The contribution of the foreign population to the high level of infant mortality in Switzerland: a demographic analysis.

BACKGROUND: In 2011 Switzerland reported the highest infant mortality rate among Western European countries, as well as the highest percentage of foreign population (23%). The comparison of the Swiss and foreign population in terms of reproductive health has received so far insufficient attention. The aim of the present study is to analyze the infant (IMR) and neonatal mortality rates (NMR) of Swiss and foreign children over the last 30 years. METHODS: Vital statistics from the period 1980 to 2011 were used to compute IMR and NMR according to year and/or citizenship. The main analyses were made contrasting Swiss versus foreigners as a single category, as well as by country of origin. Comparisons between groups were done using relative risks. RESULTS: In 1980-1989, IMR was 14% higher among foreign children as compared to Swiss children, and NMR 28% higher. In 2006-2010, IMR was 18% higher among foreign children than among Swiss children, and NMR 29% higher. The highest gap of IMR was observed during the period 1990-1993 (+21%). Looking at single countries, in 2008-2010 children of migrants from Germany, Portugal, Turkey, Italy, France, Kosovo and Spain had a higher level of IMR as compared to Swiss children. CONCLUSIONS: The analysis of vital statistics confirms that over the last 30 years the gap of IMR and NMR between Swiss and foreign children has not decreased. Whatever the combination of mechanisms, which cause the observed difference, this fundamental inequity needs to be investigated and remedied by a large scale, concerted effort.

Guidelines-based indicators to measure quality of antenatal care.

RATIONALE, AIMS AND OBJECTIVES: No comprehensive measurement of quality of antenatal care is available. Late booking or low number of checks are often used as surrogate for poor quality, leaving uncertainty on the actual content of the care received. In order to fill this gap, we have reviewed two sets of clinical guidelines and developed corresponding indicators of quality. METHOD: A group of clinicians and methodologists reviewed the National Institute for Clinical Excellency Clinical Guidelines on antenatal care, and the list of prenatal care interventions recommended by the Research and Development Group, both based on evidence of effectiveness of specific interventions. We identified single aspects in three domains: (1) services utilization; (2) screening; and (3) interventions. For each indicator, we defined: (1) eligibility, that is the characteristics of the women to whom the indicator applies; (2) standard, that is the situation when the target is met; and (3) moderators, that is all conditions which legitimately hamper the fulfilment of the standard. RESULTS: We developed four indicators of service utilization, 25 of screening and 17 of intervention. The respective eligibility, standard and moderators criteria were described for each indicator. While many indicators could be retrospectively evaluated from medical charts, quality of communication with provider, screening for sensible issues and counselling on behaviours to be avoided could only be obtained with a prospective data collection. CONCLUSIONS: The indicators of quality of antenatal care, complemented by measures of social position, social support and immigrant/ethnic status, allow for a careful description of the gaps in quality of care for specific groups of women.

A retrospective observational study of obstetric care in rural Andhra Pradesh by Dangoria Charitable Trust (1979 to 2009).

BACKGROUND & OBJECTIVES: In India several models of health care delivery have been explored to increase access to skilled obstetric care in rural areas, where there is a lack of specialists and appropriate facilities. We present here an innovative and affordable approach to the delivery of antenatal and obstetric care provided by the Dangoria Charitable Trust (DCT) since 1979, twinning a not-for-profit hospital in rural Andhra Pradesh with a for-profit one in the capital Hyderabad. METHODS: A retrospective observational study of a random sample of the deliveries performed from 1979 to 2009 by the Dangoria Charitable Trust, based on the maternity hospital birth register, was conducted. The profile of mothers, such as their age, parity and previous miscarriages, as well as type of delivery, gender and birth weight of the newborn, and frequency of stillbirths and in hospital deaths as they evolved over time were presented using simple descriptive methods. The risk of stillbirth and in hospital death over time was explored by logistic regression after allowance for selected factors. RESULTS: From 1979 to 2009 the cumulative number of deliveries at the Narsapur maternity hospital was 9333, from a few dozens per year in the early 1980s to over 1000 in 2009. The number of primiparae significantly increased over time, while the percentage of low birth weight babies (less than 2.5 kg) did not change appreciably. Caesarean section increased significantly over time, from 8.6 per cent in the first decade to 20.3 per cent in the last. The risk of death (stillbirths and in hospital death) consistently decreased over time, reaching 15 per thousand in the last decade. The results of a logistic regression adjusted for potential confounders showed that low birth weight babies had 4 times the risk of dying as compared to those weighing 2.5 kg or above. CONCLUSIONS: Over the 30 year period the percentage of babies discharged alive from DCT improved considerably. Caesarean sections increased significantly from the first decade to the third decade. The model adopted by the DCT to improve maternal and child health in rural areas could be replicated in other rural parts of the country.

Trends in maternal mortality in Switzerland among Swiss and foreign nationals, 1969-2006.

OBJECTIVES: To test whether maternal mortality was higher among immigrant women than Swiss women. METHODS: All maternal deaths and live births in Switzerland from 1969 to 2006 from official vital statistics were considered. We calculated maternal mortality ratios (MMRs) in four time intervals (1969-1979, 1980-1989, 1990-1999, 2000-2006) for both Swiss and immigrant women overall, and for Italian, Spanish and Turkish women. We also computed the odds ratios and 95% confidence intervals of maternal mortality over the four time periods, considering maternal deaths as cases, and live births as controls. RESULTS: From 1969 to 2006 there were 279 maternal deaths, 204 of Swiss women and 75 of immigrant women. Women's age, marital status and cause of death were similar in the two groups. For immigrant women, the crude odds ratio of a pregnancy ending with maternal death, not homogeneous across the four periods, was 4.38 (95% CI 1.88-10.55) in 2000-2006. CONCLUSIONS: Immigrant women have a higher risk of maternal mortality than Swiss women. A closer scrutiny of risk factors and quality of care is necessary to identify opportunities for prevention.

Pregnancy outcome of migrant women and integration policy: a systematic review of the international literature.

Immigrant mothers in developed countries often experience worse pregnancy outcomes than native women. Several epidemiological studies have described the pregnancy outcome of immigrant women in European receiving countries, with conflicting results. The present systematic review makes a quantitative synthesis of available evidence on the association between pregnancy outcomes and integration policies. We reviewed all epidemiological studies comparing the pregnancy outcome of native versus immigrant women in European countries from 1966 to 2004 and retained 65 for analysis, from 12 host countries. Overall, as compared to native women, immigrant women showed a clear disadvantage for all the outcomes considered: 43% higher risk of low birth weight, 24% of pre-term delivery, 50% of perinatal mortality, and 61% of congenital malformations. The risks were clearly and significantly reduced in countries with a strong integration policy. This trend was maintained even after adjustment for age at delivery and parity. On the basis of an analysis of naturalisation rates, five countries in our sample could be categorised as having a strong policies promoting the integration of immigrant communities. The mechanisms through which integration policies may be protective include the increased participation of immigrant communities in the life of the receiving society, and the decreased stress and discrimination they may face. The results of this study highlight a serious problem of equity in perinatal health across European countries. Immigrant women clearly need targeted attention to improve the health of their newborn, but a deep societal change is also necessary to integrate and respect immigrant communities in receiving societies.

Structural and organizational determinants of quality of care in patients with schizophrenia in Italy.

Several reports have described the poor quality of care delivered to psychotic patients. However, the context in which care was delivered, including the structure, organization, and performance of the health care system, as a possible determinant of quality of care has received less attention. In this study we explored the relationship between conformance with guidelines and structural and organizational characteristics in 2 departments of Mental Health in Italy. Dosing of antipsychotic drugs in the maintenance phase was investigated in 125 patients. Higher than recommended doses could be explained by the high patient caseload per psychiatrist, leading to insufficient contacts with patients and their families and to excessive reliance upon drug treatment. The analysis of structural and organizational determinants of care at the local level may help to explain insufficient quality and to plan suitable interventions.

Indicators of conformance with guidelines of schizophrenia treatment in mental health services.

OBJECTIVE: The aim of this study was to develop indicators of conformance in clinical practice with guidelines for care in schizophrenia. Recommended guidelines rarely apply to all patients and need to allow for social ability, family context, and phase of the disorder. These indicators were therefore devised for tailoring to patient characteristics and allowing for factors that may justify the lack of adherence to clinical guidelines. METHODS: A team of senior clinicians and methodologists reviewed three clinical guidelines (from the Schizophrenia Patient Outcomes Research Team, McEvoy and colleagues, and the National Institute for Health and Clinical Excellence) and defined criteria for their operationalization into clinical indicators. For each indicator, the team defined criteria for eligibility (requirements to be met to qualify for evaluation), conformance (criteria to be satisfied to comply with each recommendation), and moderators (factors that could justify the lack of application of a given recommendation). These indicators were tested with a random sample of 807 patients with schizophrenia or schizoaffective disorders in outpatient facilities, long-term residential facilities, and hospital units for acute care in the Piedmont region of Italy. RESULTS: A set of 15 indicators was derived, nine concerning pharmacological treatment and six for general care and psychosocial rehabilitation. Moderators such as patient or family refusal of antipsychotic treatment and the patient's level of disability helped to justify a considerable proportion of nonconformant care. CONCLUSIONS: The indicators developed are a simple and useful tool to monitor the conformance of care with recommended practices and to identify areas needing improvement.

Pregnancy outcomes and migration in Switzerland: results from a focus group study.

OBJECTIVES: To explore the issues of pregnancy and delivery in migrant women in their interaction with the Swiss healthcare system. METHODS: Focus groups were conducted with women of the Turkish and Portuguese communities. Swiss women were included as the reference group. Interpreters were used when needed. Group discussions were recorded and transcribed; all communications were categorized by specific themes and subdivided as to content. RESULTS: Eight focus groups were held: there were a total of 40 participants including 14 Turkish, 17 Portuguese, 9 Swiss. The study revealed that migrant women in Switzerland face stressful situations, which may differ according to nationality and length of stay in the country. Main factors negatively affecting pregnancy were stress due to precarious living conditions, heavy work during pregnancy, inadequate communication with healthcare providers, and feelings of racism and discrimination in society. CONCLUSIONS: Main findings of this qualitative study confirm that migrant communities need focused health attention because of numerous barriers to healthcare experienced in Switzerland. Improving the reproductive health of the migrant community is a priority that can be addressed by public health interventions, including integration of migrants into the society, strict observance of labor regulations, improved communication with healthcare providers, and better information targeting migrant communities.

Combined pharmacotherapy and psychological treatment for depression: a systematic review.

BACKGROUND: Adherence to antidepressant medication use is a problem in clinical practice. Some authors have posited that combined psychological treatment facilitates adherence to pharmacotherapy. OBJECTIVES: To study the relationship between adherence to use of and efficacy of antidepressant drugs plus psychological treatment vs drug treatment alone in depressive disorders. DATA SOURCES: MEDLINE, Current Contents, PsychInfo, Cochrane Library, and reference lists were searched, from January 1980 to November 2002. STUDY SELECTION: Randomized clinical trials comparing antidepressant treatment alone with antidepressant treatment in combination with a psychological intervention in depressive disorders were considered. The decision to include studies in the meta-analysis was performed by 2 reviewers. DATA EXTRACTION: Three independent reviewers extracted the data, using a precoded form. Methodological quality of the studies was evaluated in terms of allocation concealment and independence of evaluators. DATA SYNTHESIS: Sixteen trials met the inclusion criteria, with 932 patients randomized to pharmacotherapy alone and 910 to combined treatment. Overall, patients receiving combined treatment improved significantly compared with those receiving drug treatment alone (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.38-2.52), but dropouts and nonresponders did not differ in distribution between the 2 treatment modalities (OR, 0.86; 95% CI, 0.60-1.24). Studies longer than 12 weeks showed a significant advantage of combined treatment over drug treatment alone (OR, 2.21; 95% CI, 1.22-4.03), with a significant reduction in dropouts compared with nonresponders (OR, 0.59; 95% CI, 0.39-0.88). These estimates were not affected by study quality. CONCLUSIONS: Psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone. In longer therapies, the addition of psychotherapy helps to keep patients in treatment. Further studies are needed to investigate whether the improvement in response attributable to the combination of drug treatment and psychotherapy can be achieved by a combination of pharmacotherapy and a compliance-enhancing intervention.

Palliative care in developing countries: why research is needed.

Contemporary medical knowledge is sufficient to control the suffering of most of the millions of terminally patients in the world if applied appropriately. However, palliative care is still unavailable to most patients in developing countries. Effective models of palliative care delivery that have been tested in developed countries seldom apply to the developing world where poverty, extended families, and insufficient health infrastructure require the adaptation of such care to local cultures and circumstances. Research from developing countries is therefore needed to develop, implement, and monitor the delivery of palliative care in ways that are feasible in resource-poor settings and acceptable to local populations. Palliative care research shares most of the obstacles common to health research in the developing world. Additional obstacles include a lack of consideration of palliative care as part of cancer control strategies and the low political acceptability of such care because it involves the use of opioid analgesics. Coordinated research efforts through active networking and common protocols would increase the visibility of the discipline, provide answers relevant to the local contexts, and assist in expanding palliative care services across the developing world.

HIV prevention in prisons. Do international guidelines matter?

BACKGROUND: In spite of the availability of international guidelines, HIV prevention and management of care in prison is still unsatisfactory in many countries. Factors affecting the quality of HIV prevention policies in prison have not yet been elucidated. The present study had two aims: i) to assess national HIV prevention policies in prison in a selected group of countries; and ii) to determine which factors influenced such policies at the country level. METHODS: HIV prevention policies in prison were reviewed comparatively in Moldova, Hungary, Nizhnii Novgorod region of the Russian Federation, Switzerland and Italy. The review of HIV prevention policies in prison was conducted through interviews with government officials, non-governmental organizations, professionals involved in this field, and visits to selected prisons. Information on the health of prisoners, including tuberculosis, sexually transmitted diseases, and other infectious diseases has also been collected. RESULTS: The results indicated that all countries had adopted a policy, irrespective of the burden of HIV infection in the prison system. The content of the policy mirrored the philosophy and strategies of HIV prevention and care in the community. The 1993 WHO Guidelines were fully implemented only in one country out of four (Switzerland), and partially in two (Italy and Hungary). CONCLUSIONS: A greater effort aimed at dissemination of information, provision of technical know-how and material resources could be the answer to at least part of the problems identified. In addition, greater national and international efforts are needed to stimulate the debate and build consensus on harm reduction activities in prison.