Maria Helena de Sousa

Revisão sistemática sobre morbidade materna near miss

This systematic literature review on maternal near miss aims to evaluate data on the incidence and different operational definitions of near miss. An electronic search was performed in databases of scientific journals and also in the references of the identified studies. Initially, 1,247 studies were identified, 35 of which were comprehensively assessed, with 17 excluded and 18 included. Review of reference lists from these articles identified an additional 20 articles, thus completing 38 studies included: 20 adopting definitions of near miss related to management complexity, 6 to organ dysfunction, 2 with a mixed definition, and 10 according to symptoms, signs, or specific clinical entities. The mean near miss ratio was 8.2/1,000 live births, the maternal mortality index was 6.3%, and the case/fatality ratio was 16:1. The study concluded that there was a trend towards higher incidence of near miss in developing countries and when using near miss definitions by organ dysfunction. The study of near miss maternal morbidity can help improve obstetric care and support the struggle against maternal mortality.

Conhecimento sobre métodos anticoncepcionais por estudantes adolescentes

OBJETIVO: Comparar o conhecimento sobre metodos anticoncepcionais e identificar os fatores associados ao conhecimento adequado dos adolescentes de escolas publicas e privadas. METODOS: Realizou-se estudo transversal, do qual participaram 1.594 adolescentes entre 12 e 19 anos, de 13 escolas publicas e cinco privadas do Municipio de Sao Paulo entre junho e dezembro de 2003. As escolas foram selecionadas aleatoriamente e os alunos responderam um questionario sobre caracteristicas sociodemograficas, reprodutivas e metodos anticoncepcionais. As razoes de prevalencia foram calculadas com intervalo de confianca de 95% para cada questao sobre conhecimento de metodos e o tipo de escola. Atribuiu-se meio ponto para cada questao correta sobre conhecimento de anticoncepcionais, o ponto de corte foi 50% de acerto. Os testes estatisticos utilizados foram o qui-quadrado, o Wilcoxon-Gehan e a regressao multipla de Poisson. RESULTADOS: Dentre os adolescentes, 61% eram do sexo feminino nos dois grupos de escolas. Predominou nivel socioeconomico baixo nas escolas publicas e alto nas privadas (p<0,001). Cerca de 18,6% dos adolescentes nas escolas privadas e 28,6% nas publicas tinham atividade sexual (p<0,002). Quanto ao conhecimento, 25,7% dos adolescentes das escolas publicas e 40,8% das privadas apresentaram escore superior ou igual a cinco. Os fatores associados ao maior conhecimento foram ser do sexo feminino, estudar em escola privada, estar no ensino medio, ter nivel socioeconomico alto, ter relacao sexual e ter maior idade. CONCLUSOES: O nivel de conhecimento adequado sobre metodos anticoncepcionais foi baixo para os adolescentes de ambos os tipos de escolas. Os resultados revelam que, assim como os mais desfavorecidos, os adolescentes de maior nivel socioeconomico necessitam de informacoes adequadas sobre planejamento familiar, visando a melhorar esse conhecimento para mudanca seu comportamento.

Atenção ao planejamento familiar no Brasil hoje: reflexões sobre os resultados de uma pesquisa

This two-component study (descriptive cross-sectional and qualitative) assessed the availability of contraceptives in primary care clinics in Brazilian municipalities. The family planning program was also analyzed as part of the countrys Family Health Strategy. Phone interviews were held with local health managers to obtain information on contraceptive supply in a selected sample of municipalities. Four municipalities were selected and visited for the qualitative analysis, using direct observation and semi-structured interviews with health professionals and managers. Descriptive statistical and multiple logistic regression analyses were performed. Content analysis technique was used for qualitative data. According to the results, family planning activities are often not integrated with other health activities. Health professionals and managers failed to understand family planning as part of primary health care and felt unable to assist patients. Family planning in Brazil is marked by the unavailability of contraceptives in public health programs.

Using Life Cycle Assessment to Evaluate Green and Grey Combined Sewer Overflow Control Strategies

Decentralized approaches to managing urban stormwater are gaining increased attention within the contexts of urban sustainability, climate change adaptation, and as a means of reducing combined sewer overflows (CSOs). This study applied a life cycle assessment (LCA) to comparing the environmental efficiency of three means of equivalently reducing CSOs to the Bronx River (Bronx, NY, USA). Strategy 1 featured decentralized green infrastructure technologies, while “grey” strategies 2 and 3 detained, and detained and treated, respectively, excess flows at the end of pipe. We estimated greenhouse gas emissions (in metric tons of carbon dioxide equivalents [t CO‐eq]) over the construction, operation, and maintenance phases, including energy consumed at the wastewater treatment plant (WWTP), carbon sequestered, and shading provided by vegetation (in the case of the green approach) over a 50‐year analysis period. The study area comprised the entire drainage area contributing to New York State permitted CSO discharge points associated with the Hunts Point WWTP. The analysis was performed using a hybrid of process and economic input‐output (EIO) LCA methods. The decentralized green strategy outperformed the two grey strategies in terms of this set of environmental metrics. The net emissions of the green strategy over 50 years was 19,000 t CO‐eq, whereas the grey strategies emitted 85,000 t CO‐eq (detention) and 400,000 t CO‐eq (detention and treatment). These results were significantly influenced by the emissions associated with the operation and maintenance activities required for strategies 2 and 3, and the carbon sequestered and shading provided by the vegetation in strategy 1, and suggest that watershed managers who seek to reduce CSOs and reduce carbon footprints would opt for the green approach.

Abortion in Brazil: a demographic approach

PURPOSE To evaluate the prevalence of spontaneous and induced abortion reported by a sample of Brazilian women interviewed in the National Demographic Health Survey of 1996. METHODS This was a secondary analysis of the Brazilian DHS-96 database, with information from interviews with a representative sample of 12,612 women about their reproductive life, focusing on the prevalence of spontaneous and induced abortion in the last five years and the associated factors for the various regions of the country and for Brazil as a whole. The sampling method was implemented with a strategy selection in two stages, one for the households and the other for women. The prevalence of spontaneous and induced abortion was estimated for Brazil and regions, and the socio-demographic characteristics of the women were analyzed as a function of the abortions experience. A multinomial regression model analysis was used for the identification of factors independently associated with both types of abortion; their OR and respective 95% CI are reported. RESULTS The prevalence of reported spontaneous abortion was 14% and the prevalence of induced abortion was 2.4% for the country as a whole. The state with the highest prevalence of induced abortion was Rio de Janeiro with 6.5%, followed by the Northeast region with 3.1%. The places with the lowest prevalence were the state of São Paulo and the South region. Both spontaneous and induced abortion showed higher prevalences with increasing age of the women studied. Being from the urban area (OR=1.5; 95%CI=1.0-2.3), having had more than one live child (OR=2.2; 95%CI=1.5-3.2) and being non-white (OR=1.4; 95%CI=1.0-1.8) were the main risk factors for induced abortion. CONCLUSIONS The non-modifiable risk factors for induced abortion identified in this study indicate the need for improvement of educational and contraceptive actions, with priority for these specific demographic groups.

A population-based surveillance study on severe acute maternal morbidity (near-miss) and adverse perinatal outcomes in Campinas Brazil: the Vigimoma Project.

BackgroundAuditing of sentinel health events based on best-practice protocols has been recommended. This study describes a population-based investigation on adverse perinatal events including severe acute maternal morbidity (near-miss), maternal and perinatal mortality, as a health intervention to help improve the surveillance system.MethodsFrom October to December 2005, all cases of maternal death (MD), near-miss (NM), fetal deaths (FD), and early neonatal deaths (END), occurring in Campinas, Brazil, were audited by maternal mortality committees.ResultsA total of 4,491 liveborn infants (LB) and 159 adverse perinatal events (35.4/1000 LB) were revised, consisting of 4 MD (89/100.000 LB) and 95 NM (21.1/1000 LB), 23.7 NM for each MD. In addition, 32 FD (7.1/1000 LB) and 28 END (6.2/1000 LB) occurred. The maternal death/near miss rate was 23.7:1. Some delay in care was recognized for 34%, and hypertensive complications comprised 57.8% of the NM events, followed by postpartum hemorrhage.ConclusionAuditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members. Hypertensive disorders and postpartum hemorrhage were identified as priority topics for health providers training, and organization of care.

Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study

BackgroundThe vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death.MethodsThis was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated.ResultsA total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD.ConclusionsAlthough this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival.

Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multidimensional evaluation of their long term consequences.

BackgroundIt has been suggested that the study of women who survive life-threatening complications related to pregnancy (maternal near-miss cases) may represent a practical alternative to surveillance of maternal morbidity/mortality since the number of cases is higher and the woman herself is able to provide information on the difficulties she faced and the long-term repercussions of the event. These repercussions, which may include sexual dysfunction, postpartum depression and posttraumatic stress disorder, may persist for prolonged periods of time, affecting womens quality of life and resulting in adverse effects to them and their babies.ObjectiveThe aims of the present study are to create a nationwide network of scientific cooperation to carry out surveillance and estimate the frequency of maternal near-miss cases, to perform a multicenter investigation into the quality of care for women with severe complications of pregnancy, and to carry out a multidimensional evaluation of these women up to six months.Methods/DesignThis project has two components: a multicenter, cross-sectional study to be implemented in 27 referral obstetric units in different geographical regions of Brazil, and a concurrent cohort study of multidimensional analysis. Over 12 months, investigators will perform prospective surveillance to identify all maternal complications. The population of the cross-sectional component will consist of all women surviving potentially life-threatening conditions (severe maternal complications) or life-threatening conditions (the maternal near miss criteria) and maternal deaths according to the new WHO definition and criteria. Data analysis will be performed in case subgroups according to the moment of occurrence and determining cause. Frequencies of near-miss and other severe maternal morbidity and the association between organ dysfunction and maternal death will be estimated. A proportion of cases identified in the cross-sectional study will comprise the cohort of women for the multidimensional analysis. Various aspects of the lives of women surviving severe maternal complications will be evaluated 3 and 6 months after the event and compared to a group of women who suffered no severe complications in pregnancy. Previously validated questionnaires will be used in the interviews to assess reproductive function, posttraumatic stress, functional capacity, quality of life, sexual function, postpartum depression and infant development.

Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity

To identify factors associated with maternal death among women with severe maternal morbidity.

Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveillance

BackgroundTo identify all the records within the Brazilian Hospital Information System (HIS) that contained information suggestive of severe maternal morbidity (near miss); to describe the diagnoses and procedures used; to identify variables associated with maternal death.MethodsA descriptive population study with data from the HIS and Mortality Information System (MIS) files of records of women during pregnancy, delivery and in the postpartum period in all the capital cities of the Brazilian states in 2002. Initially, records of women between 10 and 49 years of age were selected; next, those records with at least one criterion suggestive of near miss were selected. For the linkage of HIS with MIS and HIS with itself, a blocking strategy consisting of three independent steps was established. In the data analysis, near miss ratios were calculated with corresponding 95% confidence interval and the diagnoses and procedures were described; a multiple logistic regression model was adjusted. Primary and secondary diagnoses and the requested and performed procedures during hospitalization were the main outcome measures.ResultsThe overall maternal near miss ratio was 44.3/1,000 live births. Among the records indicating near miss, 154 maternal deaths were identified. The criteria of severity most frequently found were infection, preeclampsia and hemorrhage. Logistic regression analysis resulted in 12 variables, including four significant interactions.ConclusionAlthough some limitations, the perspective of routinely using this information system for surveillance of near miss and implementing measures to avoid maternal death is promising.