ARTCULO ORIGINAL

496 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012

Hernndez y col.
Facility-based care for delivery and
management of complications related to
pregnancy and childbirth in Mexico
Bernardo Hernndez, DSc,
(1,2)
Eduardo Ortiz-Panozo, MSc,
(2)
Ricardo Prez-Cuevas, DSc.
(3)
Hernndez B, Ortiz-Panozo E, Prez-Cuevas R.
Facility-based care for delivery and management
of complications related to pregnancy and childbirth in Mexico.
Salud Publica Mex 2012;54:496-505.
Abstract
Objective. To describe the incidence and management
of severe maternal and newborn complications in selected
health facilities in Mexico. Materials and methods. As part
of the WHO Multicountry Survey on Maternal and Newborn
health, information was collected from medical records of
women with deliveries and/or severe maternal complications
during pregnancy or puerperium in 14 hospitals in Mexico
City and the state of Guanajuato, Mexico. Results. Of 13 311
women, 157 (12 per 1 000 live births) had severe maternal
complications including 4 maternal deaths. The most frequent
complications were preeclampsia, postpartum hemorrhage,
and chronic hypertension. Adverse perinatal outcomes
were more frequent among women with severe maternal
complications. A high use of uterotonics and parenteral
antibiotics was found. A small proportion of women with
eclampsia received magnesium sulfate. Conclusions. This
study provides indicators on the incidence and management
of maternal and neonatal complications in Mexico, which
may be useful in studying and evaluating the performance of
obstetric services.
Key words: maternal mortality; pregnancy complications;
puerperal disorders; Mexico
Hernndez B, Ortiz-Panozo E, Prez-Cuevas R.
Atencin al parto y manejo hospitalario
de complicaciones del embarazo y nacimiento en Mxico.
Salud Publica Mex 2012;54:496-505.
Resumen
Objetivo. Describir la incidencia y manejo de complicaciones
maternas y neonatales severas en hospitales seleccionados de
Mxico. Material y mtodos. En el marco de la Encuesta
Multipas de la OMS sobre Salud Materna y Neonatal, se
recolect informacin de los expedientes mdicos de las
mujeres que tuvieron su parto o experimentaron complica-
ciones maternas severas durante el embarazo o puerperio
en 14 hospitales de la Ciudad de Mxico y el estado de
Guanajuato, Mxico. Resultados. De 13 311 mujeres, 157
(12/1 000 nacidos vivos) tuvieron complicaciones maternas
severas, incluyendo 4 muertes maternas. Las complicaciones
ms frecuentes fueron preeclampsia, hemorragia postparto
e hipertensin crnica. Los resultados perinatales adversos
fueron ms frecuentes en las mujeres con complicaciones
severas. Hubo un uso amplio de uterotnicos y antibiticos
parenterales. Una baja proporcin de mujeres con eclampsia
recibi sulfato de magnesio. Conclusiones. Esta encuesta
proporciona indicadores sobre la incidencia y manejo de las
complicaciones maternas y neonatales en Mxico, los cuales
pueden ser de utilidad para estudiar y evaluar el desempeo
de los servicios obsttricos.
Palabras clave: mortalidad materna; complicaciones del em-
barazo; trastornos puerperales; Mxico
(1) Institute for Health Metrics and Evaluation. University of Washington. USA.
(2) Centro de Investigacin en Salud Poblacional. Instituto Nacional de Salud Pblica. Mxico.
(3) Unidad de Investigacin en Epidemiologa y Servicios de Salud. Centro Mdico Nacional Siglo XXI. Instituto Mexicano del Seguro Social. Mxico.
Received on: October 28, 2011 Accepted on: February 15, 2012
Corresponding author: Mtro. Eduardo Ortiz-Panozo. Instituto Nacional de Salud Pblica. Av. Universidad 655,
col. Santa Mara Ahuacatitln. 62100, Cuernavaca, Morelos, Mxico.
E-mail: eduardo.ortiz@insp.mx
497 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Maternal and neonatal complications in Mexico
ARTCULO ORIGINAL
M
aternal and neonatal mortality are important
health priorities worldwide. It was forecasted that
273 500 maternal deaths and 2.8 million neonatal deaths
would occur worldwide in 2011.
1
The reduction of both
maternal and child mortality have been set as two of the
eight Millennium Development Goals,
2
helping to fuel
interventions to improve maternal, neonatal, and child
health.
3,4
Nevertheless, progress towards achieving such
goals varies substantially from country to country.
1,5,6
In 2010, Mexico had a maternal mortality ratio of
51.1 per 100 000 live births
7
and an infant mortality rate
of 14.2 per 1 000 live births.
8
In 2006, 38.1% of women
began prenatal care in frst trimester of pregnancy,
9
and
93% of deliveries were attended by health profession-
als, mainly medical doctors.
10
The cesarean section rate
among adult women who had a live birth in the fve
preceding years was 37.6%.
10
Quality of care plays an important role in reducing
maternal and neonatal mortality. Increasing care for de-
livery and obstetric emergencies has been recognized as
a key intervention for reducing maternal mortality.
3,4,11

This is substantiated by a growing body of evidence
from research studies on maternal deaths. However, it
is possible to learn about the effectiveness of interven-
tions to improve maternal health by focusing not only
on maternal deaths, but also on the near-misses, which
are cases of women who nearly died as a result of severe
complications related to pregnancy or delivery.
12
This
approach is also useful to analyze neonatal health.
In 2005, the World Health Organization (WHO)
launched a global survey (WHOGS), which obtained
information to construct criteria for the defnition of
maternal and neonatal near-misses;
13-16
in 2010 it began
data collection for a second wave, called Multicountry
Survey on Maternal and Newborn health (WHOMCS).
The objective of this survey was to analyze the incidence
and management of maternal and neonatal complica-
tions associated with maternal and neonatal mortality
in a sample of hospitals around the world. In this paper
we present the general results of WHOMCS in Mexico,
describing the main characteristics of delivery care and
the incidence and management of severe maternal and
newborn complications in selected health facilities.
Materials and methods
WHOMCS is a large facility-based survey being imple-
mented in 370 hospitals around the world. The survey
is a multicountry, multicenter near-miss criterion-based
clinical audit based on hospital records review being
implemented between 2010 and 2012, as described
elsewhere.
17
Population and sample
WHOMCS aimed to collect data on all births and all
cases with severe maternal complications which have
occurred over a period of time in selected hospitals. In
each country, the capital was included with certainty in
the sample, and two states were selected at random. In
Mexico, for logistic reasons only one state was included,
and therefore two study sites were selected: the coun-
trys capital (Mexico City) and the State of Guanajuato.
Within each study site, 7 hospitals were selected with
a probability of selection proportional to their annual
number of births. No other criteria were considered in
the selection of hospitals. The fnal sample was made up
of 14 facilities: 1 tertiary and 5 secondary hospitals from
the Ministry of Health (MoH), 3 tertiary and 3 secondary
hospitals from the Mexican Institute of Social Security
(IMSS), and 2 private sector hospitals.
The study sample included all deliveries and cases
of severe maternal complications treated in the partici-
pating hospitals within 2-3 months after August 2010.
The data collection period was 2 months for 5 facilities
with >6 000 annual births and 3 months for 9 facilities
with 6 000 annual births.
17

All women giving birth in the participating hos-
pitals and their respective newborns were eligible. All
maternal near-miss cases admitted in the participating
hospitals for up to seven days postpartum/postabor-
tion as well as all maternal deaths taking place in the
participating hospitals up to seven days postpartum/
postabortion (regardless of the gestational age and
delivery status) were also eligible.
17
Women referred
from other hospitals were included only if they were a
maternal death or a near-miss case.
Procedure
The general study was coordinated by WHO in Geneva
and in the Latin American participating countries by the
Centro Rosarino de Estudios Perinatales (CREP). Data
collection in Mexico was coordinated by the National
Institute of Public Health (INSP) and by IMSS. The
study protocol and the standardized data collection
instruments were approved by the research and ethics
committees of WHO, MoH, IMSS, and INSP, as well as
by participant hospitals when required.
Information at the individual level was collected
using a standardized format.
17
Trained personnel re-
viewed all hospital records of eligible women who were
discharged from the participating hospitals the previ-
ous day during the data collection period. Data related
to delivery, complications and care and medications
ARTCULO ORIGINAL
498 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Hernndez y col.
provided were collected. Data collected were entered
into a web-based online data entry system.
17
CREP
monitored data quality. Data queries were addressed
by comparing the data collected with their respective
hospitals records.
Denitions
We defned a maternal near-miss case as a woman
presenting at least one of the 25 WHO near-miss iden-
tifcation criteria at delivery/abortion, antepartum or
within seven days postpartum/postabortion. The WHO
near-miss identifcation criteria are based on cardiovas-
cular, respiratory, renal, coagulation/hematologic, he-
patic, neurologic, and uterine dysfunctions.
12-15,17
Severe
maternal outcome (SMO) was defned as the case of a
woman who either died or was a near-miss.
Eligible women were classifed as antepartum, de-
livery, postpartum, or abortive outcome: Antepartum
referred to women who were still pregnant when dis-
charged; Delivery included all women who gave birth;
Postpartum included all women who were admitted
anytime within seven days after delivery; Abortive out-
come was defned as the presence of any of the following:
ectopic pregnancy, abortion, product birth weight <500g,
or gestational age <22 weeks if product birth weight was
unknown.
Statistical analysis
We performed a descriptive analysis focusing on the ma-
ternal near-miss indicators as well as the criterion-based
clinical audit indicators. Several frequency measures on
maternal near-miss cases, maternal deaths, maternal
and newborn complications, and outcome and process
near-miss indicators were estimated following previ-
ously defned analyses algorithms.
17
The distribution
of selected variables was compared between women
with and without SMO by chi-square or Fishers exact
tests, as appropriate. The level of signifcance was 0.05,
two-tailed.
Results
Medical record review coverage was 90%, accounting
for 13 311 clinical records. Of them, 13 275 (99.7%)
were women admitted for delivery. Among them,
12 258 (92.3%) had no complication, 896 (6.8%) had
a no near-miss complication (i.e., a complication that
was not severe enough to be considered a near-miss),
and 121 (0.9%) had SMO. There were 36 women with
no delivery in participating facilities, of which 16 (44%)
had postpartum severe complication, 10 (28%) had an
abortive outcome and 10 (28%) had an antepartum se-
vere complication. SMO occurred in 157 of all women
(12 per 1 000 live births).
Maternal characteristics and complications
Table I depicts the maternal characteristics. Most
women were in the 20-35 age group (74.3%) [range
12-50 years], had a partner (85.6%), and had 9 or more
years of schooling (75.2%). Half of them (49.3%) were
in their frst pregnancy, and 75% had not had previous
cesarean section. These distributions were very similar
in the group of women with SMO, excepting that 38.2%
were in their frst delivery and 37.6% had a previous
cesarean section.
Table II shows the frequencies of maternal compli-
cations (comorbidity may occur). Postpartum hemor-
rhage, preeclampsia and chronic hypertension were the
most frequent. Among women with SMO, postpartum
hemorrhage occurred in 40.1% and preeclampsia in
26.8%. Coagulation/hematologic (50%), uterine (41%),
and cardiovascular (26%) were the most prevalent organ
dysfunctions among women with SMO. Considering the
entire sample, frequencies of maternal complications
were lower than 1%, except for preeclampsia (3.9%),
postpartum hemorrhage (1.7%), and chronic hyperten-
sion (1.2%). Hypertensive disorders occurred in 5.3% of
all women and in 42.7% of women with SMO.
Perinatal outcomes
Table III shows the distribution of onset of labor, mode
of delivery, and perinatal outcomes. Among all women,
73.3% experienced spontaneous onset of labor, 52.6%
had vaginal delivery and 47.4% had cesarean section
delivery. Spontaneous onset of labor (51%) and vaginal
delivery (18%) occurred at lower percentages among
women with SMO. The low birth-weight rate was 121
per 1 000 live births. The proportion of cases with ad-
verse perinatal outcomes (preterm births, fetal deaths,
early neonatal deaths, admissions to neonatal care unit
and low birth-weight) was higher (roughly 4- to 8-fold)
in the SMO group than in the total sample.
Of 10 women who had abortive outcome and SMO,
2 had vaginal delivery, 3 underwent laparotomy for
ectopic pregnancy, 4 underwent curettage or vacuum
aspiration, and one case was not determined.
Maternal near-miss indicators
Table IV shows the near-miss indicators. One-hundred-
ffty-three women had maternal near-miss complica-
tions and four died. The maternal near-miss incidence
499 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Maternal and neonatal complications in Mexico
ARTCULO ORIGINAL
Table I
MATERNAL CHARACTERISTICS OF WOMEN PARTICIPATING IN WHOMCS IN MEXICO,
FOR THE WHOLE SAMPLE AND WOMEN WITH SEVERE MATERNAL OUTCOMES.
SELECTED HOSPITALS OF THE FEDERAL DISTRICT AND STATE OF GUANAJUATO, MEXICO, 2010*
Characteristics
Women without severe maternal
outcomes

Women with severe maternal

outcomes

All women

Age

N=13 102 N=157 N=13 259

<20 years 2 272 (17.3) 17 (10.8) 2 289 (17.3)
20 35 years 9 738 (74.3) 111 (70.7) 9 849 (74.3)
>35 years 1 092 (8.3) 29 (18.5) 1 121 (8.5)
Marital status N=13 084 N=156 N=13240
No partner 1 879 (14.4) 27 (17.3) 1 906 (14.4)
With partner 11 205 (85.6) 129 (82.7) 11 334 (85.6)
Schooling years N=12 770 N=152 N=12922
< 5 years 421 (3.3) 9 (5.9) 430 (3.3)
5 8 years 2 748 (21.5) 24 (15.8) 2 772 (21.5)
9 11 years 5 372 (42.1) 67 (44.1) 5 439 (42.1)
> 11 years 4 229 (33.1) 52 (34.2) 4 281 (33.1)
Number of previous births
#
N=13 152 N=157 N=13309
0 6 507 (49.5) 60 (38.2) 6 567 (49.3)
1 2 deliveries 5 481 (41.7) 72 (45.9) 5 553 (41.7)
> 2 deliveries 1 164 (8.9) 25 (15.9) 1 189 (8.9)
Number of previous cesarean sections
#
N=13 150 N=157 N=13307
0 9 880 (75.1) 98 (62.4) 9 978 (75.0)
1 2 479 (18.9) 44 (28.0) 2 523 (19.0)
>1 791 (6.0) 15 (9.6) 806 (6.1)

* Data are n (%). Total percentages may not equal 100% due to rounding

Severe maternal outcomes dened as maternal near-miss or death

p < .001
#
p < .01. Chi-square test comparing women with and without severe maternal outcomes
ratio was 11.6 per 1 000 live births. The maternal near-
miss mortality ratio (i.e., the ratio between maternal
near-miss cases and maternal deaths) was 38 to 1.
Organ dysfunction or death occurred in the frst 24
hours of hospital stay in 46% of SMO cases (SMO24).
Of them, 43% were referred from other facilities. The
intra-hospital SMO rate was 6.5 per 1 000 live births.
SMO24 and intra-hospital mortality indices were 5.6%
and 0.0%, respectively.
Among the 1.6% (211/13 311) of women who were
admitted to the intensive care unit (ICU), 36% were wom-
en with SMO. The ICU admission rate among women
with SMO was 48% and the proportion of maternal deaths
without being admitted to the ICU was 25%. Maternal
death occurred in 1.4% of women admitted to the ICU.
Process and outcome indicators
This survey documented process and outcome indica-
tors related to specifc conditions among women who
gave birth in participating hospitals (Table V). Oxytocin
was widely used to prevent postpartum hemorrhage
(PPH) and as a therapeutic measure for severe PPH.
Two-hundred-thirteen women had PPH. Of them, 91.5%
received uterotonics, 8.9% had intrauterine tamponade
or arterial ligation, and 16.9% underwent hysterectomy.
About 25% of cases with PPH had organ dysfunction,
and one died. Magnesium sulfate was used as an anti-
convulsant in 46.7% of the 30 women with eclampsia.
Nine of them had organ dysfunction; all survived.
Among the 6 295 women who underwent cesarean sec-
ARTCULO ORIGINAL
500 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Hernndez y col.
Table II
MATERNAL COMPLICATIONS OF WOMEN PARTICIPATING IN WHOMCS IN MEXICO, FOR THE WHOLE SAMPLE
AND WOMEN WITH SEVERE MATERNAL OUTCOMES. SELECTED HOSPITALS OF THE FEDERAL DISTRICT
AND STATE OF GUANAJUATO, MEXICO, 2010*

Women without SMO

Women with SMO

All women
N=13 154 N=157 N=13 311

Hemorrhage
Abortion related hemorrhage

0 (0.00) 4 (2.55) 4 (0.03)

Ectopic pregnancy

0 (0.00) 3 (1.91) 3 (0.02)

Placenta praevia

41 (0.31) 15 (9.55) 56 (0.42)

Accreta/increta/percreta placenta

7 (0.05) 13 (8.28) 20 (0.15)

Abruptio placentae

22 (0.17) 6 (3.82) 28 (0.21)

Ruptured uterus

4 (0.03) 4 (2.55) 8 (0.06)

Postpartum hemorrhage

160 (1.22) 63 (40.13) 223 (1.68)

Other obstetric hemorrhage

24 (0.18) 16 (10.19) 40 (0.30)

Infection
Abortion related infection
#
0 (0.00) 1 (0.64) 1 (0.01)
Puerperal endometritis

5 (0.04) 3 (1.91) 8 (0.06)

Pyelonephritis 9 (0.07) 1 (0.64) 10 (0.08)
Inuenza-like illness 7 (0.05) 0 (0.00) 7 (0.05)
Other systemic infections / sepsis

70 (0.53) 10 (6.37) 80 (0.60)

Hypertensive disorders
Chronic hypertension

147 (1.12) 13 (8.28) 160 (1.20)

Pre-eclampsia (excludes eclampsia)

475 (3.61) 42 (26.75) 517 (3.88)

Eclampsia

21 (0.16) 12 (7.64) 33 (0.25)

Other complications or diseases
HIV + / AIDS / HIV wasting syndrome 3 (0.02) 0 (0.00) 3 (0.02)
Severe Anemia

52 (0.40) 15 (9.55) 67 (0.50)

Malaria / dengue 0 (0.00) 0 (0.00) 0 (0.00)
Embolic disease (thrombo/amniotic/air embolism)
#
3 (0.02) 1 (0.64) 4 (0.03)
Cancer 2 (0.02) 0 (0.00) 2 (0.02)
Heart disease 19 (0.14) 0 (0.00) 19 (0.14)
Lung disease

5 (0.04) 4 (2.55) 9 (0.07)

Renal disease

12 (0.09) 9 (5.73) 21 (0.16)

Hepatic disease

5 (0.04) 6 (3.82) 11 (0.08)

Coincidental conditions 4 (0.03) 1 (0.64) 5 (0.04)
Other conditions leading to organ dysfunction

0 (0.00) 23 (14.65) 23 (0.17)

Organ dysfunction
Cardiovascular dysfunction 0 (0.00) 41 (26.11) 41 (0.31)
Respiratory dysfunction 0 (0.00) 23 (14.65) 23 (0.17)
Renal dysfunction 0 (0.00) 11 (7.01) 11 (0.08)
Coagulation/hematologic dysfunction 0 (0.00) 79 (50.32) 79 (0.59)
Hepatic dysfunction 0 (0.00) 11 (7.01) 11 (0.08)
Neurologic dysfunction 0 (0.00) 12 (7.64) 12 (0.09)
Uterine dysfunction/hysterectomy 0 (0.00) 64 (40.76) 64 (0.48)
Unspecied organ dysfunction 0 (0.00) 0 (0.00) 0 (0.00)
Multiple organ dysfunction 0 (0.00) 41 (26.11) 41 (0.31)

* Data are n (%). Coexisting complications may occur.

SMO, Severe maternal outcomes dened as maternal near-miss or death.

p < .001
#
p < .05. Fishers exact test comparing women with and without severe maternal outcomes.
501 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Maternal and neonatal complications in Mexico
ARTCULO ORIGINAL
tion, 82.2% received prophylactic antibiotics. Eighty-one
out of the ninety-three women who had infection/sepsis
received parenteral therapeutic antibiotics. Nine women
with infection/sepsis presented organ dysfunction, and
one died. Regarding 1 190 women who had preterm
delivery after three hours of hospital stay, 37% received
corticosteroids for fetal lung maturation.
Discussion
These fndings of WHOMCS in selected Mexican hos-
pitals show that the rate of SMO was 12 per 1 000 live
births, including 4 maternal deaths; postpartum hemor-
rhage, preeclampsia, and chronic hypertension were the
most prevalent complications; hematologic, uterine, and
Table III
ONSET OF LABOR*, MODE OF DELIVERY* AND PERINATAL OUTCOMES*,

FOR THE WHOLE SAMPLE

AND WOMEN WITH SEVERE MATERNAL OUTCOMES. WHOMCS IN MEXICO. SELECTED HOSPITALS
OF THE FEDERAL DISTRICT AND STATE OF GUANAJUATO, MEXICO, 2010

Women without SMO

#
Women with SMO
#
All women

Onset of labor
&
N=13 142 N=117 N=13 259
Spontaneous 9 662 (73.5) 60 (51.3) 9 722 (73.3)
Induced 1 355 (10.3) 23 (19.7) 1 378 (10.4)
Cesarean section with no labor 2 125 (16.2) 34 (29.1) 2 159 (16.3)
Mode of delivery
&
N=13154 N=121 N=13275
Vaginal delivery 6 954 (52.9) 21 (18.0) 6 975 (52.6)
Cesarean section 6 200 (47.1) 100 (82.1) 6 300 (47.4)
Preterm births
&
N=13 138 N=117 N=13 255
1 351 (10.3) 47 (40.2) 1 398 (10.6)
Fetal deaths

N=13 154 N=117 N=13 271

104 (0.8) 9 (7.7) 113 (0.9)
Early neonatal deaths (intra-hospital)

N=13 048 N=108 N=13 156

74 (0.6) 3 (2.8) 77 (0.6)
Neonatal intensive care unit admission
&
N=13 050 N=108 N=13 158
1 544 (11.8) 48 (44.4) 1 592 (12.1)
Birth weight distribution among live births

N=13 050 N=108 N=13 158

<1750g 354 (2.7) 21 (19.4) 375 (2.9)
1750-2249g 510 (3.9) 11 (10.2) 521 (4.0)
2250-2499g 683 (5.2) 7 (6.5) 690 (5.2)
2500-3999g 11 214 (85.9) 66 (61.1) 11 280 (85.7)
>4000g 289 (2.2) 3 (2.8) 292 (2.2)

* Among women who had a delivery in the participating health facilities (excludes those women admitted in the postpartum period and those who did not
have a delivery)

In case of multiple pregnancies, data refer to rst neonate

Data are n (%). Total percentages may not equal 100% due to rounding
#
SMO, Severe maternal outcomes dened as maternal near-miss or death
&
p < .001 Chi-square test

p < .001

p < .05. Fishers exact test comparing women with and without SMO
ARTCULO ORIGINAL
502 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Hernndez y col.
cardiovascular dysfunctions were the most frequent in
women with SMO; adverse perinatal outcomes were
more prevalent in women with SMO than in the total
sample; and process and outcome indicators on preven-
tive and therapeutic measures for postpartum hemor-
rhage and infection/sepsis showed better results than
indicators for eclampsia and preterm birth.
The maternal near-miss incidence ratio in this study
(11.6 per 1 000 live births) contrasts with the fndings of
WHOGS, which showed ratios of 34.3 and 32.6 per 1 000
deliveries for Latin American countries and Mexico,
respectively.
15
This difference is probably due to the
different defnitions of maternal near-miss cases in these
two studies. By 2005, the near-miss identifcation criteria
had not yet been developed, and in WHOGS a maternal
near-miss was defned as a woman who had experienced
admission to ICU, blood transfusion, hysterectomy,
eclampsia, cardiac or renal complications.
15
The criteria
Table IV
MATERNAL NEAR-MISS INDICATORS. WHOMCS IN
MEXICO. SELECTED HOSPITALS OF THE FEDERAL DISTRICT
AND STATE OF GUANAJUATO, MEXICO, 2010
All live births* N=13 169
Severe maternal outcomes (SMO) cases N=157
Maternal deaths N=4
Maternal near-miss cases N=153
Overall near-miss indicators
Severe maternal outcome ratio (per 1,000 live births) 12
Maternal near-miss incidence ratio (per 1,000 live births) 11.6
Maternal near-miss mortality ratio

38 : 1
Mortality index 2.6%
Hospital access indicators
SMO cases presenting the organ dysfunction or maternal
death within 24 hours of hospital stay (SMO24)
N=72
Percentage of SMO24 cases among all SMO cases 45.9%
Percentage of SMO24 cases coming from other health
facilities
43.1%
SMO24 mortality index 5.6%
Intra-hospital care
Intra-hospital SMO cases N=85
Intra-hospital SMO rate (per 1,000 live births) 6.5
Intra-hospital mortality index 0.0%

* In case of multiple pregnancies, data refer to rst neonate

Ratio between maternal near-miss cases and maternal deaths

Table V
PROCESS AND OUTCOME INDICATORS RELATED
WITH SPECIFIC CONDITIONS.* WHOMCS IN MEXICO.
SELECTED HOSPITALS OF THE FEDERAL DISTRICT
AND STATE OF GUANAJUATO, MEXICO, 2010
n %
Prevention of postpartum hemorrhage
Target population: women giving birth
in health facilities

13 270 100
Oxytocin 12 586 94.9
Any uterotonic (including oxytocin) 12 601 95.0
Treatment of severe postpartum hemorrhage n %
Target population: women with
postpartum hemorrhage
213 100
Oxytocin 174 81.7
Misoprostol 30 14.1
Ergometrine 83 39.0
Other uterotonics 65 30.5
Any uterotonics 195 91.5
Artery ligation 13 6.1
Balloon or condom tamponade 6 2.8
Hysterectomy 36 16.9
Severe maternal outcomes 53 24.9
Deaths 1 0.5
Use of anticonvulsants for eclampsia n %
Target population: women with eclampsia 30 100
Magnesium sulfate 14 46.7
Other anticonvulsant 11 36.7
Any anticonvulsant 17 56.7
Severe maternal outcomes 9 30
Deaths 0 0
Prevention of cesarean section related infection n %
Target population: women undergoing
cesarean section
6 295 100
Prophylactic antibiotics during cesarean section 5 173 82.2
Treatment for sepsis n %
Target population: women with
infection/sepsis
93 100
Parenteral therapeutic antibiotics 81 87.1
Severe maternal outcomes 9 9.7
Deaths 1 1.1
Preterm birth n %
Target population: women having a
preterm delivery after 3 hours of hospital stay
1 190 100
Corticosteroids for fetal lung maturation 439 36.9

* Among women who had a delivery in the participating health facilities
(excludes those women admitted in the postpartum period and those
who did not have a delivery)

Excludes cases with unknown mode of delivery

503 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Maternal and neonatal complications in Mexico
ARTCULO ORIGINAL
used in WHOMCS are stricter than those of WHOGS
(e.g., evidence of organ dysfunction is required instead
of the simple registry of admission to ICU).
12-15,17
Devel-
opment of near-miss concept is detailed elsewhere.
12
The cesarean delivery rate was 47% for all women
and 82% for women with SMO. These results are consis-
tent with the high rates of cesarean deliveries reported
in Mexico and other Latin American countries.
13,18,19

WHO recommends cesarean delivery rates should be
between 5 and 15%,
20
and Mexican standards establish
they should be around 15 and 20% for secondary and
tertiary hospitals, respectively.
21
High rates of cesarean
delivery might be associated with increased maternal
and perinatal morbidity, especially in cases in which
cesarean section has no medical indication.
13,18
Although
the incidence of cesarean section found in this study
should be considered with caution due to the charac-
teristics of the sample (discussed later), further analyses
are needed to gain better understanding of the impact of
high cesarean delivery rates on maternal and perinatal
outcomes in Mexico.
The wide use of oxytocin for all women giving birth
and prophylactic antibiotics for women who underwent
cesarean delivery, but the lower proportion of use of
corticosteroids for fetal lung maturation for women who
had a preterm delivery after three hours of hospital stay
suggest that preventive measures for neonatal respira-
tory complications are carried out less frequently than
preventive measures for PPH and infection/sepsis. In
addition, the survey found a high use of uterotonics for
women with PPH and parental antibiotics for women
with infection/sepsis, compared to the low proportion
of women with eclampsia who received magnesium
sulfate, despite the efforts of the health sector to promote
the use of magnesium sulfate for the treatment of this
condition. Moreover the near-miss mortality ratio (i.e.,
the ratio between maternal near-miss cases and maternal
deaths) was 53:1 for PPH in comparison to 9:1 for sepsis.
The differences among these indicators should prompt
further research studies and intervention.
This study shows the importance of addressing nor-
mative aspects, such as quality of care, appropriate use
of medications and referral to mitigate or decrease the
rate of women with SMO and neonatal complications.
Regarding quality of care, the characteristics of women
such as their reproductive age and social conditions
should be taken into account during antenatal care. In
addition some of the complications such as postpartum
hemorrhage, sepsis and hypertensive disorders can be
identifed in a timely manner and even avoided with
appropriate risk-assessment during antenatal care
and the hospital stay. This survey provide information
for clinicians to guide their decision-making process
towards a risk-based approach (in which case it would
be helpful to search or identify possible complications)
vs. reactive-based approach in which their actions are
guided to care for ongoing obstetric emergencies. Re-
solving too early a complicated pregnancy or labor may
have deleterious effects on the neonate; the low rate
of use corticosteroids for fetal lung maturation shows
room for improvement. The analysis of the SMO24 also
suggests opportunities for improving the referral system
among hospitals. A signifcant percentage of women
with SMO can be reduced with appropriate measures.
The study has been supervised by a well-known
research team, taking care of the mechanisms to increase
data quality in different countries. However, analyzing
solely the information from Mexico imposes limitations
that should be taken into account when interpreting the
results. First, the sample for this study was designed to
provide information on the characteristics of delivery
care and management of maternal and neonatal compli-
cations in the total sample of WHOMCS. Therefore, the
sample at the national level is small, especially when try-
ing to study low incidence adverse maternal outcomes.
Although the sampling design determined stratifcation
according to the size of the hospital, the study sample
does not constitute a representative sample of facilities
providing delivery care in Mexico. The characteristics of
the sampling design may lead to different estimates of
the incidence of complications than the ones we could
obtain in a survey with national representativeness.
Thus, the estimates derived from this study should not
be extrapolated to the national situation or stratifed by
institution (MoH, IMSS). Despite of these limitations,
this analysis provides initial estimates that may be useful
for decision makers.
Another limitation is that the data used in this analy-
sis rely on the completeness and accuracy of hospital
records and, to some extent, on the expertise of data
collectors at interpreting medical information. It is pos-
sible that records of cases with complications were not
located, and therefore some information was missing,
thus leading to underestimate the incidence of compli-
cations. Although given the high coverage of medical
records reviewed, we would expect it to be minor. There
are a number of complex factors that might result in
inaccuracy of hospital records. Routine procedures (e.g.,
antibiotic prophylaxis) might not be fully documented.
When severe complications occur, attention might be
more focused on providing care than documenting it in
hospital records. Completeness of medical records might
be a particular issue in the case of women referred from
other hospitals, since access to information on situation
and procedures provided was only guaranteed after
admission to participating hospitals. To minimize the
ARTCULO ORIGINAL
504 salud pblica de mxico / vol. 54, no. 5, septiembre-octubre de 2012
Hernndez y col.
potential errors, CREP monitored data entry by several
quality control procedures; all data inconsistencies were
clarifed and/or amended by checking collected data
with corresponding medical records; data collectors were
trained before data collection.
The information from this survey, although it does
not provide a representative sample of facilities provid-
ing delivery care in Mexico, contributes to the general
dataset of WHOMCS, which can provide important
insights regarding the treatment of maternal and neo-
natal complications. From a national level standpoint
this survey provides data on indicators that may help to
characterize and evaluate better obstetric care in Mexico,
thus contributing to the efforts aimed at improving
quality of care.
Acknowledgements
The Multicountry Survey on Maternal and Newborn
Health is a research project implemented by WHO in
a global network of health facilities between 2010 and
2012. This project is part of the WHO response to the
United Nations Secretary-General call for action for
improving womens and childrens health around the
world. In this connection, the Organization is grateful
to the extensive network of institutions and individuals
who contributed to the project design and implemen-
tation, including researchers, study coordinators, data
collectors, data clerks and other partners including the
staff from the Ministries of Health and WHO offces.
This study is fnancially supported by the UNDP/
UNFPA/WHO/World Bank Special Programme of
Research, Development and Research Training in Hu-
man Reproduction (HRP); WHO; United States Agency
for International Development (USAID); Ministry of
Health, Labour and Welfare of Japan, and Gynuity
Health Projects.
We recognize the participation of the following
persons and institutions in this project: Global coordina-
tion unit: Joo Paulo Souza, A Metin Glmezoglu; Latin
American countries coordinator: Guillermo Carroli; Data
management and quality control procedures: CREP. We
also recognize the collaboration of Dr. Bernardo Bidart
(Secretara de Salud, SSA), Dr. Federico Lazcano (SSA
Gobierno del Distrito Federal), Dr. Jorge Aguirre and
Dr. Luis Garca (SSA Estado de Guanajuato) for their
support in data collection of this project.
Gloria Galvn, Mara Elena Reyes, Sofa Reynoso,
Rafael Rodrguez participated as feld supervisors, and
Andrea Cerecero, Margarita Torres, Karina Prieto, Karina
Castillo, Beln Reyes, Virginia Ramos, Hortensia Gmez
and Yenisey Valencia made up the support team.
We specially acknowledge the contribution and
support of the following persons in each one of the
participating hospitals:
Mexico City
Hospital Materno Infantil de Inguarn: Martn Vive-
ros, Carmen Canchola, Laura Garca, Armando
Chvez, Lourdes Garca, Toms Prez, Junne Gil
Mrquez, Mara Matilde Cruz, Alejandro Gmez,
Israel Aguilar.
Hospital Asoc. Hispano Mexicana CIMIgen Tlhuac:
Carlos Vargas, Sergio Camal, Mara Micaela Lpez,
Rosalva Bolaos.
Hospital de la Mujer: Mauricio Pichardo, Francisco
Arvalo, Ana Lilia Chvez, Dalia Zenteno, Adriana
Salgado, Evelin Herrera, Ada Contreras.
Hospital de Gneco-Obstetricia N 3 La Raza: Oscar
Martnez, Mara Guadalupe Veloz.
Hospital de Gneco-Obstetricia N 4 Dr. Luis Caste-
lazo Ayala: Gilberto Tena, Carlos Moran, Lizethe
Piedras.
Hospital General Manuel Gea Gonzlez: Octavio Sierra,
Lizette Munzo, Arturo Enrquez, Lourdes Surez,
Norberto Reyes.
Hospital Tehuantepec: Carlos Lowemberg, Eduardo
Lowemberg.
State of Guanajuato
Hospital General de Zona N 2 Irapuato: Alberto
Patio, Mercedes Patio, Adrian Velzquez, Martha
Georgina Franco.
Hospital General de Zona N 4 Celaya: Faustino Agui-
lar, David Flores, Mara Guadalupe Arana.
Hospital General de Zona N 3 Salamanca: Juan
Guillermo Regalado, Jos Luis Barrera.
Hospital de Gneco-Pediatra N 48 Len: Arturo Es-
trada, Vctor Godnez, Teresita Ros.
Hospital General de Irapuato: Julin Valero, Jos Cor-
rales, Daniel Vzquez.
Hospital General de Len: Gregorio del Campo, Juan
Carlos Gutirrez, Leopoldo Lpez.
Hospital General Guanajuato: Ral Rojas, Norma An-
glica Olmos
Declaration of conict of interests. The authors declare that they have no
conict of interests.
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