines. A total of 720 deliveries were assessed over 1 year using an ad hoc application for reviewing medical records. Aggregated adequate use was estimated for the study period, and the time series measurements were compared to a control chart to assess change. RESULTS The incidence of preeclampsia was 39.9% (287/720). Among these, 64.8% (186/287) had severe signs or symptoms and needed MgSO4. Underuse (no prescription when needed) of MgSO4 was observed in 74.7% (139/186) of women who needed the drug. Considering all women, non-compliance with the prescription protocol (underuse and overuse) was 20.0% (144/720). After introducing the SCC, the use of MgSO4 in women with preeclampsia with severe features increased from 19.1 to 34.2% (p = 0.025). Longitudinal analysis showed a significant (p < 0.05) ascending curve of adequate use of MgSO4 after the SCC was implemented. CONCLUSIONS Compliance with recommendations for the use of MgSO4 in preeclampsia was low, but improved after implementation of the SCC. Interventions to improve compliance based on diagnosis and treatment reminders may help in the implementation of this good practice.
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Affiliation(s)
| | | | - Pedro Jesus Saturno-Hernández
- National Institute of Public Health of Mexico (INSP), Avenida Universidad No. 655, Colonia Santa María Ahuacatitlán, C.P, 62100, Cuernavaca, Mor, Mexico.
| | | | - Matheus Silva Mello
- Course of Medicine, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Érico de Lima Vale
- Maternity School Januario Cicco, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | | | - Marise Reis de Freitas
- Infectious Diseases Department, Federal University of Rio Grande do Norte, Natal, Brazil
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Geleto A, Chojenta C, Taddele T, Loxton D. Magnitude and determinants of obstetric case fatality rate among women with the direct causes of maternal deaths in Ethiopia: a national cross sectional study. BMC Pregnancy Childbirth 2020; 20:130. [PMID: 32106814 PMCID: PMC7045465 DOI: 10.1186/s12884-020-2830-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/20/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, maternal death due to direct obstetric complications remains an important health threat for women. A high direct obstetric case fatality rate indicates a poor quality of obstetric care. Therefore, this study was aimed at assessing the magnitude and determinants of the direct obstetric case fatality rate among women admitted to hospitals with direct maternal complications. METHODS In 2015, the Ethiopian Public Health Institute conducted a national survey about emergency obstetric and newborn care in which data about maternal and neonatal health indicators were collected. Maternal health data from these large national dataset were analysed to address the objective of this study. Descriptive statistics were used to present hospital specific characteristics and the magnitude of direct obstetric case fatality rate. Logistic regression analysis was performed to examine determinants of the magnitude of direct obstetric case fatality rate and the degree of association was measured using an adjusted odds ratio with 95% confidence interval at p < 0.05. RESULTS Overall, 335,054 deliveries were conducted at hospitals and 68,002 (20.3%) of these women experienced direct obstetric complications. Prolonged labour (23.4%) and hypertensive disorders (11.6%) were the two leading causes of obstetric complications. Among women who experienced direct obstetric complications, 435 died, resulting in the crude direct obstetric case fatality rate of 0.64% (95% CI: 0.58-0.70%). Hypertensive disorders (27.8%) and maternal haemorrhage (23.9%) were the two leading causes of maternal deaths. The direct obstetric case fatality rate varied considerably with the complications that occurred; highest in postpartum haemorrhage (2.88%) followed by ruptured uterus (2.71%). Considerable regional variations observed in the direct obstetric case fatality rate; ranged from 0.27% (95% CI: 0.20-0.37%) at Addis Ababa city to 3.82% (95% CI: 1.42-8.13%) at the Gambella region. Type of hospitals, managing authority and payment required for the service were significantly associated with the magnitude of direct obstetric case fatality rate. CONCLUSIONS The high direct obstetric case fatality rate is an indication for poor quality of obstetric care. Considerable regional differences occurred with regard to the direct obstetric case fatality rate. Interventions should focus on quality improvement initiatives and equitable resource distribution to tackle the regional disparities.
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Affiliation(s)
- Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia. .,Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia.
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
| | - Tefera Taddele
- Health System and Reproductive Health Directorate, the Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
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Zaiden L, Nakamura-Pereira M, Gomes MAM, Esteves-Pereira AP, Leal MDC. Influence of hospital characteristics on the performance of elective cesareans in Southeast Brazil. CAD SAUDE PUBLICA 2020; 36:e00218218. [PMID: 31939550 DOI: 10.1590/0102-311x00218218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 07/08/2019] [Indexed: 11/22/2022] Open
Abstract
This article aims to assess the influence of hospital characteristics on the odds of performing an elective cesarean in the Southeast region of Brazil. Data were obtained from the Birth in Brazil study, conducted from February 2011 to October 2012. The current analysis includes the sample from Southeast Brazil, with 10,155 women. The group of women that underwent elective cesareans was compared to the women who went into labor or underwent labor induction, regardless they had intrapartum cesarean or vaginal delivery. Except for gestational age, all the obstetric characteristics analyzed were associated with elective cesarean. In this group, 60.5% had no prior cesarean and 64.7% had low-risk gestations. Among the births with public financing, there were higher odds of elective cesareans in women treated at hospitals with < 1,500 births/year (OR = 2.11; 95%CI: 1.37-3.26) and 1,500-2,999 births/year (OR = 1.45; 95%CI: 1.04-2.02) and in mixed hospitals (OR = 1.81; 95%CI: 1.37-2.39). In the mixed hospitals, the association was stronger when located in non-capital cities with > 3,000 births/year (OR = 3.45; 95%CI: 1.68-7.08), reaching the highest level in hospitals in non-capital cities with < 3,000 births/year (OR = 4.08; 95%CI: 2.61-6.37). Meanwhile, no association was seen between elective cesarean and public hospitals located in non-capital cities of the Southeast region. Prevalence rates of elective cesareans in public hospitals in Southeast Brazil are high when compared to other countries, and they are heavily influenced by hospital characteristics.
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Affiliation(s)
- Laura Zaiden
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.,Faculdade de Medicina de Petrópolis, Petrópolis, Brasil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Maria Auxiliadora Mendes Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Agegnehu AF, Gebregzi AH, Endalew NS. Review of evidences for management of rapid sequence spinal anesthesia for category one cesarean section, in resource limiting setting. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020; 26:101-105. [PMID: 34568612 PMCID: PMC7470710 DOI: 10.1016/j.ijso.2020.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Globally obstetric anesthesia is being done under spinal and epidural than general anesthesia (GA) for most caesarean sections (CSs). This is because GA is associated with failed endotracheal intubation and aspiration of gastric contents. Eventhough general anesthesia is the fastest method for anesthetizing a category 1 cesarean section, it is associated with increased maternal mortality and morbidity. Spinal anesthesia is the preferred regional technique for cesarean section but failure sometimes occurs. To minimize the time factor of spinal anesthesia as well as to avoid the side effects of general anesthesia 'rapid sequence spinal '(RSS) has developed as a novel approach in cases of category one cesarean sections. METHODS The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Search engines like PubMed through HINARI, Cochrane database and Google Scholars were used to find high-level evidences that help to draw appropriate conclusions. DISCUSSION Neuraxial anesthetic techniques have several advantages which include low risk of aspiration and failed intubation, avoidance of central nervous system (CNS) and respiratory depressant drugs, the ability to maintain a wakeful state of mother enjoying the experience of delivery of baby and also lower incidence of blood loss. 'Rapid sequence spinal' described to minimize anesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anesthesia if there are delays or problems. To do rapid sequence spinal anesthesia safely and timely, cooperative work is mandatory with good team relation for those simultaneous and necessary tasks. CONCLUSION The choice of anesthetic in Cesarean section has long been recognized as one of prime importance, because there are two lives to safeguard instead of one. A balance must be struck between the anesthetic dictated by the general condition of the mother and that suited to the needs of the fetal respiratory system.
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Affiliation(s)
- Abatneh Feleke Agegnehu
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Hailekiros Gebregzi
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nigussie Simeneh Endalew
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Levin G, Elami-Suzin M, Elchalal U, Ezra Y, Mankuta D, Lewkowicz A, Yagel S, Rottenstreich A. Subsequent Pregnancy Outcomes After Failed Vacuum-Assisted Delivery. Obstet Gynecol 2019; 134:1245-1251. [PMID: 31764735 DOI: 10.1097/aog.0000000000003527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery. METHODS We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital. RESULTS Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC. CONCLUSION Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.
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Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Small KA, Sidebotham M, Fenwick J, Gamble J. Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women Birth 2019; 33:411-418. [PMID: 31668871 DOI: 10.1016/j.wombi.2019.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 12/19/2022]
Abstract
PROBLEM Caesarean section rates have risen in high-income countries. One of the potential drivers for this is the widespread use of CTG monitoring. BACKGROUND Intrapartum cardiotocograph monitoring is considered to be indicated for women at risk for poor perinatal outcome. AIM This systematic literature review with meta-analysis examined randomised controlled trials and non-experimental research to determine whether cardiotocograph monitoring rather than intermittent auscultation during labour was associated with changes in perinatal mortality or cerebral palsy rates for high-risk women. METHODS A systematic search for research published up to 2019 was conducted using PubMed, CINAHL, Cochrane, and Web of Science databases. Non-experimental and randomised controlled trial research in populations of women at risk which compared intrapartum cardiotocography with intermittent auscultation and reported on stillbirth, neonatal mortality, perinatal mortality and/or cerebral palsy were included. Relative risks were calculated from extracted data, and meta-analysis of randomised controlled trials was undertaken. FINDINGS Nine randomised controlled trials and 26 non-experimental studies were included. Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates. The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy. DISCUSSION Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome. CONCLUSION There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits.
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Affiliation(s)
- Kirsten A Small
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Mary Sidebotham
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Jennifer Fenwick
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Jenny Gamble
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
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Silva TPRD, Carmo ASD, Novaes TG, Mendes LL, Moreira AD, Pessoa MC, Cosenza L, Pereira JFC, Matozinhos FP. Hospital-acquired conditions and length of stay in the pregnancy and puerperal cycle. Rev Saude Publica 2019; 53:64. [PMID: 31432929 PMCID: PMC6705548 DOI: 10.11606/s1518-8787.2019053000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyze the impact of the Hospital-Acquired Conditions (HAC) in women in the puerperal and pregnancy cycle during length of stay. METHODS This cross-sectional study was conducted with 113,456 women, between July 2012 and July 2017, in Brazil's national hospitals of the supplementary healthcare networks and philanthropists accredited to the Unified Health System (SUS). Data on hospital discharges were collected using the Diagnosis-Related Groups (DRG Brasil®) system. All DRGs of the major diagnostic category 14 (MDC14), including pregnancy, childbirth and puerperium, were included. The impact of HAC on length of stay was estimated by Student's t-test, and the effect size by Cohen's d, which allows to assess clinical relevance. RESULTS The most prevalent diagnostic categories related to MDC14 were vaginal and cesarean deliveries without complicating diagnoses, both at institutions accredited to SUS and those for supplementary health care. The prevalence of HAC was 3.8% in supplementary health and 2.5% in SUS. Hospitals providing services to supplementary health care providers had a longer length of stay considering HAC for patients classified as DRG: cesarean section with complications or comorbidities at admission (p < 0.001; Cohen's d = 0.74), cesarean section without complications or comorbidities at admission (p < 0.001, Cohen's d = 0.31), postpartum and post abortion without listed procedure (p < 0.001, Cohen's d = 1.05), and other antepartum diagnoses with medical complications (p < 0.001; Cohen's d = 0.77). CONCLUSIONS This study showed that the prevalence of HAC was low both in the institutions accredited to attend by SUS and in those of supplementary health; however, its presence contributes to increasing the length of stay in cases of cesarean sections without complications or comorbidities in supplementary health institutions.
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Affiliation(s)
- Thales Philipe Rodrigues da Silva
- Universidade Federal de Minas Gerais. Faculdade de Medicina. Programa de Pós-Graduação em Ciências da Saúde. Belo Horizonte, MG, Brasil
| | - Ariene Silva do Carmo
- Universidade Federal de Minas Gerais. Faculdade de Medicina. Programa de Pós-Graduação em Ciências da Saúde. Belo Horizonte, MG, Brasil
| | - Taiane Gonçalves Novaes
- Universidade Federal de Viçosa. Departamento de Nutrição. Programa de Pós-Graduação em Saúde e Nutrição de Grupos Populacionais. Viçosa, MG, Brasil
| | - Larissa Loures Mendes
- Universidade Federal de Minas Gerais. Escola de Enfermagem. Departamento de Nutrição. Belo Horizonte, MG, Brasil
| | - Alexandra Dias Moreira
- Universidade Federal de Minas Gerais. Escola de Enfermagem. Departamento de Enfermagem Materno-Infantil e Saúde Pública. Belo Horizonte, MG, Brasil
| | - Milene Cristine Pessoa
- Universidade Federal de Minas Gerais. Escola de Enfermagem. Departamento de Nutrição. Belo Horizonte, MG, Brasil
| | - Luna Cosenza
- Instituto de Acreditação e Gestão em Saúde (IAG Saúde). Belo Horizonte, MG, Brasil
| | | | - Fernanda Penido Matozinhos
- Universidade Federal de Minas Gerais. Escola de Enfermagem. Departamento de Enfermagem Materno-Infantil e Saúde Pública. Belo Horizonte, MG, Brasil
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Lansky S, Souza KVD, Peixoto ERDM, Oliveira BJ, Diniz CSG, Vieira NF, Cunha RDO, Friche AADL. Violência obstétrica: influência da Exposição Sentidos do Nascer na vivência das gestantes. CIENCIA & SAUDE COLETIVA 2019; 24:2811-2824. [DOI: 10.1590/1413-81232018248.30102017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 02/09/2018] [Indexed: 11/22/2022] Open
Abstract
Resumo O excesso de intervenções no parto no Brasil tem sido reportado como violência obstétrica e contribui para os índices elevados morbi-mortalidade materna e neonatal. A exposição Sentidos do Nascer busca incentivar o parto normal para promover a saúde e melhorar a experiência de parir e nascer no País. Este artigo analisa o perfil e a experiência de parto de 555 mulheres que visitaram a exposição durante a gestação, com enfoque na percepção sobre violência obstétrica. A violência obstétrica foi reportada por 12,6% das mulheres e associada ao estado civil, à menor renda, à ausência de companheiro, ao parto em posição litotômica, à realização da manobra de Kristeller e à separação precoce do bebê após o parto. Predominaram nos relatos de violência obstétrica: intervenção não consentida/aceita com informações parciais, cuidado indigno/abuso verbal; abuso físico; cuidado não confidencial/privativo e discriminação. A visita à exposição aumentou o conhecimento das gestantes sobre violência obstétrica. Entretanto, o reconhecimento de procedimentos obsoletos ou danosos na assistência ao parto como violência obstétrica foi ainda baixo. Iniciativas como esta podem contribuir para ampliar o conhecimento e a mobilização social sobre as práticas na assistência ao parto e nascimento.
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Affiliation(s)
- Sônia Lansky
- Secretaria Municipal de Saúde de Belo Horizonte, Brazil
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de Lima THB, Amorim MM, Buainain Kassar S, Katz L. Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study. BMC Pregnancy Childbirth 2019; 19:271. [PMID: 31370813 PMCID: PMC6670122 DOI: 10.1186/s12884-019-2381-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators. Methods A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%. Results A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74–5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45–5.82). Conclusions The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.
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Affiliation(s)
- Telmo Henrique Barbosa de Lima
- Health Sciences University of Alagoas (UNCISAL), Rua Dr. Mario Nunes Vieira, 149 - Apto. 201, Jatiuca, Maceió, AL, Brazil.
| | - Melania Maria Amorim
- Prof. Fernando Figueira Institute of Integral Medicine (IMIP), Department of Obstetrics and Gynecology, Recife, Brazil
| | | | - Leila Katz
- Prof. Fernando Figueira Institute of Integral Medicine (IMIP), Obstetric Intensive Care Unit, IMIP, Recife, Brazil
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Ahmad N, Nor SFS, Daud F. Understanding Myths in Pregnancy and Childbirth and the Potential Adverse Consequences: A Systematic Review. Malays J Med Sci 2019; 26:17-27. [PMID: 31496890 PMCID: PMC6719884 DOI: 10.21315/mjms2019.26.4.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 10/13/2018] [Indexed: 11/13/2022] Open
Abstract
The trend of choosing natural birth at home without proper supervision is gaining more attention and popularity in Malaysia. This is partly due to wrong beliefs of modern medical care. It prompts the need to explore further into other myths and wrong beliefs present in communities around the world surrounding pregnancy and childbirth that may lead to harmful consequences. A total of 25 literatures were selected and reviewed. The most reported wrong belief is the eating behaviour such as avoiding certain nutritious fruits besides eating saffron to produce fairer skinned babies which in fact contains high doses of saffron that may lead to miscarriage. The most worrying myth however, is that unregulated birth attendants such as doulas have the necessary knowledge and skills to manage complications in labour which may well end up in perinatal or even maternal death. Other myths suggested that modern medical care such as vaginal examinations and baby's heart monitoring in labour as unnecessary. A well-enforced health education programme by well-trained healthcare personnel besides sufficient number of antenatal care visits are needed to overcome these myths, wrong beliefs and practices. In conclusion, potential harmful beliefs and practices in pregnancy and childbirth are still abound in today's communities, not just in least developed and developing countries but also in developed countries. Women and children are two very vulnerable groups, therefore debunking myths and eliminating harmful practices should be one of a healthcare provider priority especially those in the primary care settings as they are the closest to the community.
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Affiliation(s)
- Norain Ahmad
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Sharifah Fazlinda Syed Nor
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Faiz Daud
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Nosratabadi M, Amini Rarani M, Shahidi S, Rahimi N. An exploratory study into social and healthcare variables of maternal mortality: a case-control study. J Perinat Med 2019; 47:409-417. [PMID: 30789825 DOI: 10.1515/jpm-2018-0334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/14/2019] [Indexed: 11/15/2022]
Abstract
Background Regarding the important role the mothers' health plays in shaping nations' well-being, this study endeavored to explore the main social and healthcare factors related to maternal mortality. Methods In this case-control study, data (viz., all maternal mortalities) were gathered from the national maternal mortality surveillance system. Likewise, control data (viz., alive mothers) were obtained from mother health records in 22 health centers located in 21 cities of Isfahan, Iran. The data were related to the years 2001-2016. Case and control groups were matched according to year of delivery, mother's age at delivery time and city of residence. Results Analysis of the gathered data revealed that during the years 2001-2016, 171 maternal mortalities occurred in Isfahan. In view of that, 523 mothers were selected as the control group. Most of the mothers attended high school (36%), were housewives (64%), delivered by cesarean section (59%) and suffered from different kinds of proximate medical causes (55%). The logistic regression results showed that being an immigrant, having a history of proximate medical cause, vaginal delivery and illiteracy raised the odds ratios (ORs) of maternal mortality up to 5.87, 4.41, 2.28 and 1.84 times, respectively. In contrast, using public antenatal care and planned pregnancy have had a protective, significant effect on maternal mortality (ORs <1). Conclusion The results suggested that in addition to social factors including immigrant status and low level of education which led to the increase of maternal mortality, healthcare factors including proximate medical causes, delivery method and antenatal care seem to be essential in tackling the issue of maternal mortality.
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Affiliation(s)
- Mehdi Nosratabadi
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of Health and Social Welfare, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mostafa Amini Rarani
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan 81746 73461, Iran.,School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Hezar-Jerib Ave., Isfahan 81746 73461, Iran, Tel.: +98-3137925128, Fax: +098-3136684799
| | - Shahla Shahidi
- Social Determinants of Health Research Center, Deputy of Social, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nadia Rahimi
- Deputy of Health, Isfahan University of Medical Sciences, Isfahan, Iran
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Sun Y, Huang K, Hu Y, Yan S, Xu Y, Zhu P, Tao F. Pregnancy-specific anxiety and elective cesarean section in primiparas: A cohort study in China. PLoS One 2019; 14:e0216870. [PMID: 31091276 PMCID: PMC6519904 DOI: 10.1371/journal.pone.0216870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/30/2019] [Indexed: 01/17/2023] Open
Abstract
The purpose of this study was to investigate the association between pregnancy-specific anxiety and elective cesarean section, and identify the critical period in which pregnancy-specific anxiety will affect the elective cesarean section. Primiparous women in the 1st trimester of pregnancy were invited to participate in the cohort. General information on maternal socio-demographic characteristics and environmental exposure were collected using questionnaires. Pregnancy-specific anxiety was assessed by using pregnancy-specific anxiety questionnaire in the 1st, 2nd and 3rd trimester, respectively. Delivery modes and pregnancy complications were abstracted from medical notes. Structural equation modeling (SEM) was adopted to examine the relationship between pregnancy-specific anxiety and elective cesarean section. Results indicated the overall elective cesarean section rate in this study was 45%. Among 1 874 pregnant women, 30.9% women experienced anxiety at least once during pregnancy, and 6.9% women suffered from anxiety in all three trimesters. Anxiety in the 2nd trimester was a significant predictor for elective cesarean section. Young maternal age and low educational level had indirect effects on women’s choice of elective caesarean section through affecting pregnancy-specific anxiety. More attention should be paid to maternal psychological problems, and professional counseling needs to be strengthened to protect women from pregnancy-specific anxiety.
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Affiliation(s)
- Yuanfang Sun
- Department of Maternal, Child and Adolescent Health, Anhui Medical University, Hefei, Anhui Province, China
| | - Kun Huang
- Department of Maternal, Child and Adolescent Health, Anhui Medical University, Hefei, Anhui Province, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Hefei, Anhui Province, China
- * E-mail:
| | - Yabin Hu
- Department of Maternal, Child and Adolescent Health, Anhui Medical University, Hefei, Anhui Province, China
| | - Shuangqin Yan
- Ma'anshan Maternal and Child Health Center, Ma'anshan, China
| | - Yeqing Xu
- Ma'anshan Maternal and Child Health Center, Ma'anshan, China
| | - Peng Zhu
- Department of Maternal, Child and Adolescent Health, Anhui Medical University, Hefei, Anhui Province, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Hefei, Anhui Province, China
| | - Fangbiao Tao
- Department of Maternal, Child and Adolescent Health, Anhui Medical University, Hefei, Anhui Province, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Hefei, Anhui Province, China
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Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, Fernandez E, Gundabattula SR, Betran AP, Khan K, Zamora J, Thangaratinam S. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet 2019; 393:1973-1982. [PMID: 30929893 DOI: 10.1016/s0140-6736(18)32386-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/15/2018] [Accepted: 09/20/2018] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Soha Sobhy
- Barts Research Centre for Women's Health, Queen Mary University of London, London, UK; Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, UK; Barts and the London School of Medicine and Dentistry, and WHO Collaborating Centre for Women's Health, Queen Mary University of London, London, UK
| | | | - Nilaani Murugesu
- Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | - Gayathri Karthikeyan
- Department of Obstetrics and Gynaecology, Madurai Medical College, Madurai, India
| | - Vinoth Kumar
- Department of Surgery, Tirunelveli Medical College, Tirunelveli, India
| | - Inderjeet Kaur
- Department of Obstetrics and Gynaecology, Fernandez Hospitals, Hyderabad, India
| | - Evita Fernandez
- Department of Obstetrics and Gynaecology, Fernandez Hospitals, Hyderabad, India
| | | | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Khalid Khan
- Barts Research Centre for Women's Health, Queen Mary University of London, London, UK; Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, UK; Barts and the London School of Medicine and Dentistry, and WHO Collaborating Centre for Women's Health, Queen Mary University of London, London, UK
| | - Javier Zamora
- Barts Research Centre for Women's Health, Queen Mary University of London, London, UK; Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, UK; Barts and the London School of Medicine and Dentistry, and WHO Collaborating Centre for Women's Health, Queen Mary University of London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS), Madrid, Spain; CIBER Epidemiology and Public Health, Madrid, Spain
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health, Queen Mary University of London, London, UK; Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, UK; Barts and the London School of Medicine and Dentistry, and WHO Collaborating Centre for Women's Health, Queen Mary University of London, London, UK.
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Jadoon B, Assar TM, Nucier AAAR, Raziq HEA, Abd El-Azym Saad AS, Megahed Amer W. Analysis of the caesarean section rate using the 10-Group Robson classification at Benha University Hospital, Egypt. Women Birth 2019; 33:e105-e110. [PMID: 30987799 DOI: 10.1016/j.wombi.2019.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Egypt has the third highest caesarean section rate (54%) in the world and lacks a standard classification system to analyse caesarean section rates. The World Health Organization (WHO) recommends the Robson classification as an effective caesarean section analysis and monitoring tool. AIM To analyse the caesarean section rate of Benha University Hospital, Egypt using the standard 10-Group Robson classification system. METHOD A prospective, cross-sectional study was conducted at the Benha University Hospital from 1 April to 30 June 2018. All women admitted for childbirth were categorised into Robson groups to determine the absolute and relative contribution made by each group to the overall caesarean section rate. Epi Data V.3.1 software programme was used to analyse the data. FINDINGS 850 women gave birth during the study period, 466 (55%) by caesarean section (CS). Robson Group 5 (multiparous, term, cephalic presentation and previous caesarean section) contributed the most (36%) to the overall CS rate. 175/308 (56%) women in this group had previously undergone one caesarean section. Group 6 (all nulliparous women with single breech pregnancy) and Group10 (cephalic preterm pregnancies) were the second and the third greatest contributors toward the overall CS rate, with 4.6% and 2.8% respectively. CONCLUSIONS In keeping with other studies, Groups 5, 6, and 10 were the main contributors to the overall caesarean section rate. We found Robson classification to be clinically relevant and an effective tool to analyse the caesarean section rate even in settings with limited resources.
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Affiliation(s)
- Bismeen Jadoon
- Research coordinator at the Faculty of Egyptian Society of Royal College of Obstetrics and Gynaecology, (ERC-RCOG), 42 Abdel Monem Road, Mohandseen, Cairo, 11231, Egypt.
| | - Tamer Mahmoud Assar
- Faculty of Medicine-Benha University, El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate, Egypt.
| | | | - Heba Elsayed Abdel Raziq
- Faculty of Medicine-Benha University, El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate, Egypt.
| | - Ahmed Samy Abd El-Azym Saad
- Faculty of Medicine-Benha University, El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate, Egypt.
| | - Wagdy Megahed Amer
- El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate, Egypt.
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Blanc J, Resseguier N, Goffinet F, Lorthe E, Kayem G, Delorme P, Vayssière C, Auquier P, D’Ercole C. Association between gestational age and severe maternal morbidity and mortality of preterm cesarean delivery: a population-based cohort study. Am J Obstet Gynecol 2019; 220:399.e1-399.e9. [PMID: 30633920 DOI: 10.1016/j.ajog.2019.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cesarean delivery rates at extreme prematurity have regularly increased over the past years, and few previous studies have investigated severe maternal morbidity associated with extreme preterm cesarean delivery. OBJECTIVE The aim of this study was to evaluate whether gestational age <26 weeks of gestation (weeks) was associated with severe maternal morbidity and mortality (SMMM) of preterm cesarean deliveries in comparison with cesarean deliveries between 26 and 34 weeks. MATERIALS AND METHODS The Etude Epidémiologique sur les petits âges gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm births in 2011. We included mothers with cesarean deliveries between 22 and 34 weeks, excluding those who had a cesarean delivery for the second twin only and those with pregnancy terminations. SMMM was analyzed as a composite endpoint defined as the occurrence of at least 1 of the following complications: severe postpartum hemorrhage defined by the use of a blood transfusion, intensive care unit admission, or death. To assess the association of gestational age <26 weeks and SMMM, we used multivariate logistic regression and a propensity score-matching approach. RESULTS Among 2525 women having preterm cesarean deliveries, 116 before 26 weeks and 2409 between 26 and 34 weeks, 407 (14.4%) presented with SMMM. The SMMM occurred in 31 mothers (26.7%) who were at gestational age <26 weeks vs 376 (14.2%) between 26 and 34 weeks (P < .001). Cluster multivariate logistic regression showed significant association of gestational age <26 weeks and SMMM (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.42-4.40) and propensity score-matching analysis was consistent with these results (aOR, 2.27; 95% CI, 1.31-3.93). CONCLUSION Obstetricians should know about the higher SMMM associated with cesarean deliveries before 26 weeks, integrate this knowledge into decisions regarding cesarean delivery, and be prepared to manage the associated complications.
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Lansky S, Oliveira BJ, Peixoto ER, Souza KV, Fernandes LM, Friche AA. The Senses of Birth intervention to decrease cesarean and prematurity rates in Brazil. Int J Gynaecol Obstet 2019; 145:91-100. [PMID: 30671949 PMCID: PMC7473078 DOI: 10.1002/ijgo.12765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 10/05/2018] [Accepted: 01/21/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To increase knowledge and promote cultural change toward valuing normal birth, and to lower rates of cesarean and unnecessary interventions during childbirth in Brazil via the Senses of Birth (SoB) exhibition. METHODS The SoB intervention targeted 22 621 participants in three Brazilian cities in 2015. The effects of the exhibition in knowledge, perceptions, and preferences regarding childbirth were analyzed in a multi-method study. Pre- and post-exhibition survey responses of 17 501 (77.0%) visitors, 1947 (8.6%) non-pregnant women, and all pregnant women (n=1287) were collected at the exhibition. A follow-up survey was completed by 555 (43.0%) postpartum women who had participated at SoB while pregnant. Univariate analyses were used to compare before and after changes. RESULTS There was a significant increase in knowledge about normal birth, varying from 10.0% to 25.0% among general visitors (P<0.001) and 27.3% to 42.0% among pregnant women (P<0.001). Perceptions and preferences for normal birth also changed, reaching 83.0% of general visitors and 87.4% of pregnant women. CONCLUSION SoB was found to effectively improve knowledge about and preference for normal birth. Scaling-up the intervention might contribute to cultural change toward valuing normal birth, and might decrease the rate of unnecessary cesarean and premature birth in Brazil.
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Affiliation(s)
- Sônia Lansky
- Department of Health, Belo Horizonte City Hall, Belo Horizonte, Brazil
| | - Bernardo J. Oliveira
- School of Education, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Eliane R.M. Peixoto
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Kleyde V. Souza
- School of Nursing, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luísa M.M. Fernandes
- School of Public Health, State University of New York at Albany, Albany, NY, USA
| | - Amélia A.L. Friche
- School of Nursing, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Fishel Bartal M, Sibai BM, Ilan H, Fried M, Rahav R, Alexandroni H, Schushan Eisan I, Hendler I. Trial of labor after cesarean (TOLAC) in women with premature rupture of membranes . J Matern Fetal Neonatal Med 2019; 33:2976-2982. [PMID: 30652525 DOI: 10.1080/14767058.2019.1566312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: The aim of this study was to assess the success rate of a trial of labor after a previous cesarean section (TOLAC) in the settings of premature rupture of membranes (PROM) and to compare conservative management with spontaneous labor and induction of labor.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2011 and March 2017. Women with singleton pregnancy and a previous cesarean section (CS) who presented with PROM and underwent TOLAC were included. Outcomes and rate of successful vaginal delivery after induction of labor were compared to conservative treatment and spontaneous labor.Results: Among 830 women who met the inclusion criteria, 723 (87.1%) had a spontaneous onset of labor following PROM and 107 (12.9%) had an induction of labor. The rate of successful TOLAC was similar between the groups (75.7 vs. 81.6%, respectively, p = .22). However, induction of labor was associated with an increased risk for uterine rupture (1.87 vs. 0.96%, p < .001), operative complications (6.7 vs. 2.3%, p < .001), and composite maternal postpartum complications (21.4 vs. 10.7%, respectively, p = .014) compared to conservative management with spontaneous initiation of labor. There was no difference in neonatal outcome between the groups.Conclusion: Induction of labor following PROM in women with a previous CS is associated with high successful vaginal delivery rate. However, the risk for uterine rupture and operative and maternal complications is significantly increased compared to spontaneous initiation of labor.
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Affiliation(s)
- Michal Fishel Bartal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Hadas Ilan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Fried
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Rahav
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Heli Alexandroni
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Schushan Eisan
- Department of Neonatology, The Edmond and Lily Safra Children's Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Hendler
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abdelazim I, Alanwar A, Shikanova S, Kanshaiym S, Farghali M, Mohamed M, Zhurabekova G, Karimova B. Complications associated with higher order compared to lower order cesarean sections. J Matern Fetal Neonatal Med 2019; 33:2395-2402. [PMID: 30463461 DOI: 10.1080/14767058.2018.1551352] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.Objectives: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.Materials and methods: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥3 cesarean sections admitted for elective cesarean section after 38 weeks' gestation, and those with ≥3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative, and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.Results: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p<.05, 95% CI; 0.1-0.2) and p<.01, 95% CI; 0.4-11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p=.01 (95% CI; 0.6-1.6) and p=.01 (95% CI; 0.5-5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035-711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147-151.5)) in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p=.52 and .38; respectively).Conclusion: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).
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Affiliation(s)
- Ibrahim Abdelazim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University Cairo, Egypt
| | - Ahmed Alanwar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University Cairo, Egypt
| | | | | | - Mohamed Farghali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University Cairo, Egypt
| | - Mohamed Mohamed
- Department of Obstetrics and Gynecology, Menofia Univeristy, Shibin El Kom, Egypt
| | | | - Bakyt Karimova
- West Kazakhstan State Medical University (WKSMU), Aktobe, Kazakhstan
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Leal MDC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVDS, Silva LBRADA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGND, Domingues RMSM, Vilela MEDA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. CAD SAUDE PUBLICA 2019; 35:e00223018. [DOI: 10.1590/0102-311x00223018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/06/2019] [Indexed: 11/22/2022] Open
Abstract
Resumo: Este artigo tem como objetivo descrever os primeiros resultados de dois estudos avaliativos, um sobre a Rede Cegonha e outro sobre o projeto Parto Adequado, denominados, respectivamente, de avaliação da Rede Cegonha e Nascer Saudável, e identificar possíveis melhorias em comparação ao estudo Nascer no Brasil. Ambos os estudos têm desenho seccional, realizados em 2017. O estudo avaliação da Rede Cegonha incluiu todas as 606 maternidades públicas e mistas envolvidas na Rede Cegonha e um total de 10.675 puérperas. O estudo Nascer Saudável incluiu uma amostra de conveniência de 12 hospitais da rede privada e um total de 4.798 mulheres. Os indicadores de atenção ao parto e nascimento avaliados foram: presença de acompanhante, atendimento por enfermeira obstétrica, preenchimento de partograma, uso de métodos não farmacológicos, deambulação, alimentação, uso de cateter venoso periférico, analgesia, posição da mulher para o parto, episiotomia e manobra de Kristeler. Esses indicadores foram comparados aos encontrados no Nascer no Brasil, estudo de base nacional realizado em 2011-2012, antes do início dos dois programas de intervenção. Para as comparações utilizamos o teste do qui-quadrado para amostras independentes e nível de 95% de confiança. Houve um aumento significativo do número de mulheres com acesso à tecnologia apropriada ao parto entre os anos de 2011 e 2017 e redução de práticas consideradas prejudiciais. No setor privado, observou-se também redução nas taxas de cesariana e aumento da idade gestacional ao nascer. Os resultados deste estudo mostram que políticas públicas bem conduzidas podem mudar o cenário da atenção ao parto e nascimento, promovendo a redução de desfechos maternos e neonatais negativos.
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Torres JA, Leal MDC, Domingues RMSM, Esteves-Pereira AP, Nakano AR, Gomes ML, Figueiró AC, Nakamura-Pereira M, de Oliveira EFV, Ayres BVDS, Sandall J, Belizán JM, Hartz Z. Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol. Reprod Health 2018; 15:194. [PMID: 30477517 PMCID: PMC6257968 DOI: 10.1186/s12978-018-0636-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/05/2018] [Indexed: 11/16/2022] Open
Abstract
Background In Brazilian private hospitals, caesarean section (CS) is almost universal (88%) and is integrated into the model of birth care. A quality improvement intervention, “Adequate Birth” (PPA), based on four driving components (governance, participation of women and families, reorganisation of care, and monitoring), has been implemented to help 23 hospitals reduce their CS rate. This is a protocol designed to evaluate the implementation of PPA and its effectiveness at reducing CS as a primary outcome of birth care. Methods Case study of PPA intervention conducted in 2017/2018. We integrated quantitative and qualitative methods into data collection and analysis. For the quantitative stage, we selected a convenient sample of twelve hospitals. In each of these hospitals, we included 400 women. This resulted in a total sample of 4800 women. We used this sample to detect a 2.5% reduction in CS rate. We interviewed managers and puerperal women, and extracted data from hospital records. In the qualitative stage, we evaluated a subsample of eight hospitals by means of systematic observation and semi-structured interviews with managers, health professionals and women. We used specific forms for each of the four PPA driving components. Forms for managers and professionals addressed the decision-making process, implemented strategies, participatory process in strategy design, and healthcare practice. Forms for women and neonatal care addressed socio-economic, demographic and health condition; prenatal and birth care; tour of the hospital before delivery; labour expectation vs. real experience; and satisfaction with care received. We will estimate the degree of implementation of PPA strategies related to two of the four driving components: “participation of women and families” and “reorganisation of care”. We will then assess its effect on CS rate and secondary outcomes for each of the twelve selected hospitals, and for the total sample. To allow for clinical, socio-demographic and obstetric characteristics in women, we will conduct multivariate analysis. Additionally, we will evaluate the influence of internal context variables (the PPA driving components “governance” and “monitoring”) on the degree of implementation of the components “participation of women and families” and “reorganisation of care”, by means of thematic content analysis. This analysis will include both quantitative and qualitative data. Discussion The effectiveness of quality improvement interventions that reduce CS rates requires examination. This study will identify strategies that could promote healthier births. Electronic supplementary material The online version of this article (10.1186/s12978-018-0636-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jacqueline Alves Torres
- Agência Nacional de Saúde Suplementar, Av. Augusto Severo, 84 - Glória, Diretoria de Desenvolvimento Setorial, Rio de Janeiro - RJ, 20021-040, Brazil.
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | - Maysa Luduvice Gomes
- Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Claudia Figueiró
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | - Jane Sandall
- Department of Women and children's Health, King's College London, London, England
| | - José M Belizán
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Zulmira Hartz
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
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