Research

Measuring the adequacy of antenatal health care: a

national cross-sectional study in Mexico
Ileana Heredia-Pi,a Edson Servan-Mori,a Blair G Darney,a Hortensia Reyes-Moralesb & Rafael Lozanoa

Objective To propose an antenatal care classification for measuring the continuum of health care based on the concept of
adequacy: timeliness of entry into antenatal care, number of antenatal care visits and key processes of care.

Methods In a cross-sectional, retrospective study we used data from the Mexican National Health and Nutrition Survey (ENSANUT) in
2012. This contained self-reported information about antenatal care use by 6494 women during their last pregnancy ending in live
birth. Antenatal care was considered to be adequate if a woman attended her first visit during the first trimester of pregnancy, made a
minimum of four antenatal care visits and underwent at least seven of the eight recommended procedures during visits. We used
multivariate ordinal logistic regression to identify correlates of adequate antenatal care and predicted coverage.
Findings Based on a population-weighted sample of 9052044, 98.4% of women received antenatal care during their last pregnancy,
but only 71.5% (95% confidence interval, CI: 69.7 to 73.2) received maternal health care classified as adequate. Significant
geographic differences in coverage of care were identified among states. The probability of receiving adequate antenatal care was
higher among women of higher socioeconomic status, with more years of schooling and with health insurance.
Conclusion While basic antenatal care coverage is high in Mexico, adequate care remains low. Efforts by health
systems, governments and researchers to measure and improve antenatal care should adopt a more rigorous
definition of care to include important elements of quality such as continuity and processes of care.
Efforts to develop indicators to with other variables across the
measure the adequacy of continuum of care,5 have been
antenatal care and the developed.13,22 Again,
continuum of care throughout however, none have as yet
the lifecycle5 have been achieved a fully
continuing for over four comprehensive ap-proach to
decades. Among the measurement of antenatal
Introduction care continuity and adequacy.
Some studies have even used
Optimizing maternal and infant health requires, but is not limited local indicators, thus limiting
to, the provision of available and accessible health care delivered international 1620

by skilled health personnel throughout the antenatal period. 1 comparisons, while

Besides offering the interventions recommended by the World these, an index to measure the others have over-looked the
Health Organization (WHO), it is essential to guarantee universal timeliness of the initial usefulness of measuring
coverage of services within a framework of continued care antenatal care intervention was conditional rather than
throughout pregnancy.28 proposed in 1973.15 However, independent probabilities: that
it over-looked content, thereby is, measuring the coverage of
ruling out the possibility of
Any assessment of maternal care needs to be performed
9 evaluating antenatal care an indicator conditional on the
within the framework of human rights. Strategies towards through process measures. coverage of another one.
ending preventable maternal mortality are aimed at the Impractical for as-sessing the
achievement of millennium development goals (up to 2015) clinical relevance of care, it
Based on our previous
and now sustainable development goals in the area of has been classified as an
research,12 and drawing on
maternal mortality. These goals seek to eliminate inequalities indicator of service use only.15
popu-lation- based data from
in access to health care and to ensure women receive Other authors have proposed the most recent health and
universal coverage of sexual and reproductive health services nutrition survey in Mexico, we
that are responsive to womens needs.10 combining several antenatal propose an antenatal 13,14,21,22

health-care indicators, but care classification that

Improving maternal and neonatal health outcomes in-volves the allows the continuum of
provision and uptake of antenatal services that are timely (first services to be measured
have as yet been unable to
visit during the first three months of pregnancy), sufficient (at accord-ing to four dimensions
offer a fully comprehensive
least four antenatal visits) and adequate (with ap-propriate of the health care process:
solution. In omitting
content). Rarely, however, have these conditions been studied access to care delivered by
components of the content of
together in the context of low- and skilled health personnel that is
care, such indices measure the
1214 timely, sufficient and with
middle-income countries.11 The use of services and not the
appropriate content. In
majority of studies including these processes of care that are a
particular, this study aimed to
indicators have measured coverage independently thus necessary condition for
describe the adequacy of
reporting high average levels but have failed to reflect the evaluating adequacy. Since
antenatal care for women in
individual dimen-sion of services provided (women who 200621 numerous studies have the context of the population
received comprehensive been published which include and geography of Mexico.
the procedures implemented Using our conditional
care and coverage in all indicators). during antenatal visits. classification we also aimed to
Complex indicators, identify the indi-
combining the content of visits
62100, Cuernavaca,
Morelos, Mexico.

Center for Health System Research, National

Institute of Public Health, Av. Universidad #655,

Ileana Heredia-Pi et al.
vidual factors associated with the type of
antenatal care received by women dur-
ing their most recent pregnancy, at both
the household and community levels.
Methods
Study design and data
source
We report a retrospective analysis of data
from the Mexican National Health and
Nutrition Survey done in 2012 (Spanish
acronym: ENSANUT). This was a cross-
sectional, population-based household
survey, based on a national population of
115170278, with sampling repre-
sentative at the state level (Mexico has
32 states) and by rural/urban stratum.
The survey was designed to estimate the
prevalence and proportions of health and
nutrition conditions, access to services,
health determinants, as well as coverage
of health-care services for spe-cific and
distinct groups of the Mexican
population. 23 Survey data (available to
the general public24) were collected in a
single interview after obtaining the
informed consent of each participant and
the approval of the ethics, research and
biosecurity committees of the National
Institute of Public Health in Mexico.
We used data from the surveys
reproductive health module, which had
been applied to a random subsample of
23056 women aged 1249 years. From
these, we selected women who had de-
livered their last live birth from 2006 on-
wards and who had been asked a series
of questions about their use of antenatal
care and obstetric services. We excluded
those who had provided incomplete
women who did
Research
Department,
Federico Gomez
Childrens Hospital,
Mexico City,
Mexico.
Correspondence to
Edson Servan-Mori
(email:
eservan@insp.mx).
(Submitted: 16
December 2015
Revised version
received: 17
February 2016
Accepted: 21
February 2016)
452 Bull World
Health Organ
2016;94:452461 | doi:
http://dx.doi.org/10.2471/B
LT.15.168302
information on the relevant variables. A
comparison of the sociodemographic and
health-related characteristics of
urine analysis; blood analysis; tetanus
vaccination; prescription of folic acid;
and prescription of vitamins iron or
dietary supplements. We excluded human
immunodeficiency virus test-ing (since
the official guidelines are that this test
should be applied only to high-risk
women25 and we were unable to ascertain
this information); ultra-sound
examination (because this is not
considered a required procedure by the
authorities in Mexico25 and because of
the inconsistencies in scientific evidence
regarding its importance); and glucose
and syphilis testing (because these tests
were grouped together in the survey item
and we could not distinguish be-tween
them). The previous literature has not
been able to identify a single cut -off to
classify antenatal care content as ad-
equate or not; studies have considered
cut-offs from 60% to 80% of the total of
procedures measured.14,21,22,26 28 We
clas-sified women in the highest quintile
of received procedures as having
received an adequate content of care
(appropri-ate in content). This
corresponded to seven out of eight of the
procedure items received. In line with
previous meth-ods,12 all interventions or
procedures provided during antenatal
care visits were weighted equally.
We divided the study sample into three
outcome categories: received ade-quate
antenatal care (delivered by skilled
health personnel, timely, sufficient and
with appropriate content); received in-
adequate antenatal care (services which
did not fully comply with these criteria);
or received no antenatal care from a
health facility.
and did not participate in the
Research
Antenatal care in Mexico
Covariates
We included individual and household-
level covariates. At the individual level
we recorded data on the womens
sociodemographic characteristics and
utilization of health- care services (an-
tenatal and obstetric care). These were:
womans age (1219, 2029 or 3049
years at the time of her last live birth),
education (0, 16, 79, 1012 or 13
years of schooling completed), previous
parity (0, 1 or 2 live births), history of
infant death (stillbirth or death within the
first year of life), history of miscar-riage
or induced abortion (we were un-able to
distinguish between spontaneous and
induced abortion), and year of the index
live birth (20062007, 20082009 or
20102012). Type of health insur-ance
was classified as: none, Social Security,
or Seguro Popular de Salud (an
employment-based health insurance for
people working in the informal sector or
without other access to insurance);
women with private health insurance
were excluded as they were a very small
percentage. In addition to our definition
of adequacy described above, we classi-
fied the type of health facility where the
majority of antenatal care was received
as: social security, ministry of health,
private or other (midwife or home). We
included six binary indicators (scored
yes/no) for diagnosis of a health problem
during pregnancy (high blood pressure,
vaginal bleeding, threat of miscarriage,
pre-eclampsia or eclampsia, gestational
diabetes or infections).
At the household level, we created
binary (yes/no) indicators for indig-
analytical sample yielded no sta-
tistically pregnancy); and and conditional coverage Appropriate
significant (iv) appropriate in analyses of the 84.7 (83.3 to 86.2)
differences. content (an coverage of the 71.5 (69.7 to 73.2)
indicator dimensions of
summarizing the antenatal care
The dependent
procedures and among
variables, i.e. the CI: confidence interval.
processes of care pregnant
four dimensions of
pro-vided during women in a
continuity and ad- Skilled a
Skilled (antenatal care provided by a nurse or a
antenatal care).
equacy of antenatal national 98.4 (98.1 to 98.8) physician); timely (initial antenatal care visit
care, were: (i) retrospective 98.4 (98.1 to during first trimester of pregnancy); sufficient (4
For the indicator antenatal care visits during pregnancy);
skilled health care study, Mexico, 98.8) appropriate (visits included at least 7/8 of
(antenatal care of appropriate 2012 recommended basic care procedures:
provided by a content we measurement of height, weight, and blood
Timely pressure, urine analysis, blood examination,
nurse or a selected eight of
Dimension of 83.2 (81.8 to 84.6) tetanus vaccine, and prescription of folic acid as
physician); (ii) the 12 procedure well as vitamin/iron/ food supplements.
83.2 (81.8 to
timely (ini-tial items used in the
% (95% CI) 84.6)
antenatal care visit survey: weight; Note: Sample n=6494; sample weighted to
during the first height; blood population n=9052044. Independent coverage was
trimester of Sufficient the percentage of the population receiving an
pressure; general antenatal carea intervention, measuring the coverage of each
pregnancy); (iii) 91.4 (90.3 to 92.5)
Independent 79.9 (78.4 to
indicator separately. Conditional coverage refers to
sufficient (at least full compliance with antenatal care indicators,
four antenatal care Table 1. coverage 81.4) measuring the coverage of each indicator conditional

visits during the Independent Conditional on the coverage of the previous one.

Bull World Organ 461| doi: http://dx.doi.org/10.2471/BL 453

Health 2016;94:452 T.15.168302
Research hold, based on community and state- dependent variables and measure

Antenatal care in Mexico Ileana Heredia-Pi et al.

enous status (a household in which the
head of the family, a spouse or an older
relative self-identifies as indigenous or
speaks an indigenous language29), and
whether the household was a ben-
eficiary from the Oportunidades social
programme (now called Prospera). We
included an asset and housing index as a
measure of socioeconomic status based
on assets and household infrastructure,
developed using polychoric correlation
matrices (range: 5.9 to 1.8),30,31 and
collapsed into terciles (low, middle or
high), whereby higher values denoted a
greater number of assets and better
housing conditions. We also included an
indicator for the location of the house-
2500 residents),
level indicators and urban (2500100
population: rural (< 000 residents) or
metropolitan (>
prob-
nosis of a health condition during
pregnancy, because this is a time-
dependent confounder that can be an
effect of adequate antenatal care as
well as a cause of more frequent
subsequent antenatal care.
For ease of interpretation we
calculated marginal effect prob-
abilities and the corresponding 95%
confidence intervals (CI). Marginal
effects are multivariables predicted for
each category of the outcome, holding
all other covariates at their median
levels. Marginal effects mea-sure
discrete change for binary in-
100000 Percentage of
women by
Fig. 1. state with
antenatal were then
the instantaneous rate of change for
continuous variables. These analyses
were implemented using the mfx com-
mand in Stata.
Results
We selected 7206 women and after
excluding 712 (9.8%) respondents with
incomplete data, the sample for analysis
was 6494 (90.1%) women (population-
weighted sample: 9052044). Of these
women, 4630 received adequate antena-
tal care, 1718 inadequate antenatal care
and 146 reported having no antenatal
care. Based on population-weighted
adequate antenatal care
in a national retrospective
study, Mexico, 2012
associated Ch os Hidalgo Quintana Roo Campeche
San Luis Potos

residents). The data abilities for care characterized by with the an- iap
were each indicators type of antenatal tenatal care as Baja California Sur
Finally, we
analysed dimension , care received services Tamaulipas Yucatn Sonora
included Baja California Coahuila
using the of antenatal measurin (adequate, in- used, we Pu Nayarit Tabasco Tlaxcala
the level of care. g the adequate or none). next used
marginaliza Stata ebl Nuevo Len Sinaloa
package Independent coverage We then estimated an ordinal a
tion (low or coverage of each adequate antenatal
high), version logistic Aguascalientes Chihuahua

13.2 was the per- indicator care coverage in Zacatecas Ciudad de Mxico
which is a regression Oaxa Quertaro Colima Durango
(StataCorp centage of condition the different states ca
Jalisco Guanajuato
community the ed on the of Mexico. Finally, model 33
LP,
-level index College population coverage we produced M
based on 95% CI
Station, receiving an of the population xic
lack of United intervention, previous estimates for all o
access to States of measuring one. The results by the
education, Amer-ica). the coverage socioeco individual
Gu
inadequate First, we of each nomic, sampling weights
err
housing and estimated indicator demogra and accounting for
er
perceived the separately. phic and the complex survey
o
insufficient consecutiv Conditional health design.
e coverage profiles
income.32 refers to full of the
Vera
cruz
independen To identify the Mich
t and compliance women key sociodemo- oac

Analysis conditional with surveyed

graphic factors
n
Morel
 women covered
85
90

%
30 of
CI:
confide
for the nce
categori interval
cal .
outcome
(none= Note:
0, Data
values
inadequ are
ate=1, shown
adequat for the
e=2). three
highest
All co- and six
variates lowest
previous states
ly (P<
0.001).
mention Adequa
ed were te
included antenat
in this al care
was
model, skilled
except (provide
diag- d by a
nurse or
a
physicia
n);
timely
(initial
visit
during
first
trimeste
r of
pregnan
cy);
sufficien
t (4
visits
during
pregnan
cy); and
appropri
ate
(visits
include
d at
least
7/8 of
recomm
ended
basic
care
procedu
res).
 Bull Hea Organ 2461|
454 World lth 2016;94:45
B 7
u
ll .
W 7
o 455 1
rl
d 2 t
H
e
Table 2. Individual and household characteristics of women by access to and adequacy of o
a antenatal care in a national retrospective study, Mexico, 2012 1
lt 9
h 5
O
Characteristic 2 9
r 2
g .
a . 7
n 6
2 )
0 % (95% CI) 5
1 (
6 1
; 1 .
9 5
4 0
: . (
4 0
5 4
2 7
t
4 .
6 o 5
1
| 3
d No antenatal care t
o 2 o
i: Inadequate antenatal care
.
h
tt Adequate antenatal carea 5 5
p Individual )
:/ 4
/ 2 .
d
x
5 6
. . )
d
o
3 5
i. ( 4
o
r
2 .
g 2 5
/ No. of years in school
1
. (
0 2 5
.
2 2
4 t .
7
1
o 3
/
B
L
2 t
T 0 8 o
.
1 22.3 (13.6 to 34.3) .
5 6.4 7 5
.
1 (5.0 to 8.1) ) 6
6 3.2 1 .
8
3 (2.4 to 4.4) 8 7
0 16 . )
2
34.3 (24.4 to 45.8) 0 3
25.1 ( 0
(22.1 to 28.3) 1
20.3 6 4
(18.5 to 22.3) . 9
79 4 2
31.5 (22.3 to 42.6) 8
41.6 t .
(38.0 to 45.3) o 8
36.8
(34.4 to 39.2) 1 (
1012 9 2
10.1 (3.8 to 24.2) . 0
20.2 9 .
(17.3 to 23.4) ) 6
26.4 2
(24.2 to 28.8) 0 t
13 o
1.7 (0.4 to 7.8) 2
6.7 (5.0 to 9.0) 9 3
13.2 4 8
(11.6 to 15.1) 8 .
Age at time of last delivery, years . 7
6 )
2
( 3
3
. ( .
6 0 3 5
( 35.1 (23.4 to 48.8) 1 (
2 35.5 . 4
0 (31.8 to 39.5) 9 2
. 31.3 .
9 (29.3 to 33.5) t 2
1 o
t 22.3 (14.9 to 32.1) t
o 27.3 3 o
(24.1 to 30.7) 6
2 33.9 . 4
6 (31.8 to 36.0) 6 6
. 2 ) .
7 42.6 (31.5 to 54.5) S 8
) 37.2 e )
2 (33.5 to 41.1) g N
7 34.8 u o
. (32.7 to 36.9) r n
4 Year of obstetric episode o e
( 3
2 p 0
5 o .
. p 2
6 u
l (
t a 2
o 20062007 r 1
23.6 (16.1 to 33.2) .
2 28.3 d 7
9 (25.0 to 31.8) e
. 26.8 t
4 (25.0 to 28.8) s o
) 20082009 a
N 41.8 (31.0 to 53.5) l 4
o 32.0 u 0
. (28.5 to 35.6) d .
o 38.6 5 3
f (36.3 to 41.0) 7 )
c 20102012 . 2
h 34.6 (25.4 to 45.1) 7 8
il 39.7 .
d (36.2 to 43.3) ( 2
r 34.6 4 (
e (32.3 to 36.8) 6 2
n Infant death (stillbirth or death within the . 4
13.8 (7.1 to 24.9) 4 .
a 3.6 (2.7 to 4.8) 6
t 3.9 (3.1 to 4.8) t
t first year of life) o t
h o
e 6
8 3
ti . 2
m 2 .
e ) 0
5 )
o At least one miscarriage or abortion 2 2
f 20.5 (12.9 to 31.0) . 1
l 13.1 0 .
a (10.9 to 15.6) ( 3
s 15.1 4 (
t (13.7 to 16.6) 8 1
d Health insurance . 9
e 0 .
li 0
v t
e o t
r o
y 5
Social security 5 2
12.1 (6.0 to 23.1) . 3
19.9 9 .
(16.9 to 23.2) ) 8
34.2 4 )
4 F
r 9.9 to 34.6) I
l
e Ministry of health e
q NA a
u 52.2 0 n
e (48.5 to 56.0) . a
n 42.7 0
H
t (40.1 to 45.4) 2 e
a Private 7 r
e
n NA d
t 23.5 i
e (20.2 to 27.1) a
n 22.8 -
P
a (20.7 to 25.1) i
t Other e
a NA t
a
l 3.2 (2.3 to 4.4) l
c 2.2 (1.7 to 2.9) .
a Health problem diagnosed during
r NA
e 55.2
(51.3 to 59.1)
p 60.4
r (58.0 to 62.7)
o pregnancyc
v
i
d
e
r

Pb

S
o
c
i
a <0.001
l
s
e
c
u
r
i
t
<0.001
y
N
A
2
1
.
1 0.001
(
1
8
.
2 <0.05

t
o <0.001

2
4 0.138
. R
2 <0.01 e
) s
3 e
2 a
. r
2 <0.001
(
c
2 h
A
n tenatal care in Mexico
(continues. . .)
Research showed that only 71.5% women (95%
CI: 69.7 to 73.2) with access to services
delivered by skilled health personnel
Antenatal care in Mexico
received adequate antenatal care
(population-weighted number: 6470401
women); 1.6% (95% CI: 1.2 to 2.0)
Characteristic received no antenatal care (population-
% (95% CI) Pb weighted number: 2439526) and 27.0%
(95% CI: 25.3 to 28.7) received
inadequate antenatal care (population-
No antenatal care Inadequate antenatal care weighted number: 142117).
Adequate antenatal carea
HouseholdIndigenous 43.8 (31.9 to 56.5) 12.1 (10.1 to 14.4) 7.9 (6.7 to 9.4) <0.001beneficiary41.4(30.1to53.6)26.8(23.7to30.1)20.9(19.2to22.7)<
0.001OportunidadesAssetandhousingindex(tercile)Low72.4(60.5to81.8)42.5(38.6to46.4)29.9(27.9to32.1)<0.001Middle17.8(11.5to26.7)33.4(29.6to37.4)32.8(30.7to35.0)High9.7(3.7to23.4)24.1(20.9to27.8)37.2(34.7to39.8)AreaofresidenceRural47.9(36.2to59.8)25.5(22.6to28.6)21.6(20.0to23.2)<
0.001Urban15.4(9.6to23.8)23.3(20.3to26.6)19.2(17.8to20.6)Metropolitan36.7(25.2to49.9)51.2(47.3to55.2)59.3(57.2to61.4)MarginalizationindexLow56.5(44.6to67.6)72.7(69.4to75.7)77.6(76.0to79.1)<0.001High43.5(32.4to55.4)27.3(24.3to30.6)22.4(20.9to24.0)

CI: confidence interval; NA: data not applicable.Adequate:antenatalcarethatwasskilled(provided by a nurse or a Fig. 1 shows the crude levels of adequate
physician); timely (initial visit during first trimester of pregnancy); sufficient (4 visits during pregnancy); and antenatal care coverage in the 32
appropriate (visits included at least 7/8 of recommended basic care a Mexican states. Three states had very
procedures).-valuesrefer to the test of equality or similar distributions across the three groups; values
low coverage levels: Chiapas (44.2%),
below 0.05 signify that distributions were statistically different with 95% confidence. Estimates included
the effect of the survey design.Pb Puebla (57.9%) and Oaxaca (60.8%).
Problems included high blood pressure, vaginal bleeding, threat of miscarriage, pre-eclampsia The coverage in these states was
or eclampsia, gestational diabetes or infections.c significantly lower (non-overlapping CI,
Notes: No antenatal care: sample =146; weighted sample =142117. Inadequate antenatal care: P<0.001) compared with the six states
sample =1718; weighted sample =2439526. Adequate antenatal care: sample =4630; with the highest coverage: Guanajuato
weighted sample =6470401.nnnnnn (81.6%), Jalisco (79.6%), Durango
(79.2%), Co-lima (78.7%), Quertaro
(78.3%) and Mexico City (77.7%).

When comparing across the three groups

(no antenatal care, inadequate care and
adequate care), we observed overall
socioeconomic disparities. Women who
received antenatal care had had more
years of schooling, were older and had
fewer children at the time of their last
delivery (P<0.001; Table 2). A smaller
percentage of women receiving antenatal
care had experienced previous stillbirths,
were from indigenous fami-lies and were
continued()... benefiting from the Opor-tunidades
social programme (P<0.001). Women
who received antenatal care lived
primarily in households with more assets
and better housing conditions, lo-cated in
less marginalized metropolitan areas (all
P<0.001) .

The results of the multivariate ordered

logit model confirmed the bivariate
analyses (Table 3). The co-variates
most highly correlated with receipt of
adequate antenatal care were mothers
education, health insur-ance,
Ileana Heredia-Pi et al.
indigenous status and household
wealth (all P <0.001). For women
numbers, the independent analysis of the probabilities of coverage with 13 years of education the
estimated that 98.4% of women received antenatal care by skilled health probability of having adequate
personnel, 83.2% received care that was timely, 91.4% care that was antenatal care was 28.2 percentage
sufficient and 84.7% received care with the appropriate number of -points (95% CI: 15.3 to 41.0) higher
antenatal care processes (Table 1). How-ever, the conditional analysis
compared with those
World Health Organ 2016;94:452461| doi: http://dx.doi.org/10.2471/BLT.15.168302
456 Bull

Research
1520

Antenatal care in Mexico

1114

Ileana Heredia-Pi et al.

Mexico, with both at the popula-tion or few years of
w indicators more level) reported schooling, low
i likely to be met for having no socioeconomic
women of higher antenatal care at status and no health
w
socioeco-nomic all during their insurance. They
o
status. Our results last pregnancy. also belonged to
O revealed that 1.6% Most of these indigenous
u of women (142117 women had none households and
 13 0.7) 12.5)
c 3.9 (6.6 to 2.7 (7.9 salud index Values are marginal effects
a 1.2) to 2.4) (tercile) expressed as percentage
24.2 (35.0 3.5 (3.0 to points. Estimates included the
D to 13.4) 10.0) effect of the survey design.
Models were also adjusted by
28.2 (15.3 to Health age at the time of last delivery
W 41.0) insurance Househol (years), children dead at
e No. of d childbirth or during the first
Low
o children at Ref
year, at least one miscarriage
u or abortion, Oportunidades
Ref beneficiary, the year of
a Ref obstetric episode, and
None Middle characteristics of place of
t
Ref Indigenous 1.1 (2.3 to residence (shown in Table 2).
P time of last Ref Covariates were not
r 0.03) statistically significant.
delivery Ref 4.3 (8.7 to Adequate: antenatal care that
o Social 0.1) was skilled (provided by a
f security 5.4 (0.1 to nurse or a physician); timely
a 2.7 (4.3 No 10.7) (initial visit during first
n to 1.1) Ref High trimester of pregnancy);
0 13.0 ( Ref sufficient (4 visits during
T 2.3 (3.9 to pregnancy); and appropriate
Ref 18.9 to Ref 0.8) (visits included at least 7/8 of
a
Ref 7.2) Yes 10.7 (16.5 recommended basic care
C Ref 15.7 (9.2 to 2.5 (0.1 to 4.9)to 4.9) procedures).
h 1 22.3) 5.8 (1.4 to 13.1 (6.5 to
M 1.5 (2.9 to Seguro 10.2) 19.7) Notes: Sample n=6494;
0.2) popular 8.3 (14.2 to weighted sample n=9052
a
6.1 (10.8 to de 2.4) 044. Post-estimation test
N 1.4) 1.4 (2.7 Asset and CI: showed that the regression
oI confidence model was correctly
7.6 (1.9 to to 0.1) housing interval; specified: _hat P<0.001,
nA 13.3) 5.5 (10.1 Ref: _hatsq P=0.63.
d 2 to 0.8) reference
0.8 (2.2 to 6.9 (1.3 to group.
B Health
u Organ
2016;94:
452
461| doi:
http://dx.
doi.org/1
0.2471/B
LT.15.16
8302
457

35,36
12,14,22
Ileana Heredia-Pi et al.
economic profile; and comparing our
estimates with population surveys that
are similar in timing and design. Our
analysis was an attempt to define an
effective antenatal care cover-age
indicator for Mexico by combining
effective access to the required health
services with other dimensions, spe-
cifically the timeliness, sufficiency and
appropriate content or procedures of
antenatal care. Future studies will need to
focus on generating more compre-
hensive indicators for measuring quality
of antenatal care, including patient and
provider-centred indicators,1,7 and align-
ing the information obtained from ad-
ministrative sources and clinical records
with population and patient surveys. Our
study has shown that important
challenges still prevent Mexican women
from receiving antenatal care services
that meet WHO recommendations for
equity in access and a continuum of
maternal care.7 To confront these chal-
lenges , the Mexican health sector needs
to strengthen its response capacity by not
only guaranteeing women access to
antenatal care, but also ensuring suf-
ficient antenatal care interventions and
a high quality in all aspects of care.
Acknowledgements Rafael Lozano is also affiliated
with the Institute for Health Metrics and Evalua-tion,
Seattle, Washington, United States
of America.
) ENSANUT(
) 73.2( 69.7 95%:
:
2012
.
: .
.
9,052,044
%98.4
.
Competing interests: None declared.
reported by the women. Nevertheless,
our analysis did not allow us to evaluate
the additional quality dimensions of
services proposed by other theoretical
frameworks, such as technical quality,
interpersonal quality and amenities37 or
efficacy, effectiveness, acceptability, ef-
ficiency, environment and empathy.3840
This highlights the need to follow-up
patients to incorporate some of these
features into future health surveys and
patient administrative registries and to
incorporate quality dimensions in
future studies. Another limitation is
that the data
analysis may have been affected by
recall bias regarding the processes of
care, because women may have been
unable to remember the functions or
names of all the processes received and
therefore underreported or reported their
experiences inadequately. There may
also be an effect due to inaccurate
weighting of the processes of care: with
no literature available on prioritizing the
care processes, we chose to weight
them all equally. To validate the
proposed metric, future studies in
Mexico can consider dif-ferent
approaches. These might include:
consulting maternal health-care experts
(for example, using Delphi methods41)
about proposed quality measures and
their assessment ; a rigorous review of
hospital, clinic or other types of
administrative records; benchmarking
our results against those of countries
with a similar demographic, social and
%71.5
. 6494
.
Research Antenatal care in Mexico
care access among certain population
groups: those who are the most vulner-
able. Our findings are consistent with
those of other studies which indicated
coverage gaps among specific popula-
tions and demonstrated that pregnant
women younger than 25 years, who had
fewer years of schooling, resided in rural
areas and belonged to households and
communities with low socioeconomic
status, were at greater risk of receiving
inadequate antenatal care. Simi-
larly, our results are congruent with a
study from Zambia showing gaps in the
continuity and adequacy of care received
by pregnant women, with a very low
percentage of these women receiving
adequate antenatal care.26 There are
several limitations to our
proposed comprehensive indicator of
quality of antenatal care. Clearly, the
prerequisites for providing women with
quality services are that antenatal care is
available and is accessible. However,
supplies and medical teams must also be
available at health facilities, together
with adequate information systems to
ensure a continuum of information on the
womens past events, general back-
ground and relevant characteristics.34
The present study was unable to evaluate
structural elements of health care quality
proposed by the Donabedian conceptual
framework: structure, processes and
outcomes.
We took into account some fea - tures
related to the supply of antenatal care
services, although these were self-

.



.
.

458 Bull World Health Organ 2016;94:452461| doi: http://dx.doi.org/10.2471/BLT.15.168302

Research

Ileana Heredia-Pi et al.

Antenatal care in Mexico

9 052 044
98.4%

71.5% 95%

2012 (ENSANUT)
6494

Rsum

Mesurer le caractre adquat des soins prnataux: une tude transversale nationale au
Mexique
celles ayant eu une scolarit plus
longue et celles disposant dune
Objectif Proposer une classification des soins prnataux Rsultats Sur un chantillon assurance maladie.
afin de mesurer la continuit des soins et leur caractre pondr en fonction de la
Conclusion Au Mexique, si la
population de 9 052 044 femmes,
adquat: date de dbut des soins prnataux, nombre de 98,4% avaient reu des soins
couverture en matire de soins
consultations prnatales et principaux processus de soins. prnataux lors de leur dernire prnataux de base est leve,
grossesse, mais seulement les soins adquats restent
limits. Les systmes de sant,
Mthodes Lors de notre tude rtrospective transversale, nous avons utilis 71,5% (intervalle de confiance de
les gouvernements et les
les donnes de lenqute nationale sur la sant et la nutrition (ENSANUT) 95%: 69,7 73,2) avaient reu
ralise au Mexique en 2012. Celle-ci contenait des informations sur le des soins jugs adquats. chercheurs, dans leurs efforts
recours aux soins prnataux dclar par 6494 femmes lors de leur dernire Dimportantes diffrences pour mesurer et amliorer les
grossesse ayant abouti une naissance vivante. Les soins prnataux ont gographiques ont t observes soins prnataux, devraient
t considrs adquats lorsquune femme avait eu sa premire entre les tats au niveau de la adopter une dfinition plus
consultation au cours du premier trimestre de grossesse, stait rendue au couverture de soins. La rigoureuse de ce type de soins
minimum quatre consultations prnatales et avait bnfici dau moins probabilit de bnficier de soins afin dy inclure dimportants
sept des huit procdures recommandes lors des consultations. Nous avons prnataux adquats tait plus
aspects qualitatifs comme la
utilis une rgression logistique ordinale multivarie pour identifier les forte pour les femmes au statut
corrlations entre soins prnataux adquats et prvisions de la couverture socioconomique plus lev, continuit et les processus de
de soins. soins.
:


:
69,773,2)

9 052 044

, ,

, ,


. .
,

. 98,4%
.


,
(ENSANUT )

2012 .
, -
,
,

71,5% (95%- .
. 6494
.
Bull World Organ 2461| doi: http://dx.do 71/BLT.15. 459
Health 2016;94:45 i.org/10.24 168302
Research
Ileana Heredia-Pi et al.
Antenatal care in Mexico
,


- , ,
. ,
,
, - . .
,
atencin sanitaria prenatal: un estudio transversal
nacional en Mxico
Resumen Medicin de la idoneidad de la
retrospectivo se visita durante el primer trimestre de adecuada. Se alta en Mxico, su
utilizaron datos de la embarazo, haca al menos cuatro visitas identificaron idoneidad sigue siendo
Objetivo Proponer Encuesta Nacional de de atencin prenatal y reciba al menos importantes diferencias escasa. Los esfuerzos
una clasificacin de Salud y Nutricin siete de los ocho procedimientos geogrficas en la realizados por
atencin prenatal (ENSANUT) realizada recomendados durante las visitas. Se cobertura de la sistemas sanitarios,
para medir la en Mxico en 2012, utiliz una regresin logstica ordinal atencin sanitaria entre gobiernos e
continuidad de la que contena multivariable para identificar las los estados. La investigadores para
atencin sanitaria informacin correlaciones de la atencin prenatal probabilidad de recibir medir y mejorar la
segn su idoneidad: autodeclarada acerca adecuada y la cobertura prevista. una atencin prenatal atencin prenatal
momento en que se del uso de atencin adecuada era mayor deberan adoptar una
empieza a recibir prenatal de 6 494 entre mujeres con una definicin ms rigurosa
mujeres durante su Resultados Segn una muestra mejor situacin de la misma para
atencin prenatal, ponderada de la poblacin de 9 052 044 socioeconmica, ms
nmero de visitas de ltimo embarazo con incluir elementos
nacidos vivos. Se personas, el 98,4% de las mujeres aos de escolarizacin importantes de calidad,
atencin prenatal y recibieron atencin prenatal durante su y seguro mdico.
procesos bsicos de consider que la como la continuidad y
atencin prenatal era ltimo embarazo, pero nicamente el Conclusin Aunque la los procesos de
atencin. 71,5% (intervalo de confianza del 95%: cobertura bsica de
adecuada si una mujer atencin.
Mtodos En un 69,7 a 73,2) recibieron atencin
realizaba su primera atencin prenatal es
estudio transversal y sanitaria prenatal clasificada como
improve the quality of maternal org/10.1186/1742- Villar J, Baaqeel H, Care Trial Research routine antenatal
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