Abstract
BackgroundReducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world’s largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years.MethodsThe study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004–2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables.ResultsBFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81–0.95), 0.84 (0.75–0.96) and 0.83 (0.71–0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67–0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69–0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66–0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04–1.07).ConclusionOur findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.
Highlights
Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both
The association between poverty and maternal deaths has been widely documented, and the majority of these deaths occur in low- and middle-income countries (LMICs), especially those with the largest social inequalities and the lowest income [1, 2]
While our study focused on the duration effects of Bolsa Familia Programme (BFP), evaluating how the different years of average BFP coverage were able to affect our outcomes, the years of average Family Health Programme (FHP) coverage were fixed at half of the study period based on previous studies [23], alternative durations were tested (Additional file 1)
Summary
Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world’s largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. Poverty affects many factors associated with maternal mortality, such as poor access to public services and infrastructure, unsanitary environmental surroundings, illiteracy, social exclusion, low household income levels and food insecurity [3]. Social protection interventions that aim to reduce social and economic risk, such as conditional cash transfers (CCT), might improve the determinants of maternal health. As a matter of fact, CCT could reduce poverty and improve access to health care services, both priority actions to decrease maternal mortality [4]. The evidence of the effects of CCT on maternal deaths is still limited and primarily based on studies that analyse a short period of CCT implementation [4]
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