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The Costs, Benefits, and Cost-Effectiveness of Interventions to Reduce Maternal Morbidity and Mortality in Mexico  [PDF]
Delphine Hu, Stefano M. Bertozzi, Emmanuela Gakidou, Steve Sweet, Sue J. Goldie
PLOS ONE , 2007, DOI: 10.1371/journal.pone.0000750
Abstract: Background In Mexico, the lifetime risk of dying from maternal causes is 1 in 370 compared to 1 in 2,500 in the U.S. Although national efforts have been made to improve maternal services in the last decade, it is unclear if Millennium Development Goal 5 - to reduce maternal mortality by three-quarters by 2015 - will be met. Methodology/Principal Findings We developed an empirically calibrated model that simulates the natural history of pregnancy and pregnancy-related complications in a cohort of 15-year-old women followed over their lifetime. After synthesizing national and sub-national trends in maternal mortality, the model was calibrated to current intervention-specific coverage levels and validated by comparing model-projected life expectancy, total fertility rate, crude birth rate and maternal mortality ratio with Mexico-specific data. Using both published and primary data, we assessed the comparative health and economic outcomes of alternative strategies to reduce maternal morbidity and mortality. A dual approach that increased coverage of family planning by 15%, and assured access to safe abortion for all women desiring elective termination of pregnancy, reduced mortality by 43% and was cost saving compared to current practice. The most effective strategy added a third component, enhanced access to comprehensive emergency obstetric care for at least 90% of women requiring referral. At a national level, this strategy reduced mortality by 75%, cost less than current practice, and had an incremental cost-effectiveness ratio of $300 per DALY relative to the next best strategy. Analyses conducted at the state level yielded similar results. Conclusions/Significance Increasing the provision of family planning and assuring access to safe abortion are feasible, complementary and cost-effective strategies that would provide the greatest benefit within a short-time frame. Incremental improvements in access to high-quality intrapartum and emergency obstetric care will further reduce maternal deaths and disability.
Estrategias de manejo mediante competencias no técnicas para la disminución de la morbimortalidad materna y perinatal Management strategies using non-technical skills to reduce maternal and perinatal morbidity and mortality  [cached]
Mauricio Vasco Ramírez
Revista Colombiana de Anestesiología , 2013,
Abstract: La morbilidad materna y perinatal es un indicador de salud pública que representa uno de los niveles de equidad que existen en un país; actualmente, la disminución de las muertes maternas es un indicador enmarcado en los denominados Objetivos del Milenio. Adicionalmente, la práctica obstétrica genera en nuestro país y el mundo un alto número de procesos médico-legales y pago por mala praxis. En el componente asistencial se ha demostrado que, además de las competencias técnicas que se deben tener para la atención diaria de los pacientes, la adquisición en escenarios de simulación de competencias no técnicas, que incluyen herramientas efectivas para la comunicación, asumir y respetar el liderazgo, trabajar como equipo y resolver adecuadamente los conflictos del grupo de atención en situaciones de crisis, en este caso emergencias obstétricas, permiten disminuir desenlaces adversos del binomio madre-hijo. El objetivo de este artículo es crear una reflexión de cómo desde la perspectiva del anestesiólogo la implementación de programas de educación continua que impacten en políticas de salud pública y la participación activa dentro del grupo interdisciplinario que atiende al binomio madre-hijo en actividades de vigilancia de salud pública y desarrollo de guías de manejo en el área de la perinatología pueden contribuir al alcance de estas metas nacionales y mundiales. Maternal and perinatal morbidity is a public health indicator of the level of equality in a country; actually, a decline in the number of maternal deaths is an indicator of the Millennium Development Goals (MDGs). Furthermore, the practice of obstetrics gives rise to a large number of lawsuits and malpractice penalties. It has been shown in medical care that in addition to the technical skills required to provide adequate patient care on a daily basis, the development of non-technical skills in simulation scenarios, including effective communication tools, exercise and respect of leadership, teamwork and proper resolution of conflicts in the group under critical situations, in this case obstetric emergencies, lower the rates of adverse outcomes for both mother and child. The purpose of this article is to consider fromthe anesthesiologist perspective, howthe implementation of continuous education programs that impact public health policies, in addition to active involvement in the interdisciplinary team caring for the mother and child through public health surveillance activities, and the development of management guidelines in perinatology, may contribute to accomplish these national and world goa
Identifying Training Requirements in Perioperative Care for Anaesthetists  [PDF]
Gautam Kumar,Beverly Wong,David Walker
Journal of Biomedical Education , 2013, DOI: 10.1155/2013/534245
Abstract: Education and training in anaesthesia have traditionally focused on the preparation and delivery of intraoperative anaesthesia but are evolving to incorporate aspects of perioperative medical care. The expansion of continued professional development and postgraduate courses in this field has gathered pace, with the aim of teaching anaesthetists and allied professionals to improve patients' surgical care. We surveyed a population of UK-based anaesthetists to establish their views on professional development within perioperative medicine, their role as perioperative medical experts of the future, and the training and educational needs of this cohort. The majority of anaesthetists acknowledged their evolving role in perioperative patient care and recognised a need to train for the task. Only 50% of the senior anaesthetists surveyed believed they had sufficient knowledge and skills to undertake perioperative care with the majority believing the current training curriculum must advance to support professional development. In line with other international healthcare systems, UK-based anaesthetic practice is adopting a responsibility for perioperative medical practice, and this survey has demonstrated willingness amongst anaesthetists of all grades to embrace change, recognise training needs, and improve the outcome for surgical patients. 1. Introduction A growing proportion of patients undergoing surgery are elderly and increasingly have coexistent disease, which may influence outcome [1, 2]. As surgical programmes develop to meet the needs of this population, it is now commonplace to see this cohort undergo major surgical interventions, which expose them to a high possibility of perioperative morbidity and mortality [3]. Such patients are often cared for within resource-limited healthcare systems, whose continued remits are to drive efficiency and streamline clinical episodes and may be at odds with best care for those patients considered to be at highest risk. This so-called high-risk patient population represents approximately 15% of the total surgical population and yet as a group contributes to 80% of perioperative mortality [4]. Current models of care, involving surgical teams working without the support of multidisciplinary input, have been challenged and led to calls from within the profession to develop broad-based perioperative medicine expertise, which better supports complex patient episodes. Perioperative medicine is defined as “the continuum of patient care involving preoperative evaluation and preparation, preanaesthetic assessment,
Maternal Morbidity And Mortality Patterns in Uttar Pradesh
Nandan Deoke,Saxena Badri N
Indian Journal of Community Medicine , 1997,
Abstract: Research question: What is the extent of maternal morbidity and mortality in the community? Objectives: To know the extent and pattern of maternal mortality in the community. Study area: The districts of Uttar Pradesh namely Agra and Farrukhabad, covering 206 villages in 15 blocks. Sample Size: 51, 186 households and 292,496 population. Participants: Married women in reproductive age group. Setting: Rural community Development Blocks. Study variables: Menstrual problems, gynaecological problems, general morbidity and maternal deaths. Outcome variables: Maternal morbidity and mortality. Study Design: Community based cross- sectional study. Analysis: Simple proportions. Results: Over 47.5% of women reported excessive discharge, 15-16% complained of foul smelling discharge besides other problems like urinary infections, incontinence, prolapse, vesico-vaginal fistula etc. Around 22-27% of women suffered general morbidity, predominant being fever/cough/cold, malaria, diarrhoea and anemiaa€ s. Overall, high level of (703 per 100,000) maternal mortality was reported in the area. Respective fingers for Agra and Farrukhabad being 582 and 992 per lakh live births. Over 50% of these deaths occurred at home, 22% in government hospitals, 12% in private hospitals and 15% in transit. Leading causes of maternal mortality were; haemorrhage, retained placenta, sepsis, anemia, jaundice and tetanus.
Does Measles Immunization Reduce Diarrhoeal Morbidity  [cached]
Reddaiah V.P,Kapoor S.K
Indian Journal of Community Medicine , 1993,
Abstract: Research question: 1. Will measles vaccination reduce the incidence and during of diarrhoeal episodes in children? 2. Will measles vaccination reduce the morbidity load because of diarrhoea? Objectives: 1. To provide measles immunization to rural children 9 to 24 months of age. 2. to study the occurrence of diarrhoeal episodes by domicillary visits every month for a period of 1 year. Design: Longitudinal study. Setting: Rural area in the state of Haryana. Participants: Children between the ages of 9 and 24 months with parental informed consent. Study variables: diarrhoeal episodes per child/year, duration of diarrhoea. Outcome Variable: the difference between the two groups (immunized and non- immunized) of attack rate and duration of diarrhoeal episodes. Statistical Analysis: Chi square test. Results: immunization coverage was 75%. Attack rates of diarrhoea in immunized children (1.6/child/year) was no different to that in the non- immunized (1.5/child/year). The mean duration of diarrhoea in both groups was 2.3 days. The prevalence diarrhoea in immunized and non-immunized was 3.85 and 3.67 respectively. Conclusion: Measles vaccination has no impact on diarrhoeal morbidity.
The Impact of HIV on Maternal Morbidity in the Pre-HAART Era in Uganda  [PDF]
Harriet Nuwagaba-Biribonwoha,Richard T. Mayon-White,Pius Okong,Peter Brocklehurst,Lucy M. Carpenter
Journal of Pregnancy , 2012, DOI: 10.1155/2012/508657
Abstract: Objective. To compare maternal morbidity in HIV-infected and uninfected pregnant women. Methods. Major maternal morbidity (severe febrile illness, illnesses requiring hospital admissions, surgical revisions, or illnesses resulting in death) was measured prospectively in a cohort of HIV-infected and uninfected women followed from 36 weeks of pregnancy to 6 weeks after delivery. Odds ratios of major morbidity and associated factors were examined using logistic regression. Results. Major morbidity was observed in 46/129 (36%) and 104/390 (27%) of the HIV-infected and HIV-uninfected women, respectively, who remained in followup. In the multivariable analysis, major morbidity was independently associated with HIV infection, adjusted odds ratio (AOR) 1.7 (1.1 to 2.7), nulliparity (AOR 2.0 (1.3 to 3.0)), and lack of, or minimal, formal education (AOR 2.1 (1.1 to 3.8)). Conclusions. HIV was associated with a 70% increase in the odds of major maternal morbidity in these Ugandan mothers. 1. Introduction Maternal morbidity is defined as illness in a woman who was or is pregnant from any cause related to the pregnancy, abortion, or child birth, excluding incidental or accidental causes [1]. In Uganda, the true level of maternal morbidity is unknown, but national estimates suggest that 5.1 maternal deaths occur for every 1,000 live births [2]. Although there has been a decline in maternal mortality since 2000 [3], child bearing is still associated with significant morbidity and mortality in this country. Like most sub-Saharan countries, Uganda has experienced a heavy burden of HIV-related disease in the last few decades. In men and non-pregnant women, HIV has been associated with at least a 2-fold increase in morbidity [4, 5] and 10–20-fold increase in mortality [6, 7]. Less is known about the association between HIV and maternal morbidity. We undertook a prospective observational study to describe, estimate, and compare the risk of maternal morbidity in HIV-infected and uninfected women in Uganda. 2. Methods 2.1. Setting The study was conducted at St. Raphael of St. Francis Hospital Nsambya, in Kampala, Uganda, between November 2002 and November 2003. The hospital is a catholic missionary hospital located in the capital city (Kampala). During the study year, there were a total of 24,461 antenatal visits (of whom 6,016 were new bookings) and 10,768 deliveries recorded. The hospital provided care to general and private patients who paid at total of about $10 (general) and $40 (private) for antenatal care and a normal vaginal delivery. This hospital was one of the
Ethnic Variations in Severe Maternal Morbidity in the UK– A Case Control Study  [PDF]
Manisha Nair, Jennifer J. Kurinczuk, Marian Knight
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0095086
Abstract: Background Previous studies showed a higher risk of maternal morbidity amongst black and other minority ethnic (BME) groups, but were unable to investigate whether this excess risk was concentrated within specific BME groups in the UK. Our aim was to analyse the specific risks and to investigate reasons for any disparity. Methods Unmatched case-control analysis using data from the United Kingdom Obstetric Surveillance System (UKOSS), February 2005-January 2013. Cases were 1,753 women who experienced severe morbidity during the peripartum period. Controls were 3,310 women who delivered immediately before the cases in the same hospital. Multivariable logistic regression modelling was used to adjust for known confounders and to understand their effects. Results Compared with white European women, the odds of severe maternal morbidity were 83% higher among black African women (adjusted odds ratio (aOR) = 1.83; 95% Confidence Interval (CI) = 1.39–2.40), 80% higher among black Caribbean (aOR = 1.80; 95% CI = 1.14–2.82), 74% higher in Bangladeshi (aOR = 1.74; 95% CI = 1.05–2.88), 56% higher in other non-whites (non-Asian) (aOR = 1.56; 95% CI = 1.05–2.33) and 43% higher among Pakistani women (aOR = 1.43; 95% CI = 1.07–1.92). There was no evidence of substantial confounding. Anaemia in current pregnancy, previous pregnancy problems, inadequate utilisation of antenatal care, pre-existing medical conditions, parity>3, and being younger and older were independent risk factors but, the odds of severe maternal morbidity did not differ by socioeconomic status, between smokers and non-smokers or by BMI. Discussion This national study demonstrates an increased risk of severe maternal morbidity among women of ethnic minority backgrounds which could not be explained by known risk factors for severe maternal morbidity.
From planning to practice: building the national network for the surveillance of severe maternal morbidity
Samira M Haddad, José G Cecatti, Mary A Parpinelli, Jo?o P Souza, Maria L Costa, Maria H Sousa, Fernanda G Surita, Jo?o L Pinto e Silva, Rodolfo C Pacagnella, Rodrigo S Camargo, Maria V Bahamondes, Vilma Zotareli, Lúcio T Gurgel, Lale Say, Robert C Pattinson, National Network for the Surveillance of Severe Maternal Morbidity Group
BMC Public Health , 2011, DOI: 10.1186/1471-2458-11-283
Abstract: The project consisted of a multicenter, cross-sectional study for the surveillance of severe maternal morbidity including near-miss, in Brazil.Following the development of a conceptual framework, centers were selected for inclusion in the network, consensus meetings were held among the centers, an electronic data collection system was identified, specific software and hardware tools were developed, research material was prepared, and the implementation process was initiated and analyzed.The conceptual framework developed for this network was based on the experience acquired in various studies carried out in the area over recent years and encompasses maternal and perinatal health. It is innovative especially in the context of a developing country. The implementation of the project represents the first step towards this planned management. The system online elaborated for this surveillance network may be used in further studies in reproductive and perinatal health.The reduction of maternal mortality is one of the targets of the Millennium Development Goals for 2015 [1]. In some countries, some progress has been achieved, but there is very little progress in the most of high mortality countries [2-4].The high mortality ratios result mainly from difficulties in accessing healthcare services, the inadequate management of obstetrical complications and failure to provide effective interventions in poorly developed areas [5]. On the other hand, the occurrence of maternal death in developed settings is a relatively rare event compared to the total number of women who survive such complications [3]. The study of severe maternal morbidity has been suggested as a useful approach to investigating quality of health care systems in order to improve women's healthcare and effectively reduce maternal morbidity [5]. Nevertheless, differences also exist in the definitions and procedures used to identify cases of morbidity, which need also progressive transformation and development [6,
WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)
Lale Say, Robert C Pattinson, A Metin Gülmezoglu
Reproductive Health , 2004, DOI: 10.1186/1742-4755-1-3
Abstract: Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software.A total of 30 studies are included in the systematic review. Designs are mainly cross-sectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country.There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates.Severe acute maternal morbidity (SAMM), also known as "near miss", is defined as "A very ill pregnant or recently delivered woman who would have died had it not been that luck and good care was on her side"
Self-reported maternal morbidity and associated factors among Brazilian women
Souza, Joao Paulo;Sousa, Maria Helena de;Parpinelli, Mary Angela;Amaral, Eliana;Cecatti, Jose Guilherme;
Revista da Associa??o Médica Brasileira , 2008, DOI: 10.1590/S0104-42302008000300019
Abstract: purpose: demographic health surveys may constitute a valuable source of information on maternal morbidity, particularly in locations where an integrated system of epidemiological surveillance with wide geographic coverage has not yet been developed. methods: this study analyzed the database obtained from a national demographic health survey carried out in brasil in 1996. data regarding how the survey was conducted, characteristics of the women interviewed who had given birth to live infants in the five preceding years, characteristics of the obstetrical care received and complications reported were evaluated. results: responses from a weighted total of 3,635 women were analyzed. statistically significant differences (p<0.001) were found between geographic domains for most characteristics studied. deliveries were predominantly hospital-based throughout the whole country. prevalence of self-reported maternal morbidity ranged from 15.5-22.9% in the various geographic domains analyzed. this geographic factor was found to be associated to differences in the occurrence of complications, generally and specifically, for cases of prolonged labour. conclusion: differences in morbidity may reflect the intricate relationship between determinants of human development and maternal health conditions.
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