Prenatal exposure to phthalates and childhood wheeze and asthma in the progress cohort.

INTRODUCTION: Prenatal phthalate exposure may influence lung development and lead to wheezing and asthma in childhood, and these associations may vary by sex. Despite ubiquity of exposure, there is limited epidemiologic data on these associations in Latin America. METHODS: We assessed 593 mother-child dyads enrolled in the Programming Research in Obesity, Growth, Environment, and Social Stressors birth cohort in Mexico City. We quantified 15 phthalate metabolites in 2nd and 3rd trimester maternal urine. Report of ever wheeze, wheeze in the past 12 months (current wheeze) and ever asthma were obtained using a validated survey when children were 4 and 6 years of age. We examined individual associations with modified Poisson models. Mixture effects were assessed using Bayesian Weighted Quantile Sum (BWQS) regression. All models were adjusted for child's sex, maternal age and education at enrollment, and parity. RESULTS: In Poisson models, a doubling of mono (carboxy-isononyl) phthalate (MCNP) during the 2nd trimester was associated with higher risk of wheeze (RR: 1.14, 95 % CI: 1.01, 1.29), and asthma (RR: 1.44, 95 % CI: 1.05, 1.97) at 4 years of age. Higher concentrations of the sum of di-isononyl phthalate metabolites (∑DiNP) during the 2nd trimester were also associated with asthma at 4 years of age (RR: 1.30, 95 % CI: 1.04, 1.61). Mixture associations of phthalate metabolite concentrations during the 2nd trimester and asthma at 4 years of age were stronger in males (BWQS, OR: 1.94, 95 % CI: 0.90, 4.60; 90 % CrI: 1.04, 3.73) compared to females (BWQS, OR: 1.23, 95 % CI: 0.56, 2.88; 90 % CrI: 0.61, 2.55). Additionally, we observed stronger inverse associations between prenatal phthalate mixtures during the 3rd trimester and current wheeze at 4 and 6 years of age in females (BWQS, OR: 0.54, 90 % CrI: 0.35, 0.82; OR: 0.45, 90 % CrI: 0.22, 0.84) compared to males (BWQS, OR: 0.95, 90 % Cri: 0.68, 1.35; OR: 0.97, 90 % CrI: 0.59, 1.54). CONCLUSIONS: Prenatal phthalate metabolite concentrations were associated with respiratory outcomes in childhood, with some evidence of sex specific effects. Future work investigating phthalate exposure and wheeze trajectories/lung function will be important for understanding how these may predict later disease.

Associations between psychosocial stress, child's anxiety, and lung function in mid-childhood.

BACKGROUND: Reducing the risk of respiratory disease during the plastic stages of lung development could have long-term health impacts. Psychosocial stress has been previously linked to adverse childhood respiratory outcomes, but the influence of child's anxiety and sex differences has not been completely elucidated. OBJECTIVE: To evaluate the association among maternal stress, child anxiety, and lung function in children and to explore differences by sex. METHODS: Cross-sectional analyses included 294 mother-child pairs from the Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS) birth cohort in Mexico City. Children's lung function was tested once at ages 8 to 13 years of age, and height- and sex-adjusted z-scores were estimated for forced vital capacity, forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity and forced expiratory flow between 25% and 75%. Maternal stress was assessed through the Crisis in Family Systems-Revised (CRISYS-R) survey, used to report negative life events experienced in the past 6 months and dichotomized at the median (<3 and ≥3). Child's self-reported anxiety was assessed using the Revised Children's Manifest Anxiety Scale short form and dichotomized at the clinically relevant cutoff (T-score ≥ 60). The association among maternal stress, child anxiety, and lung function outcomes was evaluated using linear models. Effect modification by sex was evaluated with interaction terms and in stratified analyses. RESULTS: We did not find any association between maternal stress and any lung function outcome. Clinically elevated child anxiety symptoms were associated with lower forced expiratory volume in 1 second (ß = -0.36, 95% CI -0.69 to -0.02). We found no evidence of effect modification by sex. CONCLUSION: Results highlight the importance of considering childhood mental health in relation to lung function outcomes.

Differential dietary intake and contribution of ultra-processed foods during pregnancy according to nutritional status.

Introduction: Frequent consumption of ultra-processed foods (UPFs) during pregnancy is linked to excess intake of added sugar, fat, and sodium and inadequacy of several micronutrients. Diet quality during pregnancy should be maximized as inadequate levels of key nutrients and excessive intake of energy and added sugar might influence mother-child health. We aimed to estimate the contribution (% of total calories) of ultra-processed products to the total energy intake by pre-gestational body mass index (BMI) categories and Hb status during pregnancy in participants from the MAS-Lactancia Cohort. Methods: Pre-gestational weight, hemoglobin levels, 24-h dietary intake recall interviews, and sociodemographic data were collected during the second and third trimesters of pregnancy. Reported consumed foods were categorized using the NOVA classification, and the contribution of calories from each NOVA category was estimated using the Mexican Food Database. We estimated medians and interquartile ranges (p25 and p75) for dietary intake and energy contributions. The comparison of intake between the second and third trimesters was done using the Wilcoxon test. In addition, a quantile regression model with an interaction between pre-gestational BMI and Hb levels status in tertiles over the percentage of energy from UPFs was adjusted by age and socioeconomic status. Results: The contribution to total energy intake from UPFs was 27.4% in the second trimester and 27% in the third trimester (with no statistical difference). The percentage of energy intake from UPFs was higher in women who started pregnancy with obesity and presented the lowest levels of Hb (1st tertile), 23.1, 35.8, and 44.7% for the 25th, 50th, and 75th percentiles, respectively, compared to those with normal BMI and the highest tertile of Hb levels: 18, 29.0, and 38.6% for the 25th, 50th, and 75th percentiles, respectively. Conclusion: In conclusion, UPF intake in pregnant women is similar to the general population and was higher for those with pre-gestational obesity and the lowest tertile of Hb levels. UPF contributes also to sugar, saturated fat, and sodium, which may adversely affect the health of mothers and their offspring.

Associations of prenatal exposure to phthalates and their mixture with lung function in Mexican children.

Early life phthalates exposure has been associated with adverse respiratory outcomes. However, evidence linking prenatal phthalates exposure and childhood lung function has been inconclusive. Additionally, few studies have examined phthalates exposure as a mixture and explored sexually dimorphic associations. We aimed to investigate sex-specific associations of prenatal phthalates mixtures with childhood lung function using the PROGRESS cohort in Mexico (N = 476). Prenatal phthalate concentrations were measured in maternal urine collected during the 2nd and 3rd trimesters. Children's lung function was evaluated at ages 8-13 years. Individual associations were assessed using multivariable linear regression, and mixture associations were modeled using repeated holdout WQS regression and hierarchical BKMR; data was stratified by sex to explore sex-specific associations. We identified significant interactions between 2nd trimester phthalates mixture and sex on FEV1 and FVC z-scores. Higher 2nd trimester phthalate concentrations were associated with higher FEV1 (ß = 0.054, 95 %CI: 0.005, 0.104) and FVC z-scores (ß = 0.074, 95 % CI: 0.024, 0.124) in females and with lower measures in males (FEV1, ß = -0.017, 95 %CI: -0.066, 0.026; FVC, ß = -0.014, 95 %CI: -0.065, 0.030). This study indicates that prenatal exposure to phthalates is related to childhood lung function in a sex-specific manner.

Associations between prenatal metal and metalloid mixtures in teeth and reductions in childhood lung function.

BACKGROUND: Metal(oid)s have been cross-sectionally associated with lung function outcomes in childhood but there is limited data on their combined effects starting in utero. Child sex may further modify these effects. OBJECTIVE: Examine associations between in utero and early life exposure to metals assessed via novel dentine biomarkers and childhood lung function and explore effect modification by child sex. METHODS: Analyses included 291 children enrolled in the Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS) study, a longitudinal birth cohort study in Mexico City. Weekly dentine levels of arsenic (As), cadmium (Cd), cobalt (Co), copper (Cu), manganese (Mn), nickel (Ni), and lead (Pb) were measured from 15 weeks pre-birth to 15 weeks post birth in deciduous children's teeth. Lung function was tested at ages 8-14 years and then modeled as age, height and sex adjusted z-scores. Associations were modeled using lagged weighted quantile sum (LWQS) regression to evaluate the potential for a time-varying mixture effect adjusting for maternal age and education at enrollment and exposure to environmental tobacco smoke in pregnancy. Models were also stratified by sex. RESULTS: We identified a window of susceptibility at 12-15 weeks pre-birth in which the metal mixture was associated with lower FVC z-scores in children aged 8-14 years. Cd and Mn were the largest contributors to the mixture effect (70 %). There was also some evidence of effect modification by sex, in which the mean weights and weighted correlations over the identified window was more evident in males when compared to females. In the male stratum, Cd, Mn and additionally Pb also dominated the mixture association. CONCLUSIONS: Prenatal metal(oid) exposure was associated with lower lung function in childhood. These findings underscore the need to consider both mixtures and windows of susceptibility to fully elucidate effects of prenatal metal(oid) exposure on childhood lung function.

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico.

BACKGROUND: Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery. METHODS: Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates. RESULTS: Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections. CONCLUSIONS: This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

A surge in food insecurity during the COVID-19 pandemic in a cohort in Mexico City.

BACKGROUND: The COVID-19 pandemic has not only caused tremendous loss of life and health but has also greatly disrupted the world economy. The impact of this disruption has been especially harsh in urban settings of developing countries. We estimated the impact of the pandemic on the occurrence of food insecurity in a cohort of women living in Mexico City, and the socioeconomic characteristics associated with food insecurity severity. METHODS: We analyzed data longitudinally from 685 women in the Mexico City-based ELEMENT cohort. Food insecurity at the household level was gathered using the Latin American and Caribbean Food Security Scale and measured in-person during 2015 to 2019 before the pandemic and by telephone during 2020-2021, in the midst of the pandemic. Fluctuations in the average of food insecurity as a function of calendar time were modeled using kernel-weighted local polynomial regression. Fixed and random-effects ordinal logistic regression models of food insecurity were fitted, with timing of data collection (pre-pandemic vs. during pandemic) as the main predictor. RESULTS: Food insecurity (at any level) increased from 41.6% during the pre-pandemic period to 53.8% in the pandemic stage. This increase was higher in the combined severe-moderate food insecurity levels: from 1.6% pre-pandemic to 16.8% during the pandemic. The odds of severe food insecurity were 3.4 times higher during the pandemic relative to pre-pandemic levels (p<0.01). Socioeconomic status quintile (Q) was significantly related to food insecurity (Q2 OR = 0.35 p<0.1, Q3 OR = 0.48 p = 0.014, Q4 OR = 0.24 p<0.01, and Q5 OR = 0.17 p<0.01), as well as lack of access to social security (OR = 1.69, p = 0.01), and schooling (OR = 0.37, p<0.01). CONCLUSIONS: Food insecurity increased in Mexico City households in the ELEMENT cohort as a result of the COVID-19 pandemic. These results contribute to the body of evidence suggesting that governments should implement well-designed, focalized programs in the context of economic crisis such as the one caused by COVID-19 to prevent families from the expected adverse health and well-being consequences associated to food insecurity, especially for the most vulnerable.

Lead Levels in the Most Consumed Mexican Foods: First Monitoring Effort.

Globally, there is growing concern over the presence of lead (Pb) in foods because it is a heavy metal with several toxic effects on human health. However, monitoring studies have not been conducted in Mexico. In this study, we estimated the concentrations of Pb in the most consumed foods and identified those that exceeded the maximum limits (MLs) for Pb in foods established by the International Standards. Based on the Mexican National Health and Nutrition Survey, 103 foods and beverages were selected and purchased in Mexico City retail stores and markets. Samples were analyzed twice using atomic absorption spectrophotometry. Values above the limit of quantification (0.0025 mg/kg) were considered to be detected. The percentage of detected values was 18%. The highest concentration was found in infant rice cereal (1.005 mg/kg), whole wheat bread (0.447 mg/kg), pre-cooked rice (0.276 mg/kg), black pepper (0.239 mg/kg), and turmeric (0.176 mg/kg). Among the foods with detected Pb, the levels in infant rice cereal, whole wheat bread, pre-cooked rice, and soy infant formula exceeded the MLs. The food groups with the highest percentages of exceeded MLs were baby foods (18%) and cereals (11%). Monitoring the concentration of contaminants in foods is essential for implementing food safety policies and protecting consumer health.

A high density of ultra-processed food, alcohol & tobacco retail stores, and social inequalities are associated with higher mortality rates of non-communicable diseases in Mexican adults: 2005 to 2021.

BACKGROUND: Non-communicable diseases (NCDs) are the leading causes of mortality in Mexico. Factors contributing to NCDs-related deaths may vary across small geographic areas such as municipalities. We aimed to predict municipal-level factors associated with NCD mortality in Mexican adults from 2005 to 2021 using the small-area analysis (SSA) approach. METHODS: We gathered data on population sociodemographic, access to healthcare services, and mortality records at the municipal-level from census and public institutions from 2005 to 2021. We identified municipal predictors of NCDs mortality rates (MR) using negative binomial regression models. RESULTS: A total of 584,052 observations of Mexican adults were analyzed. The national expected NCDs MR per 100,000 inhabitants was 210.7 (95%CI: 196.1-226.7) in 2005 and increased to 322.4 (95%CI: 300.3-346.4) by 2021. Predictors of NCDs mortality (quintile 5 vs. quintile 1) included; indigeneity (IRR = 1.15, 95%CI: 1.12-1.19), poverty (IRR = 1.14, 95%CI: 1.13-1.15), affiliation with Mexican Social Security Institute (IRR = 1.11, 95%CI: 1.09-1.14), households with television (IRR = 1.14, 95%CI: 1.11-1.17), and high density of ultra-processed food, alcohol & tobacco retail stores (IRR = 1.15, 95%CI: 1.13-1.17). The greatest increases in MR were observed in municipalities from Oaxaca (>200% increments). CONCLUSION: There was an overall increase in NCDs MR from 2005 to 2021, with a significant geographic variation among Mexican municipalities. The results of this study highlight the importance of identifying priority areas in the country that urgently require public policies focused on local factors associated with deaths from NCDs, such as the regulation of the ultra-processed food, alcohol & tobacco retail stores, and efforts to reduce social inequalities.

Single nucleotide polymorphisms of ANKK1, DDR4, and GRIN2B genes predict behavior in a prospective cohort of Mexican children and adolescents.

Numerous studies have established associations between single nucleotide polymorphisms (SNPs) and various behavioral and neurodevelopmental conditions. This study explores the links between SNPs in candidate genes involved in central nervous system (CNS) physiology and their implications for the behavioral and emotional aspects in children and teenagers. A total of 590 participants, aged 7-15 years, from the Early Life Exposures In Mexico To Environmental Toxicants (ELEMENT) cohort study in Mexico City, underwent genotyping for at least one of 15 CNS gene-related SNPs at different timepoints. We employed multiple linear regression models to assess the potential impact of genetic variations on behavioral and cognitive traits, as measured by the Behavioral Assessment System for Children (BASC) and Conners parent rating scales. Significant associations were observed, including the rs1800497 TC genotype (ANKK1) with the Cognitive Problems/Inattention variable (p value = 0.003), the rs1800955 CT genotype (DDR4) with the Emotional Lability Global index variable (p value = 0.01), and the rs10492138 GA and rs7970177 TC genotypes (GRIN2B) with the Depression variable (p values 0.007 and 0.012, respectively). These finds suggest potential genetic profiles associated with "risk" and "protective" behaviors for these SNPs. Our results provide valuable insights into the role of genetic variations in neurobehavior and highlight the need for further research in the early identification and intervention in individuals at risk for these conditions.

Design and implementation of AMBAR: an innovative evidence-based training program for childbirth and newborn care.

OBJECTIVE: To present the development of a training model called AMBAR (Atención a la mujer embarazada y al recién nacido [Care for pregnant women and newborns]), which was designed to improve the quality of attention of health personnel responsible for obstetric care. MATERIALS AND METHODS: AMBAR was designed based on the results of a qualitative study exploring public health providers' needs and experiences. It was implemented in three health networks, and a total of 339 health personnel participated. RESULTS: The educational design of the course was appealing to the trained personnel, and the inclusion of simulations in all modules encouraged interest, participation, as well as the integration of new knowledge and skills into practice. CONCLUSION: AMBAR can promote better practices and increase the quality of birth care. With the proper support and willingness of staff and management, AMBAR can be implemented in all health services, both public and private.

The Cervical Cancer Treatment Gap in Mexico Under Seguro Popular, 2006-2016.

From 2005 to 2019, the Mexican government financed cervical cancer treatment for individuals without social security insurance through Seguro Popular's Fund for Protection against Catastrophic Health Expenses. To better understand the impact of this program on access to treatment, we estimated the cervical cancer treatment gap (the proportion of patients with cervical cancer in this population who did not receive treatment). To calculate the expected number of incident cervical cancer cases we used national surveys with information on insurance affiliation and incidence estimates from the Global Burden of Disease study. We used a national claims database to determine the number of cases whose treatment was financed by Seguro Popular. From 2006 to 2016, the national cervical cancer treatment gap changed from 0.61 (95% CI 0.59 to 0.62) to 0.45 (95% CI 0.43 to 0.48), with an average yearly reduction of -0.012 (95% CI -0.024 to -0.001). The gap was greater in states with higher levels of marginalization and in the youngest and oldest age groups. Although the cervical cancer treatment gap among individuals eligible for Seguro Popular decreased after the introduction of public financing for treatment, it remained high. Seguro Popular was eliminated in 2019; however, individuals without social security have continued to receive cancer care financed by the government in the same healthcare facilities. These results suggest that barriers to care persisted after the introduction of public financing for treatment. These barriers must be reduced to improve cervical cancer care in Mexico, particularly in states with high levels of marginalization.

Plasma Fatty Acid Biomarkers of Dairy Consumption Are Associated with Sex-Dependent Effects on Metabolic Syndrome Components in Mexican Adolescents.

INTRODUCTION: During adolescence, dairy product intake has shown conflicting associations with metabolic syndrome (MetS) components, which are risk factors for cardiovascular disease (CVD). This study aims to investigate the association between plasma fatty acids (FAs) C15:0, C17:0, and t-C16:1n-7, as biomarkers of dairy intake, with MetS and its components in Mexican adolescents. METHODS: A sample of 311 participants from the Early Life Exposure in Mexico City to Environmental Toxicants (ELEMENT) cohort was included in this cross-sectional analysis. FA concentrations were measured in plasma as a percentage of total FA. We used quantile regression models stratified by sex to evaluate the association between FA quantiles and MetS components, adjusting for age, socioeconomic status (SES), sedentary behavior, BMI z-score, pubertal status, and energy intake. RESULTS: We found significant associations between dairy biomarkers and the median of MetS variables. In females, t-C16:1n-7 was associated with a decrease of 2.97 cm in WC (Q4 vs. Q1; 95% CI: -5.79, -0.16). In males, C15:0 was associated with an increase of 5.84 mm/Hg in SBP (Q4 vs. Q1; CI: 1.82, 9.85). For HDL-C, we observed opposite associations by sex. C15:0 in males was associated with decreased HDL-C (Q3 vs. Q1: ß = -4.23; 95% CI: -7.98, -0.48), while in females, C15:0 and t-C16:1n-7 were associated with increased HDL-C (Q3 vs. Q1: ß = 4.75; 95% CI: 0.68, 8.82 and Q4 vs. Q1: ß = 6.54; 95% CI: 2.01, 11.07), respectively. Additionally, in both sexes, different levels of C15:0, C17:0, and t-C16:1n-7 were associated with increased triglycerides (TG). CONCLUSION: Our results suggest that adolescent dairy intake may be associated in different directions with MetS components and that associations are sex-dependent.

Associations between early-life exposure to PM2.5 and reductions in childhood lung function in two North American longitudinal pregnancy cohort studies.

Data integration of epidemiologic studies across different geographic regions can provide enhanced exposure contrast and statistical power to examine adverse respiratory effects of early-life exposure to particulate matter <2.5 microns in diameter (PM2.5). Methodological tools improve our ability to combine data while more fully accounting for study heterogeneity. Methods: Analyses included children enrolled in two longitudinal birth cohorts in Boston, Massachusetts, and Mexico City. Propensity score matching using the 1:3 nearest neighbor with caliper method was used. Residential PM2.5 exposure was estimated from 2 months before birth to age 6 years using a validated satellite-based spatiotemporal model. Lung function was tested at ages 6-11 years and age, height, race, and sex adjusted z scores were estimated for FEV1, FVC, FEF25-75%, and FEV1/FVC. Using distributed lag nonlinear models, we examined associations between monthly averaged PM2.5 levels and lung function outcomes adjusted for covariates, in unmatched and matched pooled samples. Results: In the matched pooled sample, PM2.5 exposure between postnatal months 35-44 and 35-52 was associated with lower FEV1 and FVC z scores, respectively. A 5 µg/m3 increase in PM2.5 was associated with a reduction in FEV1 z score of 0.13 (95% CI = -0.26, -0.01) and a reduction in FVC z score of 0.13 (95% CI = -0.25, -0.01). Additionally PM2.5 during postnatal months 23-39 was associated with a reduction in FEF25-75% z score of 0.31 (95% CI = -0.57, -0.05). Conclusions: Methodological tools enhanced our ability to combine multisite data while accounting for study heterogeneity. Ambient PM2.5 exposure in early childhood was associated with lung function reductions in middle childhood.

Burden, Incidence, Mortality and Lethality of Maternal Disorders in Mexico 1990-2019: An Analysis for the Global Burden of Disease Study 2019.

BACKGROUND: Estimates of the sub-national distribution of maternal disorders in Mexico beyond Maternal Mortality Ratios are scarce. Characterizing the sub-national variation of maternal disorders may make it possible to focus more on interventions and thereby reduce their occurrence in a more meaningful and sustained manner. AIM: To analyze and describe the sub-national distribution, magnitude, trends and changes in the contribution of maternal causes to women's loss of health in Mexico from 1990-2019. METHODS: Using estimates from the Global Burden of Disease (GBD) 2019 study, we describe the distribution and trends of maternal mortality ratio (MMR), mortality rate, case-fatality rate and disability-adjusted life years (DALYs) due to maternal causes, at both national and state levels. RESULTS: Between 1990 and 2019, DALYs attributable to maternal causes had decreased 59.5%, mortality 63.8%, and incidence 46.5%. However, Maternal Mortality Ratio only decreased by 33%. The case-fatality rate of maternal disorders decreased by 50% overall; although for obstructed labor and uterine rupture, it remained unchanged. Lethality showed great variation between states, with a 3 fold difference between the maximum and minimum values. CONCLUSIONS: Although mortality and incidence of maternal causes in Mexico have greatly decreased in the last 30 years, these changes mostly reflect declines in fertility. The decrease seen in case-fatality rates is driven by decreases in causes such as hypertension and hemorrhage, though for others it remained constant. Efforts should be directed at improving access to, and management of, locally frequent maternal emergencies, formulating tailor-made regional interventions for maternal health.

AMBAR: A midwifery-led training program to improve obstetric and neonatal practices among low-risk births in Mexico.

BACKGROUND: Birth care in Mexican health institutions is highly medicalized and of poor quality because of the prevalence of outdated and dangerous practices. AMBAR-a training program for health care providers on the use of evidence-based midwifery practices-was implemented during 2016-2018 and evaluated to assess the impact of training on key practices. METHODS: For this mixed-methods study, we evaluated the effects of a training program implemented in three public hospital networks in Mexico. Qualitative data were collected and integrated into the program before evaluating the effects of the intervention on 10 birth practices, 5 beneficial and 5 potentially harmful. Quantitative data on birth practices and covariates were collected at six time points (baseline and 5 follow-ups) in a final sample of 330 direct observations. Effect estimates were obtained by longitudinal logistic and Poisson regression models, adjusted for confounding variables. RESULTS: AMBAR had a significant effect on 4 of the 10 birth practices that were evaluated. Beneficial practices, such as skin-to-skin contact (P = 0.003) and delayed cord clamping (P = 0.039), increased significantly. Harmful when overused birth practices, such as vaginal examinations (P = 0.001), and cesarean birth (P < 0.001) decreased significantly. CONCLUSIONS: Midwifery-based training programs for health care providers can have an impact on the quality of care of birthing people and newborns, increasing the use of evidence-based practices and decreasing frequently overused practices.

Early life exposure to lead and its association with parent-reported aggression and conduct problems during childhood and adolescence.

BACKGROUND AND AIM: An association between lead (Pb) exposure and antisocial behaviors has been documented, but findings have been inconclusive. We aimed to estimate the association between prenatal, early childhood, and preadolescent/adolescent (periadolescent) Pb exposure and aggression and conduct problems in periadolescent residents of Mexico City. METHODS: Using information from the ELEMENT cohort study, we assessed prenatal Pb exposure through maternal patella Pb (MPPb) measurement during the puerperium, early childhood (birth to 5 years of age) exposure through a cumulative blood lead index (CBLI), and periadolescent exposure through a blood Pb (BPb) measurement concurrent with the evaluation of the outcomes. Outcomes were assessed during periadolescence using the parent-reported scales of aggression and conduct problems of the Behavioral Assessment System for Children-2nd version (BASC-2). We modeled the association between Pb exposure at each stage and each outcome (defined as a T-score ≥60 in the corresponding behavioral scale) using logistic regression, adjusting for sex, maternal age at delivery, maternal education, and household socioeconomic status (SES). The differential effect by sex was assessed with an interaction term in the models. RESULTS: 743, 704, and 595 participants were respectively eligible for inclusion in final models of prenatal, early childhood, and periadolescent Pb exposure. Median Pb exposure at each stage was 9.9 µg/g for MPPb (prenatal), 5.19 µg/dl for CBLI (early childhood), and 2.62 µg/dl for concurrent BPb (periadolescence). 12 % of participants met the criterion for aggression, and 15 % for conduct problems. In adjusted models, a one interquartile range increase in MPPb increased the odds of conduct problems (OR:1.31; 95 % CI: 1.01, 1.70) and aggression (OR=1.24; 95 % CI: 0.93, 1.65) during periadolescence. Pb exposure during early childhood or periadolescence was not associated with either outcome. We found no evidence of interactions by sex. CONCLUSIONS: Exposure to Pb during the prenatal stage was associated with aggression and conduct problems during periadolescence.

Use of self-help groups by people living with HIV in Central America.

Self-help groups (SHGs) for people living with HIV (PLHIV) are organizations created by the community to provide individuals with security, affection, improved self-esteem, and a sense of belonging. However, SHGs have also been used by the government to help implement HIV control policies. This study aimed to identify the characteristics associated with the use of SHGs by PLHIV and the routes and displacement patterns adopted by users. An analytical cross-sectional study was conducted based on data collected in six Central American countries during 2012. Using a list of SHGs, a random sampling was conducted in two stages. Firstly, the SHGs were selected. Then, the selected SHGs were visited and every third user who attended the SHG was surveyed. Logistic regression models were used to identify the characteristics associated with the use of SHGs and with attending the nearest SHGs. A spatial analysis was performed to identify the routes followed by users to reach the SHGs from their home communities. We found that the characteristics significantly associated with higher odds of SHG usage were country of residence and schooling level. The average and median distances traveled by users to attend SHGs were 20 and 5 kilometers, respectively. PLHIV do not use the SHGs closest to their locality, perhaps for fear of stigma and discrimination. We recommend that research on this topic use a mixed qualitative-quantitative methodology to better understand utilization decisions, user expectations, and the degree to which these are being met.

Pre-pregnancy body mass index and gestational weight-gain predict maternal hemoglobin levels and are jointly associated with neonatal outcomes in a Mexican birth cohort / Índice de masa corporal y ganancia de peso durante el embarazo como predictores de niveles de hemoglobina materna y su asociación con desenlaces neonatales en una cohorte mexicana

Introduction: there is scarce evidence of the effects of obesity and gestational weight- gain (GWG) on hemoglobin (Hb) levels in pregnancy. Little is known about the implications in offspring when pregnant mothers present with both at delivery. Aim: to identify if pre-pregnancy body mass index (BMI) and GWG are associated with Hb levels at pregnancy third trimester; and identify if the BMI status plus anemia at delivery could influence offspring anthropometry. Methods: in a sub-sample of pregnant women (n = 108) and their offspring (n = 63) from a Mexican birth cohort, information from medical files and questionnaires were used to obtain pre-pregnancy BMI (categorized as normal, overweight, and obese), GWG, and Hb during pregnancy; at delivery and postpartum anthropometric measures were obtained for offspring. Adjusted regression models predicted Hb levels according to pre-pregnancy BMI and GWG; offspring growth trajectories from birth to 3 months old were compared according to mother´s BMI status and anemia combinations at delivery. Results: pre-pregnancy normal (N), overweight (OV), and obesity (OB) were present in 48 %, 40 %, and 12 % of the participants, respectively. Anemia was detected in 22.8 % of the participants at third trimester. Hb levels in the third trimester were significantly lower in those with pre-pregnancy OB-BMI and excessive GWG (12.1 g/dL, 95 % CI: 10.7-13.5) compared to those with pre-pregnancy OB-BMI and insufficient GWG (13.3g/dL, 95 %CI: 11.9-14.8) (p = 0.04). At delivery, 11 % presented with OB-BMI and anemia. Women with OB-BMI and normal Hb levels had children with higher scores in Weight-for-Length-Z score and triceps skinfold. Conclusion: among OB women, excessive GWG was associated with having lower Hb levels in the third trimester. Newborns had higher scores in growth patterns related to adiposity from birth to 3 months old if mothers had normal Hb levels and OB (AU)

Introducción: existe escasa evidencia de los efectos de obesidad y ganancia de peso gestacional (GPG) y niveles de hemoglobina (Hb) durante el embarazo. Poco se conoce sobre las implicaciones en la descendencia cuando las embarazadas presentan ambos en el momento del parto. Objetivos: identificar si el índice de masa corporal (IMC) previo al embarazo y el GPG están asociados con los niveles de Hb en el tercer trimestre del embarazo; e identificar si el IMC más la anemia en el momento del parto podrían influir en la antropometría de la descendencia. Metodología: se utilizó información de expedientes médicos y cuestionarios para obtener el IMC antes del embarazo (categorizado como normal, con sobrepeso y obesidad), GPG y Hb durante el embarazo; en el momento del parto y posparto se obtuvieron medidas antropométricas para la descendencia de una submuestra de mujeres embarazadas (n = 108) y su descendencia (n = 63) de una cohorte mexicana. Los modelos de regresión ajustados predijeron los niveles de Hb según IMC y GPG antes del embarazo; se compararon las trayectorias de crecimiento de la descendencia desde el nacimiento hasta los 3 meses de edad según el estado de IMC de la madre y las combinaciones de anemia en el momento del parto. Resultados: peso preembarazo normal (N), sobrepeso (SP) y obesidad (OB) estuvieron presentes en 48 %, 40 % y 12 % de las participantes, respectivamente. Se diagnosticó anemia en el 22,8 % de las participantes en el tercer trimestre. Los niveles de Hb en el tercer trimestre fueron significativamente más bajos en aquellas con IMC-OB antes del embarazo y GPG excesivo (12,1 g/dL, IC del 95 %: 10,7-13,5) en comparación con aquellas con IMC-OB antes del embarazo y GPG insuficiente (13,3 g/dl, IC del 95 %: 11,9-14,8) (p = 0,04). Al momento del parto, el 11 % presentó OB-BMI y anemia. Las mujeres con OB-BMI y niveles normales de Hb tenían hijos con puntuaciones más altas en puntuación Z de peso para longitud y pliegue cutáneo del tríceps (AU)

Pre-pregnancy body mass index and gestational weight-gain predict maternal hemoglobin levels and are jointly associated with neonatal outcomes in a Mexican birth cohort.

Introduction: Introduction: there is scarce evidence of the effects of obesity and gestational weight- gain (GWG) on hemoglobin (Hb) levels in pregnancy. Little is known about the implications in offspring when pregnant mothers present with both at delivery. Aim: to identify if pre-pregnancy body mass index (BMI) and GWG are associated with Hb levels at pregnancy third trimester; and identify if the BMI status plus anemia at delivery could influence offspring anthropometry. Methods: in a sub-sample of pregnant women (n = 108) and their offspring (n = 63) from a Mexican birth cohort, information from medical files and questionnaires were used to obtain pre-pregnancy BMI (categorized as normal, overweight, and obese), GWG, and Hb during pregnancy; at delivery and postpartum anthropometric measures were obtained for offspring. Adjusted regression models predicted Hb levels according to pre-pregnancy BMI and GWG; offspring growth trajectories from birth to 3 months old were compared according to mother´s BMI status and anemia combinations at delivery. Results: pre-pregnancy normal (N), overweight (OV), and obesity (OB) were present in 48 %, 40 %, and 12 % of the participants, respectively. Anemia was detected in 22.8 % of the participants at third trimester. Hb levels in the third trimester were significantly lower in those with pre-pregnancy OB-BMI and excessive GWG (12.1 g/dL, 95 % CI: 10.7-13.5) compared to those with pre-pregnancy OB-BMI and insufficient GWG (13.3g/dL, 95 %CI: 11.9-14.8) (p = 0.04). At delivery, 11 % presented with OB-BMI and anemia. Women with OB-BMI and normal Hb levels had children with higher scores in Weight-for-Length-Z score and triceps skinfold. Conclusion: among OB women, excessive GWG was associated with having lower Hb levels in the third trimester. Newborns had higher scores in growth patterns related to adiposity from birth to 3 months old if mothers had normal Hb levels and OB.

Introducción: Introducción: existe escasa evidencia de los efectos de obesidad y ganancia de peso gestacional (GPG) y niveles de hemoglobina (Hb) durante el embarazo. Poco se conoce sobre las implicaciones en la descendencia cuando las embarazadas presentan ambos en el momento del parto. Objetivos: identificar si el índice de masa corporal (IMC) previo al embarazo y el GPG están asociados con los niveles de Hb en el tercer trimestre del embarazo; e identificar si el IMC más la anemia en el momento del parto podrían influir en la antropometría de la descendencia. Metodología: se utilizó información de expedientes médicos y cuestionarios para obtener el IMC antes del embarazo (categorizado como normal, con sobrepeso y obesidad), GPG y Hb durante el embarazo; en el momento del parto y posparto se obtuvieron medidas antropométricas para la descendencia de una submuestra de mujeres embarazadas (n = 108) y su descendencia (n = 63) de una cohorte mexicana. Los modelos de regresión ajustados predijeron los niveles de Hb según IMC y GPG antes del embarazo; se compararon las trayectorias de crecimiento de la descendencia desde el nacimiento hasta los 3 meses de edad según el estado de IMC de la madre y las combinaciones de anemia en el momento del parto. Resultados: peso preembarazo normal (N), sobrepeso (SP) y obesidad (OB) estuvieron presentes en 48 %, 40 % y 12 % de las participantes, respectivamente. Se diagnosticó anemia en el 22,8 % de las participantes en el tercer trimestre. Los niveles de Hb en el tercer trimestre fueron significativamente más bajos en aquellas con IMC-OB antes del embarazo y GPG excesivo (12,1 g/dL, IC del 95 %: 10,7-13,5) en comparación con aquellas con IMC-OB antes del embarazo y GPG insuficiente (13,3 g/dl, IC del 95 %: 11,9-14,8) (p = 0,04). Al momento del parto, el 11 % presentó OB-BMI y anemia. Las mujeres con OB-BMI y niveles normales de Hb tenían hijos con puntuaciones más altas en puntuación Z de peso para longitud y pliegue cutáneo del tríceps. Conclusión: la GPG excesiva entre las mujeres OB se asoció con niveles más bajos de Hb en el tercer trimestre. Los recién nacidos tenían puntajes más altos en los patrones de crecimiento relacionados con la adiposidad desde el nacimiento hasta los 3 meses de edad si las madres tenían niveles normales de Hb y OB.