Lourdes Campero

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial

Object To evaluate the effects of psychosocial support during labour, delivery and the immediate postpartum period provided by a female companion (doula).

“Alone, I wouldn't have known what to do”:A qualitative study on social supportduring labor and delivery in Mexico

This article presents some of the most relevant qualitative results of a trial to evaluate the effects of the provision of psychosocial support to first-time mothers during labor, childbirth and in the immediate postpartum period in a social security hospital in Mexico City. The article focuses on the experiences of mothers who have received psychosocial support from a doula (the term doula is used to identify a woman who provides continuous support to a woman during labor. delivery and the immediate postpartum period) and compares them with the experiences of those women who gave birth following normal hospital routine. Sixteen in-depth interviews were held with women in the immediate post partum period (eight of whom had been accompanied by a doula and eight who had not) before they were discharged from hospital, and the results were analyzed using qualitative techniques. The interviews showed that the women accompanied by a doula had a more positive childbirth experience. The differences between both groups related to their perceptions of the childbirth experience; the treatment they received from hospital staff; the information they were given and how well they understood it; their perception of hospital routines; their feelings about cesarean sections and, spatial and temporal perceptions. The most important difference between the two groups was the way they expressed their feelings about their own labor, their sense of control and their self-perception.

La investigación sobre apoyo social en salud: situación actual y nuevos desafíos

On the borderline between sociology and psychology, the concept of social support has made it possible to develop a whole research tradition aimed at explaining some of the differences existing in the distribution of mental and physical disease. The concept of social support itself, however, still presents some ambiguities which must be clarified. These problems are discussed and it is showed and shows that the topic can be enriched with the contribution of the social sciences. Different definitions of the concept itself, are briefly analysed and the complexity and multidimensional character of social support are highlighted. The association between social support and health is discussed. The differences and implications of the direct effect model and the buffering effect model are addressed, and the relevance of the construct of social support is enhanced. The need to study social support not only as a likely determinant of some forms of disease, but also as a dependent variable, is brought out. Some recent developments in the study of factors associated with the availability of social support are discussed. It is shown that social support is a product of certain social factors which can be clearly identified by sociological analysis. In order to illustrate this point, the structural determinants of a specific dimension of social support-attention-are discussed. The importance of structural variables like social class and gender in attempting to explain the differential distribution of certain forms of social support is emphasized. It is proposed, on the theoretical level, that the intersection between two related autonomous constructs-social class and social support-may better explain those aspects of these concepts that are of importance to observed heterogeneity in the distribution of mental and physical health. Different theoretical and methodological approaches to the understanding of the determinants of social support and its effect on health are suggested.

La vulnerabilidad e invisibilidad de las mujeres ante el VIH/SIDA: constantes y cambios en el tema

This paper presents some thoughts on the problems endured by women facing HIV/AIDS. World and nationwide statistics show an upward trend of the epidemic among women, calling for the need to address this problem. A case is made for the way in which gender structure and relations facilitate the vulnerability of women to this disease, increasing their risk of infection related with specific factors like migration, employment unsafe conditions, and domestic violence, among others. Emphasis is made on the main obstacles faced by women to flag their concerns and needs in society, as well as on their lack of empowerment to cope effectively with their problems. Some initiatives advanced by the organized civil society and governmental strategies are presented, including accomplishments, deficiencies, needs, and challenges. Finally, conclusions and recommendations are given, highlighting the need to establish and evaluate preventative programs and policies from a gender and human rights perspective, to promote a greater awareness and improved responses to the problems imposed on women by the HIV/AIDS epidemic. The English version of this paper is available at: http://www.insp.mx/salud/index.html

A Study on Maternal Mortality in Mexico Through a Qualitative Approach

This report presents the main qualitative results of a verbal autopsy study carried out in three states of Mexico, which aimed at identifying the factors associated with maternal mortality that could be subject to modifications through concrete interventions. By reviewing death certificates issued in 1995, it was possible to identify 164 households where a maternal death had occurred. One hundred forty-five of these households were visited, and a precoded questionnaire was completed to explore socioeconomic and living conditions, as well as causes of death. An open-ended question to prompt the relatives to narrate all the facts that led to the maternal deaths was included in the questionnaire. This study presents an analysis of that question, focusing on the delays in the care-seeking process and organized according to the model of the three delays: in deciding to seek care, in reaching a care facility, and in actually receiving care after arrival. Additionally, problems related to quality of care are examined. For analysis of the accounts, structural, interactional/community, and subjective variables were identified that allowed refining of our understanding of the problem of maternal deaths. Finally, based on the findings of the study, this article presents a series of recommendations, highlighting that interventions should address the early stages of a complication and focus on decreasing the various forms of inequality (gender and socioeconomic) associated with the occurrence of maternal deaths.

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.

HIV prevention and men who have sex with women and men in México: Findings from a qualitative study with HIV‐positive men

Unprotected sex between men is the major risk factor for HIV infection in México and many other Latin American countries. There is a substantial body of literature demonstrating that the relationship between sexual identity and sexual practice is not binary or causal — men who have sex with other men do not necessarily perceive themselves as gay — and there is increasing interest in HIV prevention with men who have sex with both men and women. In México, HIV prevention with men who have sex with women and men and who are not socially affiliated or identified with gay men is lacking. This paper explores the sexual histories and HIV‐risk perception of HIV‐positive Mexican men who indicated that they have sex with women in a screening interview and then in the context of an in‐depth interview also reported having had sex with men. We consider the sexual practices and sexual and social identities of these men, examining their explanations for having sex with other men, the strategies used to affirm their masculinity, the management of their sexual identity in their social networks, HIV‐risk perception before diagnosis and sexual practices after diagnosis. Recommendations are made to improve HIV prevention for men who have sex with men as well as women and who do not assume a gay or bisexual identity.

La contribución de la violencia a la mortalidad materna en Morelos, México

Objective. To document the under-registration of violent deaths related to pregnancy and the importance of considering these violent deaths within the definition of maternal mortality. Material and Methods. The study was carried out in the state of Morelos, based on the review of all death certificates (394) of reproductive aged women (12-49 years) who died during 2001. Based on a list of diagnostic criteria we eliminated 167 certificates that were neither violent deaths nor maternal deaths. The remaining 227 certificates were further evaluated through verbal autopsy and/or review of medical charts. Results. Fifty-one violent deaths were found. Eighteen maternal deaths were officially reported in 2001, however, our study identified 23 direct maternal deaths and four violent deaths during pregnancy and the post-partum period. We found that this reproductive event was the direct trigger for the homicide or suicide of these four women, and only one of these cases was documented officially. Conclusions. Violent deaths related to pregnancy should be included in official maternal mortality statistics as indirect causes of maternal deaths. This would allow for a greater and more accurate understanding of violent maternal deaths and guide appropriate prevention and care policies, programs and services. Verbal autopsy is a useful technique for identifying cases of violent maternal deaths.

Anti-Neospora caninum and anti-Sarcocystis spp. specific antibodies cross-react with Besnoitia besnoiti and influence the serological diagnosis of bovine besnoitiosis.

Bovine besnoitiosis control remains a challenge because the disease continues to spread and control relies solely on accurate diagnosis coupled to management measures. However, recent studies have reported that routinely used ELISAs may raise a high number of false-positive results. Herein, cross-reactions between Besnoitia besnoiti antigens and anti-Neospora caninum and/or anti-Sarcocystis spp.-specific antibodies were studied in an in house ELISA since N. caninum and Sarcocystis spp. are closely related parasites, and both infections are highly prevalent in cattle worldwide. The serum panel was composed of the following categories: sera from B. besnoiti-seronegative (n=75) and -seropositive cattle (n=66), B. besnoiti-based-ELISA false-positive reactors (n=96) together with N. caninum (n=36) and Sarcocystis spp. (n=42) -seropositive reference cattle sera. B. besnoiti tachyzoite based western blot (WB) results classified animals as seropositive or seronegative. Sera were analyzed for the detection of anti-N. caninum by WB and ELISA and anti-Sarcocystis spp.-specific antibodies by WB and IFAT. Those samples recognizing a Sarcocystis spp. 18-20 kDa antigenic region and N. caninum 17-18 kDa immunodominant antigen were considered to be Sarcocystis spp. and N. caninum seropositive, respectively. The category of B. besnoiti based-ELISA false-positive reactors showed the highest number of sera with specific anti-Sarcocystis spp. and anti-N. caninum antibodies (74%; 71/96), followed by the N. caninum-seropositive cattle category (52.8%; 19/36). In contrast, few B. besnoiti-seronegative and -seropositive cattle showed antibodies against Sarcocystis spp. and N. caninum (10.7%; 8/75 and 1.5%; 1/66), respectively). This study revealed that B. besnoiti false-positive ELISA results were associated not only with the presence of anti-N. caninum and anti-Sarcocystis spp. antibodies (χ(2): 78.36; p<0.0001; OR: 34.6; CI: 14-88) but also with high antibody levels against them using ELISA and IFAT tests, respectively (p<0.05; t-test). These results may explain why only some animals seropositive to Sarcocystis spp. and/or N. caninum are Besnoitia false-positive reactors. Therefore, sera meeting these requirements should be included in future validations of serological tests for bovine besnoitiosis.

Educating Skilled Birth Attendants in Mexico: Do the Curricula Meet International Confederation of Midwives Standards?

Although the majority of births in Mexico are attended by skilled birth attendants, maternal mortality remains moderately high, raising questions about the quality of training and delivery care. We conducted an exhaustive review of the curricula of three representative schools for the education and clinical preparation of three types of birth attendant – obstetric nurses, professional midwives and general physicians – National Autonomous University of Mexico (UNAM) School of Obstetric Nursing; CASA Professional Midwifery School; and UNAM School of Medicine, Iztacala Campus. All curricular materials were measured against the 214 indicators of knowledge and ability in the International Confederation of Midwives (ICM) skilled attendant training guidelines. The CASA curriculum covered 83% of the competencies, 93% of basic knowledge and 86% of basic abilities, compared with 54%, 59% and 64% for UNAM Obstetric Nursing School and 43%, 60% and 36% for UNAM School of Medicine, respectively. Neither the Obstetric Nursing School nor the School of Medicine documented the quantity or types of clinical experience required for graduation. General physicians attend the most births in Mexico, yet based on our analysis, professional midwives had the most complete education and training as measured against the ICM competencies. We recommend that professional midwives and obstetric nurses should be formally integrated into the public health system to attend deliveries. Résumé La majorité des accouchements au Mexique bénéficient d’une assistance qualifiée. Pourtant, la mortalité maternelle demeure modérément élevée, ce qui soulève des questions sur la qualité de la formation et des soins obstétricaux. Nous avons étudié le curriculum de trois écoles représentatives pour l’enseignement et la préparation clinique de trois types de personnel obstétrical (infirmières en obstétrique, sages-femmes professionnelles et médecins généralistes): l’École de soins infirmiers obstétricaux de l’Université autonome du Mexique (UNAM), l’École de sages-femmes professionnelles CASA et l’École de médecine de l’UNAM, campus d’Iztacala. Tout le matériel pédagogique a été évalué par rapport aux 214 indicateurs de connaissances et d’aptitudes des directives de formation de la Confédération internationale de sages-femmes pour les accoucheuses professionnelles. Le curriculum CASA couvrait 83% des compétences, 93% des connaissances de base et 86% des aptitudes de base, contre 54%, 59% et 64% pour l’École de soins infirmiers obstétricaux UNAM et 43%, 60% et 36% pour l’École de médecine UNAM, respectivement. Ni l’École de soins infirmiers obstétricaux ni l’École de médecine n’informaient sur la somme ou les types d’expérience clinique requise pour obtenir le diplôme. Les médecins généralistes accouchent la plupart des femmes au Mexique, pourtant, d’après notre analyse, les sages-femmes professionnelles avaient suivi la formation la plus complète selon les critères de la Confédération internationale des sages-femmes en matière de compétences. Nous recommandons d’intégrer officiellement les sages-femmes professionnelles et les infirmières obstétricales dans le système de santé publique pour la surveillance des accouchements. Resumen Aunque la mayoría de los partos en México reciben atención calificada, la tasa de mortalidad materna continúa siendo moderadamente alta, lo cual plantea preguntas respecto a la calidad de la capacitación y la prestación de servicios. Realizamos una revisión exhaustiva de los currículos de tres escuelas representativas para la formación y preparación clínica de tres tipos de asistentes de partos – enfermeras obstétricas, parteras profesionales y médicos generales – la Facultad de Enfermería Obstétrica de la Universidad Nacional Autónoma de México (UNAM); la Escuela de CASA de Partería Profesional; y la Facultad de Medicina de la UNAM, Recinto de Iztacala. Todos los materiales curriculares fueron medidos contra los 214 indicadores de conocimiento y capacidad, enumerados en las directrices de la Confederación Internacional de Matronas respecto a la capacitación en atención del parto calificada. El currículo de CASA abarcó el 83% de las aptitudes, el 93% del conocimiento básico y el 86% de las habilidades fundamentales, comparado con el 54%, 59% y 64% para la Facultad de Enfermería Obstétrica de la UNAM y el 43%, 60% y 36% para la Facultad de Medicina de la UNAM, respectivamente. Ni la Facultad de Enfermería Obstétrica ni la Facultad de Medicina documentaron la cantidad o los tipos de experiencia clínica exigidos para graduarse. Los médicos generales atienden la mayoría de los artos en México, pero, de acuerdo con nuestro análisis, las parteras profesionales contaban con formación y capacitación más completas, conforme a las aptitudes citadas por la Confederación Internacional de Matronas. Recomendamos que las parteras profesionales y enfermeras obstétricas se integren oficialmente al sistema de salud pública para atender partos.