Indications for Cesarean Delivery in Mexico: Evaluation of Appropriate Use and Justification

The road to recovery: an interrupted time series analysis of policy intervention to restore essential health services in Mexico during the COVID-19 pandemic

Background

Recovery of health services disrupted by the COVID-19 pandemic represents a significant challenge in low- and middle-income countries. In April 2021, the Mexican Institute of Social Security (IMSS), which provides health care to 68.5 million people, launched the National Strategy for Health Services Recovery (Recovery policy). The study objective was to evaluate whether the Recovery policy addressed COVID-related declines in maternal, child health, and non-communicable diseases (NCDs) services.

Methods

We analysed the data of 35 IMSS delegations from January 2019 to November 2021 on contraceptive visits, antenatal care consultations, deliveries, caesarean sections, sick children’s consultations, child vaccination, breast and cervical cancer screening, diabetes and hypertension consultations, and control. We focused on the period before (April 2020 – March 2021) and during (April 2021 – November 2021) the Recovery policy and used an interrupted time series design and Poisson Generalized Estimating Equation models to estimate the association of this policy with service use and outcomes and change in their trends.

Results

Despite the third wave of the pandemic in 2021, service utilization increased in the Recovery period, reaching (at minimum) 49% of pre-pandemic levels for sick children’s consultations and (at maximum) 106% of pre-pandemic levels for breast cancer screenings. Evidence for the Recovery policy role was mixed: the policy was associated with increased facility deliveries (IRR = 1.15, 95%CI = 1.11-1.19) with a growing trend over time (IRR = 1.04, 95%CI = 1.03-1.05); antenatal care and child health services saw strong level effects but decrease over time. Additionally, the Recovery policy was associated with diabetes and hypertension control. Services recovery varied across delegations.

Conclusions

Health service utilization and NCDs control demonstrated important gains in 2021, but evidence suggests the policy had inconsistent effects across services and decreasing impact over time. Further efforts to strengthen essential health services and ensure consistent recovery across delegations are warranted.

Trends of caesarean delivery from 2008 to 2017, Mexico

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487–2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068–1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936–991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.

Use of the partogram in a private hospital in South Africa

OBJECTIVE

to explore and describe the use of the partogram in private hospitals in South Africa.

DESIGN

an explanatory mixed method design. In-depth interviews were conducted with the midwives and midwife specialists to explicate the significance of the initial quantitative questionnaires.

SETTING

a private maternity hospital in Gauteng Province, South Africa.

PARTICIPANTS

11 midwives and 3 advanced midwives working in the labour unit of the private maternity hospital.

FINDINGS

although all the midwives and midwife specialists knew the purpose of the partogram, where to find the recommendations on the use of the partogram and the signs of true labour, not all were sure when the partogram had to be completed and who is accountable for plotting the findings. Fetal heart rate monitoring during the active phase of labour remains a concern.

KEY CONCLUSION

the findings revealed that the midwives understood the importance of the partogram but are not using it within the parameters for which it was intended. The obstetricians intervened during labour with no or little use of the partogram.

IMPLICATIONS FOR PRACTICE

the study identified the knowledge strengths and deficits of midwives working in a private hospital on partogram use that would benefit from training interventions and professional development. Evidence suggests a culture where the partogram is not central to care as obstetricians are not using the partogram. The purpose of the partogram in the private sector needs to be reviewed.

Prevalence, Disparities, And Determinants Of Primary Cesarean Births Among First-Time Mothers In Mexico

Mexico has the second-highest prevalence of cesarean deliveries in the Americas, behind Brazil. Having had a previous cesarean delivery is highly predictive of having subsequent cesarean deliveries, yet evidence on the drivers of primary (that is, first-time) cesarean deliveries is sparse. Using 2014 Mexican birth certificate data and performing population-level analyses of data on 600,124 first-time mothers giving birth after at least thirty-seven weeks of gestation, we examined the prevalence and determinants of primary cesarean deliveries. We found a very high prevalence of cesarean deliveries among these women-48.7 percent-and wide variations across insurance coverage types. Enrollees in Seguro Popular, the public health insurance program introduced in 2003 for the previously uninsured and gradually rolled out nationally, had a cesarean rate of 40 percent, while women insured through the Social Security Institute for Civil Servants had a rate of 78 percent. The lower risk of primary cesarean deliveries among Seguro Popular enrollees persisted after adjustment for covariates. Rates of primary cesarean deliveries were particularly high in private birthing facilities for all first-time mothers. Reducing the rate of cesarean deliveries in Mexico will require interventions across types of insurance and birthing facilities and will also require targeted public health messaging.