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

Abstract

Background: The 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.

Methods: We 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).

Results: All 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).

Conclusions: Despite 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.

Keywords: Brazil; Health inequalities; Maternal health; Socioeconomic factors.

Fig. 1

National coverage of six reproductive and maternal interventions, Brazil, from 1986 to 2013. Source: Brazil DHS 1986, DHS 1996, PNDS 2006, PNS 2013

Fig. 2

Coverage of six reproductive and maternal interventions by geographic region, Brazil, from 1986 to 2013. Source: Brazil DHS 1986, DHS 1996, PNDS 2006, PNS 2013

Fig. 3

Coverage of six reproductive and maternal interventions by area of residence, Brazil, from 1986 to 2013. Source: Brazil DHS 1986, DHS 1996, PNDS 2006, PNS 2013. Coloured dots show the average coverage in each category (urban/rural). Horizontal lines connect the average coverage in urban (yellow circles) and rural (dark green circles) areas. The distance between the dots represents absolute inequality. The longer the line between the two groups, the greater the absolute inequality

Fig. 4

Coverage of six reproductive and maternal interventions by wealth quintiles, Brazil, from 1986 to 2013. Source: Brazil DHS 1986, DHS 1996, PNDS 2006, PNS 2013. Coloured dots show the average coverage in each wealth quintile. Q1 is the 20 % poorest wealth quintile; Q5 is the 20 % richest. The distance between quintiles 1 and 5 represents absolute inequality

Fig. 5

Scatter diagrams of concentration index and slope index of inequality for six reproductive and maternal interventions, Brazil, from 1986 to 2013. Source: Brazil DHS 1986, DHS 1996, PNDS 2006, PNS 2013