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OBJECTIVE: The impact of the COVID-19 pandemic goes beyond morbidity and mortality from that disease. Increases in maternal mortality have also been described but have not been extensively studied to date. This study aimed to examine changes in maternal mortality and identify correlates and predictors of excess maternal mortality in Colombia during the pandemic. SETTING: Analysis of data from the national epidemiological surveillance databases of Colombia (Sivigila). PARTICIPANTS: Deaths among 6342 Colombian pregnant women who experienced complications associated with pregnancy, childbirth or the perperium during 2008-2020 were included in this study. For inequalities analysis, a subsample of 1055 women from this group who died in 2019 or 2020 years were analysed. METHODS: We collected data from the national surveillance system (Sivigila) on maternal mortality. Analysis was carried out in two stages, starting with a time series modelling using the Box-Jenkins approach. Data from Sivigila for 2008-2019 were used to establish a baseline of expected mortality levels. Both simple and complex inequality metrics, with the maternal mortality ratios (MMRs), were then calculated using the Multidimensional Poverty Index as a socioeconomic proxy. RESULTS: Maternal deaths in 2020 were 12.6% (95% CI -21.4% to 95.7%) higher than expected. These excess deaths were statistically significant in elevation for the months of July (97.4%, 95% CI 35.1% to 250.0%) and August (87.8%, 95% CI 30.5% to 220.8%). The MMR was nearly three times higher in the poorest municipalities compared with the most affluent communities in 2020. CONCLUSIONS: The COVID-19 pandemic had considerable impact on maternal health, not only by leading to increased deaths, but also by increasing social health inequity. Barriers to access and usage of essential health services are a challenge to achieving health-related Sustainable Development Goals.

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In the public health portfolio of disaster tools, rapid needs assessments are essential intelligence data mining resources that can assess immediate needs in almost all hazard scenarios. Following prolonged and unusual seismic activity that caused significant structural damage, mainly in the southwest part of the island of Puerto Rico, thousands of area residents were forced to leave their homes and establish improvised camps. The austere environmental exposure and limited access to safety and hygiene services prompted public health authorities to request assistance with conducting a rapid needs assessment of those encampments. This report summarizes the design, organization, and execution of a rapid needs assessment of improvised camps following a strong sequence of earthquakes in Puerto Rico.

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Haiti has long had the largest proportion of people living in poverty and the highest mortality level of any country in the Americas. On January 12, 2010, the most powerful earthquake to hit Haiti in 200 years struck. Before the earthquake, half of all Haitians lacked any access to modern medical care services. Health care professionals in Haiti number around one-fourth of the world average and about one-tenth the ratio present in North America. The establishment of new primary care services in a country where half of the people had no access to modern health care prior to the earthquake requires advanced practice roles for nurses and midwives. With a high burden of infectious, parasitic, and nutritional conditions, Haiti especially needs mid-level community health workers and nurses who can train and supervise them for public health programs. As in many other developing countries, organized nursing lacks many of the management and planning skills needed to move its agenda forward. The public schools prepare 3-year diploma graduates. These programs have upgraded the curriculum little in decades and have mainly trained for hospital service. Primary care, public health program management, and patient education had often not been stressed. Specializations in midwifery and HIV care exist, while only informal programs of specialization exist in administration, surgery, and pediatrics. An advanced practice role, nonetheless, is not yet well established. Nursing has much to contribute to the recovery of Haiti and the revitalization if its health system. Professional nurses are needed in clinics and hospitals throughout the country to care for patients, including thousands in need of rehabilitation and mental health services. Haitian nursing colleagues in North America have key roles in strengthening their profession. Ways of supporting our Haitian colleagues are detailed.

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BACKGROUND: Population movements following disasters can cause important increases in morbidity and mortality. Without knowledge of the locations of affected people, relief assistance is compromised. No rapid and accurate method exists to track population movements after disasters. We used position data of subscriber identity module (SIM) cards from the largest mobile phone company in Haiti (Digicel) to estimate the magnitude and trends of population movements following the Haiti 2010 earthquake and cholera outbreak. METHODS AND FINDINGS: Geographic positions of SIM cards were determined by the location of the mobile phone tower through which each SIM card connects when calling. We followed daily positions of SIM cards 42 days before the earthquake and 158 days after. To exclude inactivated SIM cards, we included only the 1.9 million SIM cards that made at least one call both pre-earthquake and during the last month of study. In Port-au-Prince there were 3.2 persons per included SIM card. We used this ratio to extrapolate from the number of moving SIM cards to the number of moving persons. Cholera outbreak analyses covered 8 days and tracked 138,560 SIM cards. An estimated 630,000 persons (197,484 Digicel SIM cards), present in Port-au-Prince on the day of the earthquake, had left 19 days post-earthquake. Estimated net outflow of people (outflow minus inflow) corresponded to 20% of the Port-au-Prince pre-earthquake population. Geographic distribution of population movements from Port-au-Prince corresponded well with results from a large retrospective, population-based UN survey. To demonstrate feasibility of rapid estimates and to identify areas at potentially increased risk of outbreaks, we produced reports on SIM card movements from a cholera outbreak area at its immediate onset and within 12 hours of receiving data. CONCLUSIONS: Results suggest that estimates of population movements during disasters and outbreaks can be delivered rapidly and with potentially high validity in areas with high mobile phone use.

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OBJECTIVE: Among the countries of the Americas, Colombia has the highest level of deaths due to homicides and armed conflict. The objective of this research was to combine and contrast information from various sources on deaths due to violence in Colombia in order to identify major trends in violence in the country and to compare those trends with those in other nations of the Americas. METHODS: We drew together information from a wide array of sources, including the Government of Colombia, Colombian forensic institutions, nongovernmental organizations, and international research centers. We considered the impact of the violence on mortality as well as in such areas as nonfatal injuries, displacement of persons, and kidnappings. RESULTS: While there have been many deaths in Colombia directly related to military conflict, there have been many more deaths and injuries as an indirect result of war. The highest levels of deaths directly related to violence occurred during the 1990-1995 period. Although deaths due directly to armed conflict declined in the late 1990s, the related events of kidnappings and displacement did not. CONCLUSIONS: Efforts to reduce the violence-related suffering in Colombia must consider both direct and indirect causes of mortality as well as nonfatal outcomes such as kidnappings and displacement.

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OBJETIVO: De los distintos países del continente americano, Colombia tiene el más alto porcentaje de muertes por homicidios y conflictos armados. El objetivo de esta investigación ha sido combinar y contrastar información obtenida de diferentes fuentes sobre la violencia en Colombia con el fin de identificar las principales tendencias que muestra la violencia en el país y comparar dichas tendencias con las observadas en otros países del continente. MÉTODOS: Recogimos información de una gran variedad de fuentes, entre ellas el Gobierno de Colombia, institutos forenses colombianos, organizaciones no gubernamentales y centros de investigación internacionales. Examinamos el impacto de la violencia sobre la mortalidad y las heridas no mortales, el desplazamiento humano y los secuestros. RESULTADOS: En Colombia muchas muertes han sido consecuencia directa del conflicto armado; no obstante, muchas otras muertes y lesiones son el resultado directo del estado de guerra. El mayor porcentaje de muertes directamente asociadas con la violencia tuvo lugar en el período de 1990-1995. Aunque las muertes directamente atribuibles al conflicto armado se redujeron en las postrimerías de los años noventa, los secuestros y el desplazamiento humano que con ellas se asocian no disminuyeron. CONCLUSIONES: A la hora de idear estrategias para reducir el sufrimiento ocasionado por la violencia en Colombia, es aconsejable tener en cuenta las causas directas e indirectas de la mortalidad y también otros siniestros que no son mortales, tales como los secuestros y el desplazamiento de seres humanos

Objective. Among the countries of the Americas, Colombia has the highest level of deaths due to homicides and armed conflict. The objective of this research was to combine and contrast information from various sources on deaths due to violence in Colombia in order to identify major trends in violence in the country and to compare those trends with those in other nations of the Americas. Methods. We drew together information from a wide array of sources, including the Government of Colombia, Colombian forensic institutions, nongovernmental organizations, and international research centers. We considered the impact of the violence on mortality as well as in such areas as nonfatal injuries, displacement of persons, and kidnappings. Results. While there have been many deaths in Colombia directly related to military conflict, there have been many more deaths and injuries as an indirect result of war. The highest levels of deaths directly related to violence occurred during the 1990­1995 period. Although deaths due directly to armed conflict declined in the late Conclusions. Efforts to reduce the violence-related suffering in Colombia must consider both direct and indirect causes of mortality as well as nonfatal outcomes such as kidnappings and displacement

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Market-led economic reforms are usually viewed as being in conflict with government-stimulated socioeconomic development for disadvantaged groups. Nevertheless, Cear , a poor state in the Northeast of Brazil, has since 1987 pursued both of those strategies simultaneously. One part of that approach has been a program of nurse-directed auxiliary health workers serving about 5 million people - almost all the persons outside the capital city and half of those in the capital. The system requires that the auxiliaries, called agentes de saúde, live in the local communities that they serve. The health agents visit each home once a month to carry out a small number of priority health activities. While health agent positions are in high demand, the minimum-wage salary that the agents receive makes up only a small portion of the state budget. A key aspect of the system is timely and comprehensive information, which is based on agent visits and is managed by trained nurses. Since the health agents system was launched, there has been a rapid decline in infant mortality, a rapid rise in immunization, identification of bottlenecks limiting the utilization of other medical resources, and timely interventions in times of crisis. The health agents system has combined administrative decentralization with financial centralization during a period of electoral democratization. The system has strengthened Cear 's commitment to primary care even as market-oriented changes have reduced the overall role of government. The Cear program is being copied throughout the Northeast and other regions of Brazil. The key role that nurses play in the Cear program in organizing and leading a system of basic primary care in poor neighborhoods and rural areas may provide useful lessons for other countries. In addition, Cear does not have many of the favorable characteristics of other countries that have successfully invested in primary health care. Cear thus represents a more achievable model for other countries, where, like Brazil, income, educational levels, and land tenure equity are limited

Generalmente se considera que las reformas económicas dirigidas por el mercado entran en conflicto con el desarrollo socioeconómico de los grupos desfavorecidos dirigido desde el gobierno. No obstante, desde 1987, Ceará, un estado pobre del Nordeste brasileño, ha seguido simultáneamente estas dos estrategias. Parte de este abordaje ha sido un programa de auxiliares sanitarios, dirigido por personal de enfermería, que cubre cerca de 5 millones de personas: casi todas las que habitan fuera de la capital y la mitad de las residentes en la capital. El programa requiere que esos auxiliares, llamados agentes de salud, vivan en las comunidades que sirven. Los agentes de salud visitan cada domicilio una vez al mes para llevar a cabo un pequeño número de actividades sanitarias prioritarias. Aunque hay una gran demanda de empleo como agentes de salud, el salario que reciben representa tan solo una pequeña fracción del presupuesto estatal. Un aspecto clave del sistema es la provisión de información integral y oportuna, basada en las visitas de los agentes y gestionada por enfermeros entrenados. Desde que se implantó el sistema de los agentes de salud ha habido una rápida disminución de la mortalidad infantil y un rápido aumento de las inmunizaciones, se han identificado obstáculos que limitan la utilización de otros recursos médicos y ha habido intervenciones oportunas en momentos de crisis. El sistema de los agentes de salud ha combinado la descentralización administrativa con la centralización financiera en un período de democratización electoral. El sistema ha fortalecido el compromiso del estado de Ceará con la atención primaria, a pesar de los cambios dirigidos por el mercado que han reducido el papel global del gobierno. El programa de Ceará está siendo copiado en todo el Nordeste y en otras regiones de Brasil. El papel clave desempeñado por el personal de enfermería en la organización y liderazgo de un sistema de atención primaria básica en barrios pobres y áreas rurales puede proporcionar lecciones útiles a otros países, sobre todo teniendo en cuenta que Ceará carece de muchas de las características favorables de las que disponen otros países que han invertido con éxito en la atención primaria. Por tanto, Ceará representa un modelo asequible para otros países donde, al igual que en Brasil, la equidad de ingresos, nivel educacional y propiedad de la tierra es limitada.

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