Assessing the quality of childbirth care in Mexico: findings from the maternal eCohort

Abstract

Background

In 2022, the Mexican Institute of Social Security (IMSS) launched the “Comprehensive Women-Centered Maternal Health Care Model” (AMIIMSS program) to improve maternal healthcare. This research evaluated the childbirth care quality, comparing outcomes between IMSS and private hospitals and between IMSS hospitals with high and low adherence to the AMIIMSS program, and assessed whether the type of healthcare provider and delivery, the content of care, and the occurrence of obstetric violence were associated with the perceived quality of childbirth care, after controlling for other relevant demographic and clinical covariates.

Methods

Data were collected from an observational IMSS-affiliated eCohort of pregnant women aged 18 to 49, focusing on their experiences, perceptions of healthcare quality, obstetric violence, and health outcomes. The analysis included Chi-square tests and multivariable linear regression.

Results

The study included 988 women; 14.9% went to private facilities for childbirth primarily because they perceived poor quality and past mistreatment at IMSS. C-sections rates were higher in private hospitals (92.5%) than at IMSS (51.3%). IMSS hospitals with high adherence to AMIIMSS program had a 10% lower C-section rate, and their care content was similar to that in private hospitals (85% of expected clinical actions). Complications affected 20.8% of women and 28% of newborns. The overall quality of care perceptions score was higher in private hospitals (mean 34.2, standard deviation 6.7) than at IMSS (mean 27.0, SD 6.7) on an 8–40-point scale. Delivering in private hospitals or at tertiary care facilities and receiving a higher care content was associated with better quality perceived by women. Whereas obstetric violence was associated with lower perceived quality.

Conclusion

AMIIMSS improves women’s childbirth experiences but reveals weaknesses due to poor hospital adherence to the program and poor perceived quality. This underscores the need to strengthen the program’s pillars—training, infrastructure, regulatory adaptation, and women’s empowerment.

Background

Women around the world aspire to have a positive childbirth experience that respects their cultural beliefs and expectations, is rooted in evidence-based practices, and is free from obstetric violence or severe maternal or newborn complications [1, 2]. Nonetheless, as many as four out of ten women face physical or verbal abuse, stigma, or discrimination, and up to five out of ten report low quality and satisfaction with intrapartum and postpartum care [3,4,5,6].

Poor quality of care during pregnancy and childbirth is a determinant of the adverse health outcomes for the mother and the newborn. Every two minutes, a woman dies from complications related to pregnancy, childbirth, or the postpartum period, many of which are preventable [7]. Delivering high-quality antenatal, childbirth, and postpartum care could reduce maternal and neonatal deaths by 28% and stillbirths by 22% [8].

In 2021, Mexico’s maternal mortality ratio was five times higher than the Organization for Economic Co-operation and Development (OECD) average (53 vs. 10.9 deaths per 100,000 live births), and the infant mortality rate was three times higher (12.7 vs. 4.0 deaths per 1,000 live births) [9,10,11]. Additionally, the cesarean section (C-section) rate ranged from 37.9 to 60.0% [12], significantly exceeding the OECD average of 28% and the 10% threshold set by the World Health Organization (WHO) [13].

Several studies have assessed the quality of antenatal care in Mexico, but only one evaluated the technical quality of intrapartum and postpartum care using five indicators [14]. This study found low compliance with mother-newborn skin-to-skin contact indicator, postpartum contraception, and newborn care information. At the same time, some studies reported frequent disrespect and abuse during obstetric care [15, 16].

The Mexican Institute of Social Security (IMSS) is the largest healthcare provider, serving 74 million people and attending approximately 410,000 births annually in 286 general and 25 high-specialty hospitals nationwide [17].

In 2022, the institution launched the “IMSS Comprehensive Women-Centered Maternal Health Care Model” (AMIIMSS) to improve maternal health care quality. AMIIMS aims to provide timely, safe, high-quality, and women-centered care, free from obstetric violence throughout women’s reproductive lives. To conduct this program, IMSS released technical guidelines and an online course on “Friendly Obstetric Care” for hospital staff [18, 19].

The IMSS authorities established four pillars and twelve monitoring indicators to evaluate the AMIIMSS program in IMSS hospitals [18]. The pillars include healthcare staff training, infrastructure availability, regulatory adaptation, care processes, and women empowerment. Key indicators for staff training require at least 20% of hospital staff trained in friendly obstetric care and 80% in breastfeeding counseling. To meet infrastructure indicators, hospitals must have pre-labor areas, comfort items for labor, and a Human Milk Management Center. As for the regulatory requirements and care process indicators, hospitals need to achieve Baby-Friendly Hospital certification and consistently document friendly obstetric care practices. Women’s empowerment should be supported by obstetric tours and educational resources. Hospitals meeting over 50% of indicators show moderate to high adherence to the AMIIMSS program, while those with 50% or less indicate low adherence [18].

However, IMSS did not establish indicators to assess women’s experiences with healthcare. To address this gap and evaluate the progress of AMIIMSS, a longitudinal maternal eCohort study began in August 2023 and included 1,390 pregnant women affiliated with IMSS, who were enrolled after their first antenatal visit and followed throughout their pregnancy and childbirth until 8 weeks after delivery [19].

The present study utilized data from the eCohort to achieve three objectives: first, to compare the content of care, perceived quality, and health outcomes of women who delivered at IMSS facilities with those who delivered at private hospitals; second, to compare content, quality, and outcomes among women who delivered in hospitals with high adherence to AMIIMSS versus those with low adherence; and third, to investigate whether the type of healthcare provider and delivery, the content of care, and the occurrence of obstetric violence are associated with the perceived quality of childbirth care, after controlling for other relevant demographic and clinical covariates.

Methods

The present research analyzed data from the IMSS observational eCohort. In 2023, the eCohort enrolled 1,390 pregnant women aged 18 to 49 following their first antenatal visit with a family physician. The sample was drawn from 48 IMSS family medicine clinics across eight Mexican states. Participants were followed up through monthly phone interviews during their pregnancy and surveyed on the phone after being discharged following childbirth. Detailed information regarding the cohort’s inclusion criteria, sample size, and sampling strategy have been published previously [19].

The study information was collected using a postpartum survey questionnaire designed by the Quality Evidence for Health System Transformation (QuEST) network. Before data collection, the questionnaire was adapted and validated by IMSS experts [19].

The study variables included:

(1) Women’s characteristics comprised sociodemographic variables (age, education, occupation, marital status), risky health behaviors (alcohol and tobacco use), and medical history (parity, pre-gestational chronic diseases like diabetes, hypertension, and others).

(2) Content of care and user experience before, during, and after delivery. These variables included:

• (i) Place of delivery (IMSS facilities with high and low adherence to the AMIIMSS program and private hospitals), region of residence including West (Aguascalientes and Jalisco), North (Coahuila and Nuevo León), Southeast (Veracruz and Yucatán), and Center (State of Mexico and Mexico City).

• (ii) Health care provided in the hospital before delivery or C-section, including blood pressure measurement, HIV status inquiry, the provision of information related to labor or C-section, and whether the physician had information about the woman’s antenatal care, or reviewed any documentation she brought.

• (iii) Type of delivery and whether the C-section was indicated and justified according to IMSS clinical guidelines [20].

• (iv) Intrapartum care indicators including information provided about walking and moving around during labor, permission for a partner to accompany the woman, availability of liquids throughout labor, use of curtains or partitions to ensure privacy, and whether any cuts or tears near the vaginal area were sutured after delivery.

• (v) Obstetric violence during labor and delivery was assessed using a scale from the 2016 National Survey on the Dynamics of Relationships in Households, which includes six indicators of obstetric violence and five for non-consensual care, each answered with “Yes” or “No.” Two overall indicators summarize the presence or absence of obstetric violence and non-consensual care [21].

• (vi) Postpartum care indicators included whether the newborn was dried and placed on the mother’s chest for skin-to-skin contact, whether health professionals assisted with breastfeeding positioning, and whether the BCG vaccination and medical evaluations were performed before discharge. It also assessed if the mother received counseling on newborn screening, exclusive breastfeeding, umbilical cord care, vaccination schedules, maternal hygiene, warning signs for hospital visit, and when to consult a physician for postnatal care.

We then developed a summary measure to evaluate women’s overall experiences related to the content of care they received. This measure was defined as the percentage of clinical actions taken by healthcare providers before, during, and after childbirth based on the necessary activities women should receive according to their delivery type. This score encompasses all the previously mentioned specific aspects of women’s experiences with healthcare before, during, and after childbirth, with a minimum of 0% and maximum of 100%.

(3) Women’s perceived quality was assessed by rating eight care components on a scale from 1 to 5: (i) healthcare provider’s knowledge and skills; (ii) respect shown by the provider; (iii) availability of medical equipment or lab tests; (iv) clarity of healthcare provider’s explanations; (v) involvement in care decisions; (vi) staff courtesy and helpfulness; (vii) time spent with the healthcare provider; and (viii) waiting time. The overall care quality perception score, ranging from 8 to 40 points, was calculated by summarizing responses across these components [19].

(4) Maternal outcomes included self-reported complications such as preeclampsia, eclampsia, hypertension, heavy vaginal bleeding, infections, and other complications, along with admissions to the intensive care unit, blood transfusions, and hospitalization duration. Postpartum warning signs comprised severe headaches, abdominal pain, fever, and heavy bleeding. For newborn outcomes, we gathered information on stillbirths, neonatal death (the death of a live-born baby within the first 28 days of life), preterm birth (< 37 weeks of gestation), low birth weight (< 2,500 g at birth) and congenital abnormalities. Additionally, we tracked any newborn admissions to the neonatal intensive care unit and their length of hospitalization.

Statistical analysis

Descriptive statistics were used to analyze eCohort participants’ characteristics and experiences with childbirth and postpartum care. Percentages were used for categorical variables, while means and standard deviations for normally distributed numerical variables, and medians with ranges for non-normally distributed variables, as confirmed by the Shapiro-Wilk test.

Subsequently, a comparison was conducted of the baseline demographic characteristics and medical histories between the women who completed postpartum survey (74.9%) and those who dropped out during the follow-up period (25.1%) to better understand the differences between them. Following this, to address the first study objective, we compared the characteristics and quality of care for those who delivered at IMSS with those who delivered in private hospitals using chi-square tests for categorical variables and Fisher exact tests for cells with expected values of five or fewer. The Wilcoxon rank sum test was utilized for numerical variables that lack normality. Similar tests were conducted to compare healthcare experiences of women who gave birth in high-adherence versus low-adherence AMIIMSS hospitals.

For the analysis of newborn outcomes, we analyzed the information of one newborn per woman because of the limited number of twins in the cohort (n = 12), and since the outcomes for the twins were similar, we only provided details about the firstborn twin.

We conducted a linear multivariable regression analysis to examine variables related to perceived quality. This analysis was supported by the normal distribution of the perceived care quality variable (Skewness 0.141, Kurtosis 2.508) and because this regression model satisfied the assumptions of linear regression. Our modeling strategy adhered to the criteria set by VanderWeele and Shpitser for confounder selection [22, 23]. These authors recommend including all conceptually and clinically relevant covariates to ensure the final model is adjusted for even slight confounding.

To address the potential bias from a relatively high dropout rate during the eCohort follow-up, we implemented stabilized inverse probability weights (IP-weights). Moreover, there was missing data for another 8 women. We utilized IP-weights when fitting the multivariable linear regression model to ensure a more accurate representation of our findings [24]. The denominator of stabilized IP weights represented the probability of “having missing data” given the available covariates without missing data. These covariates included the participants’ age, occupation, presence of risky health behaviors, preexisting chronic disease, trimester of initiation of antenatal care, primigravida status, and region of residence. The numerator represented the probability of “having missing data” regardless of the covariates. We also confirmed the absence of interactions among the study covariates. In addition, we adjusted the standard errors of the regression model for the clustered sampling approach, using the unique ID of the hospitals where women gave birth for this adjustment. In the end, we computed Bonferroni-adjusted p-values for the results of the multivariable regression analysis to control multiple comparisons.

A p-value of ≤ 0.05 was considered statistically significant. We analyzed data using the statistical software Stata 14 (Stata Corp LP; College Station, TX). The study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Results

During the cohort follow-up, 51 out of 1,390 women experienced miscarriages, 336 dropped out, and 1,003 completed the postpartum survey, resulting in a response rate of 74.9% (see Fig. 1 in Additional file 1). A comparison of the baseline characteristics and medical histories of IMSS maternal eCohort participants showed that those who dropped out were more likely to be single, divorced, or separated, and had experienced intimate partner violence (see Table 1 in Additional file 2).

Most women (83.8%) gave birth at IMSS hospitals (including 19 high-adherence AMIIMSS hospitals and 29 low-adherence hospitals), while 14.7% opted for private hospitals and 1.5% delivered at other public hospitals. We excluded from the analysis 15 respondents who delivered in non-IMSS public health facilities due to their small number.

Childbirth care was received in various IMSS hospitals across regions. In the northern region, women received care in seven IMSS hospitals (three with high adherence to the AMIIMSS program and four with low adherence); in the central region, care was provided in twenty-three IMSS hospitals (twelve high and eleven low adherence); in the western region, there were eleven IMSS hospitals (two high and nine low adherence); and in the southern region, seven IMSS hospitals (two high and five low adherence). The rest of the women (n = 147) gave birth in various private hospitals.

Among 988 analyzed women, the majority were between 18 and 34 years old (85.9%), lived in a common law union or were married (85.2%), possessed a high school diploma or higher education (64.9%), and were employed in a paid job (60.2%). 5% reported engaging in the consumption of alcoholic beverages or smoking; 63.5% had previous pregnancies, while 17.6% reported having chronic illness before pregnancy. Within the group of women who opted for private providers, there was a greater proportion of those who had completed high school and were employed, while there was a smaller proportion of multigravida women (see Table 2 in Additional file 2).

The main reason for choosing IMSS was its convenience related to women’s affiliation and residency (71.7%). Other reasons included the respectful and friendly staff (9.5%) and high provider competency (6.0%) (see Table 2 in Additional file 2.) In contrast, women chose private hospitals due to perceptions of low-quality care or mistreatment by IMSS (32.7%), comfort and trust in private healthcare providers (23.1%), private health insurance (10.2%), or family recommendations (8.8%) (see Table 3 in Additional file 2).

The analysis of women’s experiences with care revealed that during labor, women at IMSS facilities were asked less frequently about their HIV status and received less information regarding their vaginal or C-section delivery compared to those at private hospitals (75.7% vs. 85.7% and 77.5% vs. 93.9%, respectively). In both IMSS and private hospitals, over 90% of women had their blood pressure measured, and their doctors accessed their clinical information (Table 1).

Table 1 Content of care during labor and obstetric violence by delivery location

Regarding the type of delivery, in private hospitals, 92.5% of women had C-sections, versus 51.3% at IMSS facilities, with unjustified procedures being more common in private hospitals (44.1%) compared to IMSS (25.3%) (see Table 4 in Additional file 2 and Table 2).

Among women with vaginal deliveries, a larger proportion in private hospitals reported being informed they could walk during labor (90.9%) compared to IMSS (55.3%). Similarly, 90.9% of private hospital users were allowed a partner present, versus 26.4% at IMSS. Less than half in both settings were offered liquids during labor, and 74.6% at IMSS and 81.8% at private hospitals reported having privacy with curtains or partitions (Table 1).

Obstetric violence was more common at IMSS (16.7%) than in private hospitals (2%). In contrast, non-consensual care occurred more frequently in private hospitals (19%) compared to IMSS (4.9%). The most reported form of obstetric violence involved women feeling ignored when they asked about their labor or baby, followed by instances of being yelled at or scolded, and being forced into uncomfortable or painful positions. Regarding non-consensual care, the primary concerns included a lack of clear explanation for the necessity of a C-section and women not being asked for permission before this procedure. (Table 1).

Table 2 outlines the quality of postpartum care. In both, IMSS and private hospitals, most women reported that their newborns were dried with a towel after birth (69.7% vs. 74.1%), placed on the mother’s chest (72.0% vs. 76.2%), had skin-to-skin contact (90.7% vs. 88.4%%), initiated breastfeeding (97.2% vs. 98.6%) and received assistance positioning the newborn for the first breastfeeding (71.1% vs. 75.2%). Additionally, in both, IMSS and private hospitals, most women had a medical check-up before discharge (96.6% vs. 97.3%), and most newborns also received a check-up (95.1% vs. 92.5%). However, the BCG vaccination was more frequent at IMSS than at private hospitals (68.4% vs. 17%) (Table 2). The primary reasons for the lack of immunization included the unavailability of the BCG vaccine, contraindications to apply the vaccine, and instructions to visit the primary care clinic for BCG vaccination (see Table 5 in Additional file 2).

Table 2 Content of immediate postpartum care by delivery location

Postpartum counseling was similar in both IMSS and private facilities (see Table 2). Most women were guided on newborn screening tests (91% in IMSS vs. 92.5% in private hospitals), exclusive breastfeeding (88.9% vs. 83.7%), umbilical cord care (80.5% vs. 85%), vaccination schedules (77.3% vs. 76.2%), danger signs requiring hospital visits (83.8% vs. 88.4% for newborn; 85.3% vs. 87.8% for women) and when to seek postnatal care (78.1% vs. 79.6%). However, private hospitals had a higher percentage of women receiving advice on maternal hygiene before breastfeeding (84.4% vs. 72.9% for hand hygiene and 80.3% vs. 69.8% for body hygiene). The percentage of activities performed by health professionals during and after delivery was higher among women who gave birth at private facilities, with a median of 85% of completed activities (ranging from 22.2 to 100%), compared to women who gave birth at IMSS facilities, with a median of 83.3% (ranging from 12.5 to 100%) (Table 2).

We found significant differences when comparing women delivering at hospitals with high and low adherence to AMIIMSS. In high-adherence hospitals, more women received information about labor or C-section (84.2% vs. 72.8%, p < 0.001), were encouraged to walk during labor (61.2% vs. 50.2%, p = 0.027), and reported privacy measures such as the use of curtains or screens (79.3% vs. 70.6%, p = 0.045). Additionally, C-section rates were lower in high-adherence facilities (45.7% vs. 55.2%, p = 0.007), women were less frequently ignored when asked about the delivery or the baby’s health (5.8% vs. 9.9%, p = 0.030) and faced less pressure to accept contraceptive methods (4.3% vs. 8.7%, p = 0.013) (Table 3).

Table 3 Quality of labor, delivery and postpartum care among women who gave birth in high-adherence AMIIMSS hospitals and low-adherence AMIIMSS hospitals^ɫ

In hospitals with high adherence to AMIIMSS, more newborns were towel-dried (73.0% vs. 67.3%, p = 0.002), placed on their mother’s chest (81.9% vs. 65.0%, p < 0.001) and had skin-to-skin contact (96.1% vs. 85.9%, p < 0.001). Furthermore, more women who initiated breastfeeding received assistance in positioning their newborns (79.8% vs. 64.9%, p < 0.001). Also, more newborns had a medical check-up and received the BCG vaccine before discharge (96.8% vs. 93.8%, p = 0.048 and 73.8% vs. 64.2%, p = 0.004, respectively). Moreover, more women received guidance on exclusive breastfeeding (92.8% vs. 86.1%, p = 0.002), the baby’s vaccination schedule (83.9% vs. 72.6%, p < 0.001), and warning signs that may require hospital care for both the mother and the newborn (88.8% vs. 80.2%, p = 0.001 and 88.8% vs. 82.8%, p = 0.015). In addition, women were also more frequently informed about when to seek medical consultation for postnatal care (83.9% vs. 74.0%, p = 0.001).

There were no statistically significant differences in the rest of intrapartum and postpartum care activities between women who gave birth in hospitals with high adherence to AMIIMSS and those in hospitals with low adherence. When comparing the percentage of activities performed by healthcare professionals during and after delivery, women in hospitals with high adherence to AMIIMSS received a higher percentage of clinical activities than those in hospitals with low adherence (85% vs. 80% of expected clinical actions, p < 0.001).

Figure 1 illustrates women’s perceptions regarding intrapartum and postpartum care quality. The activities rated as having excellent, very good, or good quality included the availability of medical equipment and laboratory tests, as well as the knowledge and skills of health professionals (≈ 92%). In contrast, the activities with lower ratings were the waiting time (83.9%) and the courtesy and helpfulness of the non-medical staff at the hospital (86.1%). Overall care quality perceptions score was higher in private hospitals (mean 34.2, standard deviation (SD) 6.7) than at IMSS (mean 27.0, SD 6.7) on an 8–40-point scale, p < 0.001. (see Fig. 1; Table 6 in Additional file 2). There were no statistically significant differences between women who gave birth in hospitals with high adherence to AMIIMSS and those in hospitals with low adherence regarding their perceptions of the quality of intrapartum and postpartum care in bivariate comparison.

Fig. 1

Perception of quality of intrapartum and postpartum care

Table 4 displays the outcomes related to maternal and newborn health during the partum and postpartum periods. About 21% of women reported experiencing one or more complications, with a higher incidence observed among IMSS affiliates. The most common complications included hypertensive disorders of pregnancy (9.5%), as well as heavy vaginal bleeding (6.5%). Only 0.9% of women required blood transfusions. Furthermore, 11.8% of women exhibited postpartum warning signs, primarily severe headaches (7.5%), intense abdominal pain (3.2%), or fever (2.6%). Approximately 1.7% were admitted to the intensive care unit.

Table 4 Maternal and newborn outcomes by delivery location

Most women who had vaginal deliveries were hospitalized for 24 to 48 h (84.1%), while 7.4% were discharged in less than 24 h, and 8.5% stayed longer than 48 h. Among those who underwent C-sections, most (65.1%) were discharged before 72 h, while 6.3% needed hospitalization for more than 72 h. Women who delivered at private health facilities generally experienced shorter hospital stays for both vaginal deliveries and C-sections.

In terms of newborn outcomes, there were five stillbirths: four women responded to the postpartum survey (0.4%), while one chose not to. Additionally, there were three neonatal deaths, with two women (0.2%) responding to the survey, one not responding, and ten reports of congenital abnormalities (1%). Moreover, approximately 8.6% of newborns experienced preterm birth and low birth weight, particularly those delivered in public health institutions. Furthermore, 28% of newborns faced complications during or after delivery. These complications included difficulty breathing (11.9%), jaundice (8.9%), infections and/or fever (5.0%), feeding problems (3.7%), and other issues (3.7%). About 7.5% of newborns required hospitalization in the neonatal intensive care unit, while 4.7% were admitted to a pathological nursery. The median hospitalization time for newborns was two days, ranging from 0.25 to 90 days. Notably, those born in private hospitals had shorter hospital stays.

Hospitals with higher adherence to AMIIMSS had fewer intrapartum maternal complications, such as hypertensive disorders of pregnancy, and heavy bleeding, with rates of 16.4% compared to 26.4% in low-adherence hospitals (p = 0.001). Postpartum warning signs were also lower, at 9.2% versus 14.4% (p = 0.023) (Table 5).

Table 5 Maternal and newborn outcomes among women who gave birth in high-adherence vs. low-adherence AMIIMSS hospitals

In terms of neonatal outcomes, the low-adherence group had five stillbirths and two neonatal deaths, while only one neonatal death was reported in the high-adherence group. Newborns in hospitals with high adherence to AMIIMSS were also less likely to experience jaundice and feeding problems, with rates of 6.3% versus 12.1% (p = 0.006) and 2% versus 4.9% (p = 0.039), respectively (Table 5). No other statistically significant differences regarding maternal and neonatal outcomes were identified between these two groups.

Table 6 shows the factors associated with perceived quality of care during the intrapartum and postpartum periods. Women who delivered in private hospitals, who reported a higher care content, and those who gave birth at a third-level hospital (compared to secondary care hospital) and in the Western, or Southern Regions (compared to the North region) were more likely to report better-perceived quality. In contrast, facing obstetric violence was associated with a lower perception of care quality.

Table 6 Factors associated with perceived quality of labor, intrapartum and postpartum care

Discussion

The present study found that hospitals with high adherence to the AMIIMSS program provide more comprehensive intrapartum and postpartum care content, as assessed through user experiences. Women who gave birth at these hospitals had 10% fewer C-sections and reported fewer maternal complications and only one neonatal death compared to five fetal deaths and two neonatal deaths in low-adherence hospitals. However, 14.9% of pregnant women affiliated with IMSS opted for private health facilities for deliveries primarily due to concerns about care quality and past mistreatment. In private facilities, 92.5% of women had C-sections compared to 51% at IMSS. Delivering at private hospitals and receiving higher care content, as well as giving birth at a third-level care facility in Western, or Southern regions were associated with a perception of higher care quality during intrapartum and postpartum periods, while obstetric violence was linked to a lower perception of care quality.

IMSS is a social security institution aimed at protecting health and mitigating the economic burden related to healthcare for formally employed individuals and their families across Mexico. Women and newborn health are among the IMSS priorities. To ensure quality, safety, and respect during all stages of women’s reproductive lives, in March 2022, IMSS introduced the “Comprehensive Women-Centered Maternal Care Model” (AMIIMSS).

Our evaluation of women’s experiences revealed that those delivering in facilities with high adherence to the AMIIMSS program received a higher percentage of clinical activities during childbirth than those in low-adherence hospitals. Notably, the percentage of clinical activities performed in high-adherence hospitals was similar to that in private hospitals. Our findings align with several interventions aimed at enhancing intrapartum and postpartum care through respectful, evidence-based approaches. For instance, the “Nurse-Led Respectful Delivery Care Model” accompanied by the nurses training at the Angel Albino Corzo Basic Community Hospital in rural Chiapas showed increased companions during childbirth, immediate skin-to-skin contact, and exclusive breastfeeding, while reducing unnecessary interventions, such as episiotomy and non-medically indicated intravenous access [25]. Similarly, a training and mentoring improvement initiative in India that focused in intrapartum and immediate postpartum care boosted healthcare providers’ competency in essential newborn care [26].

Respect, comprehensive care, safety, comfort, and elimination of obstetric violence are fundamental principles of women-centered care throughout the childbirth that affect the perception of the quality of childbirth care [1, 27]. Our research demonstrated that although the content of care was more comprehensive in the hospitals with high AMIIMSS adherence compared to those with low adherence, women’s perceptions of the quality of care remained relatively low in IMSS hospitals compared to private facilities. This was evident in the multivariable analysis, which indicated that childbirth in private hospitals was the health provider-related variable associated with enhanced quality perception. This finding corresponds with a recent People Voice Survey in Mexico, which revealed that up to 39% of IMSS affiliates seek private healthcare due to perceptions of low quality at IMSS facilities [28]. The perception of quality was also adversely affected by obstetric violence, which was associated with a reduced perception of care quality among women. Reports of healthcare quality gaps during labor and obstetric violence are published worldwide, ranging from 3 to 78% [5, 29]. These issues can lead to poor outcomes for mothers and newborns and may discourage future engagements with healthcare providers [8]. In contrast to the AMIIMSS program, various interventions in resource-limited settings have shown promising results in reducing obstetric violence and enhancing women’s satisfaction with healthcare. For example, research conducted in Africa demonstrated that multi-component respectful maternity care interventions could improve women’s childbirth experiences and decrease disrespect and abuse [30]. In Iran, an intrapartum care model based on WHO recommendations significantly enhanced childbirth experiences and maternal satisfaction [31]. In Bangladesh, Ghana, and Tanzania, the “Every Mother Every Newborn Quality of Care standards” program established quality improvement teams across all leadership levels and created an enabling environment with necessary resources, policies, guidelines and clinical staff training on caregiving with compassion and respect and on engagement of women and their families in the decisions around the care. This intervention led to a reduction in physical abuse in Bangladesh, allowed women to voice their concerns and reduced verbal and physical abuse in Ghana, and improved privacy for women in Tanzania [32]. Similar to the AMIIMSS program, these successful interventions employed a multi-component approach that focused on improving infrastructure, addressing regulatory issues, training healthcare professionals, and empowering women. However, the relatively low perception of care quality at IMSS highlights gaps in staff training on women-centered care. This underlines the need for mandatory training in friendly obstetric care for all healthcare professionals involved in childbirth rather than just the 20% specified by the program. This training should focus on staff values, attitudes, and behaviors, as a vehicle for changing disrespectful and abusive practices [30].

A C-section is a safe delivery option when the vaginal delivery is contraindicated because the health of the mother and baby are at risk. The WHO recommends that C-section rates remain below 10–15%, as unnecessary C-sections offer no benefits and carry potential risks for both current and future pregnancies [33]. In our study, nine out of ten women in private hospitals and five out of ten women at IMSS underwent C-Sect. 30% of these surgeries were deemed unnecessary, and nearly 20% of women did not receive clear explanations regarding this procedure. The C-section rate at IMSS is comparable to other Latin American countries [34], but significantly higher than the OECD average of 28% [35]. Research indicates that strong medical leadership at both the institutional and hospital levels is essential to ensure that C-sections are performed only when they are genuinely needed. It is also important to provide healthcare professionals with continuous training on the benefits, risks, and appropriate indications for C-sections and offer meaningful counseling to women to support informed decision-making [36].

Hypertensive disorders of pregnancy and severe bleeding are leading causes of maternal deaths worldwide [7]. Two out of ten women in the eCohort faced complications during labor and postpartum, mainly from hypertensive disorders and severe vaginal bleeding, and only 2% of women were admitted to the intensive care units, which indirectly indicates that maternal complications during labor and postpartum were managed appropriately. However, 7.1% of women after vaginal delivery at IMSS and 60.3% after C-sections were discharged earlier than the WHO’s recommended times—24 h for vaginal deliveries and 72 h for C-sections. [37, 38]. These percentages were even higher in private hospitals. The WHO considers such early discharges too short to prevent, detect, and treat postpartum complications and provide adequate counseling. However, no maternal deaths were recorded in the eCohort, including those who dropped out from the study, as confirmed by the institutional mortality register.

Nearly one in three newborns in the IMSS cohort presented one or more complications during or after birth. There were five stillbirths and three neonatal deaths. Almost 9% of the births were preterm and of low birth weight. The most reported complication during delivery and after was difficulty in breathing, which can be partially attributed to the absence of surfactant and inadequate lung development in preterm infants. The newborns were admitted to the neonatal intensive care unit or pathological nursery when required. Globally, preterm birth is the leading cause for newborns being admitted to intensive care units and is linked to high neonatal mortality rates, as well as long-term physical, neurodevelopmental, and socioeconomic implications, due to the high costs for health systems and families [39].

Our research has some limitations. Firstly, participants self-reported the content of care, which may lead to inaccuracies regarding what occurred during the partum and postpartum. Also, women who are more educated or multiparous might better recall specific care components and are more likely to use private sector facilities. IMSS content of care may, therefore, be underestimated. Additionally, there is a chance that participants’ evaluations of their experiences could be influenced by social desirability bias, where they respond they believe are expected by society; however, the physical separation between the interviewer and the participant, along with the latter’s inability to observe the interviewer’s non-verbal cues, may result in more honest answers. Furthermore, we faced significant missing data due to a high dropout rate, which we managed by employing stabilized inverse probability weights.

In conclusion, the AMIIMSS program demonstrates significant potential in enhancing healthcare clinical activities during childbirth. Nevertheless, the existence of numerous hospitals exhibiting low adherence to the program, coupled with a comparatively lower quality of care perceived by women in relation to private hospitals, underscores the necessity to reinforce the program’s foundational pillars—namely, training, infrastructure, regulatory adaptation, and women’s empowerment—to improve experiences and promote the utilization of IMSS facilities. In addition, regular monitoring of women’s experiences and satisfaction with care is strongly recommended to assess AMIIMSS program advances and barriers to refine strategies for achieving Women-Centered Maternal Health Care at IMSS.