Rose L. Molina

Navigating and circumventing a fragmented health system: the patient's pathway in the Sierra Madre Region of Chiapas, Mexico.

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders--the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies--are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexicos poorest states. These insights have important implications for the structure and implementation of on-going reforms.

Beware the scar : Laparoscopic hysterectomy for 7-week cesarean delivery scar implantation pregnancy

Case notes A 36-year-old G4P2012 at 6 weeks by last menstrual period presented to the emergency department with abdominal pain and vaginal bleeding. On examination, she had normal vital signs with mild suprapubic tenderness without rebound or guarding. Her medical history was notable for 2 uncomplicated cesarean deliveries. Ultrasound imaging showed implantation of a 7-week gestation within the endometrium overlying the prior cesarean delivery scar with thin adjacent myometrium. The serum human chorionic gonadotropin (hCG) was 155,009mIU/mL. Due

Mycoplasma genitalium: An Overlooked Sexually Transmitted Pathogen in Women?

Mycoplasma genitalium is a facultative anaerobic organism and a recognized cause of nongonococcal urethritis in men. In women, M. genitalium has been associated with cervicitis, endometritis, pelvic inflammatory disease (PID), infertility, susceptibility to human immunodeficiency virus (HIV), and adverse birth outcomes, indicating a consistent relationship with female genital tract pathology. The global prevalence of M. genitalium among symptomatic and asymptomatic sexually active women ranges between 1 and 6.4%. M. genitalium may play a role in pathogenesis as an independent sexually transmitted pathogen or by facilitating coinfection with another pathogen. The long-term reproductive consequences of M. genitalium infection in asymptomatic individuals need to be investigated further. Though screening for this pathogen is not currently recommended, it should be considered in high-risk populations. Recent guidelines from the Centers for Disease Control regarding first-line treatment for PID do not cover M. genitalium but recommend considering treatment in patients without improvement on standard PID regimens. Prospective studies on the prevalence, pathophysiology, and long-term reproductive consequences of M. genitalium infection in the general population are needed to determine if screening protocols are necessary. New treatment regimens need to be investigated due to increasing drug resistance.

Striving for Respectful Maternity Care Everywhere

Purpose The mistreatment of women during childbirth in health facilities is a growing area of research and public attention. Description In many countries, disrespect and abuse from maternal health providers discourage women from seeking childbirth with a skilled birth attendant, which can lead to poor maternal and neonatal outcomes. This commentary highlights examples from three countries—Kenya, Mexico and the United States—and presents different forms of mistreatment during childbirth, which range from physical abuse to non-consented care to discriminatory practices. Assessment Building on the momentum from the United Nations Sustainable Development Goals, the International Federation of Gynecology and Obstetrics, and the Global and Maternal Neonatal Health Conference, the global community has placed respectful maternity care at the forefront of the maternal and neonatal health agenda. Conclusion Research efforts must focus on context-specific patient satisfaction during childbirth to identify areas for quality improvement.

A Renewed Focus on Maternal Health in the United States

High maternal mortality in the United States as compared with other high-income countries and continued increases in deaths and severe pregnancy-related morbidity highlight gaps in our care for reproductive-age women.

Defining Physiological Predictors of Peripartum Maternal Bacteremia.

OBJECTIVE This study aims to examine physiological and laboratory parameters associated with peripartum maternal bacteremia. STUDY DESIGN This case-control study matched 115 cases (women with fever and bacteremia during the peripartum period) to 285 controls (defined as the next two febrile women with negative blood cultures at the same institution) from two academic medical centers from 2009 to 2013. Conditional logistic regression models were used to evaluate the association of physiological and laboratory parameters with maternal bacteremia at the time of initial and maximum fever. RESULTS At the time of initial fever, temperature > 103°F (adjusted odds ratio [aOR]: 5.58, 95% confidence interval [CI]: 2.05-15.19) and respiratory rate (RR) > 20 respirations per minute (aOR: 5.27, 95% CI: 2.32-11.96) were associated with bacteremia. At the time of maximum fever, temperature (> 102°F, aOR: 3.37, 95% CI: 1.61-7.06; > 103°F, aOR: 7.96, 95% CI: 3.56-17.82), heart rate > 110 beats per minute (aOR: 2.20, 95% CI: 1.21-3.99), and RR > 20 (aOR: 3.65, 95% CI: 1.65-8.08) were associated with bacteremia. Bandemia > 10% (aOR: 2.44, 95% CI: 1.07-5.54) was associated with bacteremia. CONCLUSION Physiological and laboratory parameters associated with maternal bacteremia differed from those reported with sepsis in the adult critical care population. Further studies of objective markers are needed to improve detection and treatment of peripartum bacteremia.

A Community-Based Approach to Cervical Cancer Prevention: Lessons Learned in Rural Guatemala

Abstract:Background: One international and three local organizations developed the Santa Ana Womens Health Partnership (SAWHP) to address cervical cancer in Santa Ana Huista, Huehuetenango, Guatemala. This paper describes the structure, outcomes, and lessons learned from our community partnership and program.Methods: The community partnership developed a singlevisit approach (SVA) program that guided medically underserved women through screening and treatment of cervical cancer.Lessons Learned: The program promoted acceptability of SVA among rural women by engaging local female leaders and improving access to screening services. The programs approach focused on maximizing access and generated interest beyond the coverage area. Distrust among the community partners and weak financial management contributed to the programs cessation after 4 years.Conclusions: The SAWHP design may guide future implementation of cervical cancer screening programs to reach medically underserved women. Open, ongoing dialogue among leaders in each partner institution is paramount to success.

“Morir En Camino”: Community Narratives about Childbirth Care in Rural Chiapas

ABSTRACT This anthropological study explores why more women in the rural Sierra Madre region of Chiapas, Mexico birth at home rather than at the hospital. Between January and May of 2014, the primary investigator conducted in-depth, semi-structured interviews with twenty-six interlocutors: six parteras (home birth attendants), nine pregnant women, four mothers, four healthcare providers, and three local government leaders. Participant observation occurred in the health clinic, participants’ homes, and other spaces in a community with a population of 1,188 people. Drawing from narrative analysis, the findings suggest that women face structural obstacles to accessing high-quality childbirth care, which lead them to give birth at home instead of the hospital. These obstacles include financial barriers in obtaining facility-based care and poor quality of care, such as mistreatment in the facility. The study highlights the importance of centreing community narratives in healthcare programming in order to bridge the implementation gap between women in rural communities, healthcare workers, and policymakers.

Sexually transmitted infection screening and follow-up in a high-risk urban obstetric clinic

RESULTS: Of 1,785 participants, 58 (3.3%) pregnancies resulted in stillbirth and 198 (11.4%) had a poor birth outcome. In multivariable analysis controlling for age, distance from hospital, referral status, receipt of malaria prophylaxis, report of prior syphilis infection, and parity; attending 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P1⁄40.02). Receipt of malaria prophylaxis at ANC was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P1⁄40.04), but report of prior syphilis infection was not associated with stillbirth (aOR 1.0, 95% CI 0.2-1.5, P1⁄40.98). In a multivariable sensitivity analysis of risk factors associated with the composite poor birth outcome, attending 4 ANC visits remained associated with significantly reduced odds of poor birth outcomes when accounting for multiple potential confounders (aOR 0.66, 95% CI 0.4-0.96, P1⁄40.03). CONCLUSIONS: For this cohort of women in rural Uganda, attending 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes, which may be related to receipt of antenatal infection screening, treatment, and prevention services.