COVID-19 mitigation measures increase preterm birth and low birth weight in the public healthcare system in Uruguay

OBJECTIVE

To evaluate the impact of the COVID-19 pandemic on preterm birth (PB) and low birth weight (LBW), comparing public and private healthcare systems of the National Integrated Health System in Uruguay, where the mitigation measures for the COVID-19 pandemic generated an immediate socioeconomic and psychological crisis, which caused a sharp widening of existing socioeconomic inequalities.

METHODS

A national observational study was conducted comparing perinatal outcomes in the first 6 months of 2020 (period of the pandemic without pregnancy infections), which was the beginning of the pandemic, with the same period of the previous year 2019 (pre-pandemic period with no mitigation measures) among pregnant women from the public and private health systems. Data were retrieved from the national database (Informatic Perinatal System) and analyzed by healthcare system category.

RESULTS

A total of 36 559 deliveries were assessed: 18 563 in the 2019 study period and 17 996 in the 2020 study period. In the public system, there was a significant increase in the risk of LBW (adjusted relative risk [aRR] 1.12, 95% confidence interval [CI] 1.05-1.36) and of the composite outcome (PB or LBW) (aRR 1.15, 95% CI 1.04-1.26). In the private system, by contrast, there was a non-statistically significant decrease of LBW and there were no changes in the incidence of PB and the composite outcome in 2020.

CONCLUSION

The different evolution of birth outcomes in the public and private systems suggests an unequal impact of mitigation measures on populations of different socioeconomic levels. Given that no COVID-19 infections were identified in pregnant women during the study period, this research offers an opportunity to differentiate the biologic effects of the virus from the psychological and social impacts derived from containment measures.

CLINICALTRIALS

GOV IDENTIFIER

NCT05087160.

Effect of the unfavorable maternal-fetal environment cause by mitigation measures of the covid-19 pandemic in the public maternity of reference of Uruguay

INTRODUCTION

The mitigation measures to face the health emergency due to the COVID 19 pandemic generated a deep economic, social, and psychological crisis at the community level. This effect is greater in the people, who are the most violated in their rights. In relation to the social crisis and gender perspective, women are particularly affected by the pandemic. Given the disadvantaged situation of women socially, economically, and politically, their self-care is diminished.

OBJECTIVE

To identify whether there is an association between the classic risk factors for prematurity and fetal growth restriction and the increase in these pathologies in the period March-September 2020, in a maternity hospital that assists women from low resources.

MATERIALS AND METHODS

A retrospective study, with a comparative analysis of the periods between 15 March and 30 September 2019 and the same period in 2020. The data were obtained from an electronic clinical database. The prevalence of preterm birth and small-for-gestational age newborn was analyzed. Indicators available in the database that reflect maternal conditions that lead to an unfavorable maternal environment were selected and they were classified into categories.

RESULTS

In the period of 2019, 3225 births were registered and in the period of 2020, 3036 births. In the 2019 period, 12.2% of prematurity was evidenced, while in the 2020 period, 14.5% (RR = 1.19, IC 95% = 1.05-1.35, p = .005). In relation to PEG 5.5% in the first period versus 6.9% in the second (RR = 1.26, CI 95% = 1.04-1.53, p = .01). No increases were found in the indicators that are traditionally related to the etiologies proposed to explain the increase in prematurity and small-for-age gestational, there was no evidence of an increase in inflammatory or vascular conditions.

CONCLUSION

The economic, psychological and social crises, in the 1st semester of the health emergency, seriously affected the social determinants of the health of pregnant women who use the Public Maternity of reference in Uruguay. This situation is at the base of the poor perinatal results in the period of the maximum mediated mitigation of the pandemic.

Impact of mitigation measures against the COVID 19 pandemic on the perinatal results of the reference maternity hospital in Uruguay

INTRODUCTION

Social consequences of pandemics, impacts on perinatal results, especially those who are the most vulnerable.

OBJECTIVE

Determine effect of mitigation measures of the COVID 19 pandemic on perinatal results in the maternity hospital of the Pereira Rossell Hospital Center (CHPR).

METHODS

A retrospective cross-sectional cohort study, with a comparative analysis of the semesters of March 15-30 September 2019 versus the same period in 2020 based on three variables low birth weight (LBW), preterm birth (PB), and small for gestational age (SGA).

RESULTS

Incidence of PB (14.5%), LBW (12%) and SGA (6.9%) was higher in the 2020 semester during COVID 19 pandemic compared to the same period of 2019 (12.2%; 9.8%; 5.5%). PB showed a statistically significant increase of 21% in our hospital.

CONCLUSION

Mitigation measures of the COVID 19 pandemic, aggravate the effects of the global syndemic on the reproductive process of the social sectors most violated in their rights.

Conscientious objection as a barrier for implementing voluntary termination of pregnancy in Uruguay: Gynecologists' attitudes and behavior

OBJECTIVE

To analyze the attitudes and behavior of gynecologists in Uruguay with respect to the right to conscientious objection that is included in the law concerning voluntary termination of pregnancy.

METHODS

The relevant laws and decrees, academic articles, legal or administrative claims, and the positions published by the institutions representing physicians or by groups of gynecologists were analyzed.

RESULTS

In general, the institutions positioned themselves in favor of correct application of conscientious objection and the immense majority of gynecologists followed this conduct. Small groups mounted a strong opposition and in one department (province) all gynecologists declared themselves to be objectors.

CONCLUSION

Most gynecologists, whether or not they are objectors, proved to have a "loyalty to duty," fulfilling their primary obligation to abide by the ethical duty to give treatment to the persons who need it. A small group used conscientious objection to impede the provision of care to the women who needed the service, some group members being genuine objectors and others pseudo-objectors.

From risk and harm reduction to decriminalizing abortion: The Uruguayan model for women's rights

OBJECTIVE

To describe public policies, social actions, particularly those of obstetricians/gynecologists, and changes in abortion-related legislation in the different historical periods between 1990 and 2015, and to analyze temporal correlations with a reduction in maternal mortality.

METHODS

The 1990-2015 period was divided into three different stages to permit evaluation of the legislation, health regulations, healthcare system, and professional practices related to the care provided in cases of unsafe abortion: 1990-2001, characterized by illegality and the healthcare system's denial of abortion; 2001-2012, when the model for reducing the risk and harm of unsafe abortions was developed; and 2012-2015, when abortion was finally decriminalized.

RESULTS

Changes in public policies and expansion of the risk reduction model coincided with changes in the social perception of abortion and a decrease in maternal mortality and abortion rates, probably due to a set of public policies that led to the decriminalization of abortion in 2012.

CONCLUSION

Changes in public policies and health actions such as the model for reducing the risk and harm of unsafe abortions coincided with a marked reduction in abortion-related maternal mortality. The challenges still to be faced include managing second trimester abortions, ensuring the creation of multidisciplinary teams, and offering postabortion contraception.

Implementation of the risk and harm reduction strategy against unsafe abortion in Uruguay: From a university hospital to the entire country

The history of the creation of the risk and harm reduction model applied to unsafe abortion is reviewed, from its initial implementation by a small group of gynecologists at the Pereira Rossell Hospital Center in Uruguay to its spread to the rest of the country. Its ethical rationale, its successful application in the hospital, the decision to disseminate it with the cooperation of the International Federation of Gynecology and Obstetrics (FIGO), and the intervention procedures are explained. It was evaluated from the epidemiological and anthropological viewpoints, from the changes in professionals' and users' perception of the care offered and its impact on complications and maternal deaths. A very favorable change was seen in the number and quality of the services, the providers' attitude, and maternal morbidity and mortality were reduced. It also brought visibility to women with unplanned and unwanted pregnancies and an improved understanding of their problems, which contributed to the legislative changes that were made subsequently.

Improving care of women at risk of unsafe abortion: implementing a risk-reduction model at the Uruguayan-Brazilian border

OBJECTIVE

To describe the initial stages of the implementation of a risk-reduction model designed by Iniciativas Sanitarias to shield women from unsafe abortion in a traditional community on the Uruguay-Brazil border.

METHODS

This mixed-design study was conducted first between 22 and 26 March 2010, and then between 2 and 7 May 2011, in Rivera, Uruguay, to gather information from women seen at health centers, healthcare providers, and local policy makers before the project started and midway through the project.

RESULTS

At baseline most women and providers considered abortion justifiable only on narrow grounds, yet favored the implementation of a risk-reduction model that would include preabortion as well as postabortion counseling, the former providing information on different abortion methods and their risks. By the midterm assessment, the counseling service had assisted 87 women with unwanted pregnancies. Of the 52 who came for a postabortion visit, 50 had self-administered misoprostol, with no complications. Women were highly satisfied with the counseling. At baseline, misoprostol seemed to be available from both pharmacists and informal sellers. At midterm, it was still available from informal vendors but pharmacists said they did not provide misoprostol. The risk-reduction initiative heightened public attention to the abortion issue but the controversy it generated did not seriously impede its implementation.

CONCLUSION

It is feasible to implement the proposed risk-reduction model in a traditional community such as Rivera, not only in Uruguay but in any country irrespective of its abortion laws.

Right to protection from unsafe abortion and postabortion care

The International Congress on Population and Development (ICPD) Programme of Action urged governments and intergovernmental and nongovernmental organizations to reduce women's recourse to abortion through improved family planning services; reliable information and counseling should be readily accessible to women who have unwanted pregnancies; where abortion is legal, it should be safe; and in all cases, quality services for management of abortion complications should be accessible. Review of the extent to which these recommendations have been implemented over the last 15 years shows that, with few exceptions, little attention has been given to this serious problem. Because of its political and religious implications, abortion is mostly ignored. Those with the power to promote change have an obligation to raise the issue of abortion from the darkness in which it is currently hidden, and bring it into the public light as a human drama and a health problem that is not difficult to solve if the ICPD recommendations are taken seriously.

Tocolysis and delayed delivery versus emergency delivery in cases of non-reassuring fetal status during labor

AIM

To determine whether fetal intrauterine resuscitation using tocolysis and delayed delivery is better for the fetus than emergency delivery when fetal hypoxia is suspected because of a non-reassuring fetal heart-rate (FHR) pattern using conventional heart rate monitoring.

METHODS

This was a prospective and randomized study, conducted between 2001 and 2004 at Pereira Rossell Hospital, Montevideo, Uruguay. The population consisted of 390 fetuses, in which intrauterine distress was diagnosed using electronic FHR monitoring. Of these, 197 were randomly assigned to the emergency delivery group and 193 to the fetal intrauterine resuscitation group. The inclusion criteria were: term singleton pregnancy, in labor, cephalic presentation, and no placental accidents.

RESULTS

The time between randomization and birth was 16.9 +/- 7.6 min (mean +/- SD) for the emergency delivery group, and 34.5 +/- 11.7 min (mean +/- SD) for the resuscitation group. The relative risk (RR) of acidosis in the umbilical artery (pH < 7.1) in the emergency delivery group was 1.47 (0.95-2.27). The RR of base deficit < or =12 mEq/L in the emergency delivery group was higher than in the resuscitation group (RR = 1.48 [1.0-2.2], P = 0.04). When considering the need for admission to the neonatal care unit, the relative risk was higher in the emergency delivery group than in the resuscitation group (RR = 2.14 [1.23.3.74], P = 0.005). No maternal adverse effects were reported.

CONCLUSION

Tocolysis and delayed delivery renders better immediate neonatal results than emergency delivery when fetal distress is suspected because of a non-reassuring fetal heart pattern. In addition, it may decrease the need for emergency delivery without increasing maternal and fetal adverse side-effects.

A risk reduction strategy to prevent maternal deaths associated with unsafe abortion

INTRODUCTION

Worldwide, 13% of maternal deaths are caused by complications of spontaneous or induced abortion, 29% in Uruguay and nearly half (48%) in the Pereira Rossell Hospital.

PURPOSE

This paper describes a risk reduction strategy for unsafe abortions in Montevideo, Uruguay, where over one-fourth of maternal deaths are caused by unsafe abortion.

METHODS

Although abortion is not legal in Uruguay, women desiring abortions can be counseled before and immediately after to reduce the risk of injury. Women contemplating abortion were invited to attend a "before-abortion" and an "after-abortion" visit at a reproductive health polyclinic. At the "before-abortion" visit, gestational age, condition of the fetus and pathologies were diagnosed and the risks associated with the use of different abortion methods (based on the best available scientific evidence) were described. The "after-abortion" visit allowed for checking for possible complications and offering contraception.

RESULTS

From March 2004 through June 2005, 675 women attended the "before-abortion" and 495 the "after-abortion" visit, the number increasing over time. Some women (3.5%) decided not to abort, others were either not pregnant, the fetus/embryo was dead or the woman had a condition that permitted legal termination of pregnancy in the hospital (7.5%). Most women, however, aborted. All women used vaginal misoprostol in the doses recommended in the medical literature. There were no serious complications (one mild infection and two hemorrhages not requiring transfusion).

CONCLUSION

The strategy is effective in reducing unsafe abortions and their health consequences.

Pulmonary alveolar microlithiasis and pregnancy

The following is the case of a 36-year old pregnant woman reaching term, suffering from advanced pulmonary alveolar microlithiasis. To our knowledge, this is the first record of such a case.