Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and ...adverse outcomes, adjusted for population characteristics.
In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.
Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The medicalisation of childbirth has diminished the role of labouring people. We conducted an exploratory phenomenological qualitative study, using purposive sampling, and then conducted 17 ...semi-structured interviews between December 2016 and October 2017 with people who had recently given birth in a public hospital in the Northern Metropolitan area of Santiago, Chile. The sufficiency of the study group was determined according to saturation criteria. Triangulated content analysis was applied to explore the clinical relationship and processes of autonomy and decision-making. The predominant clinical relationship observed was paternalism. The participation of labouring people in decision-making is scarce, with no evidence of ethically valid processes of informed consent.
The World Health Organization (WHO) recommends a companion of choice during labor and birth, to improve maternal and perinatal outcomes and women's satisfaction with health services. To better ...understand the status of companion of choice in Latin America and the Caribbean (LAC), an online survey was conducted with members of a midwifery virtual community of practice and with key informants, aiming to identify: 1) existing regulatory instruments related to companion of choice in the countries where the members are practicing; and, 2) key characteristics of implementation of companion of choice, where regulation exists. Responses (
= 112) were received from representatives of 20 of the 43 countries of LAC. Respondents reported existence of a national policy or legislation in seven countries, ministerial norms or institutional protocols in five countries, and no existing policy/protocol in eight countries. Respondents from the same country often provided contradictory responses. Responses differed from information provided by ministries of health in a WHO-led global policy survey in 11 instances. These variations may reflect that midwives were not always aware of the national policy/guideline in their country. We propose that a more robust effort should be undertaken to understand the status of companion of choice for labor and birth in LAC countries, at national, regional, and local level, in public and private facilities. It is important to know if policies exist, at what level of the system, and if key stakeholders, maternity-care health providers, and women are aware of their existence. Efforts should also be made to understand barriers to implementing companion of choice.
SRHR are at the heart of the SDGs, as they affect the survival and short-term and long-term health and well-being of individuals, with mental health and socioeconomic consequences for women, trans, ...non-binary people, children, families, communities and populations.3 4 Knowledge derived from global health research should guide policy, planning and practice. To understand the methodological characteristics of the articles in the dataset (n=515), we categorised each publication by type: (1) description-focused: research that describes ‘what is’, that is, measurement and description of the problem/problems; (2) potential solution-focused: research that uses data to identify/focus on potential solutions and (3) implementation and/or evaluation focused: research that is focused on implementing or testing solutions in applied contexts. ...we identified the top authors, those with six or more publications, within the main dataset (n=43) to understand their author characteristics. ...we examined the author and funder characteristics of the 23 highly cited articles.
Introducción: América Latina y el Caribe han disminuido la mortalidad materna; sin embargo, aún poseen países con altas tasas, lo que refleja inequidades en el acceso a servicios de salud. La ...capacitación de recurso humano competente en atención primaria es una de las principales estrategias para abordar la problemática. Objetivo: Describir la experiencia de planificación, implementación y evaluación de un programa de capacitaciones en salud materna en países de la región (Bolivia, Colombia, Ecuador, Guatemala, Honduras, Nicaragua, Haití y Perú). Metodología: Entre 2016 y 2019, el Departamento de Sistemas y Servicios de Salud y la Unidad de Recursos Humanos de la Organización Panamericana de la Salud, junto a centros colaboradores, universidades y al Centro Latinoamericano de Perinatología y Salud de la Mujer, realizaron un levantamiento de necesidades de capacitación, desarrollaron plan de formación e implementaron capacitaciones para personal profesional y no profesional en salud materna. Resultados: Las necesidades de capacitación detectadas fueron liderazgo en salud, cuidados prenatales, parto, posparto, emergencias obstétricas y planificación familiar. Estas se consideraron en capacitaciones presenciales y virtuales, con 71 entrenadores de 7 países, quienes a su vez las reprodujeron para más de 4000 personas. Las evaluaciones fueron muy positivas y se espera determinar el impacto en salud en futuros proyectos. Conclusiones: Es fundamental la detección de necesidades y el trabajo colaborativo para realizar capacitaciones acordes en los países de la región, que permita contar con recurso humano motivado y competente para aumentar el acceso y la cobertura en la atención en salud materna de calidad.
Background: It has been suggested that hormonal changes and environmental alterations during the climacteric period are important in the development of psychological symptoms.
Objective: To evaluate ...the role of biological and psycho-social factors in the prevalence of climacteric symptoms.
Design: Open, cross-sectional, observational and descriptive study.
Material and methods: A total of 300 women between 40 and 59 years of age were evaluated using Greene scale for climacteric symptoms, Cooper questionnaire for psychosomatic symptoms of stress, Smilkstein family apgar for family dysfunction, Duke-UNC questionnaire for social support and Israel scale for vital events. All these tests have been previously validated in Spanish.
Results: Postmenopausal women do not have higher prevalence of psychological symptoms, they only have more vasomotor symptoms. Premenopausal women with vasomotor symptoms have more psychological and somatic symptoms and stress, independently of the vital events, family dysfunction or poor social support. Vasomotor symptoms in the premenopause are associated with increased risk of anxiety (OR: 3.7, IC: 1.4–9.7;
P<0.008), depression (OR: 8.1, IC: 2.5–26.4;
P<0.0005), somatic symptoms (OR: 14.9, IC: 3.4–65.3;
P<0.0003), sexual dysfunction (OR: 7.2, IC: 2.5–20.6;
P<0.0002) and stress (OR: 7.5, IC: 3.5–15.9;
P<0.0001). Negative vital events and family dysfunction increase in minor intensity the risk of anxiety, depression and stress.
Conclusion: In conclusion, psychological symptoms are frequent in the premenopause and are associated to vasomotor symptoms. This observation links psychological symptoms with menopausal transition and might suggest an organic base in their origin. The negative psycho-social environment is a factor that favours the development of these symptoms.
Introduction: Professionally trained midwives provide care to approximately 80% of the childbearing population in Chile. Prior to 2007, however, intrapartum care had become medicalized. In 2007, the ...Chilean Minister of Public Health adopted the Model of Integrated and Humanized Health Services, concurrently with the Clinical Guide for the Humanized Attention of Labour and Delivery. The main objective of this guide is to guarantee access to all pregnant women in Chile adequate professional assistance during labour and delivery, with “a safe, personalized and human delivery.” This attention includes continuous emotional support, reduction of intrapartum continuous fetal monitoring, use of alternative modes of pain relief, promotion of free position change and walking, restriction of episiotomy, elimination of the use of enema and genital shaving, and promotion of mother and newborn early skin‐to‐skin contact. Aims: The aims of this study are 1) to explore perceptions of this humanized attention during labour and delivery by both the professional staff (obstetricians and midwives) and consumers; 2) to identify the degree of maternal‐newborn well‐being; and 3) to describe selected obstetric outcomes of the women enrolled in the study who received care within this model. Methods: A cross‐sectional, descriptive study conducted of 450 women who gave birth in 2 major hospitals within the National Health System in the Metropolitan Area, Santiago, Chile, from September 2010 until June 2011. Qualitative methods include focus groups of midwives, obstetricians, and consumers. Quantitative methods include a validated survey of maternal well‐being and an adaptation of the American College of Nurse‐Midwives’ standardized antepartum and intrapartum data set. Results: Preliminary results show that 98% of births used oxytocin, 88% used continuous monitoring, 83% used the lithotomy position, and 60% had undergone episiotomy. Conclusions: Medicalization of birth still occurs; no changes have been observed since the implementation of the Clinical Guide for the Humanized Attention of Labor and Delivery in Chile.
La Organizacion Mundial de la Salud (OMS) recomienda la presencia de un acompanante durante el trabajo de parto y el parto debido a que mejora los resultados maternos y perinatales y la satisfaccion ...de las mujeres con los servicios de salud. Para comprender mejor la situacion acerca de los acompanantes en America Latina y el Caribe (ALC) se llevo a cabo una encuesta en linea dirigida a miembros de una comunidad de practica de parteria e informantes clave con el objetivo de identificar: 1) los instrumentos regulatorios existentes relacionados con la presencia de acompanante en los paises en los que ejercen las personas encuestadas y 2) las caracteristicas clave relacionadas con la implementacion del acompanante, en los lugares donde existe un marco regulatorio. Se recibieron 112 respuestas de 20 de los 43 paises de ALC. Las personas encuestadas informaron la existencia de una politica o legislacion nacional en siete paises, de normas ministeriales o protocolos institucionales en cinco paises, y de la inexistencia de una politica o un protocolo en ocho paises. Las respuestas provenientes del mismo pais a menudo fueron contradictorias, y en 11 casos estas difirieron de la informacion proporcionada por los ministerios de salud en una encuesta mundial sobre politicas dirigida por la OMS. Estas variaciones pueden reflejar que los profesionales de la parteria no siempre conocian la politica o el protocolo de su pais. Debe emprenderse un esfuerzo mas firme para comprender la situacion relacionada con el acompanante durante el trabajo de parto y el parto en los paises de ALC a nivel nacional, regional y local, tanto en instituciones publicas como privadas. Es importante conocer si existen politicas y en que nivel del sistema y si los principales interesados, los prestadores de servicios de salud materna y las mujeres conocen su existencia. Se deben realizar esfuerzos para comprender los obstaculos que impiden la implementacion de la presencia de un acompanante durante el parto. Palabras clave Satisfaccion del paciente; parteria; servicios de salud maternal; America Latina; Region del Caribe. A Organizacao Mundial da Saude (OMS) recomenda a presenca de um acompanhante durante o trabalho de parto e parto, ja que essa medida melhora os resultados maternos e perinatais e a satisfacao da mulher com os servicos de saude. Para caracterizar a situacao dos acompanhantes na America Latina e Caribe (ALC), realizou-se uma pesquisa on-line com membros de uma comunidade de pratica de profissionais de obstetricia e com informantes chaves para identificar: 1) a existencia de instrumentos regulatorios relacionados com a presenca de acompanhante nos paises onde os respondentes atuam e 2) caracteristicas chaves relacionadas com a implementacao das politicas de acompanhantes nos locais onde existe regulamentacao. Foram recebidas 112 respostas de 20 dos 43 paises da ALC. Os respondentes relataram a existencia de uma politica ou legislacao nacional em sete paises, normas ministeriais ou protocolos institucionais em cinco paises e nenhuma politica ou protocolo em oito paises. Respondentes de um mesmo pais deram muitas vezes respostas contraditorias. Em 11 casos, as respostas diferiram das informacoes fornecidas pelos ministerios da saude em uma pesquisa de politicas globais realizada pela OMS. Essas variacoes podem indicar que os profissionais nem sempre conheciam a politica ou protocolo em vigor no seu pais. Propoe-se a necessidade de iniciativas mais robustas para compreender a situacao do acompanhante no trabalho de parto em paises da ALC, em nivel nacional, regional e local, tanto em instituicoes publicas como privadas. E importante saber se as politicas existem, em que nivel do sistema existem e se as principais partes interessadas, os provedores de cuidados de saude materna e as mulheres estao cientes de sua existencia. Sao necessarios esforcos para compreender os obstaculos a implementacao do sistema de acompanhante de parto. Palavras-chave Satisfacao do paciente; tocologia; servicos de saude maternal; America Latina; Regiao do Caribe. The World Health Organization (WHO) recommends a companion of choice during labor and birth, to improve maternal and perinatal outcomes and women's satisfaction with health services. To better understand the status of companion of choice in Latin America and the Caribbean (LAC), an online survey was conducted with members of a midwifery virtual community of practice and with key informants, aiming to identify: 1) existing regulatory instruments related to companion of choice in the countries where the members are practicing; and, 2) key characteristics of implementation of companion of choice, where regulation exists. Responses (n = 112) were received from representatives of 20 of the 43 countries of LAC. Respondents reported existence of a national policy or legislation in seven countries, ministerial norms or institutional protocols in five countries, and no existing policy/protocol in eight countries. Respondents from the same country often provided contradictory responses. Responses differed from information provided by ministries of health in a WHO-led global policy survey in 11 instances. These variations may reflect that midwives were not always aware of the national policy/guideline in their country. We propose that a more robust effort should be undertaken to understand the status of companion of choice for labor and birth in LAC countries, at national, regional, and local level, in public and private facilities. It is important to know if policies exist, at what level of the system, and if key stakeholders, maternity-care health providers, and women are aware of their existence. Efforts should also be made to understand barriers to implementing companion of choice. Keywords Patient satisfaction; midwifery; maternal health services; Latin America; Caribbean Region.
Introduction
Satisfaction with care during labor and birth has been associated with various obstetric variables. The purpose of this study was to determine which labor and birth procedures are ...significant predictors of maternal patient satisfaction in a large cross‐sectional sample.
Methods
An observational, cross‐sectional study of 1660 women giving birth in Chilean public hospital facilities was conducted from 2012 to 2013. Data were collected from 9 different hospitals in 8 regions of Chile using 2 instruments, including the American College of Nurse‐Midwives Intrapartum Care Data Set and a locally validated measure of maternal well‐being. Women were eligible if they arrived at the labor and delivery unit during early labor (2‐3 centimeters dilated) and spent at least 4 hours in labor at the facility. In the current analysis, odds ratios were calculated using ordinal logistic regression for association with a less optimal well‐being score (possible outcome values were optimal, adequate, and minimal). Odds ratios were adjusted for age, education, single status, and parity (nulliparous vs multiparous). Stepwise regression was used to identify the procedural factors that were significantly associated with labor and birth care satisfaction.
Results
Factors significantly associated with lower satisfaction were cesarean birth (odds ratio OR, 1.4; 95% confidence interval CI, 1.1‐1.7), pharmacologic pain management (OR, 1.3; 95% CI, 1.02‐1.7), continuous fetal heart rate monitoring (OR. 1.4; 95% CI, 1.2‐1.8), and episiotomy (OR, 1.4; 95% CI, 1.1‐1.7). Nulliparity was also associated with minimal maternal satisfaction (OR, 1.3; 95% CI, 1.0‐1.5). Greater satisfaction was associated with accompaniment by a companion of choice during labor (OR, 0.49: 95% CI, 0.40‐0.60).
Discussion
This study is one of the first to provide empirical evidence that maternal patient satisfaction is negatively affected by many common obstetric procedures in the Latin American context. These findings are consistent with World Health Organization recommendations regarding judicious and necessary, rather than routine, use of obstetric interventions.
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