Quality over quantity: The true cost of improving maternal mortality in Mexico

If like me you are unable to make the presentation of my AAA paper with my amazing co-researcher and academic midwife Cris Alonso, I’m reproducing it here, enjoy!

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Quality over quantity: The true cost of improving maternal mortality in Mexico

Paper presented at the American Anthropological Association, Annual Meeting 2017, Washington DC.[1]

Cristina Alonso, MPH CPM, Luna Maya and Jenna Murray de López PhD, University of Manchester

Recent reflections on the successes and failures of Millennium Development Goal 5 (MDG5) have led researchers, policymakers and practitioners to recognise that the excessive medicalisation of pregnancy and birth, and emphasis on increased access to emergency facilities do little to guarantee equity and quality of care. Moreover, increases in integrated prenatal care programmes and facility delivery have failed to have any significant impact on maternal mortality ratios (MMR) in low to middle income countries (LMICs).[2] With an increase in facility based services, incidents of disrespect and abuse in childbirth have been documented across the globe[3]. Large public facilities that are understaffed and understocked provide a stressful environment where maternal health care practitioners are unable to ensure evidence based clinical care that is kind and respectful.  Threat of mistreatment and abuse has led many women to avoid accessing facilities all together, and seek alternative and more respectful forms of care.[4]

Qualitative evidence demonstrates women’s preferences for continuity of care and trusting relationships, as well as local traditions and beliefs surrounding the social significance of childbirth often outweigh free access to technocratic, facility-based services.[5] The “Midwives Voices Midwives Realities” report established that midwives working in facilities are disrespected, harassed, bullied , underpaid, unsafe and overworked[6]. It has been well established that quality care includes kindness and compassion towards women, as well as self care of midwives[7]. This cycle of abusive care is global and must be addressed to achieve excellence, evidence and rights in MNH.

World Health Organization, United Nations Population Fund and the International Confederation of Midwives all state that midwives are the ideal provider for maternal and newborn health worldwide. The Lancet “Midwifery” series details how “midwifery is a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants in all countries”[8].  Research into disrespect and abuse has begun to reveal however that midwives by themselves are not enough, they require professional autonomy and integration as competent professionals. Even though facilities may hire midwives, these are not “optimised for low-risk women, and staff monitor and intervene more than is necessary for the overwhelming majority of women”[9]. As a consequence, the term “Too little, too late and too much too soon” has come to describe low and middle income countries maternal health[10]. The push to prevent maternal mortality has driven women to large birthing facilities, and has contributed directly to a significant increase in cesarean rates, presenting added risks for women and babies and increased mortality for women[11]

Though midwives and midwifery exist, in some form or another, in all countries across the globe, there is a distinct lack of (quantitative or qualitative) data in LMICs that have no, or little professional recognition of midwives or adequate recording systems for out-of-hospital birth outcomes. Over recent decades LMICs have experienced rapid population growth and intense urbanization. It is estimated that more that 45% of LMIC populations now live in towns or cities. Yet, it is precisely out-of-hospital birth practices in towns and cities that remain the least understood and understudied. This deficiency of data, which would be able to offer a broader understanding of the ways and means in which women give birth in an urban context, is an issue for policy and implementation of strategies that aim to improve quality, choice and sustainability of infant-maternal health for large urban populations.

In this paper we report on a case example of two midwife led birth centres in Mexico, from which data has been recorded using the MANASTATS system for 10 years[12].  We present an overview and preliminary analysis of essential outcomes between 2007 to 2017, recorded in the Midwives Alliance of North America Statistics Project dataset (MANA stats version 2.0 and 3.0). The MANA stats dataset includes nearly 200 variables including: demographics of women and families; pregnancy history and general health; antepartum, intrapartum, neonatal, and postpartum events and procedures; and maternal and newborn outcomes. The variables referred to in this paper include type of birth (vaginal or caesarean section; level and type of intervention; transfer rate and mortality outcomes. We argue that this alternative accounting, using a limited sample size (N=559) is still capable of indicating quality of care, and as such has significance for global accountability and quality agendas. Whilst the birth centre data set is not comparable to facility based data sets, we ask what this level of data can tell us about birth outcomes in alternative birth spaces, what assumptions can be made about low-intervention data? And furthermore, when complemented with qualitative data, what kind of community based health indicators arise which are grounded in local ideas about what constitutes quality and respectful maternity care?

In a global health context we argue that that despite important reductions in maternal mortality and morbidity, more progress is needed to ensure all women have access to quality care that is culturally respectful. Mexico’s national maternal mortality fairs no worse than the richer states of its northern neighbour, however its cesarean section is much higher than any developed country. Wide spread health reform over 25yrs has gradually increased accessibility to healthcare and more women than ever are receiving prenatal care and birth attention at little to no personal financial cost. We propose that Mexico provides a fruitful case example because of recent national efforts to professionalize midwifery in response to high maternal mortality for income level (38 per 100,000 births[13]) and cesarean rates (49%[14]) There is potential for comparison with other Latin American, Eastern European and South Asian LMICs characterized by women having high induction and cesarean rates coupled with high rates of disrespect and abuse. Drawing from 18 months ethnographic fieldwork (Murray de López) and 13 years of clinical  experience in south and central Mexico in midwifery and public health (Alonso), we ask how our data helps us think through the following questions: Is the equity and quality agenda central to the SDG approach really any different from the MDG approach? What can women’s avoidance strategies during pregnancy, birth and postnatal tell us about poor quality care? Is maternal mortality enough of an indicator to know that women are safe? And in relation to this, is it possible to improve quality and reduce mortality and morbidity at the same time.

In these contexts, women begin to seek alternative birthing practices and providers to avoid intervention, unnecessary cesarean and abuse.

Alternative Accounting

The quantifiable evidence base approach in global health is driven by an emphasis on Random Control Trials (RCTs) as statistically viable ways of creating health indicators. Calculated as rates, ratios and percentages, health indicators quantify the qualitative experience of human life. This approach requires large amounts of data to be statistically robust. In the case of maternal health, mortality and fertility rates become the evidence base for the health and wealth of a nation and the basis for intervention.  This emphasis on the collection of ‘good numbers’, raises questions about what kind of data and what sorts of outcomes should be considered as valuable.[15] Much work carried out by small-scale organisations and independent health-workers remains ‘uncountable’ within this system and therefore remains unaccounted for. In the field of critical global health, arguments have arisen for alternative forms of accounting, which consider local interventions and cross-culturally defined health indicators.[16] Thinking critically about numbers is an attempt to rethink what is meant by evidence, rather than shift the ways in which it is gathered. Alternative accounting asks how we might account for the impact of small scale or periphery services. It argues that accountability should not focus upon what can be counted, but on how service providers can be held accountable for quality and equity. It also argues that accountability be based on local values, which in this case would be women´s perceptions of safety, quality and equity in maternal health. It is an approach that does not reject statistics, but asks that they are recognised as ‘partial, created, fallible stories’ that need to be accompanied by other forms of less measurable evidence, in order for interventions to be not only targeted, but meaningful and sustainable.

Safer Motherhood

The concepts of safe and safer motherhood have been universally defined however, what constitutes ‘unsafe motherhood’ is less clear. Whilst notions of what is ‘unsafe’ about pregnancy and birth go undefined, there remains a space for misinterpretation and manipulation at both local and global levels. A dangerous and unhelpful dichotomy appears where facility based intervention equates to ‘safe motherhood’ and anything other than facility based care (and the people who provide it) equates to ‘unsafe’ with no measurable evidence base. In LMICs where emphasis is placed upon providing increased access to institutions, in order to adhere to safer motherhood principles, less is known about the alternative spaces that women seek for pregnancy, birth and postnatal care.

Midwifery led birth centers (MLBC) are often not considered or counted as “facilities” or “obstetric units”.  MLBCs are expanding globally as a mid point model between seemingly “unsafe” home birth and “overly medicalized” facility births. Birth centers in the US and Canada and midwifery led units in the UK and Netherlands consistently demonstrate outcomes comparable to homebirth rates in HIC which include low intervention rates including cesarean and high satisfaction[17].  Research on outcomes of MLBCs is lacking in countries where midwives and MLBCs are not integrated into the health system. The Goodbirth Network has identified over 480 birth centers across the globe, and operating in countries where there is no regulation for this practice. Mexico is one example, where birth centers exist and are run by midwives but national regulation focuses solely on hospitals and is undefined around homebirth. In these cases, births at MLBCs are considered homebirths and will be documented as “unqualified care” outside of an healthcare facility. This begs two questions: what difference does lack of regulation incur in outcomes of women seeking out of hospital care with midwives in unregulated countries, if any?  And secondly if women are receiving improved care in MLBCs, as the model would infer, documenting these births as “outside of a health care facility” and “attended by an unqualified provider” would need to be revisited.

Out of hospital birth in urban Mexico

Midwifery in Mexico is currently not understood to be a profession, nor is there acceptance of the midwifery model of care as a desirable norm for most women. Over 88% of births are attended in health care facilities and 87% by a physician (INEGI, 2016). There are multiple obstacles that preclude midwifery care as an option within maternal health in Mexico. While there has been a commitment to integrated medicine in the public sector, such as the Intercultural Hospital in San Cristobal de Las Casas, and recently “Humanized Birth” areas in maternity hospitals in Tula, Hidalgo and Tlaxcala, there are different and conflicting opinions and visions how to achieve “integrated medicine,” which includes midwifery care. Access to midwifery education is limited and job placement post graduation is scarce.

A strong and growing movement from within and outside of the government in support of the professionalization of midwifery and its integration into the health sector recognizes the need to create trained and qualified midwives and provide health care that is centered on women´s values and choices, particularly given the cultural diversity that constitutes Mexico. The Ministry of Health recognizes the need to integrate multicultural solutions to a multicultural nation.  In 2009, the Ministry of Health, through its Center for Gender Equity and Reproductive Health program, published the “Holistic Strategy to Accelerate the Reduction of Maternal Mortality in Mexico.” (SSA, 2014). The strategy recommended the hiring of non-medical providers, such as professionally trained midwives, obstetric nurses and perinatal nurses for prenatal and birth care. In order to achieve this, the hiring code that recognizes Obstetric Nurses (Enfermeras obstetricas) was reinstated in 2008 and in 2011, and a hiring code was also adopted that recognizes professional midwives. In 2016, the Norm 007 that regulates the care of women during pregnancy, birth and postpartum was reviewed recognizing obstetric nurses and professional midwives as qualified providers and  their need to provide training to traditional midwives.

In Mexico there are approximately 10 birth centers that offer services under the midwifery model operating with no regulatory framework and outside of the health system. On the one hand midwives refer to be afraid of the health system because of fines, closures and legal reprisals and on the other hand, the health system expresses confusion about how to regulate these spaces without a regulatory framework. There are no specializations aimed at midwives which may provide them with tools for the direction and management of birth centers, or a view on operating a business model, human resources management, leadership, administrative, accounting and finance skills, and legal orientation. Nor is there an expert body that can advise and support birth centers according to a successful business model and negotiate with the health system based on a regulatory framework.

Despite the effort of gratuity and trainings on “nice treatment culture (cultura del buen trato)” promoted at healthcare facilities, more and more women seek for midwives for their sexual and reproductive care, as they try to avoid the obstetric violence experienced or perceived both in public and private institutions. Birth centers offer a physical space to ensure the implementation of the midwifery model.

Research conducted by Sanchez in 2016 exposed that although midwives have sought regulation and integration of birth centers, health authorities have repeatedly denied the value of homelike environments and midwifery autonomy as safe for women[18].

Luna Maya Birth Centers provide a model of community-informed maternal and family health care in two locations in Mexico: Mexico City and the southern town of San Cristobal de Las Casas near the Guatemalan Border. The flexibility of the model allows for the integration of international best practices and guidelines into the existing culture of care that has been informed and determined by women in the community it serves. The growth and success of Luna Maya’s model of care is largely due to this human-centered approach to practice implementation. Luna Maya seeks to expand the models associated with community-based midwifery care, and through this expansion has found an innovative way to meet the needs of two distinct groups of women and families in both San Cristóbal de Las Casas in Chiapas and in Mexico City.

What MANA stats data tells us

Data was contributed by 4 different midwives, including CPMs, unlicensed direct-entry midwives, apprentices. All out-of-hospital births (home, birth centre or other[19]) were attended by a lead CPM or unlicensed direct-entry midwife, aside from intrapartum transfers (see fig1.).

The total dataset consists of 618 archived forms of which 500 birth outcomes are recorded (502 newborns in total) and comprise the final sample (N=500). Briefly, 87% of women in the sample self-identified as mestiza Mexican and/or Hispanic, of that number 8% as indigenous, and the remaining 23% as other nationalities/ethnicities. It is important to note that the MANAStats data form does not include a variable that indicates indigenous Mexican. Most women paid for midwifery care out-of-pocket, with a small percentage receiving subsidised or free care dependent on economic status or vulnerability. Employment or State insurance in Mexico will not cover out-of-hospital birth. Between the sample period of 2007-2017 there were no maternal deaths and a total of 5 neonatal deaths were recorded which include previously known anomalies and anomalies detected at birth (within 6 weeks postpartum, see fig.3).

Antenatal Risk Status

High risk women were risked out of out of hospital birth care but were welcome to receive pre and postpartum midwifery care. Risk referral includes chronic diseases such as diabetes and cardiac problems. Pregnancy complications such as preeclampsia and gestational diabetes were referred. Previous cesareans were not risked out nor were twins and breeches, although full informed consent was given and women themselves chose referral or care by midwives. It is important to note that in some occasions, women opt to birth out of hospital despite being high risk due to fear of obstetric violence or non-consensual care. Age, parity, education and socio-economic status were considered for care provision but not risked out.

The reason risk criteria remains so flexible is because often women seek care from Luna Maya because they have been automatically scheduled for a cesarean in the public or private sector. Currently in Mexico women under 18 and over 35 and previous cesareans are automatically labelled as high risk and scheduled for cesarean despite ample evidence to the contrary. Some women who were risked out refused to transfer care- as in the case of several breeches, one after a previous cesarean, three severely malformed fetus´ and one diabetic and stated they would birth on their own before attending a government facility. The outcomes in some of these births were not good, including neonatal deaths, and highlight the added risk of systemic obstetric violence among high risk women which may push them to pursue suboptimal clinical care, choosing kindness and respect over technology. In all of these cases Luna Maya provided care as ethical review by midwives concluded that women deserve care always.  Although more research is necessary to describe these specific outcomes, it is important that women who are at high risk for complications are occasionally opting out of obstetric care due to perception of disrespect and abuse.

Mode of Birth

MLBC place of birth pie                  MLbc mode of birth pie

Fig.1 Place of Birth                                                              Fig.2 Mode of Birth

(Note: Other is women´s shelters that include a womens’ safe house and a shelter for single indigenous women)

Of the sample of 500 women, 85.6% completed an out-of-hospital birth (n=500). The spontaneous vaginal birth rate for the sample was 90.2% including vaginal births in the hospital. Of the 428 out-of-hospital births, 49 women had a vaginal birth after one or two or three previous caesarean sections (VBAC, VBAC2, VBAC3). The VBAC success rate for women over the complete sample was 85,2%. A total of 6 out-of-hospital births were breech presentation.

Transfers and Complications During Labour

The total intrapartum transfer rate, over the ten-year period, was 14% (N=72) of all planned out-of-hospital births. Of the 72 intrapartum transfers, 13 were urgent transfers, 49 of which resulted in caesarean section, giving an overall caesarean section rate of 9.8%. There were 5 postpartum transfers from the whole sample (3 urgent) and 7 neonatal transports (5 urgent). It is important to note that all women are out of the midwives’ care as soon as transfer takes place, though women will often return to the birth centre for postpartum care and only an insignificant amount become lost to follow-up. It is also important to note that in Chiapas the great majority of intrapartum transports result in cesarean section due to the lack of a sympathetic and supporting obstetrician, whereas the majority of transports in Mexico City resolve in vaginal birth due to a highly supportive obstetrician who includes the midwives in the continuity of care at the hospital.


Fig. 3 Out-of-hospital labour and birth complication characteristics
Shoulder dystocia n(%) 14 (2.8)
Thick or particulate meconium n(%) 13 (2.6)
Blood loss over 500 ml n(%) 89 (17.8)
Blood loss over 1000 ml n(%) 14 (2.8)
Pre-eclampsia.eclamsia during pregnancy/labour n(%) 5 (1)
Intrapartum transfer n(%) 72 (14.4)
Postpartum transfer n(%) 5 (1)
Neonatal transfer 7 (1.4)
Maternal deaths 0
Infant death before 6 weeks Postpartum 5


Reflections on the successes and failures of Millennium Development Goal 5 have led researchers, policymakers and practitioners to recognise that the excessive medicalisation of pregnancy and birth, and emphasis on increased access to emergency facilities do little to guarantee equity and quality of care. Moreover, increases in integrated prenatal programmes and hospital facility delivery have failed to have any significant impact on MMR in LMICs. By contrast, with an increase in access to hospital maternity care, incidents of disrespect and abuse have arisen as part of a global phenomenon. Large public facilities that are understaffed and understocked provide a stressful environment where maternal health care practitioners are unable to ensure evidence based quality care. In LMICs like Mexico where policy is only just beginning to recognise the possibility of technical midwives as a vital part of public health services, there is little to suggest their presence would impact on improving quality and equity. In fact, by entering an existing environment of disrespect, midwives may eventually be accused of contributing to worsening the experience and outcomes for women. Therefore, damaging the possibility of their growth as a specialist profession.

Despite this problem, the better promotion of midwifery-led care remains vital for the improvement of maternal health as a global concern. In order for this to happen there needs to be a more detailed picture of the different practices and environments within which midwives practice with autonomy. As part of this, alternative forms of accounting should be sought that consider locally based interventions and culturally defined health indicators. Accountability should not focus solely on what can be counted, but on how service providers can be held accountable for quality and equity. As a way of working towards this, this paper has presented preliminary data of outcomes from two established MLBCs to show what can happen under an alternative system of low-risk management of maternal health. The data described here presents the need for a more in-depth and broader understanding of midwifery-led care and out-of-hospital birth in the urban context of LMICs. In conclusion, we advocate for wider implementation of the MANAStats data system, adjusted to be culturally appropriate, amongst midwives attached to MLBCs in towns and cities of Mexico. Furthermore, that this form of data collection be complemented with qualitative research and be considered seriously in the future development of respectful and equitable maternal health care.


[1] Alonso, C., & Murray de Lopez, J. (2017). Quality over quantity: The true cost of improving maternal mortality in Mexico. Paper presented at the American Anthropological Association, Washington DC.

[2] Wendland CL. 2016. Estimating Death: A Close Reading of Mortality Metrics in Malawi, in Metrics: what counts in global health, Adams V (ed).  Duke University Press: Durham. p. 57-81.

[3] Bowser D and Hill K. 2010. Exploring evidence for disrespect and abuse in facility based childbirth report of a landscape analysis, USAID-TRAction Project, Harvard School of Public Health, University Research Co., LLC.

[4] Molina RL, Patel SJ, Scott J, Schantz-Dunn J, Nour NM. 2016. Striving for Respectful Maternity Care Everywhere. Maternal and child health journal, p. 1-5.

[5] Davis-Floyd R, Barclay L, Daviss B, Tritten J (eds). 2009. Birth Models That Work. University of California Press: Berkeley, California.

[6] World Health Organization. 2016. Midwives Voices, Midwives Realities, Retrieved from: http://www.who.int/maternal_child_adolescent/documents/midwives-voices-realities/en/

[7] Byrom S and Downe S. 2015. The Roar behind the Silence, Why kindness, compassion and respect matter in maternity care. Pinter and Martin Ltd

[8] The Lancet, Midwifery Series, June 2014

[9] Shaw D et al. 2016. Drivers of maternity care in high income countries: can health systems support women- centered care? The Lancet, Maternal Health Series pp. 52-65

[10] Miller S et al. 2016. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide The Lancet, Maternal Health Series pp. 19-35

[11] Freyermuth G, Muños JA and Ochoa MdeP. 2017. From therapeutic to elective cesarean deliveries: factors associated with increase in cesarean deliveries in Chiapas. International Journal for Equity in Health 16:88

[12] Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health. 2014 Jan-Feb;59(1):8-16. doi: 10.1111/jmwh.12165. Epub 2014 Jan 30.


[13] INEGI, 2016

[14] Freyermuth et al (2017)

[15] Adams V, Craig SR, Samen A. Alternative accounting in maternal and infant global health. Global Public Health, 2016. 11(3): p. 276-294.

[16] Adams V (ed). Metrics: what counts in global health. 2016, Duke University Press: Durham.

[17] Alliman J, Phillippi J. Maternal outcomes in birth centers: An integrative review (in press). J Midwifery Womens Health 2016; 61.

Hollowell J, Li Y, Bunch K, Brocklehurst P. A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of ‘low risk’ births in the birthplace in England cohort. BMC Pregnancy & Childbirth. 2017;17:95

[18] Sanchez Ramirez, G (2016) Espacios para parir diferente, un acercamiento a Casas de Parto en México. El Colegio de la Frontera Sur

[19] ‘Other’ in this dataset refers to a local women’s shelter housing indigenous women in vulnerable or violent situations and the women´s shelter for battered women.

data: 199 homebirths, 72 transports. Other is womens shelters.


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