Low quality of maternal and child nutritional care at the primary care in Mexico: an urgent call to action for policymakers and stakeholders

BACKGROUND

Maternal and child malnutrition represents a public health problem in Mexico Primary care (PC) is responsible for introducing women and children under five to the health system, detecting diseases on time, and providing medical services, including pharmacological treatment if necessary. Providing these services with quality is essential to improve maternal and child health. This study evaluated the quality of nutritional care during preconception, pregnancy, postpartum, infancy, and preschool age at the PC health units across six Mexican states between 2020 and 2021.

METHODS

We conducted a cross-sectional study with a mixed approach in units of the Secretary of Health to assess the quality of nutritional care during preconception, pregnancy, postpartum, childhood, and preschool age. The level of quality was calculated by the percentage of compliance with 16 indicators that integrated a Quality Index of Maternal and Child Nutritional Care (ICANMI, by its Spanish acronym). Compliance by indicator, by life stage, and overall was categorized using the following cut-off points: poor quality (≤ 70%), insufficient quality (71-89%), and good quality (≥ 90%). The perceptions of the barriers and facilitators that affect maternal and child nutrition were evaluated through semi-structured interviews with health professionals (HP) and users. All qualitative instruments were developed with a gender and intercultural perspective.

RESULTS

Considering the whole sample studied, maternal and child nutritional care quality during the five life stages evaluated was bad (compliance: ≤12%), reflected in the ICANMI, which had a compliance of 8.3%. Principal barriers identified to providing high-quality nutritional care were the lack of knowledge and training of health professionals, shortages of equipment, medicine, personnel, and materials, the disappearance of the social cash transfer program Prospera, the absence of local indigenous language translators to support communication between doctor and patient, and the persistence of machismo and other practices of control over women.

CONCLUSIONS

These findings underscore the need for initiatives to improve the quality of nutritional care in PC facilities across Chihuahua, State of Mexico, Veracruz, Oaxaca, Chiapas, and Yucatan. It is necessary for government and health authorities, along with various stakeholders, to collaboratively devise, implement, and assess intercultural and gender-oriented policies and programs geared towards ensuring the health infrastructure and enhancing the training of health professionals to diagnose and treat the prevalence and occurrence of diverse forms of malnutrition in both maternal and child populations.

Development and validation of a new set of indicators to assess the quality of maternal and child nutritional care at the primary care

Introduction

Maternal and child malnutrition is a worldwide public health problem with short, medium, and long-term adverse consequences for both mother and child. In Mexico, maternal and child malnutrition represents a serious public health problem that must be urgently addressed. In this context, Primary Health Care (PHC) plays an important role in the prevention, detection, monitoring, and treatment of the different forms of maternal and child malnutrition. Assessing the quality of nutritional care offered at this level of care is necessary in order to improve it; however, there are no indicators for the evaluation of this quality. Therefore, this study aimed at developing a set of indicators to assess the quality of maternal and child nutritional care at PHC.

Methods

We developed indicators for different stages of life: preconception, pregnancy, infancy, and preschool age. A systematic review of the literature on clinical guidelines for the prevention, diagnosis, and treatment of the different forms of malnutrition was carried out; the recommendations of the guidelines evaluated with good quality were extracted.

Results

Based on these recommendations, 22 indicators were constructed. A pilot study was carried out to validate the indicators and 16 indicators were selected to assess the maternal and child nutritional care at PHC.

Incidence of macrosomia in Mexico: National and subnational estimations

Fetal macrosomia (FM) is a condition with adverse consequences for both mother and offspring. The occurrence of this condition has increased worldwide. The objectives of this study were: (1) to estimate the incidence of FM at the national and state levels in Mexico in 2020; (2) to estimate the incidence of FM stratified by maternal and newborn characteristics; (3) to identify the states with the highest risk of FM; (4) to georeference the incidence of FM. Open data from the Birth Information Subsystem were used. Relative risks were estimated by adjusted Poisson regression models. The national incidence of FM was 2.75%. The entity with the lowest incidence was Mexico City (1.28%) and the most affected states were Sonora (6.20%), Baja California Sur (5.44%), and Sinaloa (5.36%), located in the north of the country. The incidence of FM at the national level is below that reported in the international literature. The results of this study can be used for the design and implementation of programs, public policies, and interventions.

Obesity Prevention in Latin America

In Latin American countries, obesity prevalence has increased significantly as a result of rapid urbanization and an improvement in socioeconomic conditions. We report the prevalence of overweight and/or obesity and prevention efforts in five countries: Mexico, Colombia, Brazil, Peru, and Chile. In children, the highest and lowest rates of obesity are found in Chile (23 % in 6-year-olds) and Peru (1.8 % in those <5 years), respectively. In adults, Mexico and Chile present similar high rates of obesity (around 35 %), whereas in Brazil and Colombia, the rates are around 20 % and 16.5 %, respectively. In general, the highest prevalence occurs in low-income women. Every country has developed initiatives to target obesity, from the government to the private sector and academia, mainly at the health sector and school settings. Food labeling is being addressed, but has not been implemented yet. Two interventions are described, a community-based in Mexico and a school-based in Chile. Because the increase in chronic diseases, especially diabetes, has paralleled that of obesity, effective prevention efforts are urgently needed.

Editorial

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Stakeholder perspectives on national policy for regulating the school food environment in Mexico

In Mexico, the school environment has been promoting sale of unhealthy foods. There is little empirical evidence on multi-stakeholder perspectives around national school food policy to regulate this. We studied stakeholders' perspectives on the proposed regulation for school sale of unhealthy foods. Comments about the regulation were available from an open consultation process held in June 2010 before the approval and implementation of the regulation. To examine perspectives, we coded 597 comments for beliefs, expectations and demands in NVivo. We created matrices by actors: academics, parents, citizens, health professionals and food industry. For academics, citizens and health professionals, the primary issue regarding the regulation was obesity, while for parents it was health of children. Academics, citizens, health professionals and parents believed that government was responsible for health of citizens, expected that this regulation would improve eating habits and health (i.e. less obesity and chronic diseases), and demanded that unhealthy foods be removed from schools. Parents demanded immediate action for school food policy that would protect their children. Citizens and health professionals demanded nutrition education and healthy food environment. Food industry opposed the regulation because it would not solve obesity or improve diet and physical activity behaviours. Instead, industry would lose income and jobs. Food industry demanded policy aimed at families that included nutrition education and physical activity. There was substantial consensus in narratives and perspectives for most actor types, with the primary narrative being the food environment followed by shared responsibility. Food industry rejected both these narratives, espousing instead the narrative of personal responsibility. Consensus among most actor groups supports the potential success of implementation of the regulation in Mexican schools. With regard to addressing childhood obesity, sound government policy is needed to balance different perspectives and desired outcomes among societal actors, particularly in Mexico between food industry and other actors.

[Prevention of infant obesity]

Childhood obesity is a serious public health problem, demanding urgent and clear defined actions in order to stop the rapid increase on its prevalence and all health consequences associated. The best strategy to stop the rapid increase in childhood obesity is to prevent it. In order to do so, multiple defined actions between government, industry, community organizations, schools, families and health-care professionals. The general and family physicians, pediatricians, nurses, dieticians and other clinicians should be engaged, as a key actor, in the prevention of childhood obesity. The health-care professionals have frequent opportunities to inform to children, youth and their parents about the importance of prevention of obesity and to promote and engage them in healthy life styles, particularly, a healthy diet and regular physical activity.