Prevalence, Disparities, And Determinants Of Primary Cesarean Births Among First-Time Mothers In Mexico.

Mexico has the second-highest prevalence of cesarean deliveries in the Americas, behind Brazil. Having had a previous cesarean delivery is highly predictive of having subsequent cesarean deliveries, yet evidence on the drivers of primary (that is, first-time) cesarean deliveries is sparse. Using 2014 Mexican birth certificate data and performing population-level analyses of data on 600,124 first-time mothers giving birth after at least thirty-seven weeks of gestation, we examined the prevalence and determinants of primary cesarean deliveries. We found a very high prevalence of cesarean deliveries among these women-48.7 percent-and wide variations across insurance coverage types. Enrollees in Seguro Popular, the public health insurance program introduced in 2003 for the previously uninsured and gradually rolled out nationally, had a cesarean rate of 40 percent, while women insured through the Social Security Institute for Civil Servants had a rate of 78 percent. The lower risk of primary cesarean deliveries among Seguro Popular enrollees persisted after adjustment for covariates. Rates of primary cesarean deliveries were particularly high in private birthing facilities for all first-time mothers. Reducing the rate of cesarean deliveries in Mexico will require interventions across types of insurance and birthing facilities and will also require targeted public health messaging.

Mexico's Seguro Popular Appears To Have Helped Reduce The Risk Of Preterm Delivery Among Women With Low Education.

Beginning in 2001 Mexico established Seguro Popular, a health insurance scheme aimed at providing coverage to its large population of uninsured people. While recent studies have evaluated the health benefits of Seguro Popular, evidence on perinatal health outcomes is lacking. We conducted a population-based study using Mexican birth certificate data for 2010 to assess the relationship between enrollment in Seguro Popular and preterm delivery among first-time mothers with singleton births in Mexico. Seguro Popular enrollees with no formal education had a far greater reduction in risk of preterm delivery, while enrollees with any formal education experienced only slight reduction in risk, after maternal age, marital status, education level, mode of delivery, and trimester in which prenatal care was initiated were controlled for. Seguro Popular appears to facilitate access to health services among mothers with low levels of education, reducing their risk for preterm delivery. Providing broad-scale health insurance coverage may help improve perinatal health outcomes in this vulnerable population.

Preterm delivery among first-time Mexico-born mothers: a binational population-based comparison of deliveries in California and Mexico.

BACKGROUND: While studies have attributed the favourable birth outcomes of Mexico-born mothers in the USA to a 'healthy immigrant effect' that confers protection to immigrants, a comparison of immigrants with the source population in Mexico has been lacking. We compared preterm delivery (PTD) rates of Mexico-born immigrants who delivered in California with Mexico-born women who delivered in Mexico (WIMX) and with a subgroup who delivered in the five top immigrant sending states in Mexico. METHODS: Using 2009 birth records, we selected all live-born singletons of primiparous WIMX (699 129) and immigrants in California (33 251). We examined the unadjusted and adjusted association between place of delivery and any PTD (<37 weeks gestation), including PTD subcategories (early, moderate, late), using relative risks (RR) and 95% CIs. Multivariate models controlled for demographic and health system characteristics. RESULTS: PTD rates were higher among immigrants in California (6.7%) than WIMX (5.8%) and compared to women in the sending states (5.5%). The unadjusted risk of any PTD (RR=1.17 (1.12 to 1.22)), early/moderate PTD (<34 weeks gestation; RR=1.27 (1.18 to 1.38)) and late PTD (34-36 weeks; RR=1.14 (1.08 to 1.19)) was higher for immigrants than for WIMX and remained higher when controlling for age, education and healthcare variables. Birth weight <1500 g was also higher among immigrants (RR=1.27 (1.14 to 1.44)). Similar patterns were observed when comparing women in the sending states. CONCLUSIONS: We found no evidence of a 'healthy immigrant effect'. Further research must assess the comparability of gestational-age data in Mexican and Californian birth certificates.

Where to deploy pre-exposure prophylaxis (PrEP) in sub-Saharan Africa?

OBJECTIVE: Two randomised controlled trials showed that pre-exposure prophylaxis (PrEP) reduces HIV transmission between heterosexual men and women. We model the potential impact on transmission and cost-effectiveness of providing PrEP in sub-Saharan Africa. METHODS: We use a deterministic, compartmental model of HIV transmission to evaluate the potential of a 5-year PrEP intervention targeting the adult population of 42 sub-Saharan African countries. We examine the incremental impact of adding PrEP at pre-existing levels of male circumcision and antiretroviral therapy (ART). The base case assumes efficacy of 68%; adherence at 80%; country coverage at 10% of the HIV-uninfected adult population; and annual costs of PrEP and ART at US$200 and US$880 per person, respectively. RESULTS: After 5 years, 390,000 HIV infections (95% UR 190,000 to 630,000) would be prevented, 24% of these in South Africa. HIV infections averted per 100 000 people (adult) would range from 500 in Lesotho to 10 in Somalia. Incremental cost-effectiveness would be US$5800/disability-adjusted life year (DALY) (95% UR 3100 to 13500). Cost-effectiveness would range from US$500/DALY in Lesotho to US$44 600/DALY in Eritrea. CONCLUSIONS: In a general adult population, PrEP is a high-cost intervention which will have maximum impact and be cost-effective only in countries that have high levels of HIV burden and low levels of male circumcision in the population. Hence, PrEP will likely be most effective in Southern Africa as a targeted intervention added to existing strategies to control the HIV pandemic.

Setting priorities for safe motherhood interventions in resource-scarce settings.

OBJECTIVE: Guide policy-makers in prioritizing safe motherhood interventions. METHODS: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models. RESULTS: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph). CONCLUSIONS: The combination of interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk. Those which save the most number of lives in each model are 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for LOW; 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for MED; and 'fpsa, anc-miso, sepsis, eclampsia treatment, safe delivery' for HIGH settings. Safe motherhood interventions save a significant number of newborn lives.

Non-medical prescribing in nurse-led community leg ulcer clinics.

Over the past decade, nurse prescribing in the community has improved clinical care, providing timely access to many products required for patients to receive appropriate treatment. Until recently, nurses who have qualified as nurse prescribers have only been able to prescribe from a limited list of products. Within the leg ulcer clinic environment, the majority of prescriptions written have been related to wound care. This article describes the introduction of extended independent prescribing (now known as non-medical prescribing) and how this type of prescribing has scope for revolutionizing clinical practice in all healthcare settings. There are, however, many contentious issues for clinicians prescribing in this new role, including systems for communication, clinical governance, and attitudes of other professionals.

Acculturation and its association with health-risk behaviors in a rural Latina population.

PURPOSE: To evaluate the performance of proxy measures of acculturation and to examine the association between acculturation and selected health-risk behaviors. METHODS: Participants were 1062 Latina pregnant women who received prenatal care at clinics in San Joaquin County, California between 1999 and 2001. We used the receiver-operating characteristic (ROC) curve to characterize the sensitivity and specificity of proxy measures and regression analysis to examine health-risk behaviors. RESULTS: Using the ARSMA-II short version scale as a reference, age at immigration had the highest percentage of correctly classified individuals. Acculturation was significantly associated with a lifetime history of substance use, risky sexual behavior, low fruit consumption, and high fast-food meal consumption. CONCLUSIONS: Acculturation is an important predictor of health-risk behavior among women. Further research is needed to better understand the phenomenon and to avert associated adverse health consequences.

Ability to pay for maternal health services: what will it take to meet who standards?

High maternal morbidity and mortality in many developing countries are highly associated with poor access to and quality of health care. Here we review the economic feasibility of the WHO's mother-baby package as a means of reducing maternal and neonatal mortality and morbidity in Tanzania. This paper examines the costs of maternal health care in Tanzania, and how much can we expect households to contribute to these expenses, if the MBP were implemented. Using data from the Tanzanian 1993 Living Standard Measurement Survey (LSMS), we analyze responses from 757 women of reproductive age who have had a birth in the 12 months preceding the survey. We estimate current spending on maternal health care by different socio-economic groups and its share in relation to total household expenditures. Using logistic regression analyses, we examine the effect of the prices paid for maternal health care on the likelihood of using antenatal and safe delivery services, controlling for relevant socio-economic and demographic factors. Results show that if the MBP recovered 100% of its costs, most of the households would have to allocate more than half of their annual consumption on maternal health care. Poor socio-economic groups would experience the greatest increase in service utilization if MBP care were subsidized. In the face of scarce resources, subsidies should be targeted according to socio-economic group, in order to attain equitable and sustainable maternal health services.

A comparison of cost-effectiveness of three protocols for diagnosis and treatment of gonococcal and chlamydial infections in women in Africa.

BACKGROUND: The cost-effectiveness of different STD diagnosis and treatment approaches has not been evaluated previously. GOALS: The goals of the study were to compare the cost-effectiveness of "gold standard" care (GS), syndromic management (SM), and mass treatment (MT) protocols for the treatment of cervical gonococcal and chlamydial infections in a hypothetical model of 1 million women in Africa. STUDY DESIGN: A decision tree model was constructed for each of the protocols. Sensitivity analyses were conducted and 10,000 Monte Carlo simulations were run to test the robustness of the cost-effectiveness estimates to changes in underlying assumptions. RESULTS: MT with doxycycline for chlamydia was the most cost-effective protocol in terms of cost per cure. SM protocol had the lowest total programmatic costs. For the GS protocol, using azithromycin for chlamydial infections was found to be more cost-effective than using doxycycline. For both the GS and SM protocols, the total cost of the program was most sensitive to the percentage of women seeking STD treatment and the prevalence of non-STD vaginal discharge, whereas the cost of MT was almost exclusively determined by coverage rates. CONCLUSIONS: No single protocol carries with it all the desired conditions of an optimal cost-effective program. The treatment-seeking behavior, STD prevalence, and coverage of each locale must be evaluated to determine the most cost-effective and highest impact program. MT was found to be the most cost-effective protocol in terms of cost per woman treated when compared with the SM and GS protocols for STDs in women.