# Presentation: 465529

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

- Special Session

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

- 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

- 			   _Abstract #_
- 			19, 133, 158, 		    159, 160
- 				83
- 				98

## Slide 3

## The U.S. – Mexico Border

**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***

**Notes:**
Define Border Area 

The US- Mexico border has an extension of2,000 miles in length. 
In 1983, Mexico and the US signed the La Paz Agreement which established that the "border area" covers the area situated 100 kilometers on either side of the inland and maritime boundaries between the US and Mexico. 
 Within these limits are 44 counties which are part of the 4  US  border states, and 80 municipios of Mexico’s  6 border states

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

**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**

**Notes:**
Public Health and epidemiology capacity in the border is limited. Over the years border binational health programs and collaborations have been developed, but there is little precedent of border binational epidemiology collaborations. There are various inherent difficulties in building epi capacity on the border; 
Different languages, different cultural and political systems 
Different health information and surveillance systems and severe macro-economic differences
Yet, both the US and Mexico border communities share epidemiological profiles and have a clear need for acquisition and analysis of local health data.

## U.S. - Mexico Border Health Commission

**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**

**Notes:**
During this decade efforts to improve the health of the border translated in the creation of the USMBHC. 
U.S. Public Law  103-400 authorized the President  of the United States to enter into an agreement with Mexico to establish the Commission.and in 2000  the binational agreement to create the Commission was signed
The mission of the Commission is: to provide international leadership to optimize health and quality of life along the United States - Mexico border .
Commision roles are: To advance strong relationships that promote unity and collaboration to address common border health issues, foster commitment to promote regional solutions to border health issue and encourage collaboration and partnerships with state and border health offices;
The Basic Elements of  Border Cooperation Promoted by the Comission are:
Identification of common problems and opportunities
Recognition of the need to learn to work with each other
Trust and respect Consensus in decision making

## U.S. - Mexico Border Health Commission Structure

**U.S. - Mexico Border Health Commission Structure**

**Notes:**

The Commission is integrated by the Secretaries of Health of Mexico and the US and delegates from the 10 border estates. Activities and hosting of partnerships are directed by Commissionm members and supported by 2 central offices and 13 Outreach Offices located in sister cities and border communities 
Commission activities complements the local State Border Health Office’s mission by coordinating work plan activities and bilateral efforts with Commission and local organizations.

## Maternal and Child Health

**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**

**Notes:**
HB2010 (MCH)
The HB2010 Program is an agenda developed in a binational manner- by the two governments and the ten border states-which identifies health priorities for the border region. It is based on U.S. Healthy People 2010 and combines Healthy Gente objectives with Mexico’s Indicadores de Resultados. Maternal and child  health objectives are included among the 11 specific topics to improve  health in the border communities  by  year 2010.   
Specific MCH objectives include decrease infant mortality, increase prenatal care and decrease the adolescent pregnancy.
CDC and the Commission have identified common objectives to
advance MCH  coinciding on the need to:develop data standards, 
develop definitions, contribute resources and identify programmatic approaches that are shared by partners.  		

## 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**

## Border Region 

- Border Region
- 14 million persons & 14 pairs of sister cities

## Population trends and projections Border Region 1970-2020

- Population trends and projections Border Region 1970-2020

- Population in millions

## 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

**Notes:**
Rapid growth fueled primarily by high birth rates and then by migration/international immigration. While US growth has slowed in last few years, there has been a 29% increase since the mid-90s.  The Mexican border population has increased by 2/3 since 1990.

30% under 18 years of age on the U.S. side 2004; 31%,15 years of age in 2000 on Mexico side.

The socioeconomic profile of the border population in each country is different from the respective non-border populations both in the border states and in the country as a whole, although the gradient is generally in the opposite direction.  

On the U.S. side, statistics have been compiled for the counties that are contiguous with the border and compared to other US states, as if the region were a 51st state.  They show that the area ranks within the first 5 states for federal crime, unemployment, military employment and young age and 50th or 51st in insurance coverage for adults and children, percent of the population with a high school education, per capita income (without San Diego, 40th with SD) and numbers of health care professionals. Mortality rates from hepatitis and diabetes are among the highest of any U.S. states, as are the incidence of tuberculosis and AIDS.

On the Mexico side, the border municipios have a health profile similar to the US counties, particularly with respect to the chronic diseases.  Of course, there is also high incidence of infectious disease, and one of our speakers will be talking more about febrile disease in children later in the session.

Although the direction of the difference in these socioeconomic and health indicators between the border counties and municipios and their respective state and national populations is different in most cases, health analysts and others have suggested that counties and municipios on each side of the border have suffered in the past from the benign neglect of their own state and federal governments.

That is a political issue that is beyond the scope of this session, but there is no doubt that the border region is a politically complicated area, with 2 federal, 10 state and 125 county, municipio and city governments, all of which need to work together to serve the needs of the local population.  

So, despite limited access to health care and high rates of poverty, health indicators on the US side are mixed.  Mortality, for example is lower than expected.  On the Mexico side, despite a higher socioeconomic profile than elsewhere in the country, the border area may experience higher than expected mortality.  

MCH indicators, what we know of them are also mixed.

## Infant Mortality, Women Age 10-54, 

**Infant Mortality, Women Age 10-54, **
**US-Mexico Border Area States,**
**1998-2002**

**Notes:**
Here is a map of US infant mortality rates summed over border counties by state.  As you can see, infant mortality is generally lower in the border counties than in the non-border counties and lower than the rate for the US overall, which is 7.0.

Lower mortality is indicated by the lighter colors.  Across all of the mps I am going to show you in the next couple minutes, the lighter, more yellow colors indicate the more favorable results and the darker redder colors the less favorable.

Mexico 2002 = 24.0 (or 13.8?).  Information is contradictory.  USMBHC says 21.0 for Border vs 13.8 for Mexico
US overall is 7.0 in 2004; 5.6 Hisp, 5.8 NHW

## Smoking During Pregnancy, Women Age 10-54, 

**Smoking During Pregnancy, Women Age 10-54, **
**US-Mexico Border Area States,**
**1998-2002**

**Notes:**
Of course, smoking during pregnancy is also low in the border counties of the US, particularly in the Texas border region with a rate of 1.1% smoking.
In US overall, 10.2% smoked during pregnancy (2.6% H, 13.8% NHW, 18.2 AI, 8.4% NHB)

## Prenatal Care in the 1st Trimester, Women Age 10-54, 

**Prenatal Care in the 1****st**** Trimester, Women Age 10-54, **
**US-Mexico Border Area States,**
**1998-2002**

**Notes:**
On the other hand, early prenatal care is less common in border counties than non border counties throughout all of the US border states, and significantly lower in the border states than in the US overall.

83.9% of US mothers in 2004 received early prenatal care (77.4% H, 88.9% NHW)

12.5% preterm births in  2004 (12.0% Hisp, 11.5% NHW, 13.7 AI, 17.9 NHB)
8.1% LBW (6.8% Hispanic, 7.2% NHW, 7.5% AI, 13.7% NHB)

## Late or No Prenatal Care, Women Age 10-19, 

**Late or No Prenatal Care, Women Age 10-19, **
**US-Mexico Border Area States,**
**1998-2002**

**Notes:**
This is particularly true for adolescent women, who have particularly high rates of late prenatal care and no prenatal care.  All of the border counties and non-border counties show rates higher than the US general rate of 3.6 percent and the US Hispanic rate of 5.4. 

## Fertility, Women Age 15-19, 

**Fertility, Women Age 15-19, **
**US-Mexico Border Area States,**
**1998-2002**

**35.9 – 45.1**
**32.9 – 35.8**
**31.4 – 32.8**
**22.8 – 31.3**
**22.1 - 22.7**
**No Data**

**Per 1,000 women **

**Notes:**
Adolescent pregnancy is a concern in many US border communities, particularly throughout Texas and NM where fertility rates are higher than for non-border counties. Border states, however, have lower adolescent rates than the US overall, which is about 41/1000 for this age group.

(US adolescent birth rate 15 – 19 = 41.2/1000 (82.6/1000 Hisp; 26.8 NHW, 62.7 NHB)., )
(66.3 = US general fertility/1000 women 2004 (97.7/1000 Hisp; 58.5 NHW, 66.7 NHB) )

On the Mexico side of the border, rates in the border municipios also appear higher than those in the border states.  Fertility among 15 – 19 year olds in Mexico in 2002 was reported at  64.0/1000 women (Consejo Nacional de poblacion CONAPO)

Neither Preterm delivery or low birth weight rates show any differences between the border and non-border counties and the border states look fairly homogeneous and like the US in general (Preterm ranging from 10 in CA – to 12/1000 births in TX) In U.S.,12.5% preterm births in  2004 (12.0% Hisp, 11.5% NHW, 13.7 AI, 17.9 NHB) and (LBW ranging from 6.0 – 8.0 CA – TX)
8.1% LBW in US overall (6.8% Hispanic, 7.2% NHW, 7.5% AI, 13.7% NHB)

## 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?

**Notes:**
Some heterogeneity across the US border counties with CA generally looking a little better and Texas generally faring a little worse, but these things can be said in general.

We have less information about the Mexican border municipios and, at this point, we have different standards in place and can’t readily compare US and Mexico data.

## Current situation

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

## Unmet programmatic demand for Border MCH data 

- Arranque Parejo
- Seguro Popular
- Atenci[on Integrada Preventiva a Recien      	Nacido
- WIC
- Healthy Start
- Head Start
- Medicaid

## Capacity-building steps

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

**Notes:**
So, how do you build capacity?

## 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

## 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

**Notes:**
Hospital discharge records
SIAIS
Medicaid records
HRSA Child Health Survey
BMSCP 
PRAMS
Other?

## 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

## #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 

- #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

- Brownsville-Matamoros Sister City Project

**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**

## Brownsville-MatamorosSister 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**

**Notes:**
Good afternoon.

ENTER: The purpose of the BMSCP was to develop, implement, and evaluate a standardized approach for surveillance of reproductive and chronic disease risk factors in the U.S.-Mexico border population, with a particular focus on women’s health and maternal and child health.   

BMSCP was designed as a 4-year demonstration project.  Data collection took place in the sister cities of Brownsville and Harlingen, Texas (Cameron County), and Matamoros Tamaulipas.  Our goal was to develop an approach that would be useful to the local public health community and could be replicated in other sister city pairs if BMSCP proved successful.

Evaluation of the project was particularly important to document what did and did not work well so that corrections could be made before replicating these methdos in other border communities.

In this presentation, I am going to tell you about the methods used in BMSCP and the methods and results of the evaluation. 

Chris Johnson will then present preliminary results of the BMSCP survey and talk about next steps.

Chris will be followed by Ana Chavez, who will discuss the unique role of language and cultural effects in this type of project.

## Collaborating Organizations

**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**

**Secretar****ía 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**

** ****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)**

**Notes:**
Partnerships and  good communication were especially important for the success of BMSCP.  I want to start by acknowledging the many collaborating organizations that contributed to the project, shown on this slide.  Specific individuals from these organizations are too many to name here, but...

## Collaborating Organizations

**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**

**Secretar****ía 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**

** ****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)**

**Notes:**
.... I do want to acknowledge the University of Texas at Brownsville, and specifically Linda MacDonald and Marge Chavez of UTB, who have been involved from the start, were instrumental in the development of partnerships in CC and Matamoros, and helped develop the protocol for BMSCP.

I also want to acknowledge:
the US-Mx Border Health Association, which implemented BMSCP data collection under a cooperative agreement with CDC;
Secretaria de Salud Tamaulipas, IMSS Tamaulipas, and Region 11 of the Tx Dept of State Health Services, which provided in-kind logistical support for study operations;
And finally, the hospitals that participated in the project. 

## 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)

**Notes:**
This slide shows the timeline and components of the project, and the groups with primary responsibility.

During 2002 and 2003, we established many partnerships, although partnership development never truly ended and continues today as we begin working with the BMSCP data.

The protocol was developed during 2003 and 2004; 

Questionnaire development took place during 2004-2005; 

USMBHA implemented data collection in 2005; 

And during the current year, with support from our state partners in Texas and Tamaulipas, we have been conducting an evaluation of the project, which is nearly complete.

## 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 _>_100 deliveries in 2005.  (4 hospitals in CC; 6 hospitals in MAT)
- Data collection: Postpartum, in-person interviews prior to hospital discharge.

**Notes:**
And now on to the BMSCP methodology.  

The target population consisted of women who delivered live-born infants in Cameron County, Tx or Matamoros, Tamaulipas.

The study population from which we sampled consisted of women with live births in area hospitals which were expected to have a minimum of 100 deliveries in 2005.  4 hospitals in CC and 6 hospitals in Matamoros met this criterion, and all 10 of these hospitals participated.

Data were collected through in-person interviews of women after they gave birth and before discharge from the hospital.  USMBHA hired 7 interviewers and 2 field coordinators.  The interviewers used laptop computers to conduct the interviews, and their work was supervised by the field coordinators. 

This approach of in-hospital interviews of new mothers had previously been used successfully as part of the Pregnancy Risk Assessment Monitoring System, or PRAMS, to collect data from difficult-to-reach urban residents in selected US metropolitan areas.    

## Questionnaire Development: Topics

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

**HB 2010**
- 		****
- 		****
- 		****
- 		****
- 		****
**	****future topic**

**Notes:**
We designed the BMSCP questionnaire to capture data that would be relevant to as many of the HB2010 objectives as we could, while still keeping interviews at a reasonable length.  Listed on the left side of this side are the topics that our questions inquire about.  The first 5 topics are included in HB2010 objectives.  Dietary and physical activity habits have been identified by USMBHC for inclusion in the HB objectives in the future.  

After selecting the questionnaire topics, we adopted questions from pre-existing survey instruments that address these topics, including PRAMS, the National Health Interview Survey, BRFSS, ENCUESTA Nacional (a national health survey used in Mx), and others.

We then developed a draft questionnaire in both English and Spanish.

To determine the appropriateness of the questionnaire content and the planned procedures for contacting and interviewing women in hospitals, 8 focus groups were conducted in Cameron County and Matamoros with women who were currently pregnant or had given birth within the previous 12 months.

A revised questionnaire was then reviewed by partners and a field test was conducted before the final version was developed and ready for use. 

## 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

**Notes:**
Sampling and data collection for BMSCP began Aug 21 and continued through Nov 9, 2005.

The delivery log in each participating hospital provided the sampling frame from which interviewers identified potentially eligible women.

We estimated that we would need 400 completed interviews in each locality.  To allow for a refusal rate of up to 20%, our targeted sample size was 500 women in each area.  

We used a stratified, systematic cluster sampling design.
stratified by hospital;  CC hospitals were grouped into two sets, and Mat hospitals were grouped into 3 sets based on location within the community.  Sampling was stratified by hospital-set in each locale
Systematic by calendar date;
 Clustered by sample days.  

## 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**
**28**

**Aug**
**29**

**Aug**
**30**

**Aug**
**31**

**Sept**
**1**

**Sept**
**2**

**Sept**
**3**

**Sept**
**4**

**Sept**
**5**

**Sept**
**6**

**Sept**
**7**

**Sept**
**8**

**Sept**
**9**

**Sept**
**10**

**Sept**
**11**

**Sept**
**12**

**Sept**
**13**

**Sept**
**14**

**Sept**
**15**

**Sept**
**16**

**Sept**
**17**

**Aug**
**21**

**Aug**
**22**

**Aug**
**23**

**Aug**
**24**

**Aug**
**25**

**Aug**
**26 **

**Aug**
**27**

**Aug**
**28**

**Aug**
**29**

**Aug**
**31**

**Aug**
**30**

**Sept**
**1**

**Sept**
**2**

**Sept**
**3**

**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**

**BMSCP Methods: Sampling schedule**

**Notes:**
You can see this more clearly here - - - this is an example of the sampling schedule.  The dates shown represent the first four weeks of data collection.  

I’d like you to focus first on the Cameron County hospitals.  We had 2 strata or sets of hospitals, with 2 hospitals in each set.  The sample days for the Brownsville hospitals are shown in pink; sample days for the Harlingen hospitals are show in purple.  The beginning of each sampling period for a given hospital set is separated by 9 days.  100% of women having a live birth on the highlighted dates were included in the sample.  These women were identified from the hospital delivery logs by the interviewers; interviewers also checked delivery logs on the day after each 48 hour sampling period to identify and interview eligible women that they might have missed.       

The schedule was similar for Matamoros, except there were 3 sets of hospitals, and the beginning of each sampling period for a given hospital set was separated by 10 days. 

## 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

**Notes:**
BMSCP was evaluated by CDC with collaboration of Tx and Tam State Health Departments, and also by an external group – Battelle.  The evaluation was based on analyses of quantitative and qualitative data.

The quantitative data included:
 - The survey data itself;
 - Hospital delivery logs;
 - Birth certificate data;
 - Data pertaining to costs;
 - Informatics data.

The qualitative data were primarily used by Battelle to evaluate the process used to implement BMSCP and to obtain feedback from stakeholders.  These data included:
 - interviews conducted by Battelle with selected BMSCP staff at CDC and USMBHA, hospital staff, and public health officials;
 - And documentary sources provided by USMBHA such as biweekly reports regarding performance of field staff and the status of data collection; interviewer training materials and debriefing forms.  

## BMSCP Evaluation: Criteria

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

**Notes:**
The criteria that were evaluated are shown here.  We assessed sample representativeness and population coverage in 3 ways.
First, we calculated response rates among women selected for the project;
Second, we analyzed birth certificate data for CC and Matamoros 
1) to identify births that occurred within the target population but outside of our participating hospitals (study population), a measure of potential non-coverage error, AND
2) to determine how similar the study population was to the target population with respect to selected demographic characteristics available in the birth certificate data. 
And third, we linked BMSCP data to birth certificate data for births that occurred within the participating hospitals.  This enabled us to 
1) identify women who should have been in the sample but were not; AND
2) to determine how similar our sampled women were to the study population.

To assess data quality:
we determined how complete the data were by looking item-specific response rates;
And we are in the process of reviewing consistency across selected survey questions;

We assessed efficiency and stability of the system by estimating costs likely to be incurred if the project was replicated, and through an assessment of the informatics components of BMSCP  
The informatics assessment addressed the ease with which informatics aspects could be replicated in other border communities [scalability], and the potential for capacity building with respect to informatics

These last two criteria are yet to be fully assessed because they are dependent on the data being available for use.  We will assess the timeliness of the data as the time between data collection and the time that the data are available for use;
And we expect to assess the utility of BMSCP data to key stakeholders - - -  we do have some information regarding expected utility from the Battelle interviews with stakeholders;

## 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**

**Notes:**
And now I’ll share some of the results from the evaluation.

Response rates were high - - - Approx 98% of the selected women in Mat and 92% of selected women in Cameron County participated.

Our study population provided good coverage of the target population based on birth certificate analyses.  About 93% of Matamoros births during the study period occurred in the hospitals participating in BMSCP; and over 98% of Cameron County births occurred in-participating hospitals.  In addition, demographic characteristics of the study population were similar to those of the target population in Matamoros.   [We compared demographic characteristics for the Matamoros groups only because coverage of the CC target population was so high]  (mother’s age, marital status, and education; birthweight and sex of baby; delivery method; and # of prior pregnancies.)  

Our sample population provided good coverage of the study population.  About 97% of the births that occurred on sample days in the study population in both Matamoros and Cameron County were included in the sample.

Only 3 variables were appropriate for the comparison of sample and study population characteristics - - - age of mother, birth-wt of infant, and delivery method.  Women in the sample were similar to women in the study population with respect to these characteristics. 

## Evaluation Results: Data Quality

- Completeness
- High item-specific response rates (90% of applicable questions answered)
- >5% 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

**Notes:**
To evaluate data quality, we are assessing completeness and consistency of the data.
 - BMSCP achieved high item response rates, with few women refusing to answer any questions
 - Some questions were more likely than others to go unanswered, and this varied between Mat and CC; but, in both areas questions about physical abuse, contraceptive use, and race were more likely to go unanswered.  However, except for the questions about physical abuse, fewer than 10% of respondents had missing values for these questions.  
[In Matamoros, questions about physical abuse, sex before first contraceptive use, HIV testing, and race were more often unanswered.  Questions about Physical abuse, age at first use of birth control, ht, wt, physical activity, and race were more often unanswered in Cameron County.] (Some of the sensitive questions might not have even been asked?) 

Consistency - - - little opportunity to look at this because of way the questionnaire and data collection program were designed.  
Skip patterns were followed correctly, response categories appeared adequate
Yet to do:
Look at those questions for which consistency might be measurable;
compare survey results to birth certificate data for study population (or sample?)

## 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)

**Notes:**
Results of the informatics assessment led to the following recommendations:
Data files should be concatenated more rapidly and should be conducted by staff in the field (for BMSCP, this occurred 2 weeks after data collection and was done by a statistician at CDC, who then had to deal with duplicate records and discrepancies in the data - - better done closer to data collection by data collectors);
Alternative criteria should be developed for creation of the unique subject ID (BMSCP approach required coordination between interviewers, correct use of hospital code, correct assignment of unique pt number within hospital, correct transcription of numbers to Sample Key and Respondent Contact Sheet - - - each step having some risk of error) 
Use of standard vocabulary and coding scheme that would be consistent with those used in other automated data collection activities;
Consider using other data entry software packages, such as Epi Info (BMSCP used CSPro).

## 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

**Notes:**
Our cost estimate for BMSCP came to a total of $150,000, and this includes the cost for questionnaire testing, data collection and data processing, and overall coordination of the project.  The cost per interview would then be approx $150.

We believe these costs are reasonable and indicate that the BMSCP methodology was an economical approach for data collection in a hard-to-reach population. 

I  

## 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

**Notes:**
And finally, the results of the independent evaluation by Battelle indicate that:
Overall, interviewers and field coordinators were well trained and exhibited strong performance.
The data flow worked well.
BMSCP was well supported by stakeholders
And a number of uses for BMSCP data and this type of project were identified by stakeholders, including
Improved MCH practicies
Ability to adapt this type of project to meet local needs and priorities
The possibility and interest in expanding this project to address other conditions of concern on the border.
And stakeholders were interested in and saw value in the potential for capacity building on the border.

## Evaluation Results:Battelle 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

**Notes:**
Recommendations resulting from Battelle’s assessment included:
Additional training for interviewers and field coordinators in the area of computer use, adherence to protocol procedures, and for field coordinators - - -project management and supervision.
Privacy for interviews - - - the concern was raised that lack of privacy in BMSCP could have had an impact on data quality.
Population-specific improvements in wording of the questionnaire.  Ana Chavez will say more about this in her presentation.
And finally, project sustainability was a concern among stakeholders and hence the recommendation that this receive more attention and focus.

## 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**

**Notes:**
In summary, then, the evaluation completed to date indicates:

Partnerships were very important for BMSCP!

BMSCP achieved good coverage and a representative sample of the target population

BMSCP data are likely to be of high quality

The approach was efficient and stable over the data collection period in CC and Mat

## 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/replication**
**Sustainability?**

**Notes:**
Timeliness of the data is to be determined... Chris Johnson will speak to development of the data sets for use.

Utility of BMSCP data and of the overall system to stakeholders is critically important, and cannot be determined until the data are available for use.  We do expect the data to be beneficial, and stakeholders have already identified areas in which they think a system like BMSCP can be valuable for their needs.

Informatics applications and the processes used to implement BMSCP need to be reexamined before the system is replicated in other communities.  

And finally, the question of how to sustain a system for surveillance like BMSCP is very important, and needs to be examined.

And now, Chris Johnson will share results of the BMSCP survey and discuss next steps. 

## Survey Data and Preliminary Results

- Chris Johnson, MS
- Division of Reproductive Health, CDC

## Unweighted vs. weighted results

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

**Notes:**
Non-coverage and nonresponse adjustment factors for survey data are usually more complicated than those derived in our analysis, attempting to compensate for uneven response or coverage among various subgroups -- for example, for teenagers who typically respond at lower rates, or for institutions with delayed reporting. The factors we calculated were comparatively simple because response and coverage were uniformly good, leaving little room for variation and no opportunity to identify a group that responded (or was covered) at a statistically significantly lower rate. An implication of this circumstance is that these components contribute little to the analysis weights, meaning that weighted and unweighted estimates do not differ appreciably for averages (including proportions).  The situation is very different, however, for estimates of population totals because of the effect of the sampling weights (in the range of a four- to five-fold inflation).
We have not yet completed the analysis file, but I am going to show you in the next several slides several of the unweighted frequencies for some key BMSCP variables.

## Age of respondents

**Notes:**
(age from Qx)

US women who are giving birth are older, but ... these percent distributions may reflect different age distributions in one community versus the other.

## 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%**

**Notes:**
Q 10.8 What is your marital status now?

## Health care coverage

**Notes:**
Q 1.4 Just before you got pregnant with this baby, did you have any kind of health care coverage plan or insurance plan?
Q 1.5 During this pregnancy did you have any kind of health care coverage plan or insurance plan? 

In the US the percentage of the nation’s population without health insurance coverage was 15.7 percent in 2004. (US Census Data) 

This slide since raises questions for further analysis and study, e.g. who are the women who report no coverage and are they receiving care in Mexico.  This all has implications for local health policies.

## 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% |
| Don’t Know | 2% | 2% |

**Notes:**
Q 2.2 How many weeks or months pregnant were you when you had your first visit for prenatal 	care? 

Both the US and Mexico have Healthy Border 2010 goals to increase the proportion of women who initiate prenatal care early in the pregnancy.  The specific goals are somewhat different, but this slide indicates Cameron County women may be far behind the US goal that 85% of women receive prenatal care in the first trimester.  On the other hand, Mexican women appear far ahead of Mexico’s goal that 70% of Mexican women receive care in the first or second trimester.

“In 2000, the prevalence of entry into prenatal care after the first trimester ranged from 14.8% (Maine) to 30.9% (New Mexico)” – PRAMS 2000 Surveillance Report

## 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% |
| Don’t know | 3% | 0% |

**Notes:**
...Q 4.1 Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?   I’m going to read a list of options.  Please choose the one that best describes how you felt.

In 2002, the prevalence of unintended pregnancy among women who had a live birth ranged from 33% in Utah to 54% Louisiana – PRAMS
We don’t have comparable data for Mexico to make comparisons. It is interesting that both communities look so similar with respect to this measure.

## Heard about folic acid

**Notes:**
{Q 3.3 Have you ever heard about folic acid?}

Increased folic acid consumption prior to conception and in early pregnancy reduces the incidence of neural tube defects, etc.  In 2000, March of Dimes National Survey found that 75% of women had heard of folic acid – PRAMS 2000 results were similar.
And we see similar results here.  Most women in both communities told us that they learned about the importance of folic acid from their doctors or nurses.

## Reason to take folic acid

|  | US | MX |
| --- | --- | --- |
| Prevent birth defects | 55% | 53% |
| Strengthen bones | 38% | 45% |
| Prevent high blood pressure | 3% | 1% |
| Don’t know | 4% | 1% |

**Notes:**
Q 3.5 Some health experts recommend taking folic acid for which one of the following reasons?
 We see here, however, that many women were misinformed about the primary purpose of folic acid.  We also see from other BMSCP data collected that only a small proportion of women were routinely taking multivitamins in the month preceding pregnancy.  This kind of information should be very helpful to local MCH entities with responsibility for MCH, especially since incidence of neural tube defects has been shown to be higher than expected in this area of the border.

## Smoking

**Notes:**
Q 3.7 In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day?  A pack has 20 cigarettes. Did you smoke _____?
Q 3.8 In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? Did you smoke ____ ?
We know that smoking rates are low on the US side of the border in comparison to the US border states. (I will show this in my slides). We have less information about smoking rates on the Mexico side of the border, but rates are known to be very low.  Mexican women on the border may be smoking more than other women in border states and at a rate approaching that of their US border counterparts.  Given the relationship between smoking and adverse pregnancy outcomes like low birthweight, programs to prevent smoking initiation on the border may deserve more consideration.  Analysis of BMSCP data may shed more light on the risks of smoking among women in these communities. 

## Drinking

**Notes:**
Q 3.10 During the 3 months before you get pregnant, how many alcoholic drinks did you have in an average week?  Did you have________?
Q 3.12 During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week? Did you have ________?

## HIV testing during pregnancy

|  | US | MX |
| --- | --- | --- |
| Yes | 90% | 53% |
| No | 5% | 42% |
| Don’t know | 5% | 5% |

**Notes:**
Q 5.2 At any time during your most recent pregnancy or during the delivery, did you have a test for HIV, the virus that causes AIDS?
HIV testing during pregnancy is recommended practice in the US and that is reflected in these preliminary data. 

AIDS mortality has declined in the US border region over the last 10 years, but not as rapidly as it has elsewhere in the U.S.  In the Mexico border region, AIDS mortality is lower than the rate on the US side, but higher than  in Mexico overall and increasing.  

It is not clear to what extent variations in prevalence and incidence may reflect different rates of testing and other factors, some of which may be clarified by further analysis of these data.  

## Ever had a Pap smear

**Notes:**
Q 6.1 Have you ever had a Pap smear test?

 “Hispanic women have the highest rates of cervical cancer in the US

{13.1 per 100,000 for 2002” (United State cancer Statistics covering 93+% of the US population) – info from Phyllis Wingo 
I would not include this info from Phyllis, unless you can say something comparable for Mexico, especially since Cervical cancer mortality in Mexico is higher than rates in the US.  Rather, I would say that}
 reducing cervical cancer mortality is a Healthy Border 2010 objective.  The BMSCP dataset has additional information about the reason for having the most recent Pap smear and these data may be helpful in designing programs to increase screening.

## Seatbelt use during 3rd trimester

|  | US | MX |
| --- | --- | --- |
| Always | 85% | 39% |
| > 50% | 6% | 11% |
| < 50% | 6% | 13% |
| Never | 2% | 22% |
| Do not ride in vehicles | 1% | 15% |

**Notes:**
Q 9.6 During the last 3 months of this pregnancy, how often did you use your seat belt when you rode in a car, truck or SUV or sport utility vehicle?  

If you excluded women who said they never ride in vehicles from the denominator, treating that response as “not applicable,” the “Always” rate for Mexico would go up to 46% -- still about half the US rate.

Reducing motor vehicle crash deaths is a HB 2010 priority, and seatbelt use is know to have great impact on mv deaths in the US.  This topic will  benefit from further analysis

## Initiated breastfeeding

**Notes:**
Q 2.9 Have you tried to breastfeed your new baby?
At time of interview!  Need to mention the time between interview and birth, that may affect these results here.
“Why should there be a difference?  (The difference will probably increase when short hospital stays on the Mexico side are taken into account.)   Could the fact that US women are given formula at the same time they get instruction on breast feeding be a factor?  Could cultural factors that differ from one side of the border to the other make a difference? With evidence that we could be doing better on the U.S. side, can we use this information to be more effective with our programs?”

## 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

**Notes:**
We at CDC will be completing in the near future, several products: (NOTE: Chris, there is a lot of sensitivity about the fact tht these data were not ready on August 30 and I am continually getting inquiries from Mexico and Texas to when the data will be ready.) 
an analysis dataset 
and a descriptive report with frequencies and cross-tabs that we hope will serve as a baseline document
Proper analysis of the weighted data requires the use of specialized software such as SUDAAN or Stata that can take into account the sample design.  Ordinary software assumes random sampling from an infinite population and cannot calculate the finite population correction factor (FPC), which recognizes the sampling of a large proportion of the population and reduces the standard error (which is proportional to sampling error).I suggest deleting what I have bolded here)  Preliminary analyses suggest that the use of a standard software package such as SAS will over-estimate standard errors by about 14%, meaning that confidence intervals calculated based on these standard errors would be 14% too wide, reducing the precision of comparisons and reducing the power of analyses (and the ability to detect significant differences among subgroups).  
Although analysis using standard software will overstate standard errors, point estimates that incorporate the weights will be correct.  Estimates that do not incorporate the weights at all -- for example, simple averages of the survey data using a package like Excel --  may be biased because of the effect of the nonresponse adjustments, which can affect various respondents' data differentially.  However, the magnitude of this bias is likely to be small.  Preliminary comparisons of weighted and unweighted prevalence estimates showed only small discrepancies, in the range of a few percentage points for proportions.  These unweighted estimates are reasonably good measures, but generally should not be used as the basis of inferring differences among subgroups.

## 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

**Notes:**
1.- - the need to increase the capacity to use data like these on the border, and
2.- - the opportunity Border partners have here to work collaboratively to analyze and interpret these data and to demonstrate how useful they can be locally.

## Language and Cultural Effect

- Ana Chavez, MS, RD
- National Center for Health Statistics

**Notes:**
Good afternoon.   

## 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

## photographer Leslie Mazoch 

- photographer Leslie Mazoch

- photographer Leslie Mazoch

- photographer Leslie Mazoch

- photographer Leslie Mazoch

## 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		 <1
- 		  49		 99	    	    2		 <1
-    28                        37

## 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**		 <1
- 		 **49**		 99
- 		 2		 <1
-   28                        37

## 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		 <1
- 		49		 99	 	  2		 <1
**  ****28**                       **37**

## Language and Culture

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

## 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

## Focus Group Findings

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

## 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 shouldn’t use contraception because “her uterus could get cold” and she won’t be able to have children later”
- Matamoros – lack of money barrier for good nutrition

## 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

## 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_

## 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

## Training, Evaluation, Data

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

## Colloquialism

- “Aliviarse”
- Literal translation – to get better
- English interpretation – to give birth

## Training, Evaluation, Data

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

## 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

## Brownsville-Matamoros 

- Brownsville-Matamoros
- Sister City Project

- Thank you!

**Notes:**
THANK YOU

## 12 th Annual Maternal and Child Health Epidemiology Conference

**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

## Background

- Industrial Border Area (115 maquiladoras)
- Female migrant population is increasing (2.5%/yr, 2000–5)
- Complex epidemiologic profile
- IMSS Coahuila serves 1.6 million persons
- Traditional reproductive health programs are not designed for Coahuila’s diverse sub-populations

**Notes:**
Coahuila es el tercer estado mexicano con mayor extensión del territorio mexicano, tiene 4 mil kilómetros de extensión en su frontera con los USA, altamente industrializado con 115 empresas inscritas en el IMSS de los dos municipios fronterizos  y con importantes movimientos migratorios internos (población de diversos estados mexicanos emigra en búsqueda de mejor salario). 
Tiene el estado 2.2. millones de habitantes, el 70% son afiliados al Instituto Mexicano del Seguro Social (IMSS), tenemos 451,000 mujeres de 15 a 44 años de edad; en la frontera se calculan 74 mil mujeres afiliadas.
La población fronteriza perteneciente al IMSS ha experimentado un crecimiento en los ultimos 5 años entre un 2 a 2.5% annual, esto se debe al crecimiento de empleos temporales y la llegada de inmigrantes en búsqueda de mejorcondición de vida. 
Lo anterior es problema para la eficiencia de los programas tradicionales de México en materia de salud pública, gran parte de sus habitantes provienen de otras zonas del país donde se tienen diferentes costumbres: hábitos de alimentación, religión, etnias, valores culturales, grado de escolaridad e inclusive la presencia de extranjeros de centroamérica.     

## Background

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

**Notes:**
Dos ejemplos del perfil epidemiológico que nos parecen interesantes y que se están estudiando de manera especial es una mayor incidencia de casos de enfermedades de Transmisión sexual, compartida con el municipio de Torreón al sur del estado.
 Asimismso en la frontera se identificaron 21 enfermos (40%) de todos los casos de hepatitits viral C de todo el estado (53 casos).
El segundo ejemplo es la confirmación de casos de hipotiroidismo congénito (5) y de hiperplasia adrenal congénita(1) en recién nacidos. 

## Study Question

**Study**** ****Question**

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

## Methods

**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)

**Notes:**
It is a cross-sectional study with data from 2005.
Comparamos los dos municipios fronterizos (Piedras Negras y Acuña) con el comportamiento del estado.
El IMSS en Coahuila organiza su atención en salud en siete zonas médicas, la frontera es la zona numero siete.
La infraestructura está compuesta por dos hospitales (200 camas en total) y siete clínicas de medicina familiar ubicadas en las principales comunidades de estos dos municipios.
Cerca de 74,000 mujeres en junio 2005 eran las adscritas en la frontera al IMSS.
Las fuentes de información de nuestro análisis han sido el SIAIS (Sistema de Atención Integrada a la salud), los certificados de nacimiento y el SIMO (Sistema Médico Operativo Hospitalario) 

## Data sources

**Data sources**

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

**Notes:**

El SIAIS aporta información vía alectrónica acerca de muchos aspectos de los servicios que otroga el IMSS a sus afiliados:clinical data, family planning and birth control, well child data, prevention measures, etc. (see more below)

(DESCRIBIR LOS SERVICIOS QUE ESTÁN EN LA DIAPOSITIVA).
El SIAIS además está enlazado a nivel nacional, lo que permite intercambios de información con las unidades de evaluación en la normativa de nivel central.
Los certificados de nacimiento son elaborados por el personal de salud que atendió el parto, tienen un control especial restringido y los formatos son enviados a distintas dependencias que concentran estadísticas (Registros civiles, INEGI, IMSS, etc.
El SIMO describe periódicamente la morbilidad y mortalidad hospitalaria, agrupando los diagnósticos por especialidad o servicio. 

________________________________
Old comments
Detail from slide:  Birth Certificate data include: Somatometria, valoración clínica al nacer,  datos de los padres, Registros de afiliacion al IMSS, Tamiz neonatal para congenit diseasdes, digital footprints.

Use of new IMSS’ software : Sistema de Atención Integrada a la salud (SIAIS 2005) 
Clinical records, medical controls controles medicos, preventive medicine, Censos de enfermedades, program’s coverage (family

## 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

**Notes:**
Los certificados de nacimiento muestran que las madres de la Zona fronteriza son más jóvenes en comparación con el promedio para el resto del estado. Cabe mencionar que muchos embarazos son no deseados o no programados ante el descuido de no utilizar algún método anticonceptivo durante la práctica sexual entre la población adolescente.
Este análisis corresponde al grupo de edad mujeres que el IMSS contempla como adolescentes (entre los 10 y 19 años de edad)
Por otra parte, los registros hospitalarios también muestran que las madres jóvenes son trabajadoras y titulares de su seguro personal en mayor proporción que lo observado en el resto de Coahuila.
Esto es debido a que procuran obtener el beneficio económico que representan 90 días de salario que les entrega el IMSS (45 días antes del parto y 45 días después del parto) en lo que se denomina “incapacidad laboral por maternidad”. La madre descansa, atiende a su bebe y sigue recibiendo sus salario en este tiempo.  

## Fertility rates per 1000 women of reproductive age 

**Notes:**
Nuestros primeros resultados dan evidencia que la tasa de nacimientos en mujeres de edad fèrtil es discretamente  mayor en la frontera comparada con el resto del estado,. Esta diferencia puede ampliarse con la llegada de mas mujeres procedentes de otros lugares del país como sucede de forma consistente 

## Average number of  prenatal care visits

**Notes:**
Con relación al promedio de consultas prenatales con que cumplen las mujeres en el estado de Coahuila, acuden a las unidades de medicina familiar con mayor frecuencia las mujeres que habitan en la zona fronteriza, independientemente de otras características como pueden ser el nivel de escolaridad o socioeconómico.
Creo que este fenómeno puede ser explicado en la siguiente diapositiva 

## Perinatal mortality rates per 1000 births

**Notes:**
La mortalidad perinatal es significativamente menor en los municipios fronterizos en comparación con el interior del estado. Una madre informada y capacitada en los riesgos obstétricos o datos alarma durante el embarazo contribuyen a este resultado.
Esto puede ser explicado porque las mujeres de esta zona acuden más a la consulta de control prenatal en contraste con el resto de las mujeres en Coahuila.
Debo aclarar que para que el IMSS otorgue el beneficio de la incapacidad por 90 días a la madre trabajadora, esta debe acudir de forma regular a su control prenatal.

## Mortality rates per 1000 births

**Notes:**
Lo mismo ocurre en el comportamiento de las muertes maternas, un control prenatal y del puerperio mediato contribuye a esta marcada dieferencia entre las madres de la frontera de Coahuila y el resto del estado.
Las causas de muerte materna son primordialmente por eclampsia y enfermedad hemorragica. 

## Percentage of women using contraceptives after live birth and miscarriage

**Percentage of women using contraceptives after live birth and miscarriage**

**Notes:**
En lo que respecta a la tasa de cobertura posparto (incluyendo cesárea), el estado de Coahuila es uno de los estados del país por debajo de la referencia nacional (80%) en este renglón; este problema es mas notorio en la frontera de Coahuila.
Esta pobre respuesta en los indicadores de cobertura se agudiza en el posaborto. 
Las mujeres puérperas más difíciles de convencer para la adopción de un método son aquellas mádres más jóvenes y con un primer embarazo.
Este comportamiento puede contribuir a elevar el riesgo reproductivo en las mujeres de la frontera y demuestra la pobre respuesta a los programas estándares de planificación familiar de nuestra institución.  

## Percentage of women employed at greater than minimum wage

**Notes:**
Es notorio mencionar que las  mujeres en la frontera tienen un mayor poder adquisitivo al incorporarse como trabajadoras de la industria maquiladora y son preferidas en la contratación por parte de los empresarios; su registro en las fábricas no depende de su nivel de escolaridad debido a que es bien conocido que la mujer es más productiva y responsable que el hombre, sobretodo en labores que requieren destreza manual

## 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

**Notes:**
Los nuevos sistemas de información del IMSS están aportando datos epidemiológicos precisos y oportunos, lo que permite medir con mayor confiabilidad los impactos en salud de los programas tradicionales vigentes, además de evaluar su permanencia.
Sin lugar a duda se ha identificado al grupo de mujeres adolescentes donde se observa una menor respuesta a las estrategias de los programas de salud reproductiva

Se confirma la presencia de diferencias en salud reproductiva entre las mujeres de la frontera y del interior del estado: tasa de nacimientos, cobertura anticonceptiva, tipo de seguro social  y de ingreso salarial.  
Adicionalmente, es necesario convencer a los empresarios para que faciliten la tarea del IMSS en trabajar con las obreras de la industria maquiladora en la capacitación y consentimiento informado de adopción a métodos de planificación familiar. El iMSS tiene una estrategia llamada “PREVENIMSS empresas” que concentra diversas actividades médico-preventivas, incluyendo la salud reproductiva  y que está dando buenos resultados.   

## Recommendations

**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

**Notes:**
Es necesario revisar los procesos de educación, capacitación, promoción a la salud, material de difusión. Etc. Con los que estamos trabajando. Es probable que no sean del interés de la mujer que vive en la frontera porque su prioridad es la de trabajar, ser jefe de familia o ayudar al gasto de su cónyugue.

Lo anterior nos hace pensar que es necesario mejorar el contenido de los programas tradicionales, incluyéndoles aspectos cotidianos y estilo de vida de las ciudades fronterizas, que nos permita demostrarles que las comprendemos y que deseamos ayudarles a protegerse de situaciones no deseadas además de las enfermedades

Las mujeres adolescentes que viven en la frontera deben atenderse con actividades que vayan de acuerdo a sus necesidades (trabajadoras, estudiantes y trabajadoras, madres solteras), por medio de programas de intervención temprana en materia de educación sexual, facilitar el acceso a métodos contraceptivos adecuados a su edad, ayudarle a vencer el sentimiento de discriminación por usar contraceptivos, actividades recreativas y la defensa de su equidad de género (hombre y mujer tienen los mismos derechos sobre su cuerpo y de decisión).   

## 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.

## 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.

## Study objective

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

- POPULATION: **1.406,495 **
- IN 42 MUNICIPALITIES

**Notes:**
Tamaulipas has a population of XXXXX and is divided into XXXX municipalities.
IMSS population is 1,406,495, or 60% Tamaulipas total population
There are XXX municipalities at the Texas-Tamaulipas border.
The vast majority of the border population resides in 3 of highly urbanized municipalities, including Matamoros, Reynosa and Nuevo Laredo

## Target and study populations

- Target population:
-    All border municipalities
-    IMSS ages 0 - _<_14 years
-  	N = 254,217
- Study population:
-    Matamoros, Reynosa & Nuevo Laredo
-    IMSS ages 0 - _<_14 years
-    N = 244,784		(96.3%)

**Notes:**
There are  254,217 children ages 0 - <14 years in the IMSS border population and
 244,784, of them (96.3%) reside in Matamoros, Reynosa and Nuevo Laredo.

The study population is limited to children who reside in these three urbanized areas	
The IMSS border population is served by 14 primary care facilities, 9 of these are located in Matamoros, Reynosa and Nuevo Laredo

## Methods

- Data:
-    Clinical data from initial consultation from electronic    	 data base  	(SIAIS)
- Case eligibility criteria:
- 	_<_ 14 years of age
-     Fever >37.8oC 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

## 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)

## Age distribution of study populationJune 2005

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

**Notes:**
10 – 14  or 10 - <14??
Please add population by age group

## 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.

**Notes:**
0 – 14 or 0 - < 14??

## Slide 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 |

## INCIDENCE

- 				_<1__	__	__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**

**Notes:**
You are switching back to Century font here from Ariel.  Is that what you intend? 

## INCIDENCE

- 					_**<1     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**

## 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.

## CONCLUSIONS

- Epidemiological transition at the México-USA border population implies the need for permanent, collaborative and efficient health programs.
- We can’t do it alone with isolated efforts

## Discussion

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