Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua.

BACKGROUND: The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery. METHODS: We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother's locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women's characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country. RESULTS: Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (ß = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (ß = - 0.130, 95% CI -0.23, - 0.03) more than in the comparison group. CONCLUSIONS: Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities' capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.

Access and use of oxytocin for postpartum haemorrhage prevention: a pre-post study targeting the poorest in six Mesoamerican countries.

OBJECTIVES: Haemorrhage remains the leading cause of maternal mortality in Central America. The Salud Mesoamérica Initiative aims to reduce such mortality via performance indicators. Our objective was to assess the availability and administration of oxytocin, before and after applying Salud Mesoamérica Initiative interventions in the poorest health facilities across Central America. DESIGN: Pre-post study. SETTING: 166 basic-level and comprehensive-level health facilities in Belize, Guatemala, Honduras, Mexico, Nicaragua and Panama. PARTICIPANTS: A random sample of medical records for uncomplicated full-term deliveries (n=2470) per International Classification of Diseases coding at baseline (July 2011 to August 2013) and at first-phase follow-up (January 2014 to October 2014). INTERVENTIONS: A year of intervention implementation prior to first-phase follow-up data collection focused on improving access to oxytocin by strengthening supply chains, procurement, storage practices and pharmacy inventory monitoring, using a results-based financing model. PRIMARY AND SECONDARY OUTCOME MEASURES: Oxytocin availability (primary outcome) and administration (secondary outcome) for postpartum haemorrhage prevention. RESULTS: Availability of oxytocin increased from 82.9% to 97.6%. Oxytocin administration increased from 83.6% to 88.4%. Significant improvements were seen for availability of oxytocin (adjusted OR (aOR)=8.41, 95% CI 1.50 to 47.30). Administration of oxytocin was found to be significantly higher in Honduras (aOR=2.96; 95% CI 1.00 to 8.76) in reference to Guatemala at follow-up. CONCLUSION: After interventions to increase health facility supplies, the study showed a significant improvement in availability but not administration of oxytocin in poor communities within Mesoamerica. Efforts are needed to improve the use of oxytocin.

Antenatal care as a means to increase participation in the continuum of maternal and child healthcare: an analysis of the poorest regions of four Mesoamérican countries.

BACKGROUND: Antenatal care (ANC) is a means to identify high-risk pregnancies and educate women so that they might experience a healthier delivery and outcome. There is a lack of evidence about whether receipt of ANC is an effective strategy for keeping women in the system so they partake in other maternal and child interventions, particularly for poor women. The present analysis examines whether ANC uptake is associated with other maternal and child health behaviors in poor mothers in Guatemala, Honduras, Nicaragua, and Mexico (Chiapas). METHODS: We conducted a cross-sectional survey of women regarding their uptake of ANC for their most recent delivery in the last two years and their uptake of selected services and healthy behaviors along a continuity of maternal and child healthcare. We conducted logistic regressions on a sample of 4844 births, controlling for demographic, household, and maternal characteristics to understand the relationship between uptake of ANC and later participation in the continuum of care. RESULTS: Uptake of four ANC visits varied by country from 17.0% uptake in Guatemala to 81.4% in Nicaragua. In all countries but Nicaragua, ANC was significantly associated with in-facility delivery (IFD) (Guatemala odds ratio [OR] = 5.28 [95% confidence interval [CI] 3.62-7.69]; Mexico OR = 5.00 [95% CI: 3.41-7.32]; Honduras OR = 2.60 [95% CI: 1.42-4.78]) and postnatal care (Guatemala OR = 4.82 [95% CI: 3.21-7.23]; Mexico OR = 4.02 [95% CI: 2.77-5.82]; Honduras OR = 2.14 [95% CI: 1.26-3.64]), but did not appear to have any positive relationship with exclusive breastfeeding habits or family planning methods, which may be more strongly determined by cultural influences. CONCLUSIONS: Our results demonstrate that uptake of the WHO-recommended four ANC visits has limited effectiveness on uptake of services in some poor populations in Mesoamérica. Our study highlights the need for continued and varied efforts in these populations to increase both the uptake and the effectiveness of ANC in encouraging positive and lasting effects on women's uptake of health care services.

Results-based aid with lasting effects: sustainability in the Salud Mesoamérica Initiative.

BACKGROUND: The Salud Mesoamérica Initiative is a public-private partnership aimed at reducing maternal and child morbidity and mortality for the poorest populations in Central America and the southernmost state of Mexico. Currently at the midpoint of implementation and with external funding expected to phase out by 2020, SMI's sustainability warrants evaluation. In this study, we examine if the major SMI components fit into the Dynamic Sustainability Framework to predict whether SMI benefits could be sustainable beyond the external funding and to identify threats to sustainability. METHODS: Through the 2016 Salud Mesoamérica Initiative Process Evaluation, we applied qualitative methods including document review, key informant interviews, focus group discussions, and a social network analysis to address our objective. RESULTS: SMI's design continuously evolves and aligns with national needs and objectives. Partnerships, the regional approach, and the results-based aid model create a culture that prioritizes health care. SMI's sector-wide approach and knowledge-sharing framework strengthen health systems. Evidence-based practice promotes policy dialogue and scale-up of interventions. CONCLUSION: Most SMI elements fit within the Dynamic Sustainability Framework, suggesting a likelihood of sustainability after external funding ceases, and subsequent application of lessons learned by the global community. This includes a flexible design, partnerships and a culture of prioritizing healthcare, health systems strengthening mechanisms, policy changes, and scale-ups of interventions. However, threats to sustainability, including possible transient culture of prioritizing health care, dissipation of reputational risk and financial partnerships, and personnel turnover, need to be addressed.

Supply-side interventions to improve health: Findings from the Salud Mesoamérica Initiative.

BACKGROUND: Results-based aid (RBA) is increasingly used to incentivize action in health. In Mesoamerica, the region consisting of southern Mexico and Central America, the RBA project known as the Salud Mesoamérica Initiative (SMI) was designed to target disparities in maternal and child health, focusing on the poorest 20% of the population across the region. METHODS AND FINDINGS: Data were first collected in 365 intervention health facilities to establish a baseline of indicators. For the first follow-up measure, 18 to 24 months later, 368 facilities were evaluated in these same areas. At both stages, we measured a near-identical set of supply-side performance indicators in line with country-specific priorities in maternal and child health. All countries showed progress in performance indicators, although with different levels. El Salvador, Honduras, Nicaragua, and Panama reached their 18-month targets, while the State of Chiapas in Mexico, Guatemala, and Belize did not. A second follow-up measurement in Chiapas and Guatemala showed continued progress, as they achieved previously missed targets nine to 12 months later, after implementing a performance improvement plan. CONCLUSIONS: Our findings show an initial success in the supply-side indicators of SMI. Our data suggest that the RBA approach can be a motivator to improve availability of drugs and services in poor areas. Moreover, our innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Health system strategies to increase HIV screening among pregnant women in Mesoamerica.

BACKGROUND: To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador. METHODS: We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening. RESULTS: Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%. CONCLUSIONS: To meet WHO's recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.

Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents.

BACKGROUND: In the poorest regions of Chiapas, Mexico, 50.2% of women in need of contraceptives do not use any modern method. A qualitative study was needed to design effective and culturally appropriate interventions. METHODS: We used purposive maximum-variation sampling to select eight municipalities with a high proportion of residents in the poorest wealth quintile, including urban, rural, indigenous, and non-indigenous communities. We conducted 44 focus group discussions with 292 women, adolescent women, and men using semi-structured topic guides. We analyzed the data through recursive abstraction. RESULTS: There were intergenerational and cultural gaps in the acceptability of family planning, and in some communities family planning use was greatly limited by gender roles and religious objections to contraception. Men strongly influenced family planning choices in many households, but were largely unreached by outreach and education programs due to their work hours. Respondents were aware of many modern methods but often lacked deeper knowledge and held misconceptions about long-term fertility risks posed by some hormonal methods. Acute physical side effects also dissuaded use. The implant was a new and highly acceptable method due to ease of use, low upkeep, and minimal side effects; however, it was perceived as subject to stock-outs. Adolescent women reported being refused services at health facilities and requested more reproductive health information from their parents and schools. Mass and social media are growing sources of reproductive health information. CONCLUSIONS: Our study identifies a number of barriers to family planning that have yet to be adequately addressed by existing programs in Chiapas' poorest regions, and calls for reinvigorated efforts to provide effective, acceptable, and culturally appropriate interventions for these communities.

Barriers and facilitators for institutional delivery among poor Mesoamerican women: a cross-sectional study.

Professional skilled care has shown to be one of the most promising strategies to reduce maternal mortality, and in-facility deliveries are a cost-effective way to ensure safe births. Countries in Mesoamerica have emphasized in-facility delivery care by professionally skilled attendants, but access to good-quality delivery care is still lacking for many women. We examined the characteristics of women who had a delivery in a health facility and determinants of the decision to bypass a closer facility and travel to a distant one. We used baseline information from the Salud Mesoamerica Initiative (SMI). Data were collected from a large household and facilities sample in the poorest quintile of the population in Guatemala, Honduras and Nicaragua. The analysis included 1592 deliveries. After controlling for characteristics of women and health facilities, being primiparous (RR = 1.15, 95% CI 1.10, 1.21), being literate (RR = 1.24, 95% CI 1.04, 1.48), having antenatal care (RR = 1.68, 95% CI 1.24, 2.27), being informed of the need for having a C-section (RR = 1.07, 95% CI 1.02, 1.11) and travel time to the closest facility totaling 1-2 h vs under 30 min (RR = 0.88, 95% CI 0.77, 0.99) were associated with in-health facility deliveries. In Guatemala, increased availability of medications and equipment at a distant facility was strongly associated with bypassing the closest facility in favor of a distant one for delivery (RR = 2.10, 95% CI 1.08, 4.07). Our study showed a strong correlation between well-equipped facilities and delivery attendance in poor areas of Mesoamerica. Indeed, women were more likely to travel to more distant facilities if the facilities were of higher level, which scored higher on our capacity score. Our findings call for improving the capacity of health facilities, quality of care and addressing cultural and accessibility barriers to increase institutional delivery among the poor population in Mesoamerica.

Coverage and timing of antenatal care among poor women in 6 Mesoamerican countries.

BACKGROUND: Poor women in the developing world have a heightened need for antenatal care (ANC) but are often the least likely to attend it. This study examines factors associated with the number and timing of ANC visits for poor women in Guatemala, Honduras, Mexico, Nicaragua, Panama, and El Salvador. METHODS: We surveyed 8366 women regarding the ANC they attended for their most recent birth in the past two years. We conducted logistic regressions to examine demographic, household, and health characteristics associated with attending at least one skilled ANC visit, four skilled visits, and a skilled visit in the first trimester. RESULTS: Across countries, 78 % of women attended at least one skilled ANC visit, 62 % attended at least four skilled visits, and 56 % attended a skilled visit in the first trimester. The proportion of women attending four skilled visits was highest in Nicaragua (81 %) and lowest in Guatemala (18 %) and Panama (38 %). In multiple countries, women who were unmarried, less-educated, adolescent, indigenous, had not wanted to conceive, and lacked media exposure were less likely to meet international ANC guidelines. In countries with health insurance programs, coverage was associated with attending skilled ANC, but not the timeliness. CONCLUSIONS: Despite significant policy reforms and initiatives targeting the poor, many women living in the poorest regions of Mesoamérica are not meeting ANC guidelines. Both supply and demand interventions are needed to prioritize vulnerable groups, reduce unplanned pregnancies, and reach populations not exposed to common forms of media. Top performing municipalities can inform effective practices across the region.

Institutional Delivery and Satisfaction among Indigenous and Poor Women in Guatemala, Mexico, and Panama.

Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44-2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18-1.81), primiparous (aRR = 1.44, 95% CI: 1.24-1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21-1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04-1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05-1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02-1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.

Diarrhea Prevalence, Care, and Risk Factors Among Poor Children Under 5 Years of Age in Mesoamerica.

Care practices and risk factors for diarrhea among impoverished communities across Mesoamerica are unknown. Using Salud Mesoamérica Initiative baseline data, collected 2011-2013, we assessed the prevalence of diarrhea, adherence to evidence-based treatment guidelines, and potential diarrhea correlates in poor and indigenous communities across Mesoamerica. This study surveyed 14,500 children under 5 years of age in poor areas of El Salvador, Guatemala, Mexico (Chiapas State), Nicaragua, and Panama. We compared diarrhea prevalence and treatment modalities using χ(2) tests and used multivariable Poisson regression models to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) for potential correlates of diarrhea. The 2-week point prevalence of diarrhea was 13% overall, with significant differences between countries (P < 0.05). Approximately one-third of diarrheal children were given oral rehydration solution and less than 3% were given zinc. Approximately 18% were given much less to drink than usual or nothing to drink at all. Antimotility medication was given to 17% of diarrheal children, while antibiotics were inappropriately given to 36%. In a multivariable regression model, compared with children 0-5 months, those 6-23 months had a 49% increased risk for diarrhea (aRR = 1.49, 95% CI = 1.15, 1.95). Our results call for programs to examine and remedy low adherence to evidence-based treatment guidelines.

Breastfeeding Practices among Poor Women in Mesoamerica.

BACKGROUND: Breastfeeding is an effective intervention to reduce pediatric morbidity and mortality. The prevalence of practices and predictors of breastfeeding among the poor in Mesoamerica has not been well described. OBJECTIVES: We estimated the prevalence of ever breastfeeding, early initiation of breastfeeding, exclusive breastfeeding, and breastfeeding between 6 mo and 2 y of age using household survey data for the poorest quintile of families living in 6 Mesoamerican countries. We also assessed the predictors of breastfeeding behaviors to identify factors amenable to policy interventions. METHODS: We analyzed data from 12,529 children in Guatemala, Honduras, Mexico (Chiapas State), Nicaragua, Panama, and El Salvador using baseline survey data from the Salud Mesoamérica 2015 Initiative. We created multivariable Poisson regression models with robust variance estimates to calculate adjusted risk ratios (aRRs) and 95% CIs for breastfeeding outcomes and to control for sociodemographic and healthcare-related factors. RESULTS: Approximately 97% of women in all countries breastfed their child at least once, and 65.1% (Nicaragua) to 79.0% (Panama) continued to do so between 6 mo and 2 y of age. Breastfeeding in the first hour of life varied by country (P < 0.001), with the highest proportion reported in Panama (89.8%) and the lowest in El Salvador (65.6%). Exclusive breastfeeding also varied by country (P = 0.037), ranging from 44.5% in Panama to 76.8% in Guatemala. For every 20% increase in the proportion of peers who exclusively breastfed, there was an 11% (aRR: 1.11, 95% CI: 1.04, 1.18) increase in the likelihood of exclusive breastfeeding. CONCLUSION: Our study revealed significant variation in the prevalence of breastfeeding practices by poor women across countries surveyed by the Salud Mesoamérica 2015 initiative. Future interventions to promote exclusive breastfeeding should consider ways to leverage the role of the community in supporting individual women.

Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015.

BACKGROUND: Individual income and poverty are associated with poor health outcomes. The poor face unique challenges related to access, education, financial capacity, environmental effects, and other factors that threaten their health outcomes. METHODS: We examined the variation in the health outcomes and health behaviors among the poorest quintile in eight countries of Mesoamerica using data from the Salud Mesomérica 2015 baseline household surveys. We used multivariable logistic regression to measure the association between delivering a child in a health facility and select household and maternal characteristics, including education and measures of wealth. RESULTS: Health indicators varied greatly between geographic segments. Controlling for other demographic characteristics, women with at least secondary education were more likely to have an in-facility delivery compared to women who had not attended school (OR: 3.20, 95 % confidence interval [CI]: 2.56-3.99, respectively). Similarly, women from households with the highest expenditure were more likely to deliver in a health facility compared to those from the lowest expenditure households (OR 3.06, 95 % CI: 2.43-3.85). Household assets did not impact these associations. Moreover, we found that commonly-used definitions of poverty do not align with the disparities in health outcomes observed in these communities. CONCLUSIONS: Although poverty measured by expenditure or wealth is associated with health disparities or health outcomes, a composite indicator of health poverty based on coverage is more likely to focus attention on health problems and solutions. Our findings call for the public health community to define poverty by health coverage measures rather than income or wealth. Such a health-poverty metric is more likely to generate attention and mobilize targeted action by the health communities than our current definition of poverty.