Prenatal care utilization and perinatal outcomes among pregnant adolescents in Mexico, 2008-2019.

OBJECTIVE: To describe utilization of prenatal care and outcomes of low birth weight and preterm birth among adolescent births in Mexico. METHODS: We used birth certificate data and included live births to individuals 10-24 years, 2008-2019. Our outcomes were binary measures of adequate prenatal care, low birth weight, and preterm birth. We compared adolescents (10-14 years, 15-16, and 17-19) to those 20-24 years. We included individual-, clinical-, and municipality-level variables, used multivariable logistic regression, and calculated adjusted predicted probabilities. We also tested whether receipt of prenatal care moderated the relationship of age with preterm birth and low birth weight. RESULTS: We included a total of 12 106 710 births to women 10-24 years. The adjusted predicted probability of adequate prenatal care increased with age: 56.07% (95% CI 55.82-56.31%) adjusted probability among adolescents 10-14 years compared with 65.51% (95% CI 65.48%-65.55%) among individuals 20-24 years. Receipt of adequate prenatal care in part mitigated disparities in preterm birth and low birthweight across all age groups: 7.30% (95% CI 7.17%-7.43%) adjusted probability of delivering a preterm infant among those 10-14 years who received adequate prenatal care compared with 9.37% (95% CI 9.20%-9.53%) among those 10-14 years without adequate prenatal care. CONCLUSION: In Mexico, adolescent pregnancies are associated with inadequate prenatal care as well as higher odds of preterm delivery and low birth weight. Youngest adolescents (10-14 years) have the highest probability of adverse outcomes. Adequate prenatal care may help partially mitigate disparities in poor perinatal outcomes.

Proximal determinants of suboptimal early child development during the first three years of life in socially deprived Mexican contexts.

Assessing the status and determinants of early child development (ECD) requires accurate and regularly updated measurements. Yet, little information has been published on the subject in low- and middle-income countries, particularly regarding the proximal determinants of childhood development in contexts of high social marginalization. This article analyzes the factors that favor or mitigate suboptimal ECD outcomes in Mexico. A cross-sectional study was conducted using recently collected data for 918 children aged 0-38 months from socially marginalized communities in 23 Mexican municipalities. The ECD outcomes of the children were estimated based on indicators of chronic undernutrition and neurodevelopment (normal, lagging and at risk of delay). The distribution of outcomes was described across the ECD proximal determinants analyzed, including the co-occurrence of chronic undernutrition and suboptimal neurodevelopment. Covariate-adjusted prevalence of the ECD outcomes and co-occurrences were calculated as post-estimations from a multiple multinomial logistic regression. The prevalence of chronic undernutrition was 23.5%; 45.9% of children were classified with neurodevelopmental lag, and 11% at risk of neurodevelopmental delay. The prevalence of stunting co-occurring with suboptimal neurodevelopment came to 15.4%. The results of the multinomial logistic regression model indicated that early gestational age, low birth weight, a low household socioeconomic level, being male and having numerous siblings were all associated with the co-occurrence of chronic undernutrition and suboptimal child neurodevelopment. This study identified important predictors of child development in the first three years of life, specifically in two of its principal indicators: nutritional and neurodevelopmental status. Most of the predictors observed can be improved by means of social programs and interventions. Trial registration: ClinicalTrials.gov ID: NCT04210362.

An assessment of the performance of the Mexican health system between 2000 and 2018.

This paper offers a comprehensive picture of the performance of the Mexican health system during the period 2000-18. Using high-quality and periodical data from the Organization for Economic Cooperation and Development, the World Bank, the Institute for Health Metrics and Evaluation and Mexico's National Survey of Household Income and Expenditure, we assess the evolution of seven types of indicators (health expenditure, health resources, health services, quality of care, health care coverage, health conditions and financial protection) over a period of 18 years during three political administrations. The reform implemented in Mexico in the period 2004-18-which includes the creation of 'Seguro Popular'-and other initiatives helped improve the financial protection levels of the Mexican population, expressed in the declining prevalence of catastrophic and impoverishing health expenditures, and various health conditions (consumption of tobacco in adults and under-five, maternal, cervical cancer and human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) mortality rates). We conclude that policies intended to move towards universal health coverage should count on strong financial mechanisms to guarantee the consistent expansion of health care coverage and the sustainability of reform efforts. However, the mobilization of additional resources for health and the expansion of health care coverage do not guarantee by themselves major improvements in health conditions. Interventions to deal with specific health needs are also needed.

Association of maternal age 35 years and over and prenatal care utilization, preterm birth, and low birth weight, Mexico 2008-2019.

OBJECTIVE: To evaluate prenatal care utilization, low birth weight, and preterm birth among women aged 35 years and older in Mexico from 2008 to 2019. METHODS: We conducted a historical cohort study of all singleton live births in Mexico from 2008 to 2019. Outcomes were inadequate prenatal care, preterm birth, and low birth weight. We compared outcomes among women aged 35-39, 40-44, and 45-49 years with births to women aged 20-34 years. We used logistic regression to account for individual, health system, and contextual confounders. RESULTS: We included a total of 19 526 922 births; 2 325 725 (11.9%) were to women aged 35 years and older. Women aged 45-49 years had the lowest levels of education, were more likely to be uninsured, and came from highly marginalized municipalities while those aged 35-39 years had the highest levels of education and insurance and came from the least marginalized municipalities. The odds of inadequate prenatal care (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI] 1.09-1.15), preterm birth (aOR 2.05; 95% CI 1.97-2.13), and low birth weight (aOR 2.03; 95% CI 1.95-2.12) were highest for women aged 45-49 years, compared with women aged 20-34 years. The odds of adverse perinatal outcomes increased progressively with age, but the odds of inadequate prenatal care (aOR 0.77; 95% CI 0.76-0.77) were lowest for women aged 35-39 years, when compared with women aged 20-34 years. CONCLUSION: Women who deliver at 35 years and over are a heterogeneous group in Mexico. Being 35 years old and older is associated with increases in preterm birth and low birth weight neonates. Women who give birth between 45 and 49 years may be especially vulnerable.

Patterns in Contraceptive Use Among Women of Mexican Origin in the United States and in Mexico.

OBJECTIVE: To examine current contraceptive use by parity among four ethnicity and nativity groups: non-Latina White women in the United States, Mexican-American women in the United States, foreign-born women of Mexican origin in the United States, and Mexican women in Mexico. METHODS: We combined nationally representative data from sexually active women, aged 15-44 years, and not seeking pregnancy from the U.S. National Survey of Family Growth and the Mexican National Survey of Demographic Dynamics. This is a secondary binational analysis. Using multivariable logistic regression, we estimated the prevalence of moderately or most effective contraceptive method use (compared with least effective or no contraceptive method) by ethnicity and nativity and tested the interaction between ethnicity and nativity and parity. RESULTS: Compared with non-Latina White women, women of Mexican origin had lower odds of using a moderately or most effective contraceptive method (adjusted odds ratio [aOR] [95% CI] Mexican-American women: 0.69 [0.54-0.87]; foreign-born women: 0.67 [0.48-0.95]; Mexican women in Mexico: 0.59 [0.40-0.87]). Among parous women, the adjusted probability of using a moderately or most effective contraceptive method was approximately 65% among all four groups. Contraceptive method use did not differ by parity among non-Latina White women. However, parous Mexican-American women were 1.5 times more likely to use moderately or most effective contraceptive methods than nulliparous Mexican-American women (adjusted probability 66.1% vs 42.7%). Parous foreign-born women were 1.8 times more likely to use most or moderately effective contraceptive methods than their nulliparous counterparts (64.5% vs 36.0%), and parous Mexican women in Mexico were three times more likely to use moderately or most effective contraceptive methods (65.2% vs 21.5%). CONCLUSION: Findings suggest that access to effective contraception is limited outside the context of childbearing for women of Mexican origin in the United States and, to an even larger extent, in Mexico.

Predictors of maternal knowledge on early childhood development in highly marginalized communities in Mexico: Implications for public policy.

INTRODUCTION: Efforts to identify the predictors of maternal knowledge on Early Child Development (ECD) have proven inconclusive thus far, particularly with respect to socially deprived contexts in Low- and Middle-Income Countries (LMICs). We quantified the extent of ECD knowledge among mothers who were the primary caregivers of 0-38-month-old infants in marginalized communities in Mexico. We also explored the characteristics of the children, both individually and with regard to their households, given the influence of these factors on childhood development. METHODS: We analyzed primary data obtained through a questionnaire administered to mothers who were the primary caregivers of 1045 girls and boys 0-38 months of age. The instrument was specifically designed for our study in order to explore the knowledge of participants about physical, neurological and psycho-affective development during childhood. We performed fractional regression analysis to assess the predictors of ECD knowledge. RESULTS: The mean score of maternal ECD knowledge increased with their age and schooling as well as with their levels of cognitive ability and self-esteem. Irrespective of age at first birth, mean knowledge was relatively high for women with high school education and low for women with elementary or no formal education, a gradient with respect to age at fist birth was more marked among women with middle school education. ECD knowledge scores increased among mothers from households enjoying higher socioeconomic levels and from households with health insurance. Scores were lower for indigenous households regardless of their participation in social programs. CONCLUSION: Public policies on ECD should promote programs that are not only adapted to specific contexts, but also designed to improve shared child-rearing, early childhood care and as well as psycho-emotional education skills as a pathway to healthier ECD. The participation of families and communities in sensitive childhood care should form part of multisectoral programs involving education, health and wellbeing.

Adolescent Reproductive Health Outcomes Among Mexican-Origin Women on Both Sides of the U.S.-Mexico Border.

PURPOSE: Much reproductive health research on the Latina population overlooks heterogeneity by national origin, nativity, and age and also ignores how U.S.-based populations differ from those in "sending" nations. The purpose of this study is to describe a history of adolescent birth, age at first sex, and contraceptive use at first sex in the Mexican-origin population in both the United States and Mexico. METHODS: We developed a binational dataset merging two comparable nationally representative cross-sectional surveys in the United States and Mexico and used covariate balancing propensity scores to balance the age structure of our four samples: U.S.-born Latinas of Mexican origin, foreign-born Latinas of Mexican origin, U.S.-born non-Latina Whites, and Mexican women residing in Mexico. We used a negative binomial regression and calculated the predicted probability of experiencing at least one adolescent birth for each ethnicity/nativity group, stratified by 5-year age group. We also described age and contraceptive use at first sex. RESULTS: Foreign-born Latinas of Mexican origin and Mexicans in Mexico had similar adjusted probabilities of reporting an adolescent birth (30.1% and 29.9%, respectively), which were higher than those of Mexican-Americans (26.2%) and U.S.-born non-Latina Whites (11.6%). History of an adolescent birth is declining across all four groups among younger ages. Differences do not appear to be driven by the timing of first sex but by contraceptive use, which is increasing among younger age groups. DISCUSSION: Access to and use of effective contraception rather than timing of initiation of sexual activity is a key determinant of U.S. Latina and Mexican adolescent births.

Early neurological development and nutritional status in Mexican socially deprived contexts.

Early childhood development (ECD) is a critical stage in the intergenerational process of human development. Targeted interventions depend on accurate and up-to-date ECD measurements. This paper presents estimates for the nutritional and neurodevelopmental status of socially marginalized children in Mexico. We performed a cross-sectional study based on data collected in 2019-2020 during home visits to 1,176 children aged 0-38 months across 24 highly marginalized locations in Oaxaca. We assessed nutritional status according to the World Health Organization 2006 child-growth standards and ECD status using the Child Development Evaluation Test, 2nd Edition. We stratified results by sex. Prevalence of stunting was 5.3 percentage points (p.p.) higher (p = 0.023) in males (25.3%; 95% CI: 20.2%, 31.1%) compared to females (20.0%; 95% CI: 15.0%, 26.1%). Overall prevalence rates stood at 5.7% (95% CI: 4.0%, 8.1%) for underweight, 1.5% (95% CI: 0.9%, 2.7%) for wasting and 3.6% (95% CI: 2.3%, 5.7%) for overweight/obesity, with no significant differences by sex. Prevalence of normal development was 8.3 p.p. lower (p = 0.001) in males (39.3%; 95% CI: 34.5%, 44.4%) compared to females (47.6%; 95% CI: 41.6%, 53.6%). By development area, the highest prevalence of suboptimal outcomes among children with developmental lag or at risk of delay was observed in their gross motor and language skills: 24.1% (95% CI: 20.0%, 28.8%) and 38.6% (95% CI: 34.0%, 43.3%), respectively. The largest difference between the sexes was found in the language area. Our results show that childhood development strategies have been insufficient thus far in the studied population. Programs specifically designed to prevent ECD lags and bridge inequality gaps are urgently needed. Trial registration: ClinicalTrials.gov ID: NCT04210362.

Performance of the Mexican nursing labor market: a repeated cross-sectional study, 2005-2019.

BACKGROUND: The close link between human resources for health and the performance of health systems calls for a comprehensive study of the labor market. This paper proposes a performance metric for the nursing labor market, measures its magnitude and analyzes its predictors over the last 15 years. DESIGN AND METHODS: A repeated cross-sectional analysis using data from the quarterly population-based National Survey of Occupation and Employment 2005-2019 (ENOE in Spanish). An aggregate total of 19,311 Mexican nurses (population N = 4,816,930) was analyzed. Nursing labor market performance was defined as the level of non-precarious employment of nurses in the health sector. After describing the sociodemographic, labor and contextual characteristics of the nurses surveyed, we identified the key correlates of market performance using repeated cross-sectional multiple logistic regression analysis. We then estimated the adjusted prevalence of market performance according to the survey period and socioeconomic region of residence. RESULTS: The exogenous indicators analyzed shed light on various aspects of the market structure. Unemployment remained stable at 5% during the period examined, but underemployment rose by 26% and precarious employment, our endogenous indicator, also grew significantly. On the whole, our indicators revealed a notable deterioration in the structure of the nursing labor market; they varied by age and sex as well as between public and private institutions. Although the steepest deterioration occurred in the private sector, we observed an increase in precarious jobs among public institutions formerly protective of employment conditions. CONCLUSIONS: The deterioration of the labor market jeopardizes the ability of nursing professionals to participate in the market as well as to obtain secure jobs once they do enter. The Mexican Health System suffers from a chronic dearth of nurses, reducing its capacity to achieve its core objectives including enhanced coverage and increased effectiveness. Nursing workforce planning requires a context where the conditions in which the market currently operates, and its potential deterioration are considered.

Assessing the effect of an educational intervention on early childhood development among Mexican preschool children in the state of Oaxaca: a study protocol of a cluster randomized stepped-wedge trial.

BACKGROUND: Early childhood development (ECD) is essential in human capacity building and a critical element in the intergenerational process of human development. In some countries, social programs targeted at improving ECD have proven to be successful. Oaxaca is one of the States with the greatest social inequities in Mexico. Therefore, children in Oaxaca are at a high risk of suboptimal ECD. In 2014, the non-governmental organization (NGO) Un Kilo de Ayuda started to implement the Neurological and Psycho-affective Early Childhood Development Program in eighty marginalized communities of Oaxaca. In this article, we present the impact evaluation design to estimate the effect of this program on ECD. METHODS: We will use a cluster randomized stepped-wedge design with an allocation ratio of 1:1. Communities will be randomly assigned to each study group: four groups of twenty communities each. We expect that children from intervened communities will show better ECD outcomes. DISCUSSION: This study is one of the few rigorous assessments of the effect of an ECD program on the neurodevelopment of Mexican children recruited in their first 3 years of life from communities of high social vulnerability. Our study design is recommended when the way in which outcomes are measured and assessed depends on age, self-selection is present, and assignment is performed at an aggregate level. Implementation research will be conducted prior to study launch and quality control measures will be in place to maximize the fidelity of study design implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04210362.

Trends in subdermal contraceptive implant use in Mexico 2009-2018: A population-based study.

OBJECTIVE: To describe subdermal implant use in Mexico over time, by state and by age. METHODS: We conducted a repeated cross-sectional study using the 2009, 2014, and 2018 waves of the National Survey of Demographic Dynamics (Encuesta Nacional de la Dinámica Demográfica [ENADID]). Our outcome was current use of contraception, by type, with a focus on the implant. We used visualizations, descriptive and bivariate statistics, and multinomial models to assess change over time, geographic patterns, method mix, and factors associated with implant use (vs intrauterine device [IUD] or other hormonal methods). RESULTS: Implant use is increasing over time in Mexico, from 1.1% of women who have ever used a method in 2009 to 4.5% in 2018 (P < 0.001); the change is greatest among adolescents (2.5% in 2009 to 12.2% in 2018; P < 0.001). Change in implant use as a fraction of modern method use was heterogeneous across Mexican states. The adjusted relative likelihood of using an implant compared with IUD was 34% higher for adolescents compared with women aged 20-29 years (relative risk ratio 1.34, 95% confidence interval 1.16-1.55, P < 0.001), controlling for other variables in the model. CONCLUSION: Use of subdermal implants is increasing over time in Mexico and is concentrated among adolescents. Implants have the potential to expand access to highly effective contraception in Mexico.

Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients.

OBJECTIVE: To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings. METHODS: We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. RESULTS: Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). CONCLUSION: ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

Comparison of immediate postpartum contraception among women with a high versus low risk pregnancy in Mexico: a retrospective cohort study.

OBJECTIVE: We tested whether women who reported high-risk pregnancies or deliveries were more likely to receive immediate postpartum contraception prior to discharge compared with normal-risk women in Mexico. METHODS: This is a retrospective study using the National Health and Nutrition Survey. We classified women as high-risk based on reported complications in pregnancy and delivery. We used multivariable logistic regression to test the association of high-risk status and receipt of postpartum contraception (any modern method and Tier one methods) prior to discharge. RESULTS: Our sample included 5030 deliveries (population N=3 923 657). Overall, 19.1% of the sample were high risk. Over 60% of women in the high-risk and normal-risk group received immediate postpartum contraception, but a greater proportion of high-risk women received a method (67% vs 61% normal risk; p<0.001). However, in multivariable models, there were no significant differences in receipt of any modern method or tier 1 method by risk group. CONCLUSION: Women with high-risk pregnancies were not more likely to receive postpartum contraception than the normal-risk group, once accounting for sociodemographic and clinical factors. Prenatal and postpartum contraception counselling should address the health effects of high-risk pregnancies and interpregnancy intervals to improve maternal health outcomes.

Preventing first births among adolescents in Mexico City's public abortion programme.

INTRODUCTION: We examined parity and age among women seeking an abortion in Mexico City's public first-trimester abortion programme, Interrupcion Legal de Embarazo (ILE). We hypothesised that younger women, especially students, used abortion to prevent first births while older women used abortion to limit births. METHODS: We used clinical data from a sample of 47 462 women who had an abortion between 2007 and 2016 and classified them as nulliparous or parous according to previous births prior to the abortion. We used logistic regression to identify sociodemographic and clinical factors associated with using abortion to prevent a first birth (nulliparous) versus limiting births (parous) and calculated absolute multivariable predicted probabilities. RESULTS: Overall, 41% of abortions were in nulliparous women seeking to prevent a first birth, and 59% were in women who already had one or more children. The adjusted probability of using abortion to prevent a first birth was 80.4% (95% CI 78.3 to 82.4) for women aged 12-17 years and 54.3% (95% CI 51.6 to 57.0) for women aged 18-24 years. Adolescents (aged 12-17 years) who were employed or students had nearly 90% adjusted probability of using abortion to prevent a first birth (employed 87.8%, 95% CI 82.9 to 92.8; students 88.5%, 95% CI 82.9 to 94.1). At all ages, employed women and students had higher probabilities of using abortion to prevent a first birth compared with unemployed women and women who work in the home. CONCLUSION: Legal first-trimester abortion services in Mexico can help prevent first births in adolescents, especially students.

Group Prenatal Care in Mexico: perspectives and experiences of health personnel.

OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

Contraceptive Receipt Among First-Trimester Abortion Clients and Postpartum Women in Urban Mexico.

CONTEXT: In Mexico, first-trimester abortion is legal in Mexico City and is available in the public and private sectors. Understanding subsequent contraceptive uptake and method mix among first-trimester abortion clients relative to that of women who deliver a live birth at a health facility could help identify where improvements in care following an obstetric event can be made across the health system. METHODS: This article uses a retrospective cohort study to compare uptake of contraception prior to discharge between abortion clients in Mexico City's public abortion program and postpartum women from urban settings. The two data sources were clinical records of 45,233 abortion clients in Mexico City and information from a population-based survey of 1,289 urban women on their immediate postpartum contraceptive adoption. The primary outcome investigated was receipt of any reversible modern contraceptive method; secondary outcomes were level of method effectiveness and method type. Logistic regression and calculated multivariable probabilities were used to control for the effects of sociodemographic factors across the two data sources. RESULTS: The adjusted probability of uptake of any reversible modern method of contraception was higher among abortion clients than among postpartum women (67% vs. 48%). However, among all women who had received a contraceptive method, abortion clients had a lower adjusted probability of having received a long-acting reversible contraceptive than did postpartum women (49% vs. 82%) and a higher probability of having received a moderately effective method (38% vs. 13%). The adjusted probability of implant uptake was higher among abortion clients than among postpartum women (9% vs. 3%), while the adjusted probability of IUD uptake was lower (38% vs. 78%). CONCLUSIONS: Women receiving abortions in Mexico City's public abortion program were more likely than urban postpartum women to receive a reversible modern contraceptive method before leaving the facility. Women should be offered the full range of contraceptive methods after any obstetric event, to help them prevent unintended pregnancy and avoid short interpregnancy intervals.

RESUMEN Contexto: En México, el aborto de primer trimestre es legal en la Ciudad de México y está disponible en los sectores público y privado. Comprender la forma en que las clientas de aborto de primer trimestre adoptan el uso de anticonceptivos y la combinación de métodos subsiguientes en comparación a como lo hacen las mujeres que dan a luz a un nacido vivo en una institución de salud, podría ayudar a identificar dónde, en el sistema de salud, se pueden realizar mejoras en la atención después de un evento obstétrico. Métodos: Este artículo utiliza un estudio de cohorte retrospectivo para comparar la adopción de anticonceptivos por parte de clientas de servicios de aborto que participan en el Programa de Interrupción Legal del Embarazo en el sector público de la Ciudad de México y las mujeres posparto de entornos urbanos, previo a ser dadas de alta de la institución de salud. Las dos fuentes de datos fueron los registros clínicos de 45,233 clientas de servicios de aborto en la Ciudad de México y la información de una encuesta poblacional aplicada a 1,289 mujeres urbanas sobre su adopción inmediata de anticonceptivos posparto. El resultado primario investigado fue la recepción de cualquier método anticonceptivo moderno reversible; los resultados secundarios fueron el nivel de efectividad del método y el tipo de método. Se utilizó regresión logística y probabilidades multivariadas calculadas para controlar los efectos de los factores sociodemográficos en las dos fuentes de datos. Resultados: La probabilidad ajustada de la adopción de cualquier método anticonceptivo moderno reversible fue mayor entre las usuarias de aborto que entre las mujeres en período posparto (67% vs. 48%). Sin embargo, en el total de mujeres que habían recibido un método anticonceptivo, las clientas de servicios de aborto tuvieron una probabilidad ajustada menor de haber recibido un anticonceptivo reversible de acción prolongada que las mujeres posparto (49% frente a 82%) y una probabilidad más alta de haber recibido un método anticonceptivo moderadamente eficaz (38% vs. 13%). La probabilidad ajustada de adopción del implante fue mayor entre las usuarias de aborto que entre las mujeres en período posparto (9% vs. 3%), mientras que la probabilidad ajustada de adopción del DIU fue menor (38% vs. 78%). Conclusiones: Las mujeres que se recibieron servicios de aborto en el Programa de Interrupción Legal del Embarazo en el sector público de la Ciudad de México tuvieron más probabilidades que las mujeres urbanas en período posparto de recibir un método anticonceptivo moderno reversible antes de ser dadas de alta de la institución de salud. A las mujeres se les debe ofrecer la gama completa de métodos anticonceptivos después de cualquier evento obstétrico, para ayudarlas a prevenir embarazos no deseados y evitar intervalos cortos entre embarazos.

RÉSUMÉ Contexte: Au Mexique, l'avortement au premier trimestre de la grossesse est légal dans la ville de Mexico et peut être obtenu dans le secteur public et privé. Comprendre l'adoption ultérieure de la contraception par les patientes de l'avortement au premier trimestre et leur éventail de méthodes, par rapport aux femmes qui accouchent d'un enfant vivant en structure sanitaire pourrait aider à identifier les possibilités d'amélioration des soins après un événement obstétrical dans l'ensemble du système de santé. Méthodes: Sur la base d'une étude de cohorte rétrospective, cet article compare l'adoption de la contraception avant la sortie de la structure de soins, entre les patientes ayant subi un avortement dans le cadre du programme public d'avortement de Mexico et les femmes post-partum en milieu urbain. Les deux sources de données considérées sont les dossiers cliniques de 45 233 patientes de l'avortement à Mexico et l'information obtenue d'une enquête en population relative à 1 289 femmes urbaines concernant leur adoption immédiate de la contraception après l'accouchement. Le résultat principal examiné était l'obtention d'une méthode contraceptive moderne réversible quelconque; les résultats secondaires étaient le niveau d'efficacité de la méthode et le type de méthode. Pour les deux sources de données, les effets de facteurs sociodémographiques ont été contrôlés par régression logistique et probabilités multivariables calculées. Résultats: La probabilité corrigée d'adoption d'une méthode de contraception moderne réversible quelconque s'est avérée supérieure parmi les patientes de l'avortement (67% contre 48% chez les femmes post-partum). Cependant, sur la totalité des femmes ayant reçu une méthode contraceptive, les patientes de l'avortement présentaient une moindre probabilité corrigée d'avoir obtenu une méthode réversible à longue durée d'action (49% contre 82% des femmes post-partum) et une plus forte probabilité d'avoir obtenu une méthode modérément efficace (38% contre 13%). La probabilité corrigée d'adoption de l'implant s'est révélée supérieure parmi les clientes de l'avortement (9% contre 3% chez les femmes post-partum), tandis que la probabilité corrigée d'adoption du DIU était plus faible (38% contre 78%). Conclusions: Les femmes qui obtiennent un avortement dans le cadre du programme public d'avortement de Mexico étaient plus susceptibles que leurs homologues post-partum urbaines de recevoir une méthode contraceptive moderne réversible avant de quitter la structure. La gamme complète de méthodes contraceptives doit être proposée aux femmes après tout événement obstétrical, pour les aider à éviter les grossesses non planifiées et les intervalles de grossesse courts.

Evaluating process fidelity during the implementation of Group Antenatal Care in Mexico.

BACKGROUND: CenteringPregnancy (CP) is a group antenatal care (G-ANC) model that has proven beneficial for mothers and their newborns. We conducted a feasibility study beginning in 2016 as part of the Mexican effort to implement G-ANC locally. This study reports on fidelity to the essential elements of CP during its implementation in Mexico. METHODS: We collected prospective data using a standardized checklist at four primary-care centers that implemented our adapted G-ANC model. We performed a descriptive analysis of fidelity to 28 processes per G-ANC session (71 sessions made up of 10 groups and 129 women across 4 health centers). We calculated fidelity to each process as a proportion with 95% confidence intervals. We present overall results and stratified by health center and by facilitation team. RESULTS: Overall fidelity to the G-ANC intervention was 82%, with variability by health center (78-88%). The elements with the highest fidelity were having space for activities such as checking vital signs, conversation in a circle, and medical check-ups (100% each) and the element with the lowest fidelity was using music to enhance privacy (27.3%). Fidelity was not significantly different by center. CONCLUSIONS: Our study suggests good model fidelity during the implementation of G-ANC in Mexico. Our findings also contribute useful information about where to focus efforts in the future to maintain and improve G-ANC model fidelity.

Con la ley y sin la ley/With and without the law: Utilization of abortion services and case fatality in Mexico, 2000-2016.

OBJECTIVE: To describe utilization of health services for, and case fatality from, abortion in Mexico. METHOD: A historical cohort study using a census of state-level aggregate hospital discharge and primary care clinic data across Mexico's 32 states from January 2000 to December 2016. Abortive events and changes over time in utilization per 1000 women aged 15-44 years, and case fatality per 100 000 abortion-related events were described by year, health sector, and state. Associations of location (Mexico City vs 31 other states) and time (Mexico City implemented legal abortion services in 2007) with outcomes were tested by linear regression, controlling for secular trends. RESULTS: The national abortion utilization rate was 6.7 per 1000 women in 2000, peaked at 7.9 in 2011, and plateaued to 7.0 in 2016. In Mexico City, utilization peaked at 16.7 in 2014 and then plateaued. Nationwide, the case-fatality rate declined over time from 53.7 deaths per 100 000 events in 2000 to 33.0 in 2016. Case fatality declined more rapidly in Mexico City than in the other 31 states to 12.3 in 2015. CONCLUSION: Case fatality from abortive events has decreased across Mexico. Where abortion became legal, utilization increased sharply but plateaued afterward.

Group Prenatal Care in Mexico: perspectives and experiences of health personnel / Atención Prenatal en Grupo en México: perspectivas y experiencias del personal de salud

ABSTRACT OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

RESUMEN OBJETIVO Identificar barreras y facilitadores de la implementación del modelo de Atención Prenatal en Grupo en México (APG), desde la perspectiva del personal de salud. MÉTODOS Estudio cualitativo descriptivo en cuatro clínicas de la Secretaría de Salud en dos estados de México (Morelos e Hidalgo) de junio de 2016 a agosto de 2018. Se realizaron 11 entrevistas semi-estructuradas a prestadores de servicios de salud. Se exploraron sus percepciones y experiencias durante la implementación del modelo de APG. Se identificaron barreras y facilitadores para su adopción en dos dimensiones: a) estructurales (espacio, recursos, personal de salud, volumen de pacientes, comunidad) y b) actitudinales (motivación, liderazgo, aceptabilidad, abordaje de problemas, clima y comunicación). RESULTADOS Las barreras más relevantes reportadas en el nivel estructural fueron la disponibilidad de espacio físico en las unidades y la sobrecarga de trabajo del personal de salud. Se identificó la dificultad para adoptar una relación menos jerárquica durante la atención a las gestantes en el nivel actitudinal. El principal facilitador a nivel actitudinal fue la aceptabilidad que los prestadores tienen del modelo. Un hallazgo específico para el contexto de la implementación en México fue la resistencia al cambio en la relación médico-paciente; resulta difícil abandonar el modelo jerárquico prevaleciente y cambiar a una relación más horizontal con las gestantes. CONCLUSIONES El análisis de la implementación del modelo de APG en México, desde la perspectiva del personal de salud, ha evidenciado barreras y facilitadores similares a las experiencias en otros contextos. Esfuerzos futuros para la adopción del modelo deberán enfocarse en la atención oportuna de las barreras identificadas, sobre todo aquellas señaladas en la dimensión actitudinal que pueden ser modificadas a través de capacitaciones continuas al personal de salud.

Group prenatal care: effectiveness and challenges to implementation.

Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.