Elsevier

The Lancet

Volume 377, Issue 9780, 28 May–3 June 2011, Pages 1863-1876
The Lancet

Series
Maternal and child health in Brazil: progress and challenges

https://doi.org/10.1016/S0140-6736(11)60138-4Get rights and content

Summary

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5·5% a year in the 1980s and 1990s, and by 4·4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974–75 to 7% in 2006–07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2·5 months in the 1970s to 14 months by 2006–07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil's progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women's health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

Introduction

In the past three decades, Brazil has undergone rapid changes in terms of socioeconomic development, urbanisation, medical care, and the health of the population. The first report1 in this Series described how the country evolved in a few decades from a low-income, mostly rural country with multi-tiered health services to a middle-income, urban country with a unified health system. This report addresses how trends in maternal and child health were affected by such changes. We expand on a previous analysis of time trends in inequalities in maternal and child health in Brazil,2 and discuss the health of pregnant women in the context of reproductive rights, which include the right to reproductive choice, safe motherhood, and sexualilty without coercion.3, 4 Our analyses focus on abortion, contraception, pregnancy, and delivery care (see panel 1 for data sources). Injuries (including sexual violence) and infectious and chronic diseases in women will be discussed elsewhere in this Series.18, 19, 20 The discussion of child health is restricted to children younger than 5 years, and focuses on infants because infant deaths account for 90% of all deaths of children younger than 5 years.2

Maternal and child health, which have improved with time, show how Brazil has evolved in terms of health systems, health conditions, and broader social determinants, which are discussed elsewhere in this Series.1, 19, 20, 21 In the past 50 years, Brazil has evolved from a predominantly rural society to one in which more than 80% of the population live in urban areas, fertility rates have decreased from more than six to fewer than two children per woman, primary education became universal, and life expectancy at birth has increased by about 5 years every decade.1, 21 The proportion of all deaths due to infectious diseases decreased substantially—Brazil is successful in the control of vaccine-preventable diseases and HIV/AIDS.18

Key messages

  • The health and nutrition of Brazilian children has improved rapidly since the 1980s. A key indicator of Millennium Development Goal 1 (a reduction in the number of underweight children by half between 1990 and 2015) has already been met and Millennium Development Goal 4 (a two-thirds reduction in mortality rate of children younger than 5 years by 2015) will probably be met within the next 2 years.

  • Progress in maternal mortality ratios is difficult to measure because time trends are distorted by improvements in vital statistics, but evidence exists of a decrease in maternal mortality ratios in the past three decades. However, Millennium Development Goal 5 (a reduction in maternal mortality by three-quarters between 1990 and 2015) will probably not be met.

  • Regional and socioeconomic inequalities in intervention coverage, nutrition, and health outcomes in Brazil have largely decreased.

  • The main factors that drive such trends probably include improvements in social determinants (ie, poverty, education of women, urbanisation, and fertility), non-health-sector interventions (ie, cash transfers, water, and sanitation), and the creation of a unified national health system with geographical targeting for primary health care (giving previously underserved populations better access to health care), in addition to disease-specific programmes.

  • Major challenges exist, including a reduction of the high frequency of caesarean section, illegal abortions, and preterm births, in addition to achieving further reductions in regional and socioeconomic inequalities in health.

Brazilian health policies and systems have changed much in the past three decades.1 In the late 1980s, a three-tiered health-care system with private, social security, and charitable institutions was replaced with a universal, tax-funded, national health system. Primary health care became the cornerstone of the system, and geographical targeting of care led to the setting-up of family health teams in the neediest areas of the country. At the same time, investments were made to improve human resources for health and scientific and technological development in the health sector.1, 21 Since the 1990s, governmental policies have become increasingly focused on the provision of social protection mechanisms—not only the well known conditional cash transfer schemes but also the promotion of social inclusion in all sectors of society. As a result of such changes, the long-standing and pronounced differences in access to health care that exist between the wealthy south and southeast regions and the poor north and northeast regions have decreased, as has the financial gap between the wealthiest and poorest families in Brazil.1, 21

Section snippets

Reproductive and maternal health

Maternal mortality constitutes a severe violation of the reproductive rights of women22 because most maternal deaths can be prevented with early and appropriate care.23 Until the late 1970s, maternal health issues were not on the scientific or health policy agendas in Brazil. This soon changed after 1980, when several maternal health policies and programmes were implemented. These initiatives, in addition to broader social changes such as improvements in women's education, urbanisation, and the

Caesarean sections

About 3 million births occurred in Brazil in 2007—89% were delivered by physicians and 8% by nurse-midwives (mostly in the north and northeast regions).12 Almost half (47%) of all births were by caesarean section—caesarean sections constituted 35% of deliveries in the Unified Health System (SUS; in which three-quarters of all births take place) and 80% of deliveries in the private sector. 48% of women with first-time pregnancies gave birth by caesarean section.12 Brazilian caesarean sections

Maternal mortality

Maternal mortality estimates in Brazil are affected by under-registration of deaths—especially in rural areas and small towns,7 where mortality ratios tend to be highest—and by under-reporting of maternal causes in registered deaths.2 A reproductive-age mortality survey in all state capitals in 2002 estimated a maternal mortality ratio (MMR) of 54·3 per 100 000 population, ranging from 42 in the south region to 73 in the northeast region.44 This survey showed that many maternal deaths had been

Illegal abortions

Induced abortions are illegal in Brazil, except for women who have been raped or when a pregnancy endangers a woman's life. Even for severe fetal malformations such as anencephaly, judicial authorisation is needed. The illegality of abortion has not stopped abortions from being done,54 has contributed to unsafe practices, and has restricted the reliability of abortion statistics. In a 2010 national survey of urban areas, 22% of 2002 women aged 35–39 years reported having had an induced abortion.

Child health

Unlike maternal health, the health of young children has been high on the political agenda for several decades. For example, the increase in infant mortality rates in some large cities during the 1970s—when the military regime was claiming record economic growth—was used by the democratic opposition as evidence that the so-called Brazilian economic miracle was failing to improve living conditions.60 Greater awareness of the status of child health than of maternal health is probably because

Child nutrition

Much improvement has been made in the nutrition of Brazilian children. Data from four national surveys done during a 33-year period show a substantial decrease in the prevalence of child stunting (defined as height-for-age less than −2 Z scores of the WHO standard),84 from 37·1% in 1974–75 to 7·1% in 2006–7. The annual rates of reduction have accelerated over time, with a 4·2% decrease between 1974–75 and 1989, a 5·4% decrease between 1989 and 1996, and a 6·0% decrease between 1996 and 2006–07.

Intervention coverage

Population-based data on selected maternal-health and child-health indicators are available from three demographic and health surveys done in 1986,14 1996,13 and 2006–07.12 Data for antenatal and delivery care are also available from a general household survey done in 1981.29 The coverage of most indicators was, in the 1980s, high compared with present coverage in most low-income and middle-income countries.91 Nevertheless, the coverage of contraception, antenatal, and delivery care indicators

Understanding the changes

Time trends in maternal and child health indicators should be interpreted in view of broad social determinants of health and of governmental actions outside the health sector, and in terms of health sector interventions. Figure 6 summarises changes in these determinants since 1970, and the webappendix (p 1) shows the results of a key-informant survey of policies and programmes—including many governmental and non-governmental initiatives—that are believed to have had the largest effect on

Conclusion

As a result of the changes described above, Brazil has been successful in terms of improving child health and nutrition.2, 91 Even though questions remain about how much maternal mortality has decreased since 1990, changes in the coverage and equity of several reproductive, antenatal, and delivery care indicators are very encouraging.

Despite such progress, the mortality rate of children younger than five years is about seven times higher in Brazil than in countries with the lowest

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