Fragmented healthcare and effective maternal coverage in Mexico, 2009-2023

Fragmentation of healthcare delivery can disrupt the maternal care continuum and undermine effective coverage. In Mexico's segmented health system, institutional discontinuities may exacerbate inequities in access and quality. We examined the prevalence, determinants, and consequences of fragmented healthcare (FHC) for effective maternal healthcare coverage (EMHC) between 2009 and 2023.

We conducted a retrospective, repeated cross-sectional analysis using nationally representative data from the 2014, 2018, and 2023 ENADID surveys, including 71,874 women aged 12-54 with a recent live birth. EMHC was defined as a composite indicator encompassing adequate antenatal care (ANC), skilled or institutional delivery, timely postpartum care, and a complication-free puerperium. FHC was defined as receiving ANC and delivery care from different healthcare providers. Pooled multivariable regressions with survey fixed effects assessed the association between FHC and EMHC, adjusting for sociodemographic and contextual characteristics.

Between 2009 and 2023, roughly one in six women experienced FHC, while only one in three achieved EMHC. Fragmentation was more frequent among women covered by publicly subsidized insurance (Seguro Popular or INSABI), Indigenous women, those living in rural areas, and women with higher obstetric risk. Receiving ANC from private providers tripled the odds of FHC compared with women covered by employment-based social security. Women exposed to FHC had a 4.7 percentage point lower probability of achieving EMHC-equivalent to a 20% reduction in the odds of effective coverage (aOR = 0.80; 95% CI: 0.69-0.91). This adverse effect was consistent across survey waves and most pronounced among Ministry of Health users.

Fragmented maternal healthcare trajectories substantially reduce the likelihood of effective coverage, disproportionately affecting socioeconomically and ethnically disadvantaged populations. The observed reduction in EMHC underscores that fragmentation is not merely a clinical or operational issue, but a structural challenge that requires reforms to improve the coordination of care. Strengthening integration across maternal care networks, ensuring interoperability of health information systems, and adopting continuity-based financing models are critical to improving coordination. Addressing FHC could prevent incomplete or unsafe care and accelerate progress toward universal health coverage. These findings offer actionable lessons for Mexico and other middle-income countries confronting health system fragmentation.