A comprehensive assessment of care competence and maternal experience of first antenatal care visits in Mexico: Insights from the baseline survey of an observational cohort study.

BACKGROUND: Comprehensive antenatal care (ANC) must prioritize competent, evidence-based medical attention to ensure a positive experience and value for its users. Unfortunately, there is scarce evidence of implementing this holistic approach to ANC in low- and middle-income countries, leading to gaps in quality and accountability. This study assessed care competence, women's experiences during the first ANC visit, and the factors associated with these care attributes. METHODS AND FINDINGS: The study analyzed cross-sectional baseline data from the maternal eCohort study conducted in Mexico from August to December 2023. The study adapted the Quality Evidence for Health System Transformation (QuEST) network questionnaires to the Mexican context and validated them through expert group and cognitive interviews with women. Pregnant women aged 18 to 49 who had their first ANC visit with a family physician were enrolled in 48 primary clinics of the Instituto Mexicano del Seguro Social across 8 states. Care competence and women's experiences with care were the primary outcomes. The statistical analysis comprised descriptive statistics, multivariable linear and Poisson regressions. A total of 1,390 pregnant women were included in the study. During their first ANC visit, women received only 67.7% of necessary clinical actions on average, and 52% rated their ANC experience as fair or poor. Women with previous pregnancies (adjusted regression coefficient [aCoef.] -3.55; (95% confidence intervals [95% CIs]): -4.88, -2.22, p < 0.001), at risk of depression (aCoef. -3.02; 95% CIs: -5.61, -0.43, p = 0.023), those with warning signs (aCoef. -2.84; 95% CIs: -4.65, -1.03, p = 0.003), common pregnancy discomforts (aCoef. -1.91; 95% CIs: -3.81, -0.02, p = 0.048), or those who had a visit duration of less than 20 minutes (<15 minutes: aCoef. -7.58; 95% CIs: -10.21, -4.95, p < 0.001 and 15 to 19 minutes: aCoef. -2.73; 95% CIs: -4.79, -0.67, p = 0.010) and received ANC in the West and Southeast regions (aCoef. -5.15; 95% CIs: -7.64, -2.66, p < 0.001 and aCoef. -5.33; 95% CIs: -7.85, -2.82, p < 0.001, respectively) had a higher probability of experiencing poorer care competence. Higher care competence (adjusted prevalence ratio [aPR] 1.004; 95% CIs:1.002, 1.005, p < 0.001) and receiving care in a small clinic (aPR 1.19; 95% CIs: 1.06, 1.34, p = 0.003) compared to a medium-sized clinic were associated with a better first ANC visit experience, while common pregnancy discomforts (aPR 0.94; 95% CIs: 0.89, 0.98, p = 0.005) and shorter visit length (aPR 0.94; 95% CIs: 0.88, 0.99, p = 0.039) were associated with lower women's experience. The primary limitation of the study is that participants' responses may be influenced by social desirability bias, leading them to provide socially acceptable responses. CONCLUSIONS: We found important gaps in adherence to ANC standards and that care competence during the first ANC visit is an important predictor of positive user experience. To inform quality improvement efforts, IMSS should institutionalize the routine monitoring of ANC competencies and ANC user experience. This will help identify poorly performing facilities and providers and address gaps in the provision of evidence-based and women-centered care.

[The need for paradigm change in maternal care: AMIIMSS model, scopes and challenges]. / La necesidad de un cambio de paradigma en atención materna: Modelo AMIIMSS, alcances y retos.

Undoubtedly, great advances have been made in terms of maternal and infant morbidity and mortality. However, in Mexican Social Security System, the quality of maternal care is questionable, as reflected in proportions of cesarean births three times higher than those recommended by WHO, abandonment of exclusive breastfeeding and the fact that up to one in three women is a victim of abuse during delivery. Given this, the IMSS decides to implement the model called Integral Maternal Care AMIIMSS, focused on users experience and based on friendly obstetric care, along different stages of the reproductive process. Four pillars underpin the model, women's empowerment, infrastructure adaptation, training and adaptation of processes and standards. Although there are advances, with 73 pre-labor rooms enabled and 14,103 friendly attentions granted, there are pending tasks and challenges. In terms of empowerment, the birth plan needs to be included as an institutional practice. In terms of infrastructure adequacy, a budget is required to build and adapt friendly spaces. In addition, it is necessary to update the staffing tables and include new categories, for an adequate operation of the program. On training, the adaptation of academic plans for doctors and nurses is pending. In terms of processes and regulations, there is a lack of qualitative evaluation of the impact of the program on people's experience and satisfaction and elimination of obstetric violence.

Sin duda, se han logrado grandes avances en materia de morbimortalidad materno-infantil. Sin embargo, la calidad de la atención en las instituciones de seguridad social es cuestionable, tal como lo reflejan las proporciones de nacimientos mediante cesárea al triple de lo recomendado por la OMS, el abandono en la lactancia materna y el hecho que hasta una de cada tres mujeres es víctima de maltrato durante la atención. Ante esto, el IMSS ha decidido implementar el modelo denominado Atención Materna Integral AMIIMSS, centrado en las personas usuarias y con sustento en la atención obstétrica amigable, que abarca distintas etapas. Cuatro pilares sustentan al modelo: empoderamiento de la mujer, adaptación de la infraestructura, capacitación y adecuación de procesos y normas. Si bien hay avances, con 73 salas de prelabor habilitadas y 14,103 atenciones amigables otorgadas, hay retos y desafíos por vencer. En materia de empoderamiento, falta incluir el plan de parto como una práctica institucional. En cuanto a adecuación de infraestructura, se requiere presupuesto para construir y adecuar espacios amigables. Además, es necesaria la actualización de las plantillas de personal e inclusión de nuevas categorías para una adecuada operación del programa. Sobre capacitación, está pendiente la adecuación de planes formativos de médicos y enfermeras. En materia de procesos y normatividad, falta evaluación cualitativa del impacto sobre la experiencia y la satisfacción de las personas y la eliminación de la violencia obstétrica.

[Usefulness of the qualitative detection of hCG in cervicovaginal lavage for the diagnosis of premature rupture of membranes]. / Utilidad de la detección cualitativa de hCG en el lavado cervicovaginal para el diagnóstico de rotura prematura de membranas.

BACKGROUND: The detection of human chorionic gonadotropin (hCG) in cervicovaginal lavage has proved useful in establishing the diagnosis of premature rupture of membranes, but the methods used for determining time-consuming. OBJECTIVE: To qualitatively determine the concentration of hCG in cervicovaginal lavage to establish the diagnosis of premature rupture of membranes. PATIENTS AND METHODS: Prospective observational study conducted in 149 pregnant women divided into three groups: group I (n = 50), patients with premature rupture of membranes, group II, with suspected ruptured membranes and group III, with premature rupture of membranes confirmed. The diagnosis was established by clinical examination and testing nitrazina and crystallography. In all patients was conducted and cervicovaginal lavage fluid obtained hCG was determined with a rapid qualitative test (sensitivity 25 mlU/mL). We calculated the sensitivity, specificity and positive and negative predictive value of the method. RESULTS: The mean gestational age was 34.6 +/- 5.2 weeks. In 8.7% of the cases were considered "inconclusive" qualitative hCG test, so only 136 samples were analyzed. The sensitivity was 95.6%, specificity 100%, the positive predictive value of 100% and negative 97.8%. CONCLUSION: The qualitative determination of hCG in cervicovaginal lavage is useful for establishing the diagnosis of premature rupture of membranes.