Successful twin pregnancy in rural Chiapas: providing quality care and comprehensive support to overcome barriers in health access—a case report
Case Report

Successful twin pregnancy in rural Chiapas: providing quality care and comprehensive support to overcome barriers in health access—a case report

María Cristina Alarcón Rebollar1, Carlos Manuel Rusque Lavalle2, Mónica Granados Ruiz1, Martha de Lourdes Arrieta Canales1,3

1Departamento de Atención Primaria, Partners In Health/Compañeros en Salud, Angel Albino Corzo, México; 2Programa de Médico Cirujano, Escuela de Medicina y Ciencias de la Salud del Instituto Tecnológico y de Estudios Superiores de Monterrey, Monterrey, México; 3Master of Medical Sciences in Global Health Delivery Program, Harvard Medical School, Boston, MA, USA

Contributions: (I) Conception and design: MC Alarcón Rebollar; (II) Administrative support: ML Arrieta Canales; (III) Provision of study materials or patients: MC Alarcón Rebollar; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: María Cristina Alarcón Rebollar, MD. Departamento de Atención Primaria, Partners In Health/Compañeros en Salud, Primera Oriente Sur 36, Angel Albino Corzo 30370, México. Email: cristialr.car@gmail.com.

Background: Twin pregnancies are associated with increased risk of complications such as preterm birth, hypertensive disorders of pregnancy and perinatal mortality. Thus, they merit comprehensive care and a multidisciplinary approach. Compañeros en Salud (CES) is a non-governmental organization (NGO) that has supported primary care clinics in rural Chiapas, Mexico since 2011. They provide quality prenatal care and comprehensive support for pregnant women, including point of care ultrasound (POCUS), alimentary support, mental health counseling and home visits by community health workers.

Case Description: A 23-year-old woman, 15.1 weeks pregnant, presented at the primary care clinic. Her home was 3 hours away by foot. Her previous pregnancy, 4 years prior, resulted in C-section. She lived in her in-law’s home with seven other people, where she felt isolated and suffered psychological violence from her husband. Initially, the pregnancy was undesired but this changed when a POCUS scan revealed a twin pregnancy. Due to increased risk of complications, the process for referral to secondary care was initiated. CES provided a formal ultrasound, laboratory tests, monthly alimentary support, and brief psychological interventions led by a mental health community worker. During follow-up visits, the woman was diagnosed and effectively treated for anemia, urinary tract infection and bacterial vaginosis. Despite many barriers to receiving specialized care in Chiapas, one consultation with an obstetrician and gynecologist (OBGYN) was secured. In March 2022, healthy twins returned to the community clinic. Alimentary support was maintained and the mother reported an improvement in her mental health.

Conclusions: Comprehensive care strategies are especially important when providing services to patients carrying twin pregnancies with added risk factors such as poor access to health services, poverty, food insecurity and violence. These strategies, along with quality care have the potential to improve outcomes and reduce inequities in healthcare.

Keywords: Twin pregnancy; rural communities; primary care; case report

Received: 16 April 2024; Accepted: 26 September 2024; Published online: 16 October 2024.

doi: 10.21037/jphe-24-63

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Key findings

• The patient’s environment and social determinants of health play a crucial part in the final outcome of the pregnancy and should be addressed, in an individual way, by health providers.

What is known and what is new?

• Twin pregnancies are associated with a higher mortality and morbidity rate versus singleton pregnancies, thus they merit a comprehensive care strategy and a multidisciplinary approach.

• During 2023, 157,109 prenatal care visits were registered in Chiapas, and a large portion of them were offered in rural settings by general practitioners.

• A task-shifting approach in provision of prenatal care with multidisciplinary teams and patient-navigation services are necessary to overcome the challenges to address health care access.

What is the implication, and what should change now?

• A multidisciplinary and community approach is crucial to ensure the delivery of quality health for the people who live in vulnerable communities and strengthen the health system.

Introduction

Twin pregnancies have increased around the world since 1980 in high- and low-income countries alike (1). In Mexico in 2023, there were 32,612 multiple births, amounting to 1.72% of total births in the country (2,3). Chiapas, a very rural state in southern Mexico with the highest natality rate in the country, had 152,082 registered births of which 1.21% were twin pregnancies and 0.01% were triplets or more (4). Chiapas is also the poorest state in Mexico where, in 2020, 46.1% of the population was in a situation of moderate poverty and 28.3% in extreme poverty. One variable to measure the level of impoverishment is the opportunity to access healthcare services (5). The main social deficiencies were deprivation of social security and lack of basic services, housing and healthcare (6). Healthcare units with in-patient services are located mainly in urban areas and only 28 health centers in the whole state offer specialized gynecology and obstetric services (7,8). People who have lower socioeconomic status often do not access healthcare services, face worse health outcomes (9), and have higher mortality rates. Additionally, people with lower socioeconomic status are often turned away from treatment or receive substandard healthcare (10). Amongst pregnant women, a low socioeconomic status increases the risk of adverse pregnancy outcomes and complications (11).

Twin pregnancies are associated with an increased risk of complications for both the mother and the children. Maternal complications such as spontaneous abortion, anemia, gestational diabetes, preeclampsia, preterm labor, postpartum hemorrhage and fetal complications including fetal growth discordance, intrauterine growth restriction and congenital anomalies are associated with a higher mortality and morbidity rate versus singleton pregnancies (12). Twin pregnancies are also associated with a 13-fold increase in stillbirth in monochorionic and a 5-fold increase in dichorionic twins (13). Thus, they require more monitoring than singleton pregnancies and early detection of complications is key to guide antenatal care and ensure timely management if necessary (14).

Compañeros en Salud (CES) is a non-governmental organization (NGO) that has supported primary care clinics in rural Chiapas, Mexico since 2011. CES focuses on a task-shifting model and a 5 S (stuff, staff, space, social support and systems) work model to strengthen the existing public system. Currently, it supports 2 birthing centers, 1 hospital and 11 rural clinics to provide a preferential option in healthcare for vulnerable communities. To achieve this, we have a comprehensive primary care strategy; we work with community health workers (CHWs) who make home visits to specific patients and provide support and accompaniment, and we hire and train primary care providers. On-site supervision of high-risk cases and skills for diagnostic tools like point of care ultrasound (POCUS) and training of health professionals through a monthly curriculum that includes prenatal care, and global health is given every year. The clinics are equipped with ultrasound machines to provide POCUS scans and rapid tests to detect potential complications during prenatal care. Medication and alimentary support are provided for free when needed. Our Right to Health Program serves as a bridge that connects patients with state-run secondary and tertiary health units while also providing patient-navigation services and the necessary support to address barriers to access (such as transportation) (15). Patients who receive specialized care are also scheduled for follow-up visits in the rural clinics to improve the coordination between primary care providers and the referral centers and overcome the fragmentation in the healthcare system (16).

Through this case report we would like to describe the social determinants of health that need to be taken into account and the structural barriers that we need to overcome to increase the chances of a favorable outcome for a twin pregnancy in rural Chiapas. We present this article in accordance with the CARE reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-63/rc).

Case presentation

A 23-year-old woman, 15.1 weeks pregnant, presented at the primary care clinic, all of the medical conditions through her pregnancy are detailed in Figure 1. Her previous pregnancy, 4 years prior, resulted in a C-section without postpartum complications. Her home was 3 hours away from the clinic by foot, and the family did not have any means of transportation. She lived in her in-law’s home with seven other people, where she felt isolated and suffered psychological violence from her husband, who had an alcohol abuse disorder. At the first clinic visit she mentioned feeling pressured into bearing more children to fulfill her partner’s desires, since he was the sole source of income for the family. This situation had a negative impact on her mental health, the patient shared feeling sad constantly, having trouble sleeping and eating, and having trouble completing household chores.

Figure 1 Timeline. Our patient’s journey from the first visit to the clinics, interventions, diagnosis and treatments to the puerperium. PHQ, Patient Health Questionnaire; POCUS, point of care ultrasound; GA, gestational age; FHR, fetal heart rate; UTI, urinary tract infection; Hb, hemogobin; CHW, community health worker; EFW, estimated fetal weight.

Initially, the pregnancy was undesired but this changed when a POCUS scan revealed a twin pregnancy, so she started prenatal care at the rural clinic. Due to the increased risk of complications and the difficulties in accessing specialized care, the process for referral to a secondary care unit with obstetric services was initiated. CES’ Right to Health program secured a consultation with a gynecologist for evaluation and planning for a C-section. CES provided funds for a formal ultrasound and laboratory tests, coverage of transportation costs for hospital visits and monthly alimentary support for her and her family. To address her mental health condition, brief psychological interventions provided by a mental health community worker and monthly mental health assessments provided by the clinical staff were implemented. During follow-up visits the patient was diagnosed and treated for the four conditions summarized in Table 1. In March 2022, healthy twins returned to the community clinic after a successful C-section performed at the nearest regional hospital. Alimentary support was maintained 6 months postpartum and the mother reported an improvement in her mental health after the CHW’s visits.

Table 1

Diagnosis and medical treatments throughout the pregnancy

Diagnosis Diagnostic method Treatment
Anemia Fingerstick hemoglobin at 10.3 mg/dL Supplemental ferrous fumarate 200 mg every day
Urinary tract infection Urine dipstick positive for blood and leukocytes Nitrofurantoine 100 mg twice daily for 5 days
Bacterial vaginosis Clinical symptoms + pelvic exam Metronidazole 500 mg twice daily for 7 days
Mild depression PHQ 9 score of 6, scale specifically validated for this population (17) Brief mental health intervention delivered by CHW and monthly follow-ups at community clinic

PHQ, Patient Health Questionnaire; CHW, community health worker.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report. A copy of written consent is available for review by the editorial office of this journal.

Discussion

Adequate antenatal care for twin pregnancies requires a referral to specialized care, at least one ultrasound assessment during the first and second trimesters to confirm a twin pregnancy, and then every 4 weeks, to further assess fetal biometry, chorionicity and amnionicity, anatomy, Doppler velocity, and amniotic fluid volume to identify and prevent adverse outcomes such as twin to twin transfusion syndrome and fetal growth restriction (4). However, to achieve these standards of care, it is necessary to improve the utilization of services, which can only be done with meaningful consideration of the patient’s context.

Whilst there is a growing body of evidence for the cost-effectiveness of maternal health programs that provide adequate antenatal care and social support, underutilization due to structural barriers is pervasive, especially among poorer populations (11). Factors such as ethnicity, language, age, socioeconomic and cultural indicators such as decision-making status, economic conditions, level of education and geographical and environmental conditions like distance, location of health facilities, transportation, costs and quality of services determine the use of maternal health services (18).

Due to the existence of a model of care that takes into account social support, CES was able to generate multiple care strategies: anemia and poor weight gain were detected so food support was provided; mild depression was detected, so a mental health intervention was implemented; it was recognized that the family did not have the means to cover transportation and clinical analysis expenses so CES covered these expenses. These targeted interventions and the ability to coordinate care with public health services were critical factors in getting our patient and her babies safely back to the community and are some of our biggest strengths in management. Some limitations in the management of the case are having to rely solely on rapid tests for diagnosis, not being able to secure more than one consultation with an obstetrician and gynecologist (OBGYN) and not being able to extend the mental health intervention to her husband who suffered from a substance abuse disorder.

In Chiapas, facilities that can provide services like laboratory and imaging studies are concentrated in urban areas, decreasing access to complete healthcare. The majority of people living in rural communities in Chiapas are unable to meet healthcare-associated costs such as purchase of medication, laboratory studies, transportation and loss of earnings without incurring catastrophic expenditure (19). Women with lower socioeconomic status are more likely to receive substandard care which is associated with poor obstetric outcomes (10). We were able to overcome these challenges through the Right to Health program which covered costs and supported the patient to navigate the healthcare system. We believe that a patient-centered system navigation approach is an intervention that will help improve obstetric care, as it has been demonstrated in the USA for chronic and oncologic illnesses (20). In Guatemala, an increase in medical care has been seen for indigenous populations with the implementation of a navigation system. This led to a decrease in social barriers when accessing healthcare (21).

In Chiapas, Ministry of Health rural primary care clinics are staffed with a general practitioner and a general nurse who provide healthcare for many communities and as such are often overworked and poorly supervised. The 156 gynecologists registered in Chiapas work in secondary and tertiary healthcare facilities, mostly located in urban areas (8,22,23) making referrals to specialized services challenging. During 2023, 157,109 prenatal care visits were given in the state and a large portion of them were offered in rural settings by general practitioners (24). Training of primary care providers is essential for the provision of quality antenatal care and allows physicians to be able to diagnose, treat and refer to specialized care when necessary. There is a positive association between the length of antenatal care training and the quality of maternal services (25). The implementation of training programs for general practitioners, who provide care in rural facilities, is a key component for adequate delivery of services, especially in areas where specialized services are scarce. Training, clinical support and mentoring of maternity care must be prioritized in rural settings (26).

To enhance the efficiency of small clinical teams, in accordance with WHO guidance (27), CES uses a task-shifting approach in provision of prenatal care implemented through competency-based training of multidisciplinary teams consisting of general practitioners, nurses and CHWs. Each member of the staff plays a different role in prenatal care allowing more efficient use of human resources and easing of bottlenecks in service delivery (27). Community-led interventions can reduce healthcare barriers and work within a task shifting model, in this particular case the CHW gave a short mental health intervention fulfilling the WHO recommendation of assessment and treatment of mental health issues in antenatal care (27).

This case exemplifies how clinical and social complexities intersect to present multiple challenges for patients and healthcare providers. Such challenges must be addressed by healthcare programs if clinical outcomes for patients are to be improved. In this case, increased risk of complications from the twin pregnancy and social vulnerability combined with barriers to healthcare access merited multidisciplinary management to facilitate access and provide social support. Still, more investigation is needed to evaluate these interventions and gather data that could help advocate for patient-centered interventions, task shifting and navigation services.

Due to the nature of this case report, evaluating the efficacy and feasibility of the service model is out of the scope of this article. Even if a single case report cannot be used to determine how this intervention might impact a larger population, our purpose is to share a different approach to patient care in resource-limited settings. The intervention itself also has limitations, such as that the mental health counselling could not be offered to the husband or relatives of the patient, and that we were not able to follow up on the mother or babies after the postpartum period. However, we hope to see more information in other case-reports and studies to find a sustainable way to incorporate similar interventions in rural settings.

Conclusions

Comprehensive care strategies are especially important when providing services to patients carrying twin pregnancies with added risk factors such as poor access to health services, poverty, food insecurity and intimate partner violence. These strategies, along with quality care have the potential to improve outcomes and reduce inequities in healthcare. Healthcare systems need to be built with a multidisciplinary approach. Policies and interventions must address the socio-economic barriers to decrease the likelihood of complications in high-risk cases.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Equity in Health: Findings from the APRU Global Health Conference 2023” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-63/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-63/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-63/coif). The series “Equity in Health: Findings from the APRU Global Health Conference 2023” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report. A copy of written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/jphe-24-63
Cite this article as: Alarcón Rebollar MC, Rusque Lavalle CM, Granados Ruiz M, Arrieta Canales ML. Successful twin pregnancy in rural Chiapas: providing quality care and comprehensive support to overcome barriers in health access—a case report. J Public Health Emerg 2024;8:37.

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