Tracing inequities: trends in antenatal and postnatal care coverage among Mexican women before and after COVID-19

Despite strenuous efforts to enhance maternal health care coverage over the past two decades, there are still significant gaps, especially in postnatal care. The COVID-19 pandemic has exacerbated healthcare disparities and horizontal inequity in maternal care, creating an urgent need for action. This study examines trends in coverage and inequity across nine stages of antenatal, delivery, and postnatal care in Mexico, comparing data from before and after the onset of COVID-19 to identify key factors and opportunities for immediate improvement. We conducted a population-based, pooled cross-sectional and retrospective analysis for the last three decades, using data from the five waves (1997, 2009, 2014, 2018, and 2023) of the Mexican National Survey of Demographic Dynamics (ENADID). Our study included 123,197 Mexican women aged 12-54 with recent live births, representing a population of 38.5 million. We estimated coverage for antenatal and postnatal care stages. We used multiple regression models to assess factors influencing the likelihood of receiving comprehensive antenatal care, skilled delivery care and postpartum care interventions, both pre-and post-COVID. We estimated horizontal inequity using concentration index and decomposition analysis to highlight disparities among women with similar needs and examine how these disparities have changed due to COVID-19 across nine antenatal, delivery, and postnatal care stages. Full antenatal and postnatal health care in Mexico was inadequate and inequitable. Only 73% received timely antenatal care, and 88.3% received frequent care, despite 97.9% claiming to have received some care. Inadequate care was linked to lower education, labor market participation, socioeconomic status, higher parity, and rural residency. The most inequitable aspects are access to skilled and institutional health care and timely post-partum care. The dismantling of the public health insurance system and strategies that incentivized the use of maternal health services during the pre-COVID period (January 2019 to March 2020) led to significant health coverage losses, exacerbating horizontal inequity in these areas. High equity was achieved in comprehensive antenatal healthcare from 2009 to 2023. However, since COVID, inequity has increased, particularly in antenatal indicators such as receiving four or more antenatal check-ups and check-ups in the first trimester. The pandemic has intensified these inequities, and they have not returned to pre-pandemic levels, underscoring the gravity of the situation. The universal target of achieving an 80% coverage index for maternal care remains unfulfilled, with only 61.8% of women receiving comprehensive antenatal care. This underscores not only the urgent need for targeted policies to enhance antenatal, delivery, and postnatal coverage at critical stages of care, but also de need to continue and strengthen strategies that have shown good results. It is imperative to prioritize reducing existing inequalities within the population, as horizontal inequity reveals significant barriers preventing equitable access to maternal health services among women with similar needs. The most pronounced disparities exist in timely healthcare access, skilled deliveries, and institutional postnatal care, where systemic issues and financial constraints are particularly impactful. Addressing these inequities is essential not only to improve overall maternal health outcomes but also to ensure that all women can benefit from the full spectrum of maternal care, particularly in the wake of the COVID-19 pandemic. In order to contribute to transparency and replicability of research, the authors of this study made the data available. Any other use than exploring or replicating the results of the above-mentioned paper is not authorized and shall not be used without the previous authorization of the investigators. If you are interested in analyzing this database for original research purposes please contact Edson Serván-Mori ([e-mail])