Health care supply, payment system and medical practice : evidence from obstetric practice

ABSTRACTA significant share of deliveries are performed by Cesarian section (C-section) in Europe and in many developed and developing countries. The aims of this thesis are to highlight the non medical, especially economic and financial, incentives that explain the use of C-section, as well as the medical consequences of C-section on women's health, in regard with other factors of ob¬stetrical care quality such as hospital concentration. Those diagnoses enable us to exhibit ways of improvement of obstetrical care quality in France. Our analysis focus on two countries, France and Switzerland. In the first part of the thesis, we show the influence of two non medical factors on the C-section use, namely the hospital payment system on the one hand and the obstetricians behaviour, especially their demand for leisure, on the other hand. With French data on the year 2003, we show firstly that the fee-for-service payment system of private for profit hospitals induces a higher probability of using C-section. Obstetricians play also a preeminent role in the decision to use a C-section, as the probability of a C-section rises with the number of obstetricians. We then focus on a French reform introduced in 2004, to investigate the impact of Prospective Payment System on obstetric practise. We show that the rise of C-section rate between 2003 and 2006 is mainly caused by changes in hospitals and patients features. Obstetricians practises do not vary a lot for patients with the same risk code. In the mean time however, the number of women coded with a high risk rises. This can be caused by improvements in the quality of coding, obstetricians chosing codes that match better the real health state of their patients. Yet, it can also show that obstetricians change their coding practises to justify the use of certain practises, such as C-section, with no regard to the health state of patients. Financial factors are not the only non medical fac¬tors that can influence the resort to C-section. Using Shelton Brown ΠΙ identification strategy, we focus on the potential impact of obstetricians leisure preference on the use of C-section. We use the distributions of days and hours of delivering and the types of C-section - planned or emergency C-sections - to show that the obstetricians demand for leisure has a significant impact on the resort to C-section, but only in emergency situations. The second part of the thesis deals with some ways to improve obstetric care quality. We use on the one hand swiss and french data to study the impact of C-section on the patients' probability of having an obstetric complication and on the other hand the influence of hospital concentration on the quality of obstetric care. We find the same results as former medical studies about the risks entailed by C-section on obstetric complications.These results prove women ought to be better informed of the medical consequences of C-section and that the slowing of C-section use should be a priority of public health policy. We finally focus on another way to improve obstetric care quality, that is hospital lmarket concentration. We investigate the impact of hospital concentration by integrating the Herfindahl-Hirschman index in our model, on health care quality, measured by the HCUP indicator. We find that hospital concentration has a negative impact on obstetric care quality, which undermines today's policy of hospital closings in France.JEL classification: 112; 118Keywords: Hospital; C-section; Payment System; Counterfactual Estimation; Quality of Care.RÉSUMÉUne part importante des accouchements sont réalisés par césarienne en Europe et dans de nom¬breux pays développés ou en développement. Les objectifs de cette thèse sont de mettre en évidence les déterminants non médicaux, notamment économiques et financiers, expliquant le développe¬ment de cette pratique, ainsi que ses conséquences sur la santé des femmes après Γ accouchement, en lien avec d'autres facteurs comme la concentration locale des structures hospitalières. Les résul¬tats exposés dans cette thèse éclairent les perspectives et voies d'amélioration de la qualité des soins en obstétriques.Notre analyse se concentre sur deux pays : la France et la Suisse. Dans la première partie de la thèse, nous mettons en évidence l'influence de deux déterminants non médicaux sur l'emploi de la césarienne : le système de paiement des hôpitaux d'une part, et le comportement des médecins obstétriciens d'autre part. En étudiant des données françaises de 2003, nous montrons d'abord que le financement à l'acte des établissements privés engendre une hausse de la proba¬bilité de pratiquer une césarienne. Le rôle de l'obstrétricien paraît également déterminant dans la décision d'opérer une césarienne, la probabilité d'employer cette technique augmentant avec le nombre d'obstétriciens. Nous nous intéressons ensuite à l'impact de la mise en place en 2004 du système de paiement prospectif sur l'évolution des pratiques obstétricales entre 2003 et 2006 en France. La hausse du taux de recours à la césarienne entre 2004 et 2006 peut ainsi être principa¬lement imputée aux évolutions des caractéristiques des hôpitaux et des patients, les pratiques des obstétriciens, pour un même codage de la situation du patient, variant peu. Dans le même temps cependant, les pratiques de codage des patients parles obstétriciens évoluent fortement, les femmes étant de plus en plus nombreuses à porter des codes correspondant à des situations à risques. Cette évolution peut indiquer que la qualité du codage en 2006 s'est améliorée par rapport à 2004, le codage correspondant de plus en plus à la situation réelle des patientes. H peut aussi indiquer que les pratiques de codage évoluent pour justifier un recours accru à la césarienne, sans lien avec l'état réel des patientes. Les facteurs financiers ne sont pas les seuls facteurs non médicaux à pouvoir expliquer le recours à la césarienne : nous nous intéressons, en suivant la stratégie d'identifica¬tion de Shelton Brown m, à l'impact potentiel de la demande de loisir des médecins obstétriciens sur la pratique de la césarienne. En utilisant la distribution des jours et heures d'accouchement, et en distinguant les césariennes planifiées de celles effectuées en urgence, nous constatons que la demande de loisir des obstétriciens influence significativement le recours à la césarienne, mais uni¬quement pour les interventions d'urgence. La deuxième partie de la thèse est consacrée à l'étude de la qualité des soins en obstétriques. Nous utilisons des données suisses et françaises pour analyser d'une part l'impact de la césarienne sur la survenue de complications obstétricales et d'autre part l'impact de la concentration des soins sur la qualité des soins en obstétrique. Nons confirmons les résultats antérieurs de la littérature médicale sur la dangerosité de la césarienne comme facteur de complications obstétricales. Ces conclusions montrent que les femmes ont besoin d'être informées des conséquences de la césarienne sur leur santé et que le ralentissement de l'augmentation de la pratique de la césarienne devrait être un objectif de la politique publique de santé. Nous nous in¬téressons à un autre facteur d'amélioration des soins en obstrétique, l'organisation des hôpitaux et particulièrement leur concentration. Nous estimons ainsi l'effet de la concentration sur la qualité des soins obstétriques en intégrant l'indice de Herfindahl-Hirschman dans notre modèle, la qualité des soins étant mesurée à l'aide de l'indicateur HCUP. Nous constatons que la concentration des naissances a un impact négatif sur la qualité des soins en obstétrique, résultat qui va dans le sens contraire des politiques de fermeture d'hôpitaux menées actuellement en France. JEL classification : 112 ; 118Mots-clés : Hôpital ; Césarienne ; Système de paiement ; Contrefactuels ; Qualité des soins, sur la qualité des soins en obstétrique.

Chagas Disease among the Latin American Adult population attending in a primary care center in Barcelona, Spain

Background/Aims: The epidemiology of Chagas disease, until recently confined to areas of continental Latin America, has undergone considerable changes in recent decades due to migration to other parts of the world, including Spain. We studied the prevalence of Chagas disease in Latin American patients treated at a health center in Barcelona and evaluated its clinical phase. We make some recommendations for screening for the disease. Methodology/Principal Findings: We performed an observational, cross-sectional prevalence study by means of an immunochromatographic test screening of all continental Latin American patients over the age of 14 years visiting the health centre from October 2007 to October 2009. The diagnosis was confirmed by serological methods: conventional in-house ELISA (cELISA), a commercial kit (rELISA) and ELISA using T cruzi lysate (Ortho-Clinical Diagnostics) (oELISA). Of 766 patients studied, 22 were diagnosed with T. cruzi infection, showing a prevalence of 2.87% (95% CI, 1.6-4.12%). Of the infected patients, 45.45% men and 54.55% women, 21 were from Bolivia, showing a prevalence in the Bolivian subgroup (n = 127) of 16.53% (95% CI, 9.6-23.39%). All the infected patients were in a chronic phase of Chagas disease: 81% with the indeterminate form, 9.5% with the cardiac form and 9.5% with the cardiodigestive form. All patients infected with T. cruzi had heard of Chagas disease in their country of origin, 82% knew someone affected, and 77% had a significant history of living in adobe houses in rural areas. Conclusions: We found a high prevalence of T. cruzi infection in immigrants from Bolivia. Detection of T. cruzi¿infected persons by screening programs in non-endemic countries would control non-vectorial transmission and would benefit the persons affected, public health and national health systems.

Information and risk management during the first trimester care for pregnant women: Some reflections about the ethical challenges and the legal framework in Switzerland. [L'information et la gestion des risques dans le suivi de la grossesse lors du 1er trimestre : quelques réflexions sur le défi éthique et le cadre légal en Suisse.]

The progress in prenatal medicine raises complex questions with respect to the physician-patient relationship. The physician needs to reconcile medical aspects, ethical principles as well as judicial norms. Already, during the first trimester, the physician has to put into practice the schedule combining for each individual pregnancy physical, laboratory and other appropriate exams. Physicians are under the obligation to inform in a clear and comprehensive way without creating unnecessary anxiety for their patients. Legal requirements include informed consent, the respect for the patient's right to self-determination, and compliance with the Swiss federal law on genetic testing, especially with its articles on prenatal screening and diagnosis. This article discusses the complexity of obstetrical practice when it comes to delivering adequate information within the scope of ethical and legal requirements in Switzerland. L'évolution de la médecine prénatale soulève des enjeux complexes dans la relation médecin-patient. Il s'agit de concilier à la fois les aspects médicaux, les principes éthiques et les normes juridiques. Dès le premier trimestre de la grossesse le médecin doit poser le cadre du suivi et des examens appropriés pour chaque grossesse. Son devoir est d'informer de manière claire et précise sans inquiéter inutilement, en respectant l'exigence légale d'un consentement éclairé et plus largement le droit de la patiente à l'autodétermination ainsi que le cadre de la loi fédérale suisse sur l'analyse génétique humaine dans le domaine du dépistage et du diagnostic prénatal. Cet article discute de la complexité de l'information et de l'application des principes éthiques et légaux dans la pratique obstétricale en Suisse.

Long-term efficacy of a rural community-based integrated intervention for prevention and management of chronic obstructive pulmonary disease: a cluster randomized controlled trial in China's rural areas

This study aimed to assess the efficacy of a rural community-based integrated intervention for early prevention and management of chronic obstructive pulmonary disease (COPD) in China. This 18-year cluster-randomized controlled trial encompassing 15 villages included 1008 patients (454 men and 40 women in the intervention group [mean age, 54 ± 10 years]; 482 men and 32 women in the control group [mean age, 53 ± 10 years]) with confirmed COPD or at risk for COPD. Villages were randomly assigned to the intervention or the control group, and study participants residing within the villages received treatment accordingly. Intervention group patients took part in a program that included systematic health education, smoking cessation counseling, and education on management of COPD. Control group patients received usual care. The groups were compared after 18 years regarding the incidence of COPD, decline in lung function, and mortality of COPD. COPD incidence was lower in the intervention group than in the control group (10% vs 16%, <0.05). A decline in lung function was also significantly delayed in the intervention group compared to the control group of COPD and high-risk patients. The intervention group showed significant improvement in smoking cessation compared with the control group, and smokers in the intervention group had lower smoking indices than in the control group (350 vs 450, <0.05). The intervention group also had a significantly lower cumulative COPD-related death rate than the control group (37% vs 47%, <0.05). A rural community-based integrated intervention is effective in reducing the incidence of COPD among those at risk, delaying a decline in lung function in COPD patients and those at risk, and reducing mortality of COPD.

Child care by choice or by default? : examining the experiences of unregulated home-based child care for women in paid work and training

This thesis aims to uncover the dynamics, causes and outcomes of women's reliance on unregulated home-based child care in Ontario, Canada, and the implications ofthis form of care for women's equality. Drawing on a longitudinal qualitative study, I examine the diverse experience of 14 women using home-based child care and engaged in both paid work/training and care work for children under the age of six, and draw comparisons with users of other forms of child care. I argue that home-based child care involves high levels of instability for continuity of care and is chosen largely as a default position based on economic considerations. It represents a compromise between the demands of social reproduction and paid work/training that entangles mothers in relations of exploitation with care providers. Doing so leaves both mothers and care providers socially and economically vulnerable and relying on social networks to fill in the gaps.

Relationship between Socio-Demographic Factors and Familial and Partner Pressures to Conceive in HIV-Positive Women in Ontario

This study examined the relationship between socio-demographic factors and family and partner pressure to conceive in women living with HIV in Ontario, Canada. A total of 490 women, aged 18-52 years were included in the study. The HIV Pregnancy Planning Questionnaire was used to collect data on socio-demographic, medical, and pressure variables. Multivariate logistic regression analysis suggest that increased age, years lived in Canada, and living in Toronto were associated with lower odds, and being married and having 0-1 lifetime births were associated with higher odds of family pressure to conceive. Increased age was associated with lower odds, and being married and living in Toronto were associated with higher odds of partner pressure to conceive. Findings suggest that socio-demographic factors influence the fertility decision-making process. Health care providers should consider socio-demographic factors along with medical factors when assisting women living with HIV and their partners to make informed reproductive decisions.

Análisis de la ayuda oficial al desarrollo. estudio de caso: programa conjunto de UNICEF y UNFPA sobre la mutilación genital femenina en Kenia (2008-2012)

El interés de este estudio de caso es analizar el Programa Conjunto de UNFPA y UNICEF sobre MGF/E en Kenia bajo la luz de los postulados poscolonialistas. Partiendo de la idea de que la MGF es una manifestación de las desigualdades de género, se argumenta que el PC reproduce la imagen de la mujer keniana como una víctima del poder masculino. A partir de esta imagen se deslegitima el orden cultural de los grupos que siguen esta tradición, afectando las lógicas de unidad y cohesión de la sociedad. El análisis de este tipo de dinámicas permite comprender mejor los procesos de intervención de las organizaciones internacionales sobre las estructuras sociales de actores frágiles del sistema internacional.

Acceptability of home-assessment post medical abortion and medical abortion in a low-resource setting in Rajasthan, India : Secondary outcome analysis of a non-inferiority randomized controlled trial

Background: Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. Objective: To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India. Design: Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India. Population: Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years. Methods: Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1: 1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible. Main outcome measures: Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups. Results: 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001). Conclusion: Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

Cost-benefit of hospitalization compared with outpatient care for pregnant women with pregestational and gestational diabetes or with mild hyperglycemia, in Brazil

CONTEXTO E OBJETIVO: Gestações complicadas pelo diabetes estão associadas com aumento de complicações maternas e neonatais. Os custos hospitalares aumentam de acordo com a assistência prestada. O objetivo foi calcular o custo-benefício e a taxa de rentabilidade social da hospitalização comparada ao atendimento ambulatorial em gestantes com diabetes ou com hiperglicemia leve. DESENHO do ESTUDO: Estudo prospectivo, observacional, quantitativo, realizado em hospital universitário, sendo incluídas todas as gestantes com diabetes pregestacional e gestacional ou com hiperglicemia leve que não desenvolveram intercorrências clínicas na gestação e que tiveram parto no Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (HC-FMB-Unesp). MÉTODOS: Trinta gestantes tratadas com dieta foram acompanhadas em ambulatório e 20 tratadas com dieta e insulina foram abordadas com hospitalizações curtas e frequentes. Foram obtidos custos diretos (pessoal, material e exames) e indiretos (despesas gerais) a partir de dados contidos no prontuário e no sistema de custo por absorção do hospital e posteriormente calculado o custo-benefício. RESULTADOS: O sucesso do tratamento das gestantes diabéticas evitou o gasto de US$ 1.517,97 e US$ 1.127,43 para pacientes hospitalizadas e ambulatoriais, respectivamente. O custo-benefício da atenção hospitalizada foi US$ 143.719,16 e ambulatorial, US$ 253.267,22, com rentabilidade social 1,87 e 5,35 respectivamente. CONCLUSÃO: A análise árvore de decisão confirma que o sucesso dos tratamentos elimina custos no hospital. A relação custo-benefício indicou que o tratamento ambulatorial é economicamente mais vantajoso do que a hospitalização. A rentabilidade social de ambos os tratamentos foi maior que 1, indicando que ambos os tipos de atendimento à gestante diabética têm benefício positivo.

Food choices and practices during pregnancy of immigrant and Aboriginal women in Canada: a study protocol

Abstract Background Facilitating the provision of appropriate health care for immigrant and Aboriginal populations in Canada is critical for maximizing health potential and well-being. Numerous reports describe heightened risks of poor maternal and birth outcomes for immigrant and Aboriginal women. Many of these outcomes may relate to food consumption/practices and thus may be obviated through provision of resources which suit the women's ethnocultural preferences. This project aims to understand ethnocultural food and health practices of Aboriginal and immigrant women, and how these intersect with respect to the legacy of Aboriginal colonialism and to the social contexts of cultural adaptation and adjustment of immigrants. The findings will inform the development of visual tools for health promotion by practitioners. Methods/Design This four-phase study employs a case study design allowing for multiple means of data collection and different units of analysis. Phase 1 consists of a scoping review of the literature. Phases 2 and 3 incorporate pictorial representations of food choices (photovoice in Phase 2) with semi-structured photo-elicited interviews (in Phase 3). The findings from Phases 1-3 and consultations with key stakeholders will generate key understandings for Phase 4, the production of culturally appropriate visual tools. For the scoping review, an emerging methodological framework will be utilized in addition to systematic review guidelines. A research librarian will assist with the search strategy and retrieval of literature. For Phases 2 and 3, recruitment of 20-24 women will be facilitated by team member affiliations at perinatal clinics in one of the city's most diverse neighbourhoods. The interviews will reveal culturally normative practices surrounding maternal food choices and consumption, including how women negotiate these practices within their own worldview and experiences. A structured and comprehensive integrated knowledge translation plan has been formulated. Discussion The findings of this study will provide practitioners with an understanding of the cultural differences that affect women's dietary choices during maternity. We expect that the developed resources will be of immediate use within the women's units and will enhance counseling efforts. Wide dissemination of outputs may have a greater long term impact in the primary and secondary prevention of these high risk conditions.

What women want: a qualitative study about postnatal midwifery care at home

In Switzerland, decreases in regular hospital treatment after birth are leading increasingly to mother and child being cared for at home by independent midwives. The research herein was carried out in order to understand the needs of mothers in their home once they leave the hospital and what this midwife provided care consists of. In 2008, eight women from central Switzerland were interviewed on two separate occasions after the birth of their child, and the interviews were analysed using content analysing techniques. Mothers explained that they wanted their baby and themselves to be well cared for. They needed rest and support for recuperation and wished to spend quality time with their new family. The midwifes assisted the mothers to fulfil their needs by counselling, by instructing and by giving information, but they rarely encouraged them to be together as a family. The relationship between midwife and mother turned out to be an important support. Mothers were satisfied if mutual trust was built and if the midwife perceived their needs, respected their autonomy and took the time to be with them. Midwives contribute to the basic well-being of families and support women with medical expertise and ongoing care. Furthermore families need support in general household issues so that new mothers can recover sufficiently.

Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study

Background Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART. Methods We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up. Findings Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26 658 patients) after 12 months, 70·8% (18 306 of 25 849 patients) after 24 months, and 69·7% (17 787 of 25 535 patients) after 36 months. Patient-level data included 29 145 patients. 14 630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured. Interpretation Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+. Funding Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.

Prenatal care content and utilization among pregnant women enrolled in managed care programs in Harris County, Texas

This research study was conducted as a descriptive study of prenatal care experiences of women enrolled in public and private managed care programs. The study's aim was to describe the demographic characteristics of the women in the study and to analyze and compare their prenatal care experiences. ^ The objective of this study was to examine the research question: Do pregnant women enrolled in Medicaid Managed Care receive the same level of care as women enrolled in other Managed Care Programs in Harris County, Texas? ^ The study population was a convenience sample of pregnant women enrolled in managed care programs who presented to one of the two hospital study sites for delivery of their infant. The study utilized a self administered survey to measure adequacy and content of prenatal care received by the women during this pregnancy. Adequacy of prenatal care utilization was determined based on the Kessner Index criteria of timing of initiation of care and number of visits. Content of care was measured by the number of different medical services the women reported they had received and the number of health information topics the women reported on which they had received information. Demographic characteristics were described with univariate and bivariate statistics of frequencies and cross tabulations. Associations were evaluated using measures of linear correlations. ^ Results from the study showed there is an association between enrollment in Medicaid Managed Care (public) and prenatal care received compared to women enrolled in other Managed Care Programs (private). The results were derived from statistical tests on data the postpartum women gave when they completed the self-administered survey. Provider type was a moderate predictor of quality and quantity of prenatal care. The results also indicate that in the study population, minority ethnicity, income and lower educational status were associated with intermediate and inadequate prenatal care. ^

The use of culturally related health practices and health care utilization among Hispanic women in farmworker communities

Breast and cervical cancer screening rates continue to be lower in Hispanic women than other ethnic subgroups. Several factors have been identified that influence health care utilization. The use of preventive services (cancer screenings and adherence) in addition to yearly doctor visits are often used to measure health care utilization. A secondary analysis of an existing dataset containing baseline survey data collected from participants of an intervention trial to test the Cultivando La Salud (CLS) program was used to analyze the association between cultural health practice use (use of curandero,s obador, and herbal remedies) and health care utilization. The sample consisted of women 50 years of age and older living in farmer communities in four sites: Eagle Pass, TX, Anthony, NM, Merced, CA, and Watsonville, CA (n=708). Participants reported using a curandero (5.67%), sobador (29.79%), and herbal remedies (46.65%) at some point in their lives. The use of cultural health practices was found to significantly influence utilization of certain health care services: use of herbal remedies influence doctor visits, adherence to mammography screening and adherence to Pap test screening; use of a curandero influenced ever having a mammogram; use of a sobador influenced ever having a mammogram, ever having a Pap test, and Pap test adherence. In addition, women reporting use of curandero or herbal remedies were found to be more avoidant of the health care system than those that reported not using them. Further research is needed to further analyze the influence of cultural health practices on health care utilization. ^

Prenatal care programs in a clinic based center in El Paso, Texas: Evaluating outcomes among Hispanic women

Early prenatal care has been found to improve pregnancy and birth outcomes by reducing the risk of low birth weight and preterm births. Statistics point to lower utilization rates of prenatal care in El Paso, Texas and increasing rates of low birth weight. This study was a secondary data analysis, which explored the perceived benefits and barriers known to influence the utilization of prenatal care, and the birth outcomes among participating subjects attending three different prenatal care programs offered at the Centro San Vincent Clinic during the period of December 2006 to February 2008. A survey was used to collect data on demographics and assess perceived benefits and barriers regarding early prenatal care and self-efficacy of the participants. Post-partum birth records were used to gather data about the participant's newborns to include birth weight, gestational age, and the type of delivery (i.e. vaginal versus Cesarean birth). Chi square analysis was conducted to test for significant differences and associations. The sample of women in the study had high risk factors for inadequate utilization of prenatal care. In spite of high demographic risk factors, these women had higher perceived benefits, lower perceived barriers and high self-efficacy associated with prenatal care utilization. The perceived benefits and barriers to prenatal care were associated with place of birth and language preferred, with women from Mexico and who preferred Spanish having higher perceived benefits and lower barriers. There was no significant difference in birth outcomes among the women in different prenatal care programs. The findings of this study suggest that of all participants in the study, those born in Mexico demonstrated higher rates of perceived benefits of early prenatal care. The analysis also suggested that healthy birth outcomes were evenly distributed among women participating in one of the three prenatal care programs. ^