Atención a la salud y morbimortalidad materna: un estudio de casos y controles de base hospitalaria en dos regiones de Colombia (Bogotá y Antioquia), 2009-2011 / Healthcare and maternal morbidity and mortality: a hospital-based case-control study in two regions of Colombia (Bogotá and Antioquia), 2009-2011 / Atenção à saúde e morbimortalidade materna: estudo caso-controle de base hospitalar em duas regiões de Colômbia (Bogotá e Antioquia), 2009-2011

Resumen: El objetivo fue identificar si formas de pago y regímenes de aseguramiento están asociados con la mortalidad materna y morbilidad obstétrica extrema. Estudio de casos y controles de base hospitalaria en dos regiones de Colombia, 2009-2011. Los datos se obtuvieron de la historia clínica de cada gestante. Se utilizó regresión logística no condicional. El resultado fue: 1.011 pacientes, 337 casos y 674 controles. Ningún componente de calidad fue estadísticamente significativo en ambas regiones. En Bogotá, el riesgo de complicación obstétrica, significativamente mayor en Régimen Contributivo que en Subsidiado y no aseguradas; Antioquia, aunque hubo asociaciones similares, no estadísticamente significativas. Diferencias en morbilidad por régimen de pago no estadísticamente significativas en Antioquia ni Bogotá. Factores asociados a la morbimortalidad materna diferentes, según la población estudiada, lo que sugiere la necesidad de estudios locales para identificar factores determinantes propios y tomar decisiones pertinentes.

Abstract: The study aimed to identify whether payment forms and insurance schemes are associated with severe obstetric complications and maternal mortality. A hospital-based case-control study was conducted in two regions of Colombia, 2009-2011. Data were obtained from each woman's clinical history. Unconditional logistic regression was used. The sample included 1,011 patients: 337 cases and 674 controls. No quality component was statistically significant in either region. In Bogotá, the risk of obstetric complications was significantly higher in the contributive insurance scheme than in subsidized coverage or uninsured; Antioquia showed similar associations, but not statistically significant. Differences in maternal morbidity according to payment scheme were not statistically significant in either Antioquia or Bogotá. Factors associated with maternal morbidity and mortality differed according to the study population, suggesting the need for local studies to identify determinants and make appropriate decisions.

Resumo: O presente estudo objetiva identificar se as formas de pagamento e regimes de seguros de saúde estão associados com a mortalidade materna e morbidade materna grave. Trata-se de um estudo caso-controle de base hospitalar em duas regiões da Colômbia entre 2009-2011. Os dados foram obtidos através da história clínica de cada gestante. Foi utilizada a regressão logística não condicionada. A mostra incluiu 1.011 pacientes: 337 casos e 674 controles. Nenhum componente de qualidade foi estatisticamente significativo em ambas as regiões. Em Bogotá, o risco de complicações obstétricas foi significativamente maior no Regime Contributivo do que no Subsidiado e em mulheres sem seguro de saúde. Em Antioquia, embora existam associações similares, não foram estatisticamente significativas. Tanto em Antioquia quanto em Bogotá não se encontraram diferenças significativas de morbilidade por regime de pagamento. Foram encontrados diferentes fatores associados à morbimortalidade materna, segundo a população estudada, o que sugere a necessidade de estudos locais para identificar fatores determinantes próprios e tomar decisões adequadas neste contexto.

Costo-efectividad de prácticas en salud pública: revisión bibliográfica de las intervenciones de la Iniciativa Mesoamericana de Salud / Cost-effectiveness of public health practices: A literature review of public health interventions from the Mesoamerican Health Initiative

OBJETIVO: Presentar y analizar información de costo-efectividad de intervenciones propuestas por la Iniciativa Mesoamericana de Salud (IMS) en las áreas de nutrición infantil, inmunizaciones, paludismo, dengue y salud materno-infantil y reproductiva. MATERIAL Y MÉTODOS: Se llevó a cabo una revisión sistemática de la literatura de evaluaciones económicas publicadas entre el año 2000 y agosto 2009 sobre intervenciones en las áreas de la salud mencionadas, en los idiomas inglés y español. RESULTADOS: Las intervenciones en nutrición y de salud materno-infantil mostraron ser altamente costo-efectivas (con rangos menores a US$200 por año de vida ajustado por discapacidad [AVAD] evitado para nutrición y US$100 para materno-infantil). En dengue sólo se encontró información sobre la aplicación de larvicidas, cuya razón de costo efectividad estimada fue de US$40.79 a US$345.06 por AVAD evitado. Respecto al paludismo, las intervenciones estudiadas resultaron costo-efectivas (

OBJECTIVE: Present and analyze cost-effectiveness information of public health interventions proposed by the Mesoamerican Health Initiative in child nutrition, vaccination, malaria, dengue, and maternal, neonatal, and reproductive health. MATERIAL AND METHODS: A systematic literature review was conducted on cost-effectiveness studies published between January 2000 and August 2009 on interventions related to the health areas previously mentioned. Studies were included if they measured effectiveness in terms of Disability-Adjusted Life Year (DALY) or death averted. RESULTS: Child nutrition and maternal and neonatal health interventions were found to be highly cost-effective (most of them below US$200 per DALY averted for nutritional interventions and US$100 for maternal and neonatal health). For dengue, information on cost-effectiveness was found just for application of larvicides, which resulted in a cost per DALY averted ranking from US$40.79 to US$345.06. Malarial interventions were found to be cost-effective (below US$150 per DALY averted or US$4,000 per death averted within Africa). In the case of pneumococcus and rotavirus vaccination, cost-effectiveness estimates were always above one GDP per capita per DALY averted. CONCLUSIONS: In Mesoamerica there are still important challenges in child nutrition, vaccination, malaria, dengue and maternal, neonatal, and reproductive health, challenges that could be addressed by scaling-up technically feasible and cost-effective interventions.

Diseño mixto de evaluación de la iniciativa Salud Mesoamérica 2015 / Mixed design for the evaluation of the Mesoamerica Health 2015 initiative

El propósito de la iniciativa Salud Mesoamérica 2015 (SM-2015) es mejorar el estado de salud y nutrición de la población con mayor grado de vulnerabilidad en Mesoamérica. El objetivo de la evaluación es generar evidencia sobre la efectividad conjunta de un paquete de intervenciones diseñadas para mejorar las condiciones de salud en la región. Se propone una evaluación de impacto con métodos mixtos, para conocer la magnitud de los cambios atribuibles a la SM-2015, e identificar los significados de estos cambios para la población objetivo, en el contexto de cada país. El eje conductor es un panel de localidades con el que se colectará información de individuos, hogares y unidades de salud de primero y segundo nivel de atención. El diseño que se describe en este documento fue desarrollado entre junio y diciembre de 2009, y su articulación se llevó a cabo en talleres realizados en Cuernavaca (México), Managua (Nicaragua), y San José (Costa Rica). El diseño propuesto permitirá generar evidencia sobre la efectividad conjunta del paquete de intervenciones propuesto en los planes maestros mesoamericanos. El éxito de este diseño radica en la voluntad y en el compromiso político de los países y los donantes.

Since the Salud Mesoamerica 2015 initiative (SM-2015) aim is to improve health and nutrition conditions of those most vulnerable in Mesoamerica, the goal of the evaluation is to generate evidence of the joint effectiveness of a package of interventions designed to improve the health conditions. We propose a mix design for the evaluation, which will allow to know the magnitude of changes attributable to the interventions, as well as the meanings of these changes for the target population, taking into account the specificities of each country. The main axis of this design is a locality panel where information about individuals, households, and health facilities (first and second level) will also be collected. The evaluation design described in this paper was developed between June and December, 2009, and it was integrated during workshops in Cuernavaca (Mexico), Managua (Nicaragua), and San Jose (Costa Rica). The proposed design will allow to generate evidence about the joint effectiveness of the package of interventions proposed for the SM-2015. The success of this design rests on the political commitment of countries and donors.

Factores asociados a la demanda de servicios para la atención del parto en México / Factors associated with the demand for delivery care in Mexico

Objetivo. Analizar los factores asociados a la utilización de la institución de atención del parto en México para documentar el proceso de integración funcional de instituciones de salud. Material y métodos. Se utilizó información de mujeres con último parto entre 2000 y 2005 en la Encuesta Nacional de Salud y Nutrición 2006. Se aplicó la prueba de ji cuadrada para probar diferencias entre institución utilizada y aseguramiento. Se usó regresión logística para identificar factores que favorecieron la demanda de instituciones diferentes a las de afiliación de la mujer. Resultados. El 62.6 por ciento de mujeres con seguridad social utilizó instituciones de afiliación y 13.4 por ciento instituciones públicas. Entre no aseguradas 43.3 por ciento utilizó instituciones públicas y 19 por ciento seguridad social; 64.3 por ciento de afiliadas al Seguro Popular se atendieron en instituciones públicas. Variables de acceso, nivel socioeconómico y condiciones de vida influyeron en la demanda referida. Conclusiones. El traslape para atención de partos institucionales documenta la existencia de integración funcional de facto entre instituciones de salud mexicanas.

Objective. Analyze the factors associated with the utilization of delivery care institutions in Mexico in order to document the functional integration of health institutions. Materials and Methods. Based on the 2006 National Health and Nutrition Survey, information from women whose last birth was between 2000 and 2005 was used. Chi square was used to test differences between institutions used and health insurance type. A logistic regression was carried out to identify factors associated with the demand for institutions with which women were not affiliated. Results. Women with social security used in 62 percent of the cases the institution of their affiliation and 13.4 percent used public institutions. For uninsured women, 43.3 percent used public institutions and 19.0 percent social security institutions; 64.3 percent of the Seguro Popular affiliates were treated in public institutions. Variables related to access, socioeconomic status and living conditions influenced said demand. Conclusions. The utilization of an institution of delivery that differed from the one with which the women were affiliated indicates the existence of a de facto functional integration between health institutions in Mexico.

Action monitoring for equity and gender in health.

Equity and gender, despite being universal concerns for all health programmes in Bangladesh, are often missing in many of the health agenda. The health programmes fail to address these important dimensions unless these are specifically included in the planning stage of a programme and are continually monitored for progress. This paper presents the situation of equity in health in Bangladesh, innovations in monitoring equity in the use of health services in general and by the poor in particular, and impact of targeted non-health interventions on health outcomes of the poor. It was argued that an equitable use of health services might also result in enhanced overall coverage of the services. The findings show that government services at the upazila level are used by the poor proportionately more than they are in the community, while at the private facilities, the situation is reverse. Commonly-used monitoring tools, at times, are not very useful for the programme managers to know how well they are doing in reaching the poor. Use of benefit-incidence ratio may provide a quick feedback to the health facility managers about their extent of serving the poor. Similarly, Lot Quality Assurance Sampling can be an easy-to-use tool for monitoring coverage at the community level requiring a very small sample size. Although health problems are biomedical phenomena, their solutions may include actions beyond the biomedical framework. Studies have shown that non-health interventions targeted towards the poor improve the use of health services and reduce mortality among children in poor households. The study on equity and health deals with various interlocking issues, and the examples and views presented in this paper intend to introduce their importance in designing and managing health and development programmes.

Household costs of healthcare during pregnancy, delivery, and the postpartum period: a case study from Matlab, Bangladesh.

A household survey was undertaken in Matlab, a rural area of Bangladesh, to estimate the costs incurred during pregnancy, delivery, and the postpartum period for women delivering at home and in a health facility. Those interviewed included 121 women who delivered at home, 120 who delivered in an ICDDR,B basic obstetric care (BEOC) facility, 27 who delivered in a public comprehensive obstetric care (CEOC) hospital, and 58 who delivered in private hospitals. There was no significant difference in total costs incurred by those delivering at home and those delivering in a BEOC facility. Costs for those delivering in CEOC facilities were over nine times greater than for those delivering in BEOC facilities. Costs of care during delivery were predominant. Antenatal and postnatal care added between 7% and 30% to the total cost. Services were more equitable at home and in a BEOC facility compared to services provided at CEOC facilities. The study highlights the regressive nature of the financing of CEOC services and the need for a financing strategy that covers both the costs of referral and BEOC care for those in need.

Costo de la atención materno infantil en el Estado de Morelos, México / Cost of mother-child care in Morelos State

OBJETIVO: Comparar el costo actual de servicios de salud materno infantiles (modelo actual) con el costo hipotético de su provisión bajo estándares definidos por el Paquete Madre Bebé, de la Organización Mundial de la Salud. MATERIAL Y MÉTODOS: Se realizó un estudio piloto de caso, de corte transversal, en septiembre de 2001, en establecimientos de salud de la Jurisdicción Sanitaria III de los Servicios de Salud del Estado de Morelos, México. Se eligieron para el estudio dos centros de salud rurales, un centro de salud urbano y un hospital general de la Secretaría de Salud. Se calculó el costo total y por intervención del modelo actual y del modelo Paquete Madre Bebé, usando el Modelo de estimación de costos de este Paquete. RESULTADOS: Se encontró que el costo total del Paquete Madre Bebé es dos veces mayor que el costo del modelo actual. De las 18 intervenciones evaluadas, la atención prenatal y el parto normal consumen la mayor proporción de los costos totales. Los costos de personal representan más de la mitad de los costos totales. CONCLUSIONES: El Modelo de estimación de costos es una herramienta práctica para la estimación y comparación de costos, y es útil para guiar la distribución de recursos financieros destinados a la atención materno infantil. Sin embargo, su aplicación es de limitada utilidad si su adaptación no responde a las características de cada sistema de atención.

Cost-effectiveness in establishing hemophilia carrier detection and prenatal diagnosis services in a developing country with limited health resources.

The cost-effectiveness of carrier detection and prenatal diagnosis for hemophilia at the International Hemophilia Training Center, Bangkok, Thailand was studied. From 1991 to 2002, 209 females from 124 families with hemophilia A and B were included. There were 180 hemophilia A carriers and 29 hemophilia B carriers which could be classified into 78 obligate and 131 possible carriers. The phenotypic analysis for possible carriers involved the determination of levels of factor VIII or IX clotting activity (FVIII:C, FIX:C) and the ratio of FVIII:C and von Willebrand factor antigen. The result revealed that 49 females (37.4%) were diagnosed as carriers, 65 females (49.6%) were normal and 17 females (13%) were undetermined. Additional genotypic analysis was provided to 46 families with 74 females with obligate, proven or undetermined carriers within the reproductive life. The polymorphisms associated with factor VIII and IX genes were used including Bcl I for the factor VIII gene and combined use of Mse I, Sal I, Nru I, Hha I and Dde I for the factor IX gene. The informative rate was 59.4% (44/74). Consequently, 12 prenatal diagnoses for fetus at risk were performed. Sex determination was initially determined and followed by the diagnosis of hemophilia through informative gene tracking and/or the measurement of fetal levels of FVIII:C or FIX:C. The result revealed that 3 male fetuses were affected. The total cost of carrier detection and prenatal diagnosis that the families had to pay in the government hospital was 238,600 Baht (US dollars 5,965). It was compared to the estimated cost of minimal replacement therapy using lyophilized cryoprecipitate for the survival time of 30 years in one patient with hemophilia of 1,012,500 Baht (US dollars 25,312.5). The cost of prevention was much less than the replacement therapy. In conclusion, it is cost-effective to establish the service for carrier detection and prenatal diagnosis for hemophilia especially in developing countries with limited health resources.

Costs of publicly provided maternity services in Rosario, Argentina

OBJECTIVE: This study estimates the costs of maternal health services in Rosario, Argentina. MATERIAL AND METHODS: The provider costs (US$ 1999) of antenatal care, a normal vaginal delivery and a caesarean section, were evaluated retrospectively in two municipal hospitals. The cost of an antenatal visit was evaluated in two health centres and the patient costs associated with the visit were evaluated in a hospital and a health centre. RESULTS: The average cost per hospital day is $114.62. The average cost of a caesarean section ($525.57) is five times greater than that of a normal vaginal delivery ($105.61). A normal delivery costs less at the general hospital and a c-section less at the maternity hospital. The average cost of an antenatal visit is $31.10. The provider cost is lower at the health centre than at the hospital. Personnel accounted for 72-94 percent of the total cost and drugs and medical supplies between 4-26 percent. On average, an antenatal visit costs women $4.70. Direct costs are minimal compared to indirect costs of travel and waiting time. CONCLUSIONS: These results suggest the potential for increasing the efficiency of resource use by promoting antenatal care visits at the primary level. Women could also benefit from reduced travel and waiting time. Similar benefits could accrue to the provider by encouraging normal delivery at general hospitals, and complicated deliveries at specialised maternity hospitals

Integrated Child Development Services (ICDS) scheme: a program for holistic development of children in India.

The Integrated Child Development Services (ICDS) scheme is the largest program for promotion of maternal and child health and nutrition not only in India but in the whole world. The scheme was launched in 1975 in pursuance of the National Policy for Children. The scheme has expanded in the last twenty-seven years form 33 projects to 5171 blocks. ICDS is a multi-sectoral program and involves several government departments. The program services are coordinated at the village, block, district, state and central government levels. The primary responsibility for the implementation of the program lies with the Department of Women & Child Development at the Centre and nodal department at the states, which may be Social Welfare, Rural Development, Tribal Welfare or Health Department or an independent Department. The beneficiaries are children below 6 years, pregnant and lactating women and women in the age group of 15 to 44 yrs. The beneficiaries of ICDS are to a large extent identical with those under the Maternal and Child Health Program. The program provides an integrated approach for converging all the basic services for improved childcare, early stimulation and learning, health and nutrition, water and environmental sanitation aimed at the young children, expectant and lactating mothers, other women and adolescent girls in a community. ICDS program is the reflection of the Government of India to effectively improve the nutrition and health status of underprivileged section of the population through direct intervention mechanism. The program covers 27.6 million beneficiaries with supplementary nutrition. The program services and beneficiaries has essentially remained the same since 1975. Recently a review of the scheme was held, sponsored by Government of India, which suggested modifications in the health and nutrition component of ICDS scheme to improve the program implementation and efficiency.

Costo de la atención materno infantil en un sistema de salud institucionalizado / Costo of materno-infantile case in an institutionalized health system

El objetivo fue calcular el costo parcial y total de la atención materno infantil. El estudio se realizó en una Unidad de Medicina Familiar (UMF) y Hospital General de Zona (HGZ) pertenecientes a un sistema de salud institucionalizado. Se definieron los servicios utilizados, el tipo de acciones realizadas y la intensidad de la utilización en la atención materno infantil. El cálculo de los costos se efectuó de manera independiente en la UMF y el HGZ. Para la estimación de los costos fijos se requirió de departamentalización, determinación de insumos y costos, construcción de ponderadores, definición de gastos de servicios básicos; esta información se relacionó con la depreciación, el tiempo laborado y la productividad. Se definieron los supuestos adoptados para el cálculo de los costos fijos. Para el cálculo de los costos variables los insumos fueron determinados por un grupo de expertos y el costo correspondió al registrado en las notas de compra. La suma del costo fijo y variable por tipo de acción determinó el costo unitario, este se multiplicó por la intensidad de la utilización y la suma total permitió conocer el costo de la atención prenatal, del parto y postnatal; la suma de esta tres estableció el costo de la atención perinatal. El costo de la atención prenatal fue de $ 1,205.33, el de la atención del parto $ 3,314.98, el de la etapa postnatal $ 559.91 y el costo total de la atención perinatal $ 5,079.22. Esta es una información valiosa para el médico ya que puede ser utilizada en las actividades de planeación

Financiamento dos programas de planejamento familiar no Brasil: estratégias econômicas de sustentaçäo / Financing of the family planning programs in Brazil: economic strategies of support

Discorre sobre planejamento familiar no Brasil. Apresenta a evoluçäo recente da populaçäo e politicas demograficas desenvolvidas. Apresenta estimativas da oferta, demanda e custos dos serviços de planejamento familiar. Analisa a questäo do financiamento e gastos dos programas de planejamento familiar e os esforços para a diversificaçäo do custeio dos programas (NMPM)

Disponibilidad y uso de servicios de atención a la madre: influencia de la ocupación del jefe de familia / Availability and use of maternal health services: influence of the family head occupation

Antecedentes: La asistencia tardía a la atención prenatal repercute desfavorablemente en las condiciones de salud de la madre y el producto; la asistencia o uso de los servicios está estrechamente relacionada con su disponibilidad y accesibilidad. El objetivo de este trabajo fue evaluar la disponibilidad de servicios médicos a partir de la ocupación desempeñada por el jefe de familia e identificar la relación de ésta con el uso de servicios para la atención prenatal. Material y Métodos: Entre julio de 1993 y julio de 1994, se realizó un estudio en tres colonias populares de un sector urbano de la ciudad de México; por medio de visitas domiciliarias en toda la zona delimitada se identificaron mujeres que tuvieron un evento reproductivo el año anterior a la entrevista, la muestra quedó constituida por 203 mujeres. Se recopiló información del jefe de familia de la mujer sobre ocupación, ingreso económico y disponibilidad de servicios (contar con un servicio médico como prestación laboral); se clasificó el tipo de servicio utilizado por la mujer para la atención prenatal y resolución del embarazo. Resultados: Se confirmó la relación entre estabilidad en el empleo e ingreso de jefe de familia con la disponibilidad de servicios médicos y el uso de estos. El 95 por ciento de los casos tuvieron atención prenatal en contraste con el 100 por ciento reportado en la Encuesta Nacional de Salud de 1987; hubo inclusive casos en esta muestra que no tuvieron atención institucional para la resolución de su embarazo; las mujeres de estratos socioeconómicos más bajos sin disponibilidad de servicios tuvieron en mayor medida asistencia inadecuada para su atención prenatal (4 consultas o menos) en constraste con las de mejor estrato socioeconómico y que disponían de servicios (44 vs 17 por ciento). Discusión: Las características socioeconómicas de este grupo y la atención del embarazo debe enmarcarse en el contexto socioeconómico general