Abortion care in Haiti: A secondary analysis of demographic and health data.


BACKGROUND:
Abortion-related mortality accounts for 8% of all global maternal deaths and 97% of the estimated 25 million unsafe abortions performed each year occur in low- and middle-income countries. Haiti has the highest rate of maternal mortality in the western hemisphere and to further understand the circumstances of induced abortion in Haiti, the current work uses data from the 2012 Demographic and Health Survey (DHS) to describe the methods of induced abortion in Haiti between 2007-2012 and to identify potential factors associated with use of different abortion methods.

METHODS:
This is a secondary analysis of nationally representative cross-sectional data from the 2012 Haitian DHS, a two-stage cluster randomized household survey. Analysis included descriptive statistics on participant demographics, methods of abortion, and location of / assistant for the abortion. Multivariate regression was conducted to determine if demographic characteristics were associated with: 1) increased or decreased odds of having an abortion; or 2) increased or decreased odds of reporting an evidence based or non-evidence based method of abortion.

RESULTS:
Among the 14,287 women of childbearing age who completed the 2012 Haiti DHS survey, 289 women reported having an induced abortion in the previous five years. Recommended methods, manual vacuum aspiration (MVA) or misoprostol alone, were used in 26.6% of the abortions (n = 77). Additionally, 13.8% (n = 40) of abortions used these recommended methods in combination with a non-evidenced based method such as injections, plants or tablets. A total of 92 women had a dilation and curettage (D&C) abortion, either alone (n = 77) or in combination with another method (n = 15) and over a quarter (n = 80) of reported abortions were conducted by non-evidence based methods (n = 80). A majority of abortions using a recommended method were assisted by a relative/friend (n = 28) or were unassisted (n = 34). Most abortions occurred in private homes (n = 174) with hospitals/clinics being the second most common location (n = 84). Women in the middle (OR = 3.3, 95% CI = 2.0-5.6) and highest (OR = 7.4, 95% CI = 4.4-12.3) wealth brackets were more likely to have had an abortion in comparison to women in the lowest wealth bracket. Women who had ever been in a marital union were more likely to have had an abortion than those who had not. The only demographic factor predictive of aborting using a recommended method was living in an urban area, with urban-dwelling women being less likely to use a recommended abortion method (OR = 0.4, 95% CI = 0.2-0.9) in comparison with women living in rural settings.

CONCLUSION:
In a nationally representative survey in Haiti, 2% of women of childbearing age reported having an abortion in the five years prior to the survey. A large proportion of these abortions were carried out using non-evidence based methods and over half occurred outside of the formal health care system. Understanding women’s attitudes, knowledge and barriers around abortion is paramount to improving knowledge and access to evidence-based abortion care in an effort to decrease maternal morbidity and mortality in Haiti.

Astrocytic Tumors in Mexico: An Overview of Characteristics and Prognosis in an Open Reference Center for Low-Income Population.


Objective:
The authors aimed to analyze the current epidemiology of high- and low-grade gliomas, follow-up strategies, and prognosis in a national reference center of a developing country.

Materials and Methods:
Medical records of patients diagnosed with intracranial gliomas from January 2012 to January 2016 were reviewed. Data were classified by age, symptoms, Karnofsky functional scale (KFS), tumor location, extent of resection (EOR), histopathology, hospital stay, Glasgow outcome scale (GOS), adjuvant treatments, overall survival (OS), and mortality.

Results:
Astrocytomas accounted for 28.2% of the intracranial tumors and 53.5% were male. Headache was the most common symptom, while sensory disturbance was the least frequent. The right cerebral hemisphere was involved in 56.5% of cases and frontal lobe in 31.3%. Gross total resection (GTR) was achieved in 18.1% cases, 35.3% subtotal resection, and 46.4% biopsy. Regarding the astrocytomas, 43.3% were low grade and 56.4% high grade. Low-grade tumors had the highest frequency in the fourth decade of life, while Grade III and IV in the fifth and seventh decades of life, respectively. In high-grade lesions, there was a slight male predominance (~1.4:1). The initial KFS was regularly 80 for low-grade gliomas and 60 for high-grade. By 1-month postdischarge, the score decreased by 10 points. About half of the patients (47.5%) received adjuvant therapy after surgery. From the Glasgow Outcome Scale (GOS), the majority had a form of disability and 30-month OS was above 88% for Grade I-II and 0% for Grade III and IV.

Conclusions:
Astrocytic tumors were the most frequently noted intra-axial tumors. Age, histological grade, and EOR are important prognostic factors. These results are similar to other reports; however, increased variability was noted when treatment-related factors were considered. Additional studies are necessary to identify the factors related to these treatment results.

Oral Nutritional Supplementation in Children Treated for Cancer in Low- and Middle-Income Countries Is Feasible and Effective: the Experience of the Children’s Hospital Manuel De Jesus Rivera “La Mascota” in Nicaragua.


Children with cancer are particularly vulnerable to malnutrition, which can affect their tolerance of chemotherapy and outcome. In Nicaragua approximately two-thirds of children diagnosed with cancer present with under-nutrition. A nutritional program for children with cancer has been developed at “La Mascota” Hospital. Results of this oral nutritional intervention including difficulties, benefits, and relevance for children treated for cancer in low- and middle-income countries are here reported and discussed.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala.


Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

Health Care in Guatemala.


There are 10 hospitals with general surgery training programs in Guatemala. Of those 10 hospitals, only 3 are tertiary care hospitals, and all of these are located in Guatemala City. Two are part of the public health system and the other belongs to a semiprivate public health system. There are currently no colorectal training programs. If a Guatemalan surgeon wishes to pursue a career in coloproctology, he or she has to look for training opportunities abroad.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.


BACKGROUND:
The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

METHODS:
The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

RESULTS:
Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

CONCLUSION:
Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.