Dilys Walker

Routine follow-up visits after first-trimester induced abortion.

Routine follow-up visits after abortion are intended to confirm that the abortion is complete and to diagnose and treat complications. Many clinicians also take advantage of the follow-up visit to provide general reproductive health care: discussing contraceptive plans and providing family planning services; diagnosing sexually transmitted infections; performing a Pap test or discussing abnormal Pap results. We reviewed the evidence related to the routine postabortion follow-up visit. Other than mifepristone medical abortion performed at 50 days of gestation or later and methotrexate medical abortion, we found little evidence that mandatory follow-up visits typically detect conditions that women themselves could not be taught to recognize. In addition, the natural history of the most severe complications after abortion—infection and unrecognized ectopic pregnancy—have time courses inconsistent with the usual timing of the follow-up visit. Costs associated with this visit can be great. These include travel expenses, lost wages, child-care expenses, privacy and emotional burdens for women, and scheduling disruptions and the related opportunity costs caused by “no-shows” for the provider. Follow-up appointments should be scheduled for those women likely to benefit from a physical examination. For the remainder of women, simple instructions and advice about detecting complications, possibly coupled with telephone follow-up, might suffice. Although arguably valuable in their own right, counseling, family planning services, or sexually transmitted infection diagnosis and treatment should not be so inflexibly bundled with postabortion care. Protocols that require in-person follow-up after abortion may not make the best use of a womens time or abilities, or of the medical system.

HIV prevention in Mexican schools: prospective randomised evaluation of intervention

Abstract Objective To assess effects on condom use and other sexual behaviour of an HIV prevention programme at school that promotes the use of condoms with and without emergency contraception. Design Cluster randomised controlled trial. Setting 40 public high schools in the state of Morelos, Mexico. Participants 10 954 first year high school students. Intervention Schools were randomised to one of three arms: an HIV prevention course that promoted condom use, the same course with emergency contraception as back-up, or the existing sex education course. Self administered anonymous questionnaires were completed at baseline, four months, and 16 months. Students at intervention schools received a 30 hour course (over 15 weeks) on HIV prevention and life skills, designed in accordance with guidelines of the joint United Nations programme on HIV/AIDS. Two extra hours of education on emergency contraception were given to students in the condom promotion with contraception arm. Main outcome measures Primary outcome measure was reported condom use. Other outcomes were reported sexual activity; knowledge and attitudes about HIV and emergency contraception; and attitudes and confidence about condom use. Results Intervention did not affect reported condom use. Knowledge of HIV improved in both intervention arms and knowledge of emergency contraception improved in the condom promotion with contraception arm. Reported sexual behaviour was similar in the intervention arms and the control group. Conclusion A rigorously designed, implemented, and evaluated HIV education course based in public high schools did not reduce risk behaviour, so such courses need to be redesigned and evaluated. Addition of emergency contraception did not decrease reported condom use or increase risky sexual behaviour but did increase reported use of emergency contraception.

Learning effect of a conditional cash transfer programme on poor rural women’s selection of delivery care in Mexico

BACKGROUND The Mexican programme Oportunidades/Progresa conditionally transfers money to beneficiary families. Over the past 10 years, poor rural women have been obliged to attend antenatal care (ANC) visits and reproductive health talks. We propose that the length of time in the programme influences womens preferences, thus increasing their use not only of services directly linked to the cash transfers, but also of other services, such as clinic-based delivery, whose utilization is not obligatory. OBJECTIVE To analyse the long-term effect of Oportunidades on womens use of antenatal and delivery care. METHODOLOGY 5051 women aged between 15 and 49 years old with at least one child aged less than 24 months living in rural localities were analysed. Multilevel probit and logit models were used to analyse ANC visits and physician/nurse attended delivery, respectively. Models were adjusted with individual and socio-economic variables and the localitys exposure time to Oportunidades. Findings On average women living in localities with longer exposure to Oportunidades report 2.1% more ANC visits than women living in localities with less exposure. Young women aged 15-19 and 20-24 years and living in localities with longer exposure to Oportunidades (since 1998) have 88% and 41% greater likelihood of choosing a physician/nurse vs. traditional midwife for childbirth, respectively. Women of indigenous origin are 68.9% less likely to choose a physician/nurse for delivery care than non-indigenous women. CONCLUSIONS An increase in the average number of ANC visits has been achieved among Oportunidades beneficiaries. An indirect effect is the increased selection of a physician/nurse for delivery care among young women living in localities with greater exposure time to Oportunidades. Disadvantaged women in Mexico (indigenous women) continue to have less access to skilled delivery care. Developing countries must develop strategies to increase access and use of skilled obstetric care for marginalized women.

Deaths from complications of unsafe abortion: misclassified second trimester deaths.

Abstract This study measured the contribution of abortion-related deaths to overall maternal mortality and calculated the underestimation of maternal mortality using verbal autopsy and clinical record review where available. We reviewed 807 death certificates of women aged 12—50 who died in 2001 in two sites of about 1.5 million inhabitants each in the state of Morelos (primarily rural) and the municipality of Nezahualcóyotl (primarily urban) in the state of Mexico. Deaths were classified as definite, possible or non-maternal deaths. Finally, we identified abortion-related deaths and calculated the underestimation of maternal mortality. Among 326 possible maternal deaths, we encountered five misclassified cases: one spontaneous abortion and four non-abortion maternal deaths. Among 32 registered maternal deaths, we found four misclassified cases that were actually second trimester, abortion-related deaths. There were no officially registered abortion-related deaths in either Morelos or Nezahualcóyotl, making the overall underestimation of abortion mortality 100%. Abortion contributed 13.5% of all maternal deaths. The overall underestimation of maternal mortality was 13.5%, higher in Morelos (21.7%). There were no unregistered maternal deaths in Nezahualcóyotl. Unsafe abortion continues to be an important cause of maternal mortality, though first trimester deaths appear to be decreasing. We identified domestic violence as an important cause of death among pregnant and post-partum women, and two abortion-related suicides, and believe these should be reconsidered as indirect maternal deaths. The misclassification of second trimester abortion deaths as maternal deaths from other causes is an obstacle to preventing them. Résumé Cette étude a mesuré la proportion des décès par avortement dans la mortalité maternelle globale et a calculé la sous-estimation de la mortalité maternelle. Nous avons examiné 807 certificats de décès de femmes âgées de 12à50 ans mortes en 2001 dans deux sites d’environ 1,5 million d’habitants chacun dans l’Átat de Morelos (surtout rural) et la municipalité de Nezahualcóyotl (principalement urbaine) dans l’Átat de Mexico. Les décès ont été classés comme formels, possibles et non maternels. Enfin, nous avons identifié les décès par avortement et calculé la sous-estimation de la mortalité maternelle. Sur 326 décès maternels possibles, 5 cas étaient mal classés : un fausse couche et quatre décès maternels non imputablesàl’avortement. Sur les 32 décès maternels enregistrés, quatre cas étaient mal classés, se rapportant en faitàdes avortements du deuxième trimestre. Aucun décès par avortement n’avait été enregistré officiellementàMorelos niàNezahualcóyotl, portantà100% la sous-estimation globale de la mortalité par avortement. Les avortements ont provoqué 13,5% des décès maternels. La sous-estimation de la mortalité maternelle était de 13,5%, supérieureàMorelos (21,7%). Il n’y avait pas de décès maternels non enregistrésàNezahualcóyotl. L’avortement non médicalisé demeure une cause importante de mortalité maternelle, mÁme si les décès pendant le premier trimestre semblent diminuer. Nous avons identifié la violence familiale comme responsable de nombreux décès de femmes enceintes et de jeunes mères, et deux suicides liésàl’avortement, et nous pensons qu’ils devraient Átre reconsidérés comme décès maternels indirects. La classification erronée des décès par avortement au deuxième trimestre comme décès maternels dusàd’autres causes entrave leur prévention. Resumen Este estudio midió la contribución de las muertes relacionadas con el aborto a la cifra general de mortalidad materna y calculó la subestimación de la mortalidad materna mediante la autopsia verbal y la revisión de expedientes clinicos, cuando fue posible. Revisamos 807 certificados de defunción de mujeres entre los 12 y 50 años, quienes murieron en el 2001 en dos Estados, de aproximadamente 1.5 millones de habitantes, en el estado de Morelos (principalmente rural) y en el Municipio de Nezahualcóyotl (principalmente urbano) en el estado de México. Las muertes se clasificaron como muertes maternas definitivas, posibles o no maternas. Finalmente, identificamos las muertes atribuibles al aborto y calculamos la subestimación de la mortalidad materna. Entre 326 posibles muertes maternas, encontramos cinco casos mal clasificados: un aborto espontáneo y cuatro muertes maternas no atribuibles al aborto. Entre 32 muertes maternas registradas, encontramos cuatro casos mal clasificados, que fueron muertes en el segundo trimestre relacionadas con aborto. Ni en Morelos ni en Nezahualcóyotl se registraron oficialmente muertes relacionadas con el aborto, lo cual da una subestimación general de un 100% de la mortalidad por aborto. El 13.5% de todas las muertes maternas se atribuyó al aborto. La subestimación general de la mortalidad materna fue de 13.5%, más alta en Morelos (21.7%). En Nezahualcóyotl se registraron todas las muertes maternas. El aborto inseguro continúa siendo una causa importante de mortalidad materna, aunque el número de muertes en el primer trimestre parece estar disminuyendo. Identificamos la violencia intrafamiliar como una causa importante de defunción entre las mujeres embarazadas y en postparto, y dos suicidios relacionados con el aborto, y creemos que éstas deben reconsiderarse como muertes maternas indirectas. La clasificación errónea de las muertes atribuibles al aborto en el segundo trimestre como muertes maternas por otras causas obstaculiza su prevención.

PRONTO training for obstetric and neonatal emergencies in Mexico

To evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low‐tech and high‐fidelity simulation‐based training for obstetric and neonatal emergencies and teamwork using the PartoPants low‐cost birth simulator.

Estrategias novedosas de prevención de embarazo e ITS/VIH/SIDA entre adolescentes escolarizados mexicanos

Objective. To introduce the study design of an HIV/AIDS and unplanned pregnancy prevention program targeting high school students, and to present the results from the baseline survey. Material and Methods. A school curriculum was developed to inform adolescent students about HIV/AIDS/STD prevention, which included information on emergency contraception (EC) for adolescent students. A randomized controlled study was conducted to simultaneously evaluate the effect of this intervention. The baseline survey collected data on contraception knowledge and attitudes regarding sexual behaviors. Results. A total of 11 117 students from 40 schools participated in the baseline (52% female, the mean age of both males and females was 15.5). A total of 10% of the females and 24% of the men surveyed were sexually active at baseline, but only 39% of those sexually active reported using a condom at the time of their first sexual intercourse. Among the sexually active students surveyed, a third of the males and a fifth of the females reported at least one condom slip or breakage. Most of the students were aware of EC. Conclusions. The low proportion of students that report using condoms accompanied by their incorrect use points to the need for HIV/AIDS and unplanned pregnancy prevention efforts. This novel approach offers adolescents EC, a backup method to the condom. The approach is feasible as students know what EC is and furthermore it appears that they are willing to use this method.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators

BackgroundIneffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators.MethodsData was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement.ResultsA total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score.ConclusionsThese results suggest that PRONTO’s highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings.Trial registrationNCT01477554

The Oportunidades Conditional Cash Transfer Program: Effects on Pregnancy and Contraceptive Use among Young Rural Women in Mexico

CONTEXT Oportunidades is a large conditional cash transfer program in Mexico. It is important to examine whether the program has any direct effect on pregnancy experience and contraceptive use among young rural women, apart from those through education. METHODS Data from the 1992, 2006 and 2009 waves of a nationally representative, population-based survey were used to describe trends in pregnancy experience, contraceptive use and education among rural adolescent (15-19) and young adult (20-24) women in Mexico. To examine differences in pregnancy experience and current modern contraceptive use among young women, multivariable logistic regression analyses were conducted between matched 2006 samples of women with and without exposure to Oportunidades, predicted probabilities were calculated and indirect effects were estimated. RESULTS Over the three survey waves, the proportion of adolescent and young adult women reporting ever being pregnant stayed flat (33-36%) and contraceptive use increased steadily (from 13% in 1992 to 19% in 2009). Educational attainment rose dramatically: The proportion of women with a secondary education increased from 28% in 1992 to 46% in 2009. In multivariable analyses, exposure to Oportunidades was not associated with pregnancy experience among adolescents. Educational attainment, marital status, pregnancy experience and access to health insurance--but not exposure to Oportunidades--were positively associated with current modern contraceptive use among adolescent and young adult women. CONCLUSION Through its effect on education, Oportunidades indirectly influences fertility among adolescents. It is important for Mexico to focus on strategies to increase contraceptive use among young rural nulliparous women, regardless of whether they are enrolled in Oportunidades.

Práctica de mastografías y pruebas de Papanicolaou entre mujeres de áreas rurales de México

Objective. To analyze the frequency of reporting a recently conducted mammogram and/or pap smear and follow-up of abnormal findings among rural poor women in Mexico. Methods. We performed a cross-sectional analysis using data collected in the ENCEL 2007 - Oportunidades survey carried out between July - November, 2007. We used multilevel logistic regression to model the use of mammography and pap smears. Results. We found a low frequency of reported recent mammogram among the rural poor from 30-39 years old (12%) and 40-49 years old (16%) and a low frequency of reported medical follow-up of abnormal findings (60%), particularly among women at higher risk because of age or abnormal findings. These findings were associated with a lack of availability of medical resources and being of indigenous origin. Conclusion. It is fundamental to strengthen both access to and follow-up of mammography and papsmears, particularly among high-risk rural women in order to reduce the level of mortality associated with breast and cervicaluterine cancer.

Skilled Birth Attendants in Mexico: How Does Care During Normal Birth by General Physicians, Obstetric Nurses, and Professional Midwives Compare With World Health Organization Evidence-Based Practice Guidelines?

INTRODUCTION We evaluated the quality of basic obstetric care provided by Mexican general physicians, obstetric nurses, and professional midwives compared with World Health Organization (WHO) guidelines for evidence-based practices and national guidelines. METHODS Vaginal births were observed in 5 hospitals in 5 states from June 2006 until July 2007. We created 5 indices based on WHO guidelines and national standards for care during normal birth. These indices included 1) favorable practices at admission, 2) favorable practices during labor, birth, and immediately postpartum, 3) harmful or excessively used practices, 4) newborn practices, and 5) obstetric outcomes. We assessed each provider types performance as high or low compared with the WHO standard and performed bivariate and multivariate logistic regression analyses to assess the association between indices, patient characteristics, and provider type, adjusting for standard errors for intragroup correlation. RESULTS We observed 876 independently managed vaginal births. Adjusted regression analyses compared with the general physicians standard revealed significant results for favorable care by obstetric nurses on admission (odds ratio [OR] 6.25; 95% confidence interval [CI], 2.08-18.84); for care by professional midwives (OR 21.08; 95% CI, 4.24-104.94) and obstetric nurses (OR 7.88; 95% CI, 2.76-22.52) during labor, birth, and postpartum; and for newborn practices by obstetric nurses (OR 4.14; 95% CI, 1.08-15.90). Professional midwives were least likely to perform harmful/excessively used practices during labor, birth, and the postpartum period (OR 0.06; 95% CI, 0.00-0.35). DISCUSSION Professional midwives and obstetric nurses perform equally or better than general physicians when assessed by use or misuse of evidence-based practices. Professional midwives are an underutilized resource in Mexico. If integrated into the mainstream Mexican health system, they may improve the quality of obstetric care.