Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey

Lozano R (2014) Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey. PLoS ONE 9(8): e104166. doi:10.1371/journal.pone.0104166 Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey Ileana Heredia-Pi 0 Edson E. Servan-Mori 0 Veronika J. Wirtz 0 Leticia Avila-Burgos 0 Rafael Lozano 0 Josef Neu, University of Florida, United States of America 0 1 National Institute of Public Health , Cuernavaca, Morelos , Mexico , 2 Center for Global Health and Development, Boston University , Boston , Massachusetts, United States of America, 3 Institute for Health Metrics and Evaluation , Seattle, Washington , United States of America Objective: To identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico. Materials and Methods: This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) of 6,736 women aged 12 to 49 years. Delivery types discussed in this paper include vaginal delivery, emergency cesarean section and planned cesarean section. Using bivariate analyses, sub-population group differences were identified. Logistic regression models were applied, including both binary and multinomial outcome variables from the survey. The logistic regression results identify those covariates associated with the type of delivery. Results: 53.1% of institutional births in the period 2006 through 2012 were vaginal deliveries, 46.9% were either a planned or emergency cesarean sections. The highest rates of this procedure were among women who reported a complication during delivery (OR: 4.21; 95%CI: 3.66-4.84), between the ages of 35 and 49 at the time of their last child birth (OR: 2.54; 95%CI: 2.02-3.20) and women receiving care through private healthcare providers during delivery (OR: 2.36; 95%CI: 1.843.03). Conclusions: The existence of different socio-demographic and obstetric profiles among women who receive care for vaginal or cesarean delivery, are supported by the findings of the present study. The frequency of vaginal delivery is higher in indigenous women, when the care provider is public and, in women with two or more children at time of the most recent child birth. Planned cesarean deliveries are positively associated with years of schooling, a higher socioeconomic level, and higher age. The occurrence of emergency cesarean sections is elevated in women with a diagnosis of a health issue during pregnancy or delivery, and it is reduced in highly marginalized settings. - There are many factors that contribute to the decision to deliver either vaginally or through a cesarean section in a health facility. According to the conceptual framework proposed by Freitas [1], these levels include the individual socio-demographic and cultural characteristics of the woman, her obstetric and prenatal care history, her preferences, as well as the circumstances at the time of admission to a facility and throughout the delivery process. Factors within the facility are staff member training and general facility characteristics [1,2]. In recent decades, the number of deliveries within health care facilities in Mexico has increased, from 78.7% in 1990 to 94.1% and 95.1% in 2010 and 2012, respectively [3,4]. During the same time period, the percentage of pregnancies ending in a cesarean section delivery has risen markedly [5]. This trend is present in both private and public health facilities across the country. Mexico has one of the highest cesarean delivery rates internationally [68]. According to the OECD, in 2011 Mexico was the member country with the highest rate of cesarean sections (49 cesarean sections/100 deliveries) [5,8]. UNICEF estimations for 2012 confirmed this, from 2006 to 2010, Mexico had the second highest rate of cesarean sections within the Americas, with 43 cesarean sections per 100 deliveries. This rate was only surpassed by Brazil with a rate of 50/100 deliveries [9]. The trend of increasing reliance on cesarean sections is not exclusive to Mexico, rather, it is a global public health issue especially relevant to low and middle income countries with low health budgets compared to high income countries [1014]. Concern about the overreliance on cesarean section is based on, first, the association between the procedure and both maternal and fetal medical complications and second, the higher expenditure which does not result in better health outcomes [15]. Cesarean sections are associated with increased neonatal mortality (OR: 1.7; 95%CI: 1.32.2 for intra-delivery cesarean section and OR: 1.9; 95%CI: 1.52.6 for elective cesarean section, both compared to vaginal delivery), respiratory complications and neurological deficits in newborn infants. Beyond the health complications for the infant, cesarean sections are also associated with increased maternal morbidity and mortality as well as posing a risk for complications in future pregnancies (OR: 2.0; 95%CI: 1.62.5 for intra-delivery cesarean section and OR: 2.3; 95%CI: 1.73.1 for elective cesarean section, both compared to vaginal delivery) [15]. The financial burden of cesarean sections on the health system is high, with greater utilization of medical personnel resources related to the surgical procedure compared to a vaginal delivery [16]. Previous studies have documented factors associated with vaginal delivery or cesarean section. On the demand side, individual characteristics of the women (demographic, socioeconomic status, type of medical insurance, obstetric history, etc.) are very important, whereas on the supply side, associated factors are type of health institution (public or private), availability of new technologies at the medical units (utilization of the cardiac fetal electronic monitoring, blood transfusions, antibiotics, etc.), clinical staff available at the health unit (obstetricians, anesthetists, etc.), and others [1118]. Health facility statistics have historically been the primary source of information used to study the prevalence of different delivery methods. However, the mothers socio-demographic characteristics and the obstetric factors that influence the delivery strategy have not yet been thoroughly investigated through population surveys in Mexico [1318]. This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) with the objective to identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico. Materials and Methods A cross-sectional study was conducted based on the data collected through the 2012 National Health and Nutrition Survey (ENSANUT), a probabilistic survey that is representative at the national and state level, as well as by urban/rural stratum. The data for the analysis were requested and obtained from the surveys public repository hosted at the Nati (...truncated)