Publications by authors named "Silvina Ramos"

27 Publications

  • Page 1 of 1

Health Care Provider Perceptions of Facilitators and Barriers to Human Papillomavirus Vaccination Delivery in Five Countries.

Sex Transm Dis 2021 08;48(8):557-564

Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: National human papillomavirus (HPV) vaccination programs could reduce global cervical cancer morbidity and mortality with support from health care providers. We assessed providers' perceptions of HPV vaccination in 5 countries.

Methods: We identified providers from 5 countries where national HPV vaccination programs were at various stages of implementation: Argentina, Malaysia, South Africa, South Korea, and Spain. Providers authorized to administer adolescent vaccines completed an in-depth survey, reporting perceptions of barriers and facilitators to initiating and completing HPV vaccination, and logistical challenges to HPV vaccination.

Results: Among 151 providers, common barriers to HPV vaccination initiation across all countries were parents' lack of awareness (39%), concerns about vaccine safety or efficacy (33%), and cost to patients (30%). Vaccination education campaign (70%) was the most commonly cited facilitator of HPV vaccination initiation. Common barriers to series completion included no reminder system or dosing schedule (37%), loss to follow-up or forgetting appointment (29%), and cost to patients (25%). Cited facilitators to completing the vaccine series were education campaigns (45%), affordable vaccination (32%), and reminder/recall systems (22%). Among all countries, high cost of vaccination was the most common logistical challenge to offering vaccination to adolescents (33%).

Conclusions: Incorporating provider insights into future HPV vaccination programs could accelerate vaccine delivery to increase HPV vaccination rates globally.
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http://dx.doi.org/10.1097/OLQ.0000000000001389DOI Listing
August 2021

Optimizing the use of cesarean section in Argentina: design and methodology of a formative research for the development of interventions.

Reprod Health 2021 Jan 26;18(1):23. Epub 2021 Jan 26.

Department of Reproductive Health and Research, UNDP, UNFPA, UNICEF, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland.

Background: While cesarean section is an essential life-saving strategy for women and newborns, its current overuse constitutes a global problem. The aim of this formative research is to collect information from hospitals, health professionals and women regarding the use of cesarean section in Argentina. This article describes the methodology of the study, the characteristics of the hospitals and the profile of the participants.

Methods: This formative research is a mixed-method study that will be conducted in seven provinces of Argentina. The eligibility criteria for the hospitals are (a) use of the Perinatal Information System, (b) cesarean section rate higher than 27% in 2016, (c) ≥ 1000 deliveries per year. Quantitative and qualitative research techniques will be used for data collection and analysis. The main inquiry points are the determining factors for the use of cesarean section, the potential interventions to optimize the use of cesarean section and, in the case of women, their preferred type of delivery.

Discussion: It is expected that the findings will provide a situation diagnosis to help a context-sensitive implementation of the interventions recommended by the World Health Organization to optimize cesarean section use. Trial registration IS002316 Cesarean section is an essential medical tool for mothers and their children, but nowadays its overuse is a problem worldwide. Our purpose is to get information from hospitals, health professionals and women about how cesarean section is used in Argentina. In this protocol we describe how we will carry out the study and the characteristics of the hospitals and participants. We will implement this study in seven provinces of Argentina, in hospitals that have more than 1,000 births each year, had a cesarean section rate higher than 27% in 2016 and use the Perinatal Information System. We will gather information using forms, surveys and interviews. We want to identify the factors that decide the use of a cesarean section, the potential interventions that can improve the use of cesarean section and, in the case of women, the type of delivery they prefer. We expect that this study will give us a diagnosis of how cesarean section is used in Argentina, and that this will help to apply the interventions that the World Health Organization recommends to optimize the use of cesarean section in our specific context.
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http://dx.doi.org/10.1186/s12978-021-01080-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836162PMC
January 2021

[Concerns and demands regarding COVID-19. Survey of health personnel].

Medicina (B Aires) 2020 ;80 Suppl 3:16-24

Instituto Gino Germani, Universidad de Buenos Aires, Argentina.

The COVID-19 pandemic affected the organization of health services and had consequences for health teams, according to the pre-existing safety and working conditions. During the first week of April 2020, a cross sectional study was carried out with a qualitative-quantitative approach. The aim was to explore the conditions determining the organizational climate: leadership, communication, institutional resources, cohesion/conflict management, and training; and how these were perceived by health personnel to deal with the pandemic. A total of 5670 healthcare workers participated in an online survey and 50 were interviewed, from all subsectors of the Argentinean health system (public, private and union-health insurance); 72.9% were women, 51.4% were physicians, and the predominant age group was under 40 years. In the qualitative sample (interviews), 52% were men, 62% were physicians, and the average age was 44.8 years. The dimensions of the organizational climate were stratified and five independent predictors of perception of conditions were identified: age, gender, tasks performed, health system subsector, and jurisdiction. The condition most frequently perceived as inadequate were the inaccessibility of institutional resources and the access to personal protective equipment was a major concern. Claims included the need of institutional strategies to support healthcare workers and of a clear and uniform communication. In conclusion, at the time of the study, the health personnel perceived serious deficits in their organizations regarding the conditions necessary to confront COVID-19, with differences among subsectors of the health system.
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August 2020

Persuasive messaging for human papillomavirus vaccination by adolescent providers in a five-country multi-site study.

Int J Gynecol Cancer 2019 02 4;29(2):250-256. Epub 2019 Jan 4.

Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA

Objective: Strong persuasive messaging by providers is a key predictor for patient acceptance of prophylactic human papillomavirus vaccination. We aimed to determine optimal messaging to promote human papillomavirus adolescent vaccination across different geographical sites.

Methods: Adolescent providers (n = 151) from Argentina, Malaysia, South Africa, South Korea, and Spain were surveyed on messages, family decision makers, and sources of communication to best motivate parents to vaccinate their adolescent daughters overall, and against human papillomavirus. Multivariate logistic regression assessed the likelihood of recommending messages specifically targeted at cervical cancer with providers' characteristics: gender, medical specialization, and previous administration of human papillomavirus vaccination.

Results: Mothers were considered the most important human papillomavirus vaccination decision makers for their daughters (range 93%-100%). Television was cited as the best source of information on human papillomavirus vaccination in surveyed countries (range 56.5%-87.1%), except Spain where one-on-one discussions were most common (73.3%). Prevention messages were considered the most likely to motivate parents to vaccinate their daughters overall, and against human papillomavirus, in all five countries (range 30.8%-55.9%). Optimal messages emphasized cervical cancer prevention, and included strong provider recommendation to vaccinate, vaccine safety and efficacy, timely vaccination, and national policy for human papillomavirus vaccination. Pediatricians and obstetricians/gynecologists were more likely to cite that the best prevention messages should focus on cervical cancer (OR: 4.2, 95% CI: 1.17 to 15.02 vs other medical specialists).

Conclusions: Provider communication messages that would motivate parents to vaccinate against human papillomavirus were based on strong recommendation emphasizing prevention of cervical cancer. To frame convincing messages to increase vaccination uptake, adolescent providers should receive updated training on human papillomavirus and associated cancers, while clearly addressing human papillomavirus vaccination safety and efficacy.
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http://dx.doi.org/10.1136/ijgc-2018-000004DOI Listing
February 2019

Adolescent providers' knowledge of human papillomavirus vaccination age guidelines in five countries.

Hum Vaccin Immunother 2019 4;15(7-8):1672-1677. Epub 2019 Apr 4.

a Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina , Chapel Hill , NC , USA.

: To examine provider knowledge of HPV vaccination age guidelines in five countries. : A total of 151 providers of adolescent vaccinations in Argentina, Malaysia, South Africa, South Korea, and Spain were interviewed between October 2013 and April 2014. Univariate analyses compared providers' understanding of recommended age groups for HPV vaccination to that of each country's national guidelines. : In three of five countries surveyed, most providers (97% South Africa, 95% Argentina, 87% Malaysia) included all nationally recommended ages in their target age group. However, a relatively large proportion of vaccinators in some countries (83% Malaysia, 55% Argentina) believed that HPV vaccination was recommended for women above age 26, far exceeding national guidelines, and beyond the maximum recommended age in the United States. National median minimum and maximum age recommendations cited by the respondents for HPV vaccination were 11 and 29 years in Argentina (national guideline: 11-14), 13 and 48 years in Malaysia (guideline 13-14), 8 and 14 years in South Africa (guideline 9-14), 10 and 20 years in South Korea (guideline 11-14), and 11 and 12 years in Spain (guideline 11-14). In all countries, a higher percentage of vaccinators included all nationally recommended ages for vaccination, as compared to providers who did not administer HPV vaccination. : Overall, a substantial proportion of providers incorrectly reported their country's age guidelines for HPV vaccination, particularly the upper age limit. As provider recommendation is among the strongest predictors of successful vaccination uptake among adolescents, improved education and clarification of national guidelines for providers administering HPV vaccination is essential to optimize prevention of infection and associated disease.
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http://dx.doi.org/10.1080/21645515.2018.1558688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746518PMC
February 2020

Acceptability of two- versus three-dose human papillomavirus vaccination schedule among providers and mothers of adolescent girls: a mixed-methods study in five countries.

Cancer Causes Control 2018 Nov 4;29(11):1115-1130. Epub 2018 Oct 4.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.

Purpose: The World Health Organization revised its human papillomavirus (HPV) vaccination recommendations to include a two (2-) dose schedule for girls aged ≤ 15 years. We investigated acceptability of 2- versus 3-dose schedule among adolescent vaccination providers and mothers of adolescent girls in five countries.

Methods: Adolescent vaccination providers (N = 151) and mothers of adolescent girls aged 9-14 years (N = 118) were recruited from Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers' preference for a 2- versus 3-dose HPV vaccination schedule via quantitative surveys. Mothers' attitudes towards a 2-dose schedule were assessed through focus group discussions.

Results: Most adolescent providers preferred a 2- over a 3-dose HPV vaccination schedule (overall: 74%), with preference ranging from 45.2% (South Africa) to 90.0% (South Korea). Lower cost, fewer clinic visits, and higher series completion were commonly cited reasons for 2-dose preference among providers and mothers. Safety and efficacy concerns were commonly cited barriers to accepting a 2-dose HPV vaccination schedule among providers and mothers. Mothers generally accepted the reduced schedule, however requested further information from a trusted source.

Conclusions: Adolescent vaccination providers and mothers preferred the 2-dose over 3-dose HPV vaccination schedule. Acceptability of a 2-dose HPV vaccination could be improved with additional information to providers and mothers on HPV vaccination safety and efficacy.
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http://dx.doi.org/10.1007/s10552-018-1085-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589352PMC
November 2018

HPV Vaccination Recommendation Practices among Adolescent Health Care Providers in 5 Countries.

J Pediatr Adolesc Gynecol 2018 Dec 12;31(6):575-582.e2. Epub 2018 Jul 12.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina. Electronic address:

Study Objective: To assess adolescent health care providers' recommendations for, and attitudes towards human papillomavirus (HPV) vaccination in 5 countries.

Design: In-depth interviews of adolescent health care providers, 2013-2014.

Setting: Five countries where HPV vaccination is at various stages of implementation into national programs: Argentina, Malaysia, South Africa, South Korea, and Spain.

Participants: Adolescent health care providers (N = 151) who had administered or overseen provision of adolescent vaccinations (N = Argentina: 30, Malaysia: 30, South Africa: 31, South Korea: 30, Spain: 30).

Main Outcome Measures: Frequency of HPV vaccination recommendation, reasons providers do not always recommend the vaccine and facilitators to doing so, comfort level with recommending the vaccine, reasons for any discomfort, and positive and negative aspects of HPV vaccination.

Results: Over half of providers 82/151 (54%) recommend HPV vaccination always or most of the time (range: 20% in Malaysia to 90% in Argentina). Most providers 112/151 (74%) said they were comfortable recommending HPV vaccination, although South Korea was an outlier 10/30 (33%). Providers cited protection against cervical cancer 124/151 (83%) and genital warts 56/151 (37%) as benefits of HPV vaccination. When asked about the problems with HPV vaccination, providers mentioned high cost 75/151 (50% overall; range: 26% in South Africa to 77% in South Korea) and vaccination safety 28/151 (19%; range: 7% in South Africa to 33% in Spain). Free, low-cost, or publicly available vaccination 59/151 (39%), and additional data on vaccination safety 52/151 (34%) and efficacy 43/151 (28%) were the most commonly cited facilitators of health provider vaccination recommendation.

Conclusion: Interventions to increase HPV vaccination should consider a country's specific provider concerns, such as reducing cost and providing information on vaccination safety and efficacy.
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http://dx.doi.org/10.1016/j.jpag.2018.06.010DOI Listing
December 2018

Acceptability of multipurpose human papillomavirus vaccines among providers and mothers of adolescent girls: A mixed-methods study in five countries.

Papillomavirus Res 2017 Jun 6;3:126-133. Epub 2017 Apr 6.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, CB# 7435, Chapel Hill, NC 27599, USA; UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.

Introduction: Multipurpose vaccines (MPVs) could be formulated to prevent multiple sexually transmitted infections simultaneously. Little is known about acceptability of MPVs among vaccine health care providers (HCPs) or mothers of adolescent girls.

Methods: 151 adolescent vaccine providers and 118 mothers of adolescent girls aged 9-14 were recruited from five geographically-diverse countries: Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers' preferences for single-purpose human papillomavirus (HPV) vaccine versus MPVs (including HPV+herpes simplex virus (HSV)-2, HPV+HIV, or HPV+HSV-2+HIV) via quantitative surveys. Maternal MPV attitudes were assessed in four focus group discussions (FGDs) in each country.

Results: Most providers preferred MPVs over single-purpose HPV vaccination, with preference ranging from 61% in Malaysia to 96% in South Africa. HPV+HSV-2+HIV was the most preferred MPV formulation (56-82%). Overall, 53% of the mothers preferred MPVs over single-purpose HPV vaccines, with strongest support in South Africa (90%) and lowest support in South Korea (29%). Convenience and trust in the health care system were commonly-cited reasons for MPV acceptability. Safety and efficacy concerns were common barriers to accepting MPVs, though specific concerns differed by country. Across FGDs, additional safety and efficacy information on MPVs were requested, particularly from trusted sources like HCPs.

Conclusions: Though maternal acceptability of MPVs varied by country, MPV acceptability would be enhanced by having HCPs provide parents with additional MPV vaccine safety and efficacy information. While most providers preferred MPVs, future health behavior research should identify acceptability barriers, and targeted provider interventions should equip providers to improve vaccination discussions with parents.
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http://dx.doi.org/10.1016/j.pvr.2017.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608022PMC
June 2017

[Regionalization of perinatal health care in the province of Santa Fe, Argentina].

Rev Panam Salud Publica 2017 May 25;41:e38. Epub 2017 May 25.

Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina.

Objective: Improve the performance of the regionalization policy in the province of Santa Fe, Argentina, as a strategy to improve perinatal health care by analyzing implementation processes and building consensus among decision makers and stakeholders around an action plan.

Methods: Implementation research was conducted using mixed methodology. A needs assessment established tracer indicators to measure adherence to the components of the policy. Actors were studied to identify the barriers and facilitators of implementation. Training was provided on the development of consensus- and evidence-based policies, through workshops in which policy briefs were prepared and through a deliberative dialogue.

Results: There were improvements in the number of births in appropriate hospitals and in the number of births in maternity hospitals with Essential Obstetric and Neonatal Care (CONE). Barriers were identified in the referral systems and in communication on policy, which resulted in an initial agreement on the need for guidelines and specific technical training on the transfer of babies and mothers.

Conclusions: The participation of health workers in identifying barriers and strategies to overcome them, and the use of tools to report this to management, permit the adoption of consensus- and evidence-based strategies to improve policy implementation.
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May 2017

HPV testing: a mixed-method approach to understand why women prefer self-collection in a middle-income country.

BMC Public Health 2016 08 19;16:832. Epub 2016 Aug 19.

Biostatistics Unit, Faculty of Health, Deakin University, Geelong, 3148, VIC, Australia.

Background: HPV test self-collection has been shown to reduce barriers to cervical screening and increase uptake. However, little is known about women's preferences when given the choice between self-collected and clinician-collected tests. This paper aims to describe experiences with HPV self-collection among women in Jujuy, the first Argentinean province to have introduced HPV testing as the primary screening method, provided free of cost in all public health centers.

Methods: Between July and December 2012, data on acceptability of HPV self-collection and several social variables including past screening were collected from 2616 self-collection accepters and 433 non-accepters, and were analyzed using multivariate regression. In addition, in-depth interviews (n = 30) and 2 focus groups were carried out and analyzed using thematic analysis.

Results: Quantitative findings indicate that main reasons for choosing self-collection are those reducing barriers related to women's roles of responsibility for domestic work and work/family organization, and to health care services' organization. No social variables were significantly associated with acceptability. Among those who preferred clinician-collection, the main reasons were trust in health professionals and fear of hurting themselves. Qualitative findings also showed that self-collection allows women to overcome barriers related to the health system (i.e. long wait times), without sacrificing time devoted to work/domestic responsibilities.

Conclusions: Findings have implications for self-collection recommendations, as they show it is the preferred method when women are given the choice, even if they are not screening non-attenders. Findings also highlight the importance of incorporating women's needs/preferences in HPV screening recommendations.
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http://dx.doi.org/10.1186/s12889-016-3474-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990977PMC
August 2016

[Safe and family-centered maternity hospitals: organizational culture of maternity hospitals in the province of Buenos Aires].

Arch Argent Pediatr 2015 Dec;113(6):510-8

Centro de Estudios de Estado y Sociedad.

Introduction: In 2010, the Safe and Family-Centered Maternity Hospitals initiative was launched in order to transform large public maternity centers into settings where safe practices are implemented and the rights of women, newborn infants and families are warranted. As a result, the paradigm of perinatal care was modified. This article reports on the findings of organizational culture as a component for the implementation of the initiative.

Population And Methods: The sample was selected in a non-probabilistic way and was made up of 29 public hospitals located in the province of Buenos Aires that participated in the initiative. During 2011 and 2012, an anonymous, self-administered survey was completed by members of the Department of Neonatology and the Department of Obstetrics. The survey collected information on three dimensions of the organizational culture: organizational environment, safe practices, and facilitation of change.

Results: A total of 1828 surveys were collected; 51% of survey respondents stated that there is a need to improve communication by having more meetings, while 60% made a positive assessment of various aspects of leadership. Work overload was described as the main cause of conflicts by 60%. Approximately 25% agreed and showed commitment with the initiative of transforming maternity centers. Adherence to practices was dissimilar depending on the practice, but half of survey respondents reported that there were genuine reasons for change.

Conclusions: The assessment of the organizational culture showed that commitment to the Safe and Family-Centered Maternity Hospitals initiative is yet to be consolidated, and the evaluation of leadership is not comprehensive. Work overload and communication failures are the main reasons for conflict.
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http://dx.doi.org/10.5546/aap.2015.510DOI Listing
December 2015

Social determinants of nonadherence to tuberculosis treatment in Buenos Aires, Argentina.

Cad Saude Publica 2015 Sep;31(9):1983-94

Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil.

This study aimed to identify the individual and environmental determinants of nonadherence to tuberculosis (TB) treatment in selected districts in the Buenos Aires Metropolitan Area, in Argentina. We conducted a cross-sectional study using a hierarchical model. Using primary and secondary data, logistic regression was performed to analyze two types of determinants. The likelihood of nonadherence to treatment was greatest among male patients. The following factors led to a greater likelihood of nonadherence to treatment: patients living in a home without running water; head of household without medical insurance; need to use more than one means of transport to reach the health center; place of residence in an area with a high proportion of households connected to the natural gas network; place of residence in an area where a large proportion of families fall below the minimum threshold of subsistence capacity; place of residence in an area where a high proportion of households do not have flushing toilets and basic sanitation. Our results show that social and economic factors - related to both individual and environmental characteristics - influence adherence to TB treatment.
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http://dx.doi.org/10.1590/0102-311X00024314DOI Listing
September 2015

Spatial analysis of the tuberculosis treatment dropout, Buenos Aires, Argentina.

Rev Saude Publica 2015 7;49:49. Epub 2015 Aug 7.

Departamento de Epidemiologia e Métodos Quantitativos, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.

OBJECTIVE Identify spatial distribution patterns of the proportion of nonadherence to tuberculosis treatment and its associated factors. METHODS We conducted an ecological study based on secondary and primary data from municipalities of the metropolitan area of Buenos Aires, Argentina. An exploratory analysis of the characteristics of the area and the distributions of the cases included in the sample (proportion of nonadherence) was also carried out along with a multifactor analysis by linear regression. The variables related to the characteristics of the population, residences and families were analyzed. RESULTS Areas with higher proportion of the population without social security benefits (p = 0.007) and of households with unsatisfied basic needs had a higher risk of nonadherence (p = 0.032). In addition, the proportion of nonadherence was higher in areas with the highest proportion of households with no public transportation within 300 meters (p = 0.070). CONCLUSIONS We found a risk area for the nonadherence to treatment characterized by a population living in poverty, with precarious jobs and difficult access to public transportation.
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http://dx.doi.org/10.1590/S0034-8910.2015049005391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4544507PMC
March 2016

Determinants of non adherence to tuberculosis treatment in Argentina: barriers related to access to treatment.

Rev Bras Epidemiol 2015 Apr-Jun;18(2):287-98

Centro de Estudios de Estado y Sociedad, Ciudad Autónoma de Buenos Aires, Argentina.

Objective: To identify the association between non-adherence to tuberculosis treatment and access to treatment.

Methods: A cross-sectional study was carried out in the Metropolitan Area of Buenos Aires, Argentina. One hundred twenty three patients notified in 2007 (38 non adherent and 85 adherents) were interviewed regarding the health care process and socio-demographic characteristics. Factors associated to non-adherence were assessed through logistic regression analysis.

Results: An increased risk of non-adherence with to treatment was found in male patients (OR = 2.8; 95%CI 1.2 - 6.7), patients who had medical check-ups at hospitals (OR = 3.4; 95%CI 1.1 - 10.0) and those who had difficulties with transportation costs (OR = 2.5; 95%CI 1.1 - 5.9).

Conclusion: Risk of non-adherence increases as a result of economic barriers in accessing health care facilities. Decentralization of treatment to primary health care centers and social protection measures for patients should be considered as priorities for disease control strategies in order to lessen the impact of those barriers on adherence to treatment.
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http://dx.doi.org/10.1590/1980-5497201500020001DOI Listing
November 2016

Women's experiences with the use of medical abortion in a legally restricted context: the case of Argentina.

Reprod Health Matters 2015 Feb;22(44 Suppl 1):4-15

External Researcher, CEDES, Buenos Aires, Argentina.

This article presents the findings of a qualitative study exploring the experiences of women living in Buenos Aires Metropolitan Area, Argentina, with the use of misoprostol for inducing an abortion. We asked women about the range of decisions they had to make, their emotions, the physical experience, strategies they needed to use, including seeking health care advice and in dealing with a clandestine medical abortion, and their overall evaluation of the experience. An in-depth interview schedule was used. The women had either used misoprostol and sought counselling or care at a public hospital (n=24) or had used misoprostol based on the advice of a local hotline, information from the internet or from other women (n=21). Four stages in the women's experiences were identified: how the decision to terminate the pregnancy was taken, how the medication was obtained, how the tablets were used, and reflections on the outcome whether or not they sought medical advice. Safety and privacy were key in deciding to use medical abortion. Access to the medication was the main obstacle, requiring a prescription or a friendly drugstore. Correct information about the number of pills to use and dosage intervals was the least easy to obtain and caused concerns. The possibility of choosing a time of privacy and having the company of a close one was highlighted as a unique advantage of medical abortion. Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled.
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http://dx.doi.org/10.1016/S0968-8080(14)43786-8DOI Listing
February 2015

Health care providers' opinions on abortion: a study for the implementation of the legal abortion public policy in the Province of Santa Fe, Argentina.

Reprod Health 2014 Sep 24;11:72. Epub 2014 Sep 24.

Center for the Study of State and Society (CEDES), Sánchez de Bustamante 27, 1173 Buenos Aires, Argentina.

Background: In Argentina, abortion has been decriminalized under certain circumstances since the enactment of the Penal Code in 1922. Nevertheless, access to abortion under this regulatory framework has been extremely limited in spite of some recent changes. This article reports the findings of the first phase of an operations research study conducted in the Province of Santa Fe, Argentina, regarding the implementation of the local legal and safe abortion access policy.

Methods: The project combined research and training to generate a virtuous circle of knowledge production, decision-making, and the fostering of an informed healthcare policy. The project used a pre-post design of three phases: baseline, intervention, and evaluation. It was conducted in two public hospitals. An anonymous self-administered questionnaire (n = 157) and semi-structured interviews (n = 27) were applied to gather information about tacit knowledge about the regulatory framework; personal opinions regarding abortion and its decriminalization; opinions on the requirements needed to carry out legal abortions; and service's responses to women in need of an abortion.

Results: Firstly, a fairly high percentage of health care providers lack accurate information on current legal framework. This deficit goes side by side with a restrictive understanding of both health and rape indications. Secondly, while a great majority of health care providers support abortion under the circumstances consider in the Penal Code, most of them are reluctant towards unrestricted access to abortion. Thirdly, health care providers' willingness to perform abortions is noticeably low given that only half of them are ready to perform an abortion when a woman's life is at risk. Willingness is even lower for each of the other current legal indications.

Conclusions: Findings suggest that there are important challenges for the implementation of a legal abortion policy. Results of the study call for specific strategies targeting health care providers in order to better inform about current legal abortion regulations and to sensitize them about abortion social determinants. The interpretation of the current legal framework needs to be broadened in order to reflect a comprehensive view of the health indication, and stereotypes regarding women's sexuality and abortion decisions need to be dismantled.
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http://dx.doi.org/10.1186/1742-4755-11-72DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197265PMC
September 2014

Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: results of the FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation) trial.

J Am Coll Cardiol 2013 Jan 19;61(4):463-468. Epub 2012 Dec 19.

Fundación GESICA (Grupo de Estudio de Investigación Clínica en Argentina), Buenos Aires, Argentina.

Objectives: The aim of this study was to evaluate the efficacy of polyunsaturated fatty acids (n-3 PUFA) for the prevention of recurrent atrial fibrillation (AF) in patients with normal sinus rhythm.

Background: Current pharmacological treatments to limit recurrent AF in patients with previous AF have limited efficacy and high rates of adverse events. Results of trials that tested the efficacy of n-3 PUFA provided heterogeneous results.

Methods: This was a prospective, randomized, double-blind, placebo-controlled, multicenter trial involving 586 outpatient participants with confirmed symptomatic paroxysmal AF that required cardioversion (n = 428), at least 2 episodes of AF in the 6 months before randomization (n = 55), or both (103). Patients were randomly allocated to n-3 PUFA (1 g/day) or placebo for 12 months. The primary endpoint was symptomatic recurrence of AF.

Results: There were no significant differences between patients allocated to placebo and those who received n-3 PUFA for the main outcome. At 12 months, 56 of 297 participants (18.9%) in the placebo group and 69 of 289 participants (24.0%) in the n-3 PUFA group had a recurrent symptomatic AF (hazard ratio: 1.28, 95% confidence interval: 0.90 to 1.83, p = 0.17). There was no difference between treatment with placebo and n-3 PUFA for any of the other pre-specified endpoints, including the composite of all-cause mortality, nonfatal stroke, nonfatal acute myocardial infarction, systemic embolism, heart failure development, or severe bleeding that occurred in 20 (6.7%) and 16 (5.5%) of patients randomized to placebo or n-3 PUFA, respectively (hazard ratio: 0.86, 95% confidence interval: 0.44 to 1.66, p = 0.65).

Conclusions: Pharmacological supplementation with 1 g of n-3 PUFA for 1 year did not reduce recurrent AF. (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation [FORWARD]; NCT00597220).
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http://dx.doi.org/10.1016/j.jacc.2012.11.021DOI Listing
January 2013

Latin American women's experiences with medical abortion in settings where abortion is legally restricted.

Reprod Health 2012 Dec 22;9(1):34. Epub 2012 Dec 22.

Center for the Study of State and Society (CEDES) (External Researcher) and Adolescent Health Foundation (FUSA), Buenos Aires, Argentina.

Abortion is legally restricted in most of Latin America where 95% of the 4.4 million abortions performed annually are unsafe. Medical abortion (MA) refers to the use of a drug or a combination of drugs to terminate pregnancy. Mifepristone followed by misoprostol is the most effective and recommended regime. In settings where mifepristone is not available, misoprostol alone is used.Medical abortion has radically changed abortion practices worldwide, and particularly in legally restricted contexts. In Latin America women have been using misoprostol for self-induced home abortions for over two decades.This article summarizes the findings of a literature review on women's experiences with medical abortion in Latin American countries where voluntary abortion is illegal.Women's personal experiences with medical abortion are diverse and vary according to context, age, reproductive history, social and educational level, knowledge about medical abortion, and the physical, emotional, and social circumstances linked to the pregnancy. But most importantly, experiences are determined by whether or not women have the chance to access: 1) a medically supervised abortion in a clandestine clinic or 2) complete and accurate information on medical abortion. Other key factors are access to economic resources and emotional support.Women value the safety and effectiveness of MA as well as the privacy that it allows and the possibility of having their partner, a friend or a person of their choice nearby during the process. Women perceive MA as less painful, easier, safer, more practical, less expensive, more natural and less traumatic than other abortion methods. The fact that it is self-induced and that it avoids surgery are also pointed out as advantages. Main disadvantages identified by women are that MA is painful and takes time to complete. Other negatively evaluated aspects have to do with side effects, prolonged bleeding, the possibility that it might not be effective, and the fact that some women eventually need to seek medical care at a hospital where they might be sanctioned for having an abortion and even reported to the police.
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http://dx.doi.org/10.1186/1742-4755-9-34DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557184PMC
December 2012

Social inequality in Pap smear coverage: identifying under-users of cervical cancer screening in Argentina.

Reprod Health Matters 2008 Nov;16(32):50-8

Centro de Estudios de Estado y Sociedad (CEDES) and Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.

In Argentina, the unequal distribution of the burden of cervical cancer is striking: the mortality rate of the province of Jujuy (15/100,000) is almost four times higher than that of the city of Buenos Aires (4/100,000). We aimed to establish the socio-demographic profile of women who were under-users of Pap smear screening, based on an analysis of a representative sample of Argentinean women from the First National Survey on Risk Factors in 2005. We found that in Argentina, women who are poor, unmarried, unemployed or inactive, with lower levels of education and reduced access to health care, and women over the age of 65, were under-users of screening. Screening must not remain opportunistic. Strategies must incorporate the needs and perceptions of socially disadvantaged women, and increase their access to screening. Of utmost importance is to provide good quality screening and treatment services that reach women who are at risk. Pilot projects using new, alternative technologies should be encouraged in less developed parts of the country. Promotion among health professionals of the scientific basis and effectiveness of each screening modality is essential to reduce wasteful practices such as annual screening and screening of young women that waste resources and fail to reduce cervical cancer incidence and mortality rates.
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http://dx.doi.org/10.1016/S0968-8080(08)32410-0DOI Listing
November 2008

[Contraception and abortion in Argentina: perspective of obstetricians and gynaecologists].

Salud Publica Mex 2008 Jan-Feb;50(1):32-9

Facultad Latinoamericana de Ciencias Sociales, Argentina.

Objective: To explore the role of obstetricians and gynaecologists in reproductive public health policies in Argentina.

Material And Methods: Combination of quantitative methods (survey, n=467) and qualitative methods (semistructured interview, n=35; focus groups, n=6).

Results: The great majority of respondents believe that abortion and contraception are serious public health issues. Seven out of 10 considered the implementation of family planning services and post-abortion contraceptive counseling to be priorities. One-half favored promoting social debate on abortion. The great majority thought that de-criminalization of abortion would help to diminish maternal mortality and that abortion should not be penalized when the womans life or health is at risk, or in cases of rape or fetal malformations.

Conclusions: Abortion and contraception are important issues for physicians. Advocacy efforts within this community need to focus on an integral vision of health, emphasizing their social responsibility.
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http://dx.doi.org/10.1590/s0036-36342008000100009DOI Listing
July 2008

A comprehensive assessment of maternal deaths in Argentina: translating multicentre collaborative research into action.

Bull World Health Organ 2007 Aug;85(8):615-22

Center for the Study of State and Society, Buenos Aires, Argentina.

Objective: To perform a comprehensive assessment of maternal mortality in Argentina, the ultimate purpose being to strengthen the surveillance system and reorient reproductive health policies to prevent maternal deaths.

Methods: Our multicentre population-based study combining qualitative and quantitative methodologies included a descriptive analysis of under-registration and distribution of causes of death, a case-control study to identify risk factors in health-care delivery and verbal autopsies to analyse social determinants associated with maternal deaths.

Findings: A total of 121 maternal deaths occurred during 2002. The most common causes were abortion complications (27.4%), haemorrhage (22.1%), infection/sepsis (9.5%), hypertensive disorders (8.4%) and other causes (32.6%). Under-registration was 9.5% for maternal deaths (n = 95) and 15.4% for late maternal deaths (n = 26). The probability of dying was 10 times greater in the absence of essential obstetric care, active emergency care and qualified staff, and doubled with every 10-year increase in age. Other contributing factors included delays in recognizing "alarm signals"; reluctance in seeking care owing to desire to hide an induced abortion; delays in receiving timely treatment due to misdiagnosis or lack of supplies; and delays in referral/transportation in rural areas.

Conclusion: A combination of methodologies is required to improve research on and understanding of maternal mortality via the systematic collection of health surveillance data. There is an urgent need for a comprehensive intervention to address public health and human rights issues in maternal mortality, and our results contribute to the consensus-building necessary to improve the existing surveillance system and prevention strategies.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636380PMC
http://dx.doi.org/10.2471/blt.06.032334DOI Listing
August 2007

Maternal mortality in Argentina: a closer look at women who die outside of the health system.

Matern Child Health J 2008 Jul 23;12(4):519-24. Epub 2007 Aug 23.

Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.

Objectives: To assess maternal mortality among women who died outside health institutions. To use the technique of verbal autopsy to identify maternal deaths and to obtain qualitative information about the determinants of maternal death using the "three delays" model.

Methods: Subjects were women aged 10-49 who died outside of a health institution during 2002 in five Argentine provinces with maternal mortality ratios above the national average. Cases were identified through the national and provincial registries, and data were collected using verbal autopsies, where the relatives of the deceased are interviewed.

Results: Of 252 completed verbal autopsies, 15 maternal deaths and five late maternal deaths were found. Hemorrhage was the most common cause of maternal death. Seventy-nine percentage of women who died of maternal causes experienced at least one delay in accessing care, with delays in seeking assistance as the most common, followed by delays in accessing and receiving quality care.

Conclusions: Maternal causes of death are equally prevalent among women who die outside the health system as among those who die within it, but avoidable deaths are still a problem. Interventions to improve understanding of "alarm signals" (serious symptoms) and improved access and quality of care are necessary to reduce maternal mortality.
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http://dx.doi.org/10.1007/s10995-007-0268-2DOI Listing
July 2008

A strategic assessment of the reproductive health and responsible parenthood programme of Buenos Aires, Argentina.

Reprod Health Matters 2005 May;13(25):60-71

CEDES (Centro de Estudios de Estado y Sociedad), Buenos Aires, Argentina.

Since 1991, Argentina has had provincial reproductive health laws, a far-reaching national programme and strong public consensus in support of reproductive health policies. Nevertheless, the challenges of strengthening public services, increasing the number of programme sites and resisting conservative attacks remain. This article describes an assessment of the reproductive health programme of the city of Buenos Aires, passed in 2000, whose objectives are to prevent unwanted pregnancies and sexually transmitted diseases/HIV and to train health personnel. The programme operates in every public hospital and primary health care centre in the city. The assessment was conducted jointly by the Ombudsperson's Office of Buenos Aires and the Centre for the Study of State and Society (CEDES). Hormonal contraceptives, IUDs and male condoms were mostly available, but emergency contraception, female condoms and other barrier methods were not Some health professionals and service users were knowledgeable about the new laws and the reproductive rights recognised under the law. Over 90% were satisfied with quality of care in service delivery but many professionals described excessive workloads, deficient infrastructure, and shortages of supplies and staff. Wanting help to obtain a tubal ligation was the most frequent reason for the claims lodged with the Ombudsperson's Office, followed by HIV, quality of care, and abortion. Information and training for both health care providers and women's and human rights NGOs was carried out.
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http://dx.doi.org/10.1016/s0968-8080(05)25174-1DOI Listing
May 2005

Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial.

Lancet 2004 Jun;363(9425):1934-40

Latin American Center for Perinatology, Pan American Health Organization, WHO, Montevideo, Uruguay.

Background: Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality.

Methods: 36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy.

Findings: A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI 0.2-14.5), mostly in intrapartum sections (12.6%; 0.6-24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups.

Interpretation: In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process.
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http://dx.doi.org/10.1016/S0140-6736(04)16406-4DOI Listing
June 2004

Abortion in a restrictive legal context: the views of obstetrician-gynaecologists in Buenos Aires, Argentina.

Reprod Health Matters 2002 May;10(19):128-37

Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina.

In Argentina, unsafe abortions are the primary cause of maternal mortality, accounting for 32% of maternal deaths. During reform of the National Constitution in 1994, the women's movement effectively resisted the reactionary government/church position on abortion. Health professionals, including obstetrician-gynaecologists, played conflicting roles in this debate. This article presents results from a study carried out in 1998-1999 of the views of 467 obstetrician-gynaecologists from public hospitals in Buenos Aires and its Metropolitan Area, focus group discussions with 60 of them, and interviews with heads of department from 36 of the hospitals. The great majority believed abortion was a serious public health issue; that physicians should provide abortions which are not illegal; that abortion should not be penalized to save the woman's life, or in cases of rape or fetal malformations; and that women having illegal abortions and abortion providers should not be imprisoned. Some 40% thought abortion should not be penalized if it is a woman's autonomous decision. Those who were better disposed towards the de-penalization of abortion cited a combination of public health reasons and the need for social equity. The women's health and rights movement should do advocacy work with this professional community on women's needs and rights, given the prominent role they play in reproductive health care provision and in the public sphere.
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http://dx.doi.org/10.1016/s0968-8080(02)00014-9DOI Listing
May 2002
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