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Using systematized tacit knowledge to
prioritize implementation challenges in existing
maternal health programs: implications for the
post MDG era
Victor Becerril-Montekio,
1
Jacqueline Alcalde-Rabanal,
1,
*
Blair G. Darney
1,2
and Emanuel Orozco-Nu~
nez
1
1
Instituto Nacional de Salud P
ublica / Centro de Investigaci
on en Sistemas de Salud (National Institute of Public
Health / Centre for Health Systems Research), Av. Universidad 655, Col. Santa Mar
ıa Ahuacatitl
an, Cuernavaca,
Morelos CP 62100, Mexico and
2
Department of Obstetrics and Gynecology, Oregon Health and Science University,
3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
*Corresponding author. Calle Palmas Norte 213, Colonia Bellavista, Cuernavaca, Morelos CP 62130, Mexico. E-mail:
jacqueline.alcalde@insp.mx
Accepted on 4 March 2016
Abstract
Strategic priority setting and implementation of strategies to reduce maternal mortality are key to
the post Millennium Development Goal (MDG) 2015 agenda. This article highlights the feasibility
and the advantages of using a systematized tacit knowledge approach, using data from maternal
health program personnel, to identify local challenges to implementing policies and programs to
inform the post MDG era. Communities of practice, conceived as groups of people sharing profes-
sional interests, experiences and knowledge, were formed with diverse health personnel imple-
menting maternal health programs in Mexico and Nicaragua. Participants attended several work-
shops and developed different online activities aiming to strengthen their capacities to acquire,
analyze, adapt and apply research results and to systematize their experience and knowledge of
the actual implementation of these programs. Concept mapping, a general method designed to or-
ganize and depict the ideas of a group on a particular topic, was used to manage, discuss and sys-
tematize their tacit knowledge about implementation problems of the programs they work in.
Using a special online concept mapping platform, participants prioritized implementation prob-
lems by sorting them in conceptual clusters and rating their importance and feasibility of solution.
Two hundred and thirty-one participants from three communities of practice in each country regis-
tered on the online concept mapping platform and 200 people satisfactorily completed the sorting
and rating activities. Participants further discussed these results to prioritize the implementation
problems of maternal health programs. Our main finding was a great similarity between the
Mexican and the Nicaraguan general results highlighting the importance and the feasibility of solu-
tion of implementation problems related to the quality of healthcare. The use of rigorously organ-
ized tacit knowledge of health personnel proved to be a feasible and useful tool for prioritization to
inform implementation priorities in the post MDG agenda.
Key words: Communities of practice, implementation research, low- and middle-income countries, quality, maternal health
services, maternal mortality, tacit knowledge
V
CThe Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Health Policy and Planning, 2016, 1–8
doi: 10.1093/heapol/czw033
Original manuscript
Health Policy and Planning Advance Access published April 9, 2016
by guest on April 17, 2016http://heapol.oxfordjournals.org/Downloaded from
Introduction
Maternal mortality remains a priority global health concern, and
health programs addressing it face great expectations to achieve
stated health and policy goals. Despite a number of policies and pro-
grams targeting Millennium Development Goal (MDG) 5 (to reduce
maternal mortality by 75% between 1990 and 2015), only a few
countries will reach this goal. Two years before 2015, the global
average reduction only reached 45% (United Nations 2014). In
2013, the maternal mortality ratio in developing regions (230 mater-
nal deaths per 100 000 live births) was 14 times higher than that of
developed regions (United Nations 2014). Even though important
progress has been made in almost all regions, many countries,
among them Mexico and Nicaragua, will not meet MDG5. Failure
to achieve desired results has been explained as failure of implemen-
tation, particularly in developing countries (Peters et al. 2013).
In low- and middle-income countries (LMICs), although the de-
sign of policies and programs is increasingly based on available sci-
entific evidence, it is not yet very common to find evidence-based
decision making about the implementation of public health interven-
tions (Gonz
alez-Block et al. 2008;2011). The implementation of
maternal health programs encompasses an array of real-world actors
and processes involving health personnel, the adequate use of re-
sources and the delivery of services, at the right time and for prop-
erly identified health needs. Thus, successful implementation of
evidence-based interventions requires both organizational decisions
at different levels to adopt an intervention and its actual implemen-
tation or everyday functioning, all of which will determine failure or
success (Gonz
alez Block et al. 2011).
The need to develop reasonable and equitable priority setting
mechanisms concerning maternal health is highly recognized
(Shiffman 2007). Priority setting becomes particularly important in
contexts where resources are limited. Different approaches to priority
setting, mainly economical, have been advanced (Nair et al. 2014;
Stefanini 1999). Notwithstanding these elements, the kind of evi-
dence to be considered in public health should include not only the
different perspectives of scientific research but also other factors such
as the knowledge and views of the diverse stakeholders participating
in maternal health programs (Nair et al. 2014;Panisset et al. 2012).
This article uses data from an Alliance for Health Policy and
Systems Research (AHPSR)/World Health Organization-funded pro-
ject that tested a capacity strengthening model for maternal health
personnel in two LMICs: Mexico and Nicaragua. The project goal
was based on existing evidence and aimed to strengthen health per-
sonnel’s capacity to use research results and to understand the core
focus and characteristics of implementation research to guide evi-
dence-based decision making in maternal health programs
(Gonz
alez-Block et al. 2011;Rouvier et al. 2013).
Existing maternal health programs in Mexico and Nicaragua pro-
mote scientifically proven interventions; therefore, the capacity-
building model of this project was initially oriented towards the util-
ization of implementation research (IR), the branch of health systems
research dedicated to study the way any health intervention is made
available to the public, answering how and why scientifically proven
interventions fail or succeed in reaching their goals (Peters et al.
2013). Moreover, as Peters et al. (2013 p. 9) state, ‘implementation
research is often at its most useful where implementers have played a
part in the identification, design and conduct phases of the research
undertaken’, combining the objective of strengthening maternal
health programs’ personnel to use and apply scientific evidence with
this characteristic of IR, the project worked on the systematization of
the knowledge and perspectives of the people actually working in
them. Because the actual implementation of policies and programs in
local settings is always related to contextual factors, we considered
the role of tacit knowledge as an important element that can offer im-
portant information on how national policies and programs de-
veloped to achieve the MDGs are implemented and function locally.
We considered the tacit knowledge of the people working in the
implementation of maternal health programs as a potentially useful
approach to identify and prioritize implementation challenges that
need to be addressed. Tacit knowledge has been defined as a kind of
knowledge that every human being has a relation to his or her every-
day practice of a task or profession (Business Dictionary 2014;
Polanyi 1966). Tacit knowledge is always linked to a particular indi-
vidual, making it hard to formalize and communicate (Nonaka
1994). It includes two dimensions: (1) a technical element that has
been described as the know how related to certain skills in a particu-
lar context and (b) a cognitive element that ‘refers to the individual’s
images of reality and visions for the future, that is to say, what is
and what ought to be’ (Nonaka 1994, p. 16). Other authors also
note that it is usually shared through informal channels, and that to
be transferred, it requires close or extensive personal contact and
trust (Ambrosini and Bowman 2001;Kothari et al. 2011;Landry
et al. 2006; McAdam et al. 2011). Finally, to assure its best utiliza-
tion, tacit knowledge needs to be socialized and systematized.
The purpose of this article is to assess the feasibility of using the
tacit knowledge methodology to prioritize challenges to implemen-
tation of current maternal health programs and inform the post
MDG agenda in LMICs.
Methods
In this project, we implemented a participative approach by creating
six communities of practice (CoPs). CoPs function as interactive
interfaces in which researchers and practitioners can meet, moti-
vated by common interests while they also foster their members’ de-
velopment both personally and professionally (Bertone et al. 2013,
Best et al. 2007;Wenger 1998). The CoPs were formed in three
states of Mexico and three departments of Nicaragua and selected
Key Messages
•The use of rigorously organized tacit knowledge of health personnel proves to be a powerful tool for prioritization in ma-
ternal health programs.
•We report on an innovative approach to using tacit knowledge from health personnel on the front lines of care to de-
velop priorities for quality improvement activities or implementation research.
•It is pertinent and useful to use health personnel’s tacit knowledge to set post MDG agendas at the local level.
•According to this tacit knowledge and its support on scientific literature, improving the quality of care in maternal health
programs should be in the first place to guide post MDG agendas.
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using three basic criteria: (1) relatively high (above national aver-
ages) rates of maternal mortality; (2) similar human development
indexes and (3) presence of health authorities willing to participate
in the project. The project included the states of Hidalgo, Morelos
and Veracruz in Mexico and the departments of Chontales, Jinotega
and Matagalpa in Nicaragua. The CoPs were formed during May to
June 2013 following a call for participation launched by the health
authorities in each state or department. Participants included man-
agers of maternal health programs and personnel in contact with pa-
tients and other healthcare providers or administrators (Table 1).
Participation in these CoPs was voluntary. In agreement with the
corresponding health authorities, a person with expertise in infor-
mation and communication technologies was named as a facilitator
to organize each CoP and serve as link with the research team. We
sought to engage the CoPs in a priority-setting process based on
their tacit knowledge of implementation challenges, face-to-face
workshops and a participatory online forum for the concept map-
ping exercise. These activities were held from July to December
2013.
Concept mapping was our main tool to extract and systematize
what we defined as the ‘raw’ tacit knowledge of each CoP about the
implementation challenges of various maternal health programs.
Concept mapping is a general methodology that helps to organize
and graphically present the ideas of a group of people about a sub-
ject of common interest (Trochim 1989). All participants gave in-
formed consent to participate in concept mapping, and the whole
process was performed in the six CoPs of the two countries. The first
workshop was based in the following protocol:
A brief didactic presentation on health systems, implementation and
implementation research.
The concept mapping initial brainstorming session to answer the
focus question: What are the main problems of the state or
departmental health system that represent an obstacle to reach the
expected results of maternal health programs?
Participants were organized in groups of 6–10 people and asked to
individually write 5–15 answers to the focus question based on
their own personal experience.
Individual answers to the question were recorded on cards.
After discussion, each group eliminated duplicated or redundant
answers.
Using this material and a content analysis approach, the research
team collated and synthesized answers from all CoPs eliminating du-
plicates and redundancies across groups and reducing the list to 98
statements (Hsieh and Shannon 2005). During a second workshop,
participants were trained on the use of the Concept Systems Global
platform, an online tool, to perform the rest of the concept mapping
activities online (Concept Systems Global 2014). The research team
uploaded the 98 statements to the platform, and the research team
leader formatted the platform according to the specific objectives of
the project.
Each CoP member was next asked to perform five tasks on the
online platform:
Register on the platform creating their own usernames and
passwords.
Provide basic anonymous sociodemographic information (country,
state or department, age, gender, education and main responsibil-
ities in the maternal health programs).
Sort the 98 statements in conceptual clusters (minimum of 5 and a
maximum of 20) and name them according to their own criteria to
finally save their personal sorting results.
Rate each statement according to its importance using a Likert
scale in which 1 equals ‘not important’ and 5 equals ‘of vital
importance’.
Table 1. Socio-demographic composition of CoP members from Mexico and Nicaragua with useful answers in Concept Mapping activities
Variables Mexico Nicaragua Total
Total % Total % Total %
Sex
Male 26 32.1 37 31.09 63 31.5
Female 55 67.9 82 68.91 137 68.5
Age
<30 13 16.05 52 43.7 65 32.5
31–50 63 77.78 58 48.74 121 60.5
>50 5 6.17 9 7.56 14 7
Education
a
Below University 9 11.11 41 34.45 50 25
University/nursing/physician 51 62.96 62 52.1 113 56.5
Postgraduate 21 25.92 16 13.44 37 18.5
Nurse 26 32.09 50 42.02 76 38
Profession
Physician 38 46.91 21 17.65 59 29.5
Manager 6 7.41 19 15.97 25 12.5
Other 11 13.58 29 24.37 40 20
Place of work
Primary care 53 65.43 77 64.71 130 65
Hospitals 17 20.99 23 19.33 40 20
Administration 11 13.58 19 15.97 30 15
Total 81 40.5 119 59.5 200 100
* Note
In Mexico and Nicaragua physicians have a university level degree, while nurses may or may not have it.
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Rate the feasibility of solving the problem referred in each statement
on a similar Likert scale in which 1 equals ‘cannot be solved’ and 5
equals ‘it’s already being solved’.
Facilitators of the CoPs were responsible for the follow-up with
each member to assure timely and accurate participation. The re-
search team reviewed and confirmed the validity of each member’s
information.
Using the statements and the results of the online sorting
exercise, we generated clusters or conceptual groups using multidi-
mensional scaling and a correlation matrix embedded in the
platform, then weighted each cluster using the priority and feasibil-
ity data provided by CoP members. The cluster or conceptual
group names were discussed with the CoPs in order to make sure
that they accurately represented the main ideas of the statements
gathered in each cluster. We next tested varying numbers of clusters
(8, 10 and 12 clusters in a map) and presented the options to the
CoPs for discussion. Consensus was reached that 10 cluster maps
were the best.
We next used the average values of the importance and
feasibility of solution rating scores for each statement to generate
a correlation to identify the importance–feasibility relationship
at the statement level. Starting with the discussion on the clus-
ters, the selection of the particular problems to be addressed
through implementation research was made by each CoP after
discussing on the problems combining the highest scores for
both criteria (importance and feasibility). We thus finished
with cluster-level and statement-level average ratings of importance
and feasibility, as well as a measure of joint importance and
feasibility.
A thorough analysis of the concept mapping results was made
during a 40-h workshop and an additional training on evidence-
based decision making in public health and implementation research
with 25 leaders of the different CoPs. By the end of the week, each
CoP had started developing an implementation research protocol
focused on a priority implementation problem to be discussed and
finalized with the participation of all of its members. The analysis of
the concept maps also served as basis for the selection of problems
upon which a more local action would be undertaken after the elab-
oration of small intervention protocols.
Results
From the 298 participants in the brainstorming activities in both
countries, 231 members of the six CoPs registered in the CSG plat-
form and 200 people satisfactorily completed them (Table 1).
Our main finding was the similarity between the Mexican and
the Nicaraguan general results as they appeared in their correspond-
ing concept maps, particularly concerning both the importance and
the feasibility of solution rating of two clusters: one containing the
statements related to the quality of healthcare and another one gath-
ering statements about the lack of financial resources. This led to
consider the global concept maps of the two countries organizing
the 98 ideas in 10 conceptual groups or clusters.
Figures 1 and 2present the maps including the relevance of each
cluster according to the average of its rating for importance
(Figure 1) and feasibility of solution (Figure 2). The points in each
cluster represent each one of the 98 problems identified by the CoPs,
with their corresponding numbers, according to the random order
given to them by the platform. The number of layers of each cluster
represents the average rating: five layers represent the highest rating
of the ideas, whereas only one layer is accorded to sets of ideas with
the lowest rating average.
Cluster 1 ‘quality of healthcare’ in Figure 1 has five layers, show-
ing the highest importance rating average, and it includes the largest
number of statements (18 points), all of which describe different
problems related to the quality of care. Two other clusters with four
layers follow: Cluster 3 and Cluster 7. Including only two layers,
Clusters 2 and 10 have average ratings between 3.88 and 3.95 while
Figure 1. Concept map of systematized tactic knowledge on maternal health programs implementation problems. Averaging rating (importance), Mexico and
Nicaragua
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the average rating of the other three clusters with only one layer is
below 3.88.
Concerning the feasibility of solution of the implementation
problems, Figure 2 shows two clusters with high rating averages
and, therefore, five layers: Cluster 1 ‘quality of healthcare’ and
Cluster 3 ‘excess of patients demand’. The following cluster in feasi-
bility of solution average rating is Cluster 5 with four layers,
whereas three clusters show intermediate averages of feasibility rat-
ing: Clusters 6, 9 and 10. Instead, the rating of Cluster 7 corres-
ponds to very difficult to resolve problems. Finally, the clusters that
are the most difficult to resolve are 3 and 8.
Figure 3 depicts the correlation of importance and feasibility rat-
ings of each of the 10 clusters. This figure compares the average
value of the two ratings of the statements included in each cluster.
Some clusters were rated similarly—quality high on both, import-
ance and feasibility, municipal authorities and social/educational
level low on both—whereas others received different ratings for the
two criteria.
In addition to classifying the importance and feasibility rating of
all clusters, we also classified individual statements according the
highest average ratings for importance and feasibility of solution
(Figure 4). The statements (problems) falling in Square I of Figure 4
combine the lowest rating for importance and feasibility of solution.
Square II gathers those problems with a higher rating average for
feasibility of solution, but a low rating concerning importance.
Square III includes problems with a high importance average rating
but low feasibility of solution. Finally, Square IV or Go Zone gath-
ers those problems with the highest average ratings for importance
and feasibility of solution. Logically, this is the priority zone where
decision makers and researchers should look for the development of
their proposals. The most important finding is that 15 out of 25
problems in Square IV focus on quality issues. Although the clusters
correlation permitted to give a general orientation towards quality
of health care, the position of each statement in Figure 4 permitted
to focus, in particular, on implementation problems.
Table 2 also shows that out of 25 statements in the Go Zone, 15
are part of Cluster 1 ‘quality of healthcare’, whereas the other 10
are distributed among five other clusters.
After analyzing their own systematized tacit knowledge, the
leaders of each CoP focused on the priority clusters and individual
statements rated highly on both importance and feasibility of their
state or department and decided upon the implementation problems
they would choose either to develop a small local intervention
protocol or a larger implementation research protocol. The first
aimed at improving the implementation of local issues with high and
relatively simple feasibility of solution concerning such things as pre-
natal control, obstetric risk identification, health professionals train-
ing, post-natal follow-up and the referral system. In the cases of
problems demanding a deeper consideration and study, implementa-
tion research protocols were designed.
For the implementation research protocols, in Mexico, the CoP
Hidalgo chose statements 2 (‘deficient valuation of pregnant women
by the personnel who receives them -physicians and nurses’) and 14
(‘deficient quality of care during pregnancy, delivery and postpar-
tum’). The choice of the CoP from Morelos was statement number 6
(‘pregnant women and their families fail to make a timely detection of
alarm signs’), also in the Go Zone of both countries. In the case of
Veracruz, the CoP also selected statement 14, but did not link it to
any other one. In Nicaragua, also finding a relevant relationship be-
tween statements 14 and 26 (‘lack of compliance to official norms
and practice guides’), the cops of Chontales and Jinotega resolved to
address the quality of care vis-
a-vis the Health Ministry’s norm on
prenatal care (Ministerio de Salud 2008). Finally, the CoP of
Matagalpa focused on statement number 48 (‘inadequate identifica-
tion of obstetric risk by health personnel’) to work on an IR protocol.
Discussion
We report on an innovative approach to using tacit knowledge from
health personnel on the front lines of care to develop priorities for
quality improvement activities or implementation research. Our
Communities of Practice and concept mapping approach was feas-
ible and acceptable to participants. Tacit knowledge is supported by
what we know from the literature. It is feasible and valuable to use
tacit knowledge to prioritize problems in the implementation of ma-
ternal health programs that can eventually inform the post-MDG
agenda at the local level. We are aware that tacit knowledge might
leave certain issues aside, as could be the case of unsafe abortion,
HIV and other stigmatized issues. So, even though we found it use-
ful, we recognize that the tacit knowledge approach needs to be
complemented by other methods. Our key finding is that deficiencies
in the quality of maternal health care emerged as a priority issue
based on the systemized tacit knowledge of participating healthcare
personnel in both Mexico and Nicaragua. There was clear agree-
ment on the high importance of problems related to the quality of
Figure 2. Concept map of systematized tactic knowledge on maternal health programs implementation problems. Averaging rating (feasibility), Mexico and
Nicaragua
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care and on the high feasibility of addressing such problems. When
compared with the other nine conceptual groups, the quality of care
cluster, not only combines the highest rating for importance and
feasibility of solution but also gathers the largest number of state-
ments (18 points). Finally, 15 out of 25 individual statements
describing implementation problems with the highest rating average
for both criteria are quality of care problems.
CoPs in both countries identified factors determining deficient
quality of care in public healthcare facilities that include pregnancy,
childbirth and post-partum (Yemile Ordaz-Mart
ınez et al. 2010).
Figure 4. Strategic zones of average ratings of implementation problems of maternal health programs by Mexican and Nicaraguan CoPs
Figure 3. Correlation between average ratings of the 10 clusters of implementation problems of maternal health programs by Mexican and Nicaraguan CoPs
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They considered human resources problems such as the lack of them
or their deficient training, particularly in first-level health facilities
(McIntosh et al. 2012). The absence of the humane sensibility among
health personnel was also identified, as was the inaccurate assessment
of obstetric risk, from which stems a deficient follow-up. Due to prob-
lems in timely admission, pregnant women are forced to look for care
elsewhere and many complications derive from the delays originated
in bad reference and counter-reference (Collado-Pe~
na and S
anchez-
Bringas 2012;Lassi et al. 2014). Another aspect of the quality of
healthcare that was recognized was the refusal of obstetric healthcare
that women sometimes suffer in public facilities. These practices high-
light the bad quality of care and the violation of the right to receive
healthcare (Pe´rez-Castro y V
azquez et al. 2012). CoPs also recognized
a persistent lack of drugs and other inputs, which specially hinders the
adequate care of obstetric emergencies (Rouvier et al. 2011). Finally,
different problems limit the proper follow-up of post-natal care, a
period during which many obstetric complications might arise causing
maternal deaths (Pe´rez-Castro y V
azquez et al. 2012).
The organization and delivery of maternal health services must
be able to address unpredictable events and high-risk situations
(DuPree et al. 2009;Institute of Medicine 2001). One tool to foster
best practices, monitor and improve quality in direct clinical en-
counters is the World Health Organization Childbirth Checklist
Programme (World Health Organization 2013). But there is also a
need to interventions to improve quality at the health system level
(Huntington et al. 2012). Strategies for improving the quality of ma-
ternal health care in LMICs, such as educational programs for
women, capacity strengthening programs for health professionals,
integration of services, use of clinical practice guidelines, provider
incentives and other related to the support of local opinion leaders
have been identified (Althabe et al. 2008).
Notwithstanding the important progress made during the past
decades in public hospitals of Mexico and Nicaragua, both countries
still face a long agenda to reach good quality standards in maternal
healthcare programs, particularly in rural areas (Barber et al. 2007).
The prioritization made by the CoPs is based on the experience of
people directly responsible of the administration or the health care
provided by maternal healthcare programs. And it is not a matter of
mere coincidence that they recognize bad quality of public health-
care services. The results of their systematized tacit knowledge find
substantial support in a large spectrum of scientific evidence and
represent a feasible approach that can inform priority setting in the
post MDG era (Nair et al. 2014).
Conclusions
The problems that were identified and prioritized based on the tacit
knowledge of health system actors are supported by scientific litera-
ture. We therefore consider tacit knowledge is a feasible and poten-
tially valuable approach to inform the post MDG agenda at the
local level. Tacit knowledge, as it is initially externalized by the
health personnel, can be considered as some kind of ‘raw’ material
that has to be managed using scientifically sound methods. There is
certainly not one single way to do this. Nevertheless, it is essential to
assure its systematization. The experience presented here was essen-
tially based on concept mapping combining face-to-face and virtual
exchanges among participants. No doubt researchers and health
workers can find other ways to make the best use of the latters’ tacit
knowledge.
Improving the quality of care in maternal health programs be-
comes the sine qua non strategy to assure universal and effective
coverage and stands in the first place to guide the post MDG agen-
das. Based on this new perspective, strategic planning should aim to
work on building the necessary capacities of the health system and
the health personnel in care provision and its management.
Table 2. Individual statements that rated high on importance and feasibility, Mexican and Nicaraguan CoPs
Statement Number Statements rated high on both importance and feasibility Green Go Zone Included in Cluster
1 Consultations for risk pregnancies are established in distant dates and even after the delivery date Quality of care
2 Deficient valuation of pregnant women by the personnel who receives them (physicians and nurses) Quality of care
3 Negative attitude during care of personnel towards pregnant women Quality of care
6 Pregnant women and their families fail to make a timely detection of alarm signs People’s perception
12 Bad reception of pregnant women in emergency cases by surveillance personnel in health units Quality of care
13 Problems with the distribution of delivery care inputs Lack of resources
14 Deficient quality of care during pregnancy, delivery and postpartum Quality of care
23 High rate of refusal of care for pregnant women in health units Quality of care
25 Lack of follow-up of postpartum by health care personnel Quality of care
26 Lack of compliance to Official Norms and Practice Guides Quality of care
35 Pregnant women fail to attend to antenatal control People’s perception
42 Long waiting time for pregnant women’s care in health units Quality of care
46 Inadequate follow-up of obstetric complications Quality of care
48 Inadequate identification of obstetric risk by health personnel Quality of care
49 Lack of follow-up and evaluation of maternal health care processes Excess of demand
56 Lack of human attitudes in health personnel responsible for pregnant women’s care Quality of care
58 Obstetric emergency and general care equipment is in bad conditions Finance information
72 Limited follow-up of pregnant women in the first level of care Quality of care
77 Lack of drugs for normal and emergency obstetric care Finance information
86 Lack of follow-up in pregnant women’s care to guarantee an integral care Quality of care
87 Human resources for health are badly trained during their studies Excess of demand
89 Health personnel lacks training Excess of demand
90 Sexual education programs for adolescents are not implemented Social promotion
91 Community personnel linked with maternal health programs lacks training Social promotion
96 Negligence on the part of health personnel Quality of care
Elaborated from the CSG platform analysis of statements.
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Acknowledgements
This article is based on the results of the project ‘Strengthening capacities to
demand, access and apply implementation research to scale-up maternal
health programs for underserved populations in Mexico and Nicaragua’,
which is financed by the Alliance for Health Policy and Systems Research/
World Health Organization (SPHQ14-APW-2064). Dr. Octavio G
omez-
Dante´s read the final draft and contributed important commentaries.
Conflict of interest statement. None declared.
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