Associations between psychiatric symptoms and cortisol levels in Nicaraguan young school-age children.

The regulation of the Hypothalamus-Pituitary-Adrenal axis (HPA-axis) with its end product cortisol seems to be affected in several psychiatric disorders. Although findings are not conclusive, internalizing symptoms have primarily been associated with higher diurnal cortisol levels and externalizing symptoms with lower cortisol levels. In this study on nine-year-olds in Nicaragua (n=111), we investigated associations between child psychiatric symptoms, using the Child Behavior Check List (CBCL), and saliva cortisol levels collected in the morning and afternoon, also adjusting for potential confounders. In line with previous findings, internalizing symptoms were significantly associated with higher morning, but not afternoon cortisol levels. Surprisingly, externalizing symptoms were also significantly associated with higher morning cortisol levels. Possibly, this association between externalizing symptoms and cortisol levels may be characteristic of early ages, representing a higher exposure to external stressors. The study highlights the need for prospective studies, following the development of the HPA-axis and its association with psychiatric symptoms.

A population-based study of prevalence and risk factors of chronic kidney disease in León, Nicaragua.

BACKGROUND: Recent studies have shown an excess of chronic kidney disease (CKD) among younger adult males in the Pacific coastal region of Nicaragua and suggest a non-conventional CKD etiology in this region. These studies have been conducted in small, non-representative populations. OBJECTIVES: We conducted a large population-based cross-sectional study to estimate CKD prevalence in León, Nicaragua, and to evaluate the association between previously investigated risk factors and CKD. METHODS: Estimated glomerular filtration rate, derived using the MDRD equation, was assessed to determine CKD status of 2275 León residents. Multivariable logistic regression was used to estimate adjusted prevalence odds ratios. León CKD prevalence was also standardized to the demographic distributions of the León Health and Demographic Surveillance System and the León 2005 Census. RESULTS: CKD prevalence was 9.1%; twice as high for males (13.8%) than females (5.8%). In addition to gender, older age, rural zone, lower education level, and self-reported high blood pressure, more years of agricultural work, lija (unregulated alcohol) consumption, and higher levels of daily water consumption were significantly associated with CKD. Notably, self-reported diabetes was associated with CKD in adjusted models for females but not males. CONCLUSIONS: Our findings are comparable to those found in regional studies and further support the hypothesis of a Mesoamerican Nephropathy.

CONTEXTE: Selon de récentes études, il existerait une prévalence d'insuffisance rénale chronique (IRC) excessive chez les jeunes adultes de sexe masculin de la côte du Pacifique du Nicaragua. Ces études, qui ont été conduites sur des échantillons non représentatifs de la population, suggèrent une étiologie non classique de l'IRC dans cette région. OBJECTIFS DE L'ÉTUDE: Nous avons effectué une étude transversale portant sur un vaste échantillon de population, afin de pouvoir estimer la prévalence d'IRC dans la ville nicaraguéenne de León, d'une part, et évaluer la présence de liens entre l'IRC et certains facteurs de risque ayant été étudiés, d'autre part. MÉTHODE: Pour déterminer le statut d'IRC de 2275 résidents de la ville de León, nous avons utilisé le débit de filtration glomérulaire estimé, selon l'équation du MDRD. Une régression logistique multivariée a été utilisée pour estimer les ratios de probabilité corrigés de prévalence. La prévalence d'IRC de León a également été normalisée sur la base de la distribution démographique du Health and Demographic Surveillance System de León et avec son recensement de 2005. RÉSULTATS: La prévalence d'IRC était de 9,1%; elle était deux fois plus élevée chez les hommes (13,8%) que chez les femmes (5,8%). D'autres facteurs ont été liés de façon significative à l'IRC: la vieillesse, la vie rurale, un niveau d'éducation faible, une hypertension autodéclarée, plusieurs années de travail en agriculture, et la consommation de lija (alcool non contrôlé) et de grandes quantités d'eau. Le diabète autodéclaré était également lié à l'IRC dans les modèles ajustés chez les femmes, mais non chez les homm es. CONCLUSIONS: Nos résultats sont comparables à ceux des études locales et supportent l'hypothèse de l'existence d'une néphropathie méso-américaine.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.

BACKGROUND: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS: From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Measuring HIV- and AIDS-related stigma and discrimination in Nicaragua: results from a community-based study.

Psychometric properties of external HIV-related stigma and discrimination scales and their predictors were investigated. A cross-sectional community-based study was carried out among 520 participants using an ongoing health and demographic surveillance system in León, Nicaragua. Participants completed an 18-item HIV stigma scale and 19 HIV and AIDS discrimination-related statements. A factor analysis found that 15 of the 18 items in the stigma scale and 18 of the 19 items in the discrimination scale loaded clearly into five- and four-factor structures, respectively. Overall Cronbach's alpha of .81 for the HIV stigma scale and .91 for the HIV discrimination scale provided evidence of internal consistency. Hierarchical multiple linear regression analysis identified that females, rural residents, people with insufficient HIV-related transmission knowledge, those not tested for HIV, those reporting an elevated self-perception of HIV risk, and those unwilling to disclose their HIV status were associated with higher stigmatizing attitudes and higher discriminatory actions towards HIV-positive people. This is the first community-based study in Nicaragua that demonstrates that overall HIV stigma and discrimination scales were reliable and valid in a community-based sample comprised of men and women of reproductive age. Stigma and discrimination were reported high in the general population, especially among sub-groups. The findings in the current study suggest community-based strategies, including the monitoring of stigma and discrimination, and designing and implementing stigma reduction interventions, are greatly needed to reduce inequities and increase acceptance of persons with HIV.

Assessing knowledge, attitudes, and behaviors related to HIV and AIDS in Nicaragua: a community-level perspective.

BACKGROUND: Nicaragua's HIV epidemic is concentrated among men who have sex with men. Nevertheless, the increasing number of HIV cases among heterosexuals, high levels of poverty and migration rates, and incomplete epidemiological data suggest the need to improve the understanding of the epidemic. OBJECTIVE: To examine the prevalence of HIV-related knowledge, attitudes, and sexual risk-taking behaviors, and their predictors among the adult population. METHODS: A community-based cross-sectional survey was conducted in 2009 among 520 participants ages 15-49 from an ongoing Health and Demographic Surveillance System in Nicaragua. Bivariate analysis and adjusted prevalence ratios were use to examine factors associated with HIV-related knowledge, attitudes, and sexual behavior. RESULTS: Contributing factors for risk-taking behaviors included cognitive, psychosocial, and emotional elements. Insufficient knowledge affecting the accurate assessment of HIV risk were low educational level, poverty, and rural origin, especially among females. Recognizing risk was not sufficient to promote safer sex: 90% of the females and 70% of the males who reported being sexually active in the past year did not use condoms during their last sexual encounter. Inconsistent condom use among men was associated with older age, long-term relationships, and lack of awareness about acquiring HIV infection. CONCLUSIONS: Interventions to reduce social-structural contextual factors in Nicaragua are needed so that individuals may adopt and maintain HIV risk reduction strategies. Increased gender-specific HIV education and skills-building programs need to be implemented. Sensitive mass media messages may also increase the knowledge of HIV and AIDS, and serve to encourage protective attitudes and behaviors.

Intimate partner violence and early child growth: a community-based cohort study in Nicaragua.

BACKGROUND: This study analyses whether a mother's exposure to different forms of Intimate Partner Violence (IPV) during pregnancy was associated with the index child linear growth, and whether these associations were modified by the gender of the child. METHODS: A pregnancy cohort of 478 women in León, Nicaragua, resulted in 461 live births. From this group, 81% (375/461) children were available for anthropometric follow-up at 40 to 46 months. Analysis of covariance (ANCOVA) was used to assess the association between IPV and height-for-age Z-scores, adjusting for confounding factors. RESULTS: Sixty-three percent (236/375) of the mothers had been exposed to some form of IPV during pregnancy (emotional, physical, sexual or controlling behavior). After adjustment for confounding factors, maternal exposure to any IPV during pregnancy was associated with 0.24 lower mean height-for-age Z-scores (p = 0.02). A separate analysis of each IPV type showed that emotional, physical or sexual IPV during pregnancy were not significantly associated with lower mean height-for-age Z-scores, whereas ever exposure to controlling behavior by the father of the child was related to 0.29 lower mean height-for-age Z-scores (p < 0.01) When stratified by gender, these associations remained significant only for young girls. CONCLUSIONS: This study has contributed to the growing amount of evidence pointing to the pervasive effect of different forms of IPV on child health. Our study highlights the relevance of maternal autonomy for linear child growth, especially for young girls in the Nicaraguan context.

Questions about intimate partner violence should be part of contraceptive counselling: findings from a community-based longitudinal study in Nicaragua.

BACKGROUND AND METHODOLOGY: The study aim was to examine whether exposure to intimate partner violence (IPV) was associated with reversible contraceptive use in ever-pregnant partnered women. The authors conducted a longitudinal panel study in León municipality, Nicaragua. At baseline (2002-2003), 478 pregnant women were interviewed and 398 were available for questioning about contraceptive use 40-47 months after childbirth. IPV was assessed at baseline and follow-up, with women classified as never abused, ending abuse, continued abuse or new abuse. Reversible contraceptive use was defined as women using any form of contraception apart from sterilisation. Adjusted odds ratios (AORs) were used to assess the association between reversible contraceptive use, IPV patterns and IPV exposures at follow-up. RESULTS: Eighty percent of the women were not pregnant and with a partner at follow-up. Half were using reversible contraceptives and 28% were sterilised. Women exposed to a continued abuse pattern (AOR 2.50, 95% CI 11.04-5.99), and those exposed to emotional (AOR 2.80, 95% CI 1.32-5.95), physical (AOR 3.60, 95% CI 1.15-11.10) or any IPV at follow-up (AOR 2.59, 95% CI 1.24-5.40) had higher odds of reversible contraceptive use than those not exposed, even after adjusting for demographic factors. No significant differences in the type of reversible contraceptive used were found between women exposed or not to IPV. DISCUSSION AND CONCLUSIONS: IPV exposure was associated with more reversible contraceptive use. Abuse inquiring at health facilities providing contraceptives should be implemented to identify women exposed to IPV and provide adequate support.

The supportive process for ending intimate partner violence after pregnancy: the experience of Nicaraguan women.

This grounded theory study found that Nicaraguan mothers exposed to intimate partner violence (IPV) during pregnancy eventually acted to protect their children and themselves. They experienced ending abuse as an empowerment process characterized by a cognitive change in women's attitudes toward partner abuse and the emergence of help-seeking strategies that lead to ending violence with or without ending the relationship. This process was facilitated by a supportive environment that challenged abusive behaviors as well as being asked about abuse during their last pregnancy. Although environmental changes can facilitate ending abuse, Nicaragua's public institutions must be strengthened to reach women in need.

Association between intimate partner violence and irritable bowel syndrome: a population-based study in Nicaragua.

Irritable bowel syndrome (IBS) is a disabling functional gastrointestinal disorder, which serves as a model for abdominal pain syndromes. An association between intimate partner violence and IBS has been shown among White women in the industrialized world. To determine whether this relationship transcends cultural boundaries, we conducted a population-based, cross-sectional survey in Nicaragua using the innovative Health and Demographic Surveillance System in the León province. Women who had experienced physical intimate partner violence had significantly increased risk of IBS (odds ratio [OR] = 2.08; 95% confidence interval [CI] = 1.35, 3.21), as did those who had experienced sexual intimate partner violence (OR = 2.85; 95% CI = 1.45, 5.59). These findings argue for intimate partner violence screening among Latina women with IBS.

Maternal near miss and maternal death in the World Health Organization's 2005 global survey on maternal and perinatal health.

OBJECTIVE: To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. METHODS: In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter's association with maternal characteristics and perinatal outcomes. FINDINGS: Of the 97,095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. CONCLUSION: Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections.

BACKGROUND: Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. METHODS: We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. RESULTS: The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. CONCLUSION: The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.

Ending intimate partner violence after pregnancy: findings from a community-based longitudinal study in Nicaragua.

BACKGROUND: Although reducing intimate partner violence (IPV) is a pervasive public health problem, few longitudinal studies in developing countries have assessed ways to end such abuse. To this end, this paper aims to analyze individual, family, community and societal factors that facilitate reducing IPV. METHODS: A longitudinal population-based study was conducted in León, Nicaragua at a demographic surveillance site. Women (n = 478) who were pregnant between 2002 and 2003 were interviewed, and 398 were found at follow-up, 2007. Partner abuse was measured using the WHO Multi-country study on women's health and domestic violence questionnaire. Women's socio demographic variables, perceived emotional distress, partner control, social resources, women's norms and attitudes towards IPV and help-seeking behaviours were also assessed. Ending of abuse was defined as having experienced any abuse in a lifetime or during pregnancy but not at follow-up. Crude and adjusted odds ratios were applied. RESULTS: Of the women exposed to lifetime or pregnancy IPV, 59% reported that their abuse ended. This finding took place in a context of a substantial shift in women's normative attitudes towards not tolerating abuse. At the family level, no or diminishing partner control [ORadj 6.7 (95%CI 3.5-13)] was associated with ending of abuse. At the societal level, high or improved social resources [ORadj 2.0 (95%CI 1.1.-3.7)] were also associated with the end of abuse. CONCLUSION: A considerable proportion of women reported end of violence. This might be related to a favourable change in women's norms and attitudes toward gender roles and violence and a more positive attitude towards interventions from people outside their family to end abuse. Maintaining and improving social resources and decreasing partner control and isolation are key interventions to ending abuse. Abuse inquiring may also play an important role in this process and must include health care provider's training and a referral system to be more effective. Interventions at the community level are crucial to reducing partner violence.

Neuroendocrine response to violence during pregnancy--impact on duration of pregnancy and fetal growth.

OBJECTIVE: To study the neuroendocrine release of cortisol in response to perceived stress among pregnant women exposed to partner violence and how this affects the duration of pregnancy and the intrauterine growth of the infant. DESIGN: Cross-sectional community-based study. SETTING: Health and Demographic Surveillance System of Leon, Nicaragua. POPULATION: One-hundred and forty-seven pregnant women. METHODS: Standardized scales to measure intimate partner violence, social resources, perceived stress, and socio-economic conditions were applied. Two salivary samples for cortisol were collected in the morning and afternoon on the same day. Linear regression and path analysis were used. MAIN OUTCOME MEASURES: Cortisol levels, gestational age, and weight at delivery. RESULTS: Partner violence during the pregnancy, low social resources, and perceived maternal stress were associated with high level of salivary cortisol. Pregnant women with high cortisol levels were significantly more likely to give birth to small-for-gestational age babies, but not to deliver preterm. A substantial decrease of birthweight, 121-186 g, was associated with an increase in cortisol in association with violence exposure. CONCLUSION: Partner violence during pregnancy is a stressor that provokes high levels of cortisol, which is associated with reduction of birthweight.

Intracluster correlation coefficients from the 2005 WHO Global Survey on Maternal and Perinatal Health: implications for implementation research.

Cluster-based studies involving aggregate units such as hospitals or medical practices are increasingly being used in healthcare evaluation. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC). Sample size calculations for cluster-based studies need to account for the ICC, or risk underestimating the sample size required to yield the desired levels of power and significance. In this article, we present values for ICCs that were obtained from data on 97,095 pregnancies and 98,072 births taking place in a representative sample of 120 hospitals in eight Latin American countries. We present ICCs for 86 variables measured on mothers and newborns from pregnancy to the time of hospital discharge, including 'process variables' representing actual medical care received for each mother and newborn. Process variables are of primary interest in the field of implementation research. We found that overall, ICCs ranged from a minimum of 0.0003 to a maximum of 0.563 (median 0.067). For maternal and newborn outcome variables, the median ICCs were 0.011 (interquartile range 0.007-0.037) and 0.054 (interquartile range 0.013-0.075) respectively; however, for process variables, the median was 0.161 (interquartile range 0.072-0.328). Thus, we confirm previous findings that process variables tend to have higher ICCs than outcome variables. We demonstrate that ICCs generally tend to increase with higher prevalences (close to 0.5). These results can help researchers calculate the required sample size for future research studies in maternal and perinatal health.

Methodological considerations in implementing the WHO Global Survey for Monitoring Maternal and Perinatal Health.

OBJECTIVE: To set up a global system for monitoring maternal and perinatal health in 54 countries worldwide. METHODS: The WHO Global Survey for Monitoring Maternal and Perinatal Health was implemented through a network of health institutions, selected using a stratified multistage cluster sampling design. Focused information on maternal and perinatal health was abstracted from hospital records and entered in a specially developed online data management system. Data were collected over a two- to three-month period in each institution. The project was coordinated by WHO and supported by WHO regional offices and country coordinators in Africa and the Americas. FINDINGS: The initial survey was implemented between September 2004 and March 2005 in the African and American regions. A total of 125 institutions in seven African countries and 119 institutions in eight Latin American countries participated. CONCLUSION: This project has created a technologically simple and scientifically sound system for large-scale data management, which can facilitate programme monitoring in countries.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study.

OBJECTIVE: To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. DESIGN: Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. SETTING: 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data PARTICIPANTS: 106,546 deliveries reported during the three month study period, with data available for 97,095 (91% coverage). MAIN OUTCOME MEASURES: Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. RESULTS: Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. CONCLUSIONS: Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America.

BACKGROUND: Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS: We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Violence against pregnant women: prevalence and characteristics. A population-based study in Nicaragua.

OBJECTIVE: This study aims to estimate the prevalence and characteristics of partner abuse during pregnancy as well as to investigate associated social factors in León, Nicaragua. DESIGN: Cross-sectional community-based study. SETTING: All pregnant women from 50 randomly selected geographical clusters out of 208 in the municipality of León, Nicaragua. SAMPLE: A total of 478 pregnant women were included; only one woman refused to participate. METHOD: The domestic violence questionnaire from the WHO-co-ordinated Multi-Country Study on Women's Health and Life Events was used with each participant being interviewed twice during pregnancy. MAIN OUTCOME MEASURES: Prevalence and characteristics of partner violence during pregnancy. RESULTS: The prevalence of emotional, physical and sexual abuse during pregnancy was 32.4%, 13.4% and 6.7%, respectively. Seventeen percent reported experience of all three forms of violence. Two-thirds of the victims reported repeated abuse. Half of the abused women had experienced punches and kicks directed towards the abdomen and 93% had been injured. Most women had not sought health care in relation to the abuse, but those who did were usually hospitalised. Factors such as women's age below 20 years, poor access to social resources and high levels of emotional distress were independently associated with violence during pregnancy. CONCLUSION: Violence against pregnant women in Nicaragua is common and often repeated. Although these women have poor access to social resources and high levels of emotional distress, they are rarely assisted by the health services. Innovative strategies are needed to provide support and counselling.