Relationship Between Maternal Age and Macronutrient Content of Colostrum.

BACKGROUND: Little is known about the relationship between maternal age and the macronutrient content of colostrum. RESEARCH AIMS: This study aimed to evaluate the relationship between maternal age and human milk macronutrient content by comparing the concentrations of lactose, proteins, and lipids in the colostrum of women with younger, moderate, and advanced maternal age. METHODS: An observational, cross-sectional study was designed to compare the macronutrient concentrations in the colostrum of women aged < 20 years, 20 to 34 years, and > 34 years (younger, moderate, and advanced maternal age, respectively; n = 33 per group). For each participant, 3 ml of colostrum was collected by manual extraction from the right breast at 10 am, 39-48 hr after delivery, and analyzed using a Miris Human Milk Analyzer. Macronutrient concentrations were compared between the groups using analysis of variance. P < 0.05 was considered significant. RESULTS: Mothers with moderate maternal age had a higher colostrum lipid concentration than those with younger or advanced maternal age (2.3 mg, SD = 1.4 mg vs. 1.5 mg, SD = 1.0 mg vs. 1.6 mg, SD = 0.9 mg, respectively; p = 0.007). Lactose and protein contents in the analyzed samples did not differ among the three study groups. CONCLUSION: This study lends support to the potential variation of lipids in colostrum by maternal age and suggests individual adaptation to the nutritional components of milk to the needs of the infant may be beneficial.

Self-rated health among adolescents from vulnerable areas and their sociodemographic, lifestyle and contextual factors: A multilevel analysis.

PURPOSE: Understanding self-rated health in young people can help orient global health actions, especially in regions of social vulnerability. The present study analysed individual and contextual factors associated with self-rated health in a sample of Brazilian adolescents. DESIGN AND METHODS: Cross-sectional data from 1272 adolescents (aged 11-17; 48.5% of girls) in low human development index (HDI) neighbourhoods were analysed (HDI from 0.170 to 0.491). The outcome variable was self-rated health. Independent variables relating to individual factors (biological sex, age and economic class) and lifestyle (physical activity, alcohol, tobacco consumption and nutritional state) were measured using standardised instruments. The socio-environmental variables were measured using neighbourhood registered data where the adolescents studied. Multilevel regression was used to estimate the regression coefficients and their 95% confidence intervals (CI). RESULTS: Good self-rated health prevalence was of 72.2%. Being male (B: -0.165; CI: -0.250 to -0.081), age (B: -0.040; CI: -0.073 to -0.007), weekly duration of moderate to vigorous physical activity (B: 0.074; CI: 0.048-0.099), body mass index (B: -0.025; CI: -0.036 to -0.015), number of family healthcare teams in the neighbourhood (B: 0.019; CI: 0.006-0.033) and dengue incidence (B: -0.001; CI: -0.002; -0.000) were factors associated with self-rated health among students from vulnerable areas. CONCLUSIONS/PRACTICAL IMPLICATIONS: Approximately three in every 10 adolescents in areas of social vulnerability presented poor self-rated health. This fact was associated with biological sex and age (individual factors), physical activity levels and BMI (lifestyle) and the number of family healthcare teams in the neighbourhood (contextual).

A cross-sectional analysis of risk factors for cardiovascular diseases in older females: association between body fat distribution and physical fitness.

This study aimed to determine whether body fat distribution and physical fitness would be associated with risk factors for cardiovascular diseases (CVDs) in post-menopausal females. Android fat distribution were more likely to have altered total cholesterol (TC), high-density lipoprotein (HDL-C), triglycerides (TG), glycemic levels (GL) body fat percentage (%BF), and body mass index (BMI), and those with inadequate physical fitness showed clear alterations in TC, HDL-C, and TG. Gynoid fat distribution group fared better regarding CVD risk. In conclusion, adequate physical fitness demonstrates a protective factor against CVDs, with the greatest benefit to those with gynoid fat distribution.

Intimate Partner Violence Among Women of Reproductive Age in Nicaragua: Results From a Nationwide Survey.

This article aims to identify the factors associated with intimate partner violence (IPV) using data from the latest available nationwide survey in Nicaragua. A secondary analysis of the 2011-2012 Nicaraguan Demography and Health Survey (ENDESA 2011-2012) was conducted. A total of 12,605 women aged 15-49 years who had reported being married or united were included. IPV (yes/no) was defined as the outcome variable, and it was considered if a woman suffered verbal, psychological, physical, or sexual violence during the previous 12 months. Crude and adjusted odds ratios with 95% CI were calculated using a bivariate and multivariate logistic regression model. A p value <.05 was considered statistically significant and did not correct p values for multiple testing. The overall prevalence of IPV was 17.5%. Women living in urban setting (AOR: 1.51, 95% CI: 1.26-1.80), women who self-identify as native (AOR: 1.34, 95% CI: 1.34-1.61) or women who have a history of abuse as a child (AOR: 1.96, 95% CI: 1.69-2.27) were more likely to suffer IPV compared to their counterparts. Age was found to be a protective factor for IPV. Variables such as educational level and wealth index, do not report any association with IPV. Our findings shows that IPV in Nicaragua continues to be a frequent event. The results provide evidence of drivers for IPV at a national level. These findings are useful for the design of intervention policies and strategies for the prevention of IPV.

Genotipificación del Virus de Papiloma Humano en mujeres de la comuna norte de Bucaramanga / Genotypification of Human Papilloma Virus in women of the comuna Norte de Bucaramanga

Resumen Introducción: La infección persistente con Virus de Papiloma Humano de alto riesgo es causa necesaria para la aparición de cáncer de cérvix. Objetivo: Caracterizar molecularmente los genotipos circulantes de Virus de Papiloma Humano en población de la zona Norte de Bucaramanga. Métodos: Estudio de corte transversal en mujeres de 35 a 65 años con riesgo ≥3 puntos para desarrollar cáncer de cérvix determinado por una encuesta estandarizada. En una muestra cervico-vaginal por autotoma se realizaron pruebas moleculares por tecnología HPV Direct Flow CHIP. Resultados: Se encuestaron 810 mujeres, de éstas 435 (53,7%) se realizaron auto-toma por el riesgo presentado. La mediana de edad fue de 47,3 años (RIQ 41-53 años). Casi la totalidad de la población reside en estrato 1 y 2 (98,8%) y en su mayoría son del régimen subsidiado (87,2%). La prevalencia de infección fue de 10,6% (IC 95%: 7,8 - 13,8), para genotipos de alto riesgo fue de 3,9% (IC 95%: 2,3 - 6,2), de bajo riesgo de 3,5% (IC 95%: 1,4 - 5,6) y para genotipo indeterminado de 1,9%. El genotipo de alto riesgo más común fue VPH-59 y de bajo riesgo fue VPH-62/81. Hubo coinfección con genotipos alto/bajo riesgo en cinco mujeres y coinfección con dos genotipos de bajo riesgo en una mujer. Conclusión: la prevalencia de infección por Virus de Papiloma Humano en mujeres que habitan en zonas vulnerables de Bucaramanga es menor a la reportada en Bogotá y Cali (14,9% y 13%, respectivamente). No se encontró predominio de ningún genotipo de alto riesgo en particular.

Abstract Introduction: Persistent infection with high-risk Human Papilloma Virus is a necessary cause for the appearance of cervical cancer. Objective: Molecularly characterize circulating genotypes of Human Papilloma Virus in population of the north of Bucaramanga. Methods: Cross-sectional study in women aged from 35 to 65 years with risk ≥3 points for develop cervical cancer determined by a standardized survey. In a cervico-vaginal self-sampling probe a molecular test was performed by HPV Direct Flow CHIP technology. Results: 810 women were interviewed, of these 435 (53.7%) performed self-sampling due to the risk calculated. The median age was 47.3 years (RIQ 41-53 years). Almost the entire population resides in poor conditions (stratum1 and 2) (98.8%) and most of them are from the Colombian subsidized social security system (87.2%). The prevalence was 10.6% (CI 95%: 7.8 - 13.8), for high risk genotypes it was 3.9% (CI 95%: 2.3 - 6.2), low risk of 3.5% (CI 95%: 1.4 - 5.6) and for indeterminate genotype of 1.9%. HPV-59 was the most common high-risk genotype and HPV-62/81 was a low-risk genotype. There was coinfection with high risk / low risk genotypes in five women and coinfection with two low risk genotypes in a woman. Conclusion: The prevalence of infection by Human Papilloma Virus in women living in vulnerable areas of Bucaramanga is lower than that reported in Bogotá and Cali (14.9% and 13%, respectively). No predominance of any particular high-risk genotype was found.

Morphometric study of five constant skull base foramina in the Muisca population of the Tibanica anthropological collection of the Universidad de Los Andes / Estudio morfométrico de cinco forámenes constantes de la base del cráneo en la población Muisca de la colección antropológica Tibanica de la Universidad de Los Andes

Among osteological anatomic variations are those of the skull base foramina. These openings have conventionally been classified as either constant or variant. Their presence and dimensions have been associated with certain pathologies and procedural complications. Additionally, variability in these foramina between different ethnic groups has been observed, and it is sometimes possible to identify particular patterns of variability in certain populations. This anthropometric cross-sectional study seeks to determine the principal dimensions (bilateral anteroposterior and lateromedial diameters) of five constant skull base foramina in the adult Muisca population of the Tibanica anthropological collection at Universidad de los Andes. The studied foramina were magnum, jugular, ovale, spinosum, and external opening of the carotid canal. Only dimensions of the external openings of the foramina were recorded, owing to the preservation state of the skulls in the collection. The mean left and right anteroposterior and lateromedial diameters were 3.48 mm, 6.16 mm and 3.25 mm, 6.26 mm for the foramen ovale; 2.38 mm, 2.65 mm and 2.39 mm, 2.66 mm for foramen spinosum; 8.36 mm, 15.41 mm and 8.55 mm, 15.10 mm for the jugular foramen; 5.28 mm, 6.75 mm and 5.48 mm, 6.97 mm for the external opening of the carotid canal; and 33.90 mm, 29.47 mm for the foramen magnum. All foramina were measured twice, no important differences were observed between the results obtained in the first and second measurements. The skull base foramina of the sample studied did not suggest high variability within the population regarding these characteristics. Moreover, we can state that the morphometric profile displayed by the Tibanica collection at Universidad de los Andes is different from the one observed in other populations. Additional studies of anatomic variations in indigenous populations may be needed to make possible similarities and/or differences and their causes evident.

Entre las variaciones anatómicas óseas, se consideran aquellas referentes a los forámenes de la base del cráneo. Convencionalmente, estos orificios han sido clasificados como variantes o constantes. Su presencia y dimensiones se asocian a ciertas patologías y complicaciones procedimentales. Adicionalmente, se ha observado variabilidad en estos entre distintos grupos étnicos y en algunas ocasiones es posible identificar patrones particulares en poblaciones específicas. Este estudio morfométrico de corte transversal busca determinar las dimensiones principales (diámetros anteroposterior y lateromedial) de cinco forámenes constantes de la base del cráneo en la población adulta Muisca de la colección antropológica Tibanica de la Universidad de los Andes. Los forámenes estudiados fueron: magno, yugular, ovale, espinoso y la apertura externa del canal carotideo. Debido al estado de preservación de los cráneos, se registraron las dimensiones de las aperturas externas de los forámenes. La media de los diámetros izquierdo y derecho anteroposterior y lateromedial fue 3,48 mm, 6,16 mm y 3,25 mm, 6,26 mm para el foramen ovale; 2,38 mm, 2,65 mm y 2,39 mm, 2,66 mm para el espinoso; 8,36 mm, 15,41 mm y 8,55 mm, 15,10 mm para el yugular; 5,28 mm, 6,75 mm y 5,48 mm, 6,97 mm para la apertura externa del canal carotideo; y 33,90 mm, 29,47 mm para el foramen magno. Todos los diámetros se registraron dos veces, no se observó ninguna diferencia importante entre los registros de la primera y segunda medición. En general, las dimensiones de los forámenes estudiados no varían mucho en la colección ósea Muisca de Tibanica. En cuanto a estas características anatómicas, la población utilizada es diferente con respecto a algunas modernas. Por otro lado, se requieren investigaciones adicionales de este tipo con el fin de evidenciar posibles similitudes y diferencias entre poblaciones (prehispánicas y modernas) y determinar sus causas.

Obesity, abdominal obesity and migraine: a cross-sectional analysis of ELSA-Brasil baseline data.

BACKGROUND AND AIM: Most studies assessing the association between migraine and obesity have shown conflicting results. We aimed to evaluate the association between obesity and migraine in ELSA-Brasil, a cohort study of 15,105 individuals aged 35-74 years. METHODS: We assessed migraine using a validated questionnaire based on International Headache Society criteria and anthropometric measurements using standard techniques. Migraine was categorized as daily and non-daily. World Health Organization criteria were used to categorize overweight, obesity and abdominal obesity (AbO). We performed a cross-sectional analysis using multivariate logistic regression models to study the association between migraine and obesity (body mass index (BMI) ≥ 30 kg/m(2)), compared to controls without migraine. RESULTS: We found an association between daily migraine and obesity (odds ratio (OR) 1.86; 95% confidence interval (95% CI): 1.12-3.09). Although the presence of AbO was not associated with migraine, interaction models showed that the association between obesity and daily migraine remained strong only in the absence of AbO diagnosis, notably in individuals aged 35-49 years. DISCUSSION: In our large sample of individuals aged 35 years or older, obesity, but not AbO, was associated with daily migraine. AbO influenced the association between BMI and daily migraine in migraineurs aged 35-49 years.

Carotid intima-media thickness value distributions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

OBJECTIVE: Carotid intima-media thickness (IMT) is a noninvasive measurement of early atherosclerosis. Most IMT studies have involved populations with low rates of racial blending. The aim of the present article is to describe IMT value distributions and analyze the influence of sex and race on IMT values in a large Brazilian sample, a setting with a high rate of racial admixture. METHODS: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort of 15,105 adult (aged 35-74 years) civil servants in six Brazilian cities. Baseline assessment included IMT measurements in both common carotid arteries. Race was self-reported. We studied the association between sex and race with IMT values using multiple linear regression models. We conducted analyses in all and low-risk individuals, defined as those without classical cardiovascular risk factors. RESULTS: We analyzed complete IMT data from 10,405 ELSA-Brasil participants. We present nomograms by age for all and low-risk individuals, stratified by sex and race. We found that men had significantly higher maximal IMT values compared with women (ß = 0.058; P < 0.001). This association remained for low-risk individuals (ß = 0.027; P = 0.001). In addition, Brown and White individuals had lower maximal IMT values compared with Black individuals for all (ß = -0.034 and ß = -0.054, respectively; P < 0.001) and low-risk individuals (ß = -0.027; P = 0.013 and ß = -0.035; P < 0.001, respectively). CONCLUSION: We found significantly higher IMT values in men. We found significantly higher IMT values in Black individuals than White and Brown individuals. These results persisted when analyses were restricted to low-risk individuals.

Prevalence, genotypes and factors associated with HCV infection among prisoners in Northeastern Brazil.

AIM: To determine hepatitis C virus (HCV) seroprevalence and its genotypes, and to identify the factors associated with HCV infection. METHODS: This cross-sectional study, conducted in two prisons (one male and one female) in the State of Sergipe, Brazil, comprised 422 subjects. All of the prisoners underwent a rapid test for the detection of HCV antibodies. Patients with a positive result were tested for anti-HCV by enzyme linked immunosorbent assay and for HCV RNA by qualitative polymerase chain reaction (PCR). The virus genotype was defined in every serum sample that presented positive for PCR-HCV. In order to determine the factors independently associated with positive serology for HCV, multivariate logistic regression was used. RESULTS: HCV seroprevalence was 3.1%. Of the 13 subjects with positive anti-HCV, 11 had viremia confirmed by PCR. Of these, 90.9% had genotype 1. A total of 43 (10.2%) were injecting drug users, and HCV seroprevalence in this subgroup was 20.6%. The variable most strongly associated with positive serology for HCV was use of injecting drugs [odds ratio (OR), 23.3; 95% confidence interval (CI), 6.0-90.8]. Age over 30 years (OR, 5.5; 95%CI, 1.1-29.2), history of syphilis (OR, 9.8; 95%CI, 1.7-55.2) and history of household contact with HCV positive individual (OR, 14.1; 95%CI, 2.3-85.4) were also independently associated with HCV infection. CONCLUSION: Most of the HCV transmissions result from parenteral exposure. However, there is evidence to suggest a role for sex and household contact with an infected subject in virus transmission.

Diseño y metodología de la Encuesta Nacional de Salud 2000 / National Health Survey 2000: design and methodology

OBJETIVO: Como parte del Sistema de Encuestas Nacionales de Salud, durante los últimos meses de 1999 y los primeros tres del año 2000 se realizó la Encuesta Nacional de Salud de México (ENSA 2000). Se estudió la accesibilidad, calidad, utilización y cobertura de los Servicios de Salud; de modo adicional se actualizaron los marcadores serológicos de enfermedades infecciosas prevenibles por vacunación, infecciones de transmisión sexual y hepatitis. MATERIAL Y MÉTODOS: Para la ENSA 2000 se seleccionaron tres grupos etarios y a los utilizadores de los servicios de salud. Se captó la información mediante entrevista directa y se tomaron muestras biológicas para análisis clínicos y medidas de parámetros biológicos y somatométricos. El diseño muestral de la ENSA 2000 fue probabilístico, polietápico, estratificado y de conglomerados. El tamaño de la muestra fue de 1 470 viviendas por estado, para un total de 47 040 viviendas a nivel nacional; los factores de expansión se modificaron por la falta de respuesta y la posestratificación. El personal operativo se capacitó y estandarizó para mantener una alta respuesta, en especial para las muestras de sangre. RESULTADOS: En total se obtuvieron 83 157 muestras de sangre de las 94 000 esperadas (respuesta de 88 por ciento) que se mantuvieron refrigeradas en tanto se ubicaron en el laboratorio del Instituto Nacional de Salud Pública donde se prepararon cuatro alícuotas y se congelaron a -150° C hasta el análisis.

OBJECTIVE: The 2000 Mexican National Health Survey (NHS) was created as part of the System for National Health Surveys conducted during the last months of 1999 and the first three of 2000. The 2000 NHS is a probabilistic survey of households from which users of health services were selected according to three age groups. Information was gathered through direct interviews with appropriate informants. Biological samples were taken for clinical tests as well as for measuring biological and somatometric parameters. MATERIAL AND METHODS: The sample design of the 2000 NHS was stratified and clustered. Sample size was 1 470 households per state for a total of 47 040 households nationwide (there are 32 states in México). Sample weights were calculated and modified according to the non-response and post-stratified to calibrate for population distribution. Interviewers were trained in order to maintain a high response rate, especially for biological samples. RESULTS: A total of 83 157 blood samples were collected from the 94 000 expected (88 percent response rate). All samples were refrigerated immediately after collection and divided in four vials for storage at the National Institute for Public Health's laboratory. Samples were frozen at -150° Celsius until further analysis.

Vaginal infections in pregnant women in Jamaica: prevalence and risk factors.

Trichomoniasis, bacterial vaginosis (BV) and candidiasis are reproductive tract infections (RTIs) of the vagina. We conducted a cross-sectional study in 4 prenatal clinics in Kingston, Jamaica, to estimate the prevalence of these infections and the risk factors that may facilitate their transmission among pregnant women. Of the 269 women studied, 18.0% had culture-positive trichomoniasis, 44.1% had BV (Nugent score > or = 7) and 30.7% were positive for candidiasis by wet mount. A multiple logistic regression analysis showed that having a malodorous discharge was associated with trichomoniasis (odd ratios [OR]=3.9, confidence intervals [CI]=1.04-14.7) and BV (OR=3.4, CI=1.3-8.7). Women who took action to prevent HIV infection had lower BV prevalence (OR=0.34, CI=0.12-0.98). Women who were employed were less likely to have any of the infections (OR=0.61, CI=0.36-1.03). The strong association of a symptomatic presentation with trichomoniasis and BV suggests the merit of considering syndromic management of vaginitis in this population.

Relationship between quality of life, social support and disease-related factors in HIV-infected persons in Venezuela.

This study examines the relationships among health-related quality of life (HRQL), social support, sociodemographic factors and disease-related factors in persons infected with the human immunodeficiency virus (HIV) living in Venezuela. A sample of 118 HIV-infected persons living in Caracas, Venezuela, was surveyed using a written questionnaire that included a Spanish translation of the Interpersonal Support Evaluation List (ISEL) developed for this study, the Medical Outcomes Study Short Form-36 (SF-36) and a symptom inventory. All three instruments showed good internal consistency reliability. Multiple regression analyses were used to model SF-36 sub-scale scores as a function of symptoms, social support, HIV-status and use of antiretroviral drugs. The models explained between 16 and 39% of the variance in the different HRQL domains. Controlling for other variables in the model, level of symptomatology was significantly associated with all HRQL domains except social functioning and role-emotional scores. Social support was significantly associated with all HRQL domains except physical functioning and bodily pain. The use of antiretroviral drugs was significantly associated with social functioning. The study indicates the importance of social support to the quality of life of HIV-infected individuals in this culture.

The WHO antenatal care randomised controlled trial: rationale and study design.

The World Health Organisation and collaborating institutions in developing countries are conducting a multicentre randomised controlled trial to evaluate a new antenatal care (ANC) programme, consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. These activities are distributed, for practical reasons, over four visits during the course of pregnancy and are aimed at achieving predetermined goals. The study is taking place in four countries, Argentina, Cuba, Saudi Arabia and Thailand. Recruitment of study subjects started on 1 May 1996. All 53 ANC clinical units had been enrolled by December 1996. Clinics in each country were randomly allocated (cluster randomisation) to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for ANC at these clinics over an average period of 18 months will have been recruited. As women attending the control clinics receive the 'best standard treatment' as currently offered in these clinics, individual informed consent is requested only from women attending the intervention clinics. Authorities of the corresponding health districts and all participating clinics have provided written institutional informed consent before randomisation. The primary outcome of the trial in relation to maternal conditions is the rate of a morbidity indicator index, defined as the presence of at least one of the following conditions for which ANC is relevant: (a) pre-eclampsia or eclampsia during pregnancy or within 24 h of delivery; (b) postpartum anaemia (haemoglobin < 90 g/L); or (c) severe urinary tract infection/pyelonephritis, defined as an episode requiring antibiotic treatment and/or hospitalisation. The primary fetal outcome is the rate of low birthweight (< 2500 g). Adverse maternal and fetal outcomes are expected for approximately 10% of the control group. Several maternal and perinatal secondary outcomes are also considered. A comprehensive cost-effectiveness analysis and women's and providers' satisfaction evaluation are performed concurrently with the trial. Health-care programmes should be rigorously evaluated by randomised controlled trials, which are feasible in developing countries and should be conducted before introducing new treatments or health interventions.

PIP: The procedures and examinations included in currently practiced prenatal care have not been subjected to systematic, scientifically rigorous evaluation. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating a new prenatal care regimen with demonstrated efficacy in improving maternal and newborn outcomes. Program activities include screening for health conditions that increase the risk of specific adverse pregnancy outcomes, therapeutic interventions known to affect these outcomes beneficially, and education of pregnant women regarding potential health emergencies and appropriate responses. The study's hypothesis is that the tests, clinical procedures, and follow-up actions associated with this approach, delivered over the course of four visits during pregnancy, are more effective than the traditional prenatal care package in terms of specific maternal and perinatal results without being more expensive. This paper addresses the rationale, design, and methodology of this trial. 53 prenatal care clinics in four well-defined geographic areas (Khon Kaen Province, Thailand; Havana, Cuba; Rosario, Argentina; and Jeddah, Saudi Arabia) have been randomized to the two arms of the study. By the end of 1997, 24,000 women presenting for prenatal care at these sites had been enrolled. The primary maternal outcome is the morbidity indicator index, defined as the presence of at least one of the following conditions: pre-eclampsia or eclampsia during pregnancy or within 24 hours of delivery, postpartum anemia, or severe urinary tract infection/pyelonephritis. The primary fetal outcome is the rate of low birth weight. A comprehensive cost-effectiveness analysis and provider satisfaction evaluation will be performed concurrently with the trial. Data collection will be completed in 1998.

Methodological considerations in the design of the WHO Antenatal Care Randomised Controlled Trial.

We discuss methodological issues arising in a recent evaluation trial of a new antenatal care programme, as sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction, and WHO's Division of Reproductive Health (Technical Support). The randomisation unit for the trial is the antenatal care clinic, with 53 clinics located in four countries randomly allocated to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for antenatal care over an average period of 18 months will have been recruited.

PIP: The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating the impact of a new program of prenatal care on the health of mothers and newborns. Study subjects will receive either the standard prenatal care program currently offered at participating sites or a new regimen comprised of scientifically evaluated, objective-oriented prenatal care services. A total of 24,000 pregnant women from 53 prenatal care clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled and stratified on the basis of the number of pregnant women enrolled in each clinic during the year preceding the study, the type of clinic (free-standing or hospital), and the administrative health system to which they belong. This article discusses methodological issues related to the study's design, with emphasis on sample size considerations, planned approaches to the statistical analysis, and data quality control. The rationales for selecting clinics as the unit of randomization are to reduce the risk of treatment contamination, encourage participation, and facilitate administrative and logistic convenience in the implementation of the intervention. Randomization of intact clinics to different intervention groups with predefined strata reflects the fact that the aim of the trial is to show the equivalence, not necessarily the superiority, of the new prenatal care program with the existing program of standard care. The two major adverse outcomes, a high maternal morbidity index and low birth weight, are expected to be in the range of 10%. To ensure that a statistically nonsignificant effect can be interpreted meaningfully, the trial has been designed to have a 90% power for ruling out an absolute difference of at least 0.02 in the expected incidence of the primary end points. A confidence interval approach was selected for sample size estimation, as recommended for equivalence trials, to provide additional assurance that the sample size is adequate.

Conceptual bases and methodology for the evaluation of women's and providers' perception of the quality of antenatal care in the WHO Antenatal Care Randomised Controlled Trial.

In this paper, we describe the conceptual bases and methodology used to assess women's and providers' perception of the quality of antenatal care, as part of a large randomised trial in four developing countries. Information has been obtained by applying both qualitative and quantitative methodologies. The focus group discussions and in-depth interviews have contributed useful insights into the cultural milieu in which care is provided, users' and providers' expectations, and their concept of quality. Based on these findings, we developed two standardised questionnaires, one being administered to a representative sample of pregnant women (n = 1600) and the other for all care providers. In this paper we present some of the findings of the focus group discussions and in-depth interviews with women in one country as an example of the kind of information we have obtained. Women expressed their point of view concerning a reduced number of visits, type of provider, information that they get during clinical encounters and interpersonal relations with health professionals. The qualitative information, together with the data we obtain from the surveys, will highlight the aspects that will have be to considered if the new model of care is to be introduced on a routine basis.

PIP: Measurement of the subjective dimension of the quality of health care, including the perceptions of patients and providers, is seldom attempted. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial, underway in 53 clinics in Argentina, Cuba, Thailand, and Saudi Arabia, will apply both quantitative and qualitative methodologies to an assessment of client and staff satisfaction with a new prenatal care program. Specifically, the study addresses user and provider perceptions of quality in the context of a wide spectrum of ethnic backgrounds, social strata, organization of health services, and medical cultures. The research instrument consists of questions that explore the preferences of 1600 women and their providers in terms of the number of prenatal care visits, provider type and gender, time spent in the waiting room and with the provider, and amount and appropriateness of information received during the visits. Preliminary results from focus groups and in-depth interviews indicate that women are concerned about the safety of the reduced number of visits during pregnancy (four for low-risk women) inherent in the experimental regimen, prefer to receive care from specialists rather than family practitioners, are confused by the technical language used by providers, and want more information on the psychosocial aspects of pregnancy. Such qualitative information, together with data obtained from questionnaires, will highlight areas that must be addressed if the new prenatal care model is to be introduced on a routine basis.

[Role of the obstetric nurse in the Anhanguera community, Campo Grande (MS), in the prevention of cervical cancer]. / Atuação da enfermeira obstetra na comunidade Anhanguera, Campo Grande (MS), na prevenção do câncer cérvico-uterino.

This is a transversal study, developed between women of the Anhanguera community, with the objectives of knowing the demographic, sociocultural, gynecological and obstetric profile and of assessing health preventive behaviors in order to elaborate a plan of obstetric nursing assistance. The research tool was a form applied at home during visits to 104 women. Our results showed that 23.08% did not know about cancer prevention, 50.00% never performed it, 77.88% presented gynecological complaints but, 62.96% of these never looked for health services. Based on nursing diagnoses a plan of nursing care and health education was elaborated for the women from this community.

PIP: In the community of Anhanguera, a poor neighborhood of the state of Mato Grosso do Sul, Brazil, a cross-sectional study was carried out in May 1995 dealing with the prevention of cervical cancer. 104 out of 142 women living in the community were enrolled, and semistructured questionnaires containing questions concerning demographic, sociocultural, obstetrical, gynecological information and diagnosis were administered. Second-year nursing school students made the home visits and collected the data. A 1995 analysis showed that in the previous 10 years there had been a steady increase of deaths due to cervical cancer in this state, especially among women aged 50 years and older owing to difficulty of access to prevention programs or the lack thereof in basic health units and nonutilization of such services by women at risk. Most women studied were in reproductive age, with little or no education, and a steady partner. There was a high percentage of multiparas (38.46%), 79.25% of deliveries were normal, and 20.75% were by cesarean section. 94.66% of newborn infants were breast-fed and 73.39% were breast-fed for 6 months or more. 23.08% of the women did not know about cervical cancer prevention programs and only 50% reported that they had made a visit for preventive examination at least once. 77.88% of the women had gynecological complaints (amount of menstrual flow, vaginal discharge, dysmenorrhea, lower abdominal pain, menstrual irregularity, and vulvar itching), but only 37.04% obtained medical help.

Oral manifestations of HIV infection by gender and transmission category in Mexico City.

A cross-sectional analysis was conducted in Mexico City from September 1989 to March 1996, to determine the prevalence of HIV-related oral manifestations by gender and route of HIV transmission. The diagnosis of HIV-associated oral lesions was based on preestablished criteria. For the statistical analysis chi-squared and Fisher's exact tests were used where appropriate. Odds ratios were calculated as estimates of the relative risks. Control of confounding factors was performed by logistic regression models. Oral lesions were present in 75% of 436 HIV+ patients. Hairy leukoplakia, erythematous and pseudomembranous candidosis, angular cheilitis and oral ulcers were frequently found. Patients who contracted HIV through blood transfusion were more likely to present erythematous candidosis (P=0.005) than subjects who acquired HIV through sexual transmission. Oral ulcers were seen only in men (P=0.02) and in individuals who contracted HIV through sexual transmission (P=0.02). This study brings valuable data in regard to differences in the type and prevalence of HIV-related oral lesions by gender and the risk categories analysed, particularly blood transfusion.

PIP: A cross-sectional analysis conducted in Mexico City, Mexico, in 1989-96 investigated the prevalence of HIV-related oral manifestations by gender and route of HIV transmission. The 436 HIV-positive patients enrolled in this study were part of a larger, ongoing study conducted through the Infectious Diseases Clinic in Mexico City. The primary mode of HIV transmission was blood transfusion among female respondents (63%) and sexual activity among male respondents (90%). 71% of subjects had at least 1 (mean, 1.3) HIV-related oral lesion, including hairy leukoplakia, erythematous and pseudomembranous candidosis, angular cheilitis, and oral ulcers. Candidosis, pseudomembranous candidosis, hairy leukoplakia, exfoliative cheilitis, and xerostomia were all significantly associated with a CD4 count under 200 cells/cu. mm and were more prevalent among those with advanced HIV disease. Oral ulcers were present only in men. Women had a higher prevalence than men of hyperpigmentation (10.5% vs. 4%) and xerostomia (7% vs. 2%), but these differences were not significant. Multivariate analysis revealed a significant association between erythematous candidosis and blood transfusion, even after controlling for gender, clinical stage, CD4 count, antiretroviral therapy, smoking history, and xerostomia.

Direct and indirect estimates of HIV-1 incidence in a high-prevalence population.

While the worldwide AIDS epidemic continues to expand, directly measured incidence data are difficult to obtain. Methods to reliably estimate human immunodeficiency virus type 1 (HIV-1) incidence from more easily available data are particularly relevant in those parts of the world where prevalence is rising in heterosexually exposed populations. The authors set out to estimate HIV-1 incidence in a population of heterosexual sexually transmitted disease clinic attendees in Trinidad who had a known high prevalence of HIV-1 subtype B. Over the period 1987-1995, HIV-1 incidence estimates from serial cross-sectional studies of HIV-1 prevalence, passive follow-up of clinic recidivists, modeling of early markers of HIV-1 infection (p24 antigen screening), and a cohort study of seronegative genital ulcer disease cases were compared. Measuring incidence density in the genital ulcer disease cases directly gave the highest estimate, 6.9% per annum. Screening for the detection of early HIV-1 markers yielded an incidence of 5.0% per annum, while estimating incidence from serial cross-sectional prevalence data and clinic recidivists gave estimates of 3.5% and 4.5% per annum, respectively. These results were found to be internally consistent. Indirect estimates of incidence based on prevalence data can give accurate surrogates of true incidence. Within limitations, even crude measures of incidence are robust enough for health planning and evaluation purposes. For planning vaccine efficacy trials, consistent conservative estimates may be used to evaluate populations before targeting them for cohort studies.

PIP: HIV incidence data, necessary for the planning and evaluation of national AIDS control programs, are difficult to obtain directly. In this study, HIV-1 incidence in Trinidad was estimated in a population known to be at high risk: heterosexuals attending a sexually transmitted disease clinic in Port of Spain in 1987-95. HIV incidence estimates were obtained from serial cross-sectional studies of HIV-1 prevalence (n = 3625), passive follow-up of clinic recidivists (n = 98), modeling of early markers of HIV-1 infection (p24 antigen screening) (n = 12,154), and a cohort study of seronegative genital ulcer disease cases (n = 196). Measuring incidence density in genital ulcer disease cases directly gave the highest estimate: 6.9% per year. Screening for the detection of early HIV-1 markers yielded an incidence of 5.0% per year, while estimating incidence from serial cross-sectional prevalence data and clinic recidivists provided estimates of 3.5% and 4.5%, respectively. Although these estimates come from groups within the clinic population with differential HIV-1 risk, they were internally consistent. These findings suggest that indirect estimates of incidence based on prevalence data can provide accurate surrogates of true HIV incidence and may be used to target suitable populations for cohort studies.

Prevalence and clinical correlates of unsuccessful use of drugs to induce menstruation.

Despite its prohibition, illegal abortion is widely practiced in Brazil, with important adverse health consequences. This report aims to document the prevalence and correlates of the unsuccessful use of drugs to "induce menstrual flow" in a cohort of pregnant Brazilian women. In a cross-sectional study, 6,102 pregnant women between gestation weeks 21 and 28 were interviewed in prenatal clinics of the Brazilian National Health Care System from April 1991 to November 1995. When asked "In order to know if you were pregnant, did you take any medication to induce menstrual flow", 874 (14.4%) responded "yes." The most frequently used drugs were herbal teas (41%), estrogens and/or progestogens (30%), and misoprostol (16%). As demonstrated through logistic regression analysis, independent correlates of such use were unplanned pregnancy (odds ratio [OR] 4.3), low educational attainment (OR 3.3), absence of a husband or partner (OR 1.8), number of children (one or more) (OR 1.5), a history of a previous induced abortion (OR 1.4), and use of oral contraceptives at the time (OR 1.4). Misoprostol use occurred in 2.2% of pregnancies, and showed a very strong association with an unplanned pregnancy (OR 16.0), absence of a husband or partner (OR 3.5), and a history of a previous induced abortion (OR 2.2). It was not associated with a history of menstrual irregularity. In contradistinction, the use of medroxyprogesterone was strongly associated with previous menstrual irregularity (OR = 5.0). The use of drugs and teas, many of which are unknown in terms of fetal risk, in early pregnancy to induce menstrual flow is quite common in women in the Brazilian National Health System. Although the objective of such drug use appears to be varied, analysis of the clinical correlates of use suggest attempted abortion to be the principal aim.

PIP: In countries such as Brazil, where abortion is prohibited, a range of drugs are used to induce menstruation. The present study investigated the prevalence and clinical correlates of unsuccessful use of drugs given to pregnant women to start menstrual flow. Enrolled were 6102 pregnant women at gestational weeks 21-28 presenting to the prenatal clinics of the Brazilian National Health Care System in 1991-95. 874 women (14.4%) responded affirmatively to the question, "In order to know if you were pregnant, did you take any medication to induce menstrual flow?" The frequency varied from 6-22% among the seven cities included in the study. The most commonly used drugs were herbal teas (41%), estrogens and/or progestogens (30%), and misoprostol (16%). Significant independent predictors of such medication use included unplanned pregnancy (odds ratio (OR), 4.3), low educational attainment (OR, 3.3), absence of husband or male partner (OR, 1.8), 1 or more living children (OR, 1.5), previous induced abortion (OR, 1.4), and current use of oral contraception (OR, 1.4). Herbal tea and misoprostol use were more strongly associated with unplanned pregnancy than medroxyprogesterone acetate; however, most drug use reported for menstrual induction appeared to be intended to avoid a possible pregnancy. Of concern is the effect of these medications and herbs on fetuses in cases where an abortion attempt is unsuccessful.

Risk behaviors, HIV seropositivity, and tuberculosis infection in injecting drug users who operate shooting galleries in Puerto Rico.

This study was designed to assess HIV risk behaviors, HIV seroprevalence, and tuberculosis (TB) infection in shooting gallery managers in Puerto Rico. The subjects were 464 injection drug users (IDUs), of whom 12.5% reported managing shooting galleries. The median frequency of drug injection was higher in shooting gallery managers than in nonmanagers. A trend was observed for purified protein derivative (PPD) reactivity to increase according to the length of time spent as a gallery manager, but this trend was not statistically significant. However, anergy rates increased significantly with increase in the number of months spent as shooting gallery manager (p = .021). Multivariate analyses showed that IDUs reporting shooting gallery management experience of > or = 25 months were more likely to be infected with HIV. Prevention programs need to emphasize strategies to protect the health of shooting gallery clients and, in particular, shooting gallery managers. Additional studies are required to determine effective strategies for reducing the risk of HIV and TB infection in shooting galleries.

PIP: Little information is currently available on the health status of individuals who manage the settings in which drug injection-related behaviors occur. The present study investigated HIV risk behaviors, HIV seroprevalence, and tuberculosis infection among 464 injecting drug users recruited from areas in San Juan, Puerto Rico, known to have high levels of drug activity. 58 respondents (12.5%) reported having been a shooting gallery manager, for a median duration of 18 months. Managers were more likely to be female, over 35 years of age, not married, homeless, to inject only cocaine, to inject more frequently, to have a history of incarceration, and to report disability than drug users who were not managers. No differences in rates of HIV, tuberculosis, or anergy existed between managers with 1-24 months of management experience and nonmanagers. However, gallery managers with 25 or more months of experience were nearly 3 times more likely to be infected with HIV, nearly 2 times more likely to be anergic, and 2.5 times more likely to have tuberculosis than nonmanagers. 41% of nonmanagers, 48% of managers with 1-24 months of experience, and 71% of those who had been managers for 25 months or more were HIV-seropositive. The compromised health status of long-term shooting gallery managers underscores the need for public health interventions to interrupt the spread of sexually transmitted diseases, HIV, and tuberculosis in this high-risk setting.