Bernardo Hernández-Prado

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Risk and protective factors associated with postnatal depression in Mexican adolescents

We explored factors associated with postnatal depression and further evaluated whether any of these risk and protective factors are specific for adolescent mothers. Data concerning depression levels, family and individual factors were collected in a cross-sectional study which surveyed 298 women in Monterrey, N.L., Mexico. Mean maternal age was 24.64 years, and 27.18% of the mothers were between 14 and 19 years old. Prevalence of postnatal depression was higher in adolescents (16.05%) than in adult mothers (14.29%) but, on average, this difference was not significant. The association between individual factors and postnatal depression for both adult and adolescent mothers was explored. Our results revealed that social support is significantly associated with less possibility of postnatal depression in both groups, and that this effect is stronger for adolescents (OR = 0.81) than for adults (OR = 0.92). For the sample as a whole postnatal depression was associated with lower levels of education, reported fear during labor and living with partner. We also found that having a girl greatly increased the possibility of postnatal depression. We conclude that social support is a protective factor associated with postnatal depression, especially for adolescents.

Evaluation of the quality of antenatal care using electronic health record information in family medicine clinics of Mexico City.

BackgroundEvaluation of the quality of antenatal care (ANC) using indicators should be part of the efforts to improve primary care services in developing countries. The growing use of the electronic health record (EHR) has the potential of making the evaluation more efficient. The objectives of this study were: (a) to develop quality indicators for ANC and (b) to evaluate the quality of ANC using EHR information in family medicine clinics (FMCs) of Mexico City.MethodsWe used a mixed methods approach including: (a) in-depth interviews with health professionals; (b) development of indicators following the RAND-UCLA method; (c) a retrospective cohort study of quality of care provided to 5342 women aged 12–49 years who had completed their pregnancy in 2009 and attended to at least one ANC visit with their family doctor. The study took place in four FMCs located in Mexico City. The source of information was the EHR. SAS statistical package served for programing and performing the descriptive statistical analysis.Results14 ANC quality indicators were developed. The evaluation showed that 40.6% of women began ANC in the first trimester; 63.5% with low-risk pregnancy attended four or more ANC visits; 4.4% were referred for routine obstetric ultrasound, and 41.1% with vaginal infection were prescribed metronidazole. On average, the percentage of recommended care that women received was 32.7%.ConclusionsIt is feasible to develop quality indicators suitable for evaluating the quality of ANC using routine EHR data. The study identified the ANC areas that require improvement; which can guide future strategies aimed at improving ANC quality.

Healthy competition drives success in results-based aid: Lessons from the Salud Mesoamérica Initiative

Objectives The Salud Mesoamérica Initiative (SMI) is a three-operation strategy, and is a pioneer in the world of results-based aid (RBA) in terms of the success it has achieved in improving health system inputs following its initial operation. This success in meeting pre-defined targets is rare in the world of financial assistance for health. We investigated the influential aspects of SMI that could have contributed to its effectiveness in improving health systems, with the aim of providing international donors, bilateral organizations, philanthropies, and recipient countries with new perspectives that can help increase the effectiveness of future assistance for health, specifically in the arena of RBA. Methods Qualitative methods based on the criteria of relevance and effectiveness proposed by the Development Assistance Committee of the Organization for Economic Co-operation and Development. Our methods included document review, key informant interviews, a focus group discussion, and a partnership analysis. Participants A purposive sample of 113 key informants, comprising donors, representatives from the Inter-American Development Bank, ministries of health, technical assistance organizations, evaluation organizations, and health care providers. Results During May–October 2016, we interviewed regarding the relevance and effectiveness of SMI. Themes emerged relative to the topics we investigated, and covered the design and the drivers of success of the initiative. The success is due to 1) the initiative’s regional approach, which pressured recipient countries to compete toward meeting targets, 2) a robust and flexible design that incorporated the richness of input from stakeholders at all levels, 3) the design-embedded evaluation component that created a culture of accountability among recipient countries, and 4) the reflective knowledge environment that created a culture of evidence-based decision-making. Conclusions A regional approach involving all appropriate stakeholders, and based on knowledge sharing and embedded evaluation can help ensure the effectiveness of future results-based aid programs for health in global settings.

Association between serum uric acid levels and cardiovascular risk among university workers from the State of Mexico: a nested case–control study

BackgroundRecent evidence suggests that serum uric acid (SUA) can be an inexpensive and easy-to-obtain indicator of cardiovascular risk (CR). This is especially important in developing countries with high prevalence of cardiovascular disease. We examined the association between SUA levels and 10-year global CR among university workers from the State of Mexico, Mexico.MethodsA case–control study nested within a cohort was conducted between 2004 and 2006. Anthropometric measures, lifestyle variables, family background and CR factors were assessed. The analysis estimated odds ratios using conditional logistic regression.ResultsThe study included 319 cases with CR and 638 controls. Subjects in the upper tertile of SUA had 48.0% higher odds of having an elevated CR than those in the lower tertile (OR = 1.48, 95% CI: 1.04 - 2.10) in the crude analysis, but the association was non-significant when adjusting for other covariates. Among physically inactive individuals, being in the third tertile of SUA doubled the odds of high CR, compared with those who perform physical activity three or more hours per week being in the first tertile of SUA (OR = 2.35, 95% CI: 1.24 - 4.45).ConclusionSerum concentration of uric acid is associated with 10-year global CR among individuals with high levels of physical inactivity.

Perfil situacional y estrategias de intervención en la región mesoamericana en el área de salud materna, reproductiva y neonatal

Presentar los principales resultados del diagnostico situacional y plan regional de intervenciones en salud materna, reproductiva y neonatal elaborado como parte de los trabajos del Sistema Mesoamericano de Salud por el grupo de salud materna, reproductiva y neonatal (SMRN) en 2010. Se conformo un grupo de expertos y de representantes de los paises de la region (que incluye Centroamerica y nueve estados del sur de Mexico). Se hizo una revision documental para conformar un diagnostico situacional, una revision de practicas efectivas y se conformo un plan regional de accion. El diagnostico situacional indica que las tasas de mortalidad materna y neonatal se mantienen inaceptablemente altas en la region. Se propuso como meta regional reducir la mortalidad materna y neonatal de acuerdo a los Objetivos de Desarrollo del Milenio. Se conformo un plan regional que identifica intervenciones especificas en SMRN con enfasis en la atencion adecuada a las emergencias obstetricas y neonatales, atencion calificada al nacimiento, y en planificacion familiar. Se sugiere asimismo un plan de implementacion a cinco anos y una estrategia de evaluacion y de capacitacion. El plan regional en SMRN puede tener exito siempre y cuando los aspectos de implementacion sean atendidos debidamente.

Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica

Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.

Comparative estimates of immunisation coverage from three different sources: results from the SM2015 evaluation

Abstract Background Estimating vaccination coverage is challenging in resource-poor settings where accurate records are sparse. Household surveys, a key source of coverage information, typically capture data from child health cards and rely on maternal recall when cards are unavailable. As a result, little is known about how coverage estimates based on maternal recall differ from those based on health cards for the same children. Furthermore, little is known about how these measures compare with actual rates of seroconversion, which could be used to estimate effective coverage of immunisations. This study compares the accuracy of maternal recall, health card documentation, and antibody presence in vaccination coverage estimates in the state of Chiapas, Mexico. Methods Data for this study were collected as part of the Mesoamerican Health Initiative 2015 baseline survey. A random sample of 4700 households with children under-5 and women of reproductive age were surveyed. A pre-survey census was carried out within segments that had been randomly selected with probability proportional to size. Standardised multilingual household surveys were implemented using netbooks. Anthropometric measurements were collected for all children under-5 and dry blood spot samples for the detection of measles antibodies were collected from children aged 12–23 months. Findings Preliminary results suggest that maternal recall, child health cards, and antibody tests generate differing estimates of immunisation coverage. Recall differs from card-based estimates of vaccination coverage by up to 40 percentage points. There are potentially considerable differences in measles immunisation coverage as assessed by the presence of measles antibodies versus other survey sources, highlighting weaknesses in card accuracy, card coverage, and vaccine administration. Interpretation Current national estimates of immunisation coverage based on the combination of maternal recall and childrens health cards may be overestimating actual protection against vaccine-preventable diseases. Correcting for biases in recall and card coverage may produce more accurate estimates of intervention coverage. Funding Salud Mesoamerica 2015 is funded by the Bill & Melinda Gates Foundation, the Carlos Slim Health Institute, and the Government of Spain and is administered by the Inter-American Development Bank. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders or the Inter-American Development Bank.