Brazilian Black Women are at Higher Risk for COVID-19 Complications: An Analysis of REBRACO, a National Cohort / Mulheres negras brasileiras correm maior risco de complicações da COVID-19: uma análise do REBRACO, uma coorte nacional

Abstract Objective To evaluate the impact of the race (Black versus non-Black) on maternal and perinatal outcomes of pregnant women with COVID-19 in Brazil. Methods This is a subanalysis of REBRACO, a Brazilian multicenter cohort study designed to evaluate the impact of COVID-19 on pregnant women. From February2020 until February 2021, 15 maternity hospitals in Brazil collected data on women with respiratory symptoms. We selected all women with a positive test for COVID-19; then, we divided them into two groups: Black and non-Black women. Finally, we compared, between groups, sociodemographic, maternal, and perinatal outcomes. We obtained the frequency of events in each group and compared them using X2 test; p-values < 0.05 were considered significant. We also estimated the odds ratio (OR) and confidence intervals (CI). Results 729 symptomatic women were included in the study; of those, 285 were positive for COVID-19, 120 (42.1%) were Black, and 165 (57.9%) were non-Black. Black women had worse education (p = 0.037). The timing of access to the health system was similar between both groups, with 26.3% being included with seven or more days of symptoms. Severe acute respiratory syndrome (OR 2.22 CI 1.17-4.21), intensive care unit admission (OR 2.00 CI 1.07-3.74), and desaturation at admission (OR 3.72 CI 1.41-9.84) were more likely to occur among Black women. Maternal death was higher among Black women (7.8% vs. 2.6%, p = 0.048). Perinatal outcomes were similar between both groups. Conclusion Brazilian Black women were more likely to die due to the consequences of COVID-19.

Resumo Objetivo Avaliar o impacto da raça (negra versus não negra) nos desfechos maternos e perinatais de gestantes com COVID-19 no Brasil. Métodos Esta é uma subanálise da REBRACO, um estudo de coorte multicêntrico brasileiro desenhado para avaliar o impacto da COVID-19 em mulheres grávidas. De fevereiro de 2020 a fevereiro de 2021, 15 maternidades do Brasil coletaram dados de mulheres com sintomas respiratórios. Selecionamos todas as mulheres com teste positivo para COVID-19; em seguida, as dividimos em dois grupos: mulheres negras e não negras. Finalmente, comparamos, entre os grupos, os resultados sociodemográficos, maternos e perinatais. Obtivemos a frequência dos eventos em cada grupo e comparamos usando o teste X2; Valores de p <0,05 foram considerados significativos. Também estimamos o odds ratio (OR) e os intervalos de confiança (IC). Resultados 729 mulheres sintomáticas foram incluídas no estudo; desses, 285 foram positivos para COVID-19, 120 (42,1%) eram negros e 165 (57,9%) não eram negros. As mulheres negras apresentaram pior escolaridade (p = 0,037). O tempo de acesso ao sistema de saúde foi semelhante entre os dois grupos, com 26,3% incluídos com sete ou mais dias de sintomas. Síndrome respiratória aguda grave (OR 2,22 CI 1,17-4,21), admissão em unidade de terapia intensiva (OR 2,00 CI 1,07-3,74) e dessaturação na admissão (OR 3,72 CI 1,41-9,84) foram mais prováveis de ocorrer entre mulheres negras. A mortalidade materna foi maior entre as negras (7,8% vs. 2,6%, p = 0,048). Os resultados perinatais foram semelhantes entre os dois grupos. Conclusão Mulheres negras brasileiras tiveram maior probabilidade de morrer devido às consequências da COVID-19.

Use of intensive care unit in women with severe maternal morbidity and maternal death: results from a national multicenter study / Uso de unidade de terapia intensiva em mulheres com morbidade materna grave: resultados de um estudo nacional multicêntrico

Abstract Objective To assess the use of the intensive care unit (ICU) and its effect on maternal mortality (MM) among women with severe maternal morbidity (SMM). Materials and Methods A secondary analysis of a cross-sectional study on surveillance of SMM in 27 Brazilian obstetric referral centers. The analysis focused on the association between ICU use and maternal death according to individual characteristics and disease severity. Two multivariate regressions considering use of the ICU, age, ethnicity, adequacy of care and the human development index were performed to identify the factors associated to maternal death and maternal near-miss. Results Out of 82,388 deliveries during the period, there were 9,555 (11.6%) women with SMM, and the MM ratio was of 170.4/100 thousand live births. In total, 8,135 (85.1%) patients were managed in facilities in which ICUs were available; however, only 2,059 (25.3%) had been admitted to the ICU. On the multivariate analysis, when the severity of the maternal disease was measured by the maternal severity score (MMS), the strength of the association between the use of the ICU and maternal death was greatly reduced, along with inadequate care and non-availability of the ICU at the facility. On the assessment of only the more critical cases (SMO, severe maternal outcome), the same pattern of association between ICU and MM was observed. In the models used, only inadequate care and MSS were significantly associated with MM. Conclusion The current study indicates that the main variables associated with maternal death are the severity and adequacy of the case management, which is more frequent in ICU admissions. The use of the ICU without the stratification of the patients by severity may not produce the expected benefits for part of the women.

Resumo Objetivo Avaliar o efeito da utilização de unidades de terapia intensiva (UTIs) na mortalidade materna (MM) entre mulheres com morbidade materna grave (MMG). Materiais e Métodos Foi realizada uma análise secundária de um estudo transversal de vigilância de morbidade materna grave em 27 centros de referência obstétrica no Brasil. O foco desta análise foi a associação entre a utilização de UTI e morte materna segundo características individuais e condições de gravidade. Análises múltiplas considerando as variáveis uso de UTI, idade, etnia, adequação do cuidado e índice de desenvolvimento humano foram realizadas para identificar os fatores associados à morte materna e near-miss materno. Resultados Dos 82.388 partos ocorridos durante o período de estudo, 9.555 (11,6%) mulheres apresentaram MMG, e a razão de MM foi de 170,4/100 mil nascidos vivos. Neste grupo, 8.135 (85,1%) pacientes foram atendidas em instituições com disponibilidade de leitos de UTI, mas apenas 2.059 (25,3%) foram de fato admitidas em leitos de UTI. Na análise de regressão multivariada, quando se considerou a gravidade do caso pelo maternal severity score (pontuação de severidade materna, MMS, na sigla em inglês), houve uma grande redução da força de associação entre utilização de UTI e morte materna, além da inadequação do cuidado e não disponibilidade de UTI na instituição. Na avaliação considerando apenas os casos de maior gravidade (desfecho materno grave, DMG), observou-se o mesmo padrão de associação entre UTI e MM. Nos modelos utilizados, apenas a inadequação do cuidado e o MSS apresentam associação significativa com a MM. Conclusão O presente estudo aponta que as principais variáveis associadas à morte materna são a gravidade e a adequação do manejo do caso, mais frequentes nas internações em UTI. A utilização dos leitos de UTI sem a estratificação da gravidade da paciente pode não trazer benefícios esperados para uma parte das mulheres.

Desafios na produção do cuidado à saúde: da hipertensão arterial e do diabetes à doença renal crônica / Challenges in the production of health care: from hypertension and diabetes to chronic kidney disease

A hipertensão arterial sistêmica e o diabetes são frequentemente associados à doença renal crônica (DRC) e a sua forma mais avançada, a doença renal crônica terminal (DRCT), que por sua alta prevalência no Brasil e no mundo tem grande impacto financeiro e social...(AU)

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.

Estratégias dirigidas aos profissionais para a redução das cesáreas desnecessárias no Brasil / Strategies directed to professionals for reducing unnecessary cesarean sections in Brazil

O Brasil está entre os países com as mais elevadas taxas de cesárea, sobretudo na saúde suplementar. No entanto, tanto no setor público, como no privado, algumas características são semelhantes para os anseios e expectativas das gestantes em relação ao parto. Existe preferência para o parto vaginal entre as mulheres de todos os níveis social, econômico ou cultural, o que desloca o foco da influência negativa da mulher para os outros sujeitos envolvidos na assistência ao parto. Nenhum fator isoladamente é capaz de justificar a complexidade da decisão pelo parto por cesárea, porém o médico e o tipo de hospital são os maiores fatores associados. Os diversos efeitos prejudiciais da realização não criteriosa de parto cesárea são cientificamente comprovados. É fundamental a conscientização de médicos e demais profissionais sobre as consequências reais dessa decisão, os desvios éticos quando condutas são tomadas sem que o foco seja exclusivamente a saúde do paciente e a necessidade de capacitação e atualização constantes para o manejo das diversas situações possíveis para o nascimento.

Brazil is among the countries with the highest cesarean section rates, especially in the supplementary health sector. However, some characteristics are similar in both the public and private sectors in terms of the wishes and expectations of pregnant women regarding their delivery. There is a preference for vaginal delivery among women of all social, economic, and cultural levels, a fact that shifts the focus of the negative influence of this variable from women to other subjects involved in delivery care. No isolated factor is able to justify the complexity of making a decision for cesarean section, but the physician and the type of hospital are the main associated factors. The several harmful effects of a non-judicious performance of cesarean section are scientifically recognized. It is important to raise the awareness of doctors and of other health professionals about the real consequences of this decision, the ethical deviations when conducts are chosen without exclusively focusing on the patient`s health, and the need for constant updating for the management of the various possible conditions of childbirth.

[Ferriprive anemia and proteino-energetic status in woman from 15 to 49 years old in Tunisia]

A foodstuffs survey has been carried out on young women aged from 15 to 49 in order to determine the total and available iron supplies, in proteins and in energy so as to establish the link between an iron deficiency and the protein-energy supplies in comparison to the needs required by the FAO and the WHO. The regions studied are the Great Tunis [GT] and the South West [SW] both in urban and rural backgrounds. These two regions have been selected because of the high prevailing rate of deficiency discovered after the 1996/1997 nutritional survey. Women have been divided into two groups: those who have a deficiency and those who don't have. The study concerned 1151 homes therefore about 1468 women and from them 712 are from GT and 756 from SW. The results of foodstuffs survey demonstrated that supply of meat is more elevated in non anemic women than anemic women concerning proteins supplies. A moderate energetic deficit is noticed in non deficient women and those anemic who have an iron deficiency. Women presented anemia have total and available iron deficient and a deficiency in energy supplies