Mariana Widmer

University of São Paulo, San Paulo, São Paulo, Brazil

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Publications (34)209.72 Total impact

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    Obstetric Anesthesia Digest 01/2015; 35(1):20-21. DOI:10.1097/01.aoa.0000460388.60101.38
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    ABSTRACT: Assess the accuracy of serum soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF) and soluble endoglin (sEng) and urinary PlGF as predictors of preeclampsia in a prospective multicountry study. From 2006-9, 5121 pregnant women from centers in Argentina, Colombia, India, Italy, Kenya, Peru, Switzerland and Thailand had their serum tested for sFlt-1, PlGF and sEng levels and their urine for PlGF levels at ⩽20 (index tests, results kept blind from care givers), 23-27 and 32-35weeks' gestation. During prenatal care, women were closely monitored for signs of preeclampsia, diagnosed by systolic blood pressure ⩾140mmHg and/or diastolic blood pressure ⩾90mmHg, and proteinuria with protein/creatinine ratio ⩾0.3, protein ⩾1g/l or, one dipstick measurement ⩾2+ appearing after gestational week 20, and defined as early preeclampsia when these signs appeared before 34 weeks' gestation. Preeclampsia was diagnosed in 3.9% (198 of the 5121 women) whom 47 (0.9%) had early disease. No test performed well at <20 weeks for either early or all preeclampsia (area under receiver operating characteristics curve, AUC ⩽0.6). Multivariable models combining biomarkers with clinical features (age, body mass index, smoking, multiple pregnancy, hypertension or treatment for it) did not improve the prediction capability before 20weeks. Serum PlGF was the best predictor of preeclampsia at any gestation (AUC 0.82 at 32-35weeks) and at early onset (AUC 0.82 at 23-27weeks). Angiogenic biomarkers, alone or combined with clinical risk factors, performed poorly as predictors of preeclampsia, when measured early in pregnancy (<20weeks). M. Widmer: None. C.B. Cuesta: None. K. Khan: None. A.M. Gülmezoglu: None. S.A. Karumanchi: Consultant: Roche, Beckman, Siemens. M.D. Lindheimer: None. Copyright © 2014.
    01/2015; 5(1):50. DOI:10.1016/j.preghy.2014.10.097
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    ABSTRACT: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.
    Reproductive Health 08/2014; 11(1):61. DOI:10.1186/1742-4755-11-61 · 1.62 Impact Factor
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    ABSTRACT: Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The potential benefits of quality antenatal care services are most significant in low-resource countries where morbidity and mortality levels among women of reproductive age and neonates are higher.WHO developed an ANC model that recommended the delivery of services scientifically proven to improve maternal, perinatal and neonatal outcomes. The aim of this study is to determine the effect of an intervention designed to increase the use of the package of evidence-based services included in the WHO ANC model in Mozambique. The primary hypothesis is that the intervention will increase the use of evidence-based practices during ANC visits in comparison to the standard dissemination channels currently used in the country.
    BMC Health Services Research 05/2014; 14(1):228. DOI:10.1186/1472-6963-14-228 · 1.66 Impact Factor
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    ABSTRACT: In 2006 WHO presented the infant and child growth charts suggested for universal application. However, major determinants for perinatal outcomes and postnatal growth are laid down during antenatal development. Accordingly, monitoring fetal growth in utero by ultrasonography is important both for clinical and scientific reasons. The currently used fetal growth references are derived mainly from North American and European population and may be inappropriate for international use, given possible variances in the growth rates of fetuses from different ethnic population groups. WHO has, therefore, made it a high priority to establish charts of optimal fetal growth that can be recommended worldwide.
    BMC Pregnancy and Childbirth 05/2014; 14(1):157. DOI:10.1186/1471-2393-14-157 · 2.15 Impact Factor
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    BJOG An International Journal of Obstetrics & Gynaecology 03/2014; 121 Suppl s1:1-4. DOI:10.1111/1471-0528.12735 · 3.86 Impact Factor
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    ABSTRACT: To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions. Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database. Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East. All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period. We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model. Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes. Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions. The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.
    BJOG An International Journal of Obstetrics & Gynaecology 03/2014; 121 Suppl 1:14-24. DOI:10.1111/1471-0528.12629 · 3.86 Impact Factor
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    ABSTRACT: Background: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low-and middle-income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications.
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    ABSTRACT: Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources. We conducted a secondary analysis of the WHO Global Survey dataset to analyze maternal and perinatal outcomes in twin pregnancies and factors associated with perinatal morbidity and mortality in twins. We examined maternal and neonatal characteristics in twin deliveries in 23 LMICs and conducted multi-level logistic regression to determine the association between twins and adverse maternal and perinatal outcomes. 279,425 mothers gave birth to 276,187 (98.8%) singletons and 6,476 (1.2%) twins. Odds of severe adverse maternal outcomes (death, blood transfusion, ICU admission or hysterectomy) (AOR 1.85, 95% CI 1.60-2.14) and perinatal mortality (AOR 2.46, 95% CI 1.40-4.35) in twin pregnancies were higher, however early neonatal death (AOR 2.50, 95% CI 0.95-6.62) and stillbirth (AOR 1.22, 95% CI 0.58-2.57) did not reach significance. Amongst twins alone, maternal age <18, poor education and antenatal care, nulliparity, vaginal bleeding, non-cephalic presentations, birth weight discordance >15%, born second, preterm birth and low birthweight were associated with perinatal mortality. Marriage and caesarean section were protective. Twin pregnancy is a significant risk factor for maternal and perinatal morbidity and mortality in low-resource settings; maternal risk and access to safe caesarean section may determine safest mode of delivery in LMICs. Improving obstetric care in twin pregnancies, particularly timely access to safe caesarean section, is required to reduce risk to mother and baby.
    PLoS ONE 08/2013; 8(8):e70549. DOI:10.1371/journal.pone.0070549 · 3.53 Impact Factor
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    ABSTRACT: We sought to describe obstetric care capacity of nongovernment organization (NGO)-/faith-based organization (FBO)-run institutions compared to government-run institutions in 3 African countries using the World Health Organization Global Survey. We also compared delivery characteristics and outcomes. This is a descriptive analysis of the 22 NGO-/FBO-run institutions in Uganda, Kenya and Democratic Republic of Congo delivering 11,594 women, compared to 20 government-run institutions delivering 25,825 women in the same countries and period. Infrastructure, obstetric services, diagnostic facilities, and anesthesiology at NGO/FBO institutions were comparable to government institutions. Women delivering at NGO/FBO institutions had more antenatal care, antenatal complications, and cesarean delivery. NGO/FBO institutions had higher obstetrician attendance and lower rates of eclampsia, preterm birth, stillbirth, Apgar <7, and neonatal near miss. NGO/FBO institutions are comparable to government institutions in capacity to deliver obstetric care. NGO/FBOs have been found effective in providing delivery care in developing countries and should be appropriately recognized by stakeholders in their efforts to assist nations achieve international goals.
    American journal of obstetrics and gynecology 12/2012; 207(6):495.e1-7. DOI:10.1016/j.ajog.2012.10.003 · 3.97 Impact Factor
  • 07/2012; 2(3):195–196. DOI:10.1016/j.preghy.2012.04.038
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    ABSTRACT: Hypertensive disorders during pregnancy contribute greatly to maternal and perinatal morbidity and mortality in developing countries. The pathogenesis of such conditions may be illuminated by exploring their relationship to anemia.Objectives To determine whether several types of anemia are risk factors for hypertensive disorders during pregnancy in developing countries.Methods Using data from the World Health Organization Global Survey for Maternal and Perinatal Health, collected in hospitals in six African and six Latin American countries from 2007 to 2008 and in four Asian countries from 2004 to 2005, we examined the associations between severe anemia, sickle cell disease and thalassemia and gestational hypertension or preeclampsia/eclampsia. After exclusions for comorbidities (chronic hypertension, diabetes, HIV infection) and missing data, the severe anemia, sickle cell disease, and thalassemia groups consisted of 219,627, 117,383, and 9376 women, respectively.ResultsMultiparous women with severe anemia were at an increased risk of gestational hypertension (adjusted odds ratio (OR): 1.58; 95% confidence interval (CI): 1.15–2.19). Severe anemia had a significant association with preeclampsia/eclampsia for nulliparous (OR: 3.55; 95% CI: 2.87–4.41) and multiparous (OR: 3.94; 95% CI: 3.05–5.09) women. Sickle cell disease exhibited a significant association with gestational hypertension among nulliparous (OR: 2.49; 95% CI: 1.46–4.25) and multiparous (OR: 3.27; 95% CI: 2.33–4.58) women. No significant associations were found between sickle cell disease and preeclampsia/eclampsia, or between thalassemia and either gestational hypertension or preeclampsia/eclampsia.Conclusion Severe anemia appears to be a risk factor for preeclampsia/eclampsia, while sickle cell disease appears to be a risk factor for gestational hypertension among women seeking hospital care in developing countries.
    07/2012; 2(3):191-192. DOI:10.1016/j.preghy.2012.04.030
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    ABSTRACT: A vaginal fistula is a devastating condition, affecting an estimated 2 million girls and women across Africa and Asia. There are numerous challenges associated with providing fistula repair services in developing countries, including limited availability of operating rooms, equipment, surgeons with specialized skills, and funding from local or international donors to support surgeries and subsequent post-operative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower risk of healthcare-associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term (7 day) urethral catheterization is not worse by more than a minimal relevant difference to longer-term (14 day) urethral catheterization in terms of incidence of fistula repair breakdown among women with simple fistula presenting at study sites for fistula repair service. This study is a facility-based, multicenter, non-inferiority randomized controlled trial (RCT) comparing the new proposed short-term (7 day) urethral catheterization to longer-term (14 day) urethral catheterization in terms of predicting fistula repair breakdown. The primary outcome is fistula repair breakdown up to three months following fistula repair surgery as assessed by a urinary dye test. Secondary outcomes will include repair breakdown one week following catheter removal, intermittent catheterization due to urinary retention and the occurrence of septic or febrile episodes, prolonged hospitalization for medical reasons, catheter blockage, and self-reported residual incontinence. This trial will be conducted among 512 women with simple fistula presenting at 8 study sites for fistula repair surgery over the course of 24 months at each site. If no major safety issues are identified, the data from this trial may facilitate adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia. ClinicalTrials.gov Identifier NCT01428830.
    BMC Women's Health 03/2012; 12:5. DOI:10.1186/1472-6874-12-5 · 1.66 Impact Factor
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    ABSTRACT: Active management of the third stage of labour reduces the risk of post-partum haemorrhage. We aimed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage. We did a multicentre, non-inferiority, randomised controlled trial in 16 hospitals and two primary health-care centres in Argentina, Egypt, India, Kenya, the Philippines, South Africa, Thailand, and Uganda. Women expecting to deliver singleton babies vaginally (ie, not planned caesarean section) were randomly assigned (in a 1:1 ratio) with a centrally generated allocation sequence, stratified by country, to placental delivery with gravity and maternal effort (simplified package) or controlled cord traction applied immediately after uterine contraction and cord clamping (full package). After randomisation, allocation could not be concealed from investigators, participants, or assessors. Oxytocin 10 IU was administered immediately after birth with cord clamping after 1-3 min. Uterine massage was done after placental delivery according to local policy. The primary (non-inferiority) outcome was blood loss of 1000 mL or more (severe haemorrhage). The non-inferiority margin for the risk ratio was 1·3. Analysis was by modified intention-to-treat, excluding women who had emergency caesarean sections. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN 12608000434392. Between June 1, 2009, and Oct 30, 2010, 12,227 women were randomly assigned to the simplified package group and 12,163 to the full package group. After exclusion of women who had emergency caesarean sections, 11,861 were in the simplified package group and 11,820 were in the full package group. The primary outcome of blood loss of 1000 mL or more had a risk ratio of 1·09 (95% CI 0·91-1·31) and the upper 95% CI limit crossed the pre-stated non-inferiority margin. One case of uterine inversion occurred in the full package group. Other adverse events were haemorrhage-related. Although the hypothesis of non-inferiority was not met, omission of controlled cord traction has very little effect on the risk of severe haemorrhage. Scaling up of haemorrhage prevention programmes for non-hospital settings can safely focus on use of oxytocin. United States Agency for International Development and UN Development Programme/UN Population Fund/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research.
    The Lancet 03/2012; 379(9827):1721-7. DOI:10.1016/S0140-6736(12)60206-2 · 39.21 Impact Factor
  • Obstetric Anesthesia Digest 01/2012; 32(1):45-46. DOI:10.1097/01.aoa.0000410808.61878.a4
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    ABSTRACT: A common prophylactic intervention used in the third stage of labor to reduce postpartum hemorrhage (PPH) can be labeled as active management. In the full management package used for active management, oxytocin is administered soon after delivery in combination with controlled cord traction. However, because the proper use of controlled cord traction requires manual skills, this procedure has been recommended only for skilled birth attendants. Unfortunately, a substantial proportion of maternal deaths from hemorrhage occur in settings in which skilled birth attendants are not available. Some evidence suggests that a simplified active package omitting controlled cord traction may have a similar effect on preventing blood loss, indicating that the uterotonic component in active management may be effective on its own. The contribution of controlled cord traction to blood loss is largely unknown. This multicenter, noninferiority, randomized controlled trial investigated the effect of a simplified management package omitting controlled cord traction from active management on third-stage blood loss. The study was conducted between 2009 and 2010 in 16 hospitals and 2 primary health care centers in Argentina, Egypt, India, Kenya, the Philippines, South Africa, Thailand, and Uganda. Eligible women expecting planned singleton vaginal deliveries (not planned cesareans) were randomly assigned to placental delivery with the simplified package (with aid of gravity and maternal effort) or full package (controlled cord traction applied immediately after uterine contraction and cord clamping). Women were stratified by country. Intramuscular oxytocin 10 IU was administered in both groups immediately after birth with cord clamping after 1 to 3 minutes. Uterine massage was performed after placental delivery according to the local policy in each country. Blinding of investigators, participants, or assessors was not possible after randomization. The primary (noninferiority) outcome was severe PPH (blood loss of ≥1000 mL). The prestated noninferiority margin for the risk ratio was 1.3. Primary analysis was according to modified intention to treat, excluding women who had emergency caesarean deliveries. For the final analysis, 11,861 women were randomly assigned to the simplified package and 11,820 to the full package group. The data showed that for the primary outcome of blood loss of 1000 mL or more, the risk ratio was 1.09 (95% confidence interval [CI], 0.91-1.31), and the upper 95% CI limit crossed the prestated noninferiority margin of 1.30. One case of uterine inversion was observed in the full package group; other adverse events were hemorrhage related. These findings show that omission of controlled cord traction has little impact on the risk of severe hemorrhage. The data suggest that oxytocin can be used as the routine uterotonic for prevention of PPH in settings where a trained health care worker is not available.
    Obstetrical and Gynecological Survey 01/2012; 67(9):531-532. DOI:10.1097/01.ogx.0000421445.04738.9c · 2.36 Impact Factor
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    ABSTRACT: Understanding spontaneous preterm birth ([PTB] < 37 weeks) is difficult due to heterogeneities associated with multitudes of risk factors and pathophysiological pathways. Several biomarkers are routinely used clinically for predicting preterm labor; however, these factors are either nonspecific or detected too late. Systematic review of literature on PTB biomarkers in the last 40 years to map out the existing knowledge and gaps in understanding PTB biomarkers. Search strategies: Five electronic databases were searched for human studies on PTB biomarkers published in any language between 1965 and 2008. Selection criteria: The phenotype of interest for final data extraction was exclusively spontaneous PTB with no rupture of membranes. Data extraction included (a) general characteristics of the study (clinical setting, period, and study design), (b) study/participant characteristics (inclusion and exclusion criteria, race/ethnicity, number of participants, gestational age at sampling, (c) characteristics of the biomarker (type, rationale for its selection, type of biological sample, and assay used, and (d) concentration of biomarkers in cases and controls. Data collection and analysis: The search yielded 7255 citations and data were extracted from 217 articles which met our inclusion and exclusion criteria. A total of 116 different biomarkers were reported and these were assayed 578 times in the 217 included studies. Over two thirds of the 217 studies were performed on North American or European populations. No reliable biomarkers emerged as a risk predictor of PTB. Identifying similar studies on biomarkers for the prediction of PTB was a very challenging task due heterogeneities in study design, sampling issues (types, timing and processing), assay methods, and analyses. Major areas of concern identified in this review include poor phenotype definition, nonideal study designs and poor rationale for biomarker selection and assays and population stratification issues.
    Reproductive sciences (Thousand Oaks, Calif.) 11/2011; 18(11):1046-70. DOI:10.1177/1933719111415548 · 2.18 Impact Factor
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    ABSTRACT: Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped. A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa. MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa. Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better. Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.
    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 06/2011; 114(3):218-22. DOI:10.1016/j.ijgo.2011.03.015 · 1.56 Impact Factor
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    ABSTRACT: To assess the quality and comprehensiveness of the information on caesarean section provided in Brazilian women's magazines. Review of articles published during 1988-2008 in top selling women's magazines. Brazil, one of the countries with the highest caesarean section rates in the world. Women's magazines with the largest distribution during the study period, identified through the official national media indexing organisations. Articles with objective scientific information or advice, comments, opinions, or the experience of ordinary women or celebrities on delivery by caesarean section. Sources of information mentioned by the author of the article, the accuracy and completeness of data presented on caesarean section, and alleged reasons why women would prefer to deliver though caesarean section. 118 articles were included. The main cited sources of information were health professionals (78% (n=92) of the articles). 71% (n=84) of the articles reported at least one benefit of caesarean section, and 82% (n=97) reported at least one short term maternal risk of caesarean section. The benefits most often attributed to delivery by caesarean section were reduction of pain and convenience for family or health professionals. The most frequently reported short term maternal risks of caesarean section were increased time to recover and that it is a less natural way of giving birth. Only one third of the articles mentioned any long term maternal risks or perinatal complications associated with caesarean section. Fear of pain was the main reported reason why women would prefer to deliver by caesarean section. Most of the articles published in Brazilian women's magazines do not use optimal sources of information. The portrayal of caesarean section is mostly balanced, not explicitly in favour of one or another route of delivery, but incomplete and may be leading women to underestimate the maternal/perinatal risks associated with this route of delivery.
    BMJ (online) 01/2011; 342:d276. DOI:10.1136/bmj.d276 · 16.38 Impact Factor
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    ABSTRACT: Rising cesarean section (CS) rates are a major public health concern and cause worldwide debates. To propose and implement effective measures to reduce or increase CS rates where necessary requires an appropriate classification. Despite several existing CS classifications, there has not yet been a systematic review of these. This study aimed to 1) identify the main CS classifications used worldwide, 2) analyze advantages and deficiencies of each system. Three electronic databases were searched for classifications published 1968-2008. Two reviewers independently assessed classifications using a form created based on items rated as important by international experts. Seven domains (ease, clarity, mutually exclusive categories, totally inclusive classification, prospective identification of categories, reproducibility, implementability) were assessed and graded. Classifications were tested in 12 hypothetical clinical case-scenarios. From a total of 2948 citations, 60 were selected for full-text evaluation and 27 classifications identified. Indications classifications present important limitations and their overall score ranged from 2-9 (maximum grade =14). Degree of urgency classifications also had several drawbacks (overall scores 6-9). Woman-based classifications performed best (scores 5-14). Other types of classifications require data not routinely collected and may not be relevant in all settings (scores 3-8). This review and critical appraisal of CS classifications is a methodologically sound contribution to establish the basis for the appropriate monitoring and rational use of CS. Results suggest that women-based classifications in general, and Robson's classification, in particular, would be in the best position to fulfill current international and local needs and that efforts to develop an internationally applicable CS classification would be most appropriately placed in building upon this classification. The use of a single CS classification will facilitate auditing, analyzing and comparing CS rates across different settings and help to create and implement effective strategies specifically targeted to optimize CS rates where necessary.
    PLoS ONE 01/2011; 6(1):e14566. DOI:10.1371/journal.pone.0014566 · 3.53 Impact Factor

Publication Stats

420 Citations
209.72 Total Impact Points

Institutions

  • 2014
    • University of São Paulo
      San Paulo, São Paulo, Brazil
  • 2013
    • University of Western Australia
      • School of Population Health
      Perth City, Western Australia, Australia
  • 2009–2012
    • United Nations Development Programme
      New York, New York, United States
  • 2007
    • Harvard University
      Cambridge, Massachusetts, United States