Surgical care is an essential component of healthcare for children and adolescents, enabling the treatment of a broad range of acute and chronic conditions [1, 2]. Timely access to safe and effective surgical services is critical for reducing preventable morbidity and mortality in this population [3]. However, an estimated 1.7 billion children globally lack access to the basic, life-saving surgical care they require [4]. In many low- and middle-income countries (LMICs), pediatric surgical services remain under-resourced and insufficiently monitored, limiting efforts to evaluate and improve service delivery [5, 6]. In Central Latin America, pediatric surgical capacity remains critically limited, with only 35% of children having access to surgical care within 2 hours [7]. Although global surgery has gained increasing attention, pediatric surgical care continues to be underrepresented in policy discussions and investment priorities [8]. Addressing these inequities is central to the United Nations Sustainable Development Goals (SDG), particularly SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities), which emphasize equitable access to essential health services for children [9].

In Mexico, an upper middle-income country, challenges in pediatric surgical care are compounded by structural barriers rooted in a fragmented healthcare system characterized by institutional segmentation and substantial disparities in access to care [10]. Mexico’s healthcare system consists of multiple public and private subsystems that serve different population groups based primarily on employment and insurance status. This structure has led to unequal resource allocation, fragmented service delivery, and regional variability in care quality [11, 12]. Approximately 3–6% of the population solely relies on private healthcare services [13], while the vast majority depends on publicly funded institutions, primarily supported by the federal government. In 2022, an estimated 50.4 million Mexicans (39.1% of the population) lacked access to health services [13, 14].

Public hospitals administered by the Ministry of Health (Secretaría de Salud, MoH) are the primary providers of surgical services for children and adolescents whose families lack private insurance or employment-based social security [15, 16]. These MoH facilities are part of Mexico’s public hospital network, which accounts for about 30% of the country’s hospitals [13, 17]. Patients treated in these facilities were insured under Seguro Popular (Mexico’s Universal Health Coverage program) until its replacement by the Instituto de Salud para el Bienestar (Institute of Health for Well-being, INSABI) in late 2019 and early 2020, as part of a broader reform in Mexico’s public universal healthcare coverage policy [13]. INSABI was subsequently dissolved and merged into Instituto Mexicano del Seguro Social-Bienestar (Mexican Social Security Institute for Well-being, IMSS-Bienestar) in 2023 [13, 18–20]. Under Seguro Popular, families paid modest, income-based annual contributions, with the poorest households fully exempt. In contrast, INSABI offered care free of charge without formal enrollment, and the current IMSS-Bienestar is formally affiliating and credentialing the population it serves, providing care at no cost at the point of service [13, 21–23].

Children and adolescents account for approximately 30% of Mexico’s population [24], making it imperative to understand how they interact with the public healthcare system, particularly in surgical settings. While previous studies have examined pediatric surgical outcomes in select Mexican institutions or specialties [25, 26], no comprehensive, national analysis of pediatric surgical volume, service delivery, and outcomes, including in-hospital mortality, exists. Significant regional disparities in capacity, infrastructure, and access to specialized care further complicate efforts to evaluate system performance, address inequities, and guide evidence-based policy [27]. The COVID-19 pandemic further disrupted surgical services through widespread delays, cancellations, and capacity shifts [28–30], but its specific impact on pediatric surgery within Mexico’s MoH-administered hospitals remains unexamined.

This study addresses these gaps through a retrospective, registry-based analysis of pediatric surgical procedures performed in MoH-administered public hospitals across Mexico from 2010 to 2022. Our objectives were to: (1) quantify the pediatric surgical burden across Mexican states, (2) analyze temporal trends, including the COVID-19 impact, and (3) identify factors associated with in-hospital mortality.

Variables analyzed included sex (male, female), age category (under 5 years, 5–9 years, 10–14 years, 15–17 years) and calendar year (2010–2022). BMI-for-age category was assessed using body mass index (BMI) for age and sex, with z-scores derived from the World Health Organization (WHO) anthropometric reference standards [34]. These z-scores indicate how many standard deviations (SD) a child’s BMI deviates from the median BMI of an age- and sex-matched healthy reference population [34]. Classification followed WHO criteria: underweight (<-2 SD), normal weight (-2 to ≤ + 1 SD), overweight ( > + 1 to ≤ + 2 SD), and obese ( > + 2 SD) [34, 35]. Ward type (intensive care unit (ICU), internal medicine, pediatrics, surgery, other, missing) was also included. The category “other” includes patients admitted to wards that do not fit any of the predefined categories. Surgical procedures (cardiothoracic surgery, endocrine surgery, general surgery, neurosurgery, multiple procedures, ophthalmology, orthopedic surgery, otolaryngology and urology) were classified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) Volume 3 codes [36] and grouped into clinically meaningful categories based on AHRQ classifications (Agency for Healthcare Research and Quality) [37]. The “multiple procedures” category included patients undergoing more than one procedure during the same hospital admission. Additional variables included type of anesthesia (combined, general, local, regional, sedation, missing), hospital-acquired infections (HAI; no, yes), length of stay (LOS; <4 days, ≥ 4 days), in-hospital mortality (no, yes), as well as state and number of surgical procedures (continuous), representing the surgical procedure volume.

HAI was defined as a nosocomial infection not present at the time of admission and acquired during hospitalization [38]. Prolonged LOS was defined as a hospital stay of 4 days or more (≥ 4 days), corresponding to the 75th percentile of the LOS distribution in the analysis population, a percentile-based threshold consistent with definitions used in previous pediatric surgical studies. [39–41]. In-hospital mortality was defined as death occurring during hospitalization [42].

We included eligible children and adolescents (aged 0–17 years) who underwent a surgical procedure at MoH-administered public hospitals in Mexico from 2010 to 2022, as recorded in the national hospital discharge database (SAEH). First-time admissions were included, while data from subsequent admissions of the same children and adolescents during the study period were excluded to avoid double-counting procedures and eliminate interpatient correlation. All surgical specialties were included in the analysis except obstetrical and gynecological procedures, which were excluded due to their distinct care pathways and limited comparability to other pediatric surgical services.

During data cleaning, we removed observations with missing values for sociodemographic variables (age, sex, indigenous identity) and anthropometric indicators to ensure valid classification of BMI-for-age category. Children and adolescents with missing BMI and BMI-for-age z-scores below − 7 or above + 7 SDs were excluded [43–45]. We also excluded unspecified surgical procedures. For hospital-based variables (ward type and type of anesthesia), missing values were retained for descriptive analyses, incidence rate calculations, and trend analyses because differences might reflect facility-level documentation rather than patient characteristics. Supplementary Table 1 provides an overview of the inclusion and exclusion steps applied to the initially available 2,360,629 registry records. The final analysis population consisted of 752,654 records of children and adolescent.

The overall ASIR of surgical procedures was 141.8 per 100,000 children and adolescents across all Mexican states and years (2010–2022) (Fig. 2 and Supplementary Table 4). Guanajuato reported the highest overall ASIR during this period (333.8 per 100,000), followed by Tabasco (319.3) and Tlaxcala (315.9). In contrast, consistently low overall rates were observed in Nuevo León (18.5), Aguascalientes (41.4), and Sonora (53.2).

The highest annual ASIR were recorded in Tabasco in 2017 (463.0), Tlaxcala in 2012 (441.9) and 2011 (429.2), and Guanajuato in 2016 (380.7), while the lowest annual rates occurred in Aguascalientes in 2013 (6.8), Nuevo León in 2019 (9.6) and Querétaro de Arteaga in 2010 (28.3) (Fig. 3 and Supplementary Table 4).

Surgical procedure volumes increased from a monthly average of 4,711.4 in 2010 to a peak of 5,689.4 in 2015 (+ 20.7%), followed by a decline to 4,688.7 in 2019 (− 17.6%), indicating a downward trend even before the onset of the COVID-19 pandemic (Fig. 4 and Supplementary Table 5). This pattern was consistent across sexes, with monthly volumes for male patients peaking at 3,307.2 in 2015 before declining to 2,727.8 in 2019 (− 17.5%), and for female patients peaking at 2,382.2 in 2015 before decreasing to 1,960.9 in 2019 (− 17.7%). ITS analysis showed that surgical procedure volumes declined sharply by 35.0% in April 2020 following the onset of the pandemic lockdowns in Mexico (exp(β): 0.65, 95% CI: 0.59–0.70) (Fig. 4 and Supplementary Table 6). During the pandemic period (April 2020-December 2022), surgical procedure volumes steadily increased to a monthly average of 4,186.5 in 2022. Sex-stratified ITS analysis showed a similar level drop in April 2020, with a 37.0% decline among male patients (exp(β): 0.63, 95% CI: 0.57–0.68) and a 35.0% decline among female patients (exp(β): 0.65, 95% CI: 0.60–0.70).

When analyzing trends for each surgical specialty separately, general surgery volumes dropped by 31.0% in April 2020 (exp(β): 0.69, 95% CI: 0.63–0.75) (Fig. 5 and Supplementary Table 7). In contrast, cardiothoracic surgery volumes did not show a significant level change in April 2020 (exp(β): 1.08, 95% CI:1.00-1.16) and average monthly cardiothoracic surgery volumes increased by 73.2% during the pandemic from 119.6 in 2020 to 207.1 in 2022 (Fig. 5 and Supplementary Table 8).

This study provides a comprehensive overview of pediatric surgical procedures performed in MoH-administered public hospitals across Mexico from 2010 to 2022. To our knowledge, it represents the first national analysis of pediatric surgical epidemiology in this setting. We describe over 750,000 procedures, reveal geographic inequities that demand attention, characterize temporal trends including the pre-pandemic decline and the impact of COVID-19, and identify factors associated with in-hospital mortality among pediatric patients. Our findings reveal substantial geographic disparities, with Guanajuato reporting the highest overall incidence (333.8 per 100,000) and Nuevo León the lowest (18.5 per 100,000), illustrating persistent inequities in access to surgical care for children. We observed an increase in surgical procedure volumes from 2010, peaking in 2015, followed by a decline and an abrupt 35% drop during the COVID-19 pandemic, with gradual recovery by 2022. Factors associated with increased in-hospital mortality included age under 5 years, underweight, ICU admission, cardiothoracic surgery, HAIs, and prolonged LOS. Additionally, overweight and obesity were common, affecting 41% of pediatric surgical patients. These findings underscore the need for targeted, evidence-informed interventions to address the most affected regions and vulnerable patient groups, thereby reducing pediatric health disparities in access to surgical care.

This national analysis highlights significant geographic and temporal inequalities and inequities in pediatric surgical care across Mexico’s public hospitals from 2010 to 2022. Our findings underscore the need for context-specific strategies to strengthen surgical care for children. Beyond infrastructure, solutions must prioritize workforce development, equitable referral pathways, and culturally sensitive engagement with underserved communities. Efforts to address pediatric obesity should be aligned with broader public health and surgical system strengthening, given its growing prevalence in Mexico. Strengthening health data systems, data analysis capacity, and policy engagement is essential to build resilient surgical services that can withstand future crises and safeguard children’s access to care.

By providing the first national analysis of pediatric surgical care in this setting, this study offers critical insights to guide policy and investment decisions toward more equitable and effective surgical services for children across Mexico. Future research should explore patient-level outcomes, surgical quality indicators, and access barriers to inform targeted interventions and monitor progress over time.

Tables and Figures

The map displays age-standardized incidence rates (ASIR) of surgical procedures per 100,000 children and adolescents across Mexico’s 32 federal entities. A red color gradient denotes increasing ASIR, with darker shades indicating higher procedure rates. The scale ranges from 18.5 to 333.8 cases per 100,000 population aged under 18 years.

The heat matrix illustrates the age-standardized incidence rates (ASIR) per 100,000 children and adolescents across the 32 federal entities stratified by year. Darker tones (blue-purple) correspond to lower incidence rates, while lighter tones (yellow) indicate higher rates, with values ranging from 6.8 to 463.0 cases per 100,000 children and adolescents.

The dashed vertical line indicates the onset of the COVID-19 lockdown measures in Mexico (April 2020).

Figure 5: Trend analysis of surgical procedures from 2010–2022 in Mexico (n = 752,654) stratified by surgical specialty

The dashed vertical line indicates the onset of the COVID-19 lockdown measures in Mexico (April 2020)