Present and future of maternal mortality in Latin America

Intercultural Childbirth: Impact on the Maternal Health of the Ecuadorian Kichwa and Mestizo People of the Otavalo Region

OBJECTIVE

 Considering the increased frequency of maternal deaths reported from 2001 to 2005 for Indigenous and mestizo women from the Ecuadorian rural area of Otavalo, where the Kichwa people has lived for centuries, the objective of the present article is to describe how the efforts of the local health community and hospital workers together with a propitious political environment facilitated the implementation of intercultural childbirth, which is a strategy that respects the Andean childbirth worldview.

METHODS

 We evaluated a 3-year follow-up (2014-16) of the maternal mortality and the childbirth features (4,213 deliveries).

RESULTS

 Although the Western-style (lying down position) childbirth was adopted by 80.6% of the pregnant women, 19.4% of both mestizo and Indigenous women adopted the intercultural delivery (squatting and kneeling positions). Both intercultural (42.2%) and Western-style (57.8%) childbirths were similarly adopted by Kichwa women, whereas Western-style childbirth predominated among mestizo women (94.0%). After the implementation of the intercultural strategy in 2008, a dramatic decrease of maternal deaths has been observed until now in both rural and urban Otavalo regions.

CONCLUSION

 This scenario reveals that the intermingling of cultures and respect for childbirth traditions have decreased maternal mortality in this World Health Organization-awarded program.

Developing obstetric medicine training in Latin America

Maternal mortality is an important indicator of health in populations around the world. The distribution of maternal mortality ratio globally shows that middle- and low-income countries have ∼99% of the mortality burden. Most countries of Latin America are considered to be middle- or low-income countries, as well as areas of major inequities among the different social classes. Medical problems in pregnancy remain an important cause of morbidity and mortality in this region. Previous data indicate the need for a call to action for adequate diagnosis and care of medical diseases in obstetric care. The impact of nonobstetric and medical pathologies on maternal mortality in Latin America is largely unknown. In Latin America, two educational initiatives have been proposed to improve skills in maternity care. The Advanced Life Support in Obstetrics (ALSO®) was first started to address obstetric emergencies, and subsequently adapted for low-middle-income country settings as the Global ALSO®. In parallel, the Latin American obstetric anesthesia community has progressively focused on improvement of several intrapartum/intraoperative issues, which has secondarily taken them to embrace the obstetric medicine area on interest and join the former initiatives. In the present review, we summarize the available data regarding medical morbidity and mortality in pregnancy in Latin America, as well as the challenges, achievements, issues, initiatives, and future directions encouraging maternal health educators, health care trainers, and physicians in middle- and low-income countries, such as many Latin American ones, to improve and/or change attitudes, if needed, on current clinical practice.

Características epidemiológicas dos óbitos maternos ocorridos em Recife, PE, Brasil (2000-2006)

Estudo de corte transversal que objetivou descrever as características epidemiológicas dos óbitos maternos de residentes no Recife, PE, Brasil, ocorridos entre 2000 e 2006. A fonte de dados foi constituída pelas fichas de investigação de óbito materno da Secretaria de Saúde do Recife. Para a análise dos dados, utilizou-se o programa EpiInfo 6.04d. Foram estudados 111 óbitos, correspondendo a uma Razão de Morte Materna de 65,99/100.000 nascidos vivos. Os dados obstétricos mostraram a realização de menos de seis consultas pré-natais, entre uma e quatro gestações prévias, parto cesário e admissão em estado grave. Os transtornos hipertensivos constituíram a principal causa de óbito. A maioria dos óbitos foi considerada evitável. Os resultados indicam a necessidade de aprimorar a assistência à saúde da gestante durante o pré-natal, parto e puerpério

The analysis of eclamptic morbidity and mortality in the Specialist Hospital Gombe, Nigeria

We conducted an analysis of caesarean sections (CS) in a tertiary care hospital in Pakistan to determine the rate of CS, indications and outcome. This information will be useful to formulate strategies to control the rate of CS and its associated complications in our hospital. This was a descriptive study conducted at the Obstetrics and Gynaecology Unit III, Sir Ganga Ram Hospital, Lahore during a period of 6 months, from 1 September 2000 to 28 February 2001. A proforma was constructed to document the details of all caesarean sections during the study period. During the 6-month period, of a total of 1424 deliveries conducted in the unit, 300 women had CS. These caesarean deliveries were analysed for the present study. The rate of caesarean sections in the study group was 21.07%. Of 300 caesarean deliveries, 34 were elective (11.33%) and 266 were emergency caesarean sections (88.67%). The main indications for the emergency caesarean deliveries were dystocia (28.2%), fetal distress (22.18%), CPD (6.77%) and a previous one (5.64%) or two caesarean sections (7.52%), while the main indications in the elective caesarean deliveries were a previous two (50%) or three (2.94%) CS. One hundred and two (34%) women were primigravida, 152 (50.67%) were gravida 2-4 and 45 (15%) women were among gravida 5-9. The mean age of the study group was 29 years. There was one maternal death and overall maternal morbidity was 14%. The majority of women were hospitalised for 2-6 days. In the group of emergency caesarean sections, there were four stillbirths (1.5%) and seven perinatal deaths (2.63%). The overall perinatal mortality rate was 4% in the study group. High-risk pregnancies without antenatal care constitute a major reason for the increased rate of caesarean deliveries and its associated morbidity and mortality.

Tackling health inequities in Chile: maternal, newborn, infant, and child mortality between 1990 and 2004

OBJECTIVES

We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions.

METHODS

Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4,000,000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged > 28 days and < 1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile's poorest to richest district quintiles.

RESULTS

During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100,000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile.

CONCLUSIONS

During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions.

Diversity in the use of pregnancy-related care among ethnic groups in Guatemala

OBJECTIVE

This study investigated ethnic differentials in the use of pregnancy-related care and aimed to identify whether the differences persist when geographical access to services is equal. This study was based in the north-eastern Ch'orti area of Guatemala, an area characterised by a mixed ladino (of Spanish descent) and Maya (Ch'orti) culture.

METHODS

Data from a household survey carried out in 2001 in the town of Jocotán, and a previous survey carried out in 1994 in two nearby indigenous villages (aldeas), were used in this study. Logistic regression was used to explore the data. Unlike the Demographic and Health Survey (DHS) (1998-1999) that classifies ethnic groups according to dress and language, this study introduced an alternative approach based on self-identification.

RESULTS

The results showed significant differences and a gradient in the use of modern pregnancy care services among self-identified ethnic groups within the same town, after controlling for socioeconomic and cultural indicators. Women of 'mixed' ethnicity had an intermediate behaviour between ladino and indigenous women. Women in the nearby aldeas almost solely relied on the traditional birth attendant for pregnancy-related care. The DHS data did not permit the detection of ethnic diversity in the use of pregnancy care for this region.

CONCLUSIONS

Differences in the use of modern pregnancy care exist even among self-identified ethnic groups with no outward markers of ethnicity and persist when access to services is equal. For the majority of the population, living in indigenous villages, pregnancy care remains traditional. This ethnic diversity highlights the importance of further extending affordable, high-quality and culturally adapted maternal health care services in Guatemala.

Efectos de un programa de mejoramiento de la calidad en servicios materno perinatales en el Peru: la experiencia del proyecto 2000

OBJETIVOS: comparar la calidad de los servicios de salud materno perinatales (SMP) de los establecimientos participantes en un programa de mejora de calidad (PMC) y compararlos con un grupo control; evaluar comparativamente los conocimientos y actitudes de usuarias de servicios de salud materna; y determinar la contribución del PMC en los niveles de calidad. MÉTODOS: fue implementado un PMC en 74 establecimientos de salud seleccionados para mejorar la calidad. Se desarrolló un cuasiexperimento controlado en 74 hospitales, centros de salud y establecimientos periféricos. El análisis de la calidad de los SMP se realizó mediante comparación de promedios de escalas centesimales; los conocimientos y actitudes de las usuarias mediante análisis bivariado; y la predicción del nivel de calidad a través de análisis multivariado. RESULTADOS: al final de la intervención, la puntuación de los establecimientos con PMC tuvo un promedio de 61,8 puntos y de 37,5 en el grupo de comparación, (p <0,001). El promedio de conocimientos de signos de alarma obstétricos fue mayor en las usuarias PMC (3,6 signos/entrevistada) versus 2,5 en usuarias sin PMC, (p <0,05). La intención de parto institucional fue dos veces mayor en las usuarias de los servicios con PMC, (p = 0,038). Los predictores significativos de calidad fueron la mejora continua de la calidad y la disponibilidad de profesionales de salud. CONCLUSIONES: el nivel de calidad es mayor en los servicios que desarrollaron PMC. Las usuarias de tales servicios tienen más conocimientos de los signos de alarma obstétricos y mejor actitud hacia el parto institucional. El PMC ha contribuido para tales logros.

Sexual violence and the obstetrician/gynecologist

Sexual violence is a pathological entity that requires urgent attention. The gynecologist/obstetrician (G/O), as a medical professional in charge of women's health, especially as it pertains to women's reproductive organs, should become an active agent in the management of the sociomedical processes that constitute sexual violence. The results of a survey conducted in Mexico on the opinions and practices of G/Os regarding violence against women--especially sexual violence--are reported. It is necessary to sensitize and train G/Os and other physicians in bio-ethics, and to look for formal support of such activities in the legislative branch of government.