Figures
Abstract
Background
Monitoring and reducing inequalities in health care has become more relevant since the adoption of the Sustainable Development Goals (SDGs). The SDGs bring an opportunity to put the assessment of inequalities by ethnicity on the agenda of decision-makers. The objective of this qualitative study is to know how current monitoring is carried out and to identify what factors influence the process in order to incorporate indicators that allow the evaluation of inequalities by ethnicity.
Methods
We conducted 17 semi-structured interviews with key informants from the health ministry, monitoring observatories, research centers, and international organizations, involved in maternal health care monitoring in Mexico. Our analysis was interpretative-phenomenological and focused on examining experiences about monitoring maternal health care in order to achieve a full picture of the current context in which it takes place and the factors that influence it.
Results
The obstacles and opportunities pointed out from the participants emerge from the limitations or advantages associated with the accuracy of evaluation, availability of information and resources, and effective management and decision-making. Technicians, coordinators, researchers or decision-makers are not only aware of the inequalities but also of its importance. However, this does not lead to political decisions permitting an indicator to be developed for monitoring it. As for opportunities, the role of international organizations and their links with the countries is crucial to carry out monitoring, due to political and technical support.
Conclusions
The success of a monitoring system to help decision-makers reduce inequalities in health care depends not only on accurate evaluations but also on the context in which it is implemented. Understanding the operation, obstacles and opportunities for monitoring could be a key issue if the countries want to advance towards assessing inequalities and reducing health inequities with the aid of concrete policies and initiatives.
Citation: Armenta-Paulino N, Sandín Vázquez M, Bolúmar F (2019) Obstacles and opportunities for monitoring ethnicity-based inequalities in maternal health care: Lessons from Mexico. PLoS ONE 14(5): e0217557. https://doi.org/10.1371/journal.pone.0217557
Editor: Shelina Visram, Newcastle University, UNITED KINGDOM
Received: December 20, 2018; Accepted: May 14, 2019; Published: May 31, 2019
Copyright: © 2019 Armenta-Paulino et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Indigenous women are among the most vulnerable groups in Latin America. They live in contexts where different social determinants such as poverty, low education, gender roles and cultural factors are combined.[1] Indigenous women experience significantly worse maternal health outcomes (including high risk of maternal mortality) and have more limited access to health services than majority populations. [2] Besides, historically, indigenous populations have not been made visible in the statistics, which could hide deep inequalities concerning other populations groups that would require a prompt response from governments and health systems. [3]
In this context, the monitoring of inequalities by ethnicity is useful and necessary to identify where there are differences. Regular health inequality monitoring can help to determine the impact of policies, programs, and practices, and to inform changes required to reduce inequality. The Government, the Ministry of Health and other stakeholders, could focus research in these areas to determine the cause of the problems and improve the health situation in these populations. [4,5]
Since the Sustainable Development Goals (SDGs) were established, monitoring health inequalities is gaining attention as a political priority. The SDGs agenda provides a major impetus for establishing or strengthening systems for monitoring health inequalities and calls for the production of disaggregate data. Further, SDGs call to continue the efforts to reduce maternal mortality and inequalities within and between countries. [6–8] Therefore, now is the time to assess ethnicity-based differences.
Some research has already shown how to estimate ethnicity-based inequalities in maternal health care. These studies give information about indicators and approaches for identifying the indigenous population using data obtained from national surveys. [9–13] In addition, international agencies or initiatives have published manuals and given technical assistance to support countries in building capacity for integrating health inequality monitoring into their health information systems. [4,5]
Nevertheless, is that enough to allow the monitoring of inequalities by ethnicity? The answer is not so easy, because it is not carried out in isolation and goes beyond the estimation of indicators. Monitoring involves the cooperation and interaction of various actors if it is to be done efficiently and be of use in decision-making. It is a process which takes place in a social, political and scientific context which brings together numerous institutions and individuals, all with their interests which impact on issues like indicator selection, data sources, methods, and leadership. [12,14]
Therefore, now is the time to take a hard look at the political and technical obstacles that might be forthcoming if we want to move forward to monitoring health inequalities. For this purpose, we need to fully understand the current operation of the maternal health care monitoring and the factors that impinge on it, from the perspective of the actors involved in it.
The main objective of the study is to describe how the monitoring of maternal health care is carried out in Mexico. Through the perspective of key professionals involved in the monitoring from, we seek to discover what factors influence the monitoring process and to explore the feasibility of incorporating an indicator that measures inequalities by ethnicity.
Methods
Sample and participants
In the process of maternal health care monitoring different types of professionals are involved with specific activities. Some are familiar with information aspects while others with how to use the results. Therefore, we used stratified purposive sampling to include this diverse kind of informants that could provide detailed and relevant information about maternal health care monitoring in Mexico. [15–17] We considered different interest profiles with specific discourses such as decision-makers, coordinators, technicians, and researchers from the Health Ministry, monitoring observatories, research centers, and international organizations. The purpose of using this sampling was to reflect the diversity within a population rather than looking for statistical representativeness or generalizability. [18]
We began contacting and recruiting participants through a systematic document search to identify the main actors involved in monitoring. We identified the key informants within each institution or area, explained to them the study aims and invited them to participate. Finally, we applied the snowball strategy, and the participants were asked to indicate other institution or actors who might also be associated with the monitoring (Fig 1). [16,17]
Source: Own elaboration using information from the author’s analysis of systematic document search. Through this strategy, we also identified new areas or informants in the same organizations.
The resulting sample consisted of 17 participants from different institutions and profiles as described in Table 1.
The sample size was determined considering theoretical saturation and the relevance and novelty of the findings. [15,17] Concerning the first, the information gathered was regarded as sufficient when there was no longer any variety of ideas or new elements that enriched or took the subject of study any further. Priority was also given to information that contributed to the goals of our research or had something new to lend to the discussion.
Data collection procedure
Semi-structured interviews were conducted with a scheme covering: the respondent’s experience and role in the process, monitoring indicators or estimates used, information sources, monitoring problems and needs, interest groups and vulnerable groups, and aspects of strategic management.
We conducted the interviews between January and March 2018. Each interview was recorded and lasted an average of 60 minutes. We transcribed and coded the audios to preserve the respondents’ anonymity. All participants were informed of the purpose of the study, and once they agreed to participate, they completed written consent forms. The University of Alcalá’s Ethics Committee approved the study’s procedures (resolution no. CEID/HU/2018/38).
Methodological approach and analysis
We chose a qualitative approach to explore the key professional perceptions of maternal health care monitoring. The qualitative research enables an understanding from the perspective of the professionals involved on how the current monitoring happens or which factors affect it. [26]
The main approach of the study is descriptive. However, we considered the interpretative-phenomenological analysis (IPA) as an adequate complement to exploring in detail how participants experience their work in the monitoring. IPA builds a detailed case by case interpretation of the phenomena in question, allowing us to take account of the individual differences in experiences as well as what is shared by all participants. Our study included different types of professionals (researchers, technicians, coordinators or decision- makers) because they would have different versions of the same event (maternal health care monitoring). Hence, the IPA was used to understand the content and meaning of the information collected from the perspective of the participants. [26,27,28]
Our analysis was based upon a detailed case exploration, and we reviewed individually every transcript before moving to the next case. Each transcript was read again and again to select the most significant aspects mentioned by the participants in their responses and to identify similarities, contradictions, differences or additional input. We highlighted phrases and paragraphs of interest and annotated all possible relevant topics. Subsequently, the initial coding was transformed into emerging themes and looked for possible connections between them. Themes were clustered together, and some emerged as superordinate concepts. The first case’ themes were used as a reference to the analysis of the following cases, but also incorporated the new emerging themes found through the other transcripts. [28] Two researchers defined the general issues and the main themes as a mean to ensure the quality and rigor of the analysis of responses.
Tables 2 and 3 show the final list of themes and subthemes that arose as a function of the study’s goals, the wealth and quality of the information it provided, and their contribution to understanding and exploring more deeply the subject in hand. Five themes were identified in relation to obstacles and opportunities for maternal health care monitoring. These concern evaluation, information, resources, management, and decision-making.
Results
Monitoring activities
According to the respondents, the monitoring of maternal health care is performed by measuring or monitoring indicators related to service coverage or quality. Impact measures such as maternal mortality or public policies aiming at its reduction are evaluated (Fig 2).
Source: Analysis of the authors of the documentary review and the responses of the semi-structured interviews questions to key actors.
At all levels (health sector, research, national and international bodies) efforts are made to carry out monitoring, but they are poorly structured and coordinated. Although there are some collaborations between different actors, it is mainly about obtaining information, but in the end, they all work in isolation. The findings or recommendations of national or international research organizations are not considered to improve ministry monitoring. Bureaucracy and lack of communication are the main limitations.
The activities mentioned by the respondents are consistent with the field of action in which they are performed. The health sector gathers data about care through its information systems. Service coverage for pre-natal care, childbirth and use of contraception is measured and monitored. Researchers suggest new ways of monitoring care, analyze gaps between different groups and look for approaches to evaluating service quality. Their principal sources of information are surveys or field work in health services.
Some international organizations work to support the health sector institutions by providing technical assistance to analyze inequalities in health. They have also been designed strategies to implement inequality’s monitoring, but none has yet been implemented in Mexico. Others conduct local fact-finding missions about service quality and measured relevant indicators to monitoring maternal health.
The observatories are directly related to the health sector or have established ties with it; they also collaborate with researchers and international organizations. Their activities are mainly centered on maternal health and health equity, and they attempt to use their evaluations to influence policy-making in their fields of competence. At the time of our study, none of the observatories monitored any indicator related to inequalities in maternal health care.
Obstacles and opportunities
Evaluation obstacles: Aggregate data and complex methods.
One limitation pointed out mainly by researchers is the impossibility of carrying out the analysis by subgroups since the data in health sector information systems are generally aggregate. In addition, the system does not organize the records by name, as one researcher remarked: “there is no way of monitoring these women given the fragmented state of the system. If the goal of pre-natal care is to improve health outcomes for mother and child at birth, then we need to link the information from the two sources, but it can’t be done with the administrative data.”
Researchers, health sector and international organizations mentioned that the methodological approach is a complex task, due in part to the information available, but also to the care-related processes.”To measure family planning or in-hospital childbirth coverage there are some proxies which let you get a rough idea of what you want to know, but sometimes you get a good picture, sometimes you don’t,” commented one coordinator.
Information obstacles: Poor data quality, representativeness and updating.
The main difficulties identified by the respondents regardless of their profile or area of activity are related to data sources. Regarding the information generated by the health sector, as one technician mentioned: “The problem is data quality. When looking for data, I come across all kinds of error, although it’s not so frequent now.” Shortcomings were also mentioned related to data collection and irregular reporting intervals. In connection with surveys, researchers pointed out that they are not usually representative locally or for specific groups like the indigenous population. Moreover, there are no guarantees that the information collected in each round will always be the same or that some will not cease to be collected.
Respondents from the health sector and international organizations mentioned that evaluations were not updated due to a delay in the availability of data from the information systems. This fact might be related to the difficulties encountered in implementing a new information system since, as one coordinator commented: “Not all regions have started using the new system, [so] we only have a quarter of the target group.” Respondents showed some dissatisfaction with the lack of up-to-date data, as well as with the new system and how it might modify future evaluations.
Resource obstacles: Insufficient funding and personnel for monitoring.
Lack of funding is one limitation mentioned by researchers and observatories alike. Researchers point out how difficult it is to obtain funds for projects related to new methods for health care or equity evaluation. As the observatories are not budgeted, they depend on the financing that their members can obtain or on the collaborative work of their participants. As one coordinator put it: “The collaboration of the institutions is very important, we have no budget or staff allocated specifically for the [body’s] activities. If support from the various institutions cannot be relied on, it’s difficult to get results.” This situation could also be related to the shortage of staff or collaborators to perform monitoring. The health sector and international organizations also refer to staff shortages. Another issue identified in the health sector is overwork since other activities have to be attended to as well as measuring or monitoring the indicators.
Management obstacles: Too much bureaucracy, difficult data access and frequent turnover of ministry of health staff.
International organizations, observatories, and researchers agree that the bureaucracy hampers decision-making or slows down procedures for doing the work of monitoring. One decision-maker commented: “There’s been more interest in looking at the bureaucratic aspects [regarding the composition of this body] than in just what is going to be evaluated.”
At all levels and sectors, the respondents agree that access to some of the data held on information systems is limited. Permission has to be requested, or some personal contact in the relevant unit is needed to facilitate access. Other difficulties cited include delays in receiving the information or failure to reply. Researchers pointed out that a good deal of time is spent dealing with the authorities before information can be collected in the health services.
Directly and indirectly, staff turnover at the Ministry of Health is mentioned and how this affects the continuity of the monitoring process. One technician remarked: “The high rate of staff rotation at all levels affects us. A person learns how to use the data and to make decisions with them, but then leaves the institution or is moved to another position, and it’s a great loss”.
Decision-making obstacles: Lack of commitment and little familiarity with the use of monitoring.
Observatories, international organizations, and researchers acknowledged that the health sector had shown interest in improving monitoring of maternal health care or in measuring its inequalities, but it has not been implemented. One technician said: “I showed the document and there were some positive comments, but nothing came of it”. Along the same lines a researcher observed: “We showed it once or twice, and the manager was delighted, but it got no further. It hasn’t had the impact necessary for one of these indicators to be used for the monitoring.”
International organizations mention that they have noticed little appreciation of the utility of monitoring. The data are usually only taken into account for writing reports, while sometimes they are not analyzed or employed for decision-making purposes.
Another challenge is the discrepancy between the time needed to generate research evidence and the time taken by decision-makers to generate actions; also, achieving fruitful communication between researchers and decision-makers.
Evaluation opportunities: Using the continuum of care perspective and improving the indicators.
Researchers recommend looking at care as a continuum from pregnancy to postpartum: “This perspective has been of great use to us for identifying the main challenges for the health service in terms of enhancing coverage.” International organizations point out another opportunity, namely, to turn again to the indicators the health services already generate to improve them or to create tools to facilitate their evaluation and monitoring.
Information opportunities: The great amount of data, involvement in collection, and resource optimization.
Researchers believe that despite the limitations regarding quality and opportunity, a considerable amount of data are collected in Mexico: “Obviously, the data aren’t ideal, but we have much information which allows us to carry out the analyses.” In the event of having to collect information themselves, their participation in the fieldwork leads to improved data quality.
On the other hand, international organizations rely on the supervisory teams that regularly visit health services when they want to collect information about the quality of care.
Resource opportunities: The need to involve appropriate task forces.
Researchers and international organizations acknowledge that being able to count on a team with appropriate training and skills or already involved in the issue allows the research and the monitoring to get done and actions to be generated. One decision-maker remarked: “We asked the ministries to take on people from various fields, not only from maternal and child care, [and] we aim to include everyone involved in delivering services with a view to achieving a more systemic view.”
Management opportunities: Building stable, inter-sectorial relationships of trust.
Health sector and national and international organizations state that building relationships of trust, whether with the authorities, decision-makers or peers within the same institution, improves proceedings at the different stages of monitoring. “What has helped us to unclog issues of information or red-tape are public relations, they’re so helpful,” one coordinator remarked.
Decision-making opportunities: To have quality indicators, political decision-making, and support from the international agenda.
One important finding to emerge from international organizations is that the health ministry “has been finding the quality indicators to be of great use. For example, they can see which medicaments were lacking or which procedures were followed and which not”, as one technician noted. So, including quality indicators in monitoring has allowed generating actions to improve maternal health care.
Most respondents agreed that being able to count on the support and commitment of decision-makers allows monitoring to be done correctly or to set up bodies designed to do it. It was possible to use the interviews to confirm that the agenda drawn up between international organizations and the health sector gives added drive to monitoring. Some coordinators commented: “At the start, it was an initiative of an [international body], the health sector and civilian society,” “it was as part of a cooperation scheme between the [international body] and Mexico, and that’s how it started.”
Discussion
Main findings
This study shows an overview of how the monitoring of maternal health care is carried out in Mexico and the factors that influence the process. Our findings identify the elements that may interfere or facilitate the implementation of the monitoring of inequalities, particularly, by ethnicity.
Our study shows that, in Mexico, although there is particular sensitivity about the importance of measuring inequalities (it has institutions and personnel with experience in monitoring, technical and political support from international organizations) in practice, maternal care inequalities are not measured. We observed that, currently, none of the actors is sufficiently coordinated to do it effectively. There is a lack of commitment and leadership resulting in a set of isolated efforts.
The study unveiled five main categories of obstacles and opportunities related to evaluation, information, resources, management, and decision-making. The main obstacles are related to complex methodological approach, the low quality’s system information, lack of resources and making decisions. Political and technical support from the international agencies to the health sector were the main facilitators.
Recently, in the framework of the SDGs, there has been a discussion of which factors might restrict the performance of health inequality monitoring. The barriers identified emerge from limitations in health sector information systems as well as with political, financial, social and cultural factors. While the key opportunities that countries should move forward include robust data collection infrastructure supported by national institutions, development of technical capacity for equity analysis and communication, and find effective ways to use the results of health inequality monitoring. [7,29]Some of these factors coincide with those found in our study from the participants’ own experience in the monitoring.
The main challenges identified by those who responded referred to information, which has problems of limited access, data quality or inadequate representativeness of surveys in respect of particular interest groups. However, these obstacles are not new for Mexico or for other countries, where for many years it has been pointed out that the information systems are poorly structured, poor data quality due to an inadequate collection, and lack of resources to conduct more extensive or specific surveys. [30–32] Address these problems are essential in order to obtain better evaluations to better guidance for decision-making.
In recent years, health inequalities monitoring has gained ground in the political attention of the countries [7,33–35] Our results show that key professional at different levels such as technicians, coordinators, researchers or decision-makers are not only aware of the issue but also of its importance. However, this does not lead to political decisions to develop any measure for monitoring maternal health care inequalities in Mexico. This fact could be related to the lack of familiarity with the use of monitoring for decision making. [7,30,35] Therefore, we thought that it is essential to stress the need to establish some institutional link between the results of monitoring and concrete actions that might reduce the inequalities revealed in the monitoring.
As for opportunities, our findings suggest that the role of international organizations and their links with the countries is crucial to carry out monitoring. In this connection, given the international commitment “not to leave anyone behind,” many international organizations and initiatives are providing technical support in metric generation, enhancing monitoring systems and strengthening capacities to analyze results and put them to good use. [7,33,34] Provided that full advantage is taken of the support, cooperation and political influence of this types of organizations or initiatives, progress will be made in implementing health inequality monitoring.
Policy implications
Nobody doubts the need for ethnicity-based monitoring of maternal health care inequities if it is to be reduced. Monitoring would enable differences concerning other groups to be identified, as well as the critical points of care coverage. [36,37] However, our study shows that although there is some sensitivity towards measuring inequalities, in practice, there is still no indicator to monitor maternal health disparities.
Monitoring could play a strategic role by making decision-making more efficient and effective through the provision of information about whether policies, schemes or activities are accomplishing the purpose for which they were set up or designed. [5,12] The government, the health ministry, and other decision-makers could focus research on those areas in order to determine the cause of the problems and improve the state of maternal health among the indigenous populations.
Given our findings, we believe that in the short-term surveys might be used as the most feasible source of information, due to the poor quality, delays or lack of data available in the health sector information system. In the future, once the Mexican system is fully operational, it could be reconsidered as a possible resource.
As for evaluations, the evidence generated from researchers or deriving from the experiences of international organizations should be reviewed and analyzed to identify the most feasible and useful indicators for decision-making at the national and regional levels. According to our study, there are enough proposals that could be taken up by the observatories or the ministry of health.
Overcoming the challenges related to management and decision making for the implementation of monitoring by ethnicity requires that some of the actors involved take the commitment and leadership. The institution or area concerned should articulate and coordinate the efforts being made from different institutions. In the case of Mexico, we thought that the collaboration of the observatories could be essential to propose the implementation of monitoring inequalities in maternal healthcare. They would exchange their knowledge and experience in monitoring maternal health and how to measure disparities in health.
The political and technical support being lent currently to this issue by international organizations is an opportunity for placing ethnicity-based monitoring of maternal health care on the decision-makers’ agendas. In the past, Mexico has taken advantage of this drive to advance in health monitoring, for example, with the setting up of monitoring organizations. However, care must be taken that monitoring is continuous and mechanisms need to be defined to guarantee its future regardless of international support or changes in the administration.
Limitations
Our use of a qualitative method means that our findings derive from our respondents’ experiences and cannot, therefore, be generalized. One of the main limitations is that only one of the public health service providers was included in the study, albeit the main provider of services to groups at risk of suffering inequalities in health care as well as the provider responsible for the Mexican health sector. It is, therefore, possible that the obstacles and opportunities for other institutions may differ from those that emerge in this study; that said, having achieved discursive saturation; we have obtained the most significant opinions in this field of activity.
Conclusion
As we have argued, the success of a monitoring system to help decision-making aimed at reducing maternal health inequalities seems to depend not only on accurate evaluation but also on the context in which it is carried out and the actors involved, which is why it is fundamental to take their perspectives into account.
Our study has permitted us to analyze the case of maternal health care in Mexico as it relates to the implementation of ethnicity-based inequality monitoring. Nevertheless, actors from other countries may identify themselves with the views of our respondents and find in them a precedent demonstrating the need to understand the workings, obstacles, and opportunities for monitoring as they currently perform it; thus, progress may be made towards assessing inequalities and thereby reducing health inequities with the aid of concrete policies and initiatives.
Supporting information
S1 Table. Participants’ characteristics.
aMean; bExperience in general monitoring activities not necessarily in maternal health. Note: All actors of the Ministry interviewed was from the national level. Sources: Own elaboration using information from the questionnaire applied to participants.
https://doi.org/10.1371/journal.pone.0217557.s001
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References
- 1.
World Bank Group. Indigenous Latin America in the Twenty-First Century: The First Decade. 2015. http://hdl.handle.net/10986/23751
- 2.
UNICEF. Health Equity Report 2016: Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking. 2016. www.apromiserenewedamericas.org
- 3.
UNPFA, UNICEF, UN Women. Indigenous Women’s Maternal Health and Maternal Mortality. UNFPA; 2018 [cited 2017 Sep 18]. https://www.apromiserenewedamericas.org/publication/equidad-salud-2016/
- 4.
World Health Organization. National health inequality monitoring: a step-by-step manual. Geneva; 2017. https://www.who.int/gender-equity-rights/knowledge/national-health-inequality-monitoring/en/
- 5.
World Health Organization. Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. Geneva, Switzerland: World Health Organization; 2013. https://apps.who.int/iris/bitstream/handle/10665/85345/9789241548632_eng.pdf;jsessionid=26B38902DF0A1696E82C6DE6C28B3F35?sequence=1
- 6.
Nations U. Transforming our world: the 2030 Agenda for Sustainable Development; 2015 [cited 2018 Oct 19]. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E
- 7. Hosseinpoor AR, Bergen N, Schlotheuber A, Boerma T. National health inequality monitoring: current challenges and opportunities. Global health action. 2018;11: 1392216. pmid:29460696
- 8. Hosseinpoor AR, Bergen N, Koller T, Prasad A, Schlotheuber A, Valentine N, et al. Equity-Oriented Monitoring in the Context of Universal Health Coverage. PLoS Medicine. 2014;11. pmid:25243463
- 9. Armenta Paulino N, Sandín Vázquez M, Bolúmar F. Indigenous language and inequitable maternal health care, Guatemala, Mexico, Peru and the Plurinational State of Bolivia. Bulletin of the World Health Organization. 2018;96. pmid:30618466
- 10. Mesenburg MA, Restrepo-Mendez MC, Amigo H, Balandrán AD, Barbosa-Verdun MA, Caicedo-Velásquez B, et al. Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries. The Lancet Global Health. 2018;6: e913. pmid:30012271
- 11. Heredia-Pi I, Serván-Mori E, Reyes-Morales H, Lozano R. Gaps in the continuum of care during pregnancy and delivery in Mexico. Journal of Mexican Public Health 2013;55: S288. ISSN 0036-3634
- 12.
Adrien M, Bamberger M, Conner RF, Djokovic-Papic D, Hancioglu A, Jankovic V. Bridging the gap: The role of monitoring and evaluation in evidence-based policy making: UNICEF; 2008[cited 2018 Oct 19]. http://mics.unicef.org/files?job=W1siZiIsIjIwMTUvMDEvMzAvMDMvMTYvNDkvMjQ2L2V2aWRlbmNlX2Jhc2VkX3BvbGljeV9tYWtpbmcucGRmIl1d&sha=66f7484e16ed9da3
- 13. Barros AJD, Victora CG. Measuring Coverage in MNCH: Determining and Interpreting Inequalities in Coverage of Maternal, Newborn, and Child Health Interventions. PLoS Medicine. 2013;10: e1001390. pmid:23667332
- 14. Braveman PA. Monitoring equity in health and healthcare: a conceptual framework. J Health Popul Nutr. 2003;21: 181–192. Retrieved from http://www.jstor.org/stable/23499216 pmid:14717564
- 15.
Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. Fourth edition ed. Oaks Thousand, California: SAGE Publications, Inc; 2015.
- 16.
Ulin PR, Tolley EE, Robinson ET. Investigación aplicada en salud pública: métodos cualitativos. Washington, D.C.: OPS; 2006.
- 17. Martínez-Salgado C. El muestreo en investigación cualitativa: principios básicos y algunas controversias. Ciência & Saúde Coletiva. 2012;17: 613–619.
- 18. Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001;322: 1115–1117. pmid:11337448
- 19.
Ministry of Health. Specific action plan for maternal and perinatal health 2013–2018.2013. https://www.gob.mx/salud/documentos/programa-de-accion-especifico-salud-materna-y-perinatal-2013-2018-9809
- 20.
Maternal mortality observatory. Operating guidelines.2009. [cited 2018 Oct 19]. http://www.omm.org.mx/images/stories/Documentos%20grandes/Lineamientos_OMM.pdf
- 21. Meljem-Moctezuma José. Conformación del Observatorio de Inequidades en Salud en México. Salud Pública de México. 2016;58: 606–607.
- 22. Serván-Mori E, Contreras-Loya D, Gomez-Dantés O, Nigenda G, Sosa-Rubí SG, Lozano R. Use of performance metrics for the measurement of universal coverage for maternal care in Mexico. Health policy and planning. 2017: czw161. pmid:28453712
- 23. Servan-Mori E, Sosa-Rubi SG, Najera-Leon E, Darney BG. Timeliness, Frequency and Content of Antenatal Care: Which Is Most Important to Reducing Indigenous Disparities in Birth Weight in Mexico? Health Policy and Planning. 2016;31: 444–453. pmid:26329891
- 24. Mokdad AH, Colson KE, Zúñiga-Brenes P, Ríos-Zertuche D, Palmisano EB, Alfaro-Porras E, et al. Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings. Population health metrics. 2015;13: 3.
- 25. Kuruvilla S, Bustreo F, Kuo T, Mishra CK, Taylor K, Fogstad H, et al. The Global strategy for women’s, children’s and adolescents’ health (2016–2030): a roadmap based on evidence and country experience. Bulletin of the World Health Organization. 2016;94: 398.
- 26.
Taylor SJ, Bogdan R, Piatigorsky J. Introducción a los métodos cualitativos de investigación: la búsqueda de significados. Barcelona: Paidós; 1987.
- 27. Sandelowski M. Whatever happened to qualitative description? Research in nursing & health. 2000;23: 334. 43.0.CO;2-G.
- 28.
Smith JA, Osborn M. Interpretative phenomenological analysis. In: Smith JA, editor. Qualitative psychology: a practical guide to research methods. Los Angeles, Calif: SAGE Publications; 2008.
- 29. Hosseinpoor AR, Bergen N, Schlotheuber A, Grove J. Measuring health inequalities in the context of sustainable development goals. Bulletin of the World Health Organization. 2018;96: 654–659. pmid:30262947
- 30. Palacio-Mejía LS, Hernández-Ávila JE, Villalobos A, Cortés-Ortiz MA, Agudelo-Botero M, Plaza B. Health information systems in the Mesoamerican región. Journal of Mexican Public Health 2011; 53(suppl 3): s374.
- 31. Flórez CEP, Chapman E, Panisset U, Arredondo A, Fitzgerald J, Reveiz L. Availability of indicators for monitoring the achievement of “Universal Health” in Latin America and the Caribbean. Pan American Journal of Public Health 2016; 39(6): 330–40. pmid:27706437
- 32. Boerma T, AbouZahr C. Health information systems: the foundations of public health. Bulletin of the World Health Organization 2005; 83(8): 578. pmid:16184276
- 33. Hosseinpoor AR, Bergen N, Schlotheuber A. Promoting health equity: WHO health inequality monitoring at global and national levels. Global health action. 2015;8: 29034–8. pmid:26387506
- 34. Casas-Zamora JA, Ibrahim SA. Confronting health inequity: the global dimension. American journal of public health 2004; 94(12): 2055–8. pmid:15569950
- 35. Valle AM. The Mexican experience in monitoring and evaluation of public policies addressing social determinants of health. Global health action. 2016;9: 29030–5. pmid:26928215
- 36. Östlin P, Schrecker T, Sadana R, Bonnefoy J, Gilson L, Hertzman C, et al. Priorities for research on equity and health: towards an equity-focused health research agenda. PLoS Medicine. 2011;8. pmid:22069378
- 37. Cash-Gibson Lucinda, Rojas-Gualdrón Diego F, Pericàs Juan M, Benach Joan. Inequalities in global health inequalities research: A 50-year bibliometric analysis (1966–2015). PLoS One. 2018;13: e0191901.