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Resumo Introdução: Existem particularidades da doença renal crônica (DRC) em mulheres e seu tratamento. A biologia das mulheres as expõe a fatores de risco mais elevados para DRC e tanto a gravidez quanto o puerpério implicam um ônus adicional à saúde renal. Complicações na gestação podem causar ou piorar a DRC. Objetivo: Explorar as experiências de mulheres com DRC submetidas à hemodiálise em relação ao seu histórico reprodutivo. Métodos: Este estudo consistiu em desenho clínico-qualitativo com entrevistas individuais semiestruturadas e questões abertas. A seleção da amostra foi intencional e de acordo com o critério de saturação teórica. A análise de dados foi realizada com base nos sete passos da análise clínico-qualitativa de conteúdo e validada pelo Nvivo11. Este estudo foi realizado em uma clínica pública de hemodiálise do Sistema Único de Saúde brasileiro. Resultados: Foram entrevistadas 12 mulheres em hemodiálise. Os resultados da análise revelaram três categorias: 1) Associação da gravidez com DRC; 2) Nebulosidade em relação ao diagnóstico e à história reprodutiva; 3) Ser mulher e fazer hemodiálise. Conclusões: Nosso estudo mostrou a importância de considerar as especificidades da DRC em mulheres, sugerindo que estas questões são importantes para o diagnóstico e a adesão ao tratamento. A consideração do histórico de vida reprodutiva permite promover de forma holística a saúde das mulheres submetidas à hemodiálise, incluindo aspectos de saúde mental.

Introduction: There are particularities of chronic kidney disease (CKD) in women and their treatment. The biology of women exposes them to greater risk factors for CKD and both pregnancy and the postpartum period place an additional burden on renal health. Pregnancy complications may cause or worsen CKD. Objective: To explore the experiences of women with CKD undergoing hemodialysis in relation to their reproductive history. Methods: This study consisted of clinical-qualitative design with semi-structured individual interviews and open-ended questions. The sample selection was intentional and according to the theoretical saturation criterion. The data analysis was carried out based on the seven steps of the clinical-qualitative content analysis and validated by Nvivo11. This study was conducted in a public hemodialysis clinic of the Brazilian National Health System. Results: Twelve women undergoing hemodialysis were interviewed. The results from the analysis revealed three categories: 1) Association of pregnancy with CKD; 2) Nebulosity in relation to diagnosis and reproductive history 3) Being a woman undergoing hemodialysis. Conclusion: Our study showed the importance of considering the specificities of CKD in women, suggesting that these issues are important for diagnosis and treatment adherence. Consideration of reproductive life history allows the health of women undergoing hemodialysis to be promoted holistically, including aspects of mental health.

To assess some characteristics and outcomes associated with pregnancy among Indigenous adolescents and compare them with other women who gave birth in a public hospital in Guatemala.We conducted a retrospective cohort study of 8048 cases. Sociocultural variables, gynecological and obstetric history, childbirth, and perinatal outcomes were compared among women who gave birth at San Juan De Dios Hospital between January 2018 and June 2019. They were classified into four groups according to age and ethnicity. Indigenous adolescents (819/10.2%) were compared with Nonindigenous adolescents (813/10.1%), Indigenous adult women (3324/41.3%), and Nonindigenous adult women (3092/38.4%). Bivariate analysis and multiple logistic regression were applied.We found that Indigenous adolescents who gave birth in the public hospital had fewer years of schooling than Nonindigenous adolescents (p 0.001), Indigenous adults (p 0.001), and Nonindigenous adults (p 0.001). Indigenous adolescents were more likely to have an unplanned pregnancy than Nonindigenous adolescents (p = 0.038) and Nonindigenous adults (p 0.001) and were more likely to be single (p 0.001) and use less previous contraception than Indigenous and Nonindigenous adult women (p = 0.007 and p = 0.013, respectively). More than one-third of Indigenous adolescents and adults did not attend antenatal care; Indigenous adolescents had fewer antenatal care visits than Nonindigenous adults (p 0.001), and the results were borderline in comparison to Nonindigenous adolescents (p = 0.051). Indigenous and Nonindigenous adult women underwent episiotomy less often than Indigenous adolescents (OR: 0.60 [95% CI 0.49-0.74] and OR: 0.56 [95% CI 0.45-0.70], respectively) and received less local anesthesia than Indigenous adolescents (OR: 0.59 [95% CI 0.46-0.76] and OR: 0.77 [95% CI 0.60-0.99], respectively). Nonindigenous adults received more analgesia than Indigenous adolescents (OR: 1.36 [95% CI 1.07-1.73]). Nonindigenous adolescents had more newborns with low birth weight than Indigenous adolescents (OR: 1.44 [95% CI 1.10-1.87]).Indigenous adolescents who gave birth in a public hospital in Guatemala were more likely to be single during pregnancy and attend fewer years of school than Nonindigenous adolescents. Unplanned pregnancies were more common among Indigenous adolescents, and some of them underwent not recommended obstetric practices during childbirth, such as episiotomy. Police should be enforced ensuring equal opportunities for different ethnic and age groups regarding pregnancy.OBJETIVO: Avaliar as características e os desfechos associados à gravidez em adolescentes indígenas e compará-los com mulheres que tiveram o parto em um hospital público da Guatemala. MéTODOS: Estudo de coorte retrospectivo com 8,048 casos. Variáveis socioculturais, histórico ginecológico e obstétrico, dados referentes ao parto e resultados perinatais foram comparados entre as mulheres que deram à luz no Hospital San Juan De Dios entre janeiro de 2018 e junho de 2019. As mulheres foram classificadas em quatro grupos; segundo idade e etnia. As adolescentes indígenas (819/10.2%) foram comparadas com adolescentes não indígenas (813/10.1%), adultas indígenas (3324/41.3%) e adultas não indígenas (3092/38.4%). Análise bivariada e regressão logística múltipla foram realizadas.Adolescentes indígenas que deram à luz no hospital público tinham menos anos de estudo em relação às adolescentes não indígenas (p 0.001), adultas indígenas (p 0.001) e adultas não indígenas (p 0.001). Adolescentes indígenas apresentaram maior probabilidade de ter uma gravidez não planejada em relação às adolescentes não indígenas (p = 0.038) e adultas não indígenas (p 0.001) e maior probabilidade de serem solteiras (p 0.001) e não usarem contracepção prévia em relação às adultas indígenas e adultas não indígenas (p = 0.007 e p = 0.013, respectivamente). Mais de um terço das adolescentes e adultas indígenas não compareceram ao pré-natal; Adolescentes indígenas tiveram menos consultas de pré-natal em relação às adultas não indígenas (p 0.001), e os resultados foram limítrofes em comparação com as adolescentes não indígenas (p = 0.051). Mulheres adultas indígenas e não indígenas foram submetidas a episiotomia com menor frequência em comparação as adolescentes indígenas (OR: 0.60 [IC 95%: 0.49–0.74] e OR: 0.56 [IC 95%: 0.45–0.70], respectivamente) e receberam menos anestesia local do que as adolescentes indígenas (OR: 0.59 [IC 95%: 0.46–0.76] e OR: 0.77 [IC 95%: 0.60–0.99], respectivamente). Adultas não indígenas tiveram maior prevalência no uso de analgesia do que as adolescentes indígenas (OR: 1.36 [IC 95%: 1.07–1.73]). Adolescentes não indígenas tiveram maior prevalência de recém-nascidos com baixo peso do que adolescentes indígenas (OR: 1.44 [IC 95%: 1.10–1.87]). CONCLUSãO: Adolescentes indígenas que deram à luz em um hospital público na Guatemala tiveram maior probabilidade de serem solteiras durante a gravidez e terem menos anos de escolaridade do que as adolescentes não indígenas. Além disso, adolescentes indígenas tiveram mais gestações não planejadas e experimentaram mais práticas obstétricas não recomendadas durante o parto, como a episiotomia. Fiscalizações devem ser aplicadas a fim de garantir oportunidades iguais para diferentes grupos étnicos e etários em relação aos direitos reprodutivos e ao monitoramento da gravidez.OBJETIVO: Evaluar algunas características y resultados asociados al embarazo en adolescentes indígenas, y compararlos con otras mujeres que tuvieron partos en un hospital público de Guatemala. MéTODOS: Realizamos un estudio de cohorte retrospectivo de 8.048 casos. Se compararon variables socioculturales, antecedentes ginecológicos y obstétricos, así como resultados perinatales y del parto entre mujeres que tuvieron sus partos en el Hospital San Juan de Dios entre enero de 2018 y junio de 2019. Las mujeres fueron clasificadas en cuatro grupos, según su edad y etnia. Se compararon adolescentes indígenas (819/10,2%) con adolescentes no indígenas (813/10,1%), mujeres adultas indígenas (3.324/41,3%) y mujeres adultas no indígenas (3.092/38,4%). Para el análisis estadístico se empleó análisis bivariado y regresión logística múltiple.Las adolescentes indígenas que tuvieron su parto en un hospital público tenían menos años de escolaridad que las adolescentes no indígenas (p 0,001), las adultas indígenas (p 0,001) y las adultas no indígenas (p 0,001). Las adolescentes indígenas tenían más probabilidades de tener un embarazo no planificado que las adolescentes no indígenas (p = 0,038) y las adultas no indígenas (p 0,001), así como tenían más probabilidades de ser solteras (p 0,001) y usaban menos métodos anticonceptivos antes del embarazo que las mujeres adultas indígenas y no indígenas (p = 0,007 y p = 0,013, respectivamente). Más de un tercio de las adolescentes y de adultas indígenas no asistieron a consultas prenatales. Las adolescentes indígenas tuvieron menos consultas prenatales que las adultas no indígenas (p 0,001), y los resultados fueron limítrofes en comparación con las adolescentes no indígenas (p = 0,051). Las mujeres adultas indígenas y no indígenas fueron sometidas a episiotomía con menos frecuencia que las adolescentes indígenas (OR: 0,60 [IC 95%: 0,49–0,74] y OR: 0,56 [IC 95%: 0,45–0,70], respectivamente) y recibieron menos anestesia local que las adolescentes indígenas (OR: 0,59 [IC 95%: 0,46-0,76] y OR: 0,77 [IC 95%: 0,60-0,99], respectivamente). Las adultas no indígenas recibieron más analgesia que las adolescentes indígenas (OR: 1,36 [IC 95%: 1,07–1,73]). Las adolescentes no indígenas tuvieron más recién nacidos con bajo peso al nacer que las adolescentes indígenas (OR: 1,44 [IC 95%: 1,10–1,87]). CONCLUSIóN: Las adolescentes indígenas que tuvieron su parto en un hospital público de Guatemala tenían más probabilidades de estar solteras durante el embarazo y presentar menos años de escolaridad que las adolescentes no indígenas. Los embarazos no planificados fueron más comunes entre las adolescentes indígenas, y algunas de ellas fueron sometidas a prácticas obstétricas no recomendadas durante el parto, como episiotomía. En relación con la asistencia durante el embarazo, se deben implementar medidas que garanticen la igualdad de oportunidades para diferentes grupos étnicos y etarios.This study aims to evaluate the sociodemographic characteristics and outcomes associated with pregnancy in Indigenous adolescents and compare them to other women who gave birth in a public hospital in Guatemala. We conducted a retrospective cohort study on four groups: Indigenous adolescents, Nonindigenous adolescents, Indigenous adults, and Nonindigenous adults. Subsequently, we compared the sociodemographic characteristics of the latter three groups with those of the Indigenous adolescents to evaluate whether being in this age group in combination with belonging to an Indigenous ethnic group increased unfavorable outcomes during pregnancy, childbirth, and postpartum. We observed that Indigenous adolescents have limited academic opportunities compared with Nonindigenous adolescents; the usage of contraceptive methods was lower in adolescents (Indigenous and non-Indigenous), and unplanned pregnancies were more frequent in Indigenous adolescents than in Nonindigenous adolescents and adults), and a high percentage of all women did not attend antenatal care. We analyzed obstetric practices during childbirth, and a high incidence of episiotomies was reported in both groups of adolescents (42.5% for Indigenous women and 38.8% for Nonindigenous women). Newborns of Nonindigenous adolescents had a higher frequency of low birth weight. Our study provides an overview of the characteristics of pregnancy among different age groups, findings that could be used to develop targeted interventions for each group and create public policies that would provide equal opportunities for all women while also ensuring a healthy pregnancy.

Objective To identify the burden of severe infection within the Brazilian Network for Surveillance of Maternal Morbidity and factors associated with worse maternal outcomes. Methods This was a multicenter cross-sectional study involving 27 referral maternity hospitals in Brazil. WHOs standardized criteria for potentially life threatening conditions and maternal near miss were used to identify cases through prospective surveillance and the main cause of morbidity was identified as infection or other causes (hypertension hemorrhage or clinical/surgical). Complications due to infection were compared to complications due to the remaining causes of morbidity. Factors associated with a severe maternal outcome were accessed for the cases of infection. Results 502 (5.3%) cases of maternal morbidity were associated with severe infection vs. 9053 cases (94.7%) with other causes. Considering increased severity of cases infection was responsible for one-fourth of all maternal near miss (23.6%) and nearly half (46.4%) of maternal deaths with a maternal near miss to maternal death ratio three times (2.8:1) that of cases without infection (7.8:1) and a high mortality index (26.3%). Within cases of infection substandard care was present in over one half of the severe maternal outcome cases. Factors independently associated with worse maternal outcomes were HIV/AIDS hysterectomy prolonged hospitalization intensive care admission and delays in medical care. Conclusions Infection is an alarming cause of maternal morbidity and mortality and timely diagnosis and adequate management are key to improving outcomes during pregnancy. Delays should be addressed risk factors identified and specific protocols of surveillance and care developed for use during pregnancy.

Background The aim of this study was to assess the burden of respiratory disease, considering the influenza A pandemic season (H1N1pdm09), within the Brazilian Network for Surveillance of Severe Maternal Morbidity, and factors associated with worse maternal outcome. Methods A multicenter cross-sectional study, involving 27 referral maternity hospitals in five Brazilian regions. Cases were identified in a prospective surveillance by using the WHO standardized criteria for potentially life-threatening conditions (PLTC) and maternal near miss (MNM). Women with severe complications from respiratory disease identified as suspected or confirmed cases of H1N1 influenza or respiratory failure were compared to those with other causes of severe morbidity. A review of suspected H1N1 influenza cases classified women as non-tested, tested positive and tested negative, comparing their outcomes. Factors associated with severe maternal outcome (SMO = MNM + MD) were assessed in both groups, in comparison to PLTC, using PR and 95 % CI adjusted for design effect of cluster sampling. Results Among 9555 cases of severe maternal morbidity, 485 (5 %) had respiratory disease. Respiratory disease occurred in one-quarter of MNM cases and two-thirds of MD. H1N1 virus was suspected in 206 cases with respiratory illness. Around 60 % of these women were tested, yielding 49 confirmed cases. Confirmed H1N1 influenza cases had worse adverse outcomes (MNM:MD ratio 50 %, in comparison to 7.4 % in other causes of severe maternal morbidity. Delay in medical care was associated with SMO in all cases considered, with a two-fold increased risk among respiratory disease patients. Perinatal outcome was worse in cases complicated by respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar score

Objective To assess the occurrence of severe maternal complications owing to postpartum hemorrhage (PPH) and its associated factors. Methods A secondary analysis of data from a multicenter cross-sectional prospective surveillance study included 9555 cases of severe maternal morbidity at 27 centers in Brazil between July 2009 and June 2010. Complications of PPH, conditions of severity management, and sociodemographic and obstetric characteristics were assessed. Factors independently associated with severe maternal outcome (SMO) were identified using multiple regression analysis. Results Overall, 1192 (12.5%) of the 9555 women experienced complications owing to PPH (981 had potentially life-threatening conditions, 181 maternal near miss, and 30 had died). The SMO ratio was 2.6 per 1000 live births among women with PPH and 8.5 per 1000 live births among women with other complications. Women with PPH had a higher risk of blood transfusion and return to the operating theater than did those with complications from other causes. Maternal age, length of pregnancy, previous uterine scar, and cesarean delivery were the main factors associated with an increased risk of SMO secondary to PPH. Conclusion PPH frequently leads to severe maternal morbidity. A surveillance system can identify the main causes of morbidity and could help to improve care, especially among women identified as being at high risk of PPH.

Background: The vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death. Methods: This was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated. Results: A total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD. Conclusions: Although this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival.

A B S T R AC T BACKGROUND Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy. METHODS We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gesta- tion with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal mor- bidity, with the fetus or infant as the unit of analysis for the statistical comparison. RESULTS A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesar- ean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group deliv- ered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P = 0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P = 0.49). CONCLUSIONS In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not sig- nificantly decrease or increase the risk of fetal or neonatal death or serious neo- natal morbidity, as compared with planned vaginal delivery. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00187369; Current Controlled Trials number, ISRCTN74420086.)

ObjectivesTo validate the WHO maternal near-miss criteria and develop a benchmark tool for severe maternal morbidity assessments.MethodsIn a multicenter cross-sectional study implemented in 27 referral maternity hospitals in Brazil, a one-year prospective surveillance on severe maternal morbidity and data collection was carried out. Diagnostic accuracy tests were used to assess the validity of the WHO maternal near-miss criteria. Binary logistic regression was used to model the death probability among women with severe maternal complications and benchmark the management of severe maternal morbidity.ResultsOf the 82,388 women having deliveries in the participating health facilities, 9,555 women presented pregnancy-related complications, including 140 maternal deaths and 770 maternal near misses. The WHO maternal near-miss criteria were found to be accurate and highly associated with maternal deaths (Positive likelihood ratio 106.8 (95% CI 99.56-114.6)). The maternal severity index (MSI) model was developed and found to able to describe the relationship between life-threatening conditions and mortality (Area under the ROC curve: 0.951 (95% CI 0.909-0.993)).ConclusionThe identification of maternal near-miss cases using the WHO list of pregnancy-related life-threatening conditions was validated. The MSI model can be used as a tool for benchmarking the performance of health services managing women with severe maternal complications and provide case-mix adjustment.