Background: This paper aimed to review the literature on the factors associated with parenting stress and resilience among parents of children with autism spectrum disorder (ASD) in the South East Asia (SEA) region.Methods: An extensive search of articles in multiple online databases  resulted in 28 papers that met the inclusion criteria . Studies found were conducted in the following countries: Brunei, n = 1; Indonesia, n = 2; Malaysia, n = 12; Philippines, n = 5; Singapore, n = 5, Thailand, n = 2; and Vietnam, n = 1, but none from Cambodia, East Timor, Laos, and Myanmar were identified.Results: Across the studies, six main factors were found to be associated with parenting stress: social support, severity of autism symptoms, financial difficulty, parents' perception and understanding toward ASD, parents' anxiety and worries about their child's future, and religious beliefs. These six factors could also be categorized as either a source of parenting stress or a coping strategy/resilience mechanism that may attenuate parenting stress.Conclusion: The findings suggest that greater support services in Western countries may underlie the cultural differences observed in the SEA region. Limitations in the current review were identified. The limited number of studies yielded from the search suggests a need for expanded research on ASD and parenting stress, coping, and resilience in the SEA region especially in Cambodia, East Timor, Laos, and Myanmar. The identified stress and resilience factors may serve as sociocultural markers for clinicians, psychologists, and other professionals to consider when supporting parents of children with ASD. Parenting children with autism spectrum disorder (ASD) can be more stressful and challenging than parenting children with typical development, especially in countries where there is a dearth of various support resources. Across the literature, parents of children with ASD frequently reported higher levels of anxiety  in regards to parenting stress among parents with children with ASD, and therefore provide a discussion on the sources of stress among this sample, and the variables/ factors that may attentuate the levels of stress experienced by them. It is believed that findings from this review paper will be able to provide insights on the factors related to parenting stress, specific to the SEA region, an under-researched area. Furthermore, it is hoped that the findings will be able to provide a culture-specific understanding of the stress experienced by parents of chidren with ASD in the SEA region and that, the identified stress and resilience factors may serve as sociocultural markers for clinicians, psychologists, and other professionals to consider when supporting and treating parents and families of children with ASD.The systematic review conducted on parenting stress and resilience in parents of children with ASD began with a search of literature using multiple electronic databases  of children with other forms of cognitive delay(s) and/or disability(ies) other than ASD  were also excluded  were excluded. Finally, a total of 28 studies were deemed eligible to be reviewed.A conscious decision was made not to limit the range of years of published studies, in order not to further reduce an already narrow yield of results in this under-researched region. However, it was planned to exclude studies published before 1980, in accordance with the initial inclusion of autism in the Diagnostic and Statistical Manual, 3rd edition  affecting parenting stress were noted and recorded for each study. Characteristics of each study, as listed in Supplementary Tables Similarities and differences between studies were highlighted as well as pooling together similar reporting measures and outcomes across studies. All relevant influential factors were thematically categorized and presented in a descriptive approach. All authors agreed on the data analysis findings and factor categorization. To minimize bias and promote trustworthiness of the findings, three experienced researchers with knowledge in the topic area also reviewed the data analysis findings and agreed with our factor categorization and discussion of the results.A total of 28 studies were finally chosen for review in this paper . It would however be inaccurate to infer that SEA countries that were not yielded in this search have a lower awareness of ASD. This lack of identified articles in five SEA countries may be mainly due to the possibility that factors such as funding may have played a role in the lack of/absence of published research in those countries.The resulting search found relevant studies to be investigated in only seven of the total, 12 SEA countries . Several of the studies investigated parenting stress as the main variable in their study  social support, (ii) severity of autism symptoms, (iii) financial difficulty, (iv) parents' understanding and perception toward ASD, (v) parents' anxiety and worries about their child's future, and (vi) religious belief.Social support. Across the studies, social support was found to be a coping mechanism that was frequently reported in easing parenting stress  and emotional support  , found parents' anxiety in regards to the future of their child (who is diagnosed with ASD) to be one of their sources of stress  or as a coping strategy/mechanism that may attenuate levels of parenting stress .To a certain extent, findings from this review are comparable to that yielded from the Western context . However, it was noteworthy to find contradictory results in regards to the support received by external family members Foronda, . This diAlso noteworthy is that findings on the social support received from extended family members and/or community, seem to imply it as a cultural factor that is typical of the collective and supportive culture in an Asian context  were also found to be associated with parenting stress among parents of children with ASD. In regards to the parents' anxiety and worries about the child's future, this factor was related to the lack of resources and support services available in the region to manage the ASD symptomologies and associated comorbidities  that might also provide a better understanding of the parenting stress experienced by parents of children with ASD. Hence, the limited number of studies that met the inclusion criteria despite this precautionary step might also point to the lack of research conducted in the SEA region in regards to parenting stress and resilience among parents of children with ASD.At face value, it is noticeable that low-income countries and those with lower ratings in the Human Developmental Index  included, parents' anxiety and worries about their child's future, and religious belief. Whilst several of these factors may have similarly been reported in a Western context, findings from the current systematic review lean to suggest that the greater advanced development and implementation of policy, economical and professional support services in Western countries than in South-East Asian countries might impart cultural differences in regards to how these factors are manifested. Therefore, further research is imperative to more clearly identify cultural specificities that differentiate how parenting stress and its associated factors are uniquely experienced across countries in the SEA region in comparison to Western countries. Additionally, as majority of the studies identified in this review were not published in high-impact journals with large readerships, funding and research bodies are recommended to increasingly support the methodological rigor in the design, conduct, and publication of studies in the SEA region, especially in the lower-income countries.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In many low- and middle-income countries, the costs of delivering public health programs such as for HIV/AIDS, nutrition, and immunization are not routinely tracked. A number of recent studies have sought to estimate program costs on the basis of detailed information collected on a subsample of facilities. While unbiased estimates can be obtained via accurate measurement and appropriate analyses, they are subject to statistical uncertainty. Quantification of this uncertainty, for example, via standard errors and/or 95% confidence intervals, provides important contextual information for decision-makers and for the design of future costing studies. While other forms of uncertainty, such as that due to model misspecification, are considered and can be investigated through sensitivity analyses, statistical uncertainty is often not reported in studies estimating the total program costs. This may be due to a lack of awareness/understanding of (1) the technical details regarding uncertainty estimation and (2) the availability of software with which to calculate uncertainty for estimators resulting from complex surveys. We provide an overview of statistical uncertainty in the context of complex costing surveys, emphasizing the various potential specific sources that contribute to overall uncertainty.We describe how analysts can compute measures of uncertainty, either via appropriately derived formulae or through resampling techniques such as the bootstrap. We also provide an overview of calibration as a means of using additional auxiliary information that is readily available for the entire program, such as the total number of doses administered, to decrease uncertainty and thereby improve decision-making and the planning of future studies.A recent study of the national program for routine immunization in Honduras shows that uncertainty can be reduced by using information available prior to the study. This method can not only be used when estimating the total cost of delivering established health programs but also to decrease uncertainty when the interest lies in assessing the incremental effect of an intervention.Measures of statistical uncertainty associated with survey-based estimates of program costs, such as standard errors and 95% confidence intervals, provide important contextual information for health policy decision-making and key inputs for the design of future costing studies. Such measures are often not reported, possibly because of technical challenges associated with their calculation and a lack of awareness of appropriate software. Modern statistical analysis methods for survey data, such as calibration, provide a means to exploit additional information that is readily available but was not used in the design of the study to significantly improve the estimation of total cost through the reduction of statistical uncertainty. Although specific details varied across the six studies, the sampling was performed using a combination of purposeful and random selection at the various levels. In Honduras, for example, the final study sample consisted of 71 of 1534 facilities, from 8 of 20 health regions.16 Average costs at each level, calculated on the basis of information collected within the sampling frame, were then weighted to obtain estimates of the total national costs for routine immunization (RI).The global health community has become increasingly concerned with resource needs and financial sustainability as health programs in low- and middle-income countries (LMICs) expand coverage to include new treatment choices into routine practice, build capacity for long-term growth of their health systems, and plan for transition away from international donor support.16 Although the reporting of these types of measures is standard in the public health and medical literature, they are often not reported in health service costing studies based on data from a subsample of service delivery points; the EPIC studies are, therefore, not unusual in this regard. That uncertainty is not reported may be due, in part, to the difficulties associated with managing complex sample designs and generating appropriate sample weights, as well as a lack of awareness/understanding of techniques that can be used to compute them. Distinct from other sources of uncertainty, such as that due to model12 specification for which sensitivity analyses are available,17 understanding and quantifying statistical uncertainty is critical in that it provides important contextual information for decision-makers, which may have implications for planning and budgeting, and for prioritizing future costing studies.While the methods adopted by the European Prospective Investigation into Cancer and Nutrition (EPIC) have many strengths, the original analyses and reports published estimates of total costs although it generally did not report measures that quantify statistical uncertainty due to the fact that only a subsample of facilities were included in the survey, such as standard errors or 95% confidence intervals (CIs).Against this backdrop, this article provides an overview of statistical uncertainty in the context of complex survey-based costing studies as well as methods for quantification. In addition, we describe recently developed statistical methods that exploit auxiliary information to reduce uncertainty, thereby substantially improving the precision of the final estimates. Throughout, we illustrate the ideas using data from the Honduran EPIC study.16 At the time RI was delivered through a network of 1534 public and non-governmental organizations (NGOs) health facilities across the country, organized geographically into 298 municipalities within 20 health regions , a survey was conducted to collect detailed resource use and cost information from the sample of 71 health facilities within eight of the health regions . RelevanFrom each of the eight selected regions, between 8 and 9 health facilities were selected. In San Pedro Sula and Tegucigalpa, the EPI lead facility  was chosen along with eight additional facilities selected via stratified random sampling based on facility type. For the six other regions, three municipalities were selected in each on the basis of the size of the population below 1 year old. Within each municipality, the EPI lead facility was purposefully chosen along with 1–2 non-lead facilities selected via stratified random sampling on the basis of facility type.18 The online Supplementary Materialsdocument provides the actual code used to generate the results, along with additional technical details.As indicated in the Introduction, costing studies may have many goals. To help simplify the exposition, we present the methods in the context of estimating total costs of RI in Honduras. The ideas are generally applicable to any costing study goal, however, and to emphasize this, we also present results pertaining to the average facility-level cost per dose. Throughout, all results were obtained using the survey package for the freely available R statistical computing language.To make the task at hand more concrete, we write the total cost of RI in Honduras as r and where f in municipality m in region r. Note that the notation has been developed to acknowledge that the number of municipalities within any given region, denoted r, may vary across regions and that the number of facilities within any given municipality, m in region r, may also vary .19 Focusing on In the absence of complete data from all facilities/regions, neither r was selected and r was selected to be part of the survey. Note that in the Honduran EPIC study, 12 of the 20 regions have πronline Supplementary Materials.where Given estimates 16 the average cost per dose is substantially higher among smaller facilities than among larger facilities, with estimates ranging from US$2.99 per dose in huge facilities to US$44.62 in tiny facilities.From the second column of While the second columns of 20 For a given population structure and study design for the survey, an analytic expression (i.e. formula) for the variance of the IPW estimate can be derived and implemented. In the online Supplementary Materials document, for example, we provide a detailed derivation specific to the variance of In statistical analyses, uncertainty is typically quantified using the standard error (the square-root of the variance of the estimate), which is then used to calculate a 95% CI.22 The online Supplementary Materials document provides an algorithm for bootstrap-based estimation of the standard error and a 95% CI for 18When the number of surveyed sampling units (i.e. facilities) is small, as is the case in many costing studies, the theory that underpins the validity of analytic formulae may not hold with a resulting mischaracterization of uncertainty. As an alternative, analysts may use a resampling-based technique such as the bootstrap.Columns 3–6 of Standard error estimates and corresponding 95% CIs for the component costs are also provided. For example, the formula-based 95% CI for the total labor cost is US$16.1 million and US$24.6 million. Note that the standard error for the total vaccine costs is US$0 because these are solely accrued by the central administrative offices, are therefore known, and do not need to be estimated.Similarly, columns 3–6 of a priori, that is, before they are selected by the design.While IPW estimators provide a means of accounting for the sampling scheme in a survey, they are well known to be statistically inefficient in the sense that they tend to exhibit greater uncertainty than other estimators of the same quantity. One approach to improving statistical efficiency, thereby reducing uncertainty, and making 95% CIs tighter is to use auxiliary information that is readily available on all regions/facilities. In the context of a costing study for RI, one possibility would be to use information on the total number of doses administered in each facility; these totals have been shown to be highly correlated with the total costs. Suppose that this information is readily available, one could use it as a basis for stratifying the facilities 23 To see this, let If the auxiliary information is available, but was not used to inform the sampling scheme, analysts have at their disposal a range of methods that permit its use post hoc. One such method is calibration, the essential idea of which is to use the auxiliary information to modify the weights used in the standard IPW estimator in such a way that uncertainty is reduced.calibrated weights, can then be used to form a new IPW estimator of Ostensibly, the Supplementary Materials.We used information from Honduras on the number of doses delivered annually at each health facility to perform post hoc calibration. The R code for this, based on the survey package for R, is given in the The right-hand parts of In addition, the point estimate for large facilities is smaller than for huge facilities, whereas for the rest of categories the cost follows an increasing trend when the facility size decreases. This inconsistency, however, is addressed and corrected by the calibrated methods as observed in 24 Another type of uncertainty is statistical uncertainty, the essential question being “how different would the results/conclusions have been if a different sub-sample had been selected?” We focus on the latter in this article. Understanding and quantifying this type of uncertainty provides critical information for decision-making. For example, stratifying by facility size could have yield more efficient estimators as the cost varies significantly across the sizes. As such, studies estimating the incremental cost of health technologies or interventions report CIs for regression models that use patient-level data. Likewise, reports of analyses of complex population health surveys such as the Demographic and Health Surveys (IMF Macro) routinely include CIs. Studies aimed at measuring the full delivery cost of health services in LMICs, however, have to-date not systematically reported measures of statistical uncertainty alongside point estimates. Moreover, when they are included, the methods used usually do not leverage auxiliary information that is often available to reduce uncertainty. The calibration method not only provides a means of gaining efficiency in the estimation of the total delivery costs of health programs, but also in studies where the primary interest is to evaluate the incremental cost of a novel intervention.5 We believe that with a greater awareness of these tools and opportunities, together with the references provided, analysts and policy-makers will have more concrete information on which to base decisions as well as to design future costing studies.When analyzing data from survey-based costing studies in LMICs, researchers must contend with a range of types of uncertainty. One such type is the uncertainty associated with the model, the essential question being “do the results/conclusions change as one changes the model that is basis for the analysis?” Toward investigating this type of uncertainty, researchers may employ sensitivity analyses.Measures of uncertainty associated with survey-based estimates of program costs, such as standard errors and 95% CIs, provide important contextual information for health policy decision-making and key inputs for the design of future costing studies. Such measures are often not reported, possibly because of technical challenges associated with their calculation and a lack of awareness of appropriate software. Modern statistical analysis methods for survey data, such as calibration, provide a means to exploit additional information that is readily available but was not used in the design of the study to significantly improve the estimation of total cost through the reduction of uncertainty.Click here for additional data file.Supplemental material, SAGE_SM for Quantifying and reducing statistical uncertainty in sample-based health program costing studies in low- and middle-income countries by Claudia L Rivera-Rodriguez, Stephen Resch and Sebastien Haneuse in SAGE Open Medicine


Facing the challenges of aging populations, increasing chronic diseases prevalence and health system fragmentation, there have been several pilots of integrated health systems in China. But little is known about their structure, mechanism and effectiveness. The aim of this paper is to analyze health system integration and develop recommendations for achieving integration.Huangzhong and Hualong counties in Qinghai province were studied as study sites, with only Huangzhong having implemented health system integration. Questionnaires, interviews, and health insurance records were sources of data. Social network analysis was employed to analyze integration, through structure measurement and effectiveness evaluation.Health system integration in Huangzhong is higher than in Hualong, so is system effectiveness. The patient referral network in Hualong has more “leapfrog” referrals. The information sharing networks in both counties are larger than the other types of networks. The average distance in the joint training network of Huangzhong is less than in Hualong. Meanwhile, there are deficiencies common to both systems.Both county health systems have strengths and limitations regarding system integration. The use of medical consortia in Huangzhong has contributed to system effectiveness. Future research might consider alternative more context specific models of health system integration. The health system in China is facing considerable challenges associated with an aging population and the increasing prevalence of chronic conditions among the older population together with increases in health care utilization and cost. Forecasts by the National Aging Office, suggest that between 2001 and 2020 the Chinese population aged 60 and older will increase by an average of 5.96 million per year and will reach over 17% of the total population by 2020 [Over the past 30 years, the relatively integrated three-tier network of treatment and referral built during the era of the planned economy in China has been broken. With the development of a market economy, decentralization and the reduction in financial allocations from Central government contributed to the collapse of the integrated system . MoreoveThere have been several pilot projects of integrated health systems in China in the last decade 789, aime788911In general, health care systems worldwide have been designed primarily to deal with single, acute, and short-term illnesses 1415, how14161819212223242526For studies of integrated care, social network analysis has been seen by many as a valuable method 2830313233.303132The aim of this paper is to analyze the integration of the health care system in rural China using two contrasting cases from the Qinghai province in western China. The hypothesis is that the health system in the county, which builds medical consortia, is more integrated and effective than in another county. A methodology for describing and evaluating health systems will be presented, and policy recommendations developed for health care system integration in China. To the best of our knowledge, this is the first paper to show the structure, operation and effectiveness of a county health system using social network analysis in China.Qinghai province is in western China with a population of 5.78 million in 2013. Per capita GDP in 2014 was $6,252, ranking 21st among 31 provinces and municipalities in China. In addition to limited economic resources, there is a severe shortage of other health resources, especially the qualified workforce. The development of the health delivery system in Qinghai is less advanced than most other provinces with the need to improve the efficiency of resource utilization and service delivery. As the first province working on integration at provincial level, Qinghai Province implemented two policies in 2013: the village or township doctor as the first point of contact and gatekeeper to other institutions . In addition, considerable resources were provided for developing information technology to promote the policy implementation. As a typical western province with low GDP, the practice of health system reform in Qinghai province might provide evidence for policy developments in other provinces.As the only county with reform of health system structure, Huangzhong provided the focus for this study. In order to show the effect on integration and effectiveness of the health system by comparison, Hualong was adopted as the second county, because of two reasons: 1) they had similar health resources and implemented four important health reforms . As the numbers of departments vary across institutions, the numbers of doctors interviewed are different in the two counties. Randomly selected outpatients and inpatients completed questionnaires, which asked about satisfaction with services involving institutions at different levels.In addition, all questionnaires were completed under the guidance of trained investigators and all interviews were conducted by researchers. The number of interviewees is shown in Table Information on between institution relationships was analyzed using UCINET 6, software for social network analysis. Unconfirmed connections were included in the analysis, which meant that it wasn’t necessary for both partners indicating connections with each other. Other research has focused on the more reliable “confirmed connections”, as indicated by a mutual recognition of the connection . More reThe network effectiveness evaluation model, an adaptation of Provan’s preliminary model  is preseThe system structure was measured by five indicators from three dimensions. Density and degree of centralization are two of the most commonly used network indicators . DensityProvan proposed three levels for Network evaluation: community , network33Relationships are plotted using NETDRAW, which is an embedded function of UCINET. Nodes indicate institutions, lines show connections and arrows illustrate the direction of relationships. The institutions, which were nominated by surveyed institutions and located outside the two counties, were adopted in the figures. The figures are organized by levels of institutions, and the shape of a node indicates the type of institution. Nodes colored black indicate core members in a network.Figure Information is an important resource and sharing information is a necessary step for other types of integration 44. In thAs illustrated by Fig. As shown in Fig. The joint training networks , especi54The structures analyzed in this paper are mainly focused on health service delivery, including three of the six blocks of health systems , namely As mentioned above, social network analysis provides a snapshot at one point in time. And the survey was conducted after nine months of health system reform in Huangzhong, the structure and operation of the system may not be stable. With the evolution of contextualization, structure, and effectiveness of health care systems, network analysis would be conducted regularly to assess the dynamic nature of system development.There are two possible biases of the study: (1) Because of the natural conditions in Qinghai province, distribution of population and economy are very uneven. We could not find a county more matching with Huangzhong from every aspect than Hualong. There may be a sampling bias, which has influence on network information. (2) The small number of patients surveyed may affect the representativeness of the sample.This article has demonstrated how network analysis can be conducted in county health systems, what the structures of two systems look like and how network effectiveness is influenced by structure and contexts. It has contributed to both theory and practice. In theory, it is the first study of county health systems using social network analysis in China, which introduces viable and valuable inter-organizational network analysis into health system research. In practice, although the study was conducted in two counties, it seems reasonable to embed it into routine operations to help policy makers promote, monitor and assess health system development towards integration. The use of medical consortia in Huangzhong is only one type of integration. Future network analysis may consider alternative forms of health system contextualization and integration models. With the development of integrated health care systems, it is possible to achieve higher efficiency at lower cost at the system-level, so supporting universal health coverage at the country-level.As suggested by Provan , it is e


Adverse events (incidents that harm a patient) can also produce emotional hardship for the professionals involved (second victims). Although a few international pioneering programs exist that aim to facilitate the recovery of the second victim, there are no known initiatives that aim to raise awareness in the professional community about this issue and prevent the situation from worsening.The aim of this study was to design and evaluate an online program directed at frontline hospital and primary care health professionals that raises awareness and provides information about the second victim phenomenon.The design of the Mitigating Impact in Second Victims (MISE) online program was based on a literature review, and its contents were selected by a group of 15 experts on patient safety with experience in both clinical and academic settings. The website hosting MISE was subjected to an accreditation process by an external quality agency that specializes in evaluating health websites. The MISE structure and content were evaluated by 26 patient safety managers at hospitals and within primary care in addition to 266 frontline health care professionals who followed the program, taking into account its comprehension, usefulness of the information, and general adequacy. Finally, the amount of knowledge gained from the program was assessed with three objective measures (pre- and posttest design).P<.001).The website earned Advanced Accreditation for health websites after fulfilling required standards. The comprehension and practical value of the MISE content were positively assessed by 88% (23/26) and 92% (24/26) of patient safety managers, respectively. MISE was positively evaluated by health care professionals, who awarded it 8.8 points out of a maximum 10. Users who finished MISE improved their knowledge on patient safety terminology, prevalence and impact of adverse events and clinical errors, second victim support models, and recommended actions following a severe adverse event (The MISE program differs from existing intervention initiatives by its preventive nature in relation to the second victim phenomenon. Its online nature makes it an easily accessible tool for the professional community. This program has shown to increase user’s knowledge on this issue and it helps them correct their approach. Furthermore, it is one of the first initiatives to attempt to bring the second victim phenomenon closer to primary care. Patient safety incidents include both near misses (incidents that do not cause harm) and adverse events (incidents that do). Although the frequency of near misses in clinical practice is difficult to specify, the frequency of adverse events at hospitals in developed countries has been established at approximately 9% ; in devesecond victim is used to describe the experience of the health professional who becomes emotionally overwhelmed as a result of being involved in an incident affecting patient safety [third victims was introduced because safety incidents may damage the reputation of and reduce trust in health care organizations [Safety incidents associated with clinical errors have a negative emotional impact on patients, but also on the health professionals thought to be involved in them. The term t safety ,8. The vizations .Mitigating the impact from these incidents in patients, the health organization, and its professionals is a responsibility of managers and middle managers in the health organizations . One reaAmong second victims, fear from legal consequences deriving from the harm done to the patient, fear of damage to their professional reputation, feelings of guilt, doubts about their own abilities for making clinical decisions, anxiety, and mood swings are frequent ,13-15. IAmong professionals, suspicion—if not fear—persists in disclosing what happened to patients due to the consequences that may result from such conversations ,18. MostIncident severity, its consequences, and individual variability influence the impact of the adverse event in professionals and make the number of second victims vary.In the United States and Canada, it has been estimated that between 30%  and 43% Assistance for second victims is not part of the actions planned to be carried out when an incident affecting patient safety occurs in hospitals ,29,30, aTwo approaches in interventions have been described. On the one hand, interventions are centered on the incident . On the Scott , who leaThe work group of Wu  at JohnsThese interventions are meant to be activated after an adverse event occurs. Actions preventive in nature have not been designed for direct care professionals or for middle managers to become aware of the problem and learn how to address it.The literature has emphasized that professionals do not know how to act after an adverse event and that most health centers do not have protocols in place or provide instructions on how to support second victims ,27-30. TThis study’s purpose was to develop and assess an online awareness and information program on the second victim phenomenon directed at health professionals in direct contact with patients at both hospitals and primary care. Such a program should provide demonstrations on how to act with colleagues and patients during the first moments after a severe incident for patient safety. This intervention was initially designed for Spanish frontline health care professionals.The specific objectives included:Facilitate information and training for a large number of health professionals about the issue of second victims at a reduced cost.Describe emotional reactions and common behavior after being involved in an adverse event and that characterize the second victim phenomenon.Describe correct and incorrect actions of how to act after an adverse effect in order to respect the rights of patients and support the second victim.Act in the area of primary care, expanding the extent of studies that up to now have only taken place at hospitals.This is a design and evaluation study of a website devised to mitigate the impact from severe adverse events in hospitals and primary care professionals. This intervention was named Mitigating Impact in Second Victims (MISE).The phases in the design and evaluation of the website and the preventive intervention program to mitigate the initial impact from an error in health professionals (MISE) are described in A website was designed that hosted an awareness and preventive intervention program (MISE) to mitigate the impact from errors in frontline professionals . The webBased on patient safety literature, and that specifically on second victims, a preventive intervention program was designed with informative and demonstrative contents.A review of review studies relating to open disclosure and second and third victims published in English or Spanish between 2000 and 2015 was conducted. This search was carried out using MEDLINE and Web of Knowledge. Keywords used for the review included a combination of the terms “patient safety” and “adverse event” with the following terms: emotional response, impact, professionals, second victim, third victim, and open disclosure. This yielded 22 possible documents on second victims and 83 on open disclosure. A review of health care organization websites was also conducted. This review included proposals of applied programs, checklists, and algorithms about interventions in the aftermath of an adverse event to support patient and second victims. This was carried out with the Google meta-search engine using the same descriptors. Only websites in English or Spanish were considered. A total of 16 websites were reviewed, two from Europe and the rest from the United States.A group of 15 health professionals with at least 10 years’ experience in quality and safety participated as a promoting group, and they were responsible for identifying content and elements of relevant information and example situations to be included in MISE. Chosen first to be disseminated were elements of patient safety information, specifically on second victims. Then, an index for MISE was created. Third, problem situations were selected for the demonstrative program that were then ultimately acted out by professional actors and recorded on video.MISE was structured in two packages, one informative and the other demonstrative. The informative package offered information on basic patient safety concepts , along with the frequency, causality, consequences, avoidability, and other characteristics of adverse events at hospitals and within primary care. Furthermore, it introduced the concepts of second and third victims and the results from research on the impact of adverse events.The demonstrative intervention package provided a description of the emotional consequences from adverse events in professionals  and recommendations for action following an adverse event, specifically about how to interact with the patient and their family (open disclosure), how to support a colleague who becomes a second victim, and how to personally cope with the second victim experience. This package included 15 demonstrative videos that showed what and what not to do in different clinical situations linked to errors .Informative packageWhat is a patient safety incident? (text)What is an incident without harm—near error? What is an adverse event (AE)? Description of the research project at primary care and hospitalsWhat is intended?—project objectives (text)Why this project? Who are we? Sources of information on patient safety (PowerPoint presentation with voice narration)Second victims (text)What is a second victim? What do we know about second victims? Outcomes of our study Institutional help: BICEPS, forYOU, Johns Hopkins Hospital protocol Spanish Ministry of Health Strategy on Patient Safety What must not be done? (text)Third victimsWhat is a third victim? Outcomes of our study Crisis communication (PowerPoint presentation with voice narration)What must not be done? (text)Demonstrative packageEmotional, family, and work consequences in professionals from adverse events Recommendations about how to act after an adverse event Informing the patient (PowerPoint presentation)Open disclosure step-by-step guide Support for the second victim (text and images)Role of second victim’s peers (PowerPoint presentation with voice narration)Guide on how and how not to act How to be prepared and know what happened Root cause analysis (PowerPoint presentation with voice narration)2.5.2. London protocol (PowerPoint presentation with voice narration)In order to make MISE contents more dynamic, different formats were used to convey information: text, images, Portable Document Formats (PDFs), PowerPoint presentations with voice narration, videos in which a patient safety expert appears and explains a concept, demonstrative videos (simulations of situations with actors), in addition to a mobile app.First, an independent agency specializing in the evaluation of health websites completed the accreditation of its overall design, structure, organizational, and functional quality according to a certification standard . This exSecond, MISE was evaluated by academic and professional safety experts who themselves were responsible for the services of patient quality and safety at hospitals and within primary care in Spain.Then, MISE was evaluated by a group of professionals who voluntarily followed this program between November 2015 and February 2017. Moreover, they considered the usefulness of MISE for improving information about the second victim phenomenon and what to do after an adverse event. For this purpose, the participants answered a series of knowledge tests.The research team assessed the website (self-assessment), following the quality standards of the Andalusian Agency for Healthcare Quality . It was This accreditation procedure consisted of 55 standards  that address the following aspects: usability, accessibility, confidentiality-privacy, transparency, credibility, editorial policy, elements related to the Web user, attribution of contents, updating of information, and provision of electronic services.This evaluation was based on a double procedure of self-assessment and external evaluation. The self-assessment permitted interactive identification of elements from the webpage in need of improvements. By following this system, changes in the design and browsing conveniences were introduced into the website. The subsequent external evaluation ensured compliance with the criteria based on webpage operation, content, and resources.A group of 26 health professionals who were managers of patient safety services assessed MISE. This professional profile was chosen because their criteria were thought to be the best for assessing the program’s focus and content. To complete their assessment, they were allowed to freely explore the program for several weeks. This group included physicians and nurses from the health services at hospitals and within primary care, and the participants had more than three years’ professional experience in patient safety. They completed an online questionnaire after being called on the telephone to request their participation and to provide an email address in order to send them an online questionnaire link. Their responses were anonymous and voluntary, and these experts assessed the comprehension of the information, practical usefulness of the contents, and overall suitability on a scale from 0 to 10, with 10 representing the highest possible assessment.To assess the acquisition of knowledge by intervention program users, three objective tests with pre-established response options at different points in the program were included. Specifically, two tests with pre- and posttest measures were prepared, and these included a total of 20 questions. The first evaluated the additional knowledge gained after completing the informative package (12 items); the second evaluated additional knowledge gained in the demonstrative package (8 items). These test questions consisted of statements with true/false answers. A third series of questions was used, prepared from the demonstrative videos, in which the user had to choose the correct action between two response options. These additional questions also permitted assessing the program’s effectiveness in terms of the ability to discriminate between how to act in each situation. These consisted of a total of 25 questions and were answered only after the videos were watched.Once they finished the program, the participants assessed MISE in terms of comprehending the information, the practical value of its contents, and its overall suitability. Furthermore, the following measures were also considered: the number of connections required to finish the program, total time invested to finish it, average time of each connection, number of program dropouts, and correct answers on the knowledge test (pre- and postmeasures and questions on the situations represented in the demonstrative videos).Safety professionals from nine autonomous health services in Spain participated in this study. As a country, Spain has 17 autonomous communities, and each has its own health system. The nine participating health services account for 75% of all care activity occurring at hospitals and within primary care in the country.A sample of 351 professionals from hospitals and primary care within these health services were asked to voluntarily participate. A minimum sampling size of 245 participants was determined, considering a sampling error of 5%, 80% correct answers on the questions, and 70% participation for a 95% confidence level. Quality and safety managers at the centers collaborated in recruiting participants by extending invitations to their hospital and health center staff to participate. To enter the system, the participants had to use a personal password to identify themselves; this way, they could continue participating in the MISE program as time permitted.Before entering the system, the participants were informed about the study’s scope, objectives, and method, in addition to the conditions for their participation. They granted their consent as a requirement for access.Two databases were employed. The first contained the keys used by each participant, separate from the remaining databases. The second contained the anonymized registries of the participants’ responses. Only the authorized webmaster had access to the participant databases and no personal data in the response database were linked to the pre-post measures.t test with repeated measures (intrasubject comparisons) was used to assess the intervention’s effectiveness by comparing the pre-post measures. A McNemar test was used to assess the impact of the videos.A student This study was approved by the Ethics Committee of the San Juan de Alicante Hospital .The external evaluation recognized the entire research project website (including MISE) as a health website and awarded it the level of Advanced Accreditation on November 25, 2016. To gain this recognition, 100% of the required standards were satisfied (31/31) along with 80% or more of those recommended (8/10), surpassing the thresholds required by the evaluated standards. Overall, the website complied with 73% (40/55) of those standards. Four standards were not applicable because they referred to patients’ rights and the treatment of their health information , advertising content (absent on the website), virtual health communities (interaction between users is not included among the website’s objectives), and the provision of electronic services . If these four standards are discounted, the percentage of compliance with the requirements increases from 73% to 78%.Its strengths were related to identifying the recipients, usability, confidentiality-privacy, transparency and honesty, credibility, attribution of contents, and updating of information. Areas for improvement were related to elements related to website users, accessibility, editorial policy, and usability .Twenty-six patient safety experts from four autonomous health services assessed MISE (100% response rate). Of these, 92% (24/26) positively assessed the ease of browsing and following the programmed activities, 88% (23/26) positively assessed the comprehension of the contents , and 92% (24/26) did likewise for the practical value of the designed intervention .In all, 266 of 351 professionals (75.8% response rate) followed the activities proposed in MISE; of them, 183 were women and 83 were men .Those who completed MISE viewed 99% of its pages . On averMitigating Impact in Second Victims was highly rated by the professional users, and they awarded it almost nine points out of a maximum of 10 . Only twt265=–10.0, P<.001). There was also a significant difference in the pre- and postmeasures of the knowledge test of what to do after an adverse event or error (demonstrative package). Out of a maximum of 8, the premeasure mean was 6.3 (SD 1.5) and the postmeasure mean was 7.2 .Participants who completed MISE increased their level of knowledge on patient safety terminology , prevalence and impact of adverse events and errors , support models for the second victim, and the recommended actions following a severe adverse event. There was a significant difference in the pre- and postmeasures of the knowledge test of information about basic patient safety concepts, prevalence and nature of adverse events, and second victims (informative package). Out of a maximum of 12, the premeasure mean was 6.9 (SD 2.0) and the postmeasure mean was 8.8 .The correct answers on the knowledge tests did not vary between physicians and nurses in all cases , most test questions were answered correctly with the exception of situations representing a system failure. For these, 13.9% (37/266) of the users attributed the event of the hypothetical situation shown in the video to a human error instead of a system failure, and they considered that such failures can always be prevented .In the pretest, questions in which the answer given was incorrect more than 50% of the time had to do with the number of professionals involved in this type of event, patient safety concepts (definitions of incidents without harm and the second victim), the preventive ability against system failures, and procedures for crisis communication and open disclosure (who and how). In all these cases, the participants answered these questions as being true when in fact the correct answers were false .Mitigating Impact in Second Victims includes a set of contents that has been considered appropriate by patient safety experts. It has also shown to contribute to improving knowledge among health professionals about the second victim phenomenon. The methodology employed for disseminating this knowledge and explaining what and what not to do has been considered appropriate by the MISE participants.Data from the MISE evaluation confirm that the program increases knowledge about the issue of second victims and how to act with a colleague when either an adverse event or near miss occurs. It also shows how to interact with patients who are victims of an adverse event, providing information on how to act and how to disclose what has occurred.Five hours was the mean total time dedicated to complete MISE, distributed generally over 12 sessions lasting approximately 30 minutes each. This time demand is reasonable for this group of professionals and is compatible with other care responsibilities and tasks and their personal lives.Emotional needs immediately following incidents have been analyzed in several studies. The emotional isolation professionals find themselves in, along with the difficulty of talking about what has happened with their colleagues and the lack of protection they feel from their superiors, have been identified as two important gaps that contribute to progressing along the scale of the second victim syndrome . Both asWe know that colleagues of second victims can do much more than what they currently do to prevent the emotional impact from safety incidents for the patient from progressing until manifesting itself as posttraumatic stress ,23,40,41The role of managers is crucial in two senses due to their role as a barrier and their role as a facilitator ,28,42. MSubsequent to a severe adverse event, the second victim may become helpless and not inform the patient about the incident -49. HoweMitigating Impact in Second Victims is easily accessible to a large number of professionals. It is a low-cost program that can be accessed from work or home with ease.This program responds to three deficiencies identified in the literature and in daily practice at health centers: (1) the lack of programs raising awareness and providing information about the second victim phenomenon that reaches high numbers of professionals, (2) the issue of second victims in primary care, and (3) the inexistence of structured interventions at most health centers to support professionals and patients following adverse events.The MISE program provides information to professionals about the second victim phenomenon in nine weeks of online training in which are presented general issues and problem situations based on experiences after committing a clinical error.The need for second victims to change their care functions could be reduced and less absenteeism linked to this phenomenon  could reIt is possible that those who followed the MISE program were professionals who are more sensitive to the issue of what severe adverse events mean for professionals. We did not possess information about the type of professionals who declined invitations to follow MISE.A minimum sampling size was defined considering a worst case of 80% correct answers to the questions. The correct answers related to system failure did not match this assumption.The measure of the resulting impact was based on correct answers to knowledge tests and to self-test questions after watching a set of problem situations on video. Actual adverse events that occur may involve circumstances that are different from what these videos represented.This study was not designed to assess its effect on secondary prevention of posttraumatic stress; that is something that future research should evaluate. Thus, the effectiveness of this website in contributing to any kind of change was not assessed, and this will be done in the future. In this sense, realistic evaluation, a form of theory-driven evaluation developed by Pawson and Tilley in 1997 , may be The MISE program is designed to assist intervention programs to mitigate the impact of adverse events in professionals. It is not an emotional recovery program for second victims; instead, it responds to the need for the group of professionals to understand what is felt subsequent to an adverse event. MISE also contributes to frontline professionals gaining greater awareness about the emotional needs that are experienced when an error occurs and the importance of speaking about the incident with their colleagues. It also provides ideas about how to act with the patient victim of the adverse event . This waThese types of programs, along with other recommendations about what to do after an adverse event occurs, contribute to safer environments at hospitals and primary care.Future research could analyze whether MISE modifies the frequency, which up until now is relatively low, of patients who are victims of adverse events being informed about the incident. This research could also examine the impact of MISE in the initial hours after an incident. One example of this would be whether the colleagues of the second victims gain a greater ability to listen and act appropriately to prevent the emotional escalation that may result.


To assess a birth registry to explore maternal mortality and morbidity and their association with other factors. Exploratory multicentre cross-sectional analysis with over 700 thousand childbirths from twelve Latin American and Caribbean countries between 2009 and 2012. The WHO criteria for maternal morbidity were employed to split women, following a gradient of severity of conditions, into (1) maternal death (MD); (2) maternal near miss (MNM); (3) potentially life-threatening conditions (PLTC); (4) less severe maternal morbidity (LSMM); (5) any maternal morbidity; and (6) women with no maternal morbidity. Their prevalence and estimated risks of adverse maternal outcomes were assessed. 712,081 childbirths had a prevalence of MD and MNM of 0.14% and 3.1%, respectively, while 38% of women had experienced morbidity. Previous maternal morbidity was associated with higher risk of adverse maternal outcomes and also the extremes of reproductive ages, nonwhite ethnicity, no stable partner, no prenatal care, smoking, drug and alcohol use, elective C-section, or induction of labour. Poorer perinatal outcomes were proportional to the severity of maternal outcomes. The findings corroborate WHO concept regarding continuum of maternal morbidity, reinforcing its importance in preventing adverse maternal outcomes and improving maternal healthcare in different settings. Women suffering a severe complication during pregnancy, childbirth, or within 42 days of the postpartum period, who almost died, but survived due to luck or effective interventions are now consideredear miss .The need for better exploring the concept of maternal morbidity instead of maternal mortality arose because, fortunately, maternal deaths became rare in several settings when using absolute numbers and, therefore, it became more difficult to understand and identify factors or conditions that could possibly be associated with its occurrence. There are also a number of reasons already publicized on the advantages of looking into cases of morbidity and not only to maternal deaths . The mosHowever, until recently, the concept of maternal morbidity and the levels of severity it could present were definitely not standardized, and therefore they were used indistinctly in the scientific literature with different meanings. This, of course, represented a restriction for using the concept as a real health indicator that could be used for policy changes or even as a starting point for interventions and for comparisons between different settings or in the same location across different periods. With the WHO definition and criteria , theoretTaking these limitations into account and the availability of several possible sources of information on maternal morbidity, a considered approach was to build a pragmatic definition of maternal near miss that could be even retrospectively applied to obtain relevant information on the condition, in order to direct next steps for policy changes.The opportunity came with the information already collected from the WHO Global Survey on Maternal and Perinatal Health. Several different combinations of conditions that were hypothesized as possible predictors of maternal death due to its severity were tested in their predictive capacity of identifying cases of women who died from a maternal cause. The group of most common criteria with the highest accuracy for this prediction included hysterectomy due to haemorrhage or infection, admission to intensive care unit (ICU), blood transfusion, and eclampsia. Altogether, they are now the pragmatic criteria established by the WHO .Although already officially recommended by WHO for gathering information on maternal morbidity and also for appraising the quality of maternal healthcare , 4, thesKeeping these points into account, the objective of the current study is to perform an exploratory analysis of the database on maternal and neonatal information for childbirths occurring in several maternity hospitals located in the Latin America and Caribbean region and coordinated by CLAP, the Latin American Centre for Perinatology, Women and Reproductive Health from the Department of Family, Gender and Life Course of PAHO. The product of this analysis may be useful for identifying a group of severity markers taken as a proxy or pragmatic criteria for levels of severity in maternal morbidity and as well for building a general profile of maternal morbidity for Latin America and the Caribbean region.Information on childbirth in the region of Latin America and the Caribbean, for both maternal and neonatal health conditions, has been routinely stored in the SIP  database, when shared by countries or health institutions, during more than 25 years . Since tTherefore, although the full SIP database includes more than 4 million records, for the specific objectives currently addressed we assessed and analysed a more recent SIP database containing standardized information on over 700 thousand childbirths which occurred between 2009 and 2012. In this database, there is information from childbirths which occurred in some health facilities from 12 countries from the South Cone, Andean, Central America, and Caribbean subregions from America . The sample for each country does not necessarily represent all births in the country for the period nor is proportional to the population size and therefore is not supposed to be representative of the respective country. This is the reason why the data does not allow for analysis of specific country's reports. With data routinely collected from all births in the period occurring in the participating health facilities, the methodological approach of the current exploratory analysis is that of a cross-sectional study. No sample size was previously estimated because of the huge number of women with data available, although this was not a population-based study. Missing information for variables used was assumed to be randomly distributed among centres, countries, and time and associated neither with predictors nor with outcomes. Although the system used for data collection was built to immediately check for internal consistency and also those in charge of feeding the online platform with data from health facilities received training following standardized operating procedures and instructions, for additional quality control, several cross-checking instances between variables of interest were performed for assessing the consistency of the database. This was performed to improve the quality of data collected. However, of course, the data refers only to cases from centres that voluntarily applied for using the system. No information at all is available for childbirths occurring at home, at the health centre, or at any other health facility not using the system.This period was chosen because data were gathered with a data collection form standardized for all participating facilities and countries and because this is the period immediately before the introduction of some specific information for identifying maternal near miss cases with the WHO definition and criteria . The maiGroup of maternal death (MD): with the purpose of identifying the cases of maternal deaths, this group included the women with information that death had occurred at the health facility or who died during transport or in the place they were transferred to. This was used descriptively to estimate maternal mortality ratio in the sample, however with no classification and no attribution of cause of maternal death because this information was not reliably available in the database.Group of maternal near miss (MNM): to identify the cases with more severe conditions of maternal morbidity that could serve as a proxy for maternal near miss (supposedly with an organ dysfunction or failure), this group (MNM) was identified using some pragmatic criteria already described and even developing a new set of criteria within the database. This was the group with greater difficulty to be identified. According to the WHO pragmatic criteria as a proxy for MNM , there wGroup of potentially life-threatening conditions (PLTC): to identify the cases that could be classified as PLTC in a proxy to these exact conditions as defined by WHO . This grGroup of less severe maternal morbidity (LSMM): to identify the cases of less severe maternal morbidity, including all other remaining conditions identified as maternal morbidities with specific information collected in the SIP, this group constituted cases presenting any morbidity recorded in the SIP database, other than those above described. For this group, the following conditions were taken into account: anaemia, HIV+, diabetes mellitus, hospital admission during pregnancy, ovular infection, urinary tract infection, another maternal pathological condition, retained placenta, or need to be referred. This was mainly based on the recently issued maternal morbidity matrix, in its dimension one, including symptoms, signs, investigations, and managements related to both direct and indirect causes of maternal morbidity . The proGroup of any maternal morbidity (AMM): to identify all cases of maternal morbidity (joining groups 1 to 4), from the most severe (death) to the less severe ones, this is also aligned with the recent WHO proposal for identifying, classifying, and building a full profile of maternal morbidity occurring worldwide , 11. ThiGroup of women with no maternal morbidity: this group represents the remaining women who did not experience any maternal morbidity during childbirth and postpartum period as previously described and survived the event. The remaining women who experienced no identifiable maternal morbidity during the childbirth process were used to build a comparison group for the above-mentioned maternal morbidity and mortality groups, to generate information on factors possibly associated with worse outcomes.In order to achieve the objectives of identifying different levels of severity for maternal morbidity, in the current analysis as below outlined, we built the groups using some possible identifiers from the database:The main purpose of the current analysis was to explore the capacity of a big database of a birth registry from Latin America and the Caribbean region to retrospectively identify different levels of maternal morbidity according to what is recently recommended by WHO. It was a methodological exploration approach. The database was not originally built with the objective of an in-depth analysis of maternal mortality and morbidity. Therefore, the analyses allow for neither country variations nor a general and representative scenario of the whole region regarding maternal morbidity. No woman, health facility, or countries were identified and this information is not available in the database. The dataset is regularly fed with the previous agreement of countries that analyses of data are performed at regular intervals. The protocol for the current analyses was previously ethically evaluated and approved by CLAP/WR. All the recommendations of the Declaration of Helsinki for studies involving human beings were strictly followed.Initially, descriptive analyses were performed, with the prevalence of these adverse maternal outcomes determined together with their correspondent health indicators. Some of these health indicators had already been described and used , 5, 7. Fp values corrected for the cluster design effect (each country was considered as the primary sampling unit (PSU) and then as a cluster). Finally, for the objective of identifying factors independently associated with each degree of the worse maternal outcome, considering the “no morbidity,” the comparison, or reference group, a bivariate and a multiple logistic regression analysis was performed, using all the predictors in the model and considering the PSU in both analyses. These procedures generated estimated crude and adjusted prevalence ratios (PR + 95% CI) for risky categories of these factors in developing maternal morbidity and worse maternal outcomes. For statistical analysis, SPSS v.20.0 and Stata v.7.0 packages were used and the level of statistical significance was of 0.05.For categorical variables, chi-square tests were used, with The database from SIP used for the current analysis has information on over 712 thousand women from 12 countries of Latin America and Caribbean region, who were admitted to any health facilities using SIP routinely, for delivery or management of any complication associated with pregnancy. How these women were classified is presented in In The estimated risks for occurrence of maternal death (MD) were higher for women from ethnic group other than white , with any previous pathological condition (2-fold), if labour was induced (1.6-fold) or birth was through an elective C-section (2-fold), as shown in Neonatal outcomes stratified by groups of maternal morbidity are reported in The main results of this analysis showed that the overall MMR for the sample was high and over one-third of the total cases presented with any morbidity. Following some midiatic figures, this means that, for each woman who died in this sample, 262 others experienced any degree of morbidity and survived, although they may have had impairments and functioning disabilities lasting for different periods. While a minority had severe morbidity, almost one-fifth of them experienced less severe morbidity, which emphasizes the need for surveillance and timely and adequate diagnosis of complications. Apart from these main results, the study also showed that it is possible to explore a database of big birth registries in the search for variables or reported diagnosis with the specific purpose of identifying a gradient of morbidity. This would enable building a full profile of all pregnancies that could be a proxy for the theoretical continuum of morbidity, from normal pregnancy to maternal death. This gradient seems to work considering that the related adverse neonatal outcomes matched accordingly. The study also demonstrated that the history of previous pathological conditions played an important role in increasing the risk of severe maternal outcomes, and the same occurred for other factors already known to be associated, including extremes of maternal reproductive age, low literacy, absence of a steady partner, nulliparity, low number of prenatal visits, smoking, drug or alcohol use or violence, induction of labour, and elective caesarean section.The present study has some clear limitations. It developed an operational definition for some degrees of severity on maternal morbidity with information on variables already available in a big database of an international birth registry, which was not built for that specific purpose. It is not a population-based study and does not allow generating estimates for maternal morbidity and mortality stratified for regions and countries. Unfortunately, there is no information available on the distribution of births in the settings providing information for the database. This is the main reason why data were not stratified by countries. Although the adoption of a rigorous process of checking and assuring the quality of data collection and management exists, there is still some degree of incompleteness of some information and this is also a limitation. However, this is a retrospective analysis of a database and therefore we could no longer ask for additional corrections or completeness. The amount of missing information is anyway provided for each variable assessed.On the other hand, our study has some important strengths. To the best of our knowledge, this is the first study trying to capture a full profile of morbidity occurring during pregnancy using a routine birth registry. According to the new initiatives from WHO, this is a recommended procedure for building a full scenario of the burden of maternal morbidity for the women's lives. Using classifications for a gradient of maternal morbidity as the currently employed, additional secondary analysis will also be possible in databases from birth registries, focusing for instance on maternal morbidity linked with specific causes like hypertension or postpartum haemorrhage, twin pregnancy, obesity and overweight, ethnic groups, and other hot topics that could be easily assessed in the database, thus generating strong evidence supported by huge numbers.The overall MMR found in this analysis was high, almost 150 per 100,000 live births. Despite the fact that recently an increased trend in the estimated MMR has been shown for the US in the last decade , these tThe analysis of previous morbid conditions  shows a clear statement of the risks involving pregnancies with baseline complications. They presented a clear increase in the occurrence of any degree of morbidity. This highlights the importance of understanding and identifying this gradient or spectrum of complications as a way to provide appropriate management for any morbidity that could potentially develop furthermore severe complications. The Global Burden of Disease Study showed that around 70% of Latin American maternal deaths occurred in intrapartum and postpartum periods. The surveillance of maternal complications during hospitalization for childbirth might play a key role on prevention of maternal mortality . TherefoThe sociodemographic and pregnancy characteristics confirmed known risk factors for poor maternal outcomes, such as extreme age groups, nonwhite ethnicity, no stable partner, no prenatal care, smoking, drug and alcohol use, previous morbid conditions, elective C-section, or induction of labour. In addition, approximately the same results were found among cases with severe or less severe morbidity. Perhaps the best example is that of maternal age, whose extreme groups, adolescents and older women, are showed to be at higher risk of developing any degree of severity for maternal morbidity. Two big multicentre studies using the new WHO concepts and criteria for severe maternal outcomes showed similar results , 7. The Over one-third of women displayed any maternal morbidity. This figure is quite higher than the mean 9.2% of adverse outcome index (AOI) described as a way of assessing the quality of obstetrical care . This imNeonatal outcomes matched maternal condition when considering its degree of severity. MD and MNM were clearly associated with worse perinatal outcomes and increased preterm birth rates . They are due to either the severity of maternal condition itself that is able to impair the intrauterine fetal health condition and as a result of an early interruption of pregnancy because of the maternal condition, resulting in preterm birth and its negative consequences. The association of maternal complications with preterm delivery is an emerging topic in maternal and perinatal health. Provider-initiated preterm birth, for instance, is closely associated with maternal complications during pregnancy , 27. AltConsidering the high proportion of women experiencing maternal morbidity with varying degrees of severity and the need to ensure clinical responses to these differing morbidity profiles, it is important to develop and sustain active surveillance systems that would theoretically follow women in real time while they are experiencing the process of pregnancy and childbirth and possibly some related complications. Following the WHO recommendation, the SIP birth registry recently adopted the same concepts and criteria for maternal near miss , 4. Then


The repeated use of prohibited chemical weapons in the Syrian conflict poses serious health, humanitarian, and security threats to civilians, healthcare personnel, and first responders. Moreover, the use of chemical weapons constitutes a clear and egregious violation of international law—likely amounting to a war crime—for which continued impunity is setting a dangerous precedent in relation to current and future conflicts. This debate article calls upon concerned states, organizations, and individuals to respond urgently and unequivocally to this serious breach of international legal and humanitarian norms.Chemical Weapons Convention (1993), a comprehensive treaty that bans chemical weapons and requires their complete destruction.Based on health, humanitarian, and legal findings, this article calls for concrete action to: 1) reduce the risk of chemical weapons being used in current and future conflicts; 2) review and support the preparedness equipment and antidote supplies of first responders, humanitarian organizations, and military forces operating in Syria; 3) support international mechanisms for monitoring and enforcing the prohibition on chemical weapons, including through criminal accountability; 4) support civilian victims of chemical weapons attacks, including refugees; and 5) re-commit to the complete elimination of chemical weapons in compliance with the All involved states and organizations should take urgent steps to ensure the protection of the most vulnerable victims of conflict, including victims of chemical weapons attacks in Syria, and to reinforce international law in the face of such serious violations. In the deadliest use of chemical weapons in Syria since August 2013, at least 83 people were killed, including 28 children, and over 293 people were reported injured by a confirmed sarin gas attack on the northern rebel-held area of Khan Shaykhun, Idlib Province, Syria on April 4, 2017, carried out by the Syrian government )The danger of rescuers or grieving families subjecting themselves to toxic exposure, whether from the victim’s secretions  or directly from the nerve agent itself if the skin is not properly decontaminatedSeveral leading concerns with regard to the immediate humanitarian response include:Moreover, beyond the particular concerns outlined above, the ability of healthcare providers to respond to the use of chemical weapons has been severely hampered by the direct and repeated targeting of medical facilities and personnel—a war crime under international law—including by the use of conventional and chemical weapons . This “wThe use of chemical weapons in armed conflict not only poses a serious risk to the health of civilians but also is strictly and unambiguously prohibited under international law. Warring parties are prohibited from using chemical weapons in any situation or circumstances  against any persons (civilians or soldiers). Chemical weapons may also not be used in retaliation for a previous chemical weapons attack.These prohibitions date back to the late 19th century  and wereAs of October 2016, the OPCW verified that approximately 90% of the world’s declared stockpile of 72,304 metric tons of chemical agent had been destroyed,  includinWhile not previously a member, Syria agreed to join the CWC following international pressure sparked by the August 2013 Ghouta attack . It becaSince then, however, suspicions of undeclared stockpiles  and reports of chemical weapons use in Syria have persisted. UN investigators found “compelling confirmation” of the use of chemical weapons in Syria in 2014 and 2015, leading the UN to establish the “OPCW-UN Joint Investigative Mechanism,” which later attributed responsibility to the Syrian government (on three occasions) and ISIS (on one occasion) .In light of the evidence of continued possession and use of chemical weapons in Syria, and the volatility and complexity of the current conflict, concerns also exist over the potential for the Syrian regime to transfer such weapons to non-state actors (such as Hezbollah in Lebanon) or to other states (such as Iran or North Korea). The risk also exists, especially in the event of regime collapse, that the Syrian regime could lose control of these weapons, resulting in further proliferation. Given the events that this section has described, it is apparent that there is an immediate need to understand the extent of remaining undeclared weapons stockpiles in Syria—including potential bio-weapons capabilities—and to work toward their destruction.As the conflict in Syria becomes increasingly complex due to a range of factors—including the conflict’s protracted nature, the plethora of fragmented armed groups operating in the country, and the geopolitical importance of the conflict—it is critical to consider the international diplomatic pressure points that may prevent Syria from using chemical weapons in the future and to hold those responsible to account. Both sanctions and criminal accountability measures are available to states and the international community to enforce the international ban on the use of chemical weapons. From a humanitarian perspective, it is also crucial that any such actions be accompanied by measures to mitigate the impact on already vulnerable populations.First, states must condemn the use of chemical weapons in the strongest possible terms. Many political leaders and international bodies have already voiced strong ethical and legal objections condemning the use of chemical weapons. However, the Security Council (SC) has failed to formally condemn the attacks or take further action to stop them. On April 12, 2017, the SC tabled a draft resolution—backed by the U.S., U.K., and France but opposed by Russia with its veto power—which would have condemned the chemical weapons attack in Khan Shaykhun and called for accountability. While continuing to work to break the gridlock in the SC, other states should individually and collectively act to forcefully condemn the use of chemical weapons in Syria.Second, if the OPCW finds a state party to be in violation of the CWC, it may authorize sanctions. The OPCW may not authorize the use of military force, and although it may consult with the SC to do so if appropriate, the SC itself is limited both by individual veto power and the lack of a military response capability apart from Member States. Given the clear evidence of repeated violation in Syria – despite the OPCW disarmament mission – the OPCW should use its power to urge its Member States who have not already done so to institute sanctions against Syria over the use of chemical weapons.Third, sanctions constitute another available and non-military means for states to enforce the ban on chemical weapons vis-à-vis the Syrian regime. In February 2017, Russia cast its seventh SC veto (and China its sixth veto) blocking an attempt by the U.S., U.K., and France to impose collective sanctions on Syria over the use of chemical weapons. In contrast, the SC has passed sanctions against ISIS, Al-Nusra Front, Al-Qaida, and other designated terrorist organizations operating in Syria. A number of states have nonetheless applied a range of sanctions against the Syrian government and key individuals and organizations supporting the Assad regime since the beginning of the conflict, as have the regional bodies such as the European Union, the Arab League, and the Organization of Islamic Cooperation. States that have not already done so should consider instituting further sanctions against Syria for chemical weapons-related violations. However, this should be done with caution, as sanctions may also cause disproportionate harm to civilians, raising significant humanitarian concerns, as discussed in greater detail below.The widespread and systematic nature of international law violations in the Syrian conflict has also sparked significant debate over the potential application of the doctrine of Responsibility to Protect (R2P). In 2005, recognizing the failure to adequately respond to the most heinous crimes known to humankind, world leaders made a commitment to protect populations from genocide, war crimes, ethnic cleansing, and crimes against humanity at the UN World Summit. This commitment under R2P stipulates that individual states carry the primary responsibility for the protection of populations from mass atrocity crimes and that the international community has a responsibility to assist states in fulfilling this responsibility. Accordingly, under R2P, the international community should use appropriate diplomatic, humanitarian, and other peaceful means to protect populations from these crimes. If a State fails to protect its populations or is in fact the perpetrator of crimes, the international community must be prepared to take stronger measures, including the collective use of force through the SC. Much of the doctrine of R2P is a restatement of existing commitments, rather than new international law, though the Syrian context merits considerable reflection on R2P and how the international community can collectively renew and live up to its commitments to civilian protection . Thus faFrom a humanitarian perspective, it is crucial that any enforcement measures—such as sanctions or the use of UN peace enforcement action—consider and mitigate the impact on already vulnerable civilian populations. For instance, any military action, if deemed appropriate, must be carried out in accordance with international humanitarian law (IHL), including the obligation to protect civilians from adverse impacts of the conflict . SimilarFinally, it should be noted that while the use of chemical weapons constitutes an egregious violation of international law with devastating impacts on civilians, it is far from the only such violation to be committed in the Syrian conflict which needs to be addressed. Parties to the conflict, especially the Syrian government, have routinely used other internationally sanctioned weapons, including cluster munitions and incendiary weapons, and have carried out deliberate and systematic attacks on civilians, hospitals, cultural heritage sites, and other protected persons and objects, in direct violation of international law and medical neutrality .It is also critical to pursue individual criminal accountability for the use of chemical weapons and other serious violations of international law committed in Syria. While many of these options are currently being pursued in tandem, each faces significant barriers necessitating significantly more international support to achieve even partial justice.In December 2016, the UN General Assembly established an “Independent Mechanism” to assist in investigation and prosecution of serious international crimes committed in Syria. This Mechanism’s aim is to supplement the work of the existing UN Commission of Inquiry on Syria by taking on a pre-prosecutorial function: consolidating, preserving, and analyzing evidence in order to prepare files to assist in future investigations and prosecutions of those individually responsible for serious international crimes. The effective operation of the Independent Mechanism will depend on sufficient funding and political support by Member States, and ultimately, the opening up of avenues for prosecution.The International Criminal Court (ICC) offers one potential avenue for pursuing individual criminal accountability for the use of chemical weapons in Syria, though political and jurisdictional issues pose significant barriers to its involvement. Established by the Rome Statute in 1998 and beginning operations in 2003, the ICC is the first permanent international criminal court for the investigation and prosecution of perpetrators of the most serious international crimes, including the use of chemical weapons. Since Syria is not a State Party to the Rome Statute , the ICC does not have a clear basis for jurisdiction. The ICC would be able to exercise jurisdiction over the situation in Syria if: 1) the Syrian government ratifies the Rome Statute; 2) the Syrian government accepts the jurisdiction of the ICC through a declaration; or 3) the SC refers the situation in Syria to the ICC. With regard to a referral by the SC of the situation in Syria to the ICC, this option has thus far been attempted but blocked at the SC by the vetoes of permanent members Russia and China. The ICC could, however, exercise jurisdiction over crimes committed by dual nationals of Syria and a state party to the ICC . Furthermore, if the ICC were to gain jurisdiction over the situation in Syria, the Court would still face a number of hurdles in prosecuting cases, including gaining custody of high-level accused, such as President Assad, and protecting witness and victim participation. The prosecutor would, however, benefit from the existence of a “staggering” body of evidence that has already been gathered and analyzed .Beyond the ICC, the international community—either through a SC decision or agreement with the affected state—may also set up an ad hoc international or hybrid international-domestic criminal tribunal to prosecute serious international crimes, such as the use of chemical weapons, as states have done for cases in the former Yugoslavia, Rwanda, Sierra Leone, Lebanon, and Cambodia. Some have advocated for the establishment of such an ad hoc tribunal for Syria, though the permanent ICC is generally considered to be a more viable option, given the political difficulties and costs of establishing a separate court de novo.In addition to international criminal courts, states may also prosecute the use of prohibited chemical weapons in their domestic courts, provided that they have incorporated these international crimes into their domestic criminal codes and are able to gain custody over the accused . Several prosecutions of accused Syrian war criminals have already been initiated in European states  through the exercise of domestic or universal jurisdiction. These developments indicate that it may also be possible to prosecute further Syrian perpetrators who have fled to Turkey, Jordan, Lebanon, or the U.S., as well as dual Syrian nationals or foreign fighters. Given the lack of political will for accountability at the international level, these domestic cases are critically important to advancing justice in the near term. However, their overall impact on the situation in Syria is likely to be limited. In light of this reality, concerned states and organizations should support legal and investigative efforts in national jurisdictions, while at the same time continuing to investigate and prepare cases for future international prosecution and continuing diplomatic efforts to open a path to such eventual international criminal prosecution.Respond immediately to reduce the risk of chemical weapons being used in future conflicts: The repeated and increasing use of chemical weapons in the Syrian conflict constitutes a disturbing break with a clear and long-standing prohibition which threatens to set a dangerous precedent for future conflicts. If the use of chemical weapons is allowed to become more commonplace, it will seriously threaten the life and health of civilians, humanitarian responders, and military personnel in conflict settings worldwide.Continue to support international mechanisms for monitoring and enforcing the prohibition on chemical weapons: Organizations such as the OPCW are critical to monitoring and enforcing international prohibitions on chemical weapons. For this reason, the U.S. and other concerned states should provide robust political, financial, and other support to these institutions, including UN bodies playing a key role in disarmament.Support nonproliferation efforts: Such efforts include national cooperative threat reduction programs to prevent the proliferation of chemical, biological and other prohibited weapons in and from Syria, and to increase the capacity of neighboring states to interdict weapons transfers.Strengthen commitment to reducing national stockpiles: States—foremost being Russia and the U.S.—which remain behind schedule for completing full disarmament under the CWC should redouble efforts to reach the target of 100% disarmament. This will send a positive signal to other states that chemical weapons have no place in warfare or military arsenals.Review and support the preparedness of first responders, humanitarian organizations, and military forces: Given the involvement of an array of military, humanitarian, and other actors in the Syrian conflict, as well as the transnational threat of chemical weapons attacks in the region, it is imperative to review and support preparedness to respond in the event of any future chemical attack. Responders must have up-to-date preparedness training, personal protective equipment, and medical resources, including adequate and readily available supplies of antidotes including atropine and oximes.Support efforts toward criminal accountability for serious violations of international law in Syria: The U.S. and other concerned states and organizations should play a central role in supporting accountability efforts at both the international and national level for the use of chemical weapons as well as other serious violations of IHL.Support refugees and other victims of the conflict: The use of chemical weapons in Syria highlights the brutal impact of the conflict on civilians, and the need for states to uphold their commitments to refugee protection in accordance with international law and humanitarian norms, as well as to support other refugee-hosting countries.In light of aforementioned challenges posed by the repeated use of prohibited chemical weapons in the Syrian conflict, this article calls upon concerned states, organizations, and individuals—including the U.S.—to respond urgently and unequivocally to these attacks, which represent both a serious breach of international legal and humanitarian norms and a threat to public health. In particular, this paper calls for concrete action to: