Lorena Binfa

Age, menopause and hormone replacement therapy influences on cardiovascular risk factors in a cohort of middle-aged Chilean women

OBJECTIVE To determine the prevalence of obesity and other cardiovascular risk factors (RF) in middle-aged women, to correlate them with each other, and to describe the prevalence of such a RF and their changes with aging, menopause and Hormone Replacement Therapy (HRT) in a cohort of Chilean workers. MATERIAL AND METHOD In 1991-1992 cardiovascular RFs were assessed in 467 women between 40 and 59 who were not taking HRT at that time. Five years later these women were re-evaluated. RESULTS Sedentarism (87.2%), dyslipidemias (71.5%), high blood pressure (13.5%), obesity (13.1%), smoking (12.4%) and diabetes (2.8%) were the more prevalent RF. These RF become more prevalent with age. In the second control, 5 years later, hypertension (20.9%), obesity (27.3%), smoking (20.8%) and diabetes (5.9%) were observed increased. Dyslipidemia did not changed, although triglyceride levels rose from 125.9+/-56.4 to 136.8+/-63.5 mg/dl (P<0.01). Sedentarism dropped to 58.8%. Menopause did not deteriorate any of these RF. The use of HRT increased during the 5-years follow-up from 3.8 to 35%, and related to its use a decrease in LDL-cholesterol and an increase in HDL-cholesterol levels were detected. CONCLUSION Middle-aged women included in this cohort have a high prevalence of RF; these deteriorate with age, but no with menopause. HRT improves the lipid profile.

A scheme of combined oral contraceptives for women more than 40 years old.

ObjectiveTo study whether the addition of estrogen to the 7 hormone-free days of a combined oral contraceptive (OC) cycle improves the symptomatology in perimenopausal women with climacteric complaints. DesignA total of 56 women in their forties presenting with mood disorders and/or hot flashes were included in this randomized double-blind study. Symptoms were evaluated using the Greene test. Subjects were allocated into two groups: 23 women received an OC containing 20 &mgr;g of ethinyl-estradiol and 150 mg of desogestrel for 21 days and then 7 placebo tablets (placebo group); the other 33 women received 21 tablets with the same hormone combination, followed by 2 placebo tablets and 5 ethinyl-estradiol tablets of 10 &mgr;g each (estrogen group). After three cycles, symptoms were reassessed. ResultsSymptoms were similar in the two groups at the start of the study. Three months later, vasomotor symptoms in the placebo group dropped from 3.3 ± 1.7 to 1.7 ± 1.8, and in the estrogen group, from 3.0 ± 1.7 to 0.7 ± 0.9 (p < 0.04). Similarly, symptoms of depression fell from 8.8 ± 4.0 to 6.7 ± 3.9 in the placebo group and from 10.3 ± 3.5 to 3.8 ± 2.9 in the estrogen group (p < 0.002). Somatic symptoms fell with placebo from 10.9 ± 5.3 to 7.4 ± 5.4, and with estrogen, from 9.7 ± 4.9 to 4.0 ± 2.5 (p < 0.03). Sexual dysfunction as measured by the Greene Scale (loss of sexual interest) also improved more in women who received additional estrogen: 2.0 ± 0.9 to 0.5 ± 0.9 vs. 1.8 ± 1.2 to 1.2 ± 1.2, p < 0.03. Anxiety symptoms improved in both groups but without any significant difference between them. ConclusionsAdding 5 days of estrogen to the classic contraceptive scheme improves the climacteric symptoms of perimenopausal women who use OCs.

Assessment of the implementation of the model of integrated and humanised midwifery health services in Santiago, Chile

OBJECTIVES during 2007 the Chilean Ministry of Public Health introduced the Model of Integrated and Humanized Health Services, in addition to the Clinical Guide for Humanized Care during Delivery. Three years after its implementation, a study was conducted (i) to describe selected clinical outcomes of women who received care within this model, (ii) to identify the degree of maternal-newborn well-being and (iii) to explore the perception of this humanised attention during labour and delivery by both the professional staff (obstetricians and midwives) and consumers. DESIGN AND METHOD a cross-sectional, descriptive study using both quantitative and qualitative methods was conducted with 508 women who delivered in two major hospitals within the National Health System in the metropolitan area of Santiago, Chile, from September 2010 until June 2011. The quantitative methods included a validated survey of maternal well-being and an adapted version of the American College of Nurse-Midwives (ACNM) standardised antepartum and intrapartum data set. The qualitative methods included six focus groups discussions (FGDs), with midwives, obstetricians and consumers. Additionally, two in depth interviews were carried out with the directors of the maternity units. FINDINGS the quantitative findings showed poor implementation of the guidelines: 92.7% of the women had medically induced labours (artificial rupture of the membranes and received oxytocin and epidural anaesthesia), and almost one-third of the women reported discontent with the care they received. The qualitative findings showed that the main complaint perceived by the midwives was that the health system was highly hierarchical and medicalised and that the obstetricians were not engaged in this modality of assistance. The women (consumers) highlighted that professionals (midwives and obstetricians) were highly technically skilled, and they felt confident in their assistance. However, women complained about receiving inadequate personal treatment from these professionals. The obstetricians showed no self-critique, stating that they always expressed concern for their patients and that they provided humanised professional assistance. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE by illuminating the main strengths and weakness with regard to the application of the model, these findings can help to inform strategies and actions to improve its implementation.

Exploring historical conflicts between midwives and nurses: a perspective from Chile

Abstract This article explores issues of historical disputes between nurses and midwives based in Chile. The interaction of these two professions in that country has become an arena of competition which leads to conflicts periodically, such as those related to the ownership of the care of new-borns, and that of projects aimed at relieving nurse shortages by enhancing midwives’ nursing skills. Specifically, this article aims to build on historical and contemporary resources analysed from a sociological perspective, and present comparatively a rationale concerning nursing/midwifery jurisdictional conflicts through a social history account. Our analysis suggests that nurses/midwives interaction has been shaped by social-historical transformations and the continuous evolution of the healthcare system as a whole, resulting in a race towards technologisation. These interprofessional conflicts can be explained partly by mechanisms of boundary expansion within an organisational/interpretive domain, as well as varying degrees of medicalisation; and partly by a competition possibly originating from a middle-class consciousness. An eventual merger of the two professions might lead to the enhancement of the political power of the caring professions and integrated care.

Midwifery practice and maternity services: A multisite descriptive study in Latin America and the Caribbean

OBJECTIVE over the past three decades there has been a social movement in Latin American countries (LAC) to support humanised, physiologic birth. Rates of caesarean section overall in Latin America are approximately 35%, increasing up to 85% in some cases. There are many factors related to poor outcomes with regard to maternal and newborn/infant health in LAC countries. Maternal and perinatal outcome data within and between countries is scarce and inaccurate. The aims of this study were to: i) describe selected obstetric and neonatal outcomes of women who received midwifery care, ii) identify the level of maternal well-being after experiencing midwifery care in 6 Latin America countries. DESIGN this was a cross sectional and descriptive study, conducted in selected maternity units in Argentina, Brazil, Chile, the Dominican Republic, Peru, and Uruguay. Quantitative methods were used to measure midwifery processes of care and maternal perceptions of well-being in labour and childbirth through a validated survey of maternal well-being and an adapted version of the American College of Nurse-Midwives (ACNM) standardized antepartum and intrapartum data set. SETTING Maternity units from 6 Latin American countries. PARTICIPANTS the final sample was a convenience sample, and the total participants for all sites in the six countries was 3009 low risk women. FINDINGS for the countries reporting, overall, 82% of these low risk women had spontaneous vaginal deliveries. The rate of caesarean section was 16%; the Dominican Republic had the highest rate of Caesarean sections (30%) and Peru had the lowest rate (4%). The use of oxytocin in labour was widely variable, although overall there was a high proportion of women whose labour was augmented or induced. Ambulation was common, with the lowest proportion (48%) of women ambulating in labour in Chile, Uruguay (50%), Peru (65%), Brazil (85%). The presence of continuous support was highest in Uruguay (93%), Chile (75%) and Argentina (55%), and Peru had the lowest (22%). Episiotomies are still prevalent in all countries, the lowest rate was reported in the Dominican Republic (22%), and the highest rates were 52 and 53% (Chile and Peru, respectively). The Optimal Maternal well-being score had a prevalence of 43.5%, adequate score was 30.8%; 25% of the total sample of women rated their well-being during labour and childbirth as poor. KEY CONCLUSIONS despite evidence-based guidelines and recommendations, birth is not managed accordingly in most cases. Women feel that care is adequate, although some women report mistreatment. IMPLICATIONS FOR PRACTICE More research is needed to understand why such high levels of intervention exist and to test the implementation of evidence-based practices in local settings.

Chilean women's reflections about womanhood and sexuality during midlife in a Swedish or Chilean context.

In order to learn about Chilean womens reflections about womanhood and sexuality during midlife, we held focus group discussions (FGDs) with middle-aged Chilean women living in Stockholm, Sweden, or in Santiago, Chile. We used thematic content analysis for the qualitative data. Emerging themes follow; societal expectations on women, perceptions about sexual relationships, and womens social stigmatization. The women had since childhood been strongly influenced by a gender-imbalanced world, which had made them socially, economically, and biologically at higher risk for exploitation during life. More focus should be directed to middle-aged womens life situation and promotion of gender equity in society.

Labor and Birth Care Satisfaction Associated With Medical Interventions and Accompaniment During Labor Among Chilean Women

Introduction: Satisfaction with care during labor and birth has been associated with various obstetric variables. The purpose of this study was to determine which labor and birth procedures are significant predictors of maternal patient satisfaction in a large cross‐sectional sample. Methods: An observational, cross‐sectional study of 1660 women giving birth in Chilean public hospital facilities was conducted from 2012 to 2013. Data were collected from 9 different hospitals in 8 regions of Chile using 2 instruments, including the American College of Nurse‐Midwives Intrapartum Care Data Set and a locally validated measure of maternal well‐being. Women were eligible if they arrived at the labor and delivery unit during early labor (2‐3 centimeters dilated) and spent at least 4 hours in labor at the facility. In the current analysis, odds ratios were calculated using ordinal logistic regression for association with a less optimal well‐being score (possible outcome values were optimal, adequate, and minimal). Odds ratios were adjusted for age, education, single status, and parity (nulliparous vs multiparous). Stepwise regression was used to identify the procedural factors that were significantly associated with labor and birth care satisfaction. Results: Factors significantly associated with lower satisfaction were cesarean birth (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1‐1.7), pharmacologic pain management (OR, 1.3; 95% CI, 1.02‐1.7), continuous fetal heart rate monitoring (OR. 1.4; 95% CI, 1.2‐1.8), and episiotomy (OR, 1.4; 95% CI, 1.1‐1.7). Nulliparity was also associated with minimal maternal satisfaction (OR, 1.3; 95% CI, 1.0‐1.5). Greater satisfaction was associated with accompaniment by a companion of choice during labor (OR, 0.49: 95% CI, 0.40‐0.60). Discussion: This study is one of the first to provide empirical evidence that maternal patient satisfaction is negatively affected by many common obstetric procedures in the Latin American context. These findings are consistent with World Health Organization recommendations regarding judicious and necessary, rather than routine, use of obstetric interventions.

Clinical nursing and midwifery research in Latin American and Caribbean countries: A scoping review

AIM To identify and describe published, nursing-led and midwifery-led, clinical research that has been conducted in Latin America and the Caribbean. BACKGROUND Peer-reviewed published research may correspond to and elucidate countrys realities, priorities, and needs. DESIGN A 6-stage scoping review methodology was used to search scientific databases using an applied search strategy. DATA SOURCES Five databases were searched for articles published in English, Spanish, or Portuguese conducted in a Latin American or Caribbean country between January 1, 2006 and June 14, 2016. REVIEW METHODS Articles were independently considered for inclusion by 2 researchers, data extracted, and study characteristics described. RESULTS Of 6922 articles identified, 404 were included. The majority were conducted in Brazil (90.6%) followed by Chile (2.5%). Most were nurse-led (95.8%) and were implemented in hospitals (48.6%). Studies frequently explored patient knowledge or characterized patient populations (61.3%) and commonly assessed chronic disease (19.3%) or maternity/child health outcomes (15.9%). CONCLUSION Findings revealed a large number of publications but an uneven geographical distribution of nurse-led clinical research and an evident gap of midwifery-related research in Latin America and the Caribbean. Results may be used to build research agendas to promote nursing and midwifery research capacity and further establish evidence-based practice.

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.