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.

Performance of passive case detection for malaria surveillance: results from nine countries in Mesoamerica and the Dominican Republic.

BACKGROUND: In malaria elimination settings, available metrics for malaria surveillance have been insufficient to measure the performance of passive case detection adequately. An indicator for malaria suspected cases with malaria test (MSCT) is proposed to measure the rate of testing on persons presenting to health facilities who satisfy the definition of a suspected malaria case. This metric does not rely on prior knowledge of fever prevalence, seasonality, or external denominators, and can be used to compare detection rates in suspected cases within and between countries, including across settings with different levels of transmission. METHODS: To compute the MSCT, an operational definition for suspected malaria cases was established, including clinical and epidemiological criteria. In general, suspected cases included: (1) persons with fever detected in areas with active malaria transmission; (2) persons with fever identified in areas with no active transmission and travel history to, or residence in areas with active transmission (either national or international); and (3) persons presenting with fever, chills and sweating from any area. Data was collected from 9 countries: Belize, Colombia (in areas with active transmission), Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (September-March 2020). A sample of eligible medical records for 2018 was selected from a sample of health facilities in each country. An algorithm was constructed to assess if a malaria test was ordered or performed for cases that met the suspected case definition. RESULTS: A sample of 5873 suspected malaria cases was obtained from 239 health facilities. Except for Nicaragua and Colombia, malaria tests were requested in less than 10% of all cases. More cases were tested in areas with active transmission than areas without cases. Travel history was not systematically recorded in any country. CONCLUSIONS: A statistically comparable, replicable, and standardized metric was proposed to measure suspected malaria cases with a test (microscopy or rapid diagnostic test) that enables assessing the performance of passive case detection. Cross-country findings have important implications for malaria and infectious disease surveillance, which should be promptly addressed as countries progress towards malaria elimination. Local and easy-to-implement tools could be implemented to assess and improve passive case detection.

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.

Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries.

OBJECTIVE: Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries. DESIGN: We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software. SETTING: We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January-October 2014). RESULTS: We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI):64.5-72.9] in Costa Rica to 5.7% [CI:4.0-8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries. CONCLUSIONS: Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.

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.

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.

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.

Use of a commercial ELISA for the detection of measles-specific immunoglobulin G (IgG) in dried blood spots collected from children living in low-resource settings.

Seroepidemiological monitoring of population immunity to vaccine-preventable diseases is critical to prevent future outbreaks. Dried blood spots (DBS), drops of capillary blood dried on filter paper, are an affordable, minimally invasive alternative to venipuncture for collecting blood in field settings. However, few proven methods exist to analyze DBS for the presence of protective antibodies. This study validates a novel technique for measuring measles-specific immunoglobulin G (IgG) in capillary DBS using a commercial ELISA. The predictive performance of a new method for analyzing DBS was tested by comparing matched serum and DBS samples from 50 children. The accuracy, precision, and reliability of the procedure were evaluated, and the optimal cut points to classify positive and negative samples were determined. The method was then applied to 1,588 DBS collected during a large survey of children in Mexico and Nicaragua. Measles-specific IgG in serum samples were 62% negative, 10% equivocal, and 28% positive. In comparisons with matched serum, DBS results were 100% sensitive and 96 · 8% specific, and agreed in 46 of 50 (92%) cases. The inter-assay and intra-assay coefficients of variation from kit-provided controls were greater than desired (24.8% and 8.4%, respectively). However, in predictive simulations the average misclassification was only 3.9%. Procedures were found to be acceptable to surveyors and participants. Analyzing DBS collected in low-resources settings is a feasible and accurate means of measuring population immunity to measles and should be used to generate objective measures of health status and health system performance.

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.

Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings.

BACKGROUND: Health has improved markedly in Mesoamerica, the region consisting of southern Mexico and Central America, over the past decade. Despite this progress, there remain substantial inequalities in health outcomes, access, and quality of medical care between and within countries. Poor, indigenous, and rural populations have considerably worse health indicators than national or regional averages. In an effort to address these health inequalities, the Salud Mesoamérica 2015 Initiative (SM2015), a results-based financing initiative, was established. METHODS: For each of the eight participating countries, health targets were set to measure the progress of improvements in maternal and child health produced by the Initiative. To establish a baseline, we conducted censuses of 90,000 households, completed 20,225 household interviews, and surveyed 479 health facilities in the poorest areas of Mesoamerica. Pairing health facility and household surveys allows us to link barriers to care and health outcomes with health system infrastructure components and quality of health services. RESULTS: Indicators varied significantly within and between countries. Anemia was most prevalent in Panama and least prevalent in Honduras. Anemia varied by age, with the highest levels observed among children aged 0 to 11 months in all settings. Belize had the highest proportion of institutional deliveries (99%), while Guatemala had the lowest (24%). The proportion of women with four antenatal care visits with a skilled attendant was highest in El Salvador (90%) and the lowest in Guatemala (20%). Availability of contraceptives also varied. The availability of condoms ranged from 83% in Nicaragua to 97% in Honduras. Oral contraceptive pills and injectable contraceptives were available in just 75% of facilities in Panama. IUDs were observed in only 21.5% of facilities surveyed in El Salvador. CONCLUSIONS: These data provide a baseline of much-needed information for evidence-based action on health throughout Mesoamerica. Our baseline estimates reflect large disparities in health indicators within and between countries and will facilitate the evaluation of interventions and investments deployed in the region over the next three to five years. SM2015's innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Maternal and child health intervention to promote behaviour change: a population-level cluster-randomised controlled trial in Honduras.

OBJECTIVES: To assess the efficacy of a sustained educational intervention to affect diverse outcomes across the pregnancy and infancy timeline. SETTING: A multi-arm cluster-randomised controlled trial in 99 villages in Honduras' Copán region, involving 16 301 people in 5633 households from October 2015 to December 2019. PARTICIPANTS: Residents aged 12 and older were eligible. A photographic census involved 93% of the population, with 13 881 and 10 263 individuals completing baseline and endline surveys, respectively. INTERVENTION: 22-month household-based counselling intervention aiming to improve practices, knowledge and attitudes related to maternal, neonatal and child health. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were prenatal/postnatal care behaviours, facility births, exclusive breast feeding, parental involvement, treatment of diarrhoea and respiratory illness, reproductive health, and gender/reproductive norms. Secondary outcomes were knowledge and attitudes related to the primary outcomes. RESULTS: Parents targeted for the intervention were 16.4% (95% CI 3.1%-29.8%, p=0.016) more likely to have their newborn's health checked in a health facility within 3 days of birth; 19.6% (95% CI 4.2%-35.1%, p=0.013) more likely to not wrap a fajero around the umbilical cord in the first week after birth; and 8.9% (95% CI 0.3%-17.5%, p=0.043) more likely to report that the mother breast fed immediately after birth. Changes in knowledge and attitudes related to these primary outcomes were also observed. We found no significant effect on various other practices. CONCLUSION: A sustained counselling intervention delivered in the home setting by community health workers can meaningfully change practices, knowledge and attitudes related to proper newborn care following birth, including professional care-seeking, umbilical cord care and breast feeding. TRIAL REGISTRATION NUMBER: NCT02694679.

Performance-based incentives to improve health status of mothers and newborns: what does the evidence show?

Performance-based incentives (PBIs) aim to counteract weak providers' performance in health systems of many developing countries by providing rewards that are directly linked to better health outcomes for mothers and their newborns. Translating funding into better health requires many actions by a large number of people. The actions span from community to the national level. While different forms of PBIs are being implemented in a number of countries to improve health outcomes, there has not been a systematic review of the evidence of their impact on the health of mothers and newborns. This paper analyzes and synthesizes the available evidence from published studies on the impact of supply-side PBIs on the quantity and quality of health services for mothers and newborns. This paper reviews evidence from published and grey literature that spans PBI for public-sector facilities, PBI in social insurance reforms, and PBI in NGO contracting. Some initiatives focus on safe deliveries, and others reward a broader package of results that include deliveries. The Evidence Review Team that focused on supply-side incentives for the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives, reviewed published research reports and papers and added studies from additional grey literature that were deemed relevant. After collecting and reviewing 17 documents, nine studies were included in this review, three of which used before-after designs; four included comparison or control groups; one applied econometric methods to a five-year time series; and one reported results from a large-scale impact evaluation with randomly-assigned intervention and control facilities. The available evidence suggests that incentives that reward providers for institutional deliveries result in an increase in the number of institutional deliveries. There is some evidence that the content of antenatal care can improve with PBI. We found no direct evidence on the impact of PBI on neonatal health services or on mortality of mothers and newborns, although intention of the study was not to document impact on mortality. A number of studies describe approaches to rewarding quality as well as increases in the quantities of services provided, although how quality is defined and monitored is not always clear. Because incentives exist in all health systems, considering how to align the incentives of the many health workers and their supervisors so that they focus efforts on achieving health goals for mothers and newborns is critical if the health system is to perform more effectively and efficiently. A wide range of PBI models is being developed and tested, and there is still much to learn about what works best. Future studies should include a larger focus on rewarding quality and measuring its impact. Finally, more qualitative research to better understand PBI implementation and how various incentive models function in different settings is needed to help practitioners refine and improve their programmes.

[Situational profile and intervention strategy in the Mesoamerican region in maternal, neonatal and reproductive health area]. / Perfil situacional y estrategias de intervención en la región Mesoamericana en el área de salud materna, reproductiva y neonatal.

To present the main results of the regional situation diagnosis and intervention plan developed in 2010 as part of the planning activities of the Mesoamerican Health System by the Working Group on Maternal, Reproductive and Neonatal Health. A group of experts and representatives from countries in the region (Central America and nine southern Mexican states) conducted an exhaustive review of available data to construct a situational analysis and a review of effective practices for improving maternal, reproductive and neonatal health. Finally, the group proposed a regional action plan, defining regional goals and specific interventions. The situational diagnosis suggests that, although there has been progress in the last 10 years, maternal and neonatal mortality rates are still unnaceptably high in the region, with a substantial variability across countries. The group proposed as a regional goal the reduction of maternal and neonatal mortality in accordance with the Millenium Development Goals. The regional plan recommends specific maternal and neonatal health interventions emphasizing obstetric and neonatal emergency care, skilled birth attendance and family planning. The plan also includes a five year implementation strategy, along with training and evaluation strategies. The regional plan for maternal, neonatal and reproductive health has the potential to be successful, provided it is effectively implemented.

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.

Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica.

Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.

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.

Alcohol abuse and other factors associated with risky sexual behaviors among adolescent students from the poorest areas in Costa Rica.

OBJECTIVES: We applied the Integrative Model of Behavioral Prediction to analyze factors associated with risky sexual behaviors for adolescent students living in the poorest segments in Costa Rica. METHODS: We used data from a school-based knowledge, attitudes, and behaviors survey from the poorest districts of Costa Rica, collected for Salud Mesoamerica Initiative. We analyzed responses of 919 male and female students (12-19 years old) to determine factors associated with sexual intercourse and condom use. RESULTS: One of every four students reported being sexually active. Students that reported being sexually active were more likely to consume excessive alcohol (OR 3.04 [95 % CI 1.94-4.79]). While 88.0 % [95 % CI 73.5-95.1] of sexually active adolescents said they would use a condom the next time they have sex, only 53.1 % [95 % CI 39.3-66.5] reported condom use the last time. Non-condom-users felt purchasing condoms was uncomfortable (OR 0.34 [95 % CI 0.12-0.93]). CONCLUSIONS: Poor adolescents in Costa Rica begin sexual activities early and undertake behaviors that increase their risk for unwanted pregnancies and sexually transmitted infections. We found the urgent need to address alcohol abuse, and recognize gender differences in youth health programs.

Contraceptive knowledge and use among women living in the poorest areas of five Mesoamerican countries.

OBJECTIVE: To identify factors associated with contraceptive use among women in need living in the poorest areas in five Mesoamerican countries: Guatemala, Honduras, Nicaragua, Panama and State of Chiapas (Mexico). STUDY DESIGN: We analyzed baseline data of 7049 women of childbearing age (15-49 years old) collected for the Salud Mesoamérica Initiative. Data collection took place in the 20% poorest municipalities of each country (July, 2012-August, 2013). RESULTS: Women in the poorest areas were very poorly informed about family planning methods. Concern about side effects was the main reason for nonuse. Contraceptive use was lower among the extremely poor (<$1.25 USD PPP per day) [odds ratio (OR): 0.75; confidence interval (CI): 0.59-0.96], those living more than 30 min away from a health facility (OR 0.71, CI: 0.58-0.86), and those of indigenous ethnicity (OR 0.50, CI: 0.39-0.64). Women who were insured and visited a health facility also had higher odds of using contraceptives than insured women who did not visit a health facility (OR 1.64, CI: 1.13-2.36). CONCLUSIONS: Our study showed low use of contraceptives in poor areas in Mesoamerica. We found the urgent need to improve services for people of indigenous ethnicity, low education, extreme poverty, the uninsured, and adolescents. It is necessary to address missed opportunities and offer contraceptives to all women who visit health facilities. Governments should aim to increase the public's knowledge of long-acting reversible contraception and offer a wider range of methods to increase contraceptive use. IMPLICATIONS: We show that unmet need for contraception is higher among the poorest and describe factors associated with low use. Our results call for increased investments in programs and policies targeting the poor to decrease their unmet need.

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.