Abstract
BackgroundOver the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care. The objective of the present study was to estimate the rate of inadequate prenatal care utilization and its associated factors in São Luís, Brazil, in 2010 and to determine whether there was a reduction of inequity in prenatal care use by comparing the present data to those obtained from a previous cohort started in 1997/98.MethodsData from the BRISA (Brazilian birth cohort studies of Ribeirão Preto and São Luís) population-based cohort, which started in 2010 (5067 women), were used. The outcome variable was the inadequate utilization of prenatal care, classified according to the recommendations of the Brazilian Ministry of Health. The explanatory variables were organized into three hierarchical levels based on the Andersen’s behavioral model of the use of health services: predisposing, enabling and need factors.ResultsOnly 2.0% of the women did not attend at least one prenatal care visit. The rate of inadequate prenatal care utilization was 36.7%. Despite an improved adequacy of prenatal care use from 47.3% in 1997/98 to 58.2% in 2010, social inequality persisted: both low maternal schooling (prevalence ratio (PR) = 2.78; 95% confidence interval (95% CI) 2.23-3.47 for 0 to 4 years of study) and low family income, less than 0.5 monthly minimum wage per capita (PR = 1.37; 95% CI 1.22-1. 54), continued to be associated with higher rates of inadequate prenatal care utilization. Racial disparity regarding adequate utilization of prenatal services was detected, with black (PR = 1.19; 95% CI 1.04-1.36) and mulatto (PR = 1.14; 95% CI 1.02-1.26) women showing higher rates of inadequate use. On the other hand, women covered by the FHP - Family Health Program (PR = 0.92; 95% CI 0.85-0.98) showed a lower rate of inadequate prenatal care utilization.ConclusionsDespite strong expansion of health services and expressive improvements in adequate prenatal care use and social indicators, inequalities in prenatal care use still persist. The FHP seems to be effective in reducing inadequate prenatal care utilization.
Highlights
Over the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care
The estimate is that one-quarter of infant deaths and almost all maternal deaths are due to inadequate delivery of health care from the beginning of pregnancy to the immediate postpartum period [1]
The Brazilian Ministry of Health recommends at least six visits for a low-risk term pregnancy with an early beginning of prenatal care, up to the fourth month of pregnancy [8,9,10,11] whereas the World Health Organization (WHO) recommends a minimum of four prenatal care visits [12]
Summary
Over the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care. Important among them are the Kessner index [6], proposed in 1973, and the Kotelchuck index [7], proposed in 1994 and known as Adequacy of Prenatal Care Utilization (APNCU) index. All of these indices are based on the minimum number of visits recommended by the American College of Obstetricians and Gynecologists (ACOG), which ranges from 11 to 14 visits. The Brazilian Ministry of Health recommends at least six visits for a low-risk term pregnancy with an early beginning of prenatal care, up to the fourth month of pregnancy [8,9,10,11] whereas the World Health Organization (WHO) recommends a minimum of four prenatal care visits [12]
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