RESUMO
OBJECTIVES: Haemorrhage remains the leading cause of maternal mortality in Central America. The Salud Mesoamérica Initiative aims to reduce such mortality via performance indicators. Our objective was to assess the availability and administration of oxytocin, before and after applying Salud Mesoamérica Initiative interventions in the poorest health facilities across Central America. DESIGN: Pre-post study. SETTING: 166 basic-level and comprehensive-level health facilities in Belize, Guatemala, Honduras, Mexico, Nicaragua and Panama. PARTICIPANTS: A random sample of medical records for uncomplicated full-term deliveries (n=2470) per International Classification of Diseases coding at baseline (July 2011 to August 2013) and at first-phase follow-up (January 2014 to October 2014). INTERVENTIONS: A year of intervention implementation prior to first-phase follow-up data collection focused on improving access to oxytocin by strengthening supply chains, procurement, storage practices and pharmacy inventory monitoring, using a results-based financing model. PRIMARY AND SECONDARY OUTCOME MEASURES: Oxytocin availability (primary outcome) and administration (secondary outcome) for postpartum haemorrhage prevention. RESULTS: Availability of oxytocin increased from 82.9% to 97.6%. Oxytocin administration increased from 83.6% to 88.4%. Significant improvements were seen for availability of oxytocin (adjusted OR (aOR)=8.41, 95% CI 1.50 to 47.30). Administration of oxytocin was found to be significantly higher in Honduras (aOR=2.96; 95% CI 1.00 to 8.76) in reference to Guatemala at follow-up. CONCLUSION: After interventions to increase health facility supplies, the study showed a significant improvement in availability but not administration of oxytocin in poor communities within Mesoamerica. Efforts are needed to improve the use of oxytocin.
Assuntos
Fidelidade a Diretrizes/estatística & dados numéricos , Recursos em Saúde/provisão & distribuição , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Ocitócicos/uso terapêutico , Ocitocina/uso terapêutico , Hemorragia Pós-Parto/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Adulto , América Central , Países em Desenvolvimento , Feminino , Seguimentos , Humanos , Modelos Logísticos , Guias de Prática Clínica como Assunto , GravidezRESUMO
BACKGROUND: Antenatal care (ANC) is a means to identify high-risk pregnancies and educate women so that they might experience a healthier delivery and outcome. There is a lack of evidence about whether receipt of ANC is an effective strategy for keeping women in the system so they partake in other maternal and child interventions, particularly for poor women. The present analysis examines whether ANC uptake is associated with other maternal and child health behaviors in poor mothers in Guatemala, Honduras, Nicaragua, and Mexico (Chiapas). METHODS: We conducted a cross-sectional survey of women regarding their uptake of ANC for their most recent delivery in the last two years and their uptake of selected services and healthy behaviors along a continuity of maternal and child healthcare. We conducted logistic regressions on a sample of 4844 births, controlling for demographic, household, and maternal characteristics to understand the relationship between uptake of ANC and later participation in the continuum of care. RESULTS: Uptake of four ANC visits varied by country from 17.0% uptake in Guatemala to 81.4% in Nicaragua. In all countries but Nicaragua, ANC was significantly associated with in-facility delivery (IFD) (Guatemala odds ratio [OR] = 5.28 [95% confidence interval [CI] 3.62-7.69]; Mexico OR = 5.00 [95% CI: 3.41-7.32]; Honduras OR = 2.60 [95% CI: 1.42-4.78]) and postnatal care (Guatemala OR = 4.82 [95% CI: 3.21-7.23]; Mexico OR = 4.02 [95% CI: 2.77-5.82]; Honduras OR = 2.14 [95% CI: 1.26-3.64]), but did not appear to have any positive relationship with exclusive breastfeeding habits or family planning methods, which may be more strongly determined by cultural influences. CONCLUSIONS: Our results demonstrate that uptake of the WHO-recommended four ANC visits has limited effectiveness on uptake of services in some poor populations in Mesoamérica. Our study highlights the need for continued and varied efforts in these populations to increase both the uptake and the effectiveness of ANC in encouraging positive and lasting effects on women's uptake of health care services.
Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Adulto , Atitude Frente a Saúde/etnologia , Serviços de Saúde Comunitária/organização & administração , Estudos Transversais , Características da Família , Feminino , Guatemala , Humanos , México , Nicarágua , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: Results-based aid (RBA) is increasingly used to incentivize action in health. In Mesoamerica, the region consisting of southern Mexico and Central America, the RBA project known as the Salud Mesoamérica Initiative (SMI) was designed to target disparities in maternal and child health, focusing on the poorest 20% of the population across the region. METHODS AND FINDINGS: Data were first collected in 365 intervention health facilities to establish a baseline of indicators. For the first follow-up measure, 18 to 24 months later, 368 facilities were evaluated in these same areas. At both stages, we measured a near-identical set of supply-side performance indicators in line with country-specific priorities in maternal and child health. All countries showed progress in performance indicators, although with different levels. El Salvador, Honduras, Nicaragua, and Panama reached their 18-month targets, while the State of Chiapas in Mexico, Guatemala, and Belize did not. A second follow-up measurement in Chiapas and Guatemala showed continued progress, as they achieved previously missed targets nine to 12 months later, after implementing a performance improvement plan. CONCLUSIONS: Our findings show an initial success in the supply-side indicators of SMI. Our data suggest that the RBA approach can be a motivator to improve availability of drugs and services in poor areas. Moreover, our innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.
Assuntos
Promoção da Saúde/provisão & distribuição , América Central , Criança , Saúde da Criança/estatística & dados numéricos , Feminino , Instalações de Saúde/estatística & dados numéricos , Humanos , Saúde Materna/estatística & dados numéricos , México , Inquéritos e QuestionáriosRESUMO
BACKGROUND: To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador. METHODS: We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening. RESULTS: Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%. CONCLUSIONS: To meet WHO's recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.
Assuntos
Infecções por HIV/diagnóstico , Promoção da Saúde/métodos , Programas de Rastreamento , Pobreza , Complicações Infecciosas na Gravidez/diagnóstico , Cuidado Pré-Natal , Qualidade da Assistência à Saúde , Adulto , Escolaridade , El Salvador , Feminino , Guatemala , HIV , Infecções por HIV/virologia , Acessibilidade aos Serviços de Saúde , Honduras , Humanos , Modelos Logísticos , México , Nicarágua , Panamá , Gravidez , Complicações Infecciosas na Gravidez/virologia , Adulto JovemRESUMO
Professional skilled care has shown to be one of the most promising strategies to reduce maternal mortality, and in-facility deliveries are a cost-effective way to ensure safe births. Countries in Mesoamerica have emphasized in-facility delivery care by professionally skilled attendants, but access to good-quality delivery care is still lacking for many women. We examined the characteristics of women who had a delivery in a health facility and determinants of the decision to bypass a closer facility and travel to a distant one. We used baseline information from the Salud Mesoamerica Initiative (SMI). Data were collected from a large household and facilities sample in the poorest quintile of the population in Guatemala, Honduras and Nicaragua. The analysis included 1592 deliveries. After controlling for characteristics of women and health facilities, being primiparous (RR = 1.15, 95% CI 1.10, 1.21), being literate (RR = 1.24, 95% CI 1.04, 1.48), having antenatal care (RR = 1.68, 95% CI 1.24, 2.27), being informed of the need for having a C-section (RR = 1.07, 95% CI 1.02, 1.11) and travel time to the closest facility totaling 1-2 h vs under 30 min (RR = 0.88, 95% CI 0.77, 0.99) were associated with in-health facility deliveries. In Guatemala, increased availability of medications and equipment at a distant facility was strongly associated with bypassing the closest facility in favor of a distant one for delivery (RR = 2.10, 95% CI 1.08, 4.07). Our study showed a strong correlation between well-equipped facilities and delivery attendance in poor areas of Mesoamerica. Indeed, women were more likely to travel to more distant facilities if the facilities were of higher level, which scored higher on our capacity score. Our findings call for improving the capacity of health facilities, quality of care and addressing cultural and accessibility barriers to increase institutional delivery among the poor population in Mesoamerica.
Assuntos
Parto Obstétrico/estatística & dados numéricos , Instalações de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Serviços de Saúde Materna/organização & administração , Serviços de Saúde Materna/normas , Pobreza , Adolescente , Adulto , América Central/epidemiologia , Comportamento do Consumidor , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Qualidade da Assistência à SaúdeRESUMO
OBJECTIVE: To identify factors associated with contraceptive use among women in need living in the poorest areas in five Mesoamerican countries: Guatemala, Honduras, Nicaragua, Panama and State of Chiapas (Mexico). STUDY DESIGN: We analyzed baseline data of 7049 women of childbearing age (15-49 years old) collected for the Salud Mesoamérica Initiative. Data collection took place in the 20% poorest municipalities of each country (July, 2012-August, 2013). RESULTS: Women in the poorest areas were very poorly informed about family planning methods. Concern about side effects was the main reason for nonuse. Contraceptive use was lower among the extremely poor (<$1.25 USD PPP per day) [odds ratio (OR): 0.75; confidence interval (CI): 0.59-0.96], those living more than 30 min away from a health facility (OR 0.71, CI: 0.58-0.86), and those of indigenous ethnicity (OR 0.50, CI: 0.39-0.64). Women who were insured and visited a health facility also had higher odds of using contraceptives than insured women who did not visit a health facility (OR 1.64, CI: 1.13-2.36). CONCLUSIONS: Our study showed low use of contraceptives in poor areas in Mesoamerica. We found the urgent need to improve services for people of indigenous ethnicity, low education, extreme poverty, the uninsured, and adolescents. It is necessary to address missed opportunities and offer contraceptives to all women who visit health facilities. Governments should aim to increase the public's knowledge of long-acting reversible contraception and offer a wider range of methods to increase contraceptive use. IMPLICATIONS: We show that unmet need for contraception is higher among the poorest and describe factors associated with low use. Our results call for increased investments in programs and policies targeting the poor to decrease their unmet need.
Assuntos
Comportamento Contraceptivo , Anticoncepção , Conhecimentos, Atitudes e Prática em Saúde , Áreas de Pobreza , Adolescente , Adulto , América Central , Anticoncepção/métodos , Anticoncepção/estatística & dados numéricos , Comportamento Contraceptivo/estatística & dados numéricos , Serviços de Planejamento Familiar/educação , Serviços de Planejamento Familiar/métodos , Serviços de Planejamento Familiar/estatística & dados numéricos , Feminino , Humanos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , México , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: We applied the Integrative Model of Behavioral Prediction to analyze factors associated with risky sexual behaviors for adolescent students living in the poorest segments in Costa Rica. METHODS: We used data from a school-based knowledge, attitudes, and behaviors survey from the poorest districts of Costa Rica, collected for Salud Mesoamerica Initiative. We analyzed responses of 919 male and female students (12-19 years old) to determine factors associated with sexual intercourse and condom use. RESULTS: One of every four students reported being sexually active. Students that reported being sexually active were more likely to consume excessive alcohol (OR 3.04 [95 % CI 1.94-4.79]). While 88.0 % [95 % CI 73.5-95.1] of sexually active adolescents said they would use a condom the next time they have sex, only 53.1 % [95 % CI 39.3-66.5] reported condom use the last time. Non-condom-users felt purchasing condoms was uncomfortable (OR 0.34 [95 % CI 0.12-0.93]). CONCLUSIONS: Poor adolescents in Costa Rica begin sexual activities early and undertake behaviors that increase their risk for unwanted pregnancies and sexually transmitted infections. We found the urgent need to address alcohol abuse, and recognize gender differences in youth health programs.
Assuntos
Comportamento do Adolescente/psicologia , Alcoolismo/psicologia , Áreas de Pobreza , Assunção de Riscos , Comportamento Sexual/psicologia , Estudantes/psicologia , Adolescente , Alcoolismo/epidemiologia , Criança , Coito/psicologia , Preservativos/estatística & dados numéricos , Costa Rica/epidemiologia , Feminino , Humanos , Masculino , Modelos Psicológicos , Fatores de Risco , Estudantes/estatística & dados numéricos , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Poor women in the developing world have a heightened need for antenatal care (ANC) but are often the least likely to attend it. This study examines factors associated with the number and timing of ANC visits for poor women in Guatemala, Honduras, Mexico, Nicaragua, Panama, and El Salvador. METHODS: We surveyed 8366 women regarding the ANC they attended for their most recent birth in the past two years. We conducted logistic regressions to examine demographic, household, and health characteristics associated with attending at least one skilled ANC visit, four skilled visits, and a skilled visit in the first trimester. RESULTS: Across countries, 78 % of women attended at least one skilled ANC visit, 62 % attended at least four skilled visits, and 56 % attended a skilled visit in the first trimester. The proportion of women attending four skilled visits was highest in Nicaragua (81 %) and lowest in Guatemala (18 %) and Panama (38 %). In multiple countries, women who were unmarried, less-educated, adolescent, indigenous, had not wanted to conceive, and lacked media exposure were less likely to meet international ANC guidelines. In countries with health insurance programs, coverage was associated with attending skilled ANC, but not the timeliness. CONCLUSIONS: Despite significant policy reforms and initiatives targeting the poor, many women living in the poorest regions of Mesoamérica are not meeting ANC guidelines. Both supply and demand interventions are needed to prioritize vulnerable groups, reduce unplanned pregnancies, and reach populations not exposed to common forms of media. Top performing municipalities can inform effective practices across the region.
Assuntos
Cobertura do Seguro/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Primeiro Trimestre da Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Adolescente , Adulto , América Central , Feminino , Humanos , Modelos Logísticos , México , Pessoa de Meia-Idade , Pobreza/economia , Gravidez , Cuidado Pré-Natal/economia , Inquéritos e Questionários , Fatores de Tempo , Adulto JovemRESUMO
Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44-2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18-1.81), primiparous (aRR = 1.44, 95% CI: 1.24-1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21-1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04-1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05-1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02-1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.
Assuntos
Parto Obstétrico/mortalidade , Acessibilidade aos Serviços de Saúde/ética , Serviços de Saúde do Indígena/organização & administração , Indígenas Sul-Americanos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Satisfação Pessoal , Adolescente , Adulto , Barreiras de Comunicação , Parto Obstétrico/estatística & dados numéricos , Escolaridade , Feminino , Guatemala , Instalações de Saúde/ética , Instalações de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Serviços de Saúde do Indígena/ética , Humanos , Mortalidade Materna/etnologia , Mortalidade Materna/tendências , México , Pessoa de Meia-Idade , Panamá , Paridade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Pobreza/etnologia , Pobreza/estatística & dados numéricos , Gravidez , Cuidado Pré-Natal/ética , Cuidado Pré-Natal/estatística & dados numéricosRESUMO
Care practices and risk factors for diarrhea among impoverished communities across Mesoamerica are unknown. Using Salud Mesoamérica Initiative baseline data, collected 2011-2013, we assessed the prevalence of diarrhea, adherence to evidence-based treatment guidelines, and potential diarrhea correlates in poor and indigenous communities across Mesoamerica. This study surveyed 14,500 children under 5 years of age in poor areas of El Salvador, Guatemala, Mexico (Chiapas State), Nicaragua, and Panama. We compared diarrhea prevalence and treatment modalities using χ(2) tests and used multivariable Poisson regression models to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) for potential correlates of diarrhea. The 2-week point prevalence of diarrhea was 13% overall, with significant differences between countries (P < 0.05). Approximately one-third of diarrheal children were given oral rehydration solution and less than 3% were given zinc. Approximately 18% were given much less to drink than usual or nothing to drink at all. Antimotility medication was given to 17% of diarrheal children, while antibiotics were inappropriately given to 36%. In a multivariable regression model, compared with children 0-5 months, those 6-23 months had a 49% increased risk for diarrhea (aRR = 1.49, 95% CI = 1.15, 1.95). Our results call for programs to examine and remedy low adherence to evidence-based treatment guidelines.