Respectful and evidence-based birth care in Mexico (or lack thereof): An observational study

Prevalence of different variations of non-consented care during the childbirth process in Mexico by geographical regions: comparing ENDIREH survey data from 2016 to 2021

INTRODUCTION

Non-consented care, a form of obstetric violence involving the lack of informed consent for procedures, is a common but little-understood phenomenon in the global public health arena. The aim of this secondary analysis was to measure the prevalence and assess change over time of non-consented care during childbirth in Mexico in 2016 and 2021, as well as to examine the association of sociodemographic, pregnancy-, and childbirth-factors with this type of violence.

METHODS

We measured the prevalence of non-consented care and three of its variations, forced sterilization or contraception, forced cesarean section, and forced consent on paperwork, during childbirth in Mexico for 2016 (N = 24,036) and 2021 (N = 19,322) using data from Mexico's cross-sectional National Survey on the Dynamics of Household Relationships (ENDIREH). Weighted data were stratified by geographical regions. We performed adjusted logistic regression analyses to explore associations.

RESULTS

The national prevalence of non-consented care and one of its variations, pressure to get a contraceptive method, increased from 2016 to 2021. A decrease in the prevalence was observed for forced contraception or sterilization without knowledge, forcing women to sign paperwork, and non-consented cesarean sections nationally and in most regions. Women between the ages of 26 and 35 years, married, cohabiting with partner, living in urban settings, who do not identify as Indigenous, and who received prenatal services or gave birth at the Mexican Institute of Social Security (IMSS) facilities experienced a higher prevalence of non-consented care. Being 26 years of age and older, living in a rural setting, experiencing stillbirths in the last five years, having a vaginal delivery, receiving prenatal services at IMSS, or delivering at a private facility were significantly associated with higher odds of reporting non-consented care.

CONCLUSION

While a decrease in most of the variations of non-consented care was found, the overall prevalence of non-consented care and, in one of its variations, pressure to get contraceptives, increased at a national and regional level. Our findings suggest the need to enforce current laws and strengthen health systems, paying special attention to the geographical regions and populations that have experienced higher reported cases of this structural problem.

Exploring how non-clinical factors in childbirth care shape users' experiences in public health facilities in rural Chiapas, Mexico: a qualitative study using the WHO health systems responsiveness framework

INTRODUCTION

Many Mexicans face barriers to receive delivery care from qualified professionals, especially indigenous and poor sectors of the population, which represent most of the population in the state of Chiapas. When access to institutional delivery care is an option, experiences with childbirth care are often poor. This underscores the need for evidence to improve the quality of services from the user's perspective. The present study was conceived with the objective of understanding how non-clinical aspects of care shape women's birthing experiences in public health institutions in Chiapas.

METHODS

We conducted an exploratory qualitative study. Data collection consisted in 20 semi-structured interviews to women who had delivered in a public health facility in Chiapas during the last six months prior to the interview. For the design of the interview guide we used the WHO health system responsiveness framework, which focus on the performance of the health system in terms of the extent to which it delivers services according to the "universally legitimate expectations of individuals" and focuses on the non-financial and non-clinical qualities of care. The resulting data were analyzed using thematic analysis methodology.

RESULTS

We identified a total of 16 themes from the data, framed in eight categories which followed the eight domains of the WHO health systems responsiveness framework: Choice of the provider and the facility, prompt attention, quality of basic amenities, access to social support, respectful treatment, privacy, involvement in decisions, and communication. We shed light on the barriers women face in receiving prompt care, aspects of health facilities that impact women's comfort, the relevance of being provided with adequate food and drink during institutional delivery, how accompaniment contributes positively to the birthing experience, the aspects of childbirth that women find important to decide on, and how providers' interpersonal behaviors affect the birthing experience.

CONCLUSIONS

We have identified non-clinical aspects of childbirth care that are important to the user experience and that are not being satisfactorily addressed by public health institutions in Chiapas. This evidence constitutes a necessary first step towards the design of strategies to improve the responsiveness of the Chiapas health system in childbirth care.

The Turkish version of the students' perceptions of respectful maternity care scale: An assessment of psychometric properties

AIM

The aim of the research was to evaluate the psychometric properties of the Turkish validity and reliability of the Students' Perceptions of Respectful Maternity Care (SP-RMC) scale.

BACKGROUND

Respectful maternity care is an important contributor to intrapartum care quality and maternal birth satisfaction. Determining students' perceptions of respectful maternity care can identify knowledge gaps and inform their future practice.

DESIGN

A descriptive, methodological and cross-sectional design was used.

METHODS

This study was conducted with 226 undergraduate nursing and midwifery students in the western region of Turkey. Data were collected between May and December 2022 from students who completed their birth courses (theory and clinical practicum). Data included sociodemographic details and the Students' Perceptions of Respectful Maternity Care scale (Turkish version). Factor analysis, Cronbach's alpha and item-total score analyses were conducted.

RESULTS

The mean age of the students was 21.88 (SD 1.39). The average number of births observed was 2.57 (SD 3.16). The scale comprised 18 items including three subdimensions. In both exploratory and confirmatory factor tests, the overall factor loading was greater than 0.30, and the total explained variance was 64.89%. The Cronbach's alpha coefficient of the scale was 0.91, with Cronbach's alpha values ranging between 0.80 and 0.91 for the subscales. Pearson correlation coefficients of all the items ranged between 0.42 and 0.78.

CONCLUSIONS

The SP-RMC (Turkish version) is a valid and reliable measure, with 18 items and three dimensions. In this regard, measuring and reporting respectful maternity care perceptions and intrapartum care experiences of students, who are future members of the profession, could contribute to the improvement of the quality of care and the development of educational interventions for behavioral changes.

AMBAR: A midwifery-led training program to improve obstetric and neonatal practices among low-risk births in Mexico

BACKGROUND

Birth care in Mexican health institutions is highly medicalized and of poor quality because of the prevalence of outdated and dangerous practices. AMBAR-a training program for health care providers on the use of evidence-based midwifery practices-was implemented during 2016-2018 and evaluated to assess the impact of training on key practices.

METHODS

For this mixed-methods study, we evaluated the effects of a training program implemented in three public hospital networks in Mexico. Qualitative data were collected and integrated into the program before evaluating the effects of the intervention on 10 birth practices, 5 beneficial and 5 potentially harmful. Quantitative data on birth practices and covariates were collected at six time points (baseline and 5 follow-ups) in a final sample of 330 direct observations. Effect estimates were obtained by longitudinal logistic and Poisson regression models, adjusted for confounding variables.

RESULTS

AMBAR had a significant effect on 4 of the 10 birth practices that were evaluated. Beneficial practices, such as skin-to-skin contact (P = 0.003) and delayed cord clamping (P = 0.039), increased significantly. Harmful when overused birth practices, such as vaginal examinations (P = 0.001), and cesarean birth (P < 0.001) decreased significantly.

CONCLUSIONS

Midwifery-based training programs for health care providers can have an impact on the quality of care of birthing people and newborns, increasing the use of evidence-based practices and decreasing frequently overused practices.

Burden, Incidence, Mortality and Lethality of Maternal Disorders in Mexico 1990-2019: An Analysis for the Global Burden of Disease Study 2019

BACKGROUND

Estimates of the sub-national distribution of maternal disorders in Mexico beyond Maternal Mortality Ratios are scarce. Characterizing the sub-national variation of maternal disorders may make it possible to focus more on interventions and thereby reduce their occurrence in a more meaningful and sustained manner.

AIM

To analyze and describe the sub-national distribution, magnitude, trends and changes in the contribution of maternal causes to women's loss of health in Mexico from 1990-2019.

METHODS

Using estimates from the Global Burden of Disease (GBD) 2019 study, we describe the distribution and trends of maternal mortality ratio (MMR), mortality rate, case-fatality rate and disability-adjusted life years (DALYs) due to maternal causes, at both national and state levels.

RESULTS

Between 1990 and 2019, DALYs attributable to maternal causes had decreased 59.5%, mortality 63.8%, and incidence 46.5%. However, Maternal Mortality Ratio only decreased by 33%. The case-fatality rate of maternal disorders decreased by 50% overall; although for obstructed labor and uterine rupture, it remained unchanged. Lethality showed great variation between states, with a 3 fold difference between the maximum and minimum values.

CONCLUSIONS

Although mortality and incidence of maternal causes in Mexico have greatly decreased in the last 30 years, these changes mostly reflect declines in fertility. The decrease seen in case-fatality rates is driven by decreases in causes such as hypertension and hemorrhage, though for others it remained constant. Efforts should be directed at improving access to, and management of, locally frequent maternal emergencies, formulating tailor-made regional interventions for maternal health.

Trends in facility-based childbirth and barriers to care at a birth center and community hospital in rural Chiapas, Mexico: A mixed-methods study

OBJECTIVE

To assess trends in childbirth at a hospital-birth center among women living in Compañeros En Salud (CES)-affiliated communities in Chiapas, Mexico and explore barriers to childbirth care. Our hypothesis was that despite interventions to support and incentivize childbirth at the hospital-birth center, the proportion of births at the hospital-birth center among women from Compañeros En Salud-affiliated communities has not significantly changed after two years. We suspected that this may be due to structural factors impacting access to care and/or perceptions of care impacting desire to deliver at the birth center.

DESIGN

This explanatory mixed-methods study included a retrospective Compañeros En Salud maternal health census review followed by quantitative surveys and semi-structured qualitative interviews.

PARTICIPANTS AND SETTING

Participants were women living in municipalities in the mountainous Sierra Madre region of Chiapas, Mexico who received prenatal care in one of 10 community clinics served by Compañeros En Salud. Participants were recruited if they gave birth anywhere other than the primary-level rural hospital and adjacent birth center supported by Compañeros En Salud, either at home or at other facilities.

MEASUREMENTS

We compared rates of birth at the hospital-birth center, other health facilities, and at home from 2017-2018. We conducted surveys and interviews with women who gave birth between January 2017-July 2018 at home or at facilities other than the hospital-birth center to understand perceptions of care and decision-making surrounding childbirth location.

FINDINGS

We found no significant difference in rates of overall number of women birthing at the hospital-birth center from Compañeros En Salud-affiliated communities between 2017 and 2018 (p=0.36). Analysis of 158 surveys revealed distance (30.4%), time (27.8%), and costs (25.9%) as reasons for not birthing at the hospital-birth center. From 27 interviews, negative perceptions and experiences of the hospital included low-quality and disrespectful care, low threshold for medical interventions, and harm and suffering. Partners or family members influenced most decisions about childbirth location.

KEY CONCLUSIONS

Interventions to minimize logistical barriers may not be sufficient to overcome distance and perceptions of low-quality, disrespectful care.

IMPLICATIONS FOR PRACTICE

Better understanding of complex decision-making around childbirth will guide Compañeros En Salud in developing interventions to further meet the needs and preferences of birthing women in rural Chiapas.

Effectiveness of an online education intervention to enhance student perceptions of Respectful Maternity Care: A quasi-experimental study

BACKGROUND

Childbearing women's relationship with maternity care providers enhance childbirth outcomes. Students need to understand and offer respectful care.

OBJECTIVE

Evaluate effectiveness and impact of an online education intervention on nursing students' perceptions towards respectful maternity care during labour and childbirth in Nepal.

DESIGN

A quasi-experimental pre-post design was used.

PARTICIPANTS

A total of 89 Third Year Bachelor of Nursing students (intervention n = 40; control n = 49) from three participating colleges.

METHODS

Students completed online pre and post-test surveys using the Students' Perceptions of Respectful Maternity Care scale and questions about impact of the intervention. The intervention group received six hours of education delivered online (three sessions x three weeks). ANCOVA and non-parametric Wilcoxon signed-rank tests measured effects.

RESULTS

Compared to controls, students in the intervention group reported a significant increase in perceptions towards respectful maternity care (F (1, 86) = 28.19, p < 0.001, η_p² = 0.25). Participants reported a good understanding of respectful maternity care (75%), positive views about providing such care (82.5%), and a desire to use their new knowledge in practice (65%).

CONCLUSION

Relatively few intervention studies to promote respectful maternity care in students have been published. This brief online intervention improved students' perceptions. The intervention package can be integrated into nursing or midwifery curricula and in-service training. A larger study with longer follow-up is needed to support current findings.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.