How to deal with the suffering: Utility of an emotional containment strategy to collect data for verbal autopsies in Mexico.

Verbal autopsies are often used to establish cause of death but can be emotionally taxing on the interviewers. We conducted focus groups with interviewers (N = 15) who collected data for verbal autopsies in Mexico in order to explore the utility of an emotional containment strategy designed to boost self-confidence and resilience. The interviewers reflected on broader cultural perspectives on illness and death and described the strategy as helpful in developing strategies to manage emotionally stressful situations and develop their confidence in their work performance. This type of intervention may be useful for field personnel who perform verbal autopsy interviews.KEY MESSAGESIn low- and middle-income countries with less reliable statistics systems, a significant proportion of deaths is not certified by a professional doctor. This complicates the registration of causes of death, which is a crucial issue for health systems. In the absence of reliable vital statistics systems, verbal autopsies (VA) offer an alternative for establishing cause of death.In response to emotional crises leading to resignations among the interviewers while testing an instrument for collecting VA, we designed an emotional containment strategy (ECS). It was specifically crafted to boost the self-confidence and resilience of participants in addition to enhancing their capacity for emotional recovery and to regain a functional state. In order to explore ECS results we conducted a qualitative cross-sectional study with four focus groups of interviewers who collected VA.The results obtained were positive, the interviewers were able to perform their work better by overcoming the emotional crisis that occurred both in them and in the people they interviewed.We recommend developing this type of intervention with all field staff performing verbal autopsy interviews, not only as a resource for emotional health, but also as a means of achieving better-quality data collection.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico / Factores asociados con demoras en la búsqueda de atención en muertes de menores de cinco años en Yucatán, México

Abstract: Objective: We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death. Materials and methods: Cross-sectional study comprising household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility. Results: Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time Conclusions: Providing resources to enable caregivers to access health services in a timely manner may reduce delays in seeking care.

Resumen: Objetivo: Analizar las demoras en la búsqueda de atención y su asociación con características de la madre, del niño y los servicios de salud, así como con los síntomas reportados antes de la defunción. Material y métodos: Diseño transversal con entrevistas a 252 cuidadores que se encargaron de niños menores de cinco años que fallecieron en el estado de Yucatán, México, durante 2015-2016. Se evaluaron tres demoras: 1) tiempo en identificar la complicación e iniciar el proceso de búsqueda; 2) tiempo de transporte; y 3) tiempo de espera en la unidad de salud. Resultados: Los niños enfrentaron demoras importantes en la búsqueda de atención. La media de tiempo para iniciar la búsqueda de atención fue de 4.1 días. La media de tiempo de transporte a la primera unidad de atención fue mayor para niños inscritos en el Seguro Popular y hubo tiempos de espera más largos en unidades de salud del sector público, especialmente entre niños que tuvieron tiempos de transporte largos. Conclusión: Proporcionar recursos que permitan a los cuidadores acceder a los servicios de salud de manera oportuna puede reducir las demoras en la búsqueda de atención.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico.

OBJECTIVE: We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death. MATERIALS AND METHODS: Cross-sectional study compris-ing household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility. RESULTS: Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time. CONCLUSIONS: Providing resources to enable caregiv-ers to access health services in a timely manner may reduce delays in seeking care.

Epidemiología de la hipertensión arterial en adultos mexicanos: diagnóstico, control y tendencias. Ensanut 2020.

Objetivo. Describir la prevalencia de hipertensión arterial (HTA) en adultos mexicanos, la proporción que tiene tensión arterial (TA) controlada y la tendencia en el periodo 2018-2020. Material y métodos. Se midió la TA a 9 844 adultos en la Encuesta Nacional de Salud y Nutrición (Ensanut) 2020. Se consideró que tenían HTA o TA controlada cuando cumplían los criterios del Seventh Joint National Committee (JNC-7) o American Heart Association (AHA). Resultados. La prevalencia de HTA fue 49.4% (según AHA), de los cuales 70% desconocía su diagnóstico. Según la clasificación JNC-7, 30.2% de los adultos tenía HTA y 51.0% ignoraba su diagnóstico. Entre adultos con diagnóstico previo de HTA, 54.9% tuvo TA controlada. Entre el periodo 2018-2020 no se observaron cambios en las prevalencias. Conclusiones. Al menos un tercio de los adultos mexicanos tiene HTA y de ellos al menos la mitad no habían sido diagnosticados. Debe evaluarse la pertinencia de los actuales programas de diagnóstico de HTA porque el subdiagnóstico y mal control pueden ocasionar complicaciones y la muerte.

Bringing a health systems modelling approach to complex evaluations: multicountry applications in HIV, TB and malaria.

INTRODUCTION: Understanding how to deliver interventions more effectively is a growing emphasis in Global Health. Simultaneously, health system strengthening is a key component to improving delivery. As a result, it is challenging to evaluate programme implementation while reflecting real-world complexity. We present our experience in using a health systems modelling approach as part of a mixed-methods evaluation and describe applications of these models. METHODS: We developed a framework for how health systems translate financial inputs into health outcomes, with in-country and international experts. We collated available data to measure framework indicators and developed models for malaria in Democratic Republic of the Congo (DRC), and tuberculosis in Guatemala and Senegal using Bayesian structural equation modelling. We conducted several postmodelling analyses: measuring efficiency, assessing bottlenecks, understanding mediation, analysing the cascade of care and measuring subnational effectiveness. RESULTS: The DRC model indicated a strong relationship between shipment of commodities and utilisation thereof. In Guatemala, the strongest model coefficients were more evenly distributed. Results in Senegal varied most, but pathways related to community care had the strongest relationships. In DRC, we used model results to estimate the end-to-end cost of delivering commodities. In Guatemala, we used model results to identify potential bottlenecks and understand mediation. In Senegal, we used model results to identify potential weak links in the cascade of care, and explore subnationally. CONCLUSION: This study demonstrates a complementary modelling approach to traditional evaluation methods. Although these models have limitations, they can be applied in a variety of ways to gain greater insight into implementation and functioning of health service delivery.

Advances and challenges on the path toward the SDGs: subnational inequalities in Mexico, 1990-2017.

BACKGROUND: The sustainable development goals (SDGs) have generated momentum for global health, aligning efforts from governments and international organisations toward a set of goals that are expected to reflect improvements in life conditions across the globe. Mexico has huge social inequalities that can affect access to quality care and health outcomes. The objective of this study is to analyse inequalities among Mexico's 32 states on the health-related SDG indicators (HRSDGIs) from 1990 to 2017. METHODS: These analyses rely on the estimation of HRSDGIs as part of the Global Burden of Disease study 2017. We estimated the concentration index for 40+3 HRSDGI stratified by Socio-demographic Index and marginalisation index, and then for indicators where inequalities were identified, we ran decomposition analyses using structural variables such as gross domestic product per capita, poverty and health expenditure. FINDINGS: Mexico has made progress on most HRSDGIs, but current trends in improvement do not appear to fast enough to meet 2030 targets. Out of 43 HRSDGIs, we identified evidence of inequality between Mexico's states for 30 indicators; of those, 23 HRSDGIs were unequal distributed affecting states with lower development and seven affecting states with higher development. The decomposition analysis indicates that social determinants of health are major drivers of HRSDGI inequalities in Mexico. INTERPRETATION: Modifying current trends for HRSDGIs will require subnational-level and national-level policy action, of which should be informed by the latest available data and monitoring on the health-related SDGs. The SDGs' overarching objective of leaving no-one behind should be prioritised not only for individuals but also for communities and other subnational levels.

Unintentional injuries in Mexico, 1990-2017: findings from the Global Burden of Disease Study 2017.

BACKGROUND: To date, the burden of injury in Mexico has not been comprehensively assessed using recent advances in population health research, including those in the Global Burden of Disease Study 2017 (GBD 2017). METHODS: We used GBD 2017 for burden of unintentional injury estimates, including transport injuries, for Mexico and each state in Mexico from 1990 to 2017. We examined subnational variation, age patterns, sex differences and time trends for all injury burden metrics. RESULTS: Unintentional injury deaths in Mexico decreased from 45 363 deaths (44 662 to 46 038) in 1990 to 42 702 (41 439 to 43 745) in 2017, while age-standardised mortality rates decreased from 65.2 (64.4 to 66.1) in 1990 to 35.1 (34.1 to 36.0) per 100 000 in 2017. In terms of non-fatal outcomes, there were 3 120 211 (2 879 993 to 3 377 945) new injury cases in 1990, which increased to 5 234 214 (4 812 615 to 5 701 669) new cases of injury in 2017. We estimated 2 761 957 (2 676 267 to 2 859 777) disability-adjusted life years (DALYs) due to injuries in Mexico in 1990 compared with 2 376 952 (2 224 588 to 2 551 004) DALYs in 2017. We found subnational variation in health loss across Mexico's states, including concentrated burden in Tabasco, Chihuahua and Zacatecas. CONCLUSIONS: In Mexico, from 1990 to 2017, mortality due to unintentional injuries has decreased, while non-fatal incident cases have increased. However, unintentional injuries continue to cause considerable mortality and morbidity, with patterns that vary by state, age, sex and year. Future research should focus on targeted interventions to decrease injury burden in high-risk populations.

Access and use of oxytocin for postpartum haemorrhage prevention: a pre-post study targeting the poorest in six Mesoamerican countries.

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.

Evaluación de procesos de una intervención: actividad física durante el embarazo y postparto / Avaliação dos processos de uma intervenção: atividade física durante a gravidez e o pós-parto / Evaluation of intervention processes: physical activity during pregnancy and postpartum

Objetivo: Evaluar los procesos de una intervención de actividad física durante el embarazo y postparto. Métodos: En el contexto de un programa social que combate la pobreza extrema, las beneficiarias (n=927) recibieron una intervención que consistió en la promoción de la práctica de actividad física, a través de consejería, talleres y materiales educativos. En 2008-9, 2010 y 2012 se visitaron unidades de salud urbanas y rurales, seleccionadas aleatoriamente, de cuatro entidades federativas de México. Se recolectó información de procesos a través de prestadores de servicios de salud, observación en consulta y aplicación de encuestas de salida a beneficiarias. Se estudiaron cuatro indicadores de implementación de la intervención: fidelidad a actividades planeadas; dosis entregada a la población; alcance de la población objetivo; y recepción de la intervención por embarazadas y en el posparto de las participantes. Resultados: Se visitaron unidades de salud en la etapa inicial (n=91), intermedia (n=47) y final (n=82) del estudio. La dosis liberada presentó un nivel del 81-86% de implementación. La fidelidad presentó <50% de implementación; se observaron mejoras significativas en la mayoría de los aspectos evaluados entre las diferentes etapas del estudio como en la capacitación de los prestadores de servicios de salud, el suministro de materiales, la consejería e la impartición de talleres en las unidades de salud. Conclusión: Se observaron importantes retos de implementación y contextuales para la implementación efectiva de la intervención de actividad física en los servicios de salud.

Objetivo: Avaliar os processos de uma intervenção de atividade física durante a gravidez e o pós-parto. Métodos: No contexto de um programa social de combate à pobreza extrema, as beneficiárias (n=927) receberam uma intervenção que consistia na promoção da prática de atividade física por meio de aconselhamento, oficinas e materiais educacionais. Em 2008-9, 2010 e 2012, foram visitadas unidades de saúde urbanas e rurais, selecionadas aleatoriamente, de quatro entidades federais do México. As informações do processo foram coletadas por prestadores de serviços de saúde, durante observação de consultas e através da aplicação de questionários às beneficiárias. Foram estudados quatro indicadores de implementação da intervenção: fidelidade às atividades planejadas, dose entregue à população, escopo da população-alvo, e acolhimento da intervenção por gestantes e puérperas. Resultados: As unidades de saúde foram visitadas nas etapas inicial (n = 91), intermediária (n = 47) e final (n = 82) do estudo. A dose liberada mostrou um nível de implementação de 81-86%. A fidelidade apresentou <50% de implementação e melhorias significativas foram observadas na maioria dos aspectos avaliados entre as diferentes etapas do estudo, como treinamento de prestadores de serviços de saúde, fornecimento de materiais, aconselhamento e realização de oficinas nas unidades de saúde. Conclusão: Importantes implementações e desafios contextuais foram observados para a efetiva implementação da intervenção de atividade física para beneficiárias dos serviços de saúde investigados.

Objective: To evaluate the process of an intervention on physical activity during pregnancy and postpartum. Methods: In the context of a social program that fights extreme poverty, the beneficiaries (n=927) receive an intervention that consists of the promotion of the practice of physical activity, through counseling, workshops, and educational materials. During 2008-9, 2010 and 2012, we visited health units from urban and rural areas, randomly selected from four states of Mexico. Health service providers collected process data during observation of consultations and through the application of questionnaires to the beneficiaries. Four indicators of implementation of the intervention were studied: fidelity to the planned activities, dose delivered to the population, scope of the target population, and reception of the intervention by pregnant women and postpartum women. Results: Health units were visited in the initial (n=91), intermediate (n=47), and final (n=82) stages of the study. The delivered dose showed an implementation level of 81-86%. Fidelity had <50% implementation and significant improvements were observed in most analyzed aspects between the different stages of the study, such as training of health service providers, the supply of materials, counseling, and workshops in health units. Conclusion: Important Implementation and contextual challenges were observed for the effective fulfillment of the intervention of physical activity into primary healthcare services.

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.

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.

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

BACKGROUND: Evaluation 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. METHODS: We 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. RESULTS: 14 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%. CONCLUSIONS: It 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.

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.

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

BACKGROUND: Recent 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. METHODS: A 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. RESULTS: The 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). CONCLUSION: Serum concentration of uric acid is associated with 10-year global CR among individuals with high levels of physical inactivity.

[Effect of a community-based intervention to improve the knowledge on the warning signs of maternal complications among Mayan women from Yucatan randomized controlled trial]. / Efecto de una intervención comunitaria para mejorar conocimientos sobre signos de alarma de complicaciones maternas en mujeres mayas de Yucatán, ensayo controlado, aleatorizado.

OBJECTIVE: To evaluate a community-based intervention aimed to improve women's knowledge on alarm signs for preeclampsia-eclampsia, obstetrical hemorrhage, and puerperal sepsis, in Mayan pregnant women in the state of Yucatan, Mexico, in 2008, using participatory methodology. MATERIAL AND METHODS: Community-based randomized controlled trial, with experimental (n = 28) and control (n = 28) groups. Participatory strategies with translators of Mayan language were used. Analysis of differences in differences was carried out to evaluate the effect of intervention. RESULTS: The intervention increased knowledge on alarm signs for preeclampsia-eclampsia in 42.9% (p = 0.012), obstetrical hemorrhage in 32.1% (p = 0.071) and puerperal sepsis in 25.0% (p = 0.659). Control group increased 32.1% (p = 0.033) knowledge on alarm signs for puerperal sepsis. Overall effect of intervention was 33.3% (p = 0.007). CONCLUSIONS: The community-based intervention improved overall knowledge of women on alarm signs and specific knowledge on alarm signs for preeclampsia-eclampsia. It is necessary to spread this methodology, so that a greater number of women of the community will also be benefitted with the intervention.

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.

[Situational profile and intervention strategy in the Mesoamerican region in maternal, neonatal and reproductive health area]. / Perfil situacional y estrategias de intervención en la región Mesoamericana en el área de salud materna, reproductiva y neonatal.

To present the main results of the regional situation diagnosis and intervention plan developed in 2010 as part of the planning activities of the Mesoamerican Health System by the Working Group on Maternal, Reproductive and Neonatal Health. A group of experts and representatives from countries in the region (Central America and nine southern Mexican states) conducted an exhaustive review of available data to construct a situational analysis and a review of effective practices for improving maternal, reproductive and neonatal health. Finally, the group proposed a regional action plan, defining regional goals and specific interventions. The situational diagnosis suggests that, although there has been progress in the last 10 years, maternal and neonatal mortality rates are still unnaceptably high in the region, with a substantial variability across countries. The group proposed as a regional goal the reduction of maternal and neonatal mortality in accordance with the Millenium Development Goals. The regional plan recommends specific maternal and neonatal health interventions emphasizing obstetric and neonatal emergency care, skilled birth attendance and family planning. The plan also includes a five year implementation strategy, along with training and evaluation strategies. The regional plan for maternal, neonatal and reproductive health has the potential to be successful, provided it is effectively implemented.

Perfil situacional y estrategias de intervención en la región mesoamericana en el área de salud materna, reproductiva y neonatal / Situational profile and intervention strategy in the Mesoamerican region in maternal, neonatal and reproductive health area

Presentar los principales resultados del diagnóstico 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 conformó un grupo de expertos y de representantes de los países de la región (que incluye Centroamérica y nueve estados del sur de México). Se hizo una revisión documental para conformar un diagnóstico situacional, una revisión de prácticas efectivas y se conformó un plan regional de acción. El diagnóstico situacional indica que las tasas de mortalidad materna y neonatal se mantienen inaceptablemente altas en la región. Se propuso como meta regional reducir la mortalidad materna y neonatal de acuerdo a los Objetivos de Desarrollo del Milenio. Se conformó un plan regional que identifica intervenciones específicas en SMRN con énfasis en la atención adecuada a las emergencias obstétricas y neonatales, atención calificada al nacimiento, y en planificación familiar. Se sugiere asimismo un plan de implementación a cinco años y una estrategia de evaluación y de capacitación. El plan regional en SMRN puede tener éxito siempre y cuando los aspectos de implementación sean atendidos debidamente.

To present the main results of the regional situation diagnosis and intervention plan developed in 2010 as part of the planning activities of the Mesoamerican Health System by the Working Group on Maternal, Reproductive and Neonatal Health. A group of experts and representatives from countries in the region (Central America and nine southern Mexican states) conducted an exhaustive review of available data to construct a situational analysis and a review of effective practices for improving maternal, reproductive and neonatal health. Finally, the group proposed a regional action plan, defining regional goals and specific interventions. The situational diagnosis suggests that, although there has been progress in the last 10 years, maternal and neonatal mortality rates are still unnaceptably high in the region, with a substantial variability across countries. The group proposed as a regional goal the reduction of maternal and neonatal mortality in accordance with the Millenium Development Goals. The regional plan recommends specific maternal and neonatal health interventions emphasizing obstetric and neonatal emergency care, skilled birth attendance and family planning. The plan also includes a five year implementation strategy, along with training and evaluation strategies. The regional plan for maternal, neonatal and reproductive health has the potential to be successful, provided it is effectively implemented.

Early hospital discharge and early puerperal complications.

OBJECTIVE: To evaluate the association between time of postpartum discharge and symptoms indicative of complications during the first postpartum week. MATERIALS AND METHODS: Women with vaginal delivery at a Mexico City public hospital, without complications before the hospital discharge, were interviewed seven days after delivery. Time of postpartum discharge was classified as early (<24 hours) or late (>25 hours). The dependent variable was defined as the occurrence and severity of puerperal complication symptoms. RESULTS: Out of 303 women, 208 (68%) were discharged early. However, women with early discharge and satisfactory prenatal care had lower odds of presenting symptoms in early puerperium than women without early discharge and inadequate prenatal care (OR 0.36; 95% confidence intervals = 0.17-0.76). CONCLUSIONS: There was no association between early discharge and symptoms of complications during the first postpartum week; the odds of complications were lower for mothers with early discharge and satisfactory prenatal care.