Maternal Death in Mexico
Summary and Keywords
Today, the death of women during pregnancy, childbirth or postpartum is considered simultaneously a public health, social inequality, and gender discrimination problem. In Mexico, approximately one thousand women die each year during pregnancy, childbirth, postpartum or from an unsafe abortion, experiencing a premature and sudden death in the midst of their most productive years, often with lasting consequences for their families and surviving children. As elsewhere, the great majority of these deaths would not have occurred if women had had prompt and unlimited access to quality emergency obstetric care, as well as easy access to contraceptives to prevent unwanted pregnancies. Most deaths are related to the substandard quality of available maternal healthcare services; services that are provided for free to most Mexican women in an overly saturated and underfunded public health system that also tends to overmedicalize and pathologize normal births. Their prematurity and abruptness, their occurrence in the process of giving life, the fact that these deaths exclusively affect women, and their avoidable nature make maternal mortality unacceptable in today’s social, political, and ethical arenas.
From an historical perspective, deaths in childbirth were much more common in past centuries than today; these deaths were considered inevitable and were accepted as natural occurrences until the late 19th century. However, surrounding rituals, the meaning attached to these deaths, related notions of womanhood and motherhood, and practices to prevent or avoid them, underwent changes according to broader sociocultural, political and religious transformations from Pre-Hispanic times to the 20th century.
As elsewhere, in Mexico maternal deaths declined considerably in the 1930s–1950s with the discovery of penicillin and the concomitant decline of puerperal fever; they reached a plateau in the 1960s and 1970s and began to slowly decline again in the 1980s–1990s with an even steeper decrease after the signature of the United Nations (UN) Millennium Development Goals in the year 2000; time when the reduction of maternal mortality became one of eight high-priority global public policy objectives, closely monitored by UN bodies.
Maternal deaths are a reflection of ingrained multiple social inequalities that characterize Mexican society at large; poor, rural, marginalized and Indigenous pregnant women face a 2–10 times higher risk of dying than the rest of Mexican women, because their access to contraception and to prompt and high quality obstetric emergency care is more limited. Today, research in the field of maternal mortality etiology, measurement and reduction includes the call for women-centered respectful maternal care, the elimination of discrimination in the provision of obstetric services and the application of a human rights perspective to health policies, programs, and care.
Maternal Mortality in Numbers
According to official mortality records, between 1955 and 2012, 120,000 women died during pregnancy and childbirth in Mexico; 13,000 of these between the years 2000 and 2012.1 More accurate figures are at least 40–50 percent higher because of underreporting and misclassifications, locating actual numbers to around 170,000–200,000 women dying for obstetric causes or unsafe abortion in those two to three generations.
These numbers are high considering that most maternal deaths are either preventable or avoidable, given medical knowledge, technology, and care surrounding pregnancy and delivery. Knowledge and technology became increasingly available after the late 1930s, when antibiotics were discovered, creating a breakthrough in the reduction of infections during and after birth and related to unsafe abortions. At that time, infections were the leading maternal mortality cause. By mid-century, societal perceptions surrounding these deaths had changed, and the healthcare system was more responsive and responsible for their prevention and reduction. Although rates and numbers were comparatively higher, Mexico was similar to most developed countries, where maternal deaths declined dramatically by the mid-1900s.2
The World Health Organization (WHO) defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”3 Worldwide, maternal mortality is measured as the ratio of the total number of deaths of women during pregnancy, childbirth, postpartum (up to 42 days after delivery), or for abortion per 100,000 live births per year in a given population.4 This ratio expresses the risk of dying that any pregnant woman faces at any given time.
In everyday life, a maternal death is a relatively rare event. Accurate measurements can be problematic and maternal mortality statistics can be quite unreliable, so much so that the WHO uses estimates for many countries in the world instead of official national mortality statistics.
Yet the accurate measurement of maternal mortality is important for public health, healthcare, and social policy, and it has been a major topic in maternal mortality research in the last two decades, in Mexico as elsewhere. Reliable baselines are needed to detect trends across time and location; to make subnational, national, international, or regional comparisons as well as within or among population groups differentiated by location, age, education, income and/or health service coverage; and to measure progress toward reduction. It is imperative to design and implement general and specific health policies that aim at its prevention and reduction. The maternal mortality ratio is the most relevant and widely used indicator in the impact of policies, programs, and services. Misclassification (the classification and codification of a different mortality cause that is not pregnancy-related) and underreporting (the non-registry of maternal deaths) are common problems in maternal mortality records.
According to official statistics, the maternal mortality ratio (MMR) in Mexico diminished tenfold from 1930 to 1990.5 In the following twenty years, the rate of decline of the MMR slowed considerably; overall, only a 40 percent decline was achieved by 2010, the year when the official MMR was set at 52.6 In 2014, the last year for which official data are available, the national MMR declined to 39 per 100,000 live births.7 Despite these declines, the Mexican MMR continues to compare negatively to most Western European countries (with MMRs of 3–7) and to selected Latin American countries, such as Chile (18), Costa Rica (23), Cuba (33), and Uruguay (8).8
Mexico’s vital statistics are of good quality, but maternal deaths are among the easiest to misclassify and, together with newborn deaths, can still go unregistered under circumstances primarily associated to isolated rural living, ethnicity, and extreme poverty. Mexico has significantly improved its maternal mortality records in recent years. The United Nations calculated overall underreporting for the country at 40–50 percent up to the new millennium. From 2002 onward, Mexico reduced misclassification through constant monitoring of maternal deaths by the Federal Ministry of Health and the 32 States Ministries of Health and through the application each year of an intentional review of death records of women of reproductive age. To accomplish this review, the Federal Ministry of Health developed a modified version of the WHO-recommended Reproductive-Age Mortality Studies (RAMOS) method.9
The modified RAMOS method actively searches mortality data of women of reproductive age whose attributed clinical causes of deaths are included in a list of 46 disease conditions classified in the WHO International Classification of Diseases, 10th Revision, as unrelated to pregnancy. They refer to clinical conditions that may well and easily mask the occurrence of actual maternal deaths that were misclassified in original death certificates or records.10 Since the annual implementation of the intentional review, official sources have argued that underreporting has fallen to approximately 20 percent, roughly the same percentage of underreporting that the WHO currently assigns to Mexico.11 The greatest problems of underreporting and misclassification tend to occur in the same poverty-stricken states that have the greatest MMR.12
Historical Overview of Maternal Death in Mexico
According to archeological and paleopathology studies, in pre-Hispanic times maternal and perinatal mortality were very high. In the great city of Teotihuacán, located in the northeastern outskirts of today’s Mexico City, life expectancy at around 600 ce—the zenith of the Teotihuacán civilization—was very low at birth. In this greatly populated city of 125,000 to 200,000 inhabitants, life expectancy did not even reach 17 years of age, which increased to 38 years for people who were lucky enough to survive to 20 years of age. Evidence from burial sites seems to indicate that infections were rampant and perinatal mortality was extremely high13; it is likely that, under these circumstances, women at birth also died in very high numbers.
The monumental twelve-volume Florentine Codex from the 16th century is the first detailed ethnographic account of life, customs, beliefs and worldviews among the Aztecs, written a few decades after the Conquest. In it, Fray Bernardino de Sahagún narrates how pre-Hispanic women who died during their first childbirth were called in the Nahuatl language “mocihuaquetzque” or “valiant women.” They were thought to have fought the battle between life and death very bravely, for which they were rewarded by joining Huitzilopochtli, the Sun God, in its daily journey from East to West in its house, the sky. They shared this privilege with warriors who fought and lost their lives in battle. These women called cihuateteo (women who died in childbirth) were idolized and worshipped as Goddesses. Immediately after dying, they were taken into procession by midwives and their families. Their bodies had to be heavily protected in the days and nights following their death before and during burial lest male soldiers cut off their scalps or arms because they were thought to be invaluable by protecting them from falling prey to enemies in battle.14
The Florentine Codex also mentions that Aztec midwives were important figures in charge of assisting and providing important emotional support to women in childbirth. Midwives were highly respected in Aztec culture; they shared important technical skills and could practice embryotomy—the dismemberment of the fetus—when normal birth was impossible and/or the fetus was dead, to save the woman’s life. Embryotomy was performed with an obsidian knife after consent by the woman’s parents. If there was no consent and no other way to save her life, the midwife locked the woman inside her chamber to wait alone until death came to free her from suffering and earthly life.15
Similar to the Florentine Codex, in the Codex Borgia, a pre-Hispanic Mixtec woman who died in childbirth was considered a Ñu Dzehe, a woman-goddess.16 They were feared because they could navigate the airs and descend on earth on five dreaded dates during the calendar year, performing magic and harm. Historical interpretations tend to agree on a similar leitmotif across pre-Hispanic Mesoamerican cultures where the association between women, fertility, and their unique ability to give life was stressed and celebrated, as common archeological artifacts such as clay figures of pregnant women with ample breasts and strong legs from those times symbolize. Their death in childbirth was glorified and feared at the same time because of their essential power associated with womanhood, fertility, and the divine.
Historical demographers tend to agree that maternal, neonatal, and child mortality were very high in pre-Hispanic times, a pattern that persisted for centuries after the Conquest. General life expectancy has been calculated at approximately 21–28 years of age, according to some archeological studies on pre-Conquest Mesoamerica, where epidemics, starvation, and wars were the major,17 but surely not the only, causes of death. In that context, where life was often in jeopardy, we can understand the emphatic sociocultural meaning attributed to fertility and maternity before the Conquest and the social recognition and celebration of the role played by women in giving life or perishing in childbirth.
While pre-Hispanic Aztec women who died giving birth were glorified in the same way as valiant warriors, in Catholic colonial New Spain or even in Independent Mexico, women from all population strata and castes—nobles or commoners, Spaniards, criollas, mestizas, Indigenous or mulatto alike—became largely invisible in secular or religious chronicles, legal documents, or administrative registries dealing with death and dying. The massive genocide of indigenous men, women, and children alike in the first decades after the Conquest18 and the devastating epidemics of the 16th century and the beginning of the 17th century in New Spain may explain why maternal deaths were overlooked. Historians and demographers working on mortality tend to focus on “unnatural” deaths and to analyze population trends following epidemics that killed natives by the millions19; dramatic Indigenous population drops have been estimated at 56–95 percent in 1595 compared with 1519 pre-Conquest levels.20 In such a context, maternal deaths were not only considered natural events but were probably also perceived as insignificant in number vis-à-vis devastating epidemics as facts of life.
With the widespread Christianization of surviving indigenous people and the firm establishment of the religious and secular colonial order between the 16th and the 18th centuries, historians of colonial Spanish America continue to be quite silent on the role played by women in childbirth or to give specific attention to their deaths. In Catholic New Spain, where female sexuality was strictly controlled and women were mostly subordinated to male authority, the death of women in childbirth from different castes and classes were likely seen as uneventful deaths related to their natural vocation and expected social role to pursue reproduction and motherhood. Such events occurred within the sanctity of matrimony and with the solace of a priest in the pursuit of their souls’ salvation when death was inevitable. Because maternal and child mortality continued to presumably be quite high and life expectancy low in New Spain and because this trend continued after Mexican Independence in 1821, it is likely that maternal fatalities continued to be considered common events and natural deaths that, by themselves, did not warrant particular attention.
Nicolás León, a physician who wrote the book History of Obstetrics in Mexico in 1910, refers to the medical doctrines, practices, and remedies of previous decades and centuries. He reports that the “Compendium of Medicine,” written by a Dr. Vanegas and published in 1788 in Mexico City, enlisted a series of remedies vis-à-vis difficult deliveries that drew on the prevailing Ars Medica of the time. By the end of the 18th century, for hemorrhage and for convulsions as well, bleeding by leeches in the woman’s calf was recommended; a steaming bath as well as emollient enemas were also prescribed to the laboring woman who was bleeding excessively.21 According to the aforementioned Dr. Vanegas, administering cold water postpartum was a major cause of death because it provoked a major imbalance of the woman’s bodily humors and stopped all evacuations.22
The Spanish colonial state attempted to regulate the medical and paramedical professions, including midwives, through the Royal Tribunal of the Protomedicato in Mexico City. From 1750 until 1831, when the newly independent Mexican authorities abolished the Protomedicato, midwives were ordered to call on surgeons in difficult deliveries.23 With the development of medicine as an academic discipline and the establishment of formal training schools in obstetrics in the 19th century, the medical profession was pivotal in developing midwifery as a formal career under the direct supervision of physicians in Mexico.24 Scholars working in the history of medicine have stressed the close relationship between the origins, development, and demise of professional midwifery and the progressive establishment of the medical specialty of gynecology and obstetrics in the 19th and 20th centuries.25 Carrillo argues that in Independent as well as in post-revolutionary Mexico, physicians promoted the regulation and subordination of, as well as medical training among, formally educated midwives as ways to increasingly marginalize traditional midwives who attended the great majority of births and as a way to ensure access to pregnant and laboring women for the medical profession.26
The History of Obstetrics in Mexico is an eloquent example of the systematic effort at the turn of the century to disqualify the figure and work of midwives, attempting to displace them from the birth scene regardless of their formal training or actual practice. The author uses the following words to open a chapter dedicated to this attending figure:
Each century brings us a discovery; purposely, there was one in which the discovery was that a midwife was needed in order to give birth; the midwife is daughter to a progressive civilization that neither Adam nor Eve ever met; lucky them who did not know the midwife, this appendix of the medical-surgical profession, because truly in the Medical Body [profession] the midwife is like a wart in the human body …27
Carrillo stresses that the disqualification and attempted displacement by the medical body of midwives was carried out in an assault that lasted more than a century before finally claiming success in the 1960s–1980s. It was carried out in the name of the alleged superiority of physicians’ medical education and by virtue of their male scientific minds, as opposed to midwives who were, almost invariably, women.
This same author reminds us that
By that time [the last decades of the 19th century], there were Spanish, Black, mestizas, mulatto and of course Indigenous midwives; these still enjoyed a tremendous prestige and used therapeutic resources against sterility, to prevent or control abortion, to regulate uterine contractions, to increase breast-milk production and strengthen postpartum women. They supervised pregnant women, bathe them in the temazcal and performed external versions of the fetus in womb, even if it is likely they did not practice embryotomy anymore in case of the fetus’ death, as they used to do in Pre-Hispanic Mexico.28
The effectiveness of these skills at the time was far from inconsequential vis-à-vis limited knowledge and common iatrogenic clinical practices by professional obstetricians and surgeons. Before the firm establishment of the germ theory for infectious diseases by Pasteur, Koch, and Lister in the late 1800s, and the discovery of antibiotics that followed in the 1920s–1940s, attempts by the medical profession to establish itself as the only legitimate “scientific” ruling, supervising, and educating body in obstetrics in Mexico took place while women attended by physicians in maternity wards systematically fell ill to puerperal fever. Puerperal or childbed fever or puerperal sepsis is a very severe form of infection after delivery that was very common in the second half of the 1800s worldwide, with a fatality rate of up to 40 percent.29 In England, in the 1870s, puerperal fever made up of almost 56 percent of all registered maternal deaths by cause.30 This postpartum infection was directly imputed to lack of hand washing and invasive intrauterine interventions by attending physicians, compounded by maternity ward confinement. This practice became increasingly fashionable in the 19th century in the expansion of the biomedical obstetric care model, increasing the risk of contagion and childbed mortality up to tenfold. Historical records show that an epidemic of childbed mortality affected the Maternal and Child Hospital in Mexico City, where, in 1881 and again in 1902, 100 percent of postpartum women had contracted the infection.31 In both events, the maternity ward was temporally closed.32
Independently of the main attending figure at birth and according to official statistics, maternal mortality finally decreased significantly in Mexico after the third decade of the 20th century, following similar trends elsewhere. The maternal mortality ratio (MMR) diminished tenfold from 1930 to 1990, from a very high rate of 565 per 100,000 live births in 1930 to 54 in 1990.33 The ratio decreased by half in a twenty-year span between 1930 and 1950 (RMM: 275 per 100,000 live births), again by half between 1950 and 1970 (RMM: 143 per 100,000 live births), and by another two-thirds between 1970 and 1990 (RMM: 54 per 100,000 live births).
In the 1930s, Mexican official statistics were much less reliable than today or than in Western European countries of the time. Notwithstanding these differences in the quality of maternal deaths records, Mexico’s official maternal mortality ratios in the 1930s were not much different from those of Western Europe, North America, or Australia. However, in Great Britain, the United States, Australia, Sweden, and the Netherlands, the MMR ratio decreased at a much faster pace following the introduction of antibiotics and the subsequent dramatic decrease of puerperal fever as the first cause of death after 1937. In 1950, the MMR decreased from 700–250 per 100,000 to 110–60 per 100,000 live births in these countries. In 1960, these countries all had similar RMMs around 60 per 100,000 live births,34 while Mexico had still an official RMM of 200.
In addition to the introduction of sulfonamides and antibiotics, other clinical resources, medical interventions or health service factors contributed to the dramatic decrease in maternal mortality in the 1940s and the 1960s. As British physician and medical historian Irvine Loudon reminds us,35 the introduction of ergometrine and the implementation and access to blood transfusions were pivotal in reducing maternal deaths by hemorrhage. Better clinical training, improved anesthesia procedures, and less medical interference in normal births were also contributing factors, according to Loudon. Although with an important time lag of thirty years, Mexico also achieved a similar reduction by 1990, as the following graph illustrates.
Social Inequalities and Maternal Deaths in Mexico
The MMR is considered the most unequally distributed mortality indicator around the globe; it is very sensitive to disparities in access to maternal healthcare and in the quality (or lack thereof) of available healthcare services. The risk of maternal mortality is 350–400 times higher in some sub-Saharan African countries than in many Western European nations. The MMR compares rather unfavorably to the second-highest mortality indicator in inequality ranking: the under-five years of age mortality rate (U-5MR), which shows at maximum a 90-times spread.36
Globally, high maternal mortality is recognized as a powerful marker of gender and social inequality at large. Since 2009, the United Nations and its member agencies have additionally considered it a marker of multiple violations of women’s rights. Mexico is a country marked by profound and multiple inequalities. Similar to the Latin American region as a whole,37 income distribution is highly skewed: the richest 20 percent of households reap a 53 percent share of total household income, while the poorest 40 percent only own 14 percent of it.38 Gender gaps in education, income, participation in the workforce, and political participation (marked by the Gender Human Development Index) are still wide nationally and among different states. Chiapas, Guerrero, and Oaxaca have the lowest overall indicators and the widest gender gaps.39 Social and economic inequalities also powerfully affect the distribution of healthcare facilities and the quality of available services, with great disparities among and within states.
Maternal mortality studies from a sociocultural perspective have shown that these deaths are far from evenly distributed in Mexico between and within states, across socioeconomic, ethnic, and educational lines, and even within localities.40 Although most women who die tend to be concentrated in large populous urban areas where most births take place (the States of Mexico, Veracruz, Chiapas, and the federal district of Mexico City), inequality translates into high differentials in MMR between states and much higher ratios year after year among ethnic minorities, poor women, those living in rural areas and/or who inhabit the poverty-stricken southern states of Guerrero, Oaxaca, and Chiapas,41 as well as in indigenous regions elsewhere, such as the Tarahumara Sierra in the northern state of Chihuahua. These women face a much higher risk of dying during maternity than the national average or compared to nonindigenous, urban women of those or richer states42; specifically, they face the greatest barriers to accessing high quality maternal healthcare, especially in situations of obstetric emergencies. In 2012, pregnant women who spoke an indigenous language from the states of Guerrero, Chiapas, Hidalgo, Nayarit, and Chihuahua died 2–8 times more often than pregnant women who did not speak an indigenous language from those same states.43
Consistently since 1980, pregnant women who live in the states of Chiapas, Guerrero, and Oaxaca have faced higher risks of dying in Mexico. In 2012, Guerrero, considered today the state with the most disadvantageous socioeconomic indicators all over Mexico,44 had the highest MMR in the country. The difference in the 2012 RMM between Guerrero and the wealthier state of Querétaro (located just north of Mexico City), which presented the lowest MMR in the country for that year, was almost four times. At the same time, the MMR for the indigenous population in Guerrero was eight times that of Querétaro.45 Thus, in 2012 a pregnant woman from Guerrero faced four times greater risk of dying of maternal causes than a woman from Querétaro.
Table 1. Maternal Mortality Ratios (MMR), Mexico, 2012. Place of residence.
Baja California Sur
San Luis Potosí
(a) MMR per 100,000 estimated live births by CONAPO (2005–2030 estimates)
(b) MMR per 100,000 estimated live births by CONAPO (2010–2030 estimates)
Source: OMM, Indicators 2012.
Maternal mortality is usually disaggregated by women’s age, parity, and residence (e.g., states, municipalities, rural or urban), and some relevant deceased women’s socioeconomic characteristics (usually, education and income level). In Mexico, income level information is unavailable for individual deaths, although the deceased locations of residence can and are used as proxies for marginalization, poverty, and/or ethnicity markers. Official Mexican maternal mortality data offer further disaggregation by place of death and type of health facility (i.e., public health facility or a private one, at home, or in transit), whether the woman was provided skilled medical assistance or not at birth and/or before dying, number of prenatal visits received, whether the death certificate was filled or not by a medical practitioner, and whether she had public health insurance (i.e., Seguro Popular, established in 2003), or social security coverage.
Available disaggregation informs us about who dies during maternity and under what circumstances. Although women who die for maternal mortality causes are from all reproductive age groups, the risk of dying is slightly higher among very young women (18 years of age or younger) and tends to be the greatest among older women (35–39 and especially over 40 years of age). These risk differentials for age have remained constant since 199046; in 2015, MMR for women aged 35+ was almost three times higher than for women in the 20–34 age groups.47
Still, most women who die during pregnancy or childbirth are aged 20–34 years, and most births occur among women of these ages, which are considered the best years physiologically to have children. In 2012, 65 percent of maternal deaths occurred among Mexican women aged 19–34 years.48 Many of these women did not have any specific risk factors predisposing them to such a tragic outcome.
These findings are important for health policy as well as for public health and social sciences scholars of maternal health and mortality. Data support the idea that, irrespective of individual risk factors in pregnancy (e.g., the woman’s age, but also preexisting or cooccurring illness conditions such as diabetes, cancer, cardiovascular problems, TB, or malaria), a pregnant woman can face an obstetric emergency at any time. This reality has major policy implications. Although maternal morbidity and mortality cannot be prevented in the majority of cases, the healthcare system needs to guarantee prompt access to quality obstetric services, including and foremost in cases of obstetric emergencies. Once most women access and use prenatal care and have births in institutional health facilities, the primary responsibility to avoid maternal mortality lies with the institutional health system and its maternal healthcare services.
Education is an important marker of social inequality involved in maternal mortality, especially in countries or in socioeconomic situations where access to institutional maternal healthcare is far from universal. In Mexico in 1990, illiterate women or women who had not completed elementary school faced a threefold risk of dying during pregnancy or childbirth compared with women who had completed secondary or higher school grades.49 At that time, one in every four Mexican women gave birth with unskilled assistance or no assistance at all.50 In Chiapas, Oaxaca, and Guerrero states, the percentages of skilled attendance at birth were as low as 22.4 percent, 43.3 percent and 49.1 percent, respectively. By 2012, greater than 96 percent of Mexican women delivered in institutional medical facilities (71 percent in Chiapas, 85 percent in Guerrero and 86 percent in Oaxaca), and the correlation between educational level and MMR continues even though. In 2012, the risk of dying for pregnant women who had fewer years of schooling (including illiterate women and those with partial or complete elementary education) than the national average (8.6 years) was 1.3 times that of women with more years of schooling than the national average.51
The Clinical, Social, and Structural Etiology of Maternal Mortality in Mexico
Another crucial piece of information pertaining to maternal mortality in Mexico and elsewhere is causality. Causality is multilayered and includes immediate clinical causes, underlying macrostructural determinants, and health care and health services available.
Clinical causes are those reported in death certificates and mortality records. They differentiate between direct and indirect maternal mortality causes. The most important direct clinical causes of maternal deaths are hypertension (preeclampsia/eclampsia), intra- or post-partum hemorrhage, unsafe abortion, infection (puerperal sepsis), and obstructed labor.
Historically, the relative importance of direct causes such as sepsis and obstructed labor have diminished in Mexico as more women deliver in health facilities where cesarean sections are available (in cases of obstructed labor) and where adequate hygienic conditions and the use of antibiotics prevent puerperal infections during childbirth or postpartum. The relative importance of preeclampsia and eclampsia has increased over time, while intra- and postpartum hemorrhage has decreased over time, even though it continues to be the second most important cause and, in poor states, may continue to be the first.
The relative importance of direct versus indirect causes is undergoing major changes in Mexico, where indirect causes are acquiring much more relative weight today than ever before. Indirect causes refer to pregnancy-related deaths in women with preexisting or newly developed health problems unrelated to pregnancy but that complicated a pregnancy or that pregnancy itself made worse: HIV-aids, tuberculosis, malaria, cancer, diabetes, cardiovascular diseases or anemia, among others. In 2009, the influenza type A H1N1 affected maternal mortality in Mexico, increasing the percentage of indirect maternal deaths. Indirect maternal mortality causes used to be insignificant (1–2 percent of all maternal deaths in between 1980 and the early 1990s52), but they have been on the rise since 2000. As of 2015, they represent around 30 percent of all maternal deaths.53
Some of the most crucial social, structural, and health system determinants involved in maternal deaths are revealed by the “three delay model.” This conceptual framework was developed in the early 1990s by public health and social science researchers from the United States,54 to understand and explain the underlying reasons behind most maternal deaths, worldwide. According to this model, the first delay occurs when women or, very often, their spouses or other senior family members who are in charge of making decisions, take too long to recognize danger signs in the pregnancy during labor or immediately after delivery and do not seek care at all or when it is already too late. The second delay refers to the tardiness in reaching the healthcare facility that provides timely and effective care once a decision is made to seek care. The third delay takes place within healthcare facilities when the woman does not receive proper, effective, and timely obstetric emergency care.
The first delay is often a proxy for gender inequality issues because an underlying reason of not seeking care may well have to do with not valuing women’s lives sufficiently to deploy financial resources and/or time necessary to seek care, especially when such resources are scarce.
The first delay can also highlight the lack of information needed to properly recognize emergencies. Prevailing cultural ideas convey that labor and birth are natural events that do not need clinical care. Hospitals are often distant, and previous negative experiences with health units have led to negative perceptions of their quality of care. Generally, the costs involved in seeking care are quite high, especially for the poor. In all these cases, the first delay comprises tardiness in the response of the woman, spouse, or other family members. The second delay includes the obstacles that women and their family members face when seeking transport to the hospital. Here, the lack of ambulance or of other transportation means, actual travel time, cost of transportation, conditions of roads, and, in general, all types of physical accessibility barriers are implicated. The third delay encompasses factors related to poor quality of care or denial of care within the formal healthcare system, from the referral system, to inadequate skills of available personnel, and shortages in equipment, medical supplies, drugs, and/or human resources.56
In Mexico, the Ministry of Health used the three-delays model to explain the multifactorial nature behind maternal deaths and the relative weight that each of the delays plays in maternal mortality.58 This document amply proved that the third delay—the one within the incombency of the healthcare system—is responsible for the majority (up to 80 percent) of maternal deaths in the country. The same document outlines policy implications and offers strategic interventions that aim to prevent and reduce these deaths as a major priority in health policy in Mexico.
Public Policy and the Reduction of Maternal Mortality in Contemporary Mexico
During most of the 20th century and similarly to the rest of the world, maternal mortality was not a public health priority in Mexico. In everyday life, maternal death was and is not as common as child or infant death. This fact has contributed to making these deaths semi-invisible and their social costs less tangible.
Promoted by different bodies of the United Nations, the reduction of maternal mortality has become a high priority in public policy agendas around the world since the late 1980s, especially regarding health, gender equity, and human rights. The Safe Motherhood Initiative was launched in 1987 with the objective to reduce maternal mortality by one-half by the year 2000, and Mexico signed this Initiative. Globally, priorities were set to improve access to prenatal care and institutional deliveries and to train traditional midwives attending home births. Maternal mortality decreased but not at the expected rate. In the year 2000, the UN Millennium Conference launched the Millennium Development Goals (MDG); MDG 5 called for the reduction of maternal mortality ratios by three-quarters between 1990 and 2015. Mexico signed the MDG. To accomplish MDG 5, Mexico would have to reduce its ratio to 22 per 100,000 live births by 2015. In 2013, the actual ratio was 42.7, down from 88.7 in 1990, which represents only a 52 percent decrease in 23 years and with only two more years to go. According to official sources, MDG 5 was the only goal that Mexico was not able to reach by 2015.
It is worrisome that the Federal Health Ministry not only recognizes that the country was not able to accomplish MDG 5 by September 2015 but also downplayed its commitment to achieve that goal in the new maternal and perinatal care program 2013–2018, released in 2014.59 In this document, the goal was set at a MMR of 30 by the year 2018 and disregarded the MDG platform or a commitment post 2015.
In 2015, the great majority of Mexican women delivered in hospitals; 96 percent of births occurred with medical assistance in 2012, up from 77 percent in 1990. Likewise, the majority (82 percent) of maternal deaths occurred in medical settings, and only 7.5 percent of women who died did not receive medical care. National health authorities have recognized that shortcomings in maternal healthcare infrastructure, insufficient or unevenly distributed material, financial and human resources, and substandard quality of care in obstetric emergencies are the major problems causing women to die unnecessarily during pregnancy, childbirth, or postpartum in Mexico. Increasingly, the substandard quality of care has become the major concern of public policy and organized civil society’s efforts to reduce maternal mortality in Mexico.
In 2013, Lazcano and colleagues60 listed the following major problems and most important policy guidelines for future interventions in the country:
1. Mexico has achieved a very high coverage for institutional deliveries (96 percent); nevertheless, there is not a clear correlation between high coverage and maternal mortality reduction. It is not enough to guarantee obstetric services to all Mexican women to decrease maternal mortality. Institutional deliveries are not synonymous with high-quality, qualified skilled care. There is a need to improve the quality of prenatal, delivery, and obstetric emergency care. Medical providers’ technical skills in delivery care and in obstetric emergencies need to improve. Also, geographical and economic accessibility of services need to be expanded and improved. Finally, services and providers need to improve their intercultural skills and learn to provide respectful care, with no mistreatment, disrespect, verbal, psychological or physical abuse or discrimination. Women’s human rights need to be respected at all times.
2. Maternal mortality is reflective of social inequalities in Mexico, associated with poverty, marginalization, gender inequities, and deficient maternal healthcare services in rural and indigenous populations and in the poorer states.
3. Obstetric care needs to be aligned to scientific evidence and normative protocols.
4. Obstetric care needs to be fully integrated into a more general effort to improve the entire healthcare system in Mexico. Primary healthcare (PHC) services need to be strengthened and attending medical personnel better trained and supervised; normal deliveries should occur at PHC services.
5. Mexico needs to fully adopt a rights-based approach in maternal healthcare policies, programs and services, to fully improve the quality of provided care, diminish maternal morbidity and mortality, treat women with respect, eradicate discrimination, and improve gender equity.
Discussion of the Literature
Maternal death in Mexico is a topic discussed in population, public health, and epidemiological literature; historical studies of medicine, society and culture in Mexico from pre-Hispanic times to the 20th century; and social sciences literature drawing on anthropology, sociology, gender and feminist studies, and public policy and social accountability perspectives, among others.
Demographers, epidemiologists, and other public health specialists were among the first to study the phenomenon of maternal mortality in depth in Mexico in the 1980s and 1990s. Using vital statistics as well as healthcare data (e.g., hospital records), scholars unraveled important quantitative dimensions of the problem in Mexico: actual numbers, historical trends, geographical distribution, and causality. In population studies or within healthcare settings, they also researched specific demographic characteristics of deceased women, such as age, occupation, parity, rural vs. urban residence, and educational level, to identify group categories at greater risk of maternal mortality.
Social historians and historical demographers have shown how maternal deaths were a much more common phenomenon in the past than today, and how these deaths were perceived as unfortunate but natural events that women faced inevitably while fulfilling their expected social role to give birth and have children. Historical studies show how the ways societies organized and provided care to pregnant and laboring women, dealt with obstetric emergencies, made sense of maternal deaths, and arranged burial ceremonies for the deceased, varied considerably across time and space. While pre-Hispanic or early Conquest historiography has covered the topic of maternal deaths in Mexico, gaps remain for its study during Colonial times and after Independence.
Anthropological and other social sciences studies, on the other hand, have revealed crucial social dimensions of maternal mortality in Mexico: its close relationship with socio-economic, gender and ethnic inequality; power relationships and gender and generation dynamics within households that influence health-seeking behavior and decision-making in obstetric emergencies; the interconnections between structural, institutional and gender violence and maternal mortality; the over burdens that poor, indigenous and rural women face while pregnant and their greater risk of dying during reproduction; the social costs and family consequences of maternal deaths; the social determinants of maternal mortality; women’s experiences of distress, mistreatment, contempt and violence during maternity and as underlying causes of their deaths; social dynamics, characteristics, and shortcomings of the healthcare system in providing maternal care; the tight relationship between extreme poverty, low gender status, inexistent or ineffective healthcare, and a greater vulnerability to maternal death, among others.
This literature has contributed to construe today’s prevailing idea that maternal deaths are unacceptable because they are preventable and avoidable; therefore, public policy literature has responded by making maternal mortality prevention and reduction as a foremost priority in Mexico.
WHO Mortality Database
According to the information provided in its homepage, the World Health Organization (WHO) Mortality Data Base provides mortality data by country, year, cause of death, age groups, and sex. Data have been submitted by member States to the WHO from 1950 (Mexico from 1955) to date on a yearly basis. Data are available through an online application called “Cause of Death Query online” (CoDQL), which allows users to access and use data in an easy and friendly manner. Users can find maternal deaths easily following the International Statistical Classification of Diseases and Related Health Problems (ICD).
This database supplements the WHO Mortality Database online version, which provides mortality data for specific aggregated causes, such as causes of death related to pregnancy, chidlbirth and the puerperium. In this database, the cause of death is selected using the ICD coding systems in its different revisions, according to the years in which they were used. For Mexico, they are the following:
• 1955–1967: ICD 7th revision;
• 1968–1978: ICD 8th revision;
• 1979–1997: ICD 9th revision;
• 1998–2017: ICD 10th revision.
The Secretaría de Salud (Ministry of Health); the Dirección General de Información en Salud (DGIS, The Directorate-General on Health Information), the Sistema Nacional de Información en Salud (SINAIS, National System on Health Information), and the Instituto Nacional de Estadística y Geografía [National Institute of Statistics and Geography-INEGI] all contributed to the maternal mortality database.
This database includes all maternal deaths occurred in Mexico for 2002–2013, according to death certificate information collected by INEGI and revised by the Ministry of Health. The information is updated every year. It includes sociodemographic information of deceased women (i.e., place of residence, age, education, marital status and occupation, among others), cause that provoked the maternal death, site and healthcare institution where death occurred, among others.
Secretaría de Salud Birth Registries Database
To calculate maternal mortality ratios, it is necessary to know not only maternal mortality data by year, but also the total number of live births for the same period. Online, one can access birth registries database, available from 2008 to 2014.
The information source is the birth certificate and the information is collected by the Ministry of Health, Directorate-General on Health Information. Information about registered live births for previous years (1990–2009) is available online.
INEGI General Mortality Database
INEGI offers the microdata on general deaths occurring on a yearly basis in Mexico. Data are obtained from Civil Registry records, complemented by Minsitry of Health registries. Maternal deaths are identified by cause according to the ICD classification.
Secretaría de Salud [Ministry of Health], Dirección General de Epidemiología [Directorate-General on Epidemiology]: Weekly bulletins on maternal mortality 2011–2016.
Archivo Histórico de la Secretaría de Salud [The Historical Archive of the Ministry of Health: AHSSA]. The most important archive on the history of health and healthcare in Mexico. It consists of sixteen document collections arranged in three major groups: Church health establishment archives, health, or social security government archives; and hospital and hospice establishment archives. The health government archives include documents from the late colonial period to 1985; the hospital archives contain documents dating back to 1561 and up to the late 1990s.
Elu, María del Carmen. La luz enterrada. Estudio antropológico sobre la mortalidad materna en Tlaxcala [The buried light. An anthropological study on maternal mortality in Tlaxcala]. México City: Fondo de Cultura Económica, 1993.Find this resource:
Espinosa Damián, Gisela. Doscientos trece voces contra la muerte. Mortalidad materna en zonas indígenas [Two hundred and thirteen voices against death. Maternal mortality in indigenous regions]. La mortalidad materna en México. Cuatro visiones críticas [Maternal mortality in Mexico. Four critical appraisals]. Mexico City: Fundar/Kinal Antzetik/Coordinadora Nacional de Mujeres Indígenas/UAM/Foro Nacional de Mujeres y Políticas de Población, 161–238, 2004.Find this resource:
Freyermuth, Graciela and Paola Sesia. 2009. La muerte materna. Acciones y estrategias hacia una maternidad segura [Maternal death. Actions and strategies toward a safe motherhood]*. Mexico City: Comité Promotor por una Maternidad sin Riesgos en México/CIESAS.Find this resource:
Gayol Sandra and Gabriel Kessler. La muerte en las ciencias sociales: Una aproximación. [Death in social sciences: An approach]. Persona y Sociedad (Universidad Alberto Hurtado) 25.1 (2011): 51–74.Find this resource:
Observatorio de Mortalidad Materna en México [Maternal Mortality Observatory in Mexico-OMM] Indicadores [Indicators] 2009, 2010, 2011, 2012, 2013, Mexico City: OMM.Find this resource:
OMM. Numeralia 2009, 2010, 2011, 2012, 2013, Mexico City: OMM.Find this resource:
(1.) These data were obtained in the World Health Organization (WHO), mortality database, consulted November 22, 2014. Information on this database is included in the section Primary Sources section of this article.
(2.) Loudon, Irvine, Death in childbirth: An international study of maternal care and maternal mortality, 1800–1950 (Oxford: Clarendon, 1992).
(4.) Up to the 1990s, the ratio was calculated per 10,000 live births, given higher absolute numbers than today.
(5.) With corrections for an estimated 40 percent underreporting, the MMR for 1990 was officially recalculated at 89 per 100,000 live births (Lozano-Ascencio, Rafael, Rosa María Núñez-Urquiza, María Beatriz Duarte-Gómez and Luis Manuel Torres-Palacios. Evolución y tendencias de largo plazo de la mortalidad materna en México: Análisis de factibilidad y de efecto potencial de intervenciones seleccionadas para el cumplimiento de las metas del milenio. In México, ante los desafíos de desarrollo del milenio, ed. Helena Zúñiga Herrera, México: Consejo Nacional de Población (CONAPO), 2005, 171. Available at http://www.conapo.gob.mx/es/CONAPO/Mexico_ante_los_desafios_de_desarrollo_del_milenio). The World Health Organization and UNICEF estimated for 1990 an even higher MMR for Mexico at 110 per 100,000 live births (WHO and UNICEF. Revised 1990 estimates of maternal mortality a new approach by WHO and UNICEF (Geneva, Switzerland, 1996), available at http://apps.who.int/iris/bitstream/10665/63597/1/WHO_FRH_MSM_96.11.pdf).
(6.) Observatorio de la Mortalidad Materna (OMM). Indicadores 2012. Objetivo de Desarrollo del Milenio 5: Avances en México (Mexico: CIESAS/ OMM, 2014), available at http://www.omm.org.mx/images/stories/Documentos%20grandes/Indicadores2012octubre29.pdf.
(7.) OMM, Indicadores 2014. Mortalidad materna en México (Mexico: CIESAS/OMM, 2016), available at http://www.omm.org.mx/images/stories/Documentos%20grandes/INDICADORES_2014_Web.pdf. Unfortunately, most of the 2010–2014 decline was not due to a substantial reduction in the number of total maternal deaths; it was instead the result of improved data on live births: The 2010 national Census reported that more births had actually occurred in Mexico in the previous 12 months, than what population estimates had calculated for in previous years.
(9.) RAMOS, “use triangulation of different sources of data on deaths of women of reproductive age coupled with record review and/or verbal autopsy to identify maternal deaths. Based on multiple sources of information, RAMOS are considered the best way to estimate levels of maternal mortality,” consulted January 10, 2015.
(10.) Dirección General de Información en Salud-Subsecretaría de Integración y Desarrollo del Sector Salud and Centro Mexicano para la Clasificación de Enfermedades y Centro Colaborador para la Familia de Clasificaciones Internacionales de la OMS en México (CEMECE). Búsqueda Intencionada y Reclasificación de Muertes Maternas en México. Informe 2011 (México: Secretaría de Salud, 2013).
(11.) UNICEF, op.cit., 2014; and World Health Organization (WHO), World Health Statistics 2014 (Geneva, Switzerland: WHO, 2014), available at apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf.
(12.) Aguirre, Alejandro. Mortalidad materna en México: Medición a partir de estadísticas vitales Estudios Demográficos y Urbanos 12(1) (34) (1997): 69–99, available at http://estudiosdemograficosyurbanos.colmex.mx/index.php/edu/article/view/988/981; and Lozano-Ascencio et al., op.cit., 2005.
(13.) Escalante-Gonzalbo, Pablo “La vida urbana en el periodo Clásico mesoamericano. Teotihuacan hacia el año 600 d.c.,” in Historia de la vida cotidiana en México. Vol 1. Mesoamérica y los ámbitos indígenas de la Nueva España, 2004, 64.
(14.) Sahagún, Bernardino, Historia general de las cosas de Nueva España, vol. I, book 6 (Mexico: Consejo nacional para la Cultura y las Artes, 1989).
(16.) Rossell, Cecilia and María de los Ángeles Ojeda Díaz, Las mujeres y sus diosas en los códices prehispánicos de Oaxaca (Mexico: CIESAS/Porrúa, 2003).
(17.) Austin Alchon, Suzanne. “Las grandes causas de muerte en la América precolombina. Una perspectiva hemisférica”, Papeles de Población, 5.21 (July–September 1999) (Universidad Autónoma del Estado de México), available at http://www.redalyc.org/articulo.oa?id=11202107.
(18.) Lomnitz, Claudio, Death and the Idea of Mexico (New York: Zone Books, 2005).
(19.) According to McCaa (2001), estimates for the devastating depopulation of the 16th century calculated a minimum of 22 percent to a maximum of 95 percent descent in population reduction between 1519 and 1595 (McCaa, Robert. El poblamiento de México: De sus orígenes a la revolución. In La población de México: Tendencias y perspectivas sociodemográficas hacia el siglo XXI, eds. José Gómez de León Cruces y Cecilia Rabell Romero. Mexico: Consejo Nacional de Población [CONAPO], 2001). Most historic demographers tend to locate the figure at 56–95 percent.
(21.) León, Nicolás. La historia de la obstetricia en México (Mexico: Diaz de Leon, 1910), 136–139.
(22.) Ibidem, 138.
(23.) Carrillo, Ana María. Nacimiento y muerte de una profesión. Las parteras tituladas en México, Dynamis: Acta Hispanica ad Medicinae Scientiarumque Historiam Illustrandam 19(1999): 167–190; and León, op.cit., 1910.
(27.) “… Cada siglo nos trae un descubrimiento: y a propósito, hubo uno en que se descubrió que para parir era necesario una partera, de consiguiente, la partera era hija de esa civilización progresiva que no conocieron ni … Adán ni … Eva: dichosos ellos que no conocieron a la partera, a ese apéndice de la facultad medico-quirúrgica, porque realmente la partera en el Cuerpo Médico viene a ser lo que en un cuerpo humano un lobanillo o una verruga… ” (León, op. cit., 1910: 119). The English translation in main text is mine.
(28.) “Por entonces, había parteras españolas, negras, mestizas, mulatas y desde luego indígenas; éstas gozaban aún de un inmenso prestigio y contaban con recursos terapéuticos para combatir la esterilidad, detener el aborto, regularizar la contractilidad uterina, aumentar la producción de leche y fortalecer a la puérpera. Vigilaban a la embarazada, la bañaban en el temazcal y hacían versiones externas del feto, aunque muy probablemente ya no practicaban embriotomías en caso de la muerte del producto, como habían hecho en el México prehispánico” (Carrillo, op.cit., 1999: 169). The English translation in main text is mine.
(29.) Loudon, Irvine, Deaths in Childbed from the Eighteenth Century to 1935. Medical History 30 (1986): 1–41, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1139579/pdf/medhist00072-0005.pdf.
(30.) Loudon, Irvine, Maternal mortality in the past and its relevance to developing countries today, American Journal of Clinical Nutrition 72(suppl.) (2000): 241S–246S
(33.) Aguirre, op.cit., 1997; Secretaría de Salud/Sistema Nacional de Vigilancia Epidemiológica (SINAVE). Información histórica de estadísticas vitales nacimientos y defunciones 1893–2010 (Mexico: Secretaría de Salud, 2011), available at http://www.epidemiologia.salud.gob.mx/doctos/infoepid/publicaciones/2011/libros/I_HISTO_DE_ESTA_V_NAC_Y_DEFU_1893_2010.pdf.
(37.) Latin America is the region with the greatest income disparities in the world. According to World Bank 2007–2011 data, the 20 percent of households with the highest income receive 56 percent share of national household income, while the 40 percent of households with the lowest income only receive a 12 percent share (UNICEF, op.cit., 2014).
(39.) UNDP, Indicadores de desarrollo Humano y Género en México: Nueva metodología (Mexico: UNDP, 2014), available at http://www.mx.undp.org/content/dam/mexico/docs/Publicaciones/PublicacionesReduccionPobreza/InformesDesarrolloHumano/DHyG%20baja%20res.pdf.
(40.) Freyermuth, GracielaLas mujeres de humo. Morir en Chenalhó. Género, etnia y generación, factores constitutivos del riesgo durante la maternidad (Mexico: CIESAS/CPMVSR-Chiapas/INMujeres/Porrúa, 2010); Sesia, Paola “El papel de la desigualdad social en la muerte de mujeres indígenas en Oaxaca durante la maternidad: Aportes desde una epidemiología social y una antropología médica “crítica.” In El planteamiento de una epidemiología sociocultural. Un diálogo en torno a su sentido, métodos y alcances, ed. Jesús Armando Haro (Hermosillo, Sonora and Buenos Aires, Argentina: Colegio de Sonora/Editorial Lugar, 2011), 241–269.
(41.) These three states are among the poorest in the country: 79 of the 125 municipalities with the lowest Human Development Index (which measures education, health, and income) in Mexico are located in Oaxaca (N=46), Guerrero (N=17) and Chiapas (N=16) (UNDP, op.cit., 2014). They also have the greatest percentages of people living in rural areas and among the highest percentages of people speaking Indigenous languages: Oaxaca, 33.8 percent (ranking first in the country); Chiapas, 27.3 percent (ranking third); and Guerrero, 15.2 percent (ranking fifth) (Instituto Nacional de Estadística y Geografía (INEGI). Censo de Población y Vivienda 2010 (Aguascalientes, México: INEGI, 2010), available at http://www.inegi.org.mx/est/contenidos/proyectos/ccpv/cpv2010/).
(42.) Centro Nacional de Equidad de Género y Salud Reproductiva (CNEGySR)-Secretaría de Salud. Programa de Acción Específico (PAE) de Salud Materna y Perinatal 2013–18 (Mexico: Secretaría de Salud, 2014), available at http://cnegsr.salud.gob.mx/contenidos/descargas/SMP/SaludMaternayPerinatal_2013_2018.pdf; and Dirección General de Evaluación del Desempeño-Secretaría de Salud. Rendición de Cuentas en Salud 2012 (Mexico: Secretaría de Salud, 2013), available at http://www.dged.salud.gob.mx/contenidos/dedss/descargas/rcs/rcs_2012.pdf.
(44.) Consejo Nacional de Evaluación de la Política Social (CONEVAL), Índice Rezago Social por municipio y por entidad federativa, 2010. Available at http://www.coneval.org.mx/Medicion/IRS/Paginas/%C3%8Dndice-de-Rezago-social-2010.aspx.
(47.) SINAVE-Dirección General de Epidemiología, Weekly Epidemiological Bulletin on Maternal Deaths, week 52, 2015. Available at http://www.epidemiologia.salud.gob.mx/informes/informesh/2015/doctos/mmat/MMAT_2015_SE52.pdf.
(48.) Secretaría de Salud, CNEGySR. Programa de Acción Específico Salud Materna y Perinatal 2013-18. Mexico: Subsecretaría de Prevención y Promoción de la Salud, SSa, 2014. Available at http://cnegsr.salud.gob.mx/contenidos/Programas_de_Accion/SMP/introduccion_SMP; and OMM, op.cit., 2014.
(51.) Personal calculation from existing sources (OMM, op.cit., 2014: 45; 2010 Census Data on education and fertility x education level). I controlled for lower fertility rates among higher education levels.
(53.) OMM, Indicadores 2013. Objetivos de Desarrollo del Milenio 5: Avances en México (Mexico: CIESAS/OMM, 2015), available at http://www.omm.org.mx/images/stories/Documentos%20grandes/INDICADORES2013OPS.pdf.
(54.) Thaddeus, Sereen and Deborah Maine. Too far to walk. Maternal mortality in context. Social Science and Medicine 38(8) (1994): 1091–1110.
(55.) Sesia, fieldwork, Oaxaca, 2004–2005.
(57.) Sesia, fieldwork, Oaxaca, 2004–2005.
(58.) Secretaría de Salud-CNEGySR. Estrategia Integral para Acelerar la Reducción de la Mortalidad Materna en México (Mexico: Secretaría de Salud, 2009), available at http://www.coneval.gob.mx/rw/resource/coneval/info_public/estrategia_integral.pdf.
(60.) Lazcano-Ponce, Eduardo, Raffaela Schiavon, Patricia Uribe-Zuñiga, Dilys Walker, Leticia Suárez-López, Rufino Luna-Gordillo and Alfredo Ulloa-Aguirre. Cobertura de atención del parto en México. Su interpretación en el contexto de la mortalidad materna. Salud Publica Mexico 55(suppl. 2) (2013): S214–S224.