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OBJECTIVE: To assess the impact of the addition of 12 maternity leave (ML) weeks (2011), a pay for performance (P4P) exclusive breastfeeding (EBF) promotion strategy (2015), and the COVID-19 pandemic in EBF inequalities in Chile. STUDY DESIGN: Interrupted time-series analyses (ITSAs). METHODS: Aggregated national EBF data by municipality and month were collected from 2009 to 2020. We assess the impact of the three events in EBF inequalities using two procedures: 1. ITSA stratified by municipal SES quintiles (Q1-Q5); 2. Calculating the EBF slope index of inequality (SII). RESULTS: The EBF prevalence was higher in lower SES municipalities before and after the three time-events. No impact in EBF inequalities was observed after the extended ML. The P4P strategy increased EBF at six months in all SES quintiles (effect size between 4% and 5%), but in a higher level in poorer municipalities (SII: -0.36% and -1.05%). During COVID-19, wealthier municipalities showed a slightly higher EBF at six months prevalence (SII: 1.44%). CONCLUSION: The null impact of the extended ML in EBF inequalities could be explained by a low access to ML among affiliated to the public health system (20%). The P4P strategy includes multiple interventions that seemed effective in increasing EBF across all SES quintiles, but further in lower quintiles. The restrictions in healthcare access in poorer municipalities could explain EBF inequalities during COVID-19.

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BACKGROUND: In industrialized countries, most students are admitted to medical schools after obtaining a Bachelor degree. In 1993, the Catholic University of Chile instituted a program to obtain a Bachelor degree. These students can apply to Medical School. AIM: To compare the academic achievement of students admitted to medical school directly from high school or after obtaining a Bachelor degree. SUBJECTS AND METHODS: Cohorts of medical students coming directly from high school or after obtaining a Bachelor of Sciences degree, between 1997 and 2001, were studied. Social and demographic background, scores of the Academic Achieving test and grades obtained during high school and in medical school, were compared in both groups. RESULTS: The distribution of gender and the region of origin were similar in both groups of students. Thirty two percent of bachelors and 18 per cent of high school students admitted to medical school, came from public schools (p = 0.014). The Academic Achieving test score was 727 +/- 27 and 764 +/- 11 points in bachelor and high school students respectively (< 0.001). However the mean grades in Medical School were similar in both groups of students. CONCLUSIONS: Bachelor degrees are a good opportunity for students, that must be considered by Medical Schools in their admission systems.

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BACKGROUND: Annually, acute bronchiolitis (AB) occurrence peaks during winter and is probably associated with air pollution. AIM: To relate the number of ambulatory consultations, emergency and hospital admission due to AB with climatic factors and air pollution. PATIENTS AND METHODS: Patients of less than 1 year old with AB that consulted to outpatient clinics, the emergency room or were admitted to the Pediatrics ward of the Catholic University Hospital, were enrolled. Information about respiratory syncytial virus (RSV) was obtained from the Catholic University Medical Investigation Center. Indices of air pollution such as particulate matters of less than 10 microns/m3 (PM 10), of less than 2.5 microns/m3 (PM 2.5), CO, SO3 and O3 were obtained from the Metropolitan Environmental Service. Temperature, humidity and precipitations were obtained from the Chilean Meteorological Service. RESULTS: Ninety nine consultations in out patient clinics and 442 in emergency rooms were collected (55 per cent male, mean age 4.8 months). One hundred fifty two were admitted (34.4 per cent). Thirty percent of children consulting in emergency rooms were younger than 3 months and 43 per cent of them were hospitalized. The RSV study was made in 307 patients and 52 per cent were positive. There was a higher rate of hospital admissions among RSV positive than RSV negative patients (52.5 and 22 per cent respectively, p < 0.001). No association between environmental variables or air pollution and the number of consultations was observed. Young age and smoking inside the household were the main risk factors for hospital admission due to acute bronchiolitis. CONCLUSIONS: Environmental variables did not influence the number of cases of acute bronchiolitis. Young age and exposure to tobacco smoke were risk factors for hospital admission.

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BACKGROUND: In the last two decades, Chile has experienced advances in economical development and global health indicators. However, gender inequities persist in particular related to access to health services and financing of health insurance. AIM: To examine gender inequities in the access to health care in Chile. MATERIAL AND METHODS: An analysis of data obtained from a serial national survey applied to assess social policies (CASEN) carried out by the Ministry of Planning. During the survey 45,379 and 48,107 dwellings were interviewed in 1994 and in 1998, respectively. RESULTS: Women use health services 1.5 times more often, their salaries are 30 per cent lower in all socioeconomic strata. Besides, in the private health sector, women pay higher insurance premiums than men. Men of less than two years of age have 2.5 times more preventive consultations than girls. This difference, although of lesser magnitude, is also observed in people over 60 years. Women of high income quintiles and users of private health insurance have a better access to preventive consultations but not to specialized care. CONCLUSIONS: An improvement in equitable access of women to health care and financing is recommended. Also, monitoring systems to survey these indicators for women should improve their efficiency.

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UNLABELLED: A new challenge in health policy is the implementation of evidence-based practice. It is useful to look at international experiences which go beyond the conventional USA and UK examples. Health sector restructuring in Chile has as its goals: using evidence-based decision-making to reduce variations of practice, contain costs and increase the effectiveness of clinical practice. A key area of change is within primary health care. But how does the implementation of evidence-based health care proceed in reality? In order to understand this, it was decided to assess the policy environment using stakeholder analysis. METHODS: Fifteen stakeholders from the public health sector were interviewed in depth using a snowball strategy for sampling. Material relating to perceptions, thoughts and aspirations about evidence-based innovations in primary health care was collected. Content analysis of the material produced a matrix of criteria and indicators of operational power. RESULTS: Concepts of evidence and effectiveness are different according to the role of each stakeholder in the health system. Most innovations proposed by government are related to management and stakeholders considered them as not being evidence-based. Informal mechanisms of decision-making predominated over the formal. Political issues are more important than formal evidence. All stakeholders felt they had power to define policy criteria but not to implement them. Implementation difficulties are related to how the system is organized and the culture within each organization. Most stakeholders indicated the need for human resources with appropriate knowledge and personal skills in order to implement these changes. These findings reveal again the importance of human factors within organizations. Policy-making should consider such processual aspects in order to implement changes in practices in Chilean health care system more effectively.

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BACKGROUND: Congenital malformations are defined as those structural, metabolic or functional defects found at birth. AIM: To study the mortality due to congenital malformations in Chile between 1969 and 1997, their type, individual, temporal and geographic variations. MATERIAL AND METHODS: A descriptive analysis of deaths registered by the National Statistics Institute and the Ministry of Health. Means, frequencies, raw and adjusted rates were calculated and inferences for some variables were carried out. RESULTS: Between 1969 and 1997 ther was tendency towards a reduction in rates of mortality due to congenital malformations and an increment in their relative importance. During the period, the risk for chromosome (98%) and osteomuscular (67%) malformations increased. Men and children of less than one year had the higher risk. In 1995, 1167 deaths due to congenital malformations were registered, 90% in children of less than 5 years. Higher risks occurred in urban zones (with a rate of 8.25 per 100,000) in the third region (rate 11.59) and second region (rate 11.2). Most deaths occurred in hospitals (85%). Main causes of death were circulatory system, central nervous system and chromosome malformations. CONCLUSIONS: The differences in regional deaths due to congenital malformations suggests specific risks that deserve further study.

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BACKGROUND: Health care research has demonstrated that the primary care level can provide effective services. AIM: To propose a basic package of services for primary health care in medium income countries, based on evidences about its effectiveness. MATERIALS AND METHODS: Scientific evidence for the effectiveness of primary care services was first sought through a systematic literature research. Interventions with evidences of effectiveness and appropriate for the Chilean epidemiological profile were selected. The cost in US dollars for a 100,000 inhabitant population was established. RESULTS: Fourteen programs with evidence of effectiveness were selected: immunizations, infant growth and development surveillance, pregnancy surveillance, family planning, cervical cancer screening, diabetes, hypertension, prevention of stroke, smoking cessation, treatment of problem drinkers, depression, lower respiratory infections in children of less than 6 years old, tuberculosis and palliative care. The total cost was calculated in US$ 36 per person/year. CONCLUSIONS: This proposal must be flexible, according to local conditions and changes in evidence. It is based in the "new universality" proposed by WHO, that combines a high coverage in key zones with economical realism.

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BACKGROUND: Fetal drug addiction is a serious public health problem. In the United States 10 to 15% of children have been exposed "in utero" to cocaine. In a Chilean public health service, more than 200 offspring of cocaine free base abuser have been detected. AIM: To analyze the clinical and social features of 100 children exposed to cocaine free base during fetal development. PATIENTS AND METHODS: Clinical features of children born from cocaine free base consume mothers were described at birth. During subsequent follow up, growth and development, disease episodes, developmental alterations and social situation were recorded. Data was compared with other newborns from the same health service. RESULTS: Compared to their normal counterparts, exposed children has a lower birth weight, the frequency of premature babies was thrice higher, and small-for-gestational age children were four times more common. There was also a higher prevalence of cardiac malformations, seizures and apnea. Hospital admissions were more frequent, prolonged and required more complex facilities. During follow up, undernutrition and stunting were more prevalent. Psychomotor retardation was present in 67% of children and behavioral disturbances in 93%. Most of these children are governmental protection. CONCLUSIONS: Strategies to prevent drug abuse during pregnancy and its devastating medical and social consequences should be urgently developed (Rev Méd Chile 2000; 128: 1093-1100).

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BACKGROUND: Traffic accidents are one of the most important public health problems in the world and produce social, work and human resources losses. AIM: To perform an epidemiological description of traffic accidents occurred in Chile during 1994. MATERIAL AND METHODS: Data were obtained from death certificates in which the cause of death was a traffic accident. All death certificates obtained by the National Institute of Statistics during 1994 were used. Social, demographic and seasonal variables were recorded. RESULTS: During 1994, there were 1679 deaths due to traffic accidents (81% male), with a rate of 19.6 per 100,000 inhabitants. Gender specific risks were 19.62 and 4.48 for men and women, respectively. Mean age at the moment of death was 39 years old. Fifty three percent of deceased people were single, 42% married and 5% widowers. Ten percent had no formal education, 48% had basic education, 23% college education and 6.5% university education. Seventy seven percent of fatalities occurred in urban areas. The risk of death by traffic accidents was 7.02 per 100,000 inhabitants in the metropolitan region. CONCLUSIONS: The information obtained in the present study may help to generate preventive strategies to control deaths caused by traffic accidents.

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AIM: To study abnormal alcohol ingestion among parents and family dysfunction of pregnant and non pregnant teenagers. SUBJECTS AND METHODS: Pregnant and non pregnant girls from 12 to 18 years old consulting in the Teenager Health Unit of a public hospital outpatient clinic were studied. Their degree of instruction attained, marital status, social behavior, alcohol, drug intake and history of child abuse was recorded. The level of instruction, marital status, alcohol ingestion and work stability of their fathers was also studied. RESULTS: One hundred sixteen pregnant and 60 non pregnant teenagers were studied. The fathers of pregnant girls had a higher level of alcohol consumption, more civil irregularities and a higher level of family dysfunction. Among these girls, a higher frequency of neurological abnormalities and fetal alcohol syndrome was observed. They had also a lower educational level and a higher degree of alcohol and drug use. CONCLUSIONS: Alcohol consumption among parents leads to family dysfunction and has adverse physical, intellectual and social consequences in the offspring.

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Among children living in orphanages of the Metropolitan Region, the paternal alcohol ingestion patterns were investigated. According to abnormal parental alcohol ingestion, a sample of 291 children was studied, of whom 32% were living in simple protection homes for infants with normal intellectual coefficient and 52% in homes for mentally retarded boys. There was a higher frequency and intensity of abnormal alcohol ingestion among parents of infants living in homes for the mentally retarded. Among these, 29% of mothers were illiterate and 11% had incomplete primary school education compared to mothers of simple protection homes in whom the frequency of illiteracy was 10% and of incomplete primary education, 50%. Twenty percent of fathers of children living in homes for the mentally retarded were unemployed, 16% had occasional jobs and 11% had a stable work; these numbers were 11, 30 and 15% respectively for fathers of simple protection homes. Among infants living in homes for the mentally retarded, undernutrition was found in 44%, growth retardation in 51% and microcephaly in 34% compared to 33, 30 and 11% in children living in simple protection homes. Sixteen percent of the sample had fetal alcohol syndrome, 24% among those living in homes for the mentally retarded and 12% in simple protection homes. There was an inverse relationship between offspring intellectual coefficient and the number of drinking parents.

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The results of a retrospective study on 97 cases of congenital hip dysplasia and 100 controls matched by sex and birth weight are presented. A female: male ratio of 6.5:1 and a higher frequency (68%) of bilateral involvement were found. Statistically significant differences were found for a positive family history of congenital hip dysplasia and breech presentation and 23% cases were not clinically suspected before hip x-ray. Better screening methods by early ultrasonography and radiologic examination are proposed.

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To determine if the egg provides any clues for the regulation of ovum transport in the hamster, oocyte and embryo transport were compared. On the evening preceding ovulation, the animals were randomly assigned to one of five groups. They were caged overnight with a male of proven fertility (Group 1) or they were isolated (Group 2). Other females were artificially inseminated in both uterine horns at 2200 h either with fertile epididymal spermatozoa (Group 3), spermatozoa rendered infertile by freezing and thawing (Group 4), or with fertile spermatozoa in one uterine horn and infertile spermatozoa in the contralateral horn (Group 5). The number, condition, and distribution of ova in the genital tract were assessed at various intervals during the next 4 days. The rate of fertilization and normal development in females or sides inseminated with fertile or infertile spermatozoa was over 90% and 0% respectively. Embryos in Groups 1 and 3 reached the uterus 1 day earlier than unfertilized oocytes in Groups 2 and 4. In group 5, the transport of embryos resulting from insemination with fertile spermatozoa followed a pattern similar to those in Groups 1 and 3; the oocytes in the contralateral tract resembled those of Groups 2 and 4. The different transport rates of embryos and oocytes were not associated with the reproductive state of the female but with the condition of the ova. Moreover, the different transport rates were observed in animals transporting the two types of eggs simultaneously on different sides indicating that there is a local recognition of some unidentified factor unequally present in fertilized and unfertilized eggs.

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