Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study.

INTRODUCTION: To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera District, Rwanda. The Mentoring and Enhanced Supervision at Health Centers (MESH MH) program supported primary care-delivered mental health service delivery scale-up from 6 to 19 government-run health centers over two years. This quasi-experimental study assessed implementation reach, fidelity, and clinical outcomes at health centers supported by MESH MH during the scale up period. METHODS: MESH MH consisted of four strategies to ensure the delivery of the priority care packages at health centers: training; supervision and mentorship; audit and feedback; and systems-based quality improvement (QI). Implementation reach (service use) across the 19 health centers supported by MESH MH during the two year scale-up period was described using routine service data. Implementation fidelity was measured at four select health centers by comparing total clinical supervisory visits and checklists to target goals, and by tracking clinical observation checklist item completion rates over a nine month period. A prospective before and after evaluation measured clinical outcomes in consecutive adults presenting to four select health centers over a nine month period. Primary outcome assessments at baseline, 2 and 6 months included symptoms and functioning, measured by the General Health Questionnaire (GHQ-12) and the World Health Organization Disability Assessment Scale (WHO-DAS Brief), respectively. Secondary outcome assessments included engagement in income generating work and caregiver burden using a quantitative scale adapted to context. RESULTS: A total of 2239 mental health service users completed 15,744 visits during the scale up period. MESH MH facilitated 70% and 76% of supervisory visit and clinical checklist utilization target goals, respectively. Checklist item completion rates significantly improved overall, and for three of five checklist item subgroups examined. 121 of 146 consecutive service users completed outcome measurements six months after entry into care. Scores improved significantly over six months on both the GHQ-12, with median score improving from 26 to 10 (mean within-person change 12.5 [95% CI: 10.9-14.0] p< 0.0001), and the WHO-DAS Brief, with median score improving from 26.5 to 7 (mean within-person change 16.9 [95% CI: 14.9-18.8] p< 0.0001). Over the same period, the percentage of surveyed service users reporting an inability to work decreased significantly (51% to 6% (p < 0.001)), and the proportion of households reporting that a caregiver had left income-generating work decreased significantly (41% to 4% (p < 0.001)). CONCLUSION: MESH MH was associated with high service use, improvements in mental health care delivery by primary care nurses, and significant improvements in clinical symptoms and functional disability of service users receiving care at health centers supported by the program. Multifaceted implementation programs such as MESH MH can reduce the evidence to practice gap for mental health care delivery by nonspecialists in resource-limited settings. The primary limitation of this study is the lack of a control condition, consistent with the implementation science approach of the study. STUDY REGISTRATION: ISRCTN #37231.

From 'culture of dehumanization of childbirth' to 'childbirth as a transformative experience': changes in five municipalities in north-east Brazil.

Brazil has become a country known as having one of the most extreme examples of the consequences of the hospital-based medicalization of delivery care, while a model of humanization of birth was developed in the State of Ceará in the 1970s. The Government of Japan, through the Japanese International Cooperation Agency (JICA), collaborated with the Federal Ministry of Health of Brazil and the Government of the State of Ceará, in implementing the Maternal and Child Health Improvement Project in north-east Brazil (1996-2001). This project focused on 'humanization of childbirth', with training based intervention activities. Behavioral changes among health professionals who received the project's participatory type of training were described using rapid anthropological assessment procedure (RAP) survey results. Changes from 'a culture of dehumanization of childbirth' to 'childbirth as a transformative experience' were observed.

From 'culture of dehumanization of childbirth' to 'childbirth as a transformative experience': changes in five municipalities in north-east Brazil.

Brazil has become a country known as having one of the most extreme examples of the consequences of the hospital-based medicalization of delivery care, while a model of humanization of birth was developed in the State of Ceará in the 1970s. The Government of Japan, through the Japanese International Cooperation Agency (JICA), collaborated with the Federal Ministry of Health of Brazil and the Government of the State of Ceará, in implementing the Maternal and Child Health Improvement Project in north-east Brazil (1996-2001). This project focused on 'humanization of childbirth', with training based intervention activities. Behavioral changes among health professionals who received the project's participatory type of training were described using rapid anthropological assessment procedure (RAP) survey results. Changes from 'a culture of dehumanization of childbirth' to 'childbirth as a transformative experience' were observed.

Determinants of abortion among women admitted to hospitals in Fortaleza, North Eastern Brazil.

BACKGROUND: Maternal mortality from complications of unsafe abortion constitutes a serious problem in several developing countries. There is, however, a paucity of well-designed and implemented studies in this area, especially in Latin America. The aim of this paper is to present the findings on the determinants and medical characteristics of abortions among women admitted to hospitals. METHODS: A descriptive cross-sectional hospital-based study was carried out between October 1992 and September 1993 in Fortaleza, Brazil. A Cox's proportional hazard model was used to estimate prevalence rate ratios after adjustment for confounding. RESULTS: Among 2074 (48%) women who admitted to terminating the pregnancy, 66% reported using misoprostol to induce abortion. Women with an induced abortion as compared with those with an unlikely induced abortion are younger, more often not married, have fewer children alive and experienced one or more previous induced abortions. We have not found any important differences with regard to complication or duration of stay in hospital. CONCLUSIONS: This finding, at odds with most previous studies, could reflect the special situation in Brazil where misoprostol is used for illegally-induced abortion. The use of misoprostol by this population may have contributed to the reduction of severe complications related to induced abortion which were most prevalent with more invasive methods. Recommendations are made as to the need for confirmatory studies as well as on information regarding cultural perceptions and concepts of abortion, and reasons why poor women fail to adopt available family planning methods.

PIP: The characteristics of induced abortion were investigated among women admitted to two public maternity hospitals in Fortaleza, Brazil, in 1992-93. A total of 4359 women admitted to the hospitals during the 12-month study period with a diagnosis of pregnancy loss were interviewed. 48% of abortions were classified as certainly induced, 40% as possibly induced, and 12% as spontaneous. 1369 (66%) of the 2074 women with certainly induced abortion reported use of misoprostol (mean dose, 400 mcg; range, 200-2400 mcg). Although sales of this abortifacient were suspended in 1991 due to concerns about congenital malformations in unsuccessful procedures, the drug remains widely available on the black market. Compared with women with an unlikely induced abortion, women with a certainly induced abortion were significantly younger, more often unmarried, had fewer living children, and were more likely to have experienced one or more previous induced abortions. The risk of infection was increased by 40% in women with certain induced abortion above that of women with unlikely induced abortion. There were no significant differences between groups in terms of the complication rate or duration of hospital stay. The use of misoprostol in this series may have contributed to the relatively low rate of severe abortion-related complications. Wider availability of emergency contraception could reduce the need for unsafe abortion in Brazil.

Women's hidden transcripts about abortion in Brazil.

Two folk medical conditions, "delayed" (atrasada) and "suspended" (suspendida) menstruation, are described as perceived by poor Brazilian women in Northeast Brazil. Culturally prescribed methods to "regulate" these conditions and provoke menstrual bleeding are also described, including ingesting herbal remedies, patent drugs, and modern pharmaceuticals. The ingestion of such self-administered remedies is facilitated by the cognitive ambiguity, euphemisms, folklore, etc., which surround conception and gestation. The authors argue that the ethnomedical conditions of "delayed" and "suspended" menstruation and subsequent menstrual regulation are part of the "hidden reproductive transcript" of poor and powerless Brazilian women. Through popular culture, they voice their collective dissent to the official, public opinion about the illegality and immorality of induced abortion and the chronic lack of family planning services in Northeast Brazil. While many health professionals consider women's explanations of menstrual regulation as a "cover-up" for self-induced abortions, such popular justifications may represent either an unconscious or artful manipulation of hegemonic, anti-abortion ideology expressed in prudent, unobtrusive and veiled ways. The development of safer abortion alternatives should consider women's hidden reproductive transcripts.

Out-patient drug treatment of pneumonia among children under two years of age in Fortaleza, Brazil.

Results are reported from a study on drug use in treatment of children with pneumonia in a pediatric hospital in the city of Fortaleza, Northeastern Brazil. There were 171 out-patients; prescription details were obtained for 149. The most commonly prescribed antimicrobial drug was procaine penicillin, accounting for 33% of antimicrobial prescriptions, followed by benzathine penicillin (31%), ampicillin or amoxicillin (12%), and cotrimoxazole (8%). Benzathine penicillin was frequently given with other drugs, but was the sole antimicrobial agent for 31 children. Compliance with antimicrobial treatment was 52% overall and was higher for the injectables. Prescription patterns varied from child to child, and children were often prescribed more than one antimicrobial in the same or repeat prescriptions; combining this information with compliance, 81 (54%) of the children were estimated to have received 5 or more days of appropriate antimicrobial treatment for pneumonia. This percentage is not high, and five days were often reached after using more than one antimicrobial and after repeat visits. The authors concluded that the need remains for simple antimicrobial regimes, attractive to comply with, that can be expected to be consistently used. Other drugs were chiefly analgesics and bronchodilators.

[Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil]. / Uso da aspiração manual a vácuo na redução do custo e duração de internamentos por aborto incompleto em fortaleza, CE, Brasil.

INTRODUCTION: In most developed countries vacuum aspiration has been shown to be safer and less costly than sharp curettage (SC) for uterine evacuation. In many of the developing countries, including Brazil, sharp curettage (SC) is the most commonly used technique for treating cases of incomplete abortion admitted to hospital. The procedure often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. Two hypotheses are examined: the first, that the use of manual vacuum aspiration (MVA)--a variation of the vacuum aspiration, would be less costly than SC for the treatment of cases of incomplete abortion admitted to hospital; and the second, that the treatment of incomplete abortion with MVA would substantially reduce the length of hospital stay. METHODOLOGY: Thirty women with diagnosis of first trimester incomplete abortion were randomly allocated to the SC or MVA group. Rapid-assessment data collection techniques were used to identify factors that contributed to cost reduction and hospital stay. RESULTS AND CONCLUSION: The results of the study show that, overall, patients treated for incomplete abortion with MVA spent 77% less time in the hospital and consumed 41% fewer resources than similarly diagnosed patients treated with SC. Recommendations are made as to the need of certain changes in patient management. Particularly necessary is information regarding cultural perception and concepts of abortion treatment.

Attendance at day care centers increases the risk of childhood pneumonia among the urban poor in Fortaleza, Brazil.

We carried out a case-control study to investigate risk factors for childhood pneumonia in two groups of 650 children aged under two years in the city of Fortaleza, Ceará, Brazil. The cases were children recruited at the main pediatric hospital with a radiological diagnosis of pneumonia, and controls were children of the same age group recruited from the neighbourhood of the cases. In this paper we focus on variables related to childcare practices. Working mothers, proportion of time the mother had worked since the child was born, and use of day care centers emerged as important risk factors with estimated relative risks of 1.58, 1.76 and 5.22, respectively. Also important were the number of children living in the house and presence of grandparents. However, the presence of siblings under two years and the birth order were not associated with pneumonia. All analysis included adjustment for confounding by income, parents' education, and other risk factors as appropriate. This is the first study from a developing country to identify attendance at day care centers as a risk factor for increased childhood morbidity, in this case pneumonia. This finding is of significant public health importance for countries such as Brazil with growing urban populations and an increasing need by mothers to find work outside the home.

[Determinants of induced abortion among poor women admitted to hospitals in a locality of northeastern Brazil]. / Determinantes do aborto provocado entre mulheres admitidas em hospitais em localidade da região Nordeste do Brasil.

In Brazil, abortion is legally allowed only when it is necessary to save a woman's life or when pregnancy has occurred following rape. Despite this law, induced abortion is widely carried out. This study presents the findings as to the determinants of 2,084 abortions admitted to two major obstetric hospitals in Fortaleza, Brazil, between October 1992 and September 1993. Most of these women (2,074) have admitted an attempt to terminate pregnancy and 10 women were classified as induced abortion cases based on the findings of signs of intervention such as cervical laceration, perforation or foreign bodies in the vagina or uterus. The study findings indicate that self-administration of medicines plays an important role in terminating pregnancy. Among the 2,074 women who admitted to terminating the pregnancy 66% reported using misoprostol to induce abortion. Misoprostol, a prostaglandin E1 analogue indicated for ulcer treatment, has been widely used as an abortifacient by women in Brazil. Misoprostol has some uterine effects but it is not effective in inducing abortion. Among women who were hospitalized for complications resulting from abortion about 59.7% were 20 to 29 years old and 22.6% were aged less than 20. The majority of the women (91.6%) were Catholic and only 4.3% were illiterate. About 62% of the abortion cases lived alone or did not have a stable partner. Most of the women (59.2%) reported less than 2 live births and 11.8% had experienced a previous abortion; 61.1% of the women were not using a contraceptive method at the time of conception. The main reasons for this were "fear of side effects", "did not expect to have sexual intercourse" and "did not expect to get pregnant". The authors suggest that the situation of a high rate of self-inflicted abortion may be changed by the application of an appropriate contraceptive and reproductive health programme.

Risk factors for childhood pneumonia among the urban poor in Fortaleza, Brazil: a case--control study.

Reported are the results of a case-control study carried out between July 1989 and June 1990 in Fortaleza city, Ceará State, Brazil, to determine the factors that place young children living in urban slum conditions at increased risk of contracting pneumonia. Cases were 650 under-2-year-olds with a radiological diagnosis of pneumonia who were recruited at the main paediatric hospital in the city over a full calendar year. Age-matched controls were recruited from the neighbourhood where the cases lived. Cases and controls were compared with respect to a variety of sociodemographic, environmental, reproductive, nutritional, and morbidity factors, and a risk factor questionnaire was administered to the mother of each child or to the child's normal guardian. Cases and controls were also weighed and measured. Malnutrition was the most important risk factor for childhood pneumonia in the study population, with weight-for-age, height-for-age, and weight-for-height also being important risk factors. In view of the high prevalence of stunting in the study population, there is an urgent need to reduce the level of malnutrition as a priority. Attendance at a day care centre was also associated with a high odds ratio. In view of the growing numbers of children attending day care centres in both developing and developed countries, it is essential that ways be identified to improve the design and management of such centres in order to minimize the risk of pneumonia. Increased risks of childhood pneumonia were also associated with low birth weight, non-breast-feeding, crowding, high parity, and incomplete vaccination status, but not with socioeconomic status or environmental variables. Finally, children who had suffered from previous episodes of wheezing or been hospitalized for pneumonia had a greater than threefold increased risk of contracting the disease.

Preventing unsafe abortion and limiting its consequences: what can be done?

PIP: The continued illegality of induced abortion in Latin America has led to substantial, preventable maternal mortality and morbidity. The first strategy for preventing unsafe clandestine abortion is to reduce the incidence of unwanted pregnancy through measures such as improved access to effective contraception, post-abortion family planning counseling, health education campaigns aimed at promoting condom use among young people, involvement of men in family planning decision making, biomedical research on safer and more effective male and female contraceptive methods, and empowering women to demand the use of condoms or avoid unwanted intercourse. The second strategy is to reduce abortion-related mortality and morbidity through more effective clinical management of incomplete illegal abortions, introduction of menstrual regulation services, formation of women's solidarity groups aimed at discouraging the practice of self-induced abortion, and, ultimately, abortion legalization.^ieng

Congenital malformation of the scalp and cranium after failed first trimester abortion attempt with misoprostol.

This study reports the occurrence of three cases of an unusual congenital malformation of the skull in neonates seen at a pediatric hospital during a five-month interval in Fortaleza, Brazil. The prenatal history focused on the mothers' exposure to drugs during pregnancy. It was found that all mothers had taken misoprostol orally and/or vaginally in the first trimester of pregnancy to induce abortion. Other drugs taken during pregnancy included iron, vitamins and tetanus toxoid. There was no evidence of a family history of malformations, consanguinity or clinical infective illnesses.

PIP: Three cases of an unusual congenital malformation of the skull occurred in newborns in Fortaleza, Brazil, over a 5-month period. In each case, the only unusual feature of the pregnancy history was the fact that the mothers had taken misoprostol orally and/or vaginally in the first trimester to induce an abortion. In the first case, the mother took 800 mcg of misoprostol orally at the time of expected menses and experienced slight vaginal bleeding and intense abdominal pain. The baby was born at 36 weeks gestation with a localized fronto-temporal defect with an asymmetric, well-circumscribe deficiency of the cranium and overlying scalp and exposure of the cerebrum and dura mater. After surgery to cover the defect, the child developed convulsions which are controlled by phenobarbital. In the second case, the mother took 600 mcg misoprostol at the time of expected menses and experienced spotting and pain. One month later, she repeated the dosage and experienced only spotting. The full-term baby had a localized frontal defect with an asymmetric, well-circumscribed absence of the cranium and overlying scalp, exposing the cerebrum and dura mater. A week after surgery to cover the defect, this child also developed convulsions. In the third case, the mother took 600 mcg misoprostol orally and 200 mcg vaginally at the time of expected menses. 4 weeks later she took 1200 mcg misoprostol orally and 400 mcg vaginally. After an otherwise normal pregnancy and delivery, the child was delivered with a complete deficit in the cranium and scalp in a localized region of the frontal-temporal area. This child died postoperatively. Controlled studies have not been performed to determine the effect of misoprostol during the first trimester of pregnancy, but no teratogenic effects were found in animals. The cases reported here suggest the need for further investigation of a possible association.