Research Article: Generation and evaluation of an indicator of the health system’s performance in maternal and reproductive health in Colombia: An ecological study

Date Published: August 30, 2017

Publisher: Public Library of Science

Author(s): Carlos Eduardo Pinzón-Flórez, Julian Alfredo Fernandez-Niño, Luz Mery Cardenas-Cardenas, Diana Marcela Díaz-Quijano, Myriam Ruiz-Rodriguez, Ludovic Reveiz, Armando Arredondo-López, I. King Jordan.


To generate and evaluate an indicator of the health system’s performance in the area of maternal and reproductive health in Colombia.

An indicator was constructed based on variables related to the coverage and utilization of healthcare services for pregnant and reproductive-age women. A factor analysis was performed using a polychoric correlation matrix and the states were classified according to the indicator’s score. A path analysis was used to evaluate the relationship between the indicator and social determinants, with the maternal mortality ratio as the response variable.

The factor analysis indicates that only one principal factor exists, namely “coverage and utilization of maternal healthcare services” (eigenvalue 4.35). The indicator performed best in the states of Atlantic, Bogota, Boyaca, Cundinamarca, Huila, Risaralda and Santander (Q4). The poorest performance (Q1) occurred in Caqueta, Choco, La Guajira, Vichada, Guainia, Amazonas and Vaupes. The indicator’s behavior was found to have an association with the unsatisfied basic needs index and women’s education (β = -0.021; 95%CI -0031 to -0.01 and β 0.554; 95%CI 0.39 to 0.72, respectively). According to the path analysis, an inverse relationship exists between the proposed indicator and the behavior of the maternal mortality ratio (β = -49.34; 95%CI -77.7 to -20.9); performance was a mediating variable.

The performance of the health system with respect to its management of access and coverage for maternal and reproductive health appears to function as a mediating variable between social determinants and maternal mortality in Colombia.

Partial Text

At the beginning of this century, Colombia was among 189 countries to adopt the Millennium Development Declaration, which included a commitment to fulfill eight objectives. One of those objectives is to improve maternal health (Millennium Development Objective (MDO) # 5) [1, 2]. Maternal mortality was chosen as the primary health outcome to evaluate progress towards achieving this objective, with the goal of a reduction of 75% in the maternal mortality ratio (MMR) from 1990 to 2015. To this end, renewing the enrollment of vulnerable populations in health services was proposed as well as substantially improving access to health care [1].

The present study demonstrates the existence of a gap in the health system’s performance in the areas of coverage and utilization of maternal and reproductive health services in Colombia. The states most affected are Guainia, Choco, Vaupes, Amazonas and La Guajira, which according to other authors have the poorest social conditions and the highest maternal mortality rates [12]. The study herein provides two important contributions. First, it creates an indicator that evaluates the performance of healthcare systems in the areas of coverage and utilization of maternal health services in Colombia. This could be used in similar regions, both at the state level and the local level such as municipalities. Second, this work provides evidence of an association between the social determinants, poverty and women’s educational level, and the performance of the maternal and reproductive health system.

Improving access to modern family planning methods and institutionalizing delivery and healthcare provided by trained professionals are strategies that have had a positive impact worldwide [47]. Nevertheless, gaps in coverage and in the utilization of maternal health services exist in Colombia. The states of Choco, Guainia, Amazonas and La Guajira present the greatest deficiencies, with a negative impact on maternal health, as compared to Bogota, Atlantico and Santander which have better processes to provide healthcare services and thus have favorable health outcomes. The indicator constructed to evaluate the coverage and utilization of maternal health services is suitable for assessing this aspect of the healthcare system. It was also found to behave adequately at the state level and to be sensitive to social changes. Therefore, it can serve as an appropriate instrument to measure the functioning of the Colombian healthcare system in the area of maternal health. In addition, a possible relationship was established between social determinants and how well the health system provided healthcare services, where the performance of the system functions as a mediating factor between social determinants and health outcomes. Future studies to explore and evaluate this relationship will be worthwhile.




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