The effects of cash transfers on adult and child mortality in low- and middle-income countries.

Poverty is an important social determinant of health that is associated with increased risk of death1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

Uterine fibroid: a socially malignant illness in Haiti.

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

Assessing burden, risk factors, and perceived impact of uterine fibroids on women's lives in rural Haiti: implications for advancing a health equity agenda, a mixed methods study.

BACKGROUND: Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women's lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk factors of uterine fibroids, as well as their effects on women's quality of life. METHODS: A convergent mixed methods study was conducted between October 1, 2019 and January 31, 2020 at MUH's (Mirebalais University Hospital) OB-GYN outpatient department. Quantitatively, in a cross-sectional study 211 women completed consecutively a structured questionnaire. In-depth interviews with 17 women with fibroids and 7 family members were implemented for the qualitative component. Descriptive statistics were calculated for clinical and social demographic variables. Logistic regression was performed to examine associations between fibroids and related risk factors. An inductive thematic process was used to analyze the qualitative data. A joint display technique was used to integrate the results. RESULTS: Of 193 women analyzed 116 had fibroids (60.1%). The mean age was 41.3. Anemia was the most frequent complication- 61 (52.6%). Compared to women without uterine fibroids, factors associated with uterine fibroids included income decline (AOR = 4.7, 95% CI: 2.1-10.9, p = < 0.001), excessive expenses for transport (AOR = 4.4, 95% CI: 1.6-12.4, p = 0.005), and family history with uterine fibroids (AOR = 4.6, 95% CI: 1.6-13.6, p = 0.005). In contrast, higher level of education and micro polycystic ovarian syndrome were associated with lower prevalence (AOR = 0.3, 95% CI: 0.1-0.9, p = 0.021) and (AOR = 0.2, 95% CI: 0.1-0.97, p = 0.044), respectively. The qualitative findings delineate how contextual factors such as health system failures, long wait times, gender inequality and poverty negatively affect the quality of women's lives. The poverty cycle of uterine fibroids emerged. CONCLUSIONS: A vicious cycle of poverty negatively impacts access to care for uterine fibroids in Haiti. Health insurance, social support, and income generating activities may be keys to promote social justice through access to adequate care for women with uterine fibroids in Haiti.

A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti.

BACKGROUND: In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency. METHODS: A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee. FINDINGS: The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%). INTERPRETATION: Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings. FUNDING: Boston Children's Hospital, Harvard Business School, and Partners in Health.

A case of placental site trophoblastic tumor managed in a low resource setting.

Placental trophoblastic site tumor (PSTT) is a rare type of gestational trophoblastic neoplasia (GTN). PSTT has a higher mortality than other types of gestational trophoblastic disease (GTD), with a rate of 16.1%, due to its relatively unpredictable behavior and reduced response to chemotherapy. Its diagnostic and management are very challenging in Low resources settings particularity in Haiti where MRI, PET Scan and IHC are not available. Further, the follow-up is very difficult because of social, political, and economic issues limiting the capacity of our patients to be present at all scheduled visits. No case of PSTT has been publicly described yet the Haitian experience in the literature in the management of such case compared to the developed world. We present a case of PSTT successfully diagnosed and managed at Mirebalais University Hospital (MUH) in Haiti with the support of telepathology and intentional partners while highlighting the difference that we observed compare to the developed world.

Reframing the Three Delays framework: factors influencing referrals to facilities by matrones in rural Haiti.

In Haiti, there has been limited research on the experiences of traditional birth attendants/matrones when they decide to refer and accompany pregnant women to the facility for giving birth. Understanding this contextualised experience could help to strengthen programming aimed at improving maternal, neonatal, and child health (MNCH) outcomes in rural Haiti. This paper describes the qualitative findings from seven focus group discussions (FGDs) with matrones regarding their experience of referring pregnant women to facilities in Haiti's Central Plateau. Each FGD was conducted in Haitian Kreyol and audio recorded. Recordings were transcribed, translated to English, and thematically analysed. A conceptual model visualising factors influencing matrone decision-making was then developed using an adapted version of the Three Delays framework. Findings from this study show that matrones face a complex, multilayered web of intertwining factors related to attitudes and beliefs around their role, resource availability, and perceptions around quality of care and treatment. Each factor corresponds to a delay in the Three Delays framework. The factors can occur at the same time or each can occur individually at different times, and influence the decision to refer. The complexity of factors identified reflects the need to reassess the Three Delays framework so that it accounts for the intertwining, cyclical complexities faced by those trying to access the facility amidst the backdrop of both time and the community/social contexts. Results further reflect the need for strengthened health systems that better facilitate matrone facility-based referrals, improving outcomes for all parties involved and bridging the gap between homes/ communities and facilities. This calls for better integration of the matrones into the formal health system to systematically strengthen the continuum of MNCH health services provided from home to facility.

Amniocele associated with placental abruption: a case report.

Amniocele is a rare condition involving herniation of the amniotic sac through a uterine breach. Our case is of a 29-year-old pregnant woman at 31 weeks of pregnancy who presented to the maternity triage of the Mirebalais Teaching Hospital for abdominal pain and the passage of blood through the vagina. After an ultrasonographic evaluation, the diagnosis of amniocele was made. In practice, for a third-trimester, nonlaboring pregnant woman with this symptomatology, the most common diagnoses that come to mind are placenta previa and placental abruption. This case highlights that a diagnosis of silent uterine rupture should also be kept in mind knowing that a uterine rupture is a life-threatening event for both the mother and the fetus, therefore, early diagnosis is very important to improve the maternal-fetal prognosis.

Vulvar leiomyosarcoma: A case report.

Vulvar leiomyosarcoma is a rare malignant smooth muscle tumor and the most common type of vulvar sarcoma. It can mimic benign tumors, and misdiagnosis may delay appropriate treatment. A 35-year-old woman presented to the outpatient gynecology clinic at the Mirebalais Teaching Hospital for a right vulvar mass. A complete excision of the mass was performed. Histopathology with immunohistochemistry demonstrated leiomyosarcoma. We describe the contextual challenges that ultimately compromised her care, highlighting the challenges to safe delivery of cancer care in our setting.

Quality improvement initiative reduces overcrowding on labour and delivery unit in a university hospital in Haiti.

BACKGROUND: Following the first COVID-19 peak in 2020, came the seasonal childbirth peak at Hôpital Universitaire de Mirebalais (HUM). This peak is associated with overcrowding on the labour and delivery (L&D) ward. Lack of sufficient bed-space for sick neonates in the neonatal ICU at HUM, has led to overcrowding and lengthy stays of sick newborns on L&D. These conditions contribute to the subsequent lack of bed-space for newly postpartum mothers and potentially decreases quality of care for both new mothers and neonates. METHODS: A Maternity Task Force was created by hospital leadership to address these urgent needs. The team's objective was to eliminate mothers and newborns laying on the floor in L&D. The Six-Sigma/DMAIC quality improvement methodology was used as the problem was urgent, demanded rapid results and centred around the process of patient flow in the institution. Process flow chart and Ishikawa diagrams were used to identify the root causes of the issues. RESULTS: An average of 22% of postpartum women did not have a bed preintervention and 0% of postpartum women were laying on the floor post intervention. An average of 33% of newborns received paediatric care on the maternity ward pre-intervention compared with an average of 17% postintervention. The team did not achieve its objective for this second indicator, which was to have less than 10% of sick newborns on the maternity ward receiving paediatric care. CONCLUSION: HUM hospital leadership took the vital decision to form the Maternity Task Force to make changes, which consequently led to a sustainable positive and lasting impact on the lives of new mothers and their babies at the institution. The objective of 0 postpartum mothers and newborns on the ground was achieved and fewer newborns receive intensive paediatric care on the maternity ward as a result of our interventions.

Food insecurity as a risk factor for preterm birth: a prospective facility-based cohort study in rural Haiti.

INTRODUCTION: Haiti has an estimated neonatal mortality rate of 32/1000 live births, the highest in the Western Hemisphere. Preterm birth and being born small for gestational age (SGA) are major causes of adverse neonatal outcomes worldwide. To reduce preterm birth and infants born SGA, it is important to understand which women are most at risk and how risk varies within countries. There are few studies estimating the prevalence and risk factors for these conditions in Haiti, particularly in rural regions. METHODS: We conducted a prospective cohort study of pregnant women at a rural tertiary care centre in Haiti from May to December 2017. We collected data during interviews and from the medical record. We built multivariable models to identify risk factors for preterm birth and being born SGA among women who had a facility-based delivery. RESULTS: 1089 pregnant women delivered at the hospital and were included in this analysis. Median gestational age at delivery was 38 weeks (IQR 36-40). In multivariable analyses, risk factors for preterm birth included maternal age <20 years (adjusted OR (AOR) 1.76, 95% CI 1.14 to 2.72) and >34 years (AOR 1.46, 95% CI 1.01 to 2.11) and severe hunger in the household (AOR 1.57, 95% CI 1.09 to 2.26). Risk factors for SGA were age >34 years (AOR 1.76, 95% CI 1.18 to 2.59), twin pregnancy (AOR 3.28, 95% CI 1.20 to 8.95) and first pregnancy (AOR 1.57, 95% CI 1.12 to 2.23). Number of prior abortions was associated with reduced risk for SGA (AOR 0.41, 95% CI 0.17 to 0.97). CONCLUSIONS: Food insecurity as a risk factor for preterm birth stands out as an important addition to the understanding of the risk of neonatal morbidity and mortality. This association highlights a potentially important intervention target to improve birth outcomes and suggests that food support has an important role to play for pregnant women who are food insecure in low-income settings.

Perceptions of Intra-Uterine Device Users in Mirebalais, Haiti: A Mixed Methods Study.

INTRODUCTION: IUDs are safe, effective, and used worldwide to prevent unintended pregnancy. However, uptake in Haiti is low. There are limited data on IUD choice and experience in low resource settings; anecdotal reports from providers in Haiti have suggested that Haitian women are unlikely to choose to use or be satisfied with the IUD. The objective of this study is to explore the perceptions of a cohort of IUD users in Mirebalais, Haiti. METHODS: In June and July 2015, an IRB-approved mixed methods study of women over age eighteen with hormonal or copper IUDs inserted at Hôpital Universitaire de Mirebalais (HUM) was performed in Mirebalais, Haiti. RESULTS: Twenty-one eligible women participated, out of 58 women identified as eligible. Most women (81%) reported using the copper IUD; most (86%) had used the IUD for 6 months or more. Over half were under 30 years old (62%) and most had completed primary school or less (76%). Almost all (91%) reported prior pregnancies; 65% did not desire more children. The majority of participants were satisfied with the IUD, with 70% being very satisfied and 25% somewhat satisfied. Most women (71%) reported no very bothersome side effects, and would recommend the IUD to others (86%). Qualitative data highlighted positive perceptions of the IUD among users, as well as misperceptions and lack of knowledge regarding the IUD among members of their communities. CONCLUSION/IMPLICATIONS: Understanding of culture-specific perceptions is critical in addressing barriers to IUD uptake. Our findings indicate that IUDs can be an acceptable contraceptive method for women in Haiti, and suggest the possibility that increased access to the IUD may lead to increased acceptance of this method.

Postpartum quality improvement strategy for increasing long-acting contraception uptake at a University Hospital in Haiti.

To address the gap in the uptake of long-acting contraception (LAC) methods among high-risk postpartum women who fail to return for a family planning method at HôpitalUniversitaire de Mirebalais in the Central Plateau Department of Haiti, contraceptive implant trainings were held for providers on the Labour and Delivery, Post-Partum and Internal Medicine inpatient wards. A very high maternal mortality rate affects large numbers of women in Haiti; however, contraceptive use can reduce maternal mortality significantly. A quality improvement strategy to offer LAC methods to immediate postpartum women at a University Hospital in rural Haiti was initiated in March 2016. This new strategy produced an average improvement from 5% to 32% of women delivering at the hospital, accepting a long-acting method (including bilateral tubal ligations) by the end of the project and which has proved sustainable at an average of 20% to date.