RESUMO
BACKGROUND: Evidence shows that adequate calcium intake during pregnancy reduces the risk of hypertensive disorders of pregnancy. In most low- and middle-income countries (LMICs) the daily calcium intake is well below recommendations. Mapping calcium intake during pregnancy worldwide and identifying populations with low calcium intake will provide the evidence base for more targeted actions to improve calcium intake. OBJECTIVE: To assess dietary calcium intake during pregnancy worldwide. SEARCH STRATEGY: MEDLINE and EMBASE (from July 2004 to November 2017). SELECTION CRITERIA: Cross-sectional, cohort, and intervention studies reporting calcium intake during pregnancy. DATA COLLECTION AND ANALYSIS: Five reviewers working in pairs independently performed screening, extraction, and quality assessment. We reported summary measures of calcium intake and calculated the weighted arithmetic mean for high-income countries (HICs) and LMICs independently, and for geographic regions, among studies reporting country of recruitment, mean intake, and total number of participants. When available, inadequate intakes were reported. MAIN RESULTS: From 1880 citations 105 works met the inclusion criteria, providing data for 73 958 women in 37 countries. The mean calcium intake was 948.3 mg/day (95% CI 872.1-1024.4 mg/day) for HICs and 647.6 mg/day (95% CI 568.7-726.5 mg/day) for LMICs. Calcium intakes below 800 mg/day were reported in five (29%) countries from HICs and in 14 (82%) countries from LMICs. CONCLUSION: These results are consistent with a lack of improvement in calcium dietary intake during pregnancy and confirm the gap between HICs and LMICs, with alarmingly low intakes recorded for pregnant women in LMICs. From the public health perspective, in the absence of specific local data, calcium supplementation of pregnant women in these countries should be universal. TWEETABLE ABSTRACT: Despite dietary recommendations, women in LMICs face pregnancy with diets low in calcium.
Assuntos
Cálcio da Dieta/uso terapêutico , Dieta/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Países em Desenvolvimento , Feminino , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Gravidez , Fatores de RiscoRESUMO
OBJECTIVE: To describe country-level stillbirth rates and their change over time in Latin America, and to measure the association of stillbirth rates with socio-economic and health coverage indicators in the region. DESIGN: Ecological study. SETTING: 20 countries of Latin America. POPULATION OR SAMPLE: Aggregated data from pregnant women with countries as units of analysis. METHODS: We used stillbirth estimates, and socio-economic and healthcare coverage indicators reported from 2006 to 2016 from UNICEF, United Nations Development Programme and World Bank datasets. We calculated Spearman's correlation coefficients between stillbirths rates and socioeconomic and health coverage indicators. MAIN OUTCOME MEASURES: National estimates of stillbirth rates in each country. RESULTS: The estimated stillbirth rate for Latin America for 2015 was 8.1 per 1000 births (range 3.1-24.9). Seven Latin America countries had rates higher than 10 stillbirths per 1000 births. The average annual reduction rate for the region was 2% (range 0.1-3.8%), with the majority of Latin America countries ranging between 1.5 and 2.5%. National stillbirth rates were correlated to: women's schooling (rS = -0.7910), gross domestic product per capita (rS = -0.8226), fertility rate (rS = 0.6055), urban population (rS = -0.6316), and deliveries at health facilities (rS = -0.6454). CONCLUSIONS: Country-level estimated stillbirth rates in Latin America varied widely in 2015. The trend and magnitude of reduction in stillbirth rates between 2000 and 2015 was similar to the world average. Socio-economic and health coverage indicators were correlated to stillbirth rates in Latin America. TWEETABLE ABSTRACT: Stillbirth rates decreased in Latin America but remain relatively high, with wide variations among countries.
Assuntos
Natimorto/epidemiologia , Coeficiente de Natalidade , Parto Obstétrico , Países em Desenvolvimento , Escolaridade , Feminino , Produto Interno Bruto , Instalações de Saúde , Humanos , América Latina/epidemiologia , Mortalidade Materna , Gravidez , População UrbanaRESUMO
OBJECTIVE: To describe obstetrical providers' delivery preferences and attitudes towards caesarean section without medical indication, including on maternal request, and to examine the association between provider characteristics and preferences/attitudes. DESIGN: Cross-sectional study. SETTING: Two public and two private hospitals in Argentina. POPULATION: Obstetrician-gynaecologists and midwives who provide prenatal care and/or labour/delivery services. METHODS: Providers in hospitals with at least 1000 births per year completed a self-administered, anonymous survey. MAIN OUTCOME MEASURES: Provider delivery preference for low-risk women, perception of women's preferred delivery method, support for a woman's right to choose her delivery method and willingness to perform caesarean section on maternal request. RESULTS: 168 providers participated (89.8% coverage rate). Providers (93.2%) preferred a vaginal delivery for their patients in the absence of a medical indication for caesarean section. Whereas 74.4% of providers supported their patient's right to choose a delivery method in the absence of a medical indication for caesarean section and 66.7% would perform a caesarean section upon maternal request, only 30.4% would consider a non-medically indicated caesarean section for their own personal delivery or that of their partner. In multivariate adjusted analysis, providers in the private sector [odds ratio (OR) 4.70, 95% CI 1.19-18.62] and obstetrician-gynaecologists (OR 4.37, 95% CI 1.58-12.09) were more willing than either providers working in the public/both settings or midwives to perform a caesarean section on maternal request. CONCLUSIONS: Despite the ethical debate surrounding non-medically indicated caesarean sections, we observe very high levels of support, especially by providers in the private sector and obstetrician-gynaecologists, as aligned with the high caesarean section rates in Argentina. TWEETABLE ABSTRACT: Non-medically indicated c-section? 74% of sampled Argentine OB providers support women's right to choose.
Assuntos
Atitude do Pessoal de Saúde , Cesárea , Procedimentos Cirúrgicos Eletivos/métodos , Obstetrícia , Preferência do Paciente , Adulto , Argentina/epidemiologia , Atitude Frente a Saúde , Cesárea/ética , Cesárea/psicologia , Cesárea/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Obstetrícia/ética , Obstetrícia/métodos , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Direitos do Paciente , Gravidez , Utilização de Procedimentos e Técnicas/estatística & dados numéricosRESUMO
BACKGROUND: Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP). METHODS: This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included. RESULTS: Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis). CONCLUSIONS: There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.
Assuntos
Determinação da Pressão Arterial , Pressão Sanguínea/efeitos dos fármacos , Conservadores da Densidade Óssea/administração & dosagem , Cálcio da Dieta/administração & dosagem , Pré-Eclâmpsia/prevenção & controle , Complicações Cardiovasculares na Gravidez/prevenção & controle , Adulto , Argentina , Determinação da Pressão Arterial/métodos , Método Duplo-Cego , Feminino , Humanos , Gravidez , Medição de Risco , África do Sul , Resultado do Tratamento , Organização Mundial da Saúde , ZimbábueRESUMO
BACKGROUND: The striking increase in caesarean section rates in middle- and high-income countries has been partly attributed to maternal request. We conducted a systematic review and meta-analysis of women's preferences for caesarean section. OBJECTIVES: To review the published literature on women's preferences for caesarean section. SEARCH STRATEGY: A systematic search of MEDLINE, EMBASE, LILACS and PsychINFO was performed. References of all included articles were examined. SELECTION CRITERIA: We included studies that quantitatively evaluated women's preferences for caesarean section in any country. We excluded articles assessing health providers' preferences and qualitative studies. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened abstracts of all identified citations, selected potentially eligible studies, and assessed their full-text versions. We conducted a meta-analysis of proportions, and a meta-regression analysis to determine variables significantly associated with caesarean section preference. MAIN RESULTS: Thirty-eight studies were included (n = 19,403). The overall pooled preference for caesarean section was 15.6% (95% CI 12.5-18.9). Higher preference for caesarean section was reported in women with a previous caesarean section versus women without a previous caesarean section (29.4%; 95% CI 24.4-34.8 versus 10.1%; 95% CI 7.5-13.1), and those living in a middle-income country versus a high-income country (22.1%; 95% CI 17.6-26.9 versus 11.8%; 95% CI 8.9-15.1). AUTHORS' CONCLUSIONS: Only a minority of women in a wide variety of countries expressed a preference for caesarean delivery. Further research is needed to better estimate the contribution of women's demand to the rising caesarean section rates.
Assuntos
Cesárea/psicologia , Preferência do Paciente , Gestantes/psicologia , Estudos Transversais , Feminino , Humanos , Gravidez , Análise de RegressãoRESUMO
OBJECTIVE: To investigate whether the length of the interval between an abortion and the next pregnancy is associated with increased risks of adverse maternal and perinatal outcomes in Latin America. METHOD: Retrospective cross-sectional study using information from 258,108 women delivering singleton infants and whose previous pregnancy resulted in abortion recorded in the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 2002. Adjusted odds ratios were obtained through logistic regression analysis. RESULT: Compared with the post-abortion interpregnancy intervals of 18 to 23 months, intervals shorter than 6 months were significantly associated with increased risks of maternal anemia, premature rupture of membranes, low birth weight, very low birth weight, preterm delivery, and very preterm delivery. CONCLUSION: In Latin America, post-abortion interpregnancy intervals shorter than 6 months are independently associated with increased risks of adverse maternal and perinatal outcomes in the next pregnancy. DEFINITION: Post-abortion interpregnancy interval (PAII): the time elapsed between the day of the abortion and the first day of the last menstrual period for the index pregnancy.
Assuntos
Aborto Induzido , Intervalo entre Nascimentos , Adulto , Anemia/epidemiologia , Estudos Transversais , Bases de Dados como Assunto , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , América Latina/epidemiologia , Modelos Logísticos , Razão de Chances , Gravidez , Nascimento Prematuro/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases (to December 2002), and the Cochrane Controlled Trials Register (The Cochrane Library), were searched using the key words terms "kangaroo mother care" or "kangaroo care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomized trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). Psychomotor development at 12 months' corrected age was similar in the two groups. There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.
Assuntos
Cuidado do Lactente/métodos , Mortalidade Infantil , Recém-Nascido de Baixo Peso , Estimulação Física/métodos , Humanos , Recém-Nascido , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto , Aumento de PesoRESUMO
OBJECTIVE: To study the impact of interpregnancy interval on maternal morbidity and mortality. DESIGN: Retrospective cross sectional study with data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay. SETTING: Latin America and the Caribbean, 1985-97. PARTICIPANTS: 456 889 parous women delivering singleton infants. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios of the effects of short and long interpregnancy intervals on maternal death, pre-eclampsia, eclampsia, gestational diabetes mellitus, third trimester bleeding, premature rupture of membranes, postpartum haemorrhage, puerperal endometritis, and anaemia. RESULTS: Short (<6 months) and long (>59 months) interpregnancy intervals were observed for 2.8% and 19.5% of women, respectively. After adjustment for major confounding factors, compared with those conceiving at 18 to 23 months after a previous birth, women with interpregnancy intervals of 5 months or less had higher risks for maternal death (odds ratio 2.54; 95% confidence interval 1.22 to 5.38), third trimester bleeding (1.73; 1.42 to 2.24), premature rupture of membranes (1.72; 1.53 to 1.93), puerperal endometritis (1.33; 1.22 to 1.45), and anaemia (1.30; 1.18 to 1.43). Compared with women with interpregnancy intervals of 18 to 23 months, women with interpregnancy intervals longer than 59 months had significantly increased risks of pre-eclampsia (1.83; 1.72 to 1.94) and eclampsia (1.80; 1.38 to 2.32). CONCLUSIONS: Interpregnancy intervals less than 6 months and longer than 59 months are associated with an increased risk of adverse maternal outcomes.
Assuntos
Intervalo entre Nascimentos , Mortalidade Materna , Aborto Espontâneo/epidemiologia , Adulto , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Idade Materna , Razão de Chances , Gravidez , Complicações na Gravidez/mortalidade , Estudos Retrospectivos , Fatores de Risco , Uruguai/epidemiologiaRESUMO
BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases, and the Cochrane Controlled Trials Register (Cochrane Library) up to Issue 2, 2000, were searched using the key words terms "kangaroo mother care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomised trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.
Assuntos
Educação Infantil , Mortalidade Infantil , Recém-Nascido de Baixo Peso , Relações Pais-Filho , Aleitamento Materno , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Estimulação Física , Ensaios Clínicos Controlados Aleatórios como Assunto , Aumento de PesoRESUMO
BACKGROUND: To identify risk factors associated with fetal death, and to measure the rate and the risk of fetal death in a large cohort of Latin American women. METHODS: We analyzed 837,232 singleton births recorded in the Perinatal Information System Database of the Latin American Center for Perinatology and Human Development (CLAP) between 1985 and 1997. The risk factors analyzed included fetal factors and maternal sociodemographic, obstetric, and clinical characteristics. Adjusted relative risks were obtained, after adjustment for potential confounding factors, through multiple logistic regression models based on the method of generalized estimating equations. RESULTS: There were 14,713 fetal deaths (rate=17.6 per 1000 births). The fetal death risk increased exponentially as pregnancy advanced. Thirty-seven percent of all fetal deaths occurred at term, and 64% were antepartum. The main risk factors associated with fetal death were lack of antenatal care (adjusted relative risk [aRR]=4.26; 95% confidence interval, 3.84-4.71) and small for gestational age (aRR=3.26; 95% CI, 3.13-3.40). In addition, the risk of death during the intrapartum period was almost tenfold higher for fetuses in noncephalic presentations. Other risk factors associated with stillbirth were: third trimester bleeding, eclampsia, chronic hypertension, preeclampsia, syphilis, gestational diabetes mellitus, Rh isoimmunization, interpregnancy interval<6 months, parity > or =4, maternal age > or =35 years, illiteracy, premature rupture of membranes, body mass index > or =29.0, maternal anemia, previous abortion, and previous adverse perinatal outcomes. CONCLUSIONS: There are several preventable factors that should be dealt with in order to reduce the gap in fetal mortality between Latin America and developed countries.
Assuntos
Morte Fetal/epidemiologia , Resultado da Gravidez , Adolescente , Adulto , Anemia/complicações , Criança , Estudos de Coortes , Diabetes Gestacional/complicações , Eclampsia/complicações , Escolaridade , Feminino , Morte Fetal/etiologia , Ruptura Prematura de Membranas Fetais/complicações , Humanos , Hipertensão/complicações , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , América Latina/epidemiologia , Masculino , Estado Civil , Idade Materna , Gravidez , Gravidez de Alto Risco , Cuidado Pré-Natal , Sistema do Grupo Sanguíneo Rh-Hr , Fatores de Risco , Fumar/efeitos adversos , Sífilis/complicaçõesRESUMO
OBJECTIVE: To test the hypothesis that women with multiple gestations are at increased risk of adverse maternal outcomes. METHODS: We studied the association between multiple gestation and frequency of adverse maternal outcomes in 885,338 pregnancies recorded in the Perinatal Information System database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 1997. Relative risks (RRs) were adjusted for 14 potential confounding factors through multiple logistic regression models. RESULTS: There were 15,484 multiple gestations. Among parous women, multiple gestation was associated with a twofold increase in risk of death compared with singleton gestations [adjusted RR 2.1; 95% confidence interval (CI) 1.1, 3.9]. Compared with singleton gestations, women with multiple gestations had adjusted RRs of 3.0 (95% CI, 2.9, 3.3) for eclampsia, 2.2 (95% CI, 1. 9, 2.5) for preeclampsia, and 2.0 (95% CI, 1.9, 2.0) for postpartum hemorrhage. Likewise, there was significant association between multiple gestation and increased incidence of preterm labor, anemia, urinary tract infection, puerperal endometritis, and cesarean delivery. The incidences of premature rupture of membranes, third-trimester bleeding, and gestational diabetes mellitus were not statistically different for singleton and multiple gestations. CONCLUSION: Multiple gestation increases the risk of significant maternal morbidity and mortality.
Assuntos
Mortalidade Materna , Complicações na Gravidez , Resultado da Gravidez , Gravidez Múltipla , Adulto , Feminino , Humanos , Morbidade , Paridade , Gravidez , UruguaiRESUMO
OBJECTIVE: To study risk factors for pre-eclampsia in a large cohort of Latin American and Caribbean women. DESIGN: Retrospective cross-sectional study from the Perinatal Information System, the database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay. SETTING: Latin America and the Caribbean, 1985-1997. Population 878,680 pregnancies at 700 hospitals; of these 42,530 were complicated by pre-eclampsia and 1,872 by eclampsia. MAIN OUTCOME MEASURES: Crude and adjusted relative risks (RR) of risk factors for pre-eclampsia. Adjusted relative risks were obtained after adjustment for potential confounding factors through multiple logistic regression models based on the method of generalised estimating equations. RESULTS: The following risk factors were significantly associated with increased risk of pre-eclampsia: nulliparity (RR 2 x 38; 95% CI 2 x 28-2 x 49); multiple pregnancy (RR 2 x 10; 95% CI 1 x 90-2 x 32); history of chronic hypertension (RR 1 x 99; 95% CI 1 x 78-2 x 22); gestational diabetes mellitus (RR 1 x 93; 95% CI 1 x 66-2 x 25); maternal age > or = 35 years (RR 1 x 67; 95% CI 1 x 58-1 x 77); fetal malformation (RR 1 x 26; 95% CI 1 x 16-1 x 37); and mother not living with infant's father (RR 1 x 21; 95% CI 1 x 15-1 x 26). Pre-eclampsia risk increased according to pre-pregnancy body mass index (BMI). In comparison with women with a normal pre-pregnancy BMI (19 x 8 to 26 x 0), the RR estimates were 1 x 57 (95% CI 1 x 49-1 x 64) and 2 x 81 95% CI 2 x 69-2 x 94), respectively, for overweight women (pre-pregnancy BMI = 26 x 1 to 29 x 0) and obese women (pre-pregnancy BMI > 29 x 0). Cigarette smoking during pregnancy and a pre-pregnancy BMI < 19 x 8 were significant protective factors against the development of pre-eclampsia. The pattern of risk factors among nulliparous and multiparous women was quite similar. CONCLUSIONS: Risk factors for pre-eclampsia observed among Latin American and Caribbean women are similar to those found among North American and European women.
Assuntos
Pré-Eclâmpsia/etiologia , Adolescente , Adulto , Estatura , Índice de Massa Corporal , Criança , Estudos de Coortes , Escolaridade , Feminino , Humanos , América Latina/epidemiologia , Estado Civil , Idade Materna , Pré-Eclâmpsia/epidemiologia , Gravidez , Estudos Retrospectivos , Fatores de RiscoRESUMO
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 (r(s)=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.
Assuntos
Cesárea/estatística & dados numéricos , Coleta de Dados , Feminino , Humanos , América Latina/epidemiologia , Gravidez , Fatores de Risco , Saúde da População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Saúde da População Urbana/estatística & dados numéricosRESUMO
In this systematic review of the existing evidence regarding the relationship between cigarette smoking during pregnancy and preeclampsia, studies were found through searches of MEDLINE (1966-October 31, 1998), Embase, Popline, CINAHL, Lilacs, bibliographies of identified studies, and proceedings of meetings on preeclampsia, and also through contact with relevant researchers. No language restrictions were imposed. Only cohort and case-control studies dealing with the relationship between cigarette smoking and preeclampsia were considered. Assessment of methodologic quality and data extraction of each study were carried out by 2 authors working independently. Typical relative risks and odds ratios with 95% confidence intervals were calculated for cohort and case-control studies, respectively, with both fixed and random effects models. Twenty-eight cohort studies and 7 case-control studies including a total of 833,714 women were included. All cohort studies reported an inverse association between cigarette smoking during pregnancy and incidence of preeclampsia (typical relative risk, 0.68; 95% confidence interval, 0.67-0.69). The findings were similar for case-control studies (typical odds ratio, 0.68; 95% confidence interval, 0.57-0.81). An inverse dose-response relationship was also found. Pooled data from cohort and case-control studies showed a lower risk of preeclampsia associated with cigarette smoking during pregnancy.
Assuntos
Pré-Eclâmpsia/etiologia , Fumar/efeitos adversos , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , MEDLINE , Razão de Chances , Gravidez , Fatores de RiscoRESUMO
Every year around the world some 13 million premature children are born. Most of these children are born in developing countries, and they account for the largest share of perinatal morbidity and mortality. This review study analyzed scientifically validated data on interventions to prevent at least some portion of these preterm deliveries and to lessen their impact on neonatal health. The Cochrane and MEDLINE bibliographic databases were consulted. Fifty review pieces and research articles were studied, relating to the following aspects of preterm delivery: risk factors and early detection of the risk of preterm delivery; preventing the risk of preterm delivery; treating preterm delivery once it has begun; and preventing neonatal respiratory distress syndrome. There were few successful approaches to the prediction, prevention, or early detection of the threat of preterm delivery. The only measures that can be recommended for all pregnant women are screening for and treating asymptomatic bacteriuria as a part of prenatal check-ups. Screening for bacterial vaginosis and treating it reduce the incidence of preterm births in pregnant women with a history of premature delivery. In addition, prophylactic cerclage decreases the incidence of premature births in pregnant women who have had more than three preterm births. To treat a delivery that starts early, with or without premature membrane rupture, the interventions that have proved to be effective are administering betamimetics to the parturient woman in order to delay delivery for 48 hours, and using indomethacin for the same purpose, as the second-choice drug. The prenatal administration of corticosteroids to the pregnant woman can induce lung maturation in the fetus and reduce respiratory distress syndrome and ventricular hemorrhage, thus decreasing neonatal mortality. There is a need to continue and support basic and epidemiological research in order to develop new knowledge on the causes and mechanisms of preterm delivery and on preventing the morbidity and mortality that preterm delivery produces.
Assuntos
Doenças do Prematuro/diagnóstico , Recém-Nascido Prematuro , Trabalho de Parto Prematuro , Feminino , Humanos , Recém-Nascido , Doenças do Prematuro/epidemiologia , Doenças do Prematuro/terapia , América Latina/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Fatores de RiscoAssuntos
Países em Desenvolvimento , Pesquisa sobre Serviços de Saúde/métodos , Hospitais Privados , Hospitais Públicos , Pobreza , Cuidado Pré-Natal/organização & administração , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , América Latina , Gravidez , Complicações na Gravidez/etiologiaRESUMO
The World Health Organisation and collaborating institutions in developing countries are conducting a multicentre randomised controlled trial to evaluate a new antenatal care (ANC) programme, consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. These activities are distributed, for practical reasons, over four visits during the course of pregnancy and are aimed at achieving predetermined goals. The study is taking place in four countries, Argentina, Cuba, Saudi Arabia and Thailand. Recruitment of study subjects started on 1 May 1996. All 53 ANC clinical units had been enrolled by December 1996. Clinics in each country were randomly allocated (cluster randomisation) to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for ANC at these clinics over an average period of 18 months will have been recruited. As women attending the control clinics receive the 'best standard treatment' as currently offered in these clinics, individual informed consent is requested only from women attending the intervention clinics. Authorities of the corresponding health districts and all participating clinics have provided written institutional informed consent before randomisation. The primary outcome of the trial in relation to maternal conditions is the rate of a morbidity indicator index, defined as the presence of at least one of the following conditions for which ANC is relevant: (a) pre-eclampsia or eclampsia during pregnancy or within 24 h of delivery; (b) postpartum anaemia (haemoglobin < 90 g/L); or (c) severe urinary tract infection/pyelonephritis, defined as an episode requiring antibiotic treatment and/or hospitalisation. The primary fetal outcome is the rate of low birthweight (< 2500 g). Adverse maternal and fetal outcomes are expected for approximately 10% of the control group. Several maternal and perinatal secondary outcomes are also considered. A comprehensive cost-effectiveness analysis and women's and providers' satisfaction evaluation are performed concurrently with the trial. Health-care programmes should be rigorously evaluated by randomised controlled trials, which are feasible in developing countries and should be conducted before introducing new treatments or health interventions.
PIP: The procedures and examinations included in currently practiced prenatal care have not been subjected to systematic, scientifically rigorous evaluation. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating a new prenatal care regimen with demonstrated efficacy in improving maternal and newborn outcomes. Program activities include screening for health conditions that increase the risk of specific adverse pregnancy outcomes, therapeutic interventions known to affect these outcomes beneficially, and education of pregnant women regarding potential health emergencies and appropriate responses. The study's hypothesis is that the tests, clinical procedures, and follow-up actions associated with this approach, delivered over the course of four visits during pregnancy, are more effective than the traditional prenatal care package in terms of specific maternal and perinatal results without being more expensive. This paper addresses the rationale, design, and methodology of this trial. 53 prenatal care clinics in four well-defined geographic areas (Khon Kaen Province, Thailand; Havana, Cuba; Rosario, Argentina; and Jeddah, Saudi Arabia) have been randomized to the two arms of the study. By the end of 1997, 24,000 women presenting for prenatal care at these sites had been enrolled. The primary maternal outcome is the morbidity indicator index, defined as the presence of at least one of the following conditions: pre-eclampsia or eclampsia during pregnancy or within 24 hours of delivery, postpartum anemia, or severe urinary tract infection/pyelonephritis. The primary fetal outcome is the rate of low birth weight. A comprehensive cost-effectiveness analysis and provider satisfaction evaluation will be performed concurrently with the trial. Data collection will be completed in 1998.
Assuntos
Pesquisa sobre Serviços de Saúde/organização & administração , Estudos Multicêntricos como Assunto , Cuidado Pré-Natal/organização & administração , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Organização Mundial da Saúde , Argentina , Cuba , Países em Desenvolvimento , Feminino , Humanos , Seleção de Pacientes , Gravidez , Resultado da Gravidez , Arábia Saudita , TailândiaRESUMO
We discuss methodological issues arising in a recent evaluation trial of a new antenatal care programme, as sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction, and WHO's Division of Reproductive Health (Technical Support). The randomisation unit for the trial is the antenatal care clinic, with 53 clinics located in four countries randomly allocated to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for antenatal care over an average period of 18 months will have been recruited.
PIP: The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating the impact of a new program of prenatal care on the health of mothers and newborns. Study subjects will receive either the standard prenatal care program currently offered at participating sites or a new regimen comprised of scientifically evaluated, objective-oriented prenatal care services. A total of 24,000 pregnant women from 53 prenatal care clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled and stratified on the basis of the number of pregnant women enrolled in each clinic during the year preceding the study, the type of clinic (free-standing or hospital), and the administrative health system to which they belong. This article discusses methodological issues related to the study's design, with emphasis on sample size considerations, planned approaches to the statistical analysis, and data quality control. The rationales for selecting clinics as the unit of randomization are to reduce the risk of treatment contamination, encourage participation, and facilitate administrative and logistic convenience in the implementation of the intervention. Randomization of intact clinics to different intervention groups with predefined strata reflects the fact that the aim of the trial is to show the equivalence, not necessarily the superiority, of the new prenatal care program with the existing program of standard care. The two major adverse outcomes, a high maternal morbidity index and low birth weight, are expected to be in the range of 10%. To ensure that a statistically nonsignificant effect can be interpreted meaningfully, the trial has been designed to have a 90% power for ruling out an absolute difference of at least 0.02 in the expected incidence of the primary end points. A confidence interval approach was selected for sample size estimation, as recommended for equivalence trials, to provide additional assurance that the sample size is adequate.