Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the Unified Health System

Abstract

BackgroundThe Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable. The SUS offers free health care, independent of contribution or affiliation. Since then, great efforts and increasing investments have been made for the system to achieve its goals. We assessed how coverage and equity in selected reproductive and maternal interventions progressed in Brazil from 1986 to 2013.MethodsWe reanalysed data from four national health surveys carried out in Brazil in 1986, 1996, 2006 and 2013. We estimated coverage for six interventions [use of modern contraceptives; antenatal care (ANC) 1+ visits by any provider; ANC 4+ visits by any provider; first ANC visit during the first trimester of pregnancy; institutional delivery; and Caesarean sections] using standard international definitions, and stratified results by wealth quintile, urban or rural residence and country regions. We also calculated two inequality indicators: the slope index of inequality (SII) and the concentration index (CIX).ResultsAll indicators showed steady increases in coverage over time. ANC 1+ and 4+ and institutional delivery reached coverage above 90 % in 2013. Prevalence of use of modern contraceptives was 83 % in 2013, indicating nearly universal satisfaction of need for contraception. On a less positive note, the proportion of C-sections has also grown continuously, reaching 55 % in 2013. There were marked reductions in wealth inequalities for all preventive interventions. Inequalities were significantly reduced for all indicators except for the C-section rate (p = 0.06), particularly in absolute terms (SII).ConclusionsDespite the difficulties faced in the implementation of SUS, coverage of essential interventions increased and equity has improved dramatically, due in most cases to marked increase in coverage among the poorest 40 %. An increase in unnecessary Caesarean sections was also observed during the period. Further evaluation on the quality of healthcare provided is needed.

Evolução das desigualdades socioeconômicas na realização de consultas de pré-natal entre parturientes brasileiras: análise do período 2000-2015*

“…When analyzing population surveys conducted in Brazil in 1986Brazil in , 1996Brazil in , 2006 and 2013, France et al 11 described an increase in access to prenatal consultations and, based on the scale of ownership of domestic goods and access to services, found a reduction in inequality between having one and four consultations. Throughout the decades of 2000 and 2010, Brazil implemented various national and local strategies to promote access of pregnant women to prenatal consultations.…”

A panorama of health inequalities in Brazil

“…In relation to heath services and the performance of the Brazilian national health system, França et al [12] document important reductions in inequalities in reproductive and maternal health interventions over the past 4 decades, while Mullachery et al [13] show a slight deceleration in progress made in assuring equitable access to healthcare services since 2008. Boccolini et al [14] identify characteristics of the more than 20 million people who still underutilize the Brazilian health system and Dourado et al [15] demonstrate the importance of the Family Health Strategy in providing a usual source of healthcare as well as remaining regional disparities in its distribution.…”

Inequalities in Infant Mortality in Brazil at Subnational Levels in Brazil, 1990 to 2015

“…Despite the marked reduction of inequalities in various indicators of maternal and child health and the remarkable expansion of coverage of prenatal care and hospital delivery after the implementation of the Uni ed Health System [32], additional efforts aimed at improving access to good quality childbirth care are crucial. It is necessary to integrate actions developed in primary care to the services of childbirth care, to potentiate the municipal capacities in providing adequate assistance to maternal and delivery care [33].…”