Abstract

This study presents an overview of public sector interventions and progress made on the women’s and child health front in Brazil between 1990 and 2015. We analyzed indicators of antenatal and labor and delivery care and maternal and infant health status using data from the Live Birth Information System and Mortality Information System, national surveys, published articles, and other sources. We also outline the main women’s and child health policies and intersectoral poverty reduction programs. There was a sharp fall in fertility rates; the country achieved universal access to antenatal and labor and delivery care services; access to contraception and breastfeeding improved significantly; there was a reduction in hospital admissions due to abortion and in malnutrition. The rates of congenital syphilis, caesarean sections and preterm births remain excessive. Under-five mortality decreased by more than two-thirds, but less pronounced for the neonatal component. The maternal mortality ratio decreased from 143.2 to 59.7 per 100 000 live births. Despite worsening scores or levelling off across certain health indicators, the large majority improved markedly.

Health policy; Maternal health services; Reproductive health; Child Health Services; Vital statistics

Introduction

Over the past 30 years, Brazil has undergone demographic and socioeconomic changes that have had a direct impact on the quality of life of Brazilians. Healthcare in the country has evolved with the adoption of the Unified Health System (SUS), a programme which has instigated changes in health policy, notably the expansion of primary care¹1. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-1797.. In the 1990s, the Ministry of Health (MH) implemented the Family Health Strategy as part of a national primary healthcare policy. Product of the Community Health Agents Programme, it aimed to improve access to healthcare services and expand actions directed at the health promotion and preventative health measures²2. Dourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health 2016; 15(1):151.,³3. Victora CG, Aquino EM, Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876.. In the first decade of the twenty-first century, the government developed programmes that aimed at reducing maternal and child mortality, while poverty reduction became the main focus of intersectoral programmes.

State and local governments have strived to implement these programmes, with some organisational criteria being defined by the federal government and others by the local government, introducing the assessment of these interventions and their health impacts. National actions aimed at improving the living conditions and health of women and children were underpinned by international agreements, such as those forged at the Cairo and Beijing Conferences and the Millennium Development Goals (MDG)⁴4. Barros FC, Matijasevich A, Requejo JH, Giugliani E, Maranhão AG, Monteiro CA, Barros AJ, Bustreo F, Merialdi M, Victora CG. Recent trends in maternal, newborn, and child health in Brazil: progress toward Millennium Development Goals 4 and 5. Am J Public Health 2010; 100(10):1877-1889..

The SUS was devised following a political struggle for health reform in Brazil that was influenced by social movements. The tensions and disputes that characterised this process have resulted in significant improvements to the overall health of the Brazilian population.

This article offers a review of public sector interventions, focusing on the SUS and outcome indicators for reproductive, maternal, neonatal and child health (RMNCH), highlighting the progress made in the period 1990-2015 and future challenges. We calculated infant mortality rates for 1990 and 1995 using indirect techniques for demographic estimation (RIPSA, 2012). For subsequent years, we calculated rates directly, using data collected from vital registration systems and applying correction factors for municipalities with incomplete data. We calculated maternal mortality ratios (MMR) – shown for 2005, 2010 and 2015 – using data obtained from the M Hafter the investigation of the deaths of women of childbearing age⁵5. Szwarcwald CL, Escalante JJ, Rabello Neto DL, Souza Junior PR, Victora CG. Estimation of maternal mortality rates in Brazil, 2008-2011. Cad Saude Publica 2014; 30(Supl. 1):S1-12.. The MH calculated rates for previous years themselves. We estimated antenatal care (ANC) and labour and delivery care indicators using information obtained from the Live Births Information System (SINASC, acronym in Portuguese), and estimated indicators related to reproductive health, breast feeding, and nutritional status using data from national surveys and publications from various sources.

Reproductive Health

Brazil’s fertility rate has decreased considerably since the 1960s, when women gave birth to, on average, six children. With poor access to effective contraception, women often resorted to sterilisation by tubal ligation and abortion. In 1986, 44% of Brazilian women of childbearing age were sterilised, with this figure reaching 63% in the Northeast region at the beginning of the 1990s⁶6. Berquó E. Brasil, um Caso Exemplar-anticoncepção e parto cirúrgicos-à espera de uma ação exemplar. Estudos feministas 1993; 1(2):366.. Whilst the practice of abortion is difficult to measure because it is illegal, results show that in 1991there were 3.7 abortions per 100 women aged between 15 and 49 years, while 23% of pregnancies resulted in unwanted births and 31% in abortions⁷7. Costa SH. Aborto clandestino: uma realidade latino-americana. Washington: Alan Guttmacher Institute; 1994..

Between 1991 and 2000, the decline in the fertility rate was more noticeable among poor, black women with low levels of education living in rural areas and in the North and Northeast regions⁸8. Berquó ES, Cavenaghi SM. Notas sobre os diferenciais educacionais e econômicos da fecundidade no Brasil. Revista Brasileira de Estudos de População 2014; 31(2):471-482.. The overall fertility rate among these groups was 1.72 children per woman, which is below replacement level fertility (Table 1). The 2010 Census reported a decline in fertility rates among women aged between 15 and 19 years compared to the previous decade, which may be the result of postponement of reproduction. This correlated with a significant rise in levels of education among women⁸8. Berquó ES, Cavenaghi SM. Notas sobre os diferenciais educacionais e econômicos da fecundidade no Brasil. Revista Brasileira de Estudos de População 2014; 31(2):471-482..

Abortion is still widely practiced in Brazil⁹9. Singh S. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368(9550):1887-1892.. In 2010, a national survey conducted in urban areas¹⁰10. Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cien Saude Colet 2010; 15(Supl. 1):959-966. showed that 22% of women aged between 35 and 39 years had an abortion. The same survey repeated in 2016¹¹11. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660. confirmed a high incidence of abortion, particularly the North, Centre-West and Northeast regions.

Abortion is permitted in Brazil in cases of rape or when the mother’s life is in danger, and, since 2012,in cases of anencephaly. The criminalisation of abortion has been shown to reinforce inequality, as oppose to preventing the practice. While women with a higher socioeconomic status are able to afford safe abortion services, the majority are driven to use unsafe methods, such as taking misoprostol. These women then seek SUS hospital treatment at the first sign of bleeding to complete uterine evacuation and treat complications¹¹11. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Cien Saude Colet 2017; 22(2):653-660.. As a result, there were 205,439 hospital admissions associated with abortion in 2015 (Table 1).

The prohibition of abortion, therefore, only increases the number of hospital admissions related to unsafe abortions. For women who attempt unsafe abortions, admission to hospital represents the only alternative to deal with potentially lethal health complications. Post-abortion care focuses on the practice of curettage, which implies admission to hospital and waiting for treatment. The failure to prevent repeated unwanted pregnancies and unsafe abortions is commonplace, as is the lack of information on and access to contraception¹²12. Aquino EM, Menezes G, Barreto-de-Araujo TV, Alves MT, Alves SV, Almeida Mda C, Schiavo E, Lima LP, Menezes CA, Marinho LF, Coimbra LC, Campbell O. Quality of abortion care in the Unified Health System of Northeastern Brazil: what do women say? Cien Saude Colet 2012; 17(7):1765-1776..

Between 1995 and 2013, the number of hospital admissions because of abortions and miscarriages, and the overall number of abortions among women aged between 15 and 49 years decreased by 27% and 26%, respectively¹³13. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprodução & Climatério 2015; 30(1):11-18.. These figures suggest that women may have learned to use misoprostol more effectively, thus rendering hospital treatment unnecessary. At the same time, access to contraception improved significantly during this period (Table 1). This may have led to a decrease in the number of unwanted pregnancies. In 1986, before the creation of the SUS, 57% of women in stable relationships used contraception, compared to 80.6% two decades later. This increase was accompanied by a significant reduction in inequality in access to contraception across income quintiles (Graph 1).

Pregnancy, Labour and Delivery

A little over three million children are born in Brazil each year. Data obtained from the SINASC show that 98% of women received some form of ANC in 2015 (Table 1). According to the World Health Organization (WHO) and the MH guidelines, ANC should be continuous and include prevention, diagnosis, and treatment of disease or deficiencies, as well as health information and the provision of social, cultural and psychological support¹⁴14. World Health Organization (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016.. The WHO recommends at least eight ANC sessions, since ANC has been shown to be associated with improved perinatal outcomes for both the mother and the newborn¹⁵15. Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reproductive health 2016; 13(Supl. 3):115.. There was a significant reduction in inequalities in access to ANC services between 1986 and 2013 across all income quintiles (Graph 1), with the proportion of women having seven or more ANC sessions increasing from 49% in 1995 to 67% in 2015. However, regional inequalities persist, with rates in 2015 ranging from 47% in the North to almost 80% in the South (SINASC, 2015).

A national study of ANC showed that 60% of women were referred to a specific maternity unit for delivery¹⁶16. Viellas EF, Domingues RMSM, Dias MAB, Gama SGN, Theme Filha MM, Costa JV, Bastos MH, Leal MC. Assistência pré-natal no Brasil. Cad Saude Publica 2014; 30(Supl. 1):S85-S100.. The referral of pregnant women to a specific maternity unit from the outset of pregnancy has been obligatory under law in Brazil since 2005. However, compliance with this law is limited, particularly in the North and Northeast regions. This particularly affects adolescent mothers and women with low levels of education. Of the women who were referred to a maternity unit, 84.5% gave birth in the unit to which they were referred, while 16% sought maternity treatment in more than one hospital. As such, switching between different maternity units has been associated with severe maternal morbidity¹⁵15. Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reproductive health 2016; 13(Supl. 3):115..

The persistence of congenital syphilis, which is preventable if detected during ANC, provides further evidence of the poor quality of care. Data from almost 24,000 puerperal women in Brazil who gave birth between 2011 and 2012 showed that congenital syphilis continued to be a public health issue linked to social vulnerability and failures in ANC¹⁷17. Domingues RM, Leal MC. Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study. Cad Saude Publica 2016; 32(6).. Incidence of the disease was estimated to be 3.51/1000 live births, while the vertical transmission rate was 34.3%. Furthermore, the proportion of foetal deaths among women diagnosed with syphilis was six times greater than in women who did not have the disease¹⁷17. Domingues RM, Leal MC. Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study. Cad Saude Publica 2016; 32(6).. Analysis of data obtained from the SINAN for the period 2007-2012 showed that both the syphilis detection rate and disease incidence among pregnant women increased in the regions studied. This increase was attributed to improvements in the recognition of cases, given that there was an increase in rapid testing for the disease provided under the programme Rede Cegonha (Stork Network)¹⁸18. Saraceni V, Pereira GFM, Silveira MF, Araujo MAL, Miranda AE. Epidemiological surveillance of vertical transmission of syphilis: data from six federal units in Brazil. Rev Panam Salud Publica 2017; 41:e44..

With respect to labour and delivery care, 98.5% of women gave birth in a health facility in 2015, which is in line with global trends. Moreover, no significant regional differences were found (Table 1), reflecting significant reductions in inequalities in access to hospital care since the creation of the SUS across income quintiles (Graph 1).

A study conducted by Leal et al.¹⁹19. Carmo Leal M, Pereira AP, Domingues RM, Theme Filha MM, Dias MA, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S1-16. that used data from the Pesquisa Nascer no Brazil (the Born in Brazil Survey), showed that less than 50% of women who gave birth vaginally received labour and delivery care in accordance with the ‘best recommended practices’, as set out by WHO. Furthermore, unnecessary interventions were shown to be high. Results also showed that rates were higher among women that presented a lower health risk¹⁹19. Carmo Leal M, Pereira AP, Domingues RM, Theme Filha MM, Dias MA, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S1-16.. The same results demonstrated that 55% of women who gave birth during the period of this study received a caesarean section (Table 1), and that there was a progressive increase in the proportion of women having caesarean section between 1987 and 2014. Excessive unnecessary caesarean section was even observed in women from lower income groups (Graph 1). Following a systematic review conducted in 2015, the WHO issued a statement confirming that there was no evidence to prove the benefits of caesarean delivery for women or infants at rates higher than 10%²⁰20. World Health Organization (WHO). WHO Statement on caesarean section rates. Reproductive health matters 2015; 23(45):149-150.. Despite the association between caesarean delivery and negative perinatal outcomes for both women and infants²¹21. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G. Postpartum maternal mortality and cesarean delivery. Obstetrics and gynecology 2006; 108(3 Pt 1):541-548.

22. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ : Canadian Medical Association journal 2007; 176(4):455-460.

23. Souza J, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, Ruyan P; WHO Global Survey on Maternal and Perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Medicine 2010; 8(1):71.-²⁴24. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O’Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107(6):1226-1232., including “near miss”¹⁵15. Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reproductive health 2016; 13(Supl. 3):115. and maternal death²⁵25. Esteves-Pereira AP, Deneux-Tharaux C, Nakamura-Pereira M, Saucedo M, Bouvier-Colle MH, Leal MC. Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil. PloS one 2016; 11(4):e0153396., the rate of caesarean section in the private health sector in Brazil is 87%¹⁹19. Carmo Leal M, Pereira AP, Domingues RM, Theme Filha MM, Dias MA, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S1-16..

Preterm births accounted for 11.1% of total births in the country (Table 1), which is almost double that of European countries²⁷27. Lisonkova S, Sabr Y, Butler B, Joseph KS. International comparisons of preterm birth: higher rates of late preterm birth are associated with lower rates of stillbirth and neonatal death. BJOG 2012; 119(13):1630-9.,²⁸28. Khan KA, Petrou S, Dritsaki M, Johnson SJ, Manktelow B, Draper ES, Smith LK, Seaton SE, Marlow N, Dorling J, Field DJ, Boyle EM. Economic costs associated with moderate and late preterm birth: a prospective population-based study. BJOG 2015; 122(11):1495-1505.. No notable differences between geographic regions and the public and private sector were found²⁶26. Leal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, Dias MA, Moreira ME, Gama SG. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health 2016; 13(Supl. 3):127.. Spontaneous preterm birth was linked to social vulnerability, while non spontaneous preterm birth (over 90% of caesarean sections in the private sector) were associated with a higher socioeconomic status²⁶26. Leal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, Dias MA, Moreira ME, Gama SG. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health 2016; 13(Supl. 3):127..

The prevalence of low birth weight (LBW) (weight < 2500 g) in Brazil increased from 7.9% in 1995 to 8.4% in 2010, continuing at the same rate in 2015. The reasons for this increase during a period in which significant progress was made across various socioeconomic indicators are not well known.

LBW is associated with maternal education levels and race/skin colour. The prevalence of LBW has been shown to be greater among illiterate women²⁹29. Barros FC. Documento técnico com a avaliação das tendências em cesarianas e nascimentos de baixo peso por País, macrorregiões, Unidades da Federação e regionais de saúde, 2000-2011. Brasília: Ministério da Saúde (MS); 2013. BR/CNT/1201864.001. and black women (9.7%), and lower among indigenous women (7.4%).

LBW has also been found to be directly proportional to the size of the municipality, with prevalence rates of 7.6% in municipalities with less than 20,000 inhabitants and 9.1% in those with over 500,000 inhabitants³⁰30. Brasil. Ministério da Saúde (MS). Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília: MS; 2017.. Prevalence of LBW is higher in the Southeast, South and Center-West regions than in the North and Northeast regions. One possible explanation for this surprising finding is the poor quality of information systems in the North and Northeast regions, which may lead to the underreporting of cases³¹31. Andrade CLT, Szwarcwald CL, Castilho EA. Baixo peso ao nascer no Brasil de acordo com as informações sobre nascidos vivos do Ministério da Saúde, 2005. Cad Saude Publica 2008; 24(11):2564-2572.,³²32. Morisaki N, Ganchimeg T, Vogel JP, Zeitlin J, Cecatti JG, Souza JP, Pileggi Castro C, Torloni MR, Ota E, Mori R, Dolan SM, Tough S, Mittal S, Bataglia V, Yadamsuren B, Kramer MS; PREBIC Epidemiology Working Group and the WHO-MCS Research Network. Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health. BJOG 2017; 124(9):1346-1354..

Improved access to ANC services and labour and delivery care in the SUS contributed to a decline in negative outcomes. Nevertheless, the SUS still faces challenges in improving the quality of care and overcoming barriers facing the integration of different levels of care. The high rate of unnecessary caesarean section may be reducing the health benefits of this type of procedure especially women from higher income groups.

Breastfeeding

Impressive progress has been made in relation to breastfeeding since the 1970s when the average duration was less than three months³³33. Victora CG, Aquino EM, Do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: Progress and challenges. Lancet 2011; 377(9780):1863-1876.. There has been a sharp rise in the proportion of infants being breastfed up to 12 months, from 26% in 1986 to 47% in 2006, levelling out to 45% in 2013³⁴34. Boccolini CS, Boccolini PMM, Monteiro FR, Venancio SI, Giugliani ERJ. Breastfeeding indicators trends in Brazil for three decades. Rev Saude Publica 2017; 51:108.. Likewise, there was a significant increase in the proportion of infants being exclusively breast fed for the first six months, from 5% in 1986 to 37% in 2013³⁴34. Boccolini CS, Boccolini PMM, Monteiro FR, Venancio SI, Giugliani ERJ. Breastfeeding indicators trends in Brazil for three decades. Rev Saude Publica 2017; 51:108.. The progress made as a result of interventions at community, health service and policy level means that Brazil has a positive influence on the world stage in this area³⁵35. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG; Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387(10017):491-504.. Actions include: the regulation of the International Code of Marketing of Breast-milk Substitutes and monitoring of the implementation of the code by the IBFAN network (www.ibfan.org.br); the training of health professionals in the SUS to support breastfeeding; large-scale media campaigns to raise public awareness surrounding breastfeeding; regulation of maternity leave; and the creation of a network of baby-friendly hospitals and breast milk banks³⁵35. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG; Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387(10017):491-504.. Despite clear progress, it should be noted that these rates levelled out between 2006 and 2013 and that two-thirds of mothers did not ensure exclusive breastfeeding for six months, as recommended by the WHO.

Infant nutrition

National surveys conducted over recent decades show that significant improvements have been made in the nutrition of Brazilian infants. Based on the latest available data, we observed a significant reduction in the prevalence of height deficit, from 37.1% in 1974/75 to 7.1% in 2006/2007. We also observed a sharp reduction in regional inequalities, with rates in the Northeast region approaching those of the Southeast, but with persistent inequalities between the North and other regions. The prevalence of weight deficit also decreased during this period. While national surveys show that infant obesity rates levelled out³3. Victora CG, Aquino EM, Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876. in 2006/2007, other sources suggest that they continued to increase at a significant pace. A study of a cohort of live births in 2015 in Pelotas showed that prevalence of overweight in infants at 12 months was12.2%, representing a significant increase compared to a 1982 cohort (6.5%). Furthermore, a pooled international analysis of 2,416 population based measurement studies showed that 26.6% of Brazilian girls and 30% of boys aged between five and nineteen years were either overweight or obese³⁶36. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet 2017; 390(10113):2627-2642..

Nutrition transition is the shift in dietary consumption that coincides with a complex mix of rapid sociodemographic changes characterised by increasing consumption of ultra-processed foods and a sedentary lifestyle, affecting both children and adolescents³⁷37. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr 2001; 131(3):871S-873S.. In this respect, it is likely that Brazil is experiencing the same transition process that is affecting the rest of Latin America³⁸38. Galicia L, Grajeda R, de Romana DL. Nutrition situation in Latin America and the Caribbean: current scenario, past trends, and data gaps. Rev Panam Salud Publica 2016; 40(2):104-113..

Infant and Child Mortality

Child mortality, defined as the probability of a child dying before reaching the age of five, declined significantly between 1990 and 2015 (Table 1), from 53.7 to 15.6 per 1000 live births (a reduction of more than two-thirds), meaning that Brazil achieved the fourth Millennium Development Goal.

Among deaths with a definable cause, intestinal infectious disease proportional to mortality decreased from 14% to 1.4% in the period 1990-2015 (Table 1). Associated with malnutrition, lack of sanitation, and deficiencies in primary care, diarrhoea-proportional mortality stood out as an important marker of improved child health status. Furthermore, acute respiratory infection-proportional mortality decreased by over half.

The sharp decline in child mortality was in large part due to the fall in child mortality within the first year of life, from 47.1 to 13.5 per1000 live births (Table 1), which is equivalent to an annual decrease of 4.9% for the country as a whole. The drop in post-neonatal mortality rates was more pronounced than that of neonatal mortality rates (from 23.1 to 9.5per 1000 newborns),with deaths concentrated mainly in the early neonatal period. In 2015, 70% of child deaths occurred during the neonatal period, 54% of which were within the first week of life.

The largest reductions in child mortality rates in the period 2000-2010 occurred in the Northeast region (5.9% per year), followed by the North region (4.2%), contributing to a reduction in regional inequalities³⁹39. Szwarcwald CL, Frias PG, Junior PR, Silva Almeida W, Neto OL. Correction of vital statistics based on a proactive search of deaths and live births: evidence from a study of the North and Northeast regions of Brazil. Popul Health Metr 2014; 12:16.. The fact that reductions were largest in regions with a lower socioeconomic status reflects improvements in access to primary healthcare services directed at maternal and child care⁴4. Barros FC, Matijasevich A, Requejo JH, Giugliani E, Maranhão AG, Monteiro CA, Barros AJ, Bustreo F, Merialdi M, Victora CG. Recent trends in maternal, newborn, and child health in Brazil: progress toward Millennium Development Goals 4 and 5. Am J Public Health 2010; 100(10):1877-1889.,⁴⁰40. Macinko J, Guanais FC, Fatima M, Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Comunit Health 2006; 60(1):13-19.. The universal adoption of immunisation also played an important role in the reduction of child mortality. The last notified death from measles was in 1999, and there was a significant reduction in the number of deaths from neonatal tetanus, from 141 in 1990 to only one in 2015.

The current national rates of child mortality in Brazil are in line with those of countries with similar levels of per capita income ⁴¹41. Silva JC, Amaral AR, Ferreira BD, Petry JF, Silva MR, Krelling PC. Obesity during pregnancy: gestational complications and birth outcomes. Revista brasileira de ginecologia e obstetricia 2014; 36(11):509-513., a fact that did not occur until the middle of the first decade of the twenty-first century³3. Victora CG, Aquino EM, Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876.. However, the challenge remains to reduce the rate of neonatal mortality, particularly in the early neonatal period. Factors connected to antenatal, labour and delivery care key for this⁴²42. Lansky S, Lima Friche AA, Silva AA, Campos D, Azevedo Bittencourt SD, Carvalho ML, Frias PG, Cavalcante RS, Cunha AJ. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad Saude Publica 2014; 30(Supl. 1):S1-15..

Maternal Mortality (MM)

MM is a preventable cause of death and its reduction has been the focus of national and international efforts⁴³43. Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS one 2016; 11(2):e0148343.. Brazil witnessed a significant decline in the maternal mortality ratio (MMR) between 1990 and 2000, from 143.2 to 81.5 per100 000 live births (Table 1), which is equivalent to an annual decrease of 5.5%. However, progress began to slow in the year 2000, with an annual decrease of less than 2%. This rate picked up somewhat in 2010, nevertheless, with an annual decrease of 2.4% up to 2015 when MMR stood at 59.7 per 100 000 live births. How so ever, the MMR remains unacceptably high, considering that it is three to four times greater than rates in developed countries (based on figures from the beginning of the second decade of the twenty-first century). More disaggregated data area shows that the MMRexceeded100/100 000live births in two states⁵5. Szwarcwald CL, Escalante JJ, Rabello Neto DL, Souza Junior PR, Victora CG. Estimation of maternal mortality rates in Brazil, 2008-2011. Cad Saude Publica 2014; 30(Supl. 1):S1-12..

In 2015, 20.7% of deaths were due to hypertensive disorders during pregnancy, delivery and puerperium, 17.5% to labour and delivery complications, and 13.2% to complications predominantly related to the puerperium. Complications resulting from abortion appear in fifth place on the list of leading causes of maternal death, accounting for 7% of all deaths. The leading cause was unspecified obstetric conditions, accounting for 29.7% of deaths. A study carried out in the State of Minas Gerais showed that the proportion of maternal deaths due to abortion was twice the national rate⁴⁴44. Martins EF, Almeida PF, Paixao CO, Bicalho PG, Errico LS. Multiple causes of maternal mortality related to abortion in Minas Gerais State, Brazil, 2000-2011. Cad Saude Publica 2017; 33(1):e00133115.. The reduction of MM due to abortion constitutes a major challenge given the level of unsafe illegal abortions carried out.

The high rate of unnecessary caesarean section among women from higher income groups potentially increases the risk of death from postpartum haemorrhage and anaesthesia related complications²⁵25. Esteves-Pereira AP, Deneux-Tharaux C, Nakamura-Pereira M, Saucedo M, Bouvier-Colle MH, Leal MC. Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil. PloS one 2016; 11(4):e0153396..

Interventions addressing the determinants of maternal and child health

Policies and reproductive, maternal, neonatal, child and adolescent health programmes

Actions geared toward improving child health in Brazil date back to the beginning of the twentieth century. However, the first major milestone in this area was the National Immunisation Programme (PNI, acronym in Portuguese) in 1973, which had a significant impact on child health (Chart 1).

Also before the creation of the SUS, the Comprehensive Women’s Healthcare Programme (PAISM, acronym in Portuguese), created in 1983, is also considered a milestone in that it goes against the conventional perspective, confirming that women’s health extends beyond their reproductive capacity. By ensuring that access to family planning formed a part of the right to healthcare, it anticipated the concepts of sexual and reproductive health rights introduced by the Cairo and Beijing conferences a decade later⁴⁵45. Aquino EML. A questão do gênero em políticas públicas de saúde: situação atual e perspectivas. Silva A, Lago MCS, Ramos TRO, organizadores. Falas de gênero: teoria, análises, leituras. Florianópolis: Mulheres; 1999. p. 161-172.. The movement initiated by the PAISM played a key role in the creation of a separate department within the Ministry of Health dedicated to women’s health in 1990.In 1985, the Comprehensive Child Healthcare Programme (PAISC, acronym in Portuguese) and the National Programme for the Humanisation of Delivery and Birth were launched. The latter aimed to promote the humanisation of labour and delivery care practices and to recognise the work of traditional midwives⁴⁶46. Serruya SJ, Cecatti JG, Lago TG. O Programa de Humanização no Pré-natal e Nascimento do Ministério da Saúde no Brasil: resultados iniciais. Cad Saude Publica 2004; 20(5):1281-1289..

In the 1990s, the Community Health Agents Programme and Family Health Strategy brought significant improvements in access to primary healthcare services particularly in more remote and rural areas, and widened the coverage of reproductive and child healthcare services. Studies have shown that for each 10% increase in coverage of the Family Health Strategy, there was a 4.6% reduction in child mortality⁴⁰40. Macinko J, Guanais FC, Fatima M, Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Comunit Health 2006; 60(1):13-19.. Also in this decade, Brazil implemented the Baby Friendly Hospital Initiative (BFHI), developed by the WHO and UNICEF, and aimed to promote a change in behaviour and routines that cause early weaning. The launch of the BFHI followed the Innocenti Declaration on the protection, promotion and support of breastfeeding, which recognised that breastfeeding “Reduces incidence and severity of infectious diseases, thereby lowering infant morbidity and mortality”. Following the implementation of this and other measures under the National Breastfeeding Policy, Brazil was recognised as a reference for its achievements in promoting breastfeeding by a study comparing 150 countries⁴⁷47. Victora CG, Bahl R, Barros AJD, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-490.. The policy was reinforced by the creation of the Human Milk Bank Network, the promotion of initiatives designed to support women who want to continue breastfeeding after they return to work, and annual breastfeeding campaigns (Chart 1).

The 1990s also saw the emergence of the first National Project for the Reduction of Child Mortality (PRMI, acronym in Portuguese), which prioritised specific municipalities selected according to poverty indicators. The majority of these municipalities were located in the Northeast. This initiative improved primary healthcare and sanitation services, and simultaneously promoted intersectoral coordination involving national and international institutions and civil society organizations.

By the year 2000,child deaths were more common during the perinatal period. Programmes created in this year focused on promoting adequate labour and delivery care practices⁴⁶46. Serruya SJ, Cecatti JG, Lago TG. O Programa de Humanização no Pré-natal e Nascimento do Ministério da Saúde no Brasil: resultados iniciais. Cad Saude Publica 2004; 20(5):1281-1289., including the National Programme for the Humanisation of Delivery and Birth, and the National Policy for Humanised LBW Newborn Care - Kangaroo Method, which aimed at promoting successful breastfeeding⁴⁸48. Lamy Filho F, Silva AA, Lamy ZC, Gomes MA, Moreira ME; Grupo de Avaliação do Método Canguru; Rede Brasileira de Pesquisas Neonatais. Evaluation of the neonatal outcomes of the kangaroo mother method in Brazil. J Pediatr (Rio J) 2008; 84(5):428-435.,⁴⁹49. Venancio SI, Almeida H. Método Mãe Canguru: aplicação no Brasil, evidências científicas e impacto sobre o aleitamento materno. Jornal de Pediatria 2004; 80(5 Supl.):s173-s80..

In the same year, Brazil committed itself to the Millennium Development Goals, and to “[sparing] no effort to free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty”. The goals included the reduction of child mortality rates by two-thirds and the maternal mortality ratio by three-quarters by 2015⁵⁰50. Organização das Nações Unidas (ONU). Relatório Sobre os Objetivos de Desenvolvimento do Milénio. New York: ONU; 2015..

The National Policy for Comprehensive Women’s Healthcare (PNAISM, acronym in Portuguese), which was formulated via consultation with social movements, health professionals and specialists, came into force in 2004.Applying the principles set out in the PAISM, the PNAISM represented a step forward in recognising the diversity of women. The programme encompassed the specific health needs of different groups (black, indigenous, rural workers, etc.) throughout all stages of life and put an emphasis on sexual and reproductive health rights. The following year saw the introduction of a set of rules and regulations concerning the humanisation of abortion care and of the Lei do Acompanhante (Patient Companion Law),which guaranteed parturient women the right to choose a companion to support them during labour, delivery, and the immediate post-partum period in the SUS. In 2007, the Law Nº: 11.634 (Lei da vinculação à maternidade) was passed. It stipulated that pregnant women should be referred to a specific maternity unit from the outset of pregnancy.

Following the lower than expected decrease in MM, the National Health Council made it compulsory to report maternal deaths. Moreover, programmes that focused on reducing maternal and infant mortality rates were introduced in the Northeast and Amazônia Legal regions to combat regional inequalities. In 2004, the government also created the Programa Bolsa Família⁵¹51. Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013; 382(9886):57-64. (the Brazilian Conditional Cash Transfer Programme),which aimed at reducing poverty.

In 2011, the maternal, neonatal and child care network Rede Cegonha (Stork Network) was created. The network incorporated all of the above actions to ensure access to quality maternal and neonatal healthcare services, ranging from antenatal and labour and delivery care, to care for child growth and development up to 24 months, and family planning. It also aimed to promote a welcoming and comfortable environment and the improve capacity of healthcare institutions to resolve complications. Other important initiatives included the National Care Guidelines for Caesarean Section and for Natural Delivery, produced in 2015 and 2017, respectively. These initiatives were based on guidelines developed by the National Institute for Health and Care Excellence (NICE), part of the United Kingdom’s National Health Service.

To address the shortage of doctors in the SUS and promote a more equal distribution of doctors across primary care services, the government created the Programa Mais Médicos (More Doctors Programme).

As part of the National Early Childhood Plan, the focus of child healthcare was broadened to include the rights of children up to the age of six.This plan targeted Early Child Development (ECD). In 2012, the intersectoral programme Brasil Carinhoso (Caring Brazil) began to prioritise care for young children from families receiving the Bolsa Família. In 2016, these initiatives were complemented by the introduction of theEarly Childhood Legal Framework(Federal Law Nº: 13.257) and the Ministry of Social and Agricultural Development’s Programa Criança Feliz (Happy Child Programme) – the main strategy of this programme was to promote ECD in families benefitting from poverty reduction strategies. The National Policy for Comprehensive Child Healthcare (PNAISC, acronym in Portuguese), introduced in 2015, set out a strategic plan of action to ensure comprehensive child healthcare that took into consideration the challenges of the twenty-first century (Chart 1).

Poverty and inequality reduction policies

Social protection consists of a set of policies and programmes directed at reducing poverty, vulnerability, exposure to risk, and enhancing people’s capacity to manage social and economic risks such as unemployment, social exclusion, disease, disability, and ageing.

Conditional cash transfer programmes (CCTP) were implemented in at least 18 countries across Latin America. The Bolsa Família (BF) in Brazil was aimed at boosting poverty reduction efforts via the transfer of cash to poor families on the condition that the pre-established criteria were met⁵²52. Cecchini S, Madariaga A. Conditional cash transfer programmes: the recent experience in Latin America and the Caribbean. Washington: United Nations; 2011.. These criteria were generally related to the health and education of the women and children. Given the potential impact of these programmes on poverty, food security, access to health services, nutrition, and health, numerous studies have been conducted across different countries in Latin America to evaluate the effects on nutrition and health, particularly in children. Various studies have shown that CCTPs make a consistent contribution towards the reduction of poverty (particularly extreme poverty)and inequality, and the improvement of health⁵³53. Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev 2009; (4):CD008137.,⁵⁴54. Segura-Perez S, Grajeda R, Perez-Escamilla R. Conditional cash transfer programs and the health and nutrition of Latin American children. Rev Panam Salud Publica 2016; 40(2):124-137.. In Brazil, studies have shown that the BF helped to improve access to food and health services, enhance nutrition, and reduce child mortality rates⁵¹51. Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013; 382(9886):57-64.. This method has, in turn, played an essential role in improving child health indicators, surpassing the commitments of the fourth Millennium Development Goal. Other positive impacts have been reported, for which there is limited evidence, such as improvements in the cognitive development of children and the reduction in incidence of certain infectious diseases, such as Hansen’s disease and tuberculosis.

The proportion of Brazilians living below the poverty line (US $ 1.90 a day) fell from 24.7% in 2001 to 7.4% in 2014, which is equivalent to a reduction of 70% in 13 years. Even considering other cut-off points for measuring poverty, this reduction remains significant⁴¹41. Silva JC, Amaral AR, Ferreira BD, Petry JF, Silva MR, Krelling PC. Obesity during pregnancy: gestational complications and birth outcomes. Revista brasileira de ginecologia e obstetricia 2014; 36(11):509-513.. However, in 2015, the proportion of people living in poverty started to grow once again, as a result of cuts in programmes such as the BF, and for other reasons.

Final considerations

Over the last 30 years, Brazil has experienced profound changes in the quality of health, with a marked impact on maternal and child health. Social determinants of health, such as poverty, low levels of education, poor housing and sanitation, and social exclusion were tackled by adopting intersectoral policies and promoting wealth redistribution. There has been a noticeable fall in fertility rates and rapid urbanisation. Furthermore, extensive vertical health programmes have enhanced the control of diseases preventable by vaccine and of other infectious diseases, such as diarrhoea and pneumonia. Finally, the implementation of the SUS has enabled the universalisation of healthcare, which has resulted in a considerable reduction in inequalities in access to healthcare.

Multiple policies were developed to promote reproductive, maternal and child health after the creation of the SUS. Public participation in the formulation and monitoring of these policies occurred via committees, councils and conferences, and has intensified since the first decade of the twenty-first century. This process was characterized by progress, setbacks, disputes, and consensuses; the results for which have been recorded in the epidemiological indicators presented in this study.

Brazil has seen significant improvements in health information systems and growth of the academic and care community within the field of public health, which has allowed for the training and qualification of thousands of professionals working across all levels of the public health system. The dynamic nature of the health sector is evidenced by the large number of women and child health initiatives and programmes outlined above. Although the impact of these methods varies, the way they are formulated and implemented demonstrates the strength of public health in Brazil.

In terms of coverage and impact on health indicators, on balance the results of this process are positive, especially for child health. The level of coverage of family planning, antenatal and delivery care is high, with significant reductions in social and regional inequality. The quality of Brazil’s immunisation and breastfeeding programmes are recognised globally, as a result of the well documented positive impact on child health that they have had. There has also been a sharp reduction in malnutrition across all social classes. All these factors have contributed to a significant fall in child mortality, although reductions in neonatal mortality were not as significant. Despite progress, child mortality in 2015 was still seven to eight times higher than in countries with the lowest mortality rates⁵⁵55. United Nations International Children’s Fund (UNICEF). UNICEF Data: Monitoring the Situation of Children and Women. Statistics by Topic / Under-Five Mortality. [acessado 2018 Jan 26]. Disponível em: https://data.unicef.org/topic/child-survival/under-five-mortality/
https://data.unicef.org/topic/child-surv... .

The rate of progress has not been the same for maternal health. Following a prolonged period of stagnation, MMR began to fall slightly in 2010. However, in 2015 the rate was still around 20 times higher than in countries with the lowest mortality rates⁵⁶56. .World Health Organization (WHO). Global Health Observatory (GHO) data. Maternal mortality country profiles. 2015. [acessado 2018 Jan 26]. Disponível em: http://www.who.int/gho/maternal_health/countries/en/#S
http://www.who.int/gho/maternal_health/c... . The fact that abortion is illegal has played a part, although the amount of abortion related hospital admissions has shown a downward trend. This is possibly due to the fact that the widespread use of misoprostol is replacing other less safe methods. Problems in the quality of labour and delivery care, and pregnant women switching from one health facility to another have contributed to persistently high MM and perinatal mortality rates. Furthermore, the high rate of unnecessary caesarean section continues to be a risk factor for maternal death that could otherwise be avoided.

In stark contrast to the progress made across the majority of reproductive, maternal, and child health indicators, women and children face three serious problems: the astonishingly high rate of unnecessary caesarean section, preterm births, and childhood obesity. There is no medical justification for the excessive rate of caesarean section in Brazil, which currently stands at over 50%, making the country the world leader. The epidemic of preterm births, partially attributable to unnecessary caesarean section and the low quality of ANC, has short term consequences for both neonatal morbidity and mortality, and longterm impacts relating to the potential intellectual underdevelopment of premature infants. Finally, the childhood obesity epidemic has serious consequences for non-communicable diseases related to morbidity in adulthood.

This comprehensive review outlines progress and trends in reproductive, maternal and child health in Brazil in the 30 years since the SUS was created. It shows that, while some health conditions have worsened and others have remained stable, the large majority have shown significant improvements. Overall, the result has been an advancement for reproductive, maternal and child health and a significant reduction in inequalities on both a national and regional scale. Other articles in this volume show that in order to maintain progress it is necessary to tackle the underfunding of the SUS to ensure the effective operation of health services. Recent political setbacks pose a serious threat not only to its existence, but also to the preservation of policies and programmes that successfully take into consideration the leading social determinants of health. Although it is still too soon to assess the effect of these changes, the possibility of adverse effects on maternal and child health cannot be ignored.

Zika virus Congenital Syndrome

In 2015, there was an outbreak of microcephaly in Brazil caused by the Zika virus, a congenital infection. The crisis was declared a national public health emergency and resulted in an unprecedented number of microcephaly cases and other congenital abnormalities of the central nervous system. In 2016, the Zika virus was recognised as a significant vector of congenital malformations, affecting the cognitive development of many children. Of the 2,869 cases confirmed up to July 2017, a large proportion of cases were not receiving specialist care. This reveals the limits of the SUS in treating children with severe neurological disorders.

The epidemic had major consequences for women, who were advised that they should consider delaying pregnancy to avoid having babies with birth defects, disregarding difficulties in access to contraception, particularly emergency contraception, and ignoring the issue of unsafe abortion. As such, the need for a review of restrictive Brazilian legislation regarding abortion was brought back into question.

Acknowledgment

Thanks to Ana Paula Esteves-Pereira, Paulo Germano Frias, and Cíntia Borges for contributions towards the final version of the study.

References

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