[Regional inequalities in access to hospital birth in the state of Rio de Janeiro, Brazil: travel networks, distance, and time (2010-2019)]. / Desigualdades regionais no acesso ao parto hospitalar no Estado do Rio de Janeiro, Brasil: redes de deslocamento, distância e tempo (2010-2019).

Difficult access to birth care services is associated with infant and neonatal mortality and maternal morbidity and mortality. In this study, data from the Brazilian Unified National Health System (SUS) were used to map the evolution of geographic accessibility to hospital birth of usual risk in the state of Rio de Janeiro, Brazil, corresponding to 418,243 admissions in 2010-2011 and 2018-2019. Travel flows, distances traveled, and intermunicipal travel time between the pregnant women's municipality and hospital location were estimated. An increase from 15.9% to 21.5% was observed in the number of pregnant women who needed to travel. The distance traveled increased from 24.6 to 26km, and the travel time from 76.4 to 96.1 minutes, with high variation between Health Regions (HR). Pregnant women living in HR Central-South traveled more frequently (37.4-48.9%), and those living in the HRs Baía da Ilha Grande and Northwest traveled the largest distances (90.9-132.1km) and took more time to get to the hospital in 2018-2019 (96-137 minutes). The identification of municipalities that received pregnant women from many other municipalities and municipalities that treated a higher number of pregnant women (hubs and attraction poles, respectively) reflected the unavailability and disparities in access to services. Regional inequalities and reduced accessibility highlight the need to adapt supply to demand and review the distribution of birth care services in the state of Rio de Janeiro. This study contributes to research and planning on access to maternal and child health services and can be used as a reference study for other states in the country.

A dificuldade de acesso aos serviços de atenção ao parto está associada à mortalidade infantil e neonatal e à morbimortalidade materna. Neste estudo, dados do Sistema Único de Saúde (SUS) foram utilizados para mapear a evolução da acessibilidade geográfica ao parto hospitalar de risco habitual no Estado do Rio de Janeiro, Brasil, correspondentes a 418.243 internações nos biênios 2010-2011 e 2018-2019. Foram estimados os fluxos de deslocamento, as distâncias percorridas e o tempo de deslocamento intermunicipal entre o município de residência e de internação das gestantes. Houve um crescimento de 15,9% para 21,5% na proporção de gestantes que precisaram se deslocar. A distância percorrida aumentou de 24,6 para 26km, e o tempo de deslocamento de 76,4 para 96,1 minutos, com grande variação entre as Regiões de Saúde (RS). As gestantes residentes na RS Centro Sul se deslocaram mais frequentemente (37,4-48,9%), e as residentes nas RS Baía da Ilha Grande e Noroeste percorreram as maiores distâncias (90,9-132,1km) e levaram mais tempo para chegar ao hospital no último biênio (96-137 minutos). A identificação dos municípios que receberam gestantes de muitos outros municípios e daqueles que atenderam maior volume de gestantes (núcleos e polos de atração, respectivamente) refletiu a indisponibilidade e as disparidades no acesso aos serviços. As desigualdades regionais e a redução da acessibilidade alertam para a necessidade de adequar a oferta à demanda e de revisar a distribuição dos serviços de atenção ao parto no Rio de Janeiro. O estudo contribui para as pesquisas e o planejamento sobre o acesso a serviços de saúde materno-infantil, além de servir como referência para outros estados do país.

La dificultad para acceder a los servicios de atención al parto está asociada con la mortalidad infantil y neonatal, y con la morbimortalidad materna. En este estudio, se utilizaron datos del Sistema Único de Salud (SUS) para mapear la evolución de la accesibilidad geográfica al parto hospitalario de riesgo habitual en el estado de Río de Janeiro, Brasil, correspondiente a 418.243 hospitalizaciones en los bienios 2010-2011 y 2018-2019. Se estimaron los flujos de desplazamiento, las distancias recorridas y el tiempo de desplazamiento intermunicipal entre el municipio de residencia y la hospitalización de las mujeres embarazadas. Hubo un aumento del 15,9% al 21,5% en la proporción de mujeres embarazadas que necesitaron desplazarse. La distancia recorrida aumentó de 24,6 a 26km y el tiempo de desplazamiento de 76,4 a 96,1 minutos, con gran variación entre las Regiones de Salud (RS). Las mujeres embarazadas residentes en la RS Centro Sul se desplazaron con mayor frecuencia (37,4-48,9%), y las residentes en las RS Baía da Ilha Grande y Noroeste recorrieron las mayores distancias (90,9-132,1km) y tardaron más en llegar al hospital en el últimos bienio (96-137 minutos). La identificación de los municipios que recibieron mujeres embarazadas de muchos otros municipios y de aquellos que atendieron a un mayor volumen de mujeres embarazadas (núcleos y polos de atracción, respectivamente) reflejó la indisponibilidad y las disparidades en el acceso a los servicios. Las desigualdades regionales y la reducida accesibilidad alertan sobre la necesidad de adaptar la oferta a la demanda, y de revisar la distribución de los servicios de atención al parto en el estado de Rio de Janeiro. El estudio contribuye a las investigaciones y a la planificación sobre el acceso a los servicios de salud materno-infantil, y puede servir como referencia para otros estados del país.

Tackling maternal mortality by improving technical efficiency in the production of primary health services: longitudinal evidence from the Mexican case.

Ensuring regular and timely access to efficient and quality health services reduces the risk of maternal mortality. Specifically, improving technical efficiency (TE) can result in improved health outcomes. To date, no studies in Mexico have explored the connection of TE with either the production of maternal health services at the primary-care level or the maternal-mortality ratio (MMR) in populations without social security coverage. The present study combined data envelopment analysis (DEA), longitudinal data and selection bias correction methods with the purpose of obtaining original evidence on the impact of TE on the MMR during the period 2008-2015. The results revealed that MMR fell 0.36% (P < 0.01) for every percentage point increase in TE at the jurisdictional level or elasticity TE-MMR. This effect proved lower in highly marginalized jurisdictions and disappeared entirely in those with low- or medium-marginalization levels. Our findings also highlighted the relevance of certain social and economic aspects in the attainment of TE by jurisdictions. This clearly demonstrates the need for comprehensive, cross-cutting policies capable of modifying the structural conditions that generate vulnerability in specific population groups. In other words, achieving an effective and sustainable reduction in the MMR requires, inter alia, that the Mexican government review and update two essential elements: the criteria behind resource allocation and distribution, and the control mechanisms currently in place for executing and ensuring accountability in these two functions.

Prenatal care in the Brazilian public health services.

OBJECTIVE: To verify regional inequalities regarding access and quality of prenatal and birth care in Brazilian public health services and associated perinatal outcomes. METHODS: Birth in Brazil was a national hospital-based survey conducted between 2011 and 2012, which included 19,117 women with public-funded births. Regional differences in socio-demographic and obstetric characteristics, as well as differences in access and quality of prenatal and birth care were tested by the χ2 test. The following outcomes were assessed: spontaneous preterm birth, provider-initiated preterm birth, low birth weight, intrauterine growth restriction, Apgar in the 5th min < 8, neonatal and maternal near miss. Multiple and non-conditional logistic regressions were used for the analysis of the associated perinatal outcomes, with the results expressed in adjusted odds ratio and 95% confidence interval. RESULTS: Regional inequalities regarding access and quality of prenatal and birth care among users of public services are still evident in Brazil. Pilgrimage for birth associated with all perinatal outcomes studied, except for intrauterine growth restriction. The odds ratios ranged between 1.48 (95%CI 1.23-1.78) for neonatal near miss and 1.62 (95%CI 1.27-2.06) for provider-initiated preterm birth. Among women with clinical or obstetric complications, pilgrimage for birth associated with provider-initiated preterm birth and with Apgar in the 5th min < 8, odds ratio of 1.98 (95%CI 1.49-2.65) and 2.19 (95%CI 1.31-3.68), respectively. Inadequacy of prenatal care associated with spontaneous preterm birth in both groups of women, with or without clinical or obstetric complications. CONCLUSION: Improvements in the quality of prenatal care, appropriate coordination and comprehensive care at the time of birth have a potential to reduce prematurity rates and, consequently, infant morbidity and mortality rates in the country.

Prenatal care in the Brazilian public health services / Assistência pré-natal na rede pública do Brasil

ABSTRACT OBJECTIVE To verify regional inequalities regarding access and quality of prenatal and birth care in Brazilian public health services and associated perinatal outcomes METHODS Birth in Brazil was a national hospital-based survey conducted between 2011 and 2012, which included 19,117 women with public-funded births. Regional differences in socio-demographic and obstetric characteristics, as well as differences in access and quality of prenatal and birth care were tested by the χ2 test. The following outcomes were assessed: spontaneous preterm birth, provider-initiated preterm birth, low birth weight, intrauterine growth restriction, Apgar in the 5th min < 8, neonatal and maternal near miss. Multiple and non-conditional logistic regressions were used for the analysis of the associated perinatal outcomes, with the results expressed in adjusted odds ratio and 95% confidence interval. RESULTS Regional inequalities regarding access and quality of prenatal and birth care among users of public services are still evident in Brazil. Pilgrimage for birth associated with all perinatal outcomes studied, except for intrauterine growth restriction. The odds ratios ranged between 1.48 (95%CI 1.23-1.78) for neonatal near miss and 1.62 (95%CI 1.27-2.06) for provider-initiated preterm birth. Among women with clinical or obstetric complications, pilgrimage for birth associated with provider-initiated preterm birth and with Apgar in the 5th min < 8, odds ratio of 1.98 (95%CI 1.49-2.65) and 2.19 (95%CI 1.31-3.68), respectively. Inadequacy of prenatal care associated with spontaneous preterm birth in both groups of women, with or without clinical or obstetric complications. CONCLUSION Improvements in the quality of prenatal care, appropriate coordination and comprehensive care at the time of birth have a potential to reduce prematurity rates and, consequently, infant morbidity and mortality rates in the country.

RESUMO OBJETIVO Verificar desigualdades regionais no acesso e na qualidade da atenção ao pré-natal e ao parto nos serviços públicos de saúde no Brasil e a sua associação com a saúde perinatal. MÉTODOS Nascer no Brasil foi uma pesquisa nacional de base hospitalar realizada entre 2011 e 2012, que incluiu 19.117 mulheres com pagamento público do parto. Diferenças regionais nas características sociodemográficas e obstétricas, bem como as diferenças no acesso e qualidade do pré-natal e parto foram testadas pelo teste do χ2. Foram avaliados os desfechos: prematuridade espontânea, prematuridade iniciada por intervenção obstétrica, baixo peso ao nascer, crescimento intrauterino restrito, Apgar no 5º min < 8, near miss neonatal e near miss materno. Para a análise dos desfechos perinatais associados, foram utilizadas regressões logísticas múltiplas e não condicionais, com resultados expressos em odds ratio ajustada e intervalo de confiança de 95%. RESULTADOS As desigualdades regionais ainda são evidentes no Brasil, no que diz respeito ao acesso e qualidade do atendimento pré-natal e ao parto entre as usuárias dos serviços públicos. A peregrinação para o parto se associou a todos os desfechos perinatais estudados, exceto para crescimento intrauterino restrito. As odds ratios variaram de 1,48 (IC95% 1,23-1,78) para near miss neonatal a 1,62 (IC95% 1,27-2,06) para prematuridade iniciada por intervenção obstétrica. Entre as mulheres com alguma complicação clínica ou obstétrica, a peregrinação se associou ainda mais com a prematuridade iniciada por intervenção e com Apgar no 5º min < 8, odds ratio de 1,98 (IC95% 1,49-2,65) e 2,19 (IC95% 1,31-3,68), respectivamente. A inadequação do pré-natal se associou à prematuridade espontânea em ambos os grupos de mulheres CONCLUSÃO Melhorar a qualidade do pré-natal, a coordenação e a integralidade do atendimento no momento do parto têm um impacto potencial nas taxas de prematuridade e, consequentemente, na redução das taxas de morbimortalidade infantil no país.

Witnessing Obstetric Violence during Fieldwork: Notes from Latin America.

Violence against women in labor occurs frequently in Latin America, based on observations from my extensive ethnographic fieldwork in various Latin American countries. In this article, focused on Mexico and the Dominican Republic, I contextualize obstetric violence within the larger context of social exclusion and discrimination against women. I establish associations between maternal deaths and health care systems characterized by a lack of continuum of care, a lack of accountability toward women, and the withholding of care. I argue that clinical staff learn to operate within the structural limitations of health care systems by not assuming the responsibility of the continuum of care that each woman needs, and that this discharge of accountability is at the heart of how health professionals can navigate, tolerate, and perpetuate the structure of the system and, in so doing, create the breeding ground for obstetric violence to occur. Finally, I explain that although reporting on the suffering of women will not, on its own, prevent obstetric violence, increasing its visibility through research can contribute to human rights-based advocacy on behalf of women in labor, to the monitoring of human rights standards, and to the creation of accountability measures within health systems to prevent obstetric violence.

A longitudinal assessment of technical efficiency in the outpatient production of maternal health services in México.

We assess technical efficiency (TE) level for Mexican Ministry of Health (MoH) primary care units. Assessment was focused on the production of adequate maternal health services defined as the coverage level of women who received timely and frequent antenatal care, and institutional and medical care during childbirth. We conducted a longitudinal analysis of administrative and socio-demographic information concerning 233 health jurisdictions for the period 2008-15. Crude TE was calculated using window data envelopment analysis (Windows-DEA). Empirical analysis included the description of several factors affecting the production of maternal health services, including the heterogeneity and trends assessment of TE among health jurisdictions. We estimated a pooled regression model with robust standard errors to identify correlates of TE and estimated adjusted performance scores. Results indicate that while the production of adequate maternal-health services and TE in health jurisdictions proved insufficient, they rose by 22% (from 40.9% to 49.8%) and 14% (from 54.3% to 62%), respectively, over time. Furthermore, variance in efficiency among production units diminished and persistent regularities were observed. Performance was highest in the Northern as opposed to the Southern and Southeastern health jurisdictions, but lowest in the most marginalized zones of the country marked by economic inequality and the presence of indigenous populations. The Mexican Health System has reached a paradoxical situation: the steady escalation of financial resources in the public health subsystem over the past 15 years has yielded sub-optimal results as regards coverage for essential maternal health interventions among the poorest. Mexican government must put in place a set of measures to guarantee efficiency in the system's performance without affecting equity gains. This necessarily involves reconsidering, and where necessary replacing, the criteria behind the allocation and distribution of resources, as well as the mechanisms for controlling how resources are used and accountability is fulfilled.

Professional midwifery in Guatemala: A qualitative exploration of perceptions, attitudes and expectations among stakeholders.

BACKGROUND: Despite recommendations that women give birth with a skilled birth attendant (SBA), 70% of births in Guatemala occur outside health facilities with informally trained traditional birth attendants (TBAs). To increase SBA in rural, indigenous communities, a professional midwifery school accredited by the government is scheduled to open in 2017. Drawing from Filby's model on barriers to the successful integration of professional midwifery into health systems, this paper aims to identify threats - and facilitators-toward professional midwifery's re-introduction in Guatemala. METHODS: To elucidate perceptions, attitudes and expectations towards professional midwifery, qualitative, in-depth interviews were conducted with 32 physicians, nurses, and TBAs in six health centers and with key decision makers and professional midwives (PMs) in Guatemala City. We conducted open and axial coding in Atlas.ti and performed normative comparisons of participants' attitudes, perceptions, and expectations with the National Vision for professional midwifery and relative comparisons within and across disciplinary subgroups. RESULTS: Unprompted, physicians, nurses and TBAs were unable to correctly define professional midwifery. Yet, when professional midwifery was defined for them, they expressed willingness to work with PMs, seeing them as a needed human resource, instrumental in providing intercultural care and strengthening facility relationships with TBAs. Some stakeholders anticipated resistance toward PMs due to provider turf issues. Notable differences in expectations among all groups included ideas for supervision of and by the PMs and the PM's role in monitoring women and conducting births in communities alongside TBAs. CONCLUSIONS: Facilitators to professional midwifery's success include national political will, stakeholders' uniformity of vision, and the potential for improved intercultural care. Barriers are mostly professional in nature, including impediments to autonomous practice by PMs, hierarchical challenges, and turf issues. A specific road map addressing the identified barriers is needed for professional midwifery to succeed in reducing maternal health disparities in Guatemala.

[Inclusion of traditional birth attendants in the public health care system in Brazil: reflecting on challenges]. / Inclusão de parteiras tradicionais no Sistema Único de Saúde no Brasil: reflexão sobre desafios.

The present article describes an experience with traditional birth attendants carried out in the state of Tocantins, Brazil, between 2010 and 2014. The experience was part of a diagnostic project to survey home deliveries in the state of Tocantins and set up a registry of traditional birth attendants for the Health Ministry's Working with Traditional Birth Attendants Program (PTPT). The project aimed to articulate the home deliveries performed by traditional birth attendants to the local health care systems (SUS). Sixty-seven active traditional birth attendants were identified in the state of Tocantins, and 41 (39 indigenous) participated in workshops. During these workshops, they discussed their realities, difficulties, and solutions in the context of daily adversities. Birth attendants were also trained in the use of biomedical tools and neonatal resuscitation. Based on these experiences, the question came up regarding the true effectiveness of the strategy to include traditional birth attendants in the SUS. The present article discusses this theme with support from the relevant literature. The dearth of systematic studies focusing on the impact of PTPT actions on the routine of traditional birth attendants, including perinatal outcomes and remodeling of health practices in rural, riverfront, former slave, forest, and indigenous communities, translates into a major gap in terms of the knowledge regarding the effectiveness of such initiatives.

An adequacy evaluation of a maternal health intervention in rural Honduras: the impact of engagement of men and empowerment of women / Evaluación de la suficiencia de una intervención de salud materna en un entorno rural de Honduras: repercusión de la participación de los hombres y el empoderamiento de las mujeres

Objective. To determine the impact that a 6-year maternal and child health project in rural Honduras had on maternal health services and outcomes, and to test the effect of level of father involvement on maternal health. Methods. This was a program evaluation conducted through representative household surveys administered at baseline in 2007 and endline in 2011 using 30 cluster samples randomly-selected from the 229 participating communities. Within each cluster, 10 households having at least one mother-child pair were randomly selected to complete a questionnaire, for a total of about 300 respondents answering close to 100 questions each. Changes in key outcome variables from baseline to endline were tested using logistic regression, controlling for mother's education and father's involvement. Results. There were improvements in most maternal health indicators, including an increase in women attending prenatal checkups (84% to 92%, P = 0.05) and institutional births (44% to 63%, P = 0.002). However, the involvement of the fathers decreased as reflected by the percentage of fathers accompanying mothers to prenatal checkups (48% to 41%, P = 0.01); the fathers' reported interest in prenatal care (74% to 52%, P = 0.0001); and fathers attending the birth (66% to 54%, P = 0.05). There was an interaction between the fathers' scores and the maternal outcomes, with a larger increase in institutional births among mothers with the least-involved fathers. Conclusions. Rather than the father's involvement being key, changes in the mothers may have led to increased institutional births. The project may have empowered women through early identification of pregnancy and stronger social connections encouraged by home visits and pregnancy clubs. This would have enabled even the women with unsupportive fathers to make healthier choices and achieve higher rates of institutional births.

Objetivo. Determinar la repercusión de un proyecto de salud maternoinfantil de 6 años de duración, en un entorno rural en Honduras, sobre los servicios de salud materna y los resultados asistenciales, y estudiar el efecto del grado de participación del padre en la salud materna. Métodos. El programa se evaluó mediante una serie de encuestas a los hogares representativos administradas al inicio de la intervención, en el 2007, y al concluir en el 2011, con 30 muestras de agrupaciones de familias elegidas al azar entre las 229 comunidades participantes. Dentro de cada agrupación, se seleccionaron aleatoriamente 10 familias compuestas al menos por una madre y un hijo para que contestasen un cuestionario, con lo cual se reunieron en total cerca de 300 personas encuestadas que respondieron casi 100 preguntas cada una. Se analizaron las variaciones en los criterios principales de valoración, entre el inicio y el final de la intervención, mediante técnicas de regresión logística, controlando el nivel educativo de la madre y la participación del padre. Resultados. Se observaron mejoras en la mayoría de los indicadores de salud materna, incluido un aumento de la cantidad de mujeres que acudieron a los controles prenatales (variación de 84% a 92%, P = 0,05) y de los partos atendidos en centros sanitarios (variación de 44% a 63%, P = 0,002). Sin embargo, se redujo la participación del padre, tal como refleja el porcentaje de padres que acompañan a la madre a los controles prenatales (variación de 48% a 41%, P = 0,01), el interés comunicado por el padre en la asistencia prenatal (variación de 74% a 52%, P = 0,0001) y el porcentaje de padres que estuvieron presentes en el parto (variación de 66% a 54%, P = 0,05). Se constató una interacción entre las puntuaciones paternas y los resultados asistenciales maternos, así como un aumento mayor de los partos en centros sanitarios en los casos en que el padre se involucraba menos. Conclusiones. Más que la participación del padre como factor clave, el aumento de los partos asistidos en centros sanitarios puede haberse debido a los cambios en las madres. Es posible que el proyecto empoderase a las mujeres y les permitiese percatarse antes de su embarazo y reforzar sus conexiones sociales con visitas domiciliarias y grupos de embarazadas. Esto habría facilitado, aun en los casos en los que el padre no se involucraba, que las mujeres tomasen decisiones más saludables, y que aumentasen las tasas de partos atendidos en centros sanitarios.

Measuring coverage in MNCH: validating women's self-report of emergency cesarean sections in Ghana and the Dominican Republic.

BACKGROUND: Cesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR). METHODS AND FINDINGS: This study compares hospital-based data, considered the reference standard, against women's self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%, and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results than decision time in Ghana and slightly more favorable results in the Dominican Republic. CONCLUSIONS: Questions used in this study to identify emergency cesarean section are promising but insufficient to promote for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based indicators in advance of data collection and which use a longer recall period are warranted.

Maternity waiting homes and institutional birth in Nicaragua: policy options and strategic implications.

With the aim of promoting institutional births and reducing the high maternal and child mortality rates in rural and poor zones, the government of Nicaragua is supporting the creation of maternity waiting homes. This study analyzes that strategy and examines the factors associated with the use of maternity waiting homes and institutional birth. To that end, we apply a quantitative approach, by means of an econometric analysis of the data extracted from surveys conducted in 2006 on a sample of women and parteras or traditional birth attendants, as well as a qualitative approach based on interviews with key informants. Results indicate that although the operation of the maternity waiting homes is usually satisfactory, there is still room for improvement along the following lines: (i) disseminating information about the homes to both women and men, as the latter frequently decide the course of women's healthcare, and to parteras, who can play an important role in referring women; (ii) strengthening the postpartum care; (iii) ensuring financial sustainability by obtaining regular financial support from the government to complement contributions from the community; and (iv) strengthening the local management and involvement of the regional government. These measures might be useful for health policy makers in Nicaragua and in other developing countries that are considering this strategy.

[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.

[Progress on the Millenium Development Goals 4 and 5 in Mesoamerica]. / Avances en los Objetivos de Desarrollo del Milenio 4 y 5 en Mesoamérica.

OBJECTIVES: To describe the advances made by countries in the Mesoamerican region towards reaching Millenium Development Goals (MDG) 4 and 5, and discuss the most useful tasks to help the region in accomplishing or keeping track of these objectives. MATERIAL AND METHODS: The trend estimates of maternal and under 5 mortality from 1990 to 2008, the effective coverage of vaccination against diphteria, pertussis and tetanus (DPT), prenatal care and childbirth by qualified personnel were taken from the Institute of Health Metrics and Evaluation (IHME) and the causes of death for children under five were taken from the Children's Health Epidemiology Reference Group of WHO (CHERG). RESULTS: The regional trend in the rate of mortality for children under five (MDG-4) in the last 18 years shows an annual reduction of 4.2%, significantly above the global reduction of 2.1%. This suggests that countries of Mesoamerica will be able to fulfill this objective. In contrast, data for 2008 shows that the rate of reduction of maternal mortality is very heterogeneous and it is unlikely that any of the countries in the region will reach this goal. CONCLUSION: Efforts made by countries in Mesoamerica have been substantial in controlling mortality in children under five years but insufficient to achieve MDG-5. Although the tendency is in the right track the reduction rate will only partially fulfill the acquired commitments to eradicate poverty.

Avances en los Objetivos de Desarrollo del Milenio 4 y 5 en Mesoamérica / Progress on the Millenium Development Goals 4 and 5 in Mesoamerica

OBJETIVOS: Presentar los avances realizados en la región mesoamericana en relación con los Objetivos de Desarrollo del Milenio 4 y 5 por medio de su análisis y discutir las intervenciones más relevantes para ayudar en el logro de estos objetivos o, por lo menos, en mantener su trayectoria. MATERIAL Y MÉTODOS: Se utilizaron como fuentes las estimaciones de 1990-2008 sobre mortalidad en menores de cinco años y materna, las coberturas de vacunación contra difteria, tétanos y tosferina (DTP), atención prenatal y atención del parto por personal calificado, realizadas por el Instituto de la Métrica y Evaluación en Salud y las causas de mortalidad en menores de cinco años, realizadas por el Grupo de Referencia sobre Epidemiología y Salud en la Infancia de la OMS (CHERG). RESULTADOS: La tendencia de la tasa de mortalidad de menores de cinco años (ODM-4) muestra una reducción anual de 4.2% en los últimos 18 años, comparada con la reducción global de 2.1%. En contraste, la tasa de descenso de la mortalidad materna (ODM-5) es muy heterogénea y ninguno de los países de la región alcanzará este objetivo. CONCLUSIÓN: Los esfuerzos realizados por los países en Mesoamérica han sido sustantivos en la reducción de mortalidad en menores de cinco años; sin embargo no han sido suficientes para alcanzar la meta programada por el ODM-5. Aunque la tendencia es correcta, el ritmo de descenso cumplirá parcialmente con los compromisos adquiridos para erradicar la pobreza.

OBJECTIVES: To describe the advances made by countries in the Mesoamerican region towards reaching Millenium Development Goals (MDG) 4 and 5, and discuss the most useful tasks to help the region in accomplishing or keeping track of these objectives. MATERIAL AND METHODS: The trend estimates of maternal and under 5 mortality from 1990 to 2008, the effective coverage of vaccination against diphteria, pertussis and tetanus (DPT), prenatal care and childbirth by qualified personnel were taken from the Institute of Health Metrics and Evaluation (IHME) and the causes of death for children under five were taken from the Children's Health Epidemiology Reference Group of WHO (CHERG). RESULTS: The regional trend in the rate of mortality for children under five (MDG-4) in the last 18 years shows an annual reduction of 4.2%, significantly above the global reduction of 2.1%. This suggests that countries of Mesoamerica will be able to fulfill this objective. In contrast, data for 2008 shows that the rate of reduction of maternal mortality is very heterogeneous and it is unlikely that any of the countries in the region will reach this goal. CONCLUSION: Efforts made by countries in Mesoamerica have been substantial in controlling mortality in children under five years but insufficient to achieve MDG-5. Although the tendency is in the right track the reduction rate will only partially fulfill the acquired commitments to eradicate poverty.

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.

[Factors associated with the demand for delivery care in Mexico]. / Factores asociados a la demanda de servicios para la atención del parto en México.

OBJECTIVE: Analyze the factors associated with the utilization of delivery care institutions in Mexico in order to document the functional integration of health institutions. MATERIALS AND METHODS: Based on the 2006 National Health and Nutrition Survey, information from women whose last birth was between 2000 and 2005 was used. Chi square was used to test differences between institutions used and health insurance type. A logistic regression was carried out to identify factors associated with the demand for institutions with which women were not affiliated. RESULTS: Women with social security used in 62% of the cases the institution of their affiliation and 13.4% used public institutions. For uninsured women, 43.3% used public institutions and 19.0% social security institutions; 64.3% of the Seguro Popular affiliates were treated in public institutions. Variables related to access, socioeconomic status and living conditions influenced said demand. CONCLUSIONS: The utilization of an institution of delivery that differed from the one with which the women were affiliated indicates the existence of a de facto functional integration between health institutions in Mexico.

Factores asociados a la demanda de servicios para la atención del parto en México / Factors associated with the demand for delivery care in Mexico

Objetivo. Analizar los factores asociados a la utilización de la institución de atención del parto en México para documentar el proceso de integración funcional de instituciones de salud. Material y métodos. Se utilizó información de mujeres con último parto entre 2000 y 2005 en la Encuesta Nacional de Salud y Nutrición 2006. Se aplicó la prueba de ji cuadrada para probar diferencias entre institución utilizada y aseguramiento. Se usó regresión logística para identificar factores que favorecieron la demanda de instituciones diferentes a las de afiliación de la mujer. Resultados. El 62.6 por ciento de mujeres con seguridad social utilizó instituciones de afiliación y 13.4 por ciento instituciones públicas. Entre no aseguradas 43.3 por ciento utilizó instituciones públicas y 19 por ciento seguridad social; 64.3 por ciento de afiliadas al Seguro Popular se atendieron en instituciones públicas. Variables de acceso, nivel socioeconómico y condiciones de vida influyeron en la demanda referida. Conclusiones. El traslape para atención de partos institucionales documenta la existencia de integración funcional de facto entre instituciones de salud mexicanas.

Objective. Analyze the factors associated with the utilization of delivery care institutions in Mexico in order to document the functional integration of health institutions. Materials and Methods. Based on the 2006 National Health and Nutrition Survey, information from women whose last birth was between 2000 and 2005 was used. Chi square was used to test differences between institutions used and health insurance type. A logistic regression was carried out to identify factors associated with the demand for institutions with which women were not affiliated. Results. Women with social security used in 62 percent of the cases the institution of their affiliation and 13.4 percent used public institutions. For uninsured women, 43.3 percent used public institutions and 19.0 percent social security institutions; 64.3 percent of the Seguro Popular affiliates were treated in public institutions. Variables related to access, socioeconomic status and living conditions influenced said demand. Conclusions. The utilization of an institution of delivery that differed from the one with which the women were affiliated indicates the existence of a de facto functional integration between health institutions in Mexico.

Low priority level for infertility services within the public health sector: a Brazilian case study.

BACKGROUND: In view of the lack of information on availability of public sector infertility services and in order to contribute to the debate on access to these services, we assessed the availability of public sector infertility services, including assisted reproduction technology (ART), in Brazil. MATERIALS AND METHODS: We conducted a cross-sectional study with telephone interviews using a semi-structured questionnaire with Health Secretariats' authorities from the 26 States, the Federal District, 26 Municipal state capitals and another 16 cities with more than 500 000 inhabitants. Also, directors of 26 referral centres and teaching hospitals provide ART procedures supported by the state or university teaching hospitals. RESULTS: Authorities from 24/26 State Secretariats and the Federal District, from 39/42 cities and 26 directors of referral centres and teaching hospitals offering government-funded infertility care and ART were interviewed. In 19/25 states (76%) and 26/39 cities (66.7%), no infertility treatment was available free of charge. The most common reason for lack of services at the state and municipal levels was 'lack of any political decision to implement them', followed by 'lack of human and financial resources'. When ART was available, barriers to access included the fact that patients needed to purchase medication and the more than 1-year waiting list for treatment. CONCLUSIONS: Lack of political commitment results in inequity in the access of low-income couples in Brazil to infertility treatment, including ART.