UC Berkeley

Over half of all births in Mexico are attended in the public health care system. Prenatal care for these women is overwhelmingly at the primary healthcare clinics staffed by general practice physicians, medical residents, and in a few instances, professional midwives. Access to specialty care for those women who need it is dependent on the effective functioning of the referral system.

This dissertation seeks to understand the functioning of referral systems, the quality of care provided to women with obstetric-related referrals and aspects of care coordination to facilitate care of referred patients using a mixed methods study of a network of public health primary care clinics and secondary-level hospitals in Oaxaca and Guerrero, two of the poorest Mexican states.

Chapter 1 found that having insurance coverage, in this case, the public health insurance coverage Seguro Popular, led to greater odds of referral and therefore presents a policy solution to help break down barriers to accessing specialty care. Chapter 2 assessed the quality of care delivered in the prenatal period, measured as the proportion of screenings and preventive care actions carried out. No significant difference in the quality of care delivered was observed between referred and non-referred women. Chapter 3 assessed the change in visit-level quality of care pre- and post-referral for referred versus non-referred women. We found significant declines in quality of care over time in both referred and non-referred women, with referred women experiencing a significantly greater decline than their non-referred counterparts. Qualitative data highlight areas of process losses and potential gains with referred women and shared prenatal care between primary care providers and specialists.

While the referral system elements of physical infrastructure and human resources tend to be a focus of initiatives to strengthen systems in resource-constrained settings, failing to strengthen care coordination hamper the development of strong referrals systems that can successfully care for women who require access to more specialized care.