Advancing Maternal and Child Health in the U.S.-Mexico Border Area

1
Advancing Maternal and Child Health in the
U.S.-Mexico Border Area

• Special Session

2
Advancing Maternal and Child Health in the
U.S.-Mexico Border Area

• Abstract
• 19, 133, 158, 159, 160
• 83
• 98

• Background
• Brownsville-Matamoros Sister
• City Project
• Reproductive Health Epidemiology in the
  U.S.-Mexico Border Area of Coahuila Mexico
• Occurrence of Febrile Diseases in Children Along
  the U.S. Border A Need for Epidemiologic
  Surveillance
• Questions Discussion

3
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The U.S. Mexico Border

• Ten border states
• 14 pairs of sister cities
• U.S.-Mexico La Paz Agreement
• 2,000 miles in length
• 44 U.S. counties
• 80 Mexican municipios

5
Public Health and Epidemiology Capacity in the
U.S.- Mexico Border

• Two nations with diverse economic,
  political, and cultural realms - shared
  epidemiological region
• Need for local data
• Limited resources capacity

6
U.S. - Mexico Border Health Commission

• U.S. Public Law 103-400
• In 2000 agreement to create the Commission
  signed
• Mission
• To provide international leadership to optimize
  health and quality of life along the United
  States - Mexico border.
• Ensenada Declaration
• Promote unity and collaboration to address common
  border health issues
• Promote regional solutions
• Encourage collaboration - state border health
  offices

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U.S. - Mexico Border Health Commission Structure
8

• Access to Care
• Cancer
• Diabetes
• Environmental Health
• HIV/AIDS
• Immunizations and Infectious Diseases

• Injury Prevention
• Maternal and Child Health
• Mental Health
• Oral Health
• Respiratory Diseases

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MCH Characteristics, Needs and Potential in the
Border Region

• Jill A McDonald, PhD
• U.S.-Mexico Border Region Coordinator
• MCH Epidemiology Team
• Division of Reproductive Health
• National Center for Chronic Disease Prevention
  and Health Promotion

The findings and conclusions in this presentation
have not been formally disseminated by the
Centers for Disease Control and Prevention and
should not be construed to represent any agency
determination or policy
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Border Region 14 million persons 14 pairs of
sister cities
11
Population trends and projections Border Region
1970-2020
Population in millions
12
Sociodemographic characteristics

• Large, highly urbanized, rapidly growing
• Young in age
• U.S. border vs non-border counties
• Lower income
• Lower education
• Fewer health care professionals
• Lower insurance coverage
• Higher unemployment
• Higher Hispanic concentration
• Mexico border vs non-border municipios
• Higher income
• Higher employment
• Higher education level

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Infant Mortality, Women Age 10-54, US-Mexico
Border Area States, 1998-2002
14
Smoking During Pregnancy, Women Age 10-54,
US-Mexico Border Area States, 1998-2002
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Prenatal Care in the 1st Trimester, Women Age
10-54, US-Mexico Border Area States, 1998-2002
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Late or No Prenatal Care, Women Age 10-19,
US-Mexico Border Area States, 1998-2002
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Fertility, Women Age 15-19, US-Mexico Border
Area States, 1998-2002
Per 1,000 women
35.9 45.1 32.9 35.8 31.4 32.8 22.8
31.3 22.1 - 22.7 No Data
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Reproductive health indicators

• U.S. border vs non-border counties
• Higher adolescent fertility
• Less first trimester prenatal care
• Less smoking during pregnancy
• Lower infant mortality
• Mexico border vs non-border municipios
• Higher adolescent fertility
• Higher infant mortality?

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Current situation

• Evolving population
• Interdependent binational communities
• Politically complex
• Few resources available
• Little MCH data capacity at local level

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Unmet programmatic demand for Border MCH data

• Arranque Parejo
• Seguro Popular
• Atencion Integrada Preventiva a Recien
  Nacido
• WIC
• Healthy Start
• Head Start
• Medicaid

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Capacity-building steps

• Collaborate with partners
• Identify common program goals
• Obtain commitment of local staff time
• Facilitate training of local staff
• Provide technical assistance

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What can be done with existing data and staff
resources?

• Map vital statistic indicators (U.S. and Mexico)
• Standardize and pool data across region
• Link birth and death records
• Make comparisons
• County to municipio
• County to county
• Municipio to municipio

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What will take additional time or resources?

• Explore potential of other data sources and
  systems to address MCH priorities
• Establish a peer exchange program
• Institute binational maternal, infant and fetal
  mortality review boards

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Potential gain

• Increased MCH data capacity and stronger MCH
  programs in region
• Results can demonstrate program effectiveness or
  justify the need for additional state or federal
  resources
• Upcoming presentations show value of MCH data
  obtained from a binational project and an
  existing Mexican data system

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Brownsville-Matamoros Sister City Project

• 19 A Protocol McDonald et al
• 133 Language and Chavez et al
• Cultural Effect
• 158 Sampling Johnson et al
• 159 Assessing Smith et al
• Non-Coverage
• 160 Evaluation Folger et al

The findings and conclusions in this presentation
have not been formally disseminated by the
Centers for Disease Control and Prevention and
should not be construed to represent any agency
determination or policy
26
Brownsville-MatamorosSister City Project

• Purpose
• Develop, implement, and evaluate a standardized
  approach for surveillance of reproductive and
  chronic disease risk factors in the U.S.-Mexico
  border population

Suzanne Gaventa Folger, PhD National Center for
Chronic Disease Prevention and Health Promotion
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Collaborating Organizations
University of Texas at Brownsville / Texas
Southmost College (UTB/TSC)University of Texas
School of Public Health - Houston at Brownsville
United States-Mexico Border Health Association
(USMBHA/AFMES)United States-Mexico Border Health
Commission (USMBHC/CSFMEU)

• Texas DSHS
• Cameron County Health Dept
• City of Brownsville Dept Pub Hlth
• Valley Baptist MC-Brownsville
• Valley Baptist MC-Harlingen
• Harlingen MC
• Valley Regional MC
• Cameron Park Cultural Center
• Mano A Mano
• Su Clinica Familiar
• Brownsville Community Hlth Ctr
• Clinica Santa Maria

• Secretaría de Salud, México
• Secretaría de Salud, Tam
• Registro Civil, Tamaulipas
• IMSS, Tamaulipas
• ISSSTE, Tamaulipas
• H General de Matamoros
• IMSS, HGZ 13
• ISSSTE, Matamoros
• H Guadalupe
• COFAC, Matamoros
• CEMQ
• Vida Digna

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Collaborating Organizations
University of Texas at Brownsville / Texas
Southmost College (UTB/TSC)University of Texas
School of Public Health - Houston at Brownsville
United States-Mexico Border Health Association
(USMBHA/AFMES)United States-Mexico Border Health
Commission (USMBHC/CSFMEU)

• Texas DSHS
• Cameron County Health Dept
• City of Brownsville Dept Pub Hlth
• Valley Baptist MC-Brownsville
• Valley Baptist MC-Harlingen
• Harlingen MC
• Valley Regional MC
• Cameron Park Cultural Center
• Mano A Mano
• Su Clinica Familiar
• Brownsville Community Hlth Ctr
• Clinica Santa Maria

• Secretaría de Salud, México
• Secretaría de Salud, Tam
• Registro Civil, Tamaulipas
• IMSS, Tamaulipas
• ISSSTE, Tamaulipas
• H General de Matamoros
• IMSS, HGZ 13
• ISSSTE, Matamoros
• H Guadalupe
• COFAC, Matamoros
• CEMQ
• Vida Digna

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BMSCP Components and Timeline

• 2002-3 Partnership Development (UTB, CDC)
• 2003-4 Protocol Development (CDC, UTB)
• 2004-5 Questionnaire Design (CDC, UTB)
• 2005 Implement BMSCP (USMBHA, CDC)
• 2006 Evaluate BMSCP (Battelle, CDC)

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BMSCP Survey Methods Overview

• Target Population Women who delivered live-born
  infants in Cameron County (CC), TX or Matamoros
  (MAT), Tamaulipas.
• Study Population Women who delivered in CC or
  MAT hospitals with gt100 deliveries in 2005. (4
  hospitals in CC 6 hospitals in MAT)
• Data collection Postpartum, in-person interviews
  prior to hospital discharge.

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Questionnaire Development Topics

• BMSCP
• Access to health care
• Reproductive health
• HIV/AIDS
• Cervical cancer screening
• Unintentional injuries
• Diet, physical activity

• HB 2010
• ?
• ?
• ?
• ?
• ?
• future topic

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BMSCP Methods Sample

• Dates Aug 21 Nov 9, 2005
• Sampling frame Hospital delivery logs
• Sample size 500 women in each area
• Design Stratified systematic cluster sampling

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BMSCP Methods Sampling schedule
Cameron County Hospitals (N 4 2 sets)
Matamoros Hospitals (N 6 3 sets)
Aug 21
Aug 23
Aug 22
Aug 24
Aug 25
Aug 26
Aug 27
Aug 21
Aug 22
Aug 23
Aug 24
Aug 25
Aug 26
Aug 27
Aug 28
Aug 29
Aug 30
Aug 31
Sept 1
Sept 2
Sept 3
Aug 28
Aug 29
Aug 31
Aug 30
Sept 1
Sept 2
Sept 3
Sept 4
Sept 5
Sept 6
Sept 7
Sept 8
Sept 9
Sept 10
Sept 4
Sept 5
Sept 7
Sept 6
Sept 8
Sept 9
Sept 10
Sept 11
Sept 12
Sept 13
Sept 14
Sept 15
Sept 16
Sept 17
Sept 11
Sept 12
Sept 13
Sept 14
Sept 15
Sept 16
Sept 17
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BMSCP Evaluation Data Sources

• Quantitative Data
• Survey data
• Delivery logs
• Birth certificate data
• Costs
• Informatics data
• Qualitative Data (Battelle evaluation)
• Interviews of BMSCP staff (USMBHA /CDC), hospital
  staff, public health officials
• USMBHA biweekly reports and other study
  documentation

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BMSCP Evaluation Criteria

• Representativeness / population coverage
• Data quality
• Efficiency and stability of the system
• Timeliness of the data
• Utility of data to stakeholders

36
Evaluation Results Representativeness

• Response rates
• 97.7 Matamoros
• 92.2 Cameron County
• Coverage of target population
• 92.7 Matamoros births in BMSCP hospitals
• 98.2 Cameron County births in BMSCP hospitals
• Study population similar to target population
  (Matamoros)
• Coverage of study population
• 97.3 of Matamoros births in BMSCP hospitals on
  sample days were included in sample
• 97.4 of Cameron County births in BMSCP hospitals
  on sample days included in sample
• Characteristics of sample similar to study
  population

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Evaluation Results Data Quality

• Completeness
• High item-specific response rates (90 of
  applicable questions answered)
• gt5 responses missing for few topics (example
  physical abuse, contraceptive use, race)
• Consistency
• Skip patterns followed, response categories
  adequate
• To be checked Consistency between questions
• To be checked Consistency with birth cert data

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Evaluation Results Efficiency and Stability of
System

• Informatics Assessment Recommendations
• Concatenation of data files should occur more
  rapidly and be performed by field staff
• Develop alternative criteria for creation of
  unique ID
• Standard vocabulary and coding needed
• Consider other data entry software (Epi Info)

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Evaluation Results Efficiency and Stability of
System

• Cost estimates
• Questionnaire testing 15,000
• Data collection / processing 120,000
• Overall coordination 15,000
• Total 150,000
• Cost per interview 150

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Evaluation Results Battelle

• Staff well trained and performed well overall.
• Data flow worked well
• Strong support by stakeholders
• Expected project and data utility by
  stakeholders
• Improve MCH practices
• Adopt project to meet local needs / priorities
• Expand project to address other border conditions
• Build capacity

41
Evaluation ResultsBattelle Recommendations

• Additional training for interviewers and field
  coordinators
• Computer use
• Adherence to protocol
• Project management and supervision
• Privacy for interviews
• Population-specific improvements in wording of
  questionnaire
• Focus on project sustainability

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BMSCP Evaluation Summary

• Partnerships important!
• BMSCP achieved good coverage and representative
  sample of target population
• BMSCP data likely to be high quality
• The approach proved to be efficient and stable
  for BMSCP

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BMSCP Evaluation Summary

• Timeliness of the data TBD
• Utility of data system to stakeholders
  critically important, expected beneficial
• Informatics and BMSCP implementation processes
  should be re-examined prior to expansion/replicati
  on
• Sustainability?

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Survey Data and Preliminary Results
Chris Johnson, MS Division of Reproductive
Health, CDC
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Unweighted vs. weighted results

• Data from a random sample
• Components of weights
• Adjustments for nonsampling bias
• Adjustments for sample design

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Age of respondents
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Marital status
US MX
Single 23 8
Live-In Significant Other 24.5 38
Married 49 54
Divorced / Separated / Widowed 3.5 0
23
8
48
Health care coverage
49
Initiation of prenatal care
US MX
1st Trimester 60 45
2nd Trimester 34 46
3rd Trimester 3 4
Did not receive prenatal care 1 3
Dont Know 2 2
50
Pregnancy intention
US MX
Unwanted 15 17
Wanted later 34 29
Unintended 49 46
Wanted earlier 17 24
Wanted then 31 30
Intended 48 54
Dont know 3 0
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Heard about folic acid
52
Reason to take folic acid
US MX
Prevent birth defects 55 53
Strengthen bones 38 45
Prevent high blood pressure 3 1
Dont know 4 1
53
Smoking
54
Drinking
55
HIV testing during pregnancy
US MX
Yes 90 53
No 5 42
Dont know 5 5
56
Ever had a Pap smear
57
Seatbelt use during 3rd trimester
US MX
Always 85 39
gt 50 6 11
lt 50 6 13
Never 2 22
Do not ride in vehicles 1 15
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Initiated breastfeeding
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Next steps

• Analysis datasets
• Responses to survey
• Analysis weights
• Descriptive analysis document
• Recommendations regarding
• Software for analysis
• Standard errors
• Point estimates
• Limitations of analysis without weights

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Beyond next steps (más allá)

• USMBHA as clearinghouse for data and analyses
• Opportunity for collaborative work to
• Analyze and interpret these data
• Demonstrate their usefulness locally
• Need to increase capacity to use such data in
  area

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Language and Cultural Effect
Ana Chavez, MS, RD National Center for Health
Statistics
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Unique Lifestyle Characteristics

• Regular travel between countries
• See Brownsville and Matamoros as one large city
• Spanish is the predominant language spoken in
  downtown Brownsville
• The cultures blend into one

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photographer Leslie Mazoch
photographer Leslie Mazoch
photographer Leslie Mazoch
photographer Leslie Mazoch
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BMSCP Pilot Response Rates

• Sample Size
• Response Rate
• Interview language
• English
• Spanish
• Both languages
• Average Time

• U.S. Mexico
• No. No.
• 525 474
• 484 92 463 98
• 49 lt1
• 49 99 2 lt1
• 28 37

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BMSCP Pilot Response Rates

• Sample Size
• Response Rate
• Interview language
• English
• Spanish
• Both languages
• Average Time

• U.S. Mexico
• No. No.
• 525 474
• 484 92 463 98
• 49 lt1
• 49 99
• 2 lt1
• 28 37

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BMSCP Pilot Response Rates

• Sample Size
• Response Rate
• Interview language
• English
• Spanish
• Both languages
• Average Time

• U.S. Mexico
• No. No.
• 525 474
• 484 92 463 98
• 49 lt1
• 49 99 2 lt1
• 28 37

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Language and Culture

• Focus groups
• Training
• Battelle evaluation
• BMSCP Demonstration Project data

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Focus Group

• Method
• The Helix Group, Inc.
• 8 female groups 4 groups per country
• Women were pregnant or recently gave birth
• Grouped by age
• 19 years and 20 years
• Conducted in Spanish

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Focus Group Findings

• Older women actively participated more and
  provided more comments compared to younger women
• Mexico formal, reserved, little eye contact

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Focus Group Findings

• Most women did not use contraception until after
  1st birth
• Myths
• Long term use of pills can cause sterility
• A woman without children shouldnt use
  contraception because her uterus could get cold
  and she wont be able to have children later
• Matamoros lack of money barrier for good
  nutrition

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Sensitive Topics

• HIV/AIDS, abortion, violence, and ways to avoid
  pregnancy
• Adolescent pregnancy, abortion among young women,
  and machismo from partner and society - lack of
  institutional support from schools and law
  enforcement

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Violence

• Both cities mentioned emotional, psychological,
  verbal, sexual, and physical abuse against
  pregnant women.
• Women who shared examples attributed the violence
  to men being refused sex, being machistas and
  finding the pregnant woman unattractive

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Cervical Cancer/Pap Test

• Most were knowledgeable about Pap Tests but a few
  provided reasons for not having one
• They feel embarrassed
• Their husbands do not want another man to look at
  them
• They are afraid of being hurt during the test
• The cost is too high

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Training, Evaluation, Data

• Questionnaire
• Educational system mismatch
• Health insurance mismatch
• Other, specify race
• More colloquialism

75
Colloquialism Aliviarse Literal translation
to get better English interpretation to give
birth
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Training, Evaluation, Data

• Questionnaire
• Educational system mismatch
• Health insurance mismatch
• Other, specify race
• More colloquialism
• Smoother translation
• Lack of privacy

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Conclusions

• Slightly modify Spanish translation
• Pilot was a good test of the questionnaire and
  procedures
• Alternative methods to collect sensitive
  information
• Field Coordinators and interviewers must speak
  Spanish and be from local area
• Cultural differences along border regions

78
Brownsville-Matamoros Sister City Project
Thank you!
79
12 th Annual Maternal and Child Health
Epidemiology Conference

• Reproductive Health Epidemiology in the U.S.
  Border Area of Coahuila Mexico
• Antonio J Hernandez, MD Idelfonso S Lopez, MD
  Evangelina L Briones , MD Eduardo H Rodriguez,
  MD Alberto Gamez
• INSTITUTO MEXICANO DEL SEGURO SOCIAL
• DELEGACION ESTATAL EN COAHUILA

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Background

• Industrial Border Area (115 maquiladoras)
• Female migrant population is increasing (2.5/yr,
  20005)
• Complex epidemiologic profile
• IMSS Coahuila serves 1.6 million persons
• Traditional reproductive health programs are not
  designed for Coahuilas diverse sub-populations

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Background

• Select epidemiologic characteristics
• Incidence of sexually transmitted disease is high
• 6 cases/year (2.08 x 1000 patients) of metabolic
  congenital disease

82
Study Question

• Do reproductive health indicators in the border
  population differ from those in Coahuila as a
  whole?

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Methods

• Cross-sectional, observational and descriptive
  study using 2005 data
• Comparisons between IMSS population in border
  municipalities of Piedras Negras and Acuña and
  that of Coahuila overall
• Women covered by IMSS 73,852 (15-44 years)

84
Data sources

• SIAIS (IMSS electronic patient database)
• Birth Certificate data
• Hospital admission and discharge data (SIMO)

85
Select demographic indicators

• Average age of mothers ages 10 19
• Coahuila 17.8 years
• border 15.0 years
• Women insured as workers
• Coahuila 49.5
• border 74.9
• Source Birth certificate data and SIMO

86
Fertility rates per 1000 women of reproductive
age
87
Average number of prenatal care visits
88
Perinatal mortality rates per 1000 births
89
Mortality rates per 1000 births
90
Percentage of women using contraceptives after
live birth and miscarriage
91
Percentage of women employed at greater than
minimum wage
92
Conclusions

• SIAIS data facilitate analysis of reproductive
  health indicators at the individual level
• Differences exist between Border women and
  Coahuila women overall
• Collaboration with maquiladoras on the Border may
  be necessary to reach working women PREVENIMSS
  empresas
• Behavioral change among adolescent women on the
  Border will be necessary to improve MCH
  indicators

93
Recommendations

• Increase efforts to promote contraceptive use
  after delivery and miscarriage among women in
  border municipalities
• Conduct similar analyses in other Border states
  to see if these observations apply
• Adapt current programs to address special
  reproductive health needs of
  Border women

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OCCURRENCE OF FEBRILE ILLNESS IN CHILDREN ALONG
THE TAMAULIPAS-U.S. BORDER A NEED FOR
EPIDEMIOLOGIC SURVEILLIANCE

• Alonso Echegollen Guzmán MD
• Mexican Institute of Social Security
• Victoria, Tamaulipas.

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Background

• Febrile diseases are frequent among children.
• Every childhood fever requires a specific
  diagnosis.
• Childhood fever may have allergic, inflammatory,
  neoplastic or infectious origins.
• Emergent diseases are a potential threat to
  vulnerable population groups.

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Study objective

• To determine the incidence of selected febrile
  diseases among IMSS children in the Tamaulipas-US
  border area

97

POPULATION 1.406,495 IN 42 MUNICIPALITIES
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Target and study populations

• Target population
• All border municipalities
• IMSS ages 0 - lt14 years
• N 254,217
• Study population
• Matamoros, Reynosa Nuevo Laredo
• IMSS ages 0 - lt14 years
• N 244,784 (96.3)

100
Methods

• Data
• Clinical data from initial consultation from
  electronic data base (SIAIS)
• Case eligibility criteria
• lt 14 years of age
• Fever gt37.8ºC for no less than 2 hours
• Seen at one of 9 facilities in Matamoros,
  Reynosa and Nuevo Laredo
• Date of consult December 2004 to December
  2005.
• Measure of risk
• Incidence per 10,000 population
• Age-specific and cause-specific

101
Case definition

• ICD 10 Disease Brief
• A01 Typhoid paratyphoid fever (TPTF)
• A02 Other Salmonella infections (OSI)
• A04 Intestinal Bacterial disease (IBD)
• A27 Leptospirosis (LSP)
• A75-79 Rickettsiosis (RKT)
• A90 Dengue fever (DF)
• A91 Hemorragic Dengue fever (HDF)

102
Age distribution of study populationJune 2005

• Total 244,784
• lt 1 year 10,214
• 1-4 years 71,587
• 5-9 years 84,592
• 10-14 years 78,391

103
Results

• 148,934 first time consultations out of 244,784
  children 0-14 years of age.
• 61,242 or 41 among children 1-4 years of age.
• 848 cases of Dengue Fever.
• 92 cases of Typhoid and Paratyphoid infection
• 40 cases of Other Salmonella Infection
• 5 cases of Hemorraghic Dengue Fever in children
  1-4 years old.
• One case of Rickettsiosis.
• No reports for Leptospirosis or Other Intestinal
  Bacterial Disease.

104
ICD-10 NUEVO LAREDO REYNOSA MATAMOROS TOTAL
TYPHOID and PARATYPHOID FEVER 29 22 41 92
OTHER SALMONELLA INFECTIONS 0 8 32 40
OTHER INTESTINAL BACTERIAL DISEASE 0 0 0 0
LEPTOSPIROSIS 0 0 0 0
RICKETTSIOSIS 0 1 0 1
DENGUE FEVER 0 30 818 848
HEMORRAGHIC DENGUE FEVER 0 0 5 5
105
INCIDENCE

• lt1 1-4 5-9 10-14
• Dengue F. 14.68 11.31 34.40
  58.80
• Typhoid
• Paratyph. F. 9.7 0.70 3.42
  7.27
• Other Salmonella
• Infections 0 0.70 1.77
  2.55
• Hemorraghic
• Dengue Fever 0 0 0.12 0.51

106
INCIDENCE

• lt1 1-4 5-9 10-14
• Ricketsiosis 0.0 0.0 0.11 0.0
• Other Intestinal
• Bacterial Infect. 0.0 0.0 0.0 0.0
• Leptospirosis 0.0 0.0 0.0 0.0

107
CONCLUSIONS

• Findings consistent with DF outbreak at the
  México-USA border.
• Incidence of Ricketsiosis, Leptospirosis and
  Intestinal Bacterial Disease among children with
  fever was lower than expected.
• Need for increased epidemiologic surveillance and
  seroprevalence studies.
• Opportunity to improve diagnosis and specific
  treatment of febrile illness in children.

108
CONCLUSIONS

• Epidemiological transition at the México-USA
  border population implies the need for permanent,
  collaborative and efficient health programs.
• We cant do it alone with isolated efforts

109
Discussion

1. How do we work together? How do we communicate
   effectively across different cultural standards
   and expectations?
2. What are the key steps in developing standardized
   data from multi-cultural and binational sources?
3. How can binational initiatives and projects, once
   started, be sustained?