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Addressing Inequities in Pregnancy Care and Childbirth in Chiapas, Mexico

Andrea and Rose Jalte
Rose Molina, BWH Connors Center Global Women’s Health Fellow, and Andrea Reyes, Maternal Health Coordinator at Compañeros en Salud

By Rose Molina, MD
BWH Connors Center Global Women’s Health Fellow

The motto of every pregnancy sounds simple: “healthy mom, healthy baby.” Yet, pregnancy and childbirth remain important causes of morbidity and mortality for reproductive-age women in resource-limited settings.

While the conversation about increasing Cesarean delivery rates and “medicalization” of childbirth in the United States continues, the reality in Chiapas, Mexico, is strikingly similar yet a world apart; both under-intervention and over-intervention exist, creating significant inequities in obstetric care. In Chiapas, the lack of access to quality services remains common for marginalized women, and “medicalization” can lead to “obstetric violence,” a term used to describe disrespect and abuse during childbirth. Continue reading “Addressing Inequities in Pregnancy Care and Childbirth in Chiapas, Mexico”

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Recent Studies Demonstrate Ways to Improve Quality of Care and Reduce Costs

Thomas Gaziano

With a theme of “Noncommunicable Diseases: The Growing Burden,” the latest issue of Health Affairs features two studies co-led by BWH’s Thomas Gaziano, MD, of the Cardiovascular Division, and a team of authors.

The first study finds that cardiovascular disease screening by community health workers can be cost-effective in low resource countries. Understanding that a physician is not always available in low-resource settings, the authors demonstrated that community health workers can efficiently screen adults for cardiovascular disease in South Africa, Mexico and Guatemala. By using a paper-based or mobile phone-based screening tool that does not require blood testing, community health workers could conduct screenings in a cost-effective, or even cost-saving, manner in all three countries, compared to the usual clinic-based screening. “Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care,” write the authors.

The second study investigates the health and economic impacts of increasing prescription length for statins in South Africa, where the rates of statin use are among the lowest in the world.   “Almost five percent of the country’s total mortality has been attributed to high cholesterol levels, fueled in part by low levels of statin adherence,” write the authors.

They found that increasing prescription length from the standard 30 days to 60 or 90 days could save 1,694 or 2,553 lives per million adults, respectively. In addition, annual per patient costs related to cardiovascular disease would decrease by $152.41 and $210.29, respectively. “Increasing statin prescription length would both save resources and improve health outcomes in South Africa,” conclude the authors.

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Video: Compañeros En Salud

Dan Palazuelos, MD, MPH, lives a dual lifestyle – splitting his time between rural villages in Mexico and the city life that surrounds BWH.

For many months each year, Palazuelos lives in the Sierra Madre Mountains, waking up with the roosters and working alongside talented young Mexican doctors. For the other half of the year he lives in Boston and, in addition to practicing inpatient medicine with the hospitalist group at BWH, he helps to mentor the next generation of global health leaders in the Howard Hiatt Global Health Equity residency as the assistant director.

Palazuelos works with Compañeros En Salud, an organization that collaborates with rural government clinics in the Sierra Madre de Chiapas to revitalize underperforming rural clinics. In 2011, Partners In Health launched Compañeros En Salud to improve staffing, supplies, and links with local communities.

Watch the video below to take a peek into Palazuelos’ lifestyle and learn more about Compañeros En Salud.

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A Guide for Global Health Workers

building partnerships in the americasThe recently published book, “Building Partnerships in the Americas: A Guide for Global Health Workers,” is an important resource for those working in global health.

According to BWH Chief of Global Health Equity Paul Farmer, MD, PhD: “This book answers a great, and until now unmet, need. For all those who ask what to read before going to work in these settings, ‘Building Partnerships in the Americas’ is the answer. It’s sure to become the go-to volume for those deeply engaged in such work.”

BWH’s Dan Palazuelos, MD, MPH, of the Division of Global Health Equity, is a co-author of the book’s first chapter about Mexico. You can learn more about the global health experiences of Dr. Palazuelos and his fellow authors  during “An Evening with the Authors” on Sept. 7, 7:30 – 9 p.m., at the AIC Center, 38 Newbury St., seventh floor, Boston.

The event is free and open to the public. Refreshments will be served. Please register in advance.

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The Coming Transformation in Global Health

The 20th century witnessed a monumental transformation in hospitals: once primarily places for poor people to die, hospitals became institutions that cured illness and promoted health. A range of facilities and professionals dedicated to treating the sick grew in tandem with the proliferation of hospitals, creating the health care systems we have today.  

Health care systems are now pervasive enough that even developing countries have structures for delivering care. Advances in treating HIV, heart disease, and other chronic conditions mean that a significant part of the population now lives for years in less-than-perfect health.  As we grow increasingly reliant on this care, the question before us is how to strengthen health systems in order to deliver quality care to all who need it.

This was the pivotal theme at the talk “The coming transformation in global health,” held at Harvard Medical School on Feb. 28.  Moderated by Paul Farmer, MD, PhD, chief of the Division of Global Health Equity, the discussion was framed by Lord Nigel Crisp KCB, former head of the National Health Service in the United Kingdom, and Dean Julio Frenk, MD, MPH, PhD, former minister of health of Mexico and current dean of the Harvard School of Public Health.

Frenk discussed the challenges and opportunities he encountered while reworking the health care system in Mexico. We can create a platform for enlightened social change by carefully and conscientiously restructuring our health care systems, but Frenk felt it was vital that these reforms be evidence-based and involve explicit ethical deliberation.  When these systems change for the better, they can have a tremendous impact: 30 percent of children with leukemia in Mexico had to stop treatment because their families ran out of money, but this number dropped to two percent after the implementation of health care reforms.

Having worked extensively in both the UK and developing nations, Crisp was particularly struck by the lack of health workers in many resource-poor settings. One way around the exodus of trained medical professionals from their countries of origin is to break down the demarcations between health professions. Crisp cites settings in Africa where nurses have been trained to do Cesarean sections—patient outcomes are comparable to doctors performing the operation, with the added bonus that nurses are less likely to move abroad.

Another potential solution for limited availability of medical professionals is to engage patients in their own care, as well as with helping and supporting fellow patients. Even in settings with abundant staff and resources, such as a self-dialysis clinic in Sweden, this approach can energize and engage patients, lower infection rates, and increase patient satisfaction. Crisp emphasized that health is a co-production function: it is not something doctors give patients, but something that patients create with intermittent assistance from clinicians.

Throughout the program, the speakers underscored that health is not separable from other human endeavors. Just as the duty of hospitals shifted from comforting the dying to curing, the challenge going forward is to reform health care systems to deliver care not just to the privileged, but to all in need.