Aims: The aims of this thesis were to investigate the risk of severe maternal morbidity amongst women from different socioeconomic groups in the UK, explore why these differences exist and compare these findings to the setting in Australia. Methods: Three separate analyses were conducted. The first used UK Obstetric Surveillance System (UKOSS) data to assess the incidence and independent odds of severe maternal morbidity by socioeconomic group in the UK. The second analysis used quantitative and qualitative data from the 2010 UK National Maternity Survey (NMS) to explore the possible reasons for the difference in odds of morbidity between socioeconomic groups in the UK. The third analysis used data from the Victorian Perinatal Data Collection (VPDC) unit in Austra lia to assess the incidence and odds of severe maternal morbidity by socioeconomic group in Victoria. Results: The UKOSS analysis showed that compared with women from the highest socioeconomic group, women in the lowest 'unemployed' group had 1.22 (95%CI: 0.92 - 1.61) times greater odds associated with severe maternal morbidity. The NMS analysis demonstrated that independent of ethnicity, age and parity, women from the lowest socioeconomic quintiJe were 60% less likely to have had any antenatal care (aOR 0.40; 95%CI 0.18 - 0.87), 40% less likely to have been seen by a health professional prior to 12 weeks gestation (aOR 0.62; 95%CI 0.45 - 0.85) and 45% less likely to have had a postnatal check with their doctor (aOR 0.55; 95%CI 0.42 - 0.70) compared to women from the highest quintile. The Victorian analysis showed that women from the lowest socioeconomic group were 21% (aOR 1.21 ; 95% CI 1.00 - 1.47) more likely and that Aboriginal and Torres Strait Islander women were twice (aOR 2.02; 95%CI 1.32 - 3.09) as likely to experience severe morbidity. Discussion: The resu lts suggest that women from the lowest socioeconomic group in the UK and in Victoria have increased odds of severe maternal morbidity. Further research is needed into why these differences exist and efforts must be made to ensure that these women are appropriately prioritised in the future planning of maternity services provisio n in the UK and Australia.

Thesis (MSc)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Background Caesarean section deliveries are the most common procedures performed by obstetricians in Zimbabwe. Surgical site infections (SSI) following caesarean section delivery result in increased hospital stay, treatment, cost, hospital readmission rates and related maternal morbidity and mortality. There is no national surveillance system for SSIs in Zimbabwe, however, information is available on number of cases of post-operative wound infection after caesarean section, but the denominator and definition used is not consistent. The objective of this study were develop and strengthen the surveillance system in Zimbabwe, to establish a clinical-based system in a setting with limited microbiological access, to measure post-operative SSI after caesarean section and to describe the associated risk factors and to determine whether feedback of SSI data has any effect on the surgical site infection incidence rate. Methodology This was a before and after study with two rolling cohort periods conducted at two Central hospitals in Harare, Zimbabwe. An Infection Prevention and Control (IPC) intervention was conducted in-between. During the pre-intervention period, baseline demographic and clinical data were collected using a structured questionnaire, and during the post-intervention period the impact of the interventions was measured. Convenience sampling was employed. Results A total of 290 women consented to participate in the study in the pre intervention period, 86.9% (n= 252) completed the 30-days post-operative follow-up and the incidence rate of SSI was 29.0% (n=73, 95% CI:23.4-35.0) Interventions developed included: training in Infection Prevention and Control for health workers; implementation of a protocol for cleaning surgical instruments; dissemination of information on post-operative wound management for the women. After implementation of the intervention, 314 women were recruited for the post-intervention, 92.3%(n= 290) completed the 30-day follow-up and there was a significant (p<0.001) reduction in the incidence rate of SSIs to 12.1 % (n=35, 95% CI: 8.3 -15.8) during this period. Development of SSI after caesarean section was found to be significantly associated with emergency surgery (p<0.001), surgical wound class IV (p=0.001) and shaving at home (p<0.001) at both pre- intervention and post-intervention periods. Stellenbosch University https://scholar.sun.ac.za iii Conclusion This study shows that caesarean section can be performed with low incidence of SSI if appropriate interventions such as training in IPC, adequate cleaning of equipment and education in wound-care for the mother are adhered to. It also demonstrated a simple surveillance data collection tool can be used on a wide scale in resource limited countries to assist policy makers with monitoring and evaluation of SSI rates as well as assessment of risk factors. / AFRIKAANSE OPSOMMING: Agtergrond Keisersnitte is die mees algemene prosedure wat uitgevoer word deur obstetriese dokters in Zimbabwe. Chirurgiese wond infeksies wat op keisersnitte volg lei tot verlengde hospitaal verblyf, behandeling, koste, heropname koerse en verwante moederlike morbiditeit en mortaliteit. Alhoewel daar geen nasionale waaktoesig sisteem vir chirurgiese wondinfeksies is nie, is informasie beskikbaar vir ‘n aantal gevalle wat post-operatiewe wondinfeksie na ‘n keisersnit onwikkel het, maar die noemer en definisie word inkonsekwent gebruik. Die doel van hierdie studie was om die waaktoesig sisteem in Zimbabwe te ontwikkel en te versterk, om ‘n klinies-gebasseerde sisteem te vestig in ‘n opset met beprekte mikrobiologiese toegang, om postoperatiewe chirurgiese wond infeksies na keisersnitte te meet en om die geassosieerde risikofaktore te beskryf en om vas te stel of terugvoering van chirurgiese wondinfeksie data enige effek op die infeksiekoerse na keisersnitverlossings gehad het. Metodologie Hierdie was ‘n voor-en-na studie met twee kohort periodes uitgevoer by twee sentrale hospitale in Harare, Zimbabwe. ‘n Infeksievoorkoming en –beheer intervensie was tussenin uitgevoer. Tydens die pre-intervensie periode was basislyn demografiese en kliniese data ingesamel deur middel van ‘n gestruktureerde vraeboog, en gedurende die post-intervensie fase was die impak van die intervensies gemeet. Gerieflikheidsteekproefneming was geimplementeer. Resultate ‘n Totaal van 290 vroue het toestemming verleen om aan die studie deel te neem in die pre-intervensie periode, waarvan 86.9% (n=252) die 30 day post-operatiewe opvolg voltooi het en die insidensiekoers van chirurgiese wondinfeksies was 29.0% (n=73, 95% CI:23.4-35.0) Intervensies wat onwikkel was het ingesluit: opleiding in Infeksie Voorkoming en -Beheer vir gesondheidswerkers; die implementering van ‘n protokol om chirurgiese instrumente skoon te maak; disseminering van informasie oor post-operatiewe wondhantering vir vroue. Na die implimentering van die intervensie was 314 vroue gewerf in die post-intervensie fase, waarvan 92.3% (n=290) die 30 dae opvolg voltooi het. Daar was ‘n beduidende (p<0.001) verlaging in die insidensiekoers van chirurgiese wondinfeksies na 12.1% (n=35, 95% CI: 8.3-15.8) gedurende hierdie periode. Stellenbosch University https://scholar.sun.ac.za v Daar was bevind dat chirurgiese wondinfeksies beduidend geassosieer was met noodchirurgie (p<0.001), chirurgiese wondklassifikasie IV (p=0.001) en skeer van hare by die huis (p<0.001) by beide die pre-intervensie en post-intervensie periodes. Gevolgtrekking Hierdie studie wys dat keisersnitte uitgevoer kan word met ‘n lae insidensie van chirurgiese wondinfeksies indien toepaslike intervensies, soos opleiding in infeksievoorkoming en beheer, voldoende skoonmaak van toerusting en opvoeding in wondsorg vir die moeders. Dit het ook aangedui dat ‘n eenvoudige data-insameling instrument op ‘n wye basis gebruik kan word in beperkte-hulpbron lande om beleidmakers te help met monitering en evaluering van chirurgiese wondinfeksie koerse, asook die assessering van risikofaktore.

Rwanda has made significant progress in decreasing the number of maternal deaths and increasing the number of antenatal care visits and childbirths at health facilities. This thesis seeks to illuminate potential barriers for Rwanda’s goal for maternal survival. The studies explore the bottom-up perspective of policies and practices in regards to maternal care in Kigali. Semi-structured interviews were conducted between 2013 and 2016 with women who nearly died (‘near-miss’) during pregnancy, their partners, and with other recent fathers and community members, as well as healthcare providers who work within abortion care. The framework of naturalistic inquiry guided the study design and data collection. Analysis was conducted using framework analysis, thematic analysis and naturalistic inquiry. The findings identify paradoxical outcomes in the implementation of maternal care policies. Despite recent amendments of the abortion law, safe abortion was identified as being non-accessible. Abortion-related symptoms continue to carry a criminalized and stigmatized label, which encourages risk-taking and clandestine solutions to unwanted pregnancies, and causes care-seeking delays for women with obstetric complications in early pregnancy. Healthcare providers had limited awareness of the current abortion law, and described tensions in exercising their profession due to fear of litigation. The first antenatal care visit appeared to require the accompaniment of a male partner, which underpinned women’s reliance on men in their care-seeking. Men expressed interest in taking part in maternal care, but faced resistance for further engagement from healthcare providers. Giving birth at a health facility was identified as mandatory, yet care was experienced as suboptimal. Disrespect during counseling and care was identified, leading to repeated care-seeking and may underpin the uptake of traditional medicine. An enhanced implementation of the current abortion law is recommended. Reconsideration of policy is recommended to ensure equitable and complete access to antenatal care: women should be able to seek care accompanied by their person of choice. These findings further recommend action for improved policy to better address men’s preferred inclusion in maternal health matters. The findings of this thesis promote continued attention to implementing changes to strengthen quality, and trust, in public maternal care.

Tendo em vista o grande número de desastres naturais que têm afetado o mundo nos últimos anos e seus efeitos nocivos à economia e ao bem-estar social, é crescente o interesse da literatura, das organizações internacionais pertinentes e dos formuladores de políticas públicas, por avaliações dos impactos dessas catástrofes. O panorama brasileiro não é diferente, todos os anos o país é assolado por uma série de eventos naturais, que carecem de estudos sobre os seus diferentes impactos. Nesse contexto, o objetivo dessa pesquisa é avaliar, por meio de dois artigos, alguns dos efeitos socioeconômicos dos desastres naturais brasileiros. No primeiro estudo, foi verificado o impacto na atividade econômica dos municípios afetados, mensurada pelo Produto Interno Bruto (PIB) per capita, das chuvas e deslizamentos ocorridos na região Serrana do estado do Rio de Janeiro em janeiro de 2011. Esse evento, distinto aos demais desastres brasileiros, foi considerado em função do número de afetados e óbitos, o maior desastre natural do Brasil. Para investigar a relação de interesse, aplicou-se o método de controle sintético com procedimento de inferência baseado no descrito por Cavallo et al. (2013). Os resultados indicam que a catástrofe gerou efeitos negativos sobre o crescimento econômico dos municípios afetados. Já o segundo artigo, se propõe a avaliar a relação existente entre os desastres naturais hidrológicos e aspectos de saúde, como a morbimortalidade, nos municípios brasileiros. Essas catástrofes, apesar de não se tratarem do desastre mais comum, apresentam elevada recorrência e se destacam quando se trata do número de afetados e de óbitos. As possíveis implicações econômicas dos efeitos na saúde são variadas, perpassando pela redução da oferta de trabalho, perda de ativos, mudanças nas decisões alocativas das famílias, perda de capital humano, entre outras. Assim, o objetivo do segundo estudo é verificar os impactos regionais diretos e indiretos, de curto a longo prazo, dos eventos hidrológicos sobre a morbimortalidade por faixas etárias. Para isso, foi construído um painel de dados municipal com periodicidade mensal, de 2000 a 2012, com informações dos desastres e das taxas de mortalidade e morbidade. Os resultados indicam que, em curto prazo, se destacam os efeitos diretos como o aumento dos óbitos em virtude da exposição às forças da natureza e aos afogamentos. Em médio prazo, os impactos positivos se concentram, principalmente, nas taxas de morbidade em decorrência das doenças transmitidas pela água, com impactos relevantes na região Nordeste e sobre as crianças. Porém, dentre as enfermidades de médio prazo a mais crítica é a leptospirose. Essa doença é potencializada pelos desastres, tanto em relação às taxas de internações e atendimentos ambulatoriais quanto das taxas de mortalidade, em grande parte das regiões do Brasil. Já as doenças de longo prazo são pouco afetadas pelos eventos hidrológicos, com reflexos apenas para a morbidade em função da desnutrição na região Nordeste. Portanto, as evidências encontradas nesta tese indicam que os desastres naturais brasileiros demandam atenção, posto que geram uma série de impactos socioeconômicos nocivos no país. / In view of the large number of natural disasters that have affected the world in recent years and their detrimental effects on economy and social welfare, there is a growing interest in literature, relevant international organizations, and public policy makers on the impacts of these disasters. The Brazilian scenario is no different, every year the country is plagued by a series of natural disasters, which require studies on their different impacts. In this context, the objective of this research is to evaluate, through two articles, some of the socioeconomic effects of Brazilian natural disasters. In the first study, the impact in terms of economic growth of the affected municipalities was evaluated, measured by the Gross Domestic Product (GDP) per capita of the rains and landslides that occurred in the mountain region of Rio de Janeiro in January 2011. This event, distinct from the Brazilian disasters, was considered due to the number of people affected and deaths, it was the greatest natural disaster in Brazil. To investigate the relation of interest, the synthetic control method was applied with an inference procedure similar to that described by Cavallo et al. (2013). The results indicate that the event had negative effects on the economic growth of the affected municipalities. The second study seeks to evaluate the relationship between hydrological natural disasters and health aspects, such as morbidity and mortality, in Brazilian municipalities. These disasters, although not very common, present high recurrence and stand out when it comes to the number of people affected and deaths. The economic implications of health effects are varied, ranging from the reduction of job offers to loss of assets, changes in the allocative decisions of families, loss of human capital, among others. Thus, the objective of the second article is to verify the direct and indirect short- and long-term regional impacts of hydrological events on health on different age groups. For this purpose, a municipal data panel was compiled monthly with information from the disasters and mortality and morbidity rates from 2000 to 2012. The results indicate that, in the short term, the direct effects such as the increase of mortality rates due to exposure to forces of nature and to drownings stand out. In the medium term, the positive impacts are mainly on morbidity rates, due to waterborne diseases, with relevant impacts on the Northeast region and on children. However, of the medium-term diseases, the most critical is leptospirosis. This disease is strengthened by disasters, both in terms of hospitalization and outpatient care rates and mortality rates, in most of the regions of Brazil. Long-term diseases are little affected by hydrological disasters, with positive effects only on morbidity due to malnutrition in the Northeast region. Therefore, the evidence found in this thesis indicates that Brazilian natural disasters demand attention, since they generate a series of prejudicial socioeconomic impacts in the country.

INTRODUÇÃO: As Nações Unidas lançaram em 2016 os chamados Objetivos do Desenvolvimento Sustentável (ODS). Dentre esses objetivos as metas relacionadas à saúde materna e infantil são para redução da mortalidade. O projeto BOLD foi uma coorte para mulheres no período de cuidado intraparto que visava entender, em duas etapas, como melhorar a qualidade do cuidado dispendido a essas gestantes. O presente projeto foi uma análise secundária com dados desse projeto. OBJETIVOS: Validar o conceito de near miss neonatal sugerido por Pileggi-Castro e colaboradores, explorar possível associação entre desfechos graves maternos e neonatais e verificar possível associação entre o estado nutricional materno no momento do parto e desfechos maternos e neonatais graves bem como o comportamento do estado nutricional desta população. MÉTODOS: Trata-se de um corte transversal de uma coorte prospectiva realizada em 13 hospitais da Nigéria e Uganda com mulheres no momento do parto. A validação do near miss foi realizada utilizando valores de sensibilidade (S), especificidade (E), razão de verossimilhança positiva (RVP) e negativa (RVN) e razão de chances (OR). Foi utilizado o teste de Fisher para análise da associação entre desfechos graves e características maternas selecionadas e um modelo utilizando regressões ordinais e logísticas. RESULTADOS: O presente estudo incluiu 10203 mulheres e validou o conceito de near miss neonatal uma vez que reproduziram achados semelhantes com banco de dados diferente (S=99%, IC 92-100; E= 90%, IC 89-90, RVP= 9,69, IC 9,08-10,34) e RVN 0,02, IC 0,00-0,11; OR 600,6, IC 83,3-4330). Também consolidou a associação entre o desfecho materno e o neonatal graves mostrando uma relação de progressão: quanto mais grave a situação clínica materna durante trabalho de parto maior será a chance de seu recém-nascido ter um desfecho também grave (p<0,05). Além disso, apresentou análises buscando relacionar o estado nutricional da mulher no momento do parto com desfechos graves neonatais e a distribuição do peso materno e neonatal da população estudada. CONCLUSÃO: O conceito de near miss neonatal deve ser utilizado como parâmetro em diversos sistemas de saúde para que as medidas de gravidade neonatal sejam comparáveis entre si. As triagens de mulheres com risco potencial devem ser realizadas como tentativa de mitigar desfechos maternos e neonatais ruins. O estadonutricional das mulheres deve ser levado em consideração ao longo de toda sua gestação, inclusive no momento do parto, visto que ser classificada como obesa previamente ao parto está associado a riscos de o recém-nascido apresentar desfechos graves. Esse estudo estimula pesquisas de implementação para melhoria do cuidado com os dados já existentes bem como estudos epidemiológicos relacionados à classificação do estado nutricional no momento do parto em todos os países visto que essa medida isoladamente pode ser uma importante ferramenta para análise de triagem no momento do parto. / INTRODUCTION: The United Nations launched the Sustainable Development Goals (SDGs) in 2016. Among these goals, there are two specific for maternal and child\'s health that aims to reduce the mortality. The BOLD project was a cohort for women in the intrapartum period that aimed to understand, in two steps, how to improve the quality of pregnant women\'s care. The present project was a secondary analysis of this project. OBJECTIVES: To validate the concept of neonatal near miss suggested by Pileggi-Castro and colleagues, to explore the association between maternal and neonatal severe outcomes, to verify the possible association between the maternal nutritional status at delivery and maternal and neonatal outcomes, and to understand the behavior of the nutritional status of this population. METHODS: This was a cross-sectional view of a prospective cohort conducted in 13 hospitals in Nigeria and Uganda. The near miss validation was performed using values of sensitivity (S), specificity (E), positive (RVP) and negative (RVN) likelihood ratio and odds ratio (OR). Fisher\'s test was used to analyze the association between severe outcomes. We selected maternal characteristics to perform a model of ordinal and logistic regressions. RESULTS: The study included 10,203 women and validated the concept of neonatal near miss using a different database (S=99%, IC 92-100; E= 90%, IC 89-90, RVP= 9.69, IC 9.08-10.34) e RVN 0.02, IC 0.00-0.11; OR 600.6, IC 83.3-4330). We consolidated the association between maternal and neonatal outcomes showing a progression relationship: the more severe the women, the more severe the newborn outcome (p<0.05). We presented the analysis of the nutritional status of women at the time of delivery and we were not able to report an association. We presented the weight distribution of maternal and the newborns of studied population. CONCLUSION: The concept of neonatal near miss should be used as a parameter in different settings, so data can be comparable. Screening for women with potential risk to severe outcome is recommended to mitigate / avoid bad outcomes. Nutritional status is one parameter to be aware of during pregnancy as well as in the time of delivery because this might represent a risk for both mother and baby. This study stimulates implementation research to improve care and epidemiological studies aboutnutritional status in different populations since this measure alone can be a useful tool for screening analysis during delivery.

Muito se conhece sobre os efeitos deletérios da poluição do ar, e a sua influência sobre a mortalidade e morbidade por problemas respiratórios e também por doenças cardiovasculares. Diversos métodos têm sido estudados no sentido de se avaliar as consequências da exposição aos poluentes atmosféricos sobre a saúde humana, bem como, tentar estabelecer os mecanismos que envolvem esta relação. Dados antropométricos, exames de imagem e marcadores laboratoriais têm sido utilizados no sentido de se investigar o desenvolvimento de doença aterosclerótica e, a partir daí, tentar estabelecer uma relação entre os fatores de risco, dentre eles, os poluentes atmosféricos e a aterogênese. Sabe-se que a medida ultrassonográfica da espessura da camada íntima - média das artérias carótidas (EIMC) - tem sido descrita como uma análise complementar de grande potencial na avaliação não invasiva da atividade inflamatória vascular, da gênese e do desenvolvimento da doença aterosclerótica, sendo considerado um preditor independente de risco para morbidade e mortalidade por causas cardiovasculares. Este projeto de pesquisa utilizou o banco de dados relativos ao estado de São Paulo do Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil) e teve por objetivo investigar os possíveis efeitos da poluição atmosférica produzida pelo tráfego veicular na EIMC nos sujeitos incluídos neste projeto. A mensuração da exposição aos poluentes foi feita por meio de medidas indiretas utilizando-se a densidade de tráfego veicular dos locais georreferenciados (local de trabalho e domicílio), a distância da residência dos sujeitos do estudo em relação a vias de grande fluxo de veículos e, ainda, a distância percorrida no deslocamento dos sujeitos entre o domicílio e o local trabalho. Foi realizado um estudo de corte transversal com o modelo de regressão linear univariado e multivariado para se avaliar a possível correlação entre a exposição aos poluentes do ar e espessura da íntima média das carótidas (EIMC) / Air pollution has been well known to have deleterious effects, which leads to mortality and morbidity due to respiratory problems and cardiovascular diseases. Several methods have been used to evaluate the consequences of exposure to air pollutants on human health, to identify the mechanisms involving this relationship. Anthropometric data, imaging studies, and laboratory markers have been used to investigate the development of atherosclerotic disease and, based on this, we tried to identify the relationship between the risk factors, such as atmospheric pollutants and atherogenesis. Ultrasound measurement of the carotid intima-media thickness (CIMT) has been potentially described as a great complementary analysis in noninvasive assessment of vascular inflammatory activity, onset, and development of atherosclerotic disease, and is considered an independent predictor of risk for morbidity and mortality due to cardiovascular diseases. The database from the Longitudinal Study of Adult Health (ELSA-Brasil) in São Paulo was used in this study, to investigate the possible effects of air pollution produced by vehicular traffic in the CIMT of the subjects. The measurement of exposure to air pollutants was made through indirect measures of the density of vehicular traffic of georeferenced locations (work and home), the distance from the subjects\' residence to high traffic flow areas, as well as the distance covered during subjects\' commuting from their homes to workplace. A cross-sectional study using the univariate and multivariate linear regression models was conducted to evaluate the possible correlation between exposure to air pollutants and CIMT

Este estudo teve como objetivo avaliar os efeitos da morbidade materna grave na saúde sexual e reprodutiva de mulheres seis meses após o evento. Estudo observacional, transversal, realizado em dois hospitais na cidade de Ribeirão Preto, São Paulo Brasil: Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto onde ficam internadas as puéperas que tiveram algum tipo de complicação na gestação (Grupo 1) e Centro de Referência em Saúde da Mulher, onde ficam internadas as puérperas de baixo risco gestacional (Grupo 2), totalizando 110 participantes, no período de maio de 2015 a agosto de 2016. A coleta de dados, a qual aconteceu da mesma forma nos dois hospitais, foi realizada em duas fases: a primeira correspondeu ao recrutamento das participantes enquanto ainda estavam internadas após o parto, onde foram obtidos os dados obstétricos, neonatais, sociodemográficos e reprodutivos diretamente do prontuário médico; a segunda ocorreu seis meses após a alta hospitalar das participantes, as quais foram contatadas via telefone para agendamento das visitas domiciliares, onde foram colhidos os dados sociodemográficos, econômicos, ginecológicos, obstétrico e os relacionados à saúde sexual, através do instrumento Female Sexual Function Index. Os dados foram analisados através do software Statistical Package for the Social Sciences e R versão 3.1.2. Foram utilizadas análises univariada e bivariada com distribuição de frequências absolutas e relativas, medidas de tendência central, variabilidade dos dados, testes Mann-Whitney, Qui-quadrado e Exato de Fisher, regressão beta inflacionada. No Grupo 1, a média de idade das mulheres foi de 30 anos, com prevalência da cor branca e a maioria solteira com relação ao estado civil, mas vivia junto com o companheiro há mais de 10 anos, enquanto no Grupo 2, a idade média foi de 27,1 anos com prevalência de cor parda, casada e com tempo de relacionamento entre dois e cinco anos. A escolaridade foi praticamente a mesma nos dois grupos, com uma média de 9,5 anos de estudo. Tanto no Grupo 1 quanto no Grupo 2, a maioria não fumava, nem fazia uso de drogas ilícitas ou bebidas alcoólicas. Enquanto no Grupo 1 a maioria havia feito cesárea, sendo 36,6% dos bebês nascidos prematuros, no Grupo 2, a maioria teve parto vaginal com apenas 7,2% dos bebês nascidos antes de 37 semanas. Das mulheres do Grupo 1, as morbidades materna grave mais frequentes foram as relacionadas aos distúrbios hipertensivos. Não houveram associações entre a ocorrência de morbidade materna grave e a predisposição à disfunção sexual, no entanto, em todos os domínios relacionados à função sexual (desejo, excitação, lubrificação, orgasmo, satisfação e dor), as mulheres do Grupo 2 tiveram melhores pontuações, no entanto com a regressão Beta inflacionada, foram encontradas associações entre os domínos orgasmo e a variável cor, domínio satisfação e a variável tempo de relacionamento e entre o domínio dor e a morbidade materna grave, demonstrando que esse grupo de mulheres sofre com dispareunia quando comparadas com as mulheres que não tiveram complicações na gestação / The objective of this study was to to evaluate the effects of severe maternal morbidity on sexual and reproductive health of women six months after the event. Cross-sectional observational study carried out in two hospitals in the city of Ribeirão Preto, São Paulo Brazil: Hospital of the Clinics of the Medical School of Ribeirão Preto, where the patients who had some kind of complication during pregnancy (Group 1) and Reference Center for Women\'s Health, where low-risk pregnancies (Group 2) are hospitalized, totaling 110 participants, from May 2015 to August 2016. Data collection, which occurred in the same way in both hospitals, was performed in two phases: the first corresponded to the recruitment of the participants while they were still hospitalized after delivery, where the obstetric, neonatal, sociodemographic and reproductive data were obtained directly from the medical record; the second occurred six months after the patients were discharged from the hospital, who were contacted by telephone to schedule home visits, where socio-demographic, economic, gynecological, obstetrical and sexual health data were collected through the Female Sexual Function Index . The data were analyzed through the software Statistical Package for the Social Sciences and R version 3.1.2. Univariate and bivariate analyzes were used with absolute and relative frequency distributions, central tendency measures, data variability, Mann-Whitney, Chi-square and Fisher Exact tests, inflated beta regression. In Group 1, the average age of the women was 30 years, with white prevalence and the majority single in relation to the marital status, but lived with the partner for more than 10 years, while in Group 2, the average age was 27.1 years old, with a prevalence of brown, married and with a relationship between two and five years. Schooling was practically the same in both groups, with an average of 9.5 years of study. In both Group 1 and Group 2, most did not smoke, nor did they use illicit drugs or alcoholic beverages. While in Group 1 the majority had delivered cesarean, with 36.6% of babies born preterm in Group 2, the majority had vaginal delivery with only 7.2% of babies born before 37 weeks. Of the women in Group 1, the most frequent severe maternal morbidities were those related to hypertensive disorders. However, in all domains related to sexual function (desire, arousal, lubrication, orgasm, satisfaction and pain), there were no associations between the occurrence of severe maternal morbidity and the predisposition to sexual dysfunction, the women in Group 2 had better scores However, with inflated beta regression, associations were found between domains orgasm and color variable, satisfaction domain and time relationship variable, and between pain domain and severe maternal morbidity, demonstrating that this group of women suffers from dyspareunia when compared with women who had no complications during pregnancy

Introdução - O estudo da morbidade materna contribui para um melhor entendimento do quadro da saúde materna, no Brasil, e para o conhecimento dos problemas obstétricos que podem levar (ou não) ao internamento das gestantes. Os dados de morbidade materna são vitais para os gestores de políticas públicas de saúde, os quais precisam saber quantas mulheres necessitam de cuidados obstétricos básicos para tornar a gestação e o parto mais seguros. Objetivos - Estudar a morbidade materna e os conceptos de puérperas numa maternidade da rede pública de João Pessoa, Paraíba, e identificar mulheres com diagnósticos considerados potencialmente graves e sugestivos de morbidade materna near miss. Método - Trata-se de um estudo transversal que fez parte de uma pesquisa maior sobre a morbimortalidade materna. Foi selecionada uma amostra de 414 puérperas por um processo de amostragem aleatória sistemático, cujos dados foram coletados, prospectivamente, de setembro a novembro de 2011, a partir dos prontuários clínicos e entrevistas complementares, numa maternidade pública de referência e acentuada demanda no município. Resultados - Foram estudadas 383 gestações que terminaram em parto e 391 conceptos. Entre as puérperas, predominou a faixa etária dos 20 aos 34 anos, cor parda, baixa escolaridade, baixa renda e sem ocupação formal no mercado de trabalho. Metade delas tiveram parto cesariano e 17 por cento dos recém-nascidos apresentaram problemas de saúde. Foram identificadas as seguintes intercorrências no parto: lacerações do períneo, hematomas, traumatismos, hemorragias e hipertensões. No puerpério, destacaram-se os transtornos hipertensivos, as hemorragias do pós-parto e as infecções. Entre os 64 diagnósticos sugestivos de near miss, estão as síndromes hipertensivas (58 por cento ) e as síndromes hemorrágicas (32,8 por cento ). Na análise comparativa entre os grupos de puérperas com morbidades sugestivas e não sugestivas de near miss, as seguintes variáveis apresentaram diferenças estatisticamente significantes (p<0,001): problemas de saúde na gestação anterior e atual, hipertensão, gestação de risco e uso de anti-hipertensivos. Não foram encontradas diferenças estatísticas entre as características dos neonatos e a morbidade materna, sugestiva ou não de near miss. Conclusão - O estudo permitiu conhecer as características maternas e a prevalência (15,5 por cento ) de morbidades sugestivas de near miss que ocorrem, seja no parto seja no puerpério. Ampliar o conhecimento sobre os aspectos que envolvem a morbidade materna torna-se crucial para o adequado enfrentamento de complicações no ciclo gravídico-puerperal, além de apoiar o Plano de Ação para acelerar a redução da mortalidade materna e morbidade materna grave. / Introduction The study of maternal morbidity contributes to a better understanding of the maternal health scene in Brazil and to the fuller knowledge of obstetric problems that may lead (or not) to the hospitalization of pregnant women. Maternal morbidity data are vital for the administrators of public health policies, who need to know how many women are expected to need basic obstetric care so as to make pregnancy and delivery safer. Objectives To study maternal morbidity and the conceptuses of puerperae in a public maternity hospital in João Pessoa, Paraíba, and identify women with a diagnosis considered potentially threatening and suggestive of being possible near misses. Method - This is a transverse study that is part of a larger project on maternal morbimortality. A sample of 414 puerperae was selected by a process of systematic random sampling, the data on whom were collected, prospectively, from September to November 2011, on the basis of clinical case notes and complementary interviews, at a public maternity hospital of reference in great demand in the municipality. Results - A total of 383 pregnancies which were carried through to delivery and 391 conceptuses were studied. There predominated, among the puerperas: the 20 - 34 year age-group, of brown skin color, low level of schooling, low income and no formal professional occupation. Half of them underwent caesarian section and 17 per cent of the new-born presented health problems. The following incidents were identified during labour: lacerations of the perineum, haematomas, traumatisms, haemorrhages and hypertensions. During the puerperium, hypertensive disorders, post-partum hemorrhage and other puerperal infections were noteworthy. The most frequent mention in the case notes of maternal causes was of hypertensive disturbances of pregnancy. Among the 64 diagnoses suggestive of near-miss, are the hypertensive (58 per cent ) and the haemorrhagic syndromes (32.8 per cent ). In the comparative analysis of the groups of puerperae with morbidities suggestive of near-miss, the following variables presented statistically significant differences (p<0.001): health problems during the previous and present pregnancy, hypertension, risk pregnancy and use of hypertensive medications. No statistical differences between the characteristics of the newborn and those of maternal morbidity (whether suggestive of near miss or not) were found. Conclusion - The study allowed the identification of maternal characteristics and the prevalence (15.5 per cent ) of the morbidities suggestive of maternal near-miss which occur either during labour or puerperium. It is crucial that our knowledge of the aspects of maternal mortality should be expanded so that the complications of the pregnancy-puerperal cycle may be adequately treated and to provide support for the Action Plan to speed up the reduction of maternal mortality and severe maternal morbidity.

Die genitale Bilharziose ist eine Manifestation der Bilharziose, über deren Bedeutung für die reproduktive Gesundheit der Frau bisher wenig bekannt ist. Das klinische Bild der genitalen Bilharziose ist heterogen, da alle Genitalorgane betroffen sein können. Durch die Bilharziose verursachte gynäkologische Probleme wie z.B. Infertilität können für die betroffenen Frauen erhebliche Auswirkungen auf ihr soziales Leben haben (Scheidung wegen Kinderlosigkeit, verringerte Heiratsaussichten). In der vorliegenden Arbeit werden epidemiologische, parasitologische und klinische Untersuchungsergebnisse von Feldforschungsarbeiten zur genitalen Bilharziose der Zervix, die in Tansania durchgeführt wurden, vorgestellt. In den Studiendörfern war die Häufigkeit der genitalen Bilharziose der Zervix (38 %) bei Frauen im Alter zwischen 15 und 45 Jahren nahezu zahlengleich mit der Häufigkeit der Blasenbilharziose (42 %). Die genitale Bilharziose der Zervix ging einher mit "sandy patches", die als pathognomisch angesehen werden, Leukoplakien und Epithelläsionen. In den Biopsien von Frauen mit genitaler Bilharziose wurde im Vergleich zu nichtinfizierten Frauen eine erhöhte Anzahl von Entzündungszellen gesehen. Nach Therapie mit Praziquantel sank die Häufigkeit der genitalen Bilharziose um 70 %. Die Diagnose der genitalen Bilharziose der Zervix durch den direkten Nachweis mittels eines Quetschpräparats des Zervixgewebes ist der histologischen Untersuchung der Zervixbiopsie und der zytologischen Untersuchung des Zervixabstriches überlegen. Die diagnostische Wertigkeit indirekter Krankheitsmarker wurde untersucht. Frauen mit genitaler Bilharziose wiesen höhere Spiegel von eosinophilem kathodischen Protein (ECP) in der vaginalen Lavage auf als nichtinfizierte Frauen. Dies war aber auch bei Frauen mit sexuell übertragbaren Infektionen der Fall war. Es wurden bei Frauen mit genitaler Bilharziose - im Verhältnis zur Eiausscheidung im Urin - höhere Schistosomenantigenspiegel (CAA) festgestellt als bei Frauen mit ausschließlicher Blasenbilharziose. Dies kann durch die "ektopische" Lokalisation der adulten Würmer im Zervixgewebe erklärt werden. Die Forschungsergebnisse geben Hinweise, die die Hypothese einer möglichen Interaktion zwischen der genitalen Bilharziose und Infektionen mit HIV bzw. HPV unterstützen. Dazu gehören z.B. die Störung der Barrierefunktion des Zervixepithels bereits im jungen Alter und die Anwesenheit von HIV-empfänglichen Zellen im Zervixgewebe, die das Risiko einer Infektion mit HIV erhöhen könnten. / Female genital schistosomiasis is a neglected manifestation of schistosomiasis and its public health importance is yet to be determined. Symptoms and signs induced by genital schistosomiasis are unspecific and depending on the localisation of the infection the clinical picture is heterogenous. Pathological consequences of female genital schistosomiasis such as infertility may have a considerable impact on the social life of the diseased woman resulting in divorce or reduced chances to marry. In this paper the results of epidemiological, parasitological and clinical investigations of female genital schistosomiasis, which have been carried out in two study villages in Northern Tanzania, are described. The frequency of schistosomiasis of the cervix in women aged 15 to 45 years (38%) was similar to the frequency of urinary schistosomiasis (42%). The main pathological lesions seen were sandy patches, which seem to be pathognomic, leucoplakia and epithelial lesions. In cervical biopsies of women with genital schistosomiasis a higher absolute number of inflammatory cells were seen compared to women without the infection. The standard therapy reduced the frequency of genital schistosomiasis by 70%. The diagnostic performance of the direct parasitological examination of cervical tissue was better compared to the histopathological examination of the biopsy or the cytological examination of the cervical smear. The diagnostic value of indirect disease markers were investigated. Women with diagnosed genital schistosomiasis and sexually transmitted diseases showed higher levels of eosinophil cationic protein (ECP) in the vaginal lavage compared to women without infections. In women with genital schistosomiasis higher levels of schistosome antigens (CAA) were detected compared to women with urinary schistosomiasis only. This might be explained by the "ectopic" localisation of adult schistosomes in the genital tract. The research results support the hypothesis of a possible interaction of genital schistosomiasis with sexually transmitted infections such as HIV and HPV, e.g. the disruption of the cervical epithelial barrier in young age and the presence of HIV-sensible cells due to genital schistosomiasis might increase the risk of HIV transmission.

As metástases cerebrais são os tumores cerebrais mais freqüentes do sistema nervoso central. Entre as modalidades terapêuticas, a radiocirurgia (SRS) vem ganhando destaque nas duas últimas décadas como forma efetiva de tratamento associada com baixa morbidade e mortalidade. Porém, mesmo após ampla revisão da literatura, várias perguntas permanecem sem resposta sobre a radiocirurgia no tratamento das metástases cerebrais, perguntas estas principalmente relacionadas sobre as complicações tardias, dependência ao corticóide e relação das complicações com áreas cerebrais funcionais eloqüentes. O objetivo deste trabalho foi analisar a radiocirurgia como modalidade terapêutica das metástases cerebrais (MC) de uma grande série de casos, que estuda criteriosamente clínica e radiologicamente as lesões e identificando fatores preditivos para complicações, falha terapêutica e necrose pós-tratamento, a qual enfatiza principalmente localização da MC e suas relações com áreas eloqüentes cerebrais. Foi realizado estudo retrospectivo em 213 pacientes com 261 metástases cerebrais tratadas com radiocirurgia. Várias características demográficas deste grupo de pacientes foram analisadas, onde destacamos a boa distribuição de lesões de várias histologias tratadas e na grande maioria de pacientes em bom estado geral. Além disso, dividimos estes tumores de acordo com uma classificação estabelecida para relação com áreas eloqüentes em 3 grupos (graus I, II e III). No nosso estudo encontramos dependência ao corticóide em 24,3% dos casos, que se distribui em 15%, 25% e 29% nas lesões grau I, II e III respectivamente. O autor demonstra que o dobro das lesões localizadas nas áreas eloqüentes apresenta dependência ao corticóide, comparando-se com tumores em áreas não eloqüentes. Destacamos que a dependência ao esteróide ocorre em 54,5% dos tumores do tronco cerebral, 38,8% dos relacionados com centro motor/sensitivo, 35,5% daqueles relacionados com centros da fala e 20% dos casos relacionados com áreas visuais. Também nestes grupos específicos ocorreu queda destas taxas de dependência com o passar dos meses. Na nossa casuística, a SRS foi efetiva em 184 lesões tratadas (70,5%), diante de acompanhamento prolongado. As complicações em geral foram mais freqüentes em áreas eloqüentes, ocorrendo, especificamente, em 64,7% , 64,9% e 55,3% respectivamente, para lesões do tronco cerebral, centros da fala e áreas motoras/sensitivas. Dentre as muitas variáveis utilizadas encontramos diferenças significativas para complicações para casos com doença primária progressiva, lesões grau III (áreas eloqüentes), lesões do tronco cerebral e relacionadas com áreas motoras/sensitivas. Se estudarmos apenas os casos com falha terapêutica, notamos diferenças para predizer falha terapêutica em casos com doença sistêmica avançada, a não realização de radioterapia prévia e lesões relacionadas com áreas motoras/sensitivas e centros da fala. Foram considerados fatores preditivos de necrose pós-tratamento metástases de melanoma e carcinoma de células renais, presença de metástases outras além do encéfalo, realização prévia de radioterapia, doses acima de 20 Gy e tumores relacionados com áreas motoras/sensitivas. Em todas as análises, notamos diferenças significativas quanto maior o tamanho da lesão tratada. Não houve diferenças significativas quanto à efetividade ou complicações comparando as várias histologias, ocorrendo diferenças para o surgimento de necrose póstratamento em casos das lesões consideradas \"radioresistentes\" (melanoma e carcinoma de células renais). Considerando os resultados obtidos, concluise que a realização de radioterapia prévia a radiocirurgia esteve associada com maior efetividade e maior possibilidade de ocorrer necrose póstratamento. Doença primária em estágio avançado foi considerada como fator preditivo de complicação e de falha terapêutica. Lesões maiores apresentaram significativas diferenças para complicações, falhas terapêuticas e necrose pós-tratamento, do que lesões menores. Podemos concluir, ainda, que a localização da metástase cerebral deve ser considerada uma variável importante em predizer complicação do tratamento, visto que encontramos significativas diferenças para o surgimento de complicações em lesões localizadas em áreas eloqüentes (grau III) e ainda especificamente em lesões do tronco cerebral e em áreas motoras/sensitivas, comparando-se com demais regiões cerebrais. Tais áreas também apresentaram maior taxa de dependência ao corticóide / Brain metastases are the most common Central Nervous System tumors. Among the therapy options stereotactic radiosurgery has became in the last two decades an usefulness treatment technique attending with lower complication and mortality rate. However, even an extended literature review, many questions remain unclear about this therapy modality, mainly related with long-term complications, steroids dependency, and relations with brain eloquent areas. The goal of this project is analyze stereotactic radiosurgery as treatment modality for brain metastases in a large series, considering clinics and radiologic lesions aspects and identifying predictors factors for complications, treatment failure and treatment necrosis regarding the relation with brain eloquent areas. We retrospectively review 213 patients with 261 brain metastases treated with stereotactic radiosurgery. Several demographics aspects were analysed. We noticed a good distribution of histological groups and the performing patient status. We also lump these lesions in groups based on their location in relation with eloquent brain areas (grade I, II and III). This study found a general steroids dependency rate of 24,3% for all cases, occurring in 15%, 25% and 29% in lesions grade I, II and III respectively. That\'s twice the frequency for lesions located in eloquent brain areas compared with non eloquent located lesions. Specifically, the steroids dependency occurred in 54,5% of brain stem tumors, 38,8% tumors related with motor/sensory centers, 35,5% speech center tumors related and 20% of cases related with visual areas. Even in these subgroups the dependency rate decreases with time. The long-term tumor local control was achieved in 184 treated lesion (70,5%). Complications were more often found in eloquent areas, specifically in 64,7%, 64,9% and 55,3% respectively for brain stem, speech centers and motor/sensory related lesions. Among all variables we found significant differences for complications in cases of progressive primary disease, lesions grade III (located in eloquent areas), brain stem lesions, and related with motor/sensory areas. Regarding only treatment failure prediction, we noticed significances in cases of progressive primary disease, none previously radiated cases, and lesions related with motor/sensitive and speech areas. We considered predictors of treatment necrosis melanoma and renal cell carcinoma metastases, extra-cranial metastases, previously radiated patients, doses > 20Gy. In all analysis we found significant differences as bigger as the treated lesion. We did not find significant differences regarding efficacy and complication comparing all histological types. We identify statistically significant considering \"radioresistent\" tumors for treatment necrosis. Based on the results, we conclude that radiotherapy previously stereotactic radiosurgery were related higher effectiveness and treatment necrosis. Progressive primary disease predicts complications and treatment failure. Bigger lesions were statistically significant related with complications, treatment failure and necrosis compared with smaller ones. We can also conclude that brain location of metastases is an important variable to predict complications, with results that showed statistically significant differences found in grade III lesions, specifically brain stem tumors, lesions related in motor/sensitive areas, compared with non eloquent located lesions. These areas are also related with higher steroids dependency rates