Health system financing fragmentation and maternal mortality transition in Mexico, 2000-2022

Abstract

Objective: To analyze the temporal and territorial relationship between health system financing fragmentation and maternal mortality in the last two decades in Mexico.

Methods: We conducted an ecological-longitudinal study of the maternal mortality ratio (MMR) in the 32 states of Mexico during the period 2000-2022. Annual MMRs were estimated at the national and state levels according to health insurance. We compared the distribution of individual attributes and place of residence between deceased women with and without social security to identify overrepresented demographic profiles. Finally, we mapped state disparities in MMR by health insurance for the last four political administrations.

Findings: MMR in Mexico decreased from 59.3 maternal deaths per hundred thousand live births in 2000 to 47.3 in 2018. However, from 2019 onwards, MMR increased from 48.7 in 2019 to 72.4 in 2022. Seven out of ten maternal deaths occurred in the population without social security from 2000 to 2018, then decreasing to six out of ten from 2020. Maternal deaths in the population without social security were more frequent among younger women, with less schooling, unmarried, and residing in rural areas, with higher Indigenous presence and greater social marginalization. From 2019 onwards, the MMR was higher in the population with social security.

Conclusion: The results of this study confirm the close relationship between maternal mortality and social inequalities, and suggest that affiliation with social security has ceased to be a differentiating factor in recent years. Understanding the evolution of maternal mortality between the population with and without social security in Mexico allows us to quantify the gap in maternal deaths attributed to inequalities in access to maternal health services, which can contribute to the design of policies that mitigate these gaps.

Keywords: Financing fragmentation; Maternal mortality; Mexico; Universal health coverage.

Fig. 1

Maternal mortality ratio according to Social Security affiliation. Mexico 2000–2022. The states where the MMR is higher in the population without social security are shown in red, and those in which the MMR is higher in the population with social security are shown in blue

Fig. 2

Percentage distribution of maternal deaths and maternal mortality by Social Security affiliation. Mexico 2000–2022

Fig. 3

Disparities -social security-no social security- in state mortality ratios. Mexico, 2000–2022. A 2000–2006. B 2007–2012. C 2013–2018. D 2019–2022. The ratio of MMRs was estimated with MMR without social security in the numerator and MMR with social security in the denominator. The ratio was placed in four categories: 0–0.5 (blue), > 0.5–1 (light blue), > 1–1.5 (light red) and > 1.5 (red). The four categories were defined according to the values observed in the baseline period (2000–2006)

Fig. 4

Disparities -social security-no social security- in the state maternal mortality ratio. Mexico, 2000-2022. The dots represent the state MMR in the corresponding period for the population without social security in red and the population with social security in blue. The percentage values shown to the right of each panel are the percentage differences relative to the population with social security. The percentages above and below the MMR for social security are shown in red and blue, respectively