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ObjectiveTo investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD).DesignProspective cohort study.Setting10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.ParticipantsIndividual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%-49% across facilities.Primary outcome measuresStillbirth, predischarge neonatal mortality and maternal mortality.ResultsThe adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral.ConclusionIn this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother-baby dyad is necessary to identify opportunities to improve quality of intrapartum care.Trial registration numberNCT03112018.

Introduction The World Health Organization (WHO), major global health funders and health-care organizations all regard primary health care as the cornerstone of universal health coverage (UHC). As it is based [...], Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care's dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low-and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low- resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high- income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy- makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care. [phrase omitted] [phrase omitted] Les soins de sante primaires etablissent le cadre requis pour des soins complets adaptes aux patients, gages d'un systeme de sante solide. Ils jouent donc un role central dans la mise en place d'une couverture maladie universelle. Dans ce contexte, les medecins de famille sont les mieux places pour incarner une double perspective, la sante communautaire et la sante des populations, car ils travaillent souvent dans des hopitaux ruraux ou de district qui disposent de ressources humaines limitees, surtout en termes de specialistes. Le present document montre dans quelle mesure une formation complementaire dediee aux medecins de famille, acteurs cles des soins de sante primaires, peut avoir un impact decisif sur la diminution des inegalites d'acces aux interventions chirurgicales, obstetriques et anesthesiques dans les pays a faible et moyen revenu, ainsi que dans les milieux ruraux ou isoles. Il existe de nombreux exemples qui illustrent la fagon dont les programmes de formation peuvent etre mis en reuvre dans les endroits manquant de ressources afin que les medecins de famille acquierent des competences chirurgicales vitales, et qui indiquent comment les medecins de famille des pays a haut revenu peuvent apprendre des techniques de chirurgie essentielles pour travailler outre-mer ou dans des regions plus defavorisees. Les legislateurs devraient promouvoir la pratique chirurgicale chez les medecins de famille en soutenant les programmes qui incluent une formation complementaire aux techniques de chirurgie, et en multipliant les opportunites et sources de motivation pour que les medecins de famille exercent dans les zones rurales. Par ailleurs, les projets nationaux devraient comporter une strategie de soins de sante primaires pour les actes chirurgicaux et, globalement, les medecins de famille devraient etre pris en compte dans les discussions consacrees aux interventions chirurgicales. Enfin, chirurgiens, anesthesistes, obstetriciens et medecins de famille devraient etre encourages a collaborer pour s'assurer que tous les patients, quel que soit leur lieu de residence, puissent beneficier de soins chirurgicaux au moment opportun et en toute securite. [phrase omitted] La atencion primaria de salud establece el marco para la prestacion de una atencion socialmente informada, integral y centrada en el paciente, que es la base de los sistemas solidos de atencion sanitaria y, por lo tanto, es fundamental para lograr la cobertura sanitaria universal. Los medicos de familia son los que mejor pueden asumir el doble enfoque de la atencion primaria en la salud de la comunidad y de la poblacion porque trabajan con frecuencia en hospitales rurales o de distrito que tienen recursos humanos limitados, en especial por la falta de especialistas. En este documento, se pretende ilustrar como la capacitacion adicional de los medicos de familia, quienes son los profesionales clinicos clave en la atencion primaria, puede desempenar una funcion esencial en la reduccion de las desigualdades que existen para acceder a los procedimientos quirurgicos, obstetricos y de anestesia en los paises de ingresos bajos y medios y en los zonas rurales o remotas. Tambien se dan ejemplos de como se pueden elaborar programas de capacitacion en entornos de bajos recursos para preparar a los medicos de familia con tecnicas quirurgicas que salvan vidas y de como se puede capacitar a los medicos de familia de los paises de altos ingresos sobre las tecnicas quirurgicas esenciales para que trabajen en el extranjero en entornos de bajos ingresos. Los responsables de formular politicas deben promover la practica quirurgica entre los medicos de familia mediante su apoyo a los programas de medicina familiar que incluyan una capacitacion adicional sobre tecnicas quirurgicas, asi como la ampliacion de las oportunidades y de los incentivos para que los medicos de familia presten servicios en las zonas rurales. Ademas, los planes quirurgicos nacionales deben incluir una estrategia de atencion primaria de salud para la intervencion quirurgica y, a nivel mundial, los medicos de familia se deben tener en cuenta en los debates sobre la intervencion quirurgica. Por ultimo, se debe alentar a los cirujanos, anestesiologos, obstetras y medicos de familia a que colaboren para garantizar que todos los pacientes, sea cual sea su lugar de residencia, reciban servicios quirurgicos seguros y oportunos.

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Author(s): Jacob R. Lepard 1,2,*, Riccardo Spagiari 3, Jacquelyn Corley 2,4, Ernest J. Barthélemy 2,5, Eliana Kim 2,6, Rolvix Patterson 2,7, Sara Venturini 8, Megan E. H. Still 9, Yu [...], Background The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels. Methods and findings A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg&apos;s and Egger&apos;s tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present. Conclusions In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.