A gendered look at Mexico's health-sector reform.
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Female↗
Biomedical subjects
Ana Langer
Publications and source records attributed to Ana Langer.
Cairo after 12 years: successes, setbacks, and challenges.
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Congresses as Topic↗
Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America.
BACKGROUND: Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS: We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.
Adolescent↗
[The contribution of violence to maternal mortality in Morelos, Mexico].
OBJECTIVE: To document the under-registration of violent deaths related to pregnancy and the importance of considering these violent deaths within the definition of maternal mortality. MATERIAL AND METHODS: The study was carried out in the state of Morelos, based on the review of all death certificates (394) of reproductive aged women (12-49 years) who died during 2001. Based on a list of diagnostic criteria we eliminated 167 certificates that were neither violent deaths nor maternal deaths. The remaining 227 certificates were further evaluated through verbal autopsy and/or review of medical charts. RESULTS: Fifty-one violent deaths were found. Eighteen maternal deaths were officially reported in 2001, however, our study identified 23 direct maternal deaths and four violent deaths during pregnancy and the post-partum period. We found that this reproductive event was the direct trigger for the homicide or suicide of these four women, and only one of these cases was documented officially. CONCLUSIONS: Violent deaths related to pregnancy should be included in official maternal mortality statistics as indirect causes of maternal deaths. This would allow for a greater and more accurate understanding of violent maternal deaths and guide appropriate prevention and care policies, programs and services. Verbal autopsy is a useful technique for identifying cases of violent maternal deaths.
Adolescent↗
Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial.
BACKGROUND: Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality. METHODS: 36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy. FINDINGS: A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI 0.2-14.5), mostly in intrapartum sections (12.6%; 0.6-24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups. INTERPRETATION: In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process.
Adult↗
Cluster randomized trial of an active, multifaceted information dissemination intervention based on The WHO Reproductive health library to change obstetric practices: methods and design issues [ISRCTN14055385].
BACKGROUND: Effective strategies for implementing best practices in low and middle income countries are needed. RHL is an annually updated electronic publication containing Cochrane systematic reviews, commentaries and practical recommendations on how to implement evidence-based practices. We are conducting a trial to evaluate the improvement in obstetric practices using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library (RHL). METHODS: A cluster randomized trial to improve obstetric practices in 40 hospitals in Mexico and Thailand is conducted. The trial uses a stratified random allocation based on country, size and type of hospitals. The core intervention consists of three interactive workshops delivered over a period of six months. The main outcome measures are changes in clinical practices that are recommended in RHL measured approximately a year after the first workshop. RESULTS: The design and implementation of a complex intervention using a cluster randomized trial design are presented. CONCLUSION: Designing the intervention, choosing outcome variables and implementing the protocol in two diverse settings has been a time-consuming and challenging process. We hope that sharing this experience will help others planning similar projects and improve our ability to implement change.
Female↗
Deaths from complications of unsafe abortion: misclassified second trimester deaths.
This study measured the contribution of abortion-related deaths to overall maternal mortality and calculated the underestimation of maternal mortality using verbal autopsy and clinical record review where available. We reviewed 807 death certificates of women aged 12-50 who died in 2001 in two sites of about 1.5 million inhabitants each in the state of Morelos (primarily rural) and the municipality of Nezahualcóyotl (primarily urban) in the state of Mexico. Deaths were classified as definite, possible or non-maternal deaths. Finally we identified abortion-related deaths and calculated the underestimation of maternal mortality. Among 326 possible maternal deaths, we encountered five misclassified cases: one spontaneous abortion and four non-abortion maternal deaths. Among 32 registered maternal deaths, we found four misclassified cases that were actually second trimester, abortion-related deaths. There were no officially registered abortion-related deaths in either Morelos or Nezahualcóyotl, making the overall underestimation of abortion mortality 100%. Abortion contributed 13.5% of all maternal deaths. The overall underestimation of maternal mortality was 13.55%, higher in Morelos (21.7%). There were no unregistered maternal deaths in Nezahualcóyotl. Unsafe abortion continues to be an important cause of maternal mortality, though first trimester deaths appear to be decreasing. We identified domestic violence as an important cause of death among pregnant and post-partum women, and two abortion-related suicides, and believe these should be reconsidered as indirect maternal deaths. The misclassification of second trimester abortion deaths as maternal deaths from other causes is an obstacle to preventing them.
Abortion, Induced↗
Is induced abortion a contributing factor to tubal infertility in Mexico? Evidence from a case-control study.
OBJECTIVE: To determine the contribution of induced abortion to tubal infertility in Mexico. DESIGN: Population- and hospital-based case-control study. SETTING: Tertiary hospitals in Mexico City. SAMPLE: Women between 20 and 40 years with infertility and controls of the same age: 251 cases, 502 hospital controls, 502 neighbourhood controls. METHODS: A case-control study was conducted in four tertiary hospitals in Mexico City with 251 cases and 1004 controls (two hospital and two neighbourhood controls per case, matched by age [+/-2 years]). Cases were infertile women, aged 20-40, with tubal occlusion confirmed by laparoscopy. Controls were fertile women, who had carried a pregnancy to term within the last two years. Participants completed a previously validated questionnaire asking about reproductive history and induced abortion. RESULTS: Our study did not show an association between induced abortion and tubal infertility among women that did not relate both events (cases vs hospital controls: OR = 1.57, 95% CI: 0.29-8.65; cases vs neighbourhood controls: OR = 0.82, 95% CI: 0.07-8.99) using conditional logistic models adjusting by marital status, number of pregnancies, age at first sexual intercourse and history of pelvic inflammatory disease. In contrast, early age at sexual debut and history of pelvic inflammatory disease significantly increased the risk of tubal infertility. CONCLUSIONS: In Mexico, the lack of association between induced abortion and tubal damage causing infertility observed in this population might be explained by a shift toward "safer" abortion practices.
Abortion, Induced↗
Why is research from developing countries underrepresented in international health literature, and what can be done about it?
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Access to Information↗
Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina.
BACKGROUND: The results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country. METHODS: Through focus groups discussions we were able to assess the concepts and expectations underlying women's evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries. RESULTS: Three areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period. CONCLUSION: Recommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.
Adult↗
Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries.
BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.
Journal Article↗
Promoting evidence based practice in maternal care.
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Cesarean Section↗
Emergency contraception in Mexico City: knowledge, attitudes, and practices among providers and potential clients after a 3-year introduction effort.
Emergency contraception (EC) has the potential to reduce unwanted pregnancy significantly, in Mexico as elsewhere. Recent years have seen tremendous growth in programs and research devoted to expanding access to emergency methods worldwide. In Mexico City, we conducted a pre-intervention/post-intervention research study of one way to introduce EC. Following a baseline survey of family planning providers and clients in 1997, we organized and implemented a three-year program of training for health care providers and a multi-faceted information campaign for the general public, including a national toll-free hotline and website. In 2000, we again surveyed family planning clinic providers and clients, using instruments similar to those employed in the baseline study. EC awareness increased significantly from 13% of clients to 32%, and support jumped from 73% to 83%. Providers at study clinics improved method recognition from 88% to 100%.
Adolescent↗
Information campaign and advocacy efforts to promote access to emergency contraception in Mexico.
Emergency contraception (EC) has the potential to reduce unwanted pregnancy significantly, in Mexico as elsewhere. Recent years have seen tremendous growth in programs and research devoted to expanding access to emergency methods worldwide. In Mexico we developed a comprehensive model introduction effort that included four components: provider training, public information (through a dedicated hotline and website, free media, paid radio and TV spots, participation in talk shows, and alternative media channels), collaboration with the public sector to include EC in the official family planning norms, and assistance to partner with commercial firms to register a dedicated EC product. Ongoing efforts to combat misperceptions and overcome opposition are crucial to informing the public and ensuring greater access to the method.
Advertising↗
[Unwanted pregnancy: impact on health and society in Latin America and the Caribbean].
Engaging in sexuality and reproduction should always be something that is wanted and planned. Unfortunately, when that is not the case, one result can be unwanted pregnancy. Unwanted pregnancies have consequences for women, their families, and their countries. This document reviews the causes and results of unwanted pregnancy, emphasizing the impact that this problem has on Latin America and the Caribbean (LAC). Four reasons why unwanted pregnancy is a continuing problem in LAC are: 1) people's growing desire to have smaller families, 2) the unmet need for family planning, 3) the fact that contraceptive methods are not 100% effective, and 4) unwanted sexual relations. Unwanted pregnancies especially affect adolescent women, single women, and women over 40 years of age. Given their desperate situation with an unwanted pregnancy, some women opt for an unsafe abortion, which can lead to their death. Other women can go so far as to commit suicide, or be murdered by a family member or other person who is unhappy that the pregnancy has occurred. It has been found that women who decide to continue with the pregnancy have higher risks of suffering an illness, and the same is true for the child. Reducing unwanted pregnancies and treating post-abortion complications are key to lowering maternal mortality and morbidity. This necessitates developing mass communication programs that address gender issues, education programs for girls, and sex education programs. It is also vital to make available to all persons reproductive health services that include family planning methods. In the countries of LAC with laws that specify grounds for legally ending a pregnancy, it is necessary that health care be organized to actually provide this service, and that health care programs obtain the safest, most effective technologies now available for ending a pregnancy.
Abortion, Induced↗
Where is the "E" in MCH? The need for an evidence-based approach in safe motherhood.
Measuring the impact of obstetric interventions on maternal mortality and/or morbidity is especially difficult in developing countries, where most maternal deaths occur. Therefore, program planning has been based on theory rather than proved effectiveness. After reviewing both the strategies that have been promoted to reduce maternal mortality and the adequacy of existing evidence used to justify their selection, the investigators highlight reasons why rigorous criteria for the selection and evaluation of interventions should be adopted. Adequate evaluation of intervention effectiveness under real-life conditions in developing countries is an efficient way to identify interventions for large-scale program replication and could speed progress in reducing maternal deaths.
Developing Countries↗
[Medical methods for pregnancy termination. A review of literature and its potential role in Mexico and Latin America].
In this document, we review the relevant aspects of the different medical methods of abortion. We describe the principal medical regimens currently used in North America, Europe, and a growing number of developing countries. We also describe specific treatment regimens (which usually involve a combination of two drugs), physiological methods of action, potential side effects and complications, method requirements, including follow-up visits, any existing contraindication, and acceptability of these methods among patients. Finally, we comment on the potential role of medical abortion in Mexico and throughout Latin America.
Abortifacient Agents, Nonsteroidal↗