Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498920150004&lang=es vol. 37 num. 4-5 lang. es <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400001&lng=es&nrm=iso&tlng=es http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400002&lng=es&nrm=iso&tlng=es <![CDATA[<b>Transición obstétrica en la Encuesta Global de la Organización Mundial de la Salud sobre Salud Materna y Neonatal</b>: <b>exploración de las vías de reducción de la mortalidad materna</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400003&lng=es&nrm=iso&tlng=es OBJECTIVE: To test whether the proposed features of the Obstetric Transition Model-a theoretical framework that may explain gradual changes that countries experience as they eliminate avoidable maternal mortality-are observed in a large, multicountry, maternal and perinatal health database; and to discuss the dynamic process of maternal mortality reduction using this model as a theoretical framework. METHODS: This was a secondary analysis of a cross-sectional study by the World Health Organization that collected information on more than 300 000 women who delivered in 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East, during a 2-4-month period in 2010-2011. The ratios of Potentially Life-Threatening Conditions, Severe Maternal Outcomes, Maternal Near Miss, and Maternal Death were estimated and stratified by stages of obstetric transition. The characteristics of each stage are defined. RESULTS: Data from 314 623 women showed that female fertility, indirectly estimated by parity, was higher in countries at a lower obstetric transition stage, ranging from a mean of 3 children in Stage II to 1.8 children in Stage IV. Medicalization increased with obstetric transition stage. In Stage IV, women had 2.4 times the cesarean deliveries (15.3% in Stage II and 36.7% in Stage IV) and 2.6 times the labor inductions (7.1% in Stage II and 18.8% in Stage IV) as women in Stage II. The mean age of primiparous women also increased with stage. The occurrence of uterine rupture had a decreasing trend, dropping by 5.2 times, from 178 to 34 cases per 100 000 live births, as a country transitioned from Stage II to IV. CONCLUSIONS: This analysis supports the concept of obstetric transition using multicountry data. The Obstetric Transition Model could provide justification for customizing strategies for reducing maternal mortality according to a country's stage in the obstetric transition.<hr/>RESUMEN OBJETIVO: Evaluar si las características propuestas del Modelo de Transición Obstétrica, un marco teórico que puede explicar los cambios graduales que experimentan los países a medida que eliminan la mortalidad materna evitable, se pueden observar en una amplia base de datos de salud materna y perinatal de varios países; y tratar sobre el proceso dinámico de reducción de la mortalidad materna utilizando este modelo como marco teórico. MÉTODOS: Este estudio consistió en un análisis secundario de un estudio transversal realizado por la Organización Mundial de la Salud que recopiló información sobre más de 300 000 mujeres que dieron a luz en 359 establecimientos de salud de 29 países de África, Asia, América Latina y Oriente Medio, durante un período de 2 a 4 meses en el 2010 y el 2011. Se calcularon los índices de afecciones potencialmente mortales, resultados maternos graves, morbilidad materna extremadamente grave, y muerte materna, y se estratificaron según las etapas de transición obstétrica. Se definen las características de cada etapa. RESULTADOS: Los datos de 314 623 mujeres indicaron que la fecundidad femenina, calculada indirectamente por el número de partos, fue mayor en los países que se hallaban en las primeras etapas de la transición obstétrica, desde un promedio de 3 hijos en el estadio II a 1,8 en el estadio IV. El nivel de medicalización de los establecimientos de salud de los países participantes, definido por el número de partos por cesárea y el número de partos inducidos, tuvo tendencia a aumentar según avanzaba la etapa de transición obstétrica. En el estadio IV, las mujeres tuvieron 2,4 veces más partos por cesárea (15,3% en el estadio II y 36,7% en el estadio IV) y 2,6 veces más inducciones de parto (7,1% en el estadio II y 18,8% en el estadio IV) que las mujeres en el estadio II. A medida que avanzaban las etapas de transición obstétrica, también se incrementaba la media de edad de las mujeres primíparas. La ocurrencia de rotura uterina mostraba una tendencia descendente, y se reducía 5,2 veces, de 178 a 34 casos por 100 000 nacidos vivos, a medida que un país efectuaba la transición del estadio II al IV. CONCLUSIONES: Este análisis apoya el concepto de transición obstétrica utilizando datos de varios países. El Modelo de Transición Obstétrica podría justificar la adaptación de las estrategias para reducir la mortalidad materna según la etapa de transición obstétrica en que se halla un país. <![CDATA[<b>Consumo de alcohol antes y durante la gestación en Argentina</b>: <b>prevalencia y factores de riesgo</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400004&lng=es&nrm=iso&tlng=es OBJETIVO: Caracterizar el consumo de alcohol de mujeres argentinas antes y durante la gestación e identificar los factores asociados con ese consumo y con los cambios relacionados con la gestación. MÉTODOS: Estudio observacional transversal. Se entrevistaron mujeres puérperas atendidas en dos centros de atención perinatal de la ciudad de Santa Fe, Argentina. Se recabó la información sociodemográfica de las participantes y datos de su consumo de alcohol, entre otros. Se realizó un análisis descriptivo de las prevalencias de consumo y se identificaron los factores asociados con los patrones de consumo de alcohol mediante análisis de medidas repetidas. RESULTADOS: De las 614 participantes, 75,2% había consumido al menos un trago (unidad estándar) de alcohol durante la gestación y 83,3% lo había hecho durante el último año; 15,1% reconoció haber tenido al menos un evento de consumo excesivo episódico (5 tragos o más) durante la gestación y 27,6% durante el año anterior a la gestación. Solo 30,6% de las mujeres manifestó haber hecho algún cambio en el consumo durante el último año; de ellas, 55,6% disminuyó el consumo y 41,8% dejó de beber. Las mujeres que mostraron mayor consumo de alcohol antes y durante la gestación informaron mayor consumo de sus parejas, fumaban y tenían actitudes más permisivas respecto al consumo de alcohol durante la gestación. CONCLUSIONES: En Argentina, se requiere un plan de prevención específico para reducir el consumo de alcohol en las mujeres embarazadas, ajustado a las características del consumo en el contexto local, con intervenciones que incluyan a las parejas y se focalicen en las mujeres más jóvenes, las que consumen tabaco y las que tienen actitudes más permisivas respecto al consumo de alcohol.<hr/>OBJECTIVE: Describe alcohol consumption by Argentine women before and during pregnancy and identify the factors associated with consumption- and pregnancy-related changes. METHODS: Cross-sectional observational study. Women were interviewed after giving birth and receiving care at two perinatal health care centers in Santa Fe, Argentina. Sociodemographic information, data on their alcohol use, and other information were obtained from the participants. A descriptive analysis of consumption prevalence rates was made and the factors associated with patterns of alcohol use were identified by means of repeated measure analysis. RESULTS: Of the 614 participants, 75.2% had had at least one alcoholic drink (standard unit) during pregnancy and 83.3% had done so in the previous year; 15.1% admitted having at least one episode of binge drinking (five or more drinks) during pregnancy and 27.6% in the year prior to pregnancy. Only 30.6% of the women said they had made any change in consumption during the previous year; of those, 55.6% reduced their consumption and 41.8% stopped drinking. Women who consumed the most alcohol before and during pregnancy reported higher consumption by their partners, smoked, and had more permissive attitudes about alcohol use during pregnancy. CONCLUSIONS: A specific prevention plan is required in Argentina to reduce alcohol use in pregnant women, adjusted to local patterns of use, with interventions that include couples, and focused on the youngest women, those who use tobacco, and those who have more permissive attitudes about alcohol use. <![CDATA[<b>Maternal deaths in Belo Horizonte, Brazil</b>: <b>perceptions of quality of care and preventability</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400005&lng=es&nrm=iso&tlng=es OBJETIVO: Analisar a mortalidade materna em Belo Horizonte, no período de 2003 a 2010, a partir da percepção dos familiares de mulheres que faleceram por causas relacionadas à maternidade. MÉTODOS: Os óbitos maternos foram investigados junto ao Comitê de Prevenção do Óbito Materno, Fetal e Infantil na Secretaria Municipal de Saúde de Belo Horizonte. Os familiares das mulheres falecidas foram recrutados por telefone ou pessoalmente para entrevistas. O tamanho da amostra de entrevistados não foi previamente definido, tendo sido considerada como critério a saturação das informações obtidas. Entretanto, buscou-se a inclusão de famílias de mulheres atendidas tanto pelo sistema público quanto pelo sistema privado de saúde. As questões norteadoras das entrevistas foram: histórico de saúde prévio à gestação; história clínica do pré-natal até o falecimento; assistência recebida pela mulher falecida no pré-natal, parto e puerpério. Após transcrição e leitura de todas as entrevistas, utilizou-se o software de análise qualitativa NVivo 9 para categorização e codificação dos depoimentos. RESULTADOS: Foram entrevistados os familiares de 11 mulheres, que faleceram por causas variadas, possuíam ocupações diversas e tinham idade entre 16 e 40 anos. A maioria estava em sua primeira ou segunda gestação e era usuária do sistema público de saúde. Sete tinham de 8 a 11 anos de estudo; sete também eram solteiras; 10 eram brancas ou pardas. Todos os familiares entrevistados eram do sexo feminino, com idade variando de 18 a 66 anos. A maioria era de mães, com baixa escolaridade, casadas e que exerciam atividades do lar. Foram relatadas dificuldades com a assistência recebida durante a gravidez, com pouca valorização do quadro clínico das gestantes. Nove óbitos maternos ocorreram no período pós-parto. CONCLUSÕES: Conforme o relato dos familiares, os óbitos maternos registrados em Belo Horizonte entre 2003 e 2010 estiveram associados a questões possivelmente evitáveis, relacionadas aos direitos reprodutivos da mulher, à assistência à gravidez, ao parto e ao puerpério.<hr/>OBJECTIVE:To analyze maternal deaths in Belo Horizonte from 2003 to 2010 based on the perception of family members of women who died from pregnancy-related causes. METHODS: Maternal deaths were researched at the City of Belo Horizonte Department of Health's Maternal, Fetal, and Infant Death Prevention Committee. Family members of deceased women were recruited by telephone or personally. Sample size was not pre-defined; rather, a saturation criterion was employed. Nevertheless, an attempt was made to include families of women who received both public and private health care. The interviews focused on health history prior to the pregnancy; clinical history in the period from the start of pre-natal care until death; care received by the deceased women before, during and after delivery. After transcription and analysis of all interviews, the NVivo 9 qualitative analysis software was used to categorize and code the interviews. RESULTS: The family members of 11 women were interviewed. The victims were between 16 and 40 years old, died of various causes, and had various occupations. Most were in their first or second pregnancy, and most relied on public health care. Seven women had between 8 and 11 years of schooling, and seven were single. Ten women were white or brown. All the family members interviewed were female, with age ranging from 18 to 66 years. Most were the mothers of the deceased women, had little schooling, were married and worked in the home. The interviewees reported difficulties with the care received during the pregnancy, with little attention paid to the clinical status of the pregnant women. Nine deaths occurred after the delivery. CONCLUSIONS: According to the reports of family members, the maternal deaths recorded in Belo Horizonte between 2003 and 2010 were associated with issues that were possibly preventable, relating to the reproductive rights of women, to pregnancy, delivery, and perinatal care. <![CDATA[<b>Tendencia de la mortalidad por causas externas en mujeres gestantes o puérperas y su relación con factores socioeconómicos en Colombia, 1998-2010</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400006&lng=es&nrm=iso&tlng=es OBJETIVO: Determinar la tendencia de la mortalidad por causas externas en mujeres gestantes o puérperas y su relación con factores socioeconómicos. MÉTODOS: Estudio descriptivo, basado en los registros oficiales de defunciones reportados por el Departamento Administrativo Nacional de Estadística (DANE), período 1998-2010. Se realizó un análisis de tendencia mediante regresiones de Poisson. Se construyeron correlaciones bivariadas y modelos de regresión lineal múltiple para explorar la relación entre la mortalidad y factores socioeconómicos como el índice de desarrollo humano, índice Gini, producto bruto interno, necesidades básicas insatisfechas, tasa de desempleo, pobreza, indigencia, índice de calidad de vida, tasa de analfabetismo y porcentaje de afiliación al Sistema General de Seguridad Social en Salud. RESULTADOS: Se presentaron 2 223 muertes por causas externas en mujeres, de las cuales 1 429 se encontraban en período de gestación y 794 en período puerperal. La razón bruta de mortalidad pasó de 30,7 por cada 100 000 nacidos vivos más defunciones fetales en 1998 a 16,7 en 2010. Se presentó una tendencia decreciente en el riesgo de morir por esta causa sin puntos de inflexión significativos. El modelo de regresión lineal múltiple mostró una correlación entre la mortalidad y los indicadores socioeconómicos pobreza extrema y tasa de analfabetismo, sugiriendo que estos indicadores podrían explicar el 89,4% de la variabilidad de la mortalidad por causas externas en mujeres gestantes o puérperas por año en Colombia. CONCLUSIONES: La mortalidad por causas externas en mujeres en período de gestación o en período puerperal mostró una tendencia significativa a la reducción, este comportamiento podría ser explicado por el cambio en aspectos socioeconómicos de relevancia para el país, así como la reducción en la incidencia de la pobreza extrema y la tasa de analfabetismo.<hr/>OBJECTIVE: Determine the trend in mortality from external causes in pregnant and postpartum women and its relationship to socioeconomic factors. METHODS: Descriptive study, based on the official registries of deaths reported by the National Statistics Agency, 1998-2010. The trend was analyzed using Poisson regressions. Bivariate correlations and multiple linear regression models were constructed to explore the relationship between mortality and socioeconomic factors: human development index, Gini index, gross domestic product, unsatisfied basic needs, unemployment rate, poverty, extreme poverty, quality of life index, illiteracy rate, and percentage of affiliation to the Social Security System. RESULTS: A total of 2 223 female deaths from external causes were recorded, of which 1 429 occurred during pregnancy and 794 in the postpartum period. The gross mortality rate dropped from 30.7 per 100 000 live births plus fetal deaths in 1998 to 16.7 in 2010. A downward curve with no significant inflection points was shown in the risk of dying from this cause. The multiple linear regression model showed a correlation between mortality and extreme poverty and the illiteracy rate, suggesting that these indicators could explain 89.4% of the change in mortality from external causes in pregnant and postpartum women each year in Colombia. CONCLUSIONS: Mortality from external causes in pregnant and postpartum women showed a significant downward trend that may be explained by important socioeconomic changes in the country, including a decrease in extreme poverty and in the illiteracy rate. <![CDATA[<b>Morbilidad materna extremadamente grave entre las usuarias del sistema de salud pública en las regiones amazónica y noreste del Brasil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400007&lng=es&nrm=iso&tlng=es OBJECTIVE: To assess the prevalence of pregnancy complications identified as maternal near miss (MNM) and associated factors among women using the public health care system in the Amazon and Northeast regions of Brazil. METHODS: A secondary analysis of a population-based survey conducted in 2010 was performed focusing on women self-reporting maternal complications. The main outcome was MNM, pragmatically defined as intensive care unit admission, eclampsia, hysterectomy, or blood transfusion. In addition, the risk of MNM was estimated for certain sociodemographics and characteristics of care received. Poisson regression was performed, generating adjusted prevalence ratios (PRadj) with 95% confidence intervals (95%CI). RESULTS: A total of 13 044 women (77%) who had given birth during the prior year using the public health system were interviewed. At least one complication was reported by 37.5%, with hemorrhage (28.4%) and infection (8.3%) being the most frequent. The overall MNM ratio was 31.5 per 1 000 live births, higher for the Amazon region than for the Northeast. Factors with a higher risk for developing MNM were: indigenous ethnicity (PRadj 2.77; 95% CI: 1.50-5.14), more than one hour to reach the hospital (PRadj 1.55; 95%CI: 1.06-2.25), being refused by a full hospital and having to find another one (PRadj 1.49; 95%CI: 1.03-2.16), cesarean section (PRadj 2.56; 95%CI: 1.90-3.44), and public prenatal care (PRadj 1.95; 95%CI: 1.06-3.61). CONCLUSIONS: Users of public health system in the Amazon and Northeast regions of Brazil have high MNM rates. Some characteristics of the women and of the care they received represent inequalities associated with higher risk for MNM. Specific actions are required to improve maternal health programs in these expansive areas of the country.<hr/>OBJETIVO: Evaluar la prevalencia de las complicaciones del embarazo establecidas como morbilidad materna extremadamente grave (MMEG), y los factores asociados, entre las usuarias del sistema de atención de salud pública en las zonas amazónica y noreste del Brasil. MÉTODOS:Se realizó un análisis secundario de una encuesta poblacional llevada a cabo en el 2010 y centrado en las mujeres que autonotificaban complicaciones obstétricas. El principal resultado fue la MMEG, definida a efectos prácticos como ingreso en una unidad de cuidados intensivos, eclampsia, histerectomía o transfusión de sangre. Se calculó además el riesgo de MMEG para determinadas características sociodemográficas y de la atención recibida. Se llevó a cabo una regresión de Poisson y se generaron las razones de prevalencia ajustadas (RPa) con intervalos de confianza de 95% (IC 95%). RESULTADOS:Se entrevistó a un total de 13 044 mujeres (77%) que habían dado a luz durante el año previo en el sistema de salud pública. Un 37,5% notificó como mínimo una complicación; la hemorragia (28,4%) y la infección (8,3%) fueron las más frecuentes. El índice general de MMEG fue de 31,5 por 1 000 nacidos vivos, más elevado en la región amazónica que en la noreste. Los factores que comportaron un riesgo mayor de MMEG fueron la etnicidad autóctona (RPa 2,77; IC 95% = 1,50-5,14), precisar más de una hora para llegar al hospital (RPa 1,55; IC 95% = 1,06-2,25), no ser admitida en un hospital por estar completo y tener que encontrar otro (RPa 1,49; IC 95% = 1,03-2,16), la cesárea (RPa 2,56; IC 95% = 1,90-3,44), y la asistencia prenatal pública (RPa 1,95; IC 95% = 1,06-3,61). CONCLUSIONES: Las usuarias del sistema de salud pública en las regiones amazónica y noreste del Brasil muestran tasas elevadas de morbilidad materna extremadamente grave. Algunas características de las mujeres y de la atención recibida comportan desigualdades asociadas con un riesgo mayor de morbilidad materna extremadamente grave. Se requieren acciones específicas que mejoren los programas de salud materna en estas amplias zonas del país. <![CDATA[<b>Desigualdades y características sociodemográficas de la mortalidad materna en La Guajira, Colombia, 2010-2012</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400008&lng=es&nrm=iso&tlng=es OBJETIVO: Identificar las desigualdades y las características sociodemográficas que inciden negativamente en la mortalidad materna en el departamento de La Guajira, Colombia. MÉTODOS: Se realizó un estudio descriptivo, en el que se analizaron los casos de muerte materna ocurridos en el departamento de La Guajira entre 2010 y 2012, a partir de datos de fuentes secundarias. Se calculó la diferencia de las tasas, la razón de las tasas y el riesgo atribuible poblacional porcentual, además de los índices de Gini y de concentración. RESULTADOS: Se registraron 54 muertes maternas, de ellas, 61,1% eran indígenas y 16,7% afrocolombianas; la mayoría no tenía ningún estudio (33,3%) o solo estudios primarios (29,6%). Se encontraron desigualdades en la diferencia de las tasas, la razón de las tasas y el riesgo atribuible poblacional porcentual, entre La Guajira y otros departamentos de la región Caribe y del país; sin embargo, esas diferencias no se reflejaron en los índices de Gini y de concentración. CONCLUSIONES: La mortalidad materna fue significativamente más elevada en las mujeres indígenas en comparación con las no indígenas. Se deben fortalecer los programas de salud sexual y reproductiva y adelantar dentro de las políticas de salud materna un enfoque multicultural para eliminar o reducir las desigualdades relacionadas con la mortalidad materna en esta población.<hr/>OBJECTIVE: Identify the inequalities and sociodemographic characteristics that negatively affect maternal mortality in the department of La Guajira, Colombia. METHODS: A descriptive study was conducted in which cases of maternal deaths in the department of La Guajira between 2010 and 2012 were analyzed, based on data from secondary sources. The difference in rates, rate ratio, population attributable risk percent, and Gini and concentration coefficients were calculated. RESULTS: 54 maternal deaths were recorded, 61.1% of which were indigenous and 16.7% Afro-Colombians; the majority did not have any schooling (33.3%) or only primary schooling (29.6%). Inequalities in the difference of rates, rate ratio, and population attributable risk percent were calculated for La Guajira and other departments in the Caribbean region and in Colombia; however, the differences were not reflected in the Gini and concentration coefficients. CONCLUSIONS: Maternal mortality was significantly higher in indigenous women than in non-indigenous women. Sexual and reproductive health programs should be strengthened and maternal health policies improved through a multicultural approach to eliminate or reduce inequalities related to maternal mortality in this population. <![CDATA[<b>"<i>Siempre me critican</i>"</b>: <b>barreras de acceso a la salud reproductiva en Ocotal, Nicaragua</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400009&lng=es&nrm=iso&tlng=es OBJECTIVE: To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua's total ban on abortion. METHODS: From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes. RESULTS: Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women's ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country's total ban on abortion in most circumstances, with the possible exception of rape. CONCLUSIONS: Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women's reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.<hr/>OBJETIVO: Determinar cómo perciben las mujeres de Ocotal, Nicaragua, las barreras de acceso a la atención de salud reproductiva; describir sus conocimientos acerca de los derechos reproductivos; y consignar sus opiniones acerca de la prohibición total del aborto en Nicaragua. MÉTODOS: De mayo a junio del 2014, se establecieron tres grupos de discusión en español en los que participaron 17 mujeres de dos barrios diferentes de la ciudad de Ocotal. Se utilizó una guía de discusión semiestructurada que constaba de preguntas de respuesta libre para dilucidar las perspectivas locales con respecto a los temas del grupo de discusión. RESULTADOS: Los obstáculos graves, incluidos 1) la violencia contra la mujer, 2) el machismo, 3) las críticas por parte de otros, y 4) la falta de comunicación y formación, limitan la capacidad de las mujeres para tomar sus propias decisiones de salud reproductiva. Las mujeres mostraron una carencia generalizada de conocimientos acerca de sus derechos reproductivos y los documentos internacionales de derechos humanos que los definen. Además, como consecuencia de sus ideas religiosas y culturales, la mayor parte de las mujeres apoyaron la prohibición total del aborto en el país en la mayor parte de las circunstancias, con la posible excepción de la violación. CONCLUSIONES: Se debe alentar a los hombres y mujeres de Ocotal a participar en los programas comunitarios diseñados para reducir la repercusión de los siguientes obstáculos para obtener atención de salud reproductiva: 1) la violencia contra la mujer y el machismo; 2) la educación sexual no estandarizada y la información acerca de sus derechos reproductivos insuficientes; y 3) la comunicación deficiente dentro de las familias y en la comunidad en general. Con objeto de reducir el estigma en torno a la salud y la actividad sexuales, las futuras campañas de salud pública orientadas a tratar las necesidades de salud reproductiva de las mujeres de Ocotal deben llevar a cabo en los barrios estos tipos de programas. <![CDATA[<b>Corrected estimates of femicides in Brazil, 2009 to 2011</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400010&lng=es&nrm=iso&tlng=es OBJETIVO: Estimar as taxas de feminicídios corrigidas e apresentar o perfil desses óbitos no Brasil durante o triênio de 2009 a 2011. MÉTODOS: Foi realizado estudo descritivo com dados do Sistema de Informações sobre Mortalidade (SIM). Foram considerados como feminicídios os óbitos de mulheres cuja causa básica foi classificada nos códigos X85-Y09 da CID-10 (agressões). Esses dados foram corrigidos em duas etapas: redistribuição proporcional dos eventos cuja intenção é indeterminada (Y10-Y34) e aplicação de fatores de correção das taxas de mortalidade descritos anteriormente na literatura. RESULTADOS: No período analisado, foram registrados 13 071 feminicídios no SIM. Após a correção, estimou-se a ocorrência de 17 167 feminicídios, o que equivale a uma taxa de 5,86 óbitos por 100 000 mulheres. Taxas mais elevadas foram observadas nas regiões Nordeste, Centro-Oeste e Norte (6,93, 6,88 e 6,43 óbitos por 100 000 mulheres, respectivamente), enquanto as mais baixas foram nas regiões Sul e Sudeste (5,07 e 5,09 óbitos por 100 000 mulheres, respectivamente). Entre as vítimas, 29,7% tinham entre 20 e 29 anos; 60,9% eram negras; 48% daquelas com 15 ou mais anos de idade tinham até 8 anos de estudo. Houve envolvimento de armas de fogo em 50,2% das mortes; 27,6% ocorreram no domicílio e 35,1% aos finais de semana. CONCLUSÕES: As taxas de feminicídios foram elevadas e corroboram a necessidade de correção, visando a reduzir a subestimação. As vítimas foram mulheres de todas as faixas etárias, etnias e níveis de escolaridade. Todavia, as principais vítimas foram mulheres jovens, negras e com baixa escolaridade, residentes nas regiões Nordeste, Centro-Oeste e Norte.<hr/>OBJECTIVE: To estimate the corrected femicide rates and to describe the characteristics of these deaths in Brazil during the 2009-2011 triennium. METHODS: A descriptive study was performed with data from the Brazilian Mortality Information System. Femicides were defined as all female deaths classified in the Assault chapter of ICD-10 (X85-Y09). These data underwent two correction procedures: proportional redistribution of events of undetermined intent (Y10-Y34) and application of correction factors for mortality rates previously described in the literature. RESULTS: During the period analyzed, 13 071 femicides were recorded in the Mortality Information System. After the first correction procedure, 17 167 femicides were estimated, corresponding to a death rate of 5.86 per 100 000 women. Higher femicide rates were recorded in the Northeast, Midwest and North regions of Brazil (6.93, 6.88 and 6.43 deaths per 100 000 women respectively) vs. 5.07 and 5.09 per 100 000 women in the South and Southeast respectively. Of the victims, 29.7% were between 20 and 29 years of age and 60.9% were black. Among women aged 15 years or older, 48% had schooling of not more than 8 years. Fire guns were used in 50.2% of deaths; 27.6% of deaths took place in the household; and 35.1% took place on weekends. CONCLUSIONS: Femicide death rates were high and support the need for correction to reduce underestimation. The victims were women of all age groups, ethnicities, and schooling levels. However, most victims were young, black, with low schooling, living in the Northeast, Midwest, and North of Brazil. <![CDATA[<b>Under the shadow of maternity</b>: <b>pregnancy, suicidal ideation, and intimate partner violence</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400011&lng=es&nrm=iso&tlng=es OBJETIVO: Identificar a associação entre violência por parceiro íntimo e indicativo de ideação suicida durante a atual gestação. MÉTODOS: Estudo observacional e transversal desenvolvido com 358 gestantes selecionadas por amostragem aleatória sistemática em Ribeirão Preto (SP), Brasil. A Escala de Ideação Suicida de Beck e uma versão adaptada do instrumento usado no World Health Organization Multi-country Study on Women's Health and Domestic Violence foram utilizadas para identificar o indicativo de ideação suicida e os atos de violência psicológica, física e sexual perpetrados pelo parceiro íntimo durante a atual gestação. Utilizou-se a regressão logística múltipla para obter razões de chances (odds ratios) de prevalência ajustadas, com intervalo de confiança de 95%. RESULTADOS: A prevalência do indicativo de ideação suicida foi de 7,8%. Dentre as participantes, 17,6% estiveram em situação de violência por parceiro íntimo durante a atual gestação. Destas, 95,2% reportaram ter sofrido violência psicológica, 36,5% violência física e 1,6% violência sexual. A análise de regressão logística múltipla indicou que as mulheres vítimas de violência tiveram 6,29 vezes mais chance de apresentar indicativo de ideação suicida. CONCLUSÕES: É preciso conscientizar os formuladores de políticas e os prestadores de cuidados acerca do impacto da violência por parceiro íntimo, inclusive em termos de ideação suicida, especialmente durante a gravidez. A adoção de medidas simples, como as escalas utilizadas no presente estudo, pode facilitar o dimensionamento desse problema nos serviços de saúde.<hr/>OBJECTIVE: To investigate the association between intimate partner violence and indicators of suicidal ideation during the current pregnancy. METHODS: This is a cross-sectional observational study developed with 358 pregnant women selected by systematic random sampling in Ribeirão Preto, southeastern Brazil. The Back Suicidal Ideation Scale and an adapted version of the instrument used in the World Health Organization Multi-country Study on Women's Health and Domestic Violence were used to identify indicators of suicidal ideation and psychological, physical, and sexual acts of intimate partner violence during the current pregnancy. Multiple logistic regression was used to obtain adjusted prevalence odds ratios with a 95% confidence interval. RESULTS: The prevalence of indicators of suicidal ideation was 7.8%. Of the participants, 17.6% reported some type of intimate partner violence during the current pregnancy. Among these, 95.2% reported having suffered psychological violence, 36.5% physical violence, and 1.6% sexual violence. Multiple logistic regression analysis showed that women exposed to violence were 6.29 times more likely to have indicators of suicidal ideation. CONCLUSIONS: Policy makers and health care providers must be made aware of the impact of intimate partner violence, including in terms of suicidal ideation, especially during pregnancy. The adoption of simple measures, such as the scales used in the present study, may provide information regarding the extent of intimate partner violence and suicidal ideation in health care services. <![CDATA[<b>La violencia doméstica como una amenaza para el bienestar maternoinfantil en una comunidad urbana de migrantes del Perú</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400012&lng=es&nrm=iso&tlng=es OBJECTIVE: To examine the impact that domestic violence (DV) has on hindering the success of urban migrants in Peru and any association with maternal depression, impaired parenting, social capital, and child development. METHODS: This was a cross-sectional study consisting of structured interviews with 97 mothers and their school-aged children in El Porvenir, a predominantly migrant area of the city of Trujillo, Peru. Data collection occurred in February-June 2011. Proven tools previously validated for use in Spanish were used to assess the following variables: maternal depression, social capital, domestic violence, parenting behaviors, child socioemotional development, and child cognitive development. Correlational, multiple regression, tests of interaction, and indirect/mediator models were used for analysis. RESULTS: Sixty-five percent of women reported currently experiencing DV. DV strongly predicted depression (P < 0.001). Women who reported DV were less likely to be employed (P < 0.05), had lower cognitive social capital (P < 0.01), engaged in fewer caregiving activities (P < 0.05), had less maternal energy (P < 0.05), and were less warm (P < 0.05). DV was associated with internalizing behaviors in children (P < 0.01), with impaired parenting partially mediating this relationship. CONCLUSIONS: DV compromises women's mental health and parenting ability. High rates of DV among urban migrants affect the whole community by hindering employment potential and reducing trust among community members. Interventions targeting DV-related variables (e.g., substance abuse and limited job opportunities for men) could reduce the deleterious effects of DV on urban migrant communities across Latin America.<hr/>OBJETIVO: Analizar la repercusión de la violencia doméstica como obstáculo para el éxito de los migrantes urbanos del Perú, y su asociación con la depresión materna, el deterioro de la crianza, el capital social y el desarrollo infantil. MÉTODOS: Se realizó un estudio transversal que constaba de entrevistas estructuradas dirigidas a 97 madres y sus hijos en edad escolar residentes en El Porvenir, una zona predominantemente migratoria de la ciudad de Trujillo (Perú). Se recopilaron datos de febrero a junio del 2011. Se emplearon instrumentos comprobados, validados anteriormente para su uso en español, con objeto de evaluar las siguientes variables: la depresión materna, el capital social, la violencia doméstica, los comportamientos de crianza, y el desarrollo socioemocional y cognoscitivo de los niños. Para el análisis se utilizaron diseños correlacionales y de regresión múltiple, pruebas de interacción y modelos indirectos o de mediadores. RESULTADOS: El 65% de las mujeres notificaron que eran víctimas de algún tipo de violencia doméstica en aquel momento, y esta predijo intensamente la depresión (P < 0,001). Las mujeres que notificaron violencia doméstica tenían menores probabilidades de tener un empleo (P < 0,05), poseían un capital social cognoscitivo inferior (P < 0,01), realizaban menos actividades de cuidado de otras personas (P < 0,05), tenían menos energía para la crianza (P < 0,05), y eran menos afectuosas (P < 0,05). La violencia doméstica se asoció con comportamientos de internalización en niños (P < 0,01), y el deterioro de la crianza mediaba parcialmente esta relación. CONCLUSIONES: La violencia doméstica compromete la salud mental y la capacidad de crianza de las mujeres. Las tasas elevadas de esta entre los migrantes urbanos afectan a toda la comunidad al entorpecer su potencial para lograr un empleo y reducir la confianza entre los miembros de la comunidad. Las intervenciones que actúen sobre las variables relacionadas con la violencia doméstica (por ejemplo, el consumo de sustancias psicoactivas y las limitadas oportunidades de trabajo para los hombres) podrían reducir los efectos nocivos de la violencia doméstica en las comunidades de migrantes urbanos en América Latina. <![CDATA[<b>Sexual violence</b>: <b>narratives of women with mental disorders in Brazil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400013&lng=es&nrm=iso&tlng=es OBJETIVO: Compreender o impacto da violência sexual sofrida por mulheres com transtornos mentais a partir de autorrelato de suas experiências. MÉTODOS: Os relatos emergiram de entrevistas abertas realizadas com mulheres atendidas em serviços públicos de saúde mental de Minas Gerais e Rio de Janeiro como parte de uma pesquisa de cunho mais amplo que teve como objetivo geral investigar as formas de viver e pensar a sexualidade por esse grupo populacional, visando a contribuir para as ações de promoção da saúde sexual. A coleta dos dados se deu em 2008. RESULTADOS: Foram entrevistadas 17 mulheres com idade entre 18 e 68 anos. Quatorze entrevistadas afirmaram ter vivido relações estáveis, mas somente três permaneciam nessas relações. A maioria dos relacionamentos estáveis não havia sido oficializada. Duas mulheres eram viúvas e 13 tinham filhos. Todas relataram enfrentar dificuldades na convivência com os parceiros e com os filhos, ter poucos amigos e dispor de pouco apoio familiar. A instabilidade dos relacionamentos foi atribuída a situações de agressividade, infidelidade do parceiro e uso de drogas ou álcool. Houve relatos de terem sido vítimas de violência física na família, sobretudo por parte de parceiros, e também de violência sexual, sendo que, em alguns casos, os agressores eram pessoas da família. Duas entrevistadas afirmaram nunca ter tido relação sexual. CONCLUSÕES: Faz-se necessário capacitar os profissionais de saúde para que propiciem o relato de situações de violência sexual por parte das mulheres e para que encaminhem de forma adequada a situação. Também é fundamental a necessidade de ações intersetoriais para o enfrentamento dessa problemática.<hr/>OBJECTIVES: To understand the impact of sexual violence suffered by women with mental disorders based on self-reports of these experiences. METHODS: The reports emerged from open interviews with women receiving care at public mental health services in the states of Minas Gerais and Rio de Janeiro, Brazil. These interviews were part of a larger research project that had the overall objective of investigating how this population group lives and thinks sexuality, in order to contribute to actions to promote sexual health. Data collection took place in 2008. RESULTS: Seventeen women with age between 18 and 68 years were interviewed. Fourteen reported having had stable relationships, but only three were still in these relationships. Most of the stable relationships had not been formalized into marriage. Two participants were widows and 13 had children. All the participants reported difficulties in living with their partners and children and having few friends and little family support. The instability of relationships was attributed to situations of aggression, infidelity, and use of drugs and alcohol. Seven women reported having been victims of physical violence within the family, mostly from partners. Two participants reported never having had sexual relations. CONCLUSIONS: Health care professionals must be trained to encourage the report of sexual violence by women and adequately handle the situation. Intersectoral actions to deal with this issue are also essential. <![CDATA[<b>Tendencias de la mortalidad por agresiones en mujeres de países seleccionados de América Latina, 2001-2011</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400014&lng=es&nrm=iso&tlng=es OBJETIVO: Describir la tendencia temporal de las muertes por agresiones en mujeres en Argentina, Brasil, Chile, Colombia y México entre 2001 y 2011. MÉTODOS: Estudio descriptivo. Se calcularon las tasas de mortalidad por agresiones y eventos de intención no determinada, ajustadas por la edad, según el método directo y la población estándar de la Organización Mundial de la Salud. Se utilizaron modelos joinpoint para identificar los cambios estadísticamente significativos. Se comparó la razón hombre:mujer de mortalidad y se calcularon las tendencias de las tasas ajustadas para cada una de las dos causas de muerte y las tasas específicas de mortalidad por agresiones en mujeres por grupos de edad. RESULTADOS: En Brasil se registraron las mayores tasas de agresiones en mujeres, seguido por Colombia, México, Argentina y Chile. Entre 2001 y 2011, en Argentina y Colombia se constataron disminuciones, en Brasil y México hubo incrementos y en Chile las tasas se mantuvieron estables. Las mayores tasas específicas se encontraron en mujeres jóvenes (15-29 años) y adultas (30-44 y 45-59 años). En Colombia las tasas disminuyeron en todos los grupos, mientras que en México se incrementaron en mujeres de 15 a 59 años. Solo Colombia evidenció una reducción en las tasas de mortalidad por eventos de intención no determinada; en Argentina y México hubo una disminución al principio del período con un aumento posterior; en Brasil no se observaron variaciones. CONCLUSIONES: Las tasas de mortalidad por agresiones en mujeres de Brasil, Colombia y México entre 2001 y 2011 resultaron superiores al promedio mundial y al promedio de América Latina; en Argentina y Chile fueron más bajas y con menores diferencias entre los sexos. Se debe avanzar en la visualización de las relaciones de poder que subyacen en los asesinatos de mujeres e incluir el feminicidio en las legislaciones penales nacionales.<hr/>OBJECTIVE: Describe the trend in deaths by assault in women in Argentina, Brazil, Chile, Colombia, and Mexico between 2001 and 2011. METHODS: Descriptive study. Mortality from assaults and undetermined intentional acts was calculated, adjusted for age, using the direct method and the World Health Organization's standard population. Joinpoint regression models were used to identify statistically significant changes. The male:female mortality ratio was compared and trends in the rates were calculated and adjusted for each of the two causes of death and the specific rates of mortality by assault in women by age group. RESULTS: The highest rates of assault of women were reported in Brazil, followed by Colombia, Mexico, Argentina, and Chile. Between 2001 and 2011, decreases were reported from Argentina and Colombia; in Brazil and Mexico the rates increased; and in Chile they remained stable. The highest specific rates were found in young women (15-29 years) and adults (30-44 and 45-59 years). In Colombia the rates declined in all groups, while in Mexico they increased in women aged 15 to 59 years. Only Colombia showed a decrease in mortality from undetermined intentional acts; in Argentina and Mexico there was a decrease at the beginning of the period with a later increase; in Brazil no variations were observed. CONCLUSIONS: Mortality from assaults on women in Brazil, Colombia, and Mexico between 2001 and 2011 was higher than the world average and the Latin American average; rates were lower in Argentina and Chile, with minor differences between the sexes. Progress must be made in terms of understanding the power relationships that underlie femicide, which should be included in national criminal legislation. <![CDATA[<b>HIV and violence against women</b>: <b>study in a municipality with high prevalence of Aids in the South of Brazil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400015&lng=es&nrm=iso&tlng=es OBJETIVO: Investigar a prevalência e os fatores associados à violência contra mulheres com HIV em um município de porte médio no Sul do Brasil. MÉTODOS: Estudo transversal com amostra de 161 usuárias de um Serviço de Assistência Especializada para HIV em um município com alta prevalência de Aids no estado do Rio Grande do Sul. Para verificar a prevalência e as formas de violência, foram utilizadas 13 questões do instrumento World Health Organization Violence Against Women (WHO VAW), adaptado e validado para português brasileiro. Pesquisou-se a presença de violência psicológica, física e sexual sofrida em algum momento da vida e perpetrada por parceiro ou ex-parceiro íntimo, familiares, conhecidos, amigos, vizinhos, colegas e desconhecidos. A análise estatística foi realizada através do teste qui-quadrado e regressão múltipla de Poisson. RESULTADOS: A violência psicológica foi relatada por 117 mulheres (72,7%), a física por 88 (54,6%) e a sexual por 41 (25,4%). A prevalência ajustada da violência em mulheres que viviam há mais de 5 anos com HIV foi 11,5 vezes maior do que a prevalência naquelas que viviam com HIV há < 5 anos; 9,5 vezes maior nas que tinham mais de três filhos vs. três ou menos filhos; e 7,2 vezes maior nas que fizeram sexo antes dos 15 anos vs. a partir dos 15 anos (P < 0,001). CONCLUSÕES: As frequências de todos os tipos de violência foram elevadas nesse grupo de mulheres com HIV. É importante que os profissionais de saúde compreendam e abordem questões relativas à discriminação e realizem o cuidado de forma integral, perguntando sobre a presença de violências na vida das mulheres.<hr/>OBJECTIVE: To investigate the prevalence and factors associated with violence against women with HIV in a mid-sized city in the South of Brazil. METHODS: This cross-sectional study included 161 users of an HIV Specialized Care Service in a city with high prevalence of Aids in the state of Rio Grande do Sul. To determine the prevalence and forms of violence, 13 questions of the World Health Organization Violence Against Women (WHO VAW) instrument, adapted and validated for Brazilian Portuguese, were used. The presence of lifetime psychological, physical, and sexual violence perpetrated by intimate partners or former partners, family members, acquaintances, friends, neighbors, colleagues, or strangers was investigated. Statistical analysis employed the chi-square test and Poisson multiple regression. RESULTS: Psychological violence was reported by 117 women (72.7%), physical violence by 88 women (54.6%), and sexual violence by 41 women (25.4%). The adjusted prevalence of violence was 11.5 times higher in women living with HIV for more than 5 years as compared to those living with HIV for < 5 years; 9.5 times higher in those with more than three children vs. three or fewer children; and 7.2 times higher in those who had sex before before the age of 15 years vs. at 15 years of age or older (P < 0.01). CONCLUSIONS: The frequency of all types of violence was high in this group of women with HIV. Health care professionals should understand and address issues relating to prejudice and provide comprehensive care, asking about the presence of violence in the life of women. <![CDATA[<b>La brecha de género en violencia doméstica en adultos mayores en América Latina</b>: <b>el Estudio IMIAS</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400016&lng=es&nrm=iso&tlng=es OBJETIVO: Describir la prevalencia de violencia doméstica en hombres y mujeres mayores de Natal, Brasil y Manizales, Colombia y explorar si las diferencias de género se deben a diferencias en condiciones sociales y económicas a lo largo de la vida. MÉTODOS: Estudio transversal con muestra aleatoria de 802 hombres y mujeres del Estudio IMIAS (International Mobility in Aging Study) (65-74 años) desarrollado en Natal y Manizales. La violencia perpetrada, durante los últimos seis meses y alguna vez en la vida, fue evaluada por la escala HITS. La regresión de Poisson fue utilizada para estimar las razones de prevalencia de violencia de las mujeres respecto a los hombres. RESULTADOS: La experiencia de violencia física ocurrida alguna vez en la vida varió entre 2,2 y 18,3% según la ciudad y el sexo. La violencia psicológica fue más elevada en mujeres, siendo la violencia perpetrada por el compañero de 25,7% en Natal y 19,4% en Manizales; y por la familia de 18,3% en Manizales y 10% en Natal. Casi la mitad de los participantes informaron haber sufrido violencia psicológica alguna vez en la vida. La violencia actual o alguna vez en la vida fue más frecuente en las mujeres, incluso tras ajustes por covariables, presentando razones de prevalencia entre 1,60 y 2,14. CONCLUSIONES: Las tasas de prevalencia de violencia doméstica en los adultos mayores revelan que las mujeres son más afectadas, por lo cual deben ser consideradas como prioridad en las políticas de prevención de la agenda de salud para Latinoamérica.<hr/>OBJECTIVE: Describe the prevalence of domestic violence in older men and women in Natal, Brazil, and Manizales, Colombia and explore whether the differences by gender are due to lifetime differences in social and financial status. METHODS: Cross-sectional study with a random sampling of 802 men and women in the IMIAS Study (International Mobility in Aging Study) (65-74 years old) conducted in Natal (Brazil) and Manizales (Colombia). Incidents that occurred in the last six months and any time during their lives were evaluated using the HITS scale. Poisson regression was used to estimate the reasons for the prevalence of violence against women by men. RESULTS: Experience of physical violence occurring any time in life ranged from 2.2% to 18.3%, depending on the city and the sex. Psychological violence was higher in women: violence perpetrated by partners affected 25.7% of women in Natal and 19.4% in Manizales; and by the family, 18.3% in Manizales and 10% in Natal. Almost half of the participants reported suffering psychological violence at some time during their life. Experience of current violence or at some time during life was most frequent in women, even after adjustment for co-variables, with prevalence ratios of 1.60 to 2.14. CONCLUSIONS: The rates of prevalence of domestic violence in older adults show that women are more affected, which means that they should be considered a priority in the prevention policies on Latin America's health agenda. <![CDATA[<b>Factores de riesgo psicosocial y satisfacción laboral en trabajadoras estacionales de Chile</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400017&lng=es&nrm=iso&tlng=es OBJETIVO: Caracterizar la relación entre los factores de riesgo psicosocial y la satisfacción laboral en trabajadoras estacionales agrícolas de la zona central de Chile. MÉTODOS: Estudio transversal en una muestra no probabilística de 106 trabajadoras de una empresa comercializadora y exportadora de frutas de la región del Maule, Chile. Las entrevistas se realizaron entre septiembre y octubre de 2013. Se empleó el cuestionario SUSESO ISTAS-21 para evaluar los riesgos psicosociales en el trabajo según cinco dimensiones (exigencias psicológicas, trabajo activo y posibilidades de desarrollo, apoyo social en la empresa y calidad del liderazgo, compensaciones, y doble presencia). Se utilizó el cuestionario S10/12 para medir la satisfacción laboral según tres dimensiones (satisfacción con las prestaciones recibidas, satisfacción con el ambiente físico de la empresa y satisfacción con la supervisión) y en general. RESULTADOS: El nivel de riesgo psicosocial fue alto en dos dimensiones (doble presencia, y trabajo activo y posibilidades de desarrollo) y medio en las otras; el nivel de satisfacción fue alto en las tres dimensiones. La percepción de factores de riesgo psicosocial se asoció negativamente con la satisfacción laboral en tres dimensiones: trabajo activo y posibilidades de desarrollo, apoyo social en la empresa y calidad del liderazgo, y compensaciones (en esta última, excepto con la satisfacción con el ambiente físico de la empresa). CONCLUSIONES: En las tres áreas identificadas se concentran los riesgos asociados con el trabajo estacional y los principales aspectos que las trabajadoras consideran que afectan a su satisfacción con el trabajo y, por extensión, a su bienestar en general.<hr/>OBJECTIVE: Characterize the relationship between psychosocial risk factors and work satisfaction in female seasonal agricultural workers in central Chile. METHODS: Cross-sectional study in a non-probability sample of 106 female workers for a fruit trading and export company in the region of Maule, Chile. The interviews were conducted in September and October 2013. The SUSESO ISTA-21 questionnaire was used to evaluate five areas of psychosocial risk in the workplace (psychological requirements, active work and opportunities for development, social support in the company and quality of leadership, compensation, and "double presence"). Questionnaire S10/12 was used to measure labor satisfaction in three areas (satisfaction with benefits received, satisfaction with the company's physical environment, and satisfaction with supervision) and satisfaction in general. RESULTS: The level of psychosocial risk was high in two areas (double presence, and active work and possibilities of development) and medium in the other areas; the level of satisfaction was high in all three areas. The perception of psychosocial risk factors was negatively associated with work satisfaction in three areas: active work and opportunities for development, social support in the company and quality of leadership, and compensation (compensation was negatively associated except for satisfaction with the company's physical environment). CONCLUSIONS: Risks associated with seasonal work and the main issues that workers consider to affect their satisfaction with work and, by extension, their general well-being, are concentrated mainly in the three areas identified. <![CDATA[<b>Los traumas durante la niñez se asocian con síntomas depresivos en las mujeres de la Ciudad de México</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400018&lng=es&nrm=iso&tlng=es OBJECTIVE: To describe childhood trauma and depressive symptoms in Mexican women and to explore the relationships between number and type of childhood traumatic events and depressive symptoms. METHODS: A community-based sample of 100 women was interviewed using a demographic questionnaire, the Life Stressor Checklist-Revised (LSC-R), and the Center for Epidemiologic Studies Depression Scale (CES-D). Childhood trauma (trauma at or before 16 years of age) and depressive symptoms were described, and logistic and linear regressions were used to analyze the relationship between childhood traumatic events and current depressive symptoms. RESULTS: Participants reported a mean of 9.46 (standard deviation (SD): 4.18) lifetime traumas and 2.76 (SD: 2.34) childhood traumas. The mean CES-D score was 18.9 (SD: 12.0) and 36.0% of participants had clinically significant depression (CES-D > 24). Depression scores were correlated with lifetime trauma, childhood trauma, education level, employment status, and number of self-reported current medical conditions. Depression scores were not significantly correlated with age, marital status, number of children, or socioeconomic status. For every additional childhood trauma experienced, the odds of clinically significant depressive symptoms (CES-D > 24) increased by 50.0% (adjusted odds ratio (OR): 1.50; 95% confidence interval: 1.14-1.96), after controlling for number of children, age, education level, employment status, and number of self-reported medical conditions. CONCLUSIONS: The results indicated that the number of childhood trauma exposures is associated with current depression among urban Mexican women, suggesting a need for trauma-informed care in this setting.<hr/>OBJETIVO: Describir los traumas durante la niñez y los síntomas depresivos en mujeres mexicanas, y explorar las relaciones entre el número y tipo de sucesos traumáticos durante la niñez y los síntomas depresivos. MÉTODOS: Se entrevistó a una muestra comunitaria de 100 mujeres mediante un cuestionario demográfico, la Lista de Verificación de Estresores Vitales Revisada (LSC-R, por sus siglas en inglés), y la Escala de Depresión del Centro de Estudios Epidemiológicos (CES-D, por sus siglas en inglés). Se describieron los traumas durante la niñez (por debajo de los 16 años) y los síntomas depresivos. Se utilizaron regresiones logísticas y lineales para analizar la relación entre los sucesos traumáticos durante la niñez y los síntomas depresivos actuales. RESULTADOS: Las participantes notificaron un promedio de 9,46 (desviación estándar [SD] = 4,18) traumas a lo largo de la vida y 2,76 traumas (SD = 2,34) durante la niñez. La puntuación media obtenida en el CES-D fue de 18,9 (SD = 12,0). Un 36,0% de las participantes mostró una depresión clínicamente significativa (CES-D > 24). Las puntuaciones de la escala de depresión se correlacionaron con los traumas a lo largo de la vida, los traumas durante la niñez, el nivel de formación, la situación laboral, y el número de trastornos médicos actuales autonotificados por las participantes. Las puntuaciones de la escala de depresión no se correlacionaron significativamente con la edad, el estado civil, el número de hijos o la situación socioeconómica. Por cada trauma adicional durante la niñez, las probabilidades de síntomas depresivos clínicamente significativos (CES-D > 24) se incrementaron en 50,0% (razón de posibilidades [OR] ajustada: 1,50; intervalo de confianza [IC] de 95%: 1,14-1,96), tras controlar el número de hijos, la edad, el nivel de formación, la situación laboral y el número de trastornos médicos autonotificados. CONCLUSIONES: Los resultados indicaron que el número de exposiciones traumáticas durante la niñez se asociaba con la depresión actual en las mujeres mexicanas residentes en un entorno urbano; ello indica la necesidad de una atención que tenga en cuenta los antecedentes de sucesos traumáticos en este entorno. <![CDATA[<b>Fútbol y educación en salud sexual</b>: <b>un enfoque prometedor para reducir los partos en adolescentes en Haití</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400019&lng=es&nrm=iso&tlng=es OBJECTIVE: To explore the effect of an innovative, integrative program in female sexual reproductive health (SRH) and soccer (or fútbol, in Haitian Creole) in rural Haiti by measuring the rate of births among program participants 15-19 years old and their nonparticipant peers. METHODS: A retrospective cohort study using 2006-2009 data from the computerized data-tracking system of the Haitian Health Foundation (HHF), a U.S.-based nongovernmental organization serving urban and rural populations in Haiti, was used to assess births among girls 15-19 years old who participated in HHF's GenNext program, a combination education-soccer program for youth, based on SRH classes HHF nurses and community workers had been conducting in Haiti for mothers, fathers, and youth; girl-centered health screenings; and an all-female summer soccer league, during 2006-2009 (n = 4 251). Bivariate and multiple logistic regression analyses were carried out to assess differences in the rate of births among program participants according to their level of participation (SRH component only ("EDU") versus both the SRH and soccer components ("SO") compared to their village peers who did not participate. Hazard ratios (HRs) of birth rates were estimated using Cox regression analysis of childbearing data for the three different groups. RESULTS: In the multiple logistic regression analysis, only the girls in the "EDU" group had significantly fewer births than the nonparticipants after adjusting for confounders (odds ratio = 0.535; 95% confidence interval (CI) = 0.304, 0.940). The Cox regression analysis demonstrated that those in the EDU group (HR = 0.893; 95% CI = 0.802, 0.994) and to a greater degree those in the SO group (HR = 0.631; 95% CI = 0.558, 0.714) were significantly protected against childbearing between the ages of 15 and 19 years. CONCLUSIONS: HHF's GenNext program demonstrates the effectiveness of utilizing nurse educators, community mobilization, and youth participation in sports, education, and structured youth groups to promote and sustain health for adolescent girls and young women.<hr/>OBJETIVO: Explorar la repercusión de un programa innovador e integrador de salud sexual y reproductiva femenina y fútbol llevado a cabo en una zona rural de Haití, mediante la medición de la tasa de partos entre las participantes del programa, de 15 a 19 años de edad, y entre sus compañeras no participantes. MÉTODOS: Se utilizó un estudio retrospectivo de cohortes, que usaba los datos del periodo 2006-2009 del sistema de seguimiento de datos computadorizados de la Fundación Haitiana de Salud (HHF, una organización no gubernamental con sede en los Estados Unidos que presta servicio a las poblaciones urbanas y rurales de Haití, para evaluar los partos en las adolescentes de 15 a 19 años de edad que participaron en el programa GenNext de la HHF. Este programa es una combinación de educación y fútbol para jóvenes y se basa en las clases de salud sexual y reproductiva que el personal de enfermería de la HHF y los trabajadores comunitarios han impartido en Haití para madres, padres y jóvenes; los tamizajes de salud centrados en las adolescentes; y una liga de fútbol de verano solo para mujeres durante dicho periodo (n = 4 251). Se llevaron a cabo análisis bivariado y de regresión logística múltiple para evaluar las diferencias en las tasas de partos entre las participantes del programa según su nivel de participación (sólo el componente de salud sexual y reproductiva ["EDU"] frente a ambos componentes, salud sexual y reproductiva, y fútbol ["FU"]) en comparación con las compañeras de su municipio que no participaron . Se calcularon las razones de riesgo (RR) de las tasas de partos mediante análisis de regresión de Cox de los datos de maternidad de los tres grupos. RESULTADOS: En el análisis de regresión logística múltiple, sólo las adolescentes del grupo "EDU" tuvieron significativamente menos partos que las no participantes tras ajustar para los factores de confusión (razón de posibilidades = 0,535; intervalo de confianza [IC] 95% = 0,304-0,940). El análisis de regresión de Cox demostró que las del grupo EDU (RR = 0,893; IC 95% = 0,802-0,994), y en un mayor grado las del grupo FU (RR = 0,631; IC 95% = 0,558-0,714), estaban significativamente protegidas contra la maternidad en edades comprendidas entre los 15 y los 19 años. CONCLUSIONES: El programa GenNext de la HHF demuestra la eficacia de utilizar al personal de enfermería como educadores, la movilización comunitaria, y la participación de las jóvenes en actividades educativas y deportivas, y en grupos juveniles estructurados, para promover y mantener la salud de las adolescentes y las mujeres jóvenes. <![CDATA[<b>HIV infection in female adolescents</b>: <b>a qualitative study</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400020&lng=es&nrm=iso&tlng=es OBJETIVO: Conhecer as vulnerabilidades que favoreceram a infecção pelo HIV em adolescentes e jovens do sexo feminino e verificar as dificuldades enfrentadas por essa população após o diagnóstico. MÉTODOS: Estudo qualitativo realizado por meio de entrevistas com mulheres adolescentes e jovens soropositivas em tratamento, com diagnóstico feito na adolescência. As entrevistas foram gravadas e transcritas na íntegra e os dados obtidos foram analisados através de leitura intensiva, classificação por temas e interpretação na perspectiva hermenêutica-dialética em diálogo com a literatura. RESULTADOS: Foram entrevistadas 23 mulheres cujo diagnóstico ocorreu entre 11 e 19 anos e que, em sua maioria, foram infectadas através do contato sexual, exceto em dois casos (um com via de transmissão sanguínea e outro desconhecida). Evidenciaram-se como situações de vulnerabilidade a descrença na possibilidade de contaminação, a baixa idade da iniciação sexual (menor que a média brasileira), o não uso de preservativo, parceiros promíscuos ou usuários de drogas injetáveis e submissão a situações de violência. Os principais problemas enfrentados após o diagnóstico foram o preconceito, a discriminação, a necessidade de tomar medicamentos diariamente e as preocupações relacionadas ao desejo de ser mãe. CONCLUSÕES: Reduzir a feminização da Aids implica em ampliar e aprofundar o debate em torno da sexualidade e dos dilemas vivenciados por adolescentes a respeito desse assunto, de forma aberta, não preconceituosa e não normatizadora, nas escolas e cenários de convivência de jovens, além de fornecer orientação sobre doenças sexualmente transmissíveis, com distribuição gratuita e desburocratizada de preservativos.<hr/>OBJECTIVE:To investigate the vulnerabilities that favor HIV infection by female adolescents and young adults and to determine the difficulties faced by this population following diagnosis. METHODS: For this qualitative study we interviewed HIV-seropositive young or adolescent women diagnosed as adolescents and receiving treatment at the time of the interviews. The interviews were audio recorded and entirely transcribed. The data obtained were analyzed through intensive reading, classification of themes, and hermeneutic dialectic analysis in dialogue with the literature. RESULTS: Twenty-three women diagnosed between 11 and 19 years of age were interviewed. Twenty-one participants had acquired Aids via sexual transmission and one from blood. Transmission mode was unknown in one case. The interviews revealed the following vulnerability situations: disbelief in the possibility of contamination, young age at sexual initiation (below the Brazilian national average), not using a condom, having promiscuous partners or partners who used injectable drugs, and submitting to violence. The main problems faced after the diagnosis were prejudice, discrimination, need to take medication daily, and concerns associated with the desire of becoming a mother. CONCLUSIONS: Reducing the feminization of Aids entails enhancing the debate regarding sexuality and the dilemmas faced by adolescents to establish an open and unprejudiced dialogue that is not biased by norms, in addition to providing guidance about sexually transmitted diseases, with free and uncomplicated distribution of condoms. <![CDATA[<b>Tendencias de mortalidad por cáncer de mama en Córdoba, Argentina, 1986-2011</b>: <b>algunas interpretaciones sociohistóricas</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400021&lng=es&nrm=iso&tlng=es OBJETIVO: Analizar e interpretar las tendencias de mortalidad por cáncer de mama (CM) en las últimas décadas en la provincia de Córdoba, Argentina, en función de los cambios demográficos y características del contexto sociopolítico. MÉTODOS: Se calcularon tasas de mortalidad por CM crudas, estandarizadas (método directo) y específicas por edad, para Córdoba, en el período 1986-2011. Mediante la aplicación RiskDiff®, se analizó la variación observada en las tasas crudas entre 1986 y 2011. Se ajustaron modelos de regresión Joinpoint® a las tasas estandarizadas y específicas por grupos etarios. Se consultaron fuentes de datos secundarias (leyes, decretos, programas de salud) para obtener información sobre el contexto sociopolítico del período estudiado. RESULTADOS: La tasa cruda de mortalidad por CM aumentó 24,97% entre 1986 y 2011, siendo esto atribuible a un aumento del riesgo de morir (5,22%), a cambios en la estructura (19,75%) y al tamaño poblacional (39,66%). La tasa estandarizada de mortalidad por CM presentó tendencia creciente hasta 1996 (porcentaje de cambio anual [PCA] = 1,62%; P < 0,05), y luego comienza a descender (PCA = -2,1%; P < 0,05), advirtiéndose una desaceleración alrededor del año 2001. Para las interpretaciones sociohistóricas, se consideraron como ejes de análisis las transiciones demográfica, epidemiológica y sanitaria, así como hechos socioeconómicos y políticos del período estudiado. CONCLUSIONES: El comportamiento de la mortalidad por CM en este período se asocia a factores de índole contextual (demográficos, históricos, económicos, políticos). Los resultados de este trabajo contribuyen a definir acciones y políticas en torno la problemática del CM y en materia del cuidado de salud de las mujeres.<hr/>OBJECTIVE: Analyze and interpret trends in mortality from breast cancer in recent decades in the province of Córdoba, Argentina, relative to demographic changes and the sociopolitical context. METHODS: Raw, standardized (direct method), and age-specific mortality from breast cancer was calculated for 1986-2011 in Córdoba. Using RiskDiff® software, variations in the 1986 to 2011 raw rates were analyzed. Joinpoint regression models were adjusted to standardized and specific rates by age group. Secondary data sources (laws, decrees, health programs) were consulted for information on the sociopolitical context of the period. RESULTS: Raw mortality due to breast cancer increased 24.97% from 1986 to 2011, an increase that can be attributed to the increase in the risk of dying (5.22%), to structural changes (19.75%), and to population size (39.66%). Standardized mortality from breast cancer shows a rising trend up to 1996 (annual percentage change [APC] = 1.62%; P <0.05), and then begins to decline (APC = -2.1%; P <0.05), slowing around the year 2001. For socio-historical interpretations, the analysis focused on demographic, epidemiological, and health-related changes, as well as the socioeconomic and political events of the period studied. CONCLUSIONS: The behavior of mortality from breast cancer in this period is associated with contextual factors (demographic, historical, economic, and political). The results of this study will help define actions and policies in breast cancer and women's health care. <![CDATA[<b>Obesity in Brazilian women</b>: <b>association with parity and socioeconomic status</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400022&lng=es&nrm=iso&tlng=es OBJETIVO: Determinar a influência da história reprodutiva sobre a prevalência de obesidade em mulheres brasileiras e o possível efeito modificador de variáveis socioeconômicas sobre a associação entre paridade e excesso de peso. MÉTODOS: Neste estudo retrospectivo, foram analisados os dados de 11 961 mulheres de 20 a 49 anos que participaram da Pesquisa Nacional de Demografia e Saúde 2006, inquérito que utilizou amostragem complexa representativa de mulheres em idade reprodutiva. A associação entre o fator de estudo (paridade) e o desfecho (obesidade) foi testada mediante análise de regressão logística. O efeito ajustado da paridade sobre a obesidade foi avaliado em modelo múltiplo contendo como variáveis de controle: idade, classes de poder aquisitivo conforme a classificação da Associação Brasileira de Empresas de Pesquisa (ABEP), anos de estudo e assistência à saúde. Foram considerados significativos valores de P inferiores a 0,05. RESULTADOS: A prevalência de obesidade na população do estudo foi de 18,6%. O efeito da paridade sobre a obesidade foi significativo (P de tendência < 0,001). Na análise bruta, a paridade e a idade mostraram associação positiva com a obesidade. A variável classe de poder aquisitivo apresentou uma razão de chances significativa de obesidade apenas na análise bruta. No modelo ajustado, essa variável não foi significativa para explicar a obesidade. CONCLUSÕES: Os achados deste trabalho sugerem que a paridade exerce influência sobre a obesidade nas mulheres brasileiras em idade reprodutiva, sendo mais prevalente entre as mulheres que possuem filhos do que entre as nulíparas.<hr/>OBJECTIVE: To determine the influence of reproductive history on the prevalence of obesity in Brazilian women and the possible modifying effect of socioeconomic variables on the association between parity and excess weight. METHODS: A retrospective analysis of complex sample data collected as part of the 2006 Brazilian National Survey on Demography and Health, which included a group representative of women of childbearing age in Brazil was conducted. The study included 11 961 women aged 20 to 49 years. The association between the study factor (parity) and the outcome of interest (obesity) was tested using logistic regression analysis. The adjusted effect of parity on obesity was assessed in a multiple regression model containing control variables: age, family purchasing power, as defined by the Brazilian Association of Research Enterprises (ABEP), schooling, and health care. Significance level was set at below 0.05. RESULTS: The prevalence of obesity in the study population was 18.6%. The effect of parity on obesity was significant (P for trend < 0.001). Unadjusted analysis showed a positive association of obesity with parity and age. Family purchase power had a significant odds ratio for obesity only in the unadjusted analysis. In the adjusted model, this variable did not explain obesity. CONCLUSIONS: The present findings suggest that parity has an influence on obesity in Brazilian women of childbearing age, with higher prevalence in women vs. without children. <![CDATA[<b>Evaluación de la competencia de los proveedores y la calidad de la atención materna y del recién nacido en países de América Latina y el Caribe</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400023&lng=es&nrm=iso&tlng=es OBJECTIVE: To obtain a snapshot of the maternal and newborn care provided by different types of maternal and child health providers in Latin America and the Caribbean (LAC) to 1) better inform advocacy and programmatic strategies and interventions to improve the quality of those services in the region, and 2) determine the need for more rigorous study of the issues. METHODS: A rapid assessment of 83 health workers providing antepartum, intrapartum, and immediate postpartum and newborn care (within two hours of birth) in eight LAC countries was conducted in November and December of 2011. Health workers were observed by two-person expert maternal/newborn clinician teams using pretested forms based on international quality-of-care standards. A total of 105 care encounters were observed, primarily in urban, public, referral-level settings. Providers of care included obstetricians, midwives, generalist physicians, medical residents, registered nurses, auxiliary nurses, and students of medicine, midwifery, and nursing. RESULTS: Hand washing, as an indicator of quality of antepartum care, was observed in only 41% of the observed encounters. Labor management often lacked certain elements of respectful maternity care across all provider groups. Several clinical tasks of high importance in the identification and prevention of common complications of antepartum, intrapartum, and immediate postpartum/newborn care were not documented as performed during the observation periods. Providers self-reported limited competence (ability to perform to a defined level of proficiency) in manual removal of the placenta, bimanual compression of the uterus, and newborn resuscitation. CONCLUSIONS: The findings suggest that 1) the quality of maternal and newborn care and 2) the competence of maternal and child health providers in the diverse selection of LAC countries that were studied require substantial attention.<hr/>OBJETIVO: Obtener una visión panorámica de la atención materna y del recién nacido prestada por diferentes tipos de proveedores de salud maternoinfantil en América Latina y el Caribe para 1) fundamentar mejor las estrategias e intervenciones de promoción de la causa y programáticas con objeto de mejorar la calidad de esos servicios en la región, y 2) determinar la necesidad de estudios más rigurosos sobre estos temas. MÉTODOS: En noviembre y diciembre del 2011, se llevó a cabo una evaluación rápida de 83 trabajadores sanitarios que prestaban atención antes del parto, intraparto, y posparto inmediata y del recién nacido (durante las dos horas posteriores al parto) en ocho países de América Latina y el Caribe. Los trabajadores sanitarios fueron observados por equipos de dos clínicos expertos en atención materna y del recién nacido mediante el empleo de instrumentos previamente puestos a prueba y basados en estándares internacionales de calidad de la atención. Se observaron 105 encuentros de atención que tuvieron lugar principalmente en centros de atención urbanos, públicos y de derivación. Los proveedores de atención fueron obstetras, parteras, médicos generalistas, médicos residentes, personal de enfermería titulado, personal auxiliar de enfermería, y estudiantes de medicina, partería y enfermería. RESULTADOS: El lavado de las manos, como indicador de la calidad de la atención antes del parto, solo se observó en 41% de los encuentros observados. El manejo del parto a menudo carecía de ciertos elementos de atención respetuosa a la maternidad en todos los grupos de proveedores. Durante los períodos de observación, no se pudo comprobar la realización de diversas tareas clínicas de alta importancia para detectar y prevenir las complicaciones comunes de la atención antes del parto, intraparto, y posparto inmediata y del recién nacido. Los proveedores autonotificaron limitada competencia (capacidad para operar a un nivel definido de habilidad) en la extracción manual de la placenta, la compresión bimanual del útero y la reanimación del recién nacido. CONCLUSIONES: Los resultados indican que 1) la calidad de la atención materna y del recién nacido y 2) la competencia de los proveedores de salud maternoinfantil en los países de América Latina y el Caribe estudiados requieren considerable atención. <![CDATA[<b>Modelo para abordar integralmente la mortalidad materna y la morbilidad materna grave</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400024&lng=es&nrm=iso&tlng=es La mortalidad materna es un importante problema de salud pública y de derechos humanos y refleja los efectos de los determinantes sociales sobre la salud de las mujeres. El conocimiento de la magnitud y las causas de las muertes maternas ha sido insuficiente para intervenir efectivamente en el alcance de los Objetivos de Desarrollo del Milenio. Por ello, se plantea un modelo para abordar integralmente la mortalidad materna, con siete campos: priorización y definición del problema, caracterización contextual, amplitud metodológica, gestión del conocimiento, innovación, implementación, y un sistema de monitoreo y evaluación. Este modelo permite abordar los problemas asociados con la mortalidad materna y la morbilidad materna grave mediante la integración, desde una perspectiva anticipatoria, de las complicaciones potencialmente fatales asociadas con el proceso reproductivo y su vigilancia. Se destaca la importancia de la gestión del conocimiento para la reorientación de políticas, programas y la atención sanitaria. Se debe mejorar la interacción y explotar las sinergias entre las personas, las comunidades y los actores del sistema de salud para potenciar los resultados de los programas sanitarios. Se requiere más información científica validada sobre la forma en que las intervenciones deben aplicarse en diferentes entornos. Para ello, es esencial fortalecer la articulación entre los centros de investigación, las agencias de cooperación y los organismos del Estado y su incorporación a las acciones programáticas y a la definición de una nueva agenda de salud de la mujer para la Región de las Américas.<hr/>Maternal mortality is an important public health and human rights problem and reflects the effects of social determinants on women's health. Understanding the extent and causes of maternal death has been insufficient to achieve the Millennium Development Goals. This article proposes a model for a comprehensive approach to maternal mortality, covering seven areas: prioritization and definition of the problem, contextual description, methodological scope, knowledge management, innovation, implementation, and a monitoring and evaluation system. This model helps address problems associated with maternal mortality and severe maternal morbidity through early monitoring of potentially fatal complications in the reproductive process. Knowledge management is important for the reorientation of policies, programs, and health care. Interaction and synergies among people, communities, and actors in the health system should be strengthened in order to improve the results of health programs. More validated scientific information is needed on how actions should be implemented in different environments. It is essential to strengthen communication among research centers, cooperation agencies, and government organizations and to include them in programs and in the definition of a new women's health agenda in the Region of the Americas. <![CDATA[<b>Exigibilidad del derecho a la protección de la salud en los servicios de obstetricia en México</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400025&lng=es&nrm=iso&tlng=es La incorporación del marco de los derechos humanos a la salud materna se menciona cada vez con mayor frecuencia como una propuesta factible para mejorar la atención que reciben las mujeres en los servicios de atención obstétrica. Si bien es cierto que en México se cuenta con un sólido marco normativo en la materia, un elemento fundamental para garantizar el cumplimiento los derechos humanos relacionados con la salud son los mecanismos de exigibilidad que, además de encontrarse disponibles, deben ser efectivos y próximos a la población, principalmente en la atención obstétrica, espacio en donde ocurren reiteradas violaciones a los derechos humanos que ponen en riesgo la salud y la vida de las mujeres. El objetivo de este artículo es precisar los elementos normativos, jurídicos y extrajurídicos que deben ser considerados para incorporar la salud materna como un conjunto de derechos humanos exigibles.<hr/>The inclusion of the framework of human rights in maternal health is mentioned more and more frequently as a feasible proposal to improve the care that women receive in obstetric health care services. Despite the fact Mexico has a solid regulatory framework for obstetric care, mechanisms of enforceability are essential to ensure that health-related human rights are upheld. In addition to being in place, enforceability mechanisms should be effective and accessible to people, particularly in obstetric care, where repeated human rights violations occur that endanger women's health and lives. The objective of this article is to specify the regulatory, legal, and extralegal elements that need to be considered in order to include maternal health in a set of enforceable human rights. <![CDATA[<b>Inclusion of traditional birth attendants in the public health care system in Brazil</b>: <b>reflecting on challenges</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892015000400026&lng=es&nrm=iso&tlng=es O presente artigo apresenta uma experiência de trabalho com parteiras tradicionais realizada no estado do Tocantins, Brasil, entre 2010 e 2014, no âmbito do Projeto Diagnóstico da Situação do Parto Domiciliar no Tocantins e Cadastramento de Parteiras Tradicionais, vinculado ao Programa Trabalhando com Parteiras Tradicionais (PTPT), do Ministério da Saúde. O projeto objetivou uma articulação entre o parto e o nascimento domiciliares assistidos por parteiras tradicionais e os sistemas locais de saúde. No estado, identificaram-se 67 parteiras atuantes. Durante oficinas de capacitação, 41 parteiras tradicionais, dentre as quais 39 indígenas, discutiram suas realidades, dificuldades e soluções frente a um cotidiano com muitas adversidades. Essas parteiras foram ainda capacitadas no uso de instrumentos biomédicos e na condução da reanimação neonatal. A partir dessas experiências, surgiu o questionamento sobre a real efetividade da estratégia para incluir as parteiras tradicionais no SUS. O presente artigo discute esse tema com apoio na literatura pertinente. A carência de estudos sistemáticos acerca do impacto das ações do PTPT no cotidiano das parteiras, incluindo os desfechos perinatais e o remodelamento das práticas de saúde em populações rurais, ribeirinhas, quilombolas, de floresta e indígenas, implica lacunas importantes no que diz respeito à efetividade desse tipo de iniciativa.<hr/>The present article describes an experience with traditional birth attendants carried out in the state of Tocantins, Brazil, between 2010 and 2014. The experience was part of a diagnostic project to survey home deliveries in the state of Tocantins and set up a registry of traditional birth attendants for the Health Ministry's Working with Traditional Birth Attendants Program (PTPT). The project aimed to articulate the home deliveries performed by traditional birth attendants to the local health care systems (SUS). Sixty-seven active traditional birth attendants were identified in the state of Tocantins, and 41 (39 indigenous) participated in workshops. During these workshops, they discussed their realities, difficulties, and solutions in the context of daily adversities. Birth attendants were also trained in the use of biomedical tools and neonatal resuscitation. Based on these experiences, the question came up regarding the true effectiveness of the strategy to include traditional birth attendants in the SUS. The present article discusses this theme with support from the relevant literature. The dearth of systematic studies focusing on the impact of PTPT actions on the routine of traditional birth attendants, including perinatal outcomes and remodeling of health practices in rural, riverfront, former slave, forest, and indigenous communities, translates into a major gap in terms of the knowledge regarding the effectiveness of such initiatives.