Fernando Althabe

Rates and implications of caesarean sections in Latin America: ecological study

Abstract Objectives: To estimate the incidences of caesarean sections in Latin American countries and correlate these with socioeconomic, demographic, and healthcare variables. Design: Descriptive and ecological study. Setting: 19 Latin American countries. Main outcome measures: National estimates of caesarean section rates in each country. Results: Seven countries had caesarean section rates below 15%. The remaining 12 countries had rates above 15% (range 16.8% to 40.0%). These 12 countries account for 81% of the deliveries in the region. A positive and significant correlation was observed between the gross national product per capita and rate of caesarean section (rs=0.746), and higher rates were observed in private hospitals than in public ones. Taking 15% as a medically justified accepted rate, over 850 000 unnecessary caesarean sections are performed each year in the region. Conclusions: The reported figures represent an unnecessary increased risk for young women and their babies. From the economic perspective, this is a burden to health systems that work with limited budgets. Key messages 12 of the 19 Latin American countries studied had caesarean section rates above 15%, ranging from 16.8% to 40% These12 countries account for 81% of the deliveries in the region Better socioeconomic conditions were associated with higher caesarean section rates Over 850 000 unnecessary caesarean sections are performed each year in Latin America Reduction of caesarean section rates will need concerted action from public health authorities, medical associations, medical schools, health professionals, the general population, and the media

Zika virus and microcephaly: why is this situation a PHEIC?

Fil: Heymann, David L. London School of Hygiene & Tropical Medicine; Reino Unido. The Royal Institute of International Affairs; Reino Unido

Caesarean section: the paradox

In todays Lancet Carine Ronsmans and colleagues present strong evidence for inequalities in access to caesarean sections in developing countries. Their thorough analysis of data from Demographic and Health Surveys in 42 low-income and middle-income countries comparing caesarean section rates in quintiles of wealth showed that women of low income received significantly fewer interventions compared with the highest. However fewer caesarean sections do not necessarily mean lower health-care quality. The appropriate range for the caesarean section rate in a country remains a matter of debate. The recommended lower limit ranges from a minimum of 1% to an optimum target of 5% to avoid death and severe morbidity in the mother. Although these figures are good estimates based on complication rates in the mother and on historical data whether the frequency of intervention is enough to prevent avoidable perinatal deaths is unknown. The best known recommended upper limit is 15% suggested by WHO. (excerpt)

Inequities in the use of cesarean section deliveries in the world

OBJECTIVE The purpose of this study was to describe the unequal distribution in the performance of cesarean section delivery (CS) in the world and the resource-use implications of such inequity. STUDY DESIGN We obtained data on the number of CSs performed in 137 countries in 2008. The consensus is that countries should achieve a 10% rate of CS; therefore, for countries that are below that rate, we calculated the cost to achieve a 10% rate. For countries with a CS rate of >15%, we calculated the savings that could be made by the achievement of a 15% rate. RESULTS Fifty-four countries had CS rates of <10%, whereas 69 countries showed rates of >15%. The cost of the global saving by a reduction of CS rates to 15% was estimated to be

Women's preference for caesarean section: a systematic review and meta-analysis of observational studies

2.32 billion (US dollars); the cost to attain a 10% CS rate was

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

432 million (US dollars). CONCLUSION CSs that are potentially medically unjustified appear to command a disproportionate share of global economic resources.

A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: The ACT cluster-randomised trial

Please cite this paper as: Mazzoni A, Althabe F, Liu N, Bonotti A, Gibbons L, Sánchez A, Belizán J. Women’s preference for caesarean section: a systematic review and meta‐analysis of observational studies. BJOG 2011;118:391–399.

Risk Factors for Postpartum Hemorrhage in Vaginal Deliveries in a Latin-American Population

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Tobacco use and secondhand smoke exposure during pregnancy: An investigative survey of women in 9 developing nations:

BACKGROUND Antenatal corticosteroids for pregnant women at risk of preterm birth are among the most effective hospital-based interventions to reduce neonatal mortality. We aimed to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries. METHODS In this 18-month, cluster-randomised trial, we randomly assigned (1:1) rural and semi-urban clusters within six countries (Argentina, Guatemala, India, Kenya, Pakistan, and Zambia) to standard care or a multifaceted intervention including components to improve identification of women at risk of preterm birth and to facilitate appropriate use of antenatal corticosteroids. The primary outcome was 28-day neonatal mortality among infants less than the 5th percentile for birthweight (a proxy for preterm birth) across the clusters. Use of antenatal corticosteroids and suspected maternal infection were additional main outcomes. This trial is registered with ClinicalTrials.gov, number NCT01084096. FINDINGS The ACT trial took place between October, 2011, and March, 2014 (start dates varied by site). 51 intervention clusters with 47,394 livebirths (2520 [5%] less than 5th percentile for birthweight) and 50 control clusters with 50,743 livebirths (2258 [4%] less than 5th percentile) completed follow-up. 1052 (45%) of 2327 women in intervention clusters who delivered less-than-5th-percentile infants received antenatal corticosteroids, compared with 215 (10%) of 2062 in control clusters (p<0·0001). Among the less-than-5th-percentile infants, 28-day neonatal mortality was 225 per 1000 livebirths for the intervention group and 232 per 1000 livebirths for the control group (relative risk [RR] 0·96, 95% CI 0·87-1·06, p=0·65) and suspected maternal infection was reported in 236 (10%) of 2361 women in the intervention group and 133 (6%) of 2094 in the control group (odds ratio [OR] 1·67, 1·33-2·09, p<0·0001). Among the whole population, 28-day neonatal mortality was 27·4 per 1000 livebirths for the intervention group and 23·9 per 1000 livebirths for the control group (RR 1·12, 1·02-1·22, p=0·0127) and suspected maternal infection was reported in 1207 (3%) of 48,219 women in the intervention group and 867 (2%) of 51,523 in the control group (OR 1·45, 1·33-1·58, p<0·0001). INTERPRETATION Despite increased use of antenatal corticosteroids in low-birthweight infants in the intervention groups, neonatal mortality did not decrease in this group, and increased in the population overall. For every 1000 women exposed to this strategy, an excess of 3·5 neonatal deaths occurred, and the risk of maternal infection seems to have been increased. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial

OBJECTIVE: To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population. METHODS: This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively. RESULTS: Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50–10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41–9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93–2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15–2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11–2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15–35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46–12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27–5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30–3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87–3.36). CONCLUSION: Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor. LEVEL OF EVIDENCE: II