Abstract

This article aims to evaluate the performance of preconception health indicators according to sociodemographic characteristics among Brazilian women of reproductive age. We conducted a descriptive epidemiological study using data from 21,645 and 25,228 women, respectively, who responded the 2013 and 2019 national health surveys, and data for the period 2010 to 2020 derived from the national health system’s Department of Informatics (DATASUS). We calculated the prevalence of indicators according to sociodemographic characteristics and statistical significance of differences was measured using Pearson’s chi-squared test. Syphilis and HIV incidence rates were also calculated. There was an increase in the prevalence of access to health service indicators (medical and dental consultations and recent Pap smear). However, there was an increase in the prevalence of hypertension, alcohol use, and obesity. The prevalence of use of contraceptive methods and fertility treatment remained stable. Syphilis incidence increased sevenfold between 2010 and 2020. Black/brown women with a low level of education, higher parity, and living in the North or Northeast performed worse for preconception health indicators. Despite the increase in access to health services, performance on preconception health indicators declined and health inequities continued.

Key words:
Preconception health; Women; Health inequities; Epidemiological studies; Nursing

Introduction

Preconception care aims to identify and reduce health risks and adverse pregnancy outcomes through interventions for women of reproductive age, thereby promoting the prevention and control of health complications before and between pregnancies¹1 Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011; 15(2):158-168.. This type of care provides health benefits by promoting healthy lifestyles - especially in relation to the prevention of noncommunicable diseases (NCDs), the leading cause of morbidity and mortality among women worldwide²2 Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2019 Results [Internet]. 2019. [cited 2020 jul 22]. Available from: http://ghdx.healthdata.org/gbd-results-tool
http://ghdx.healthdata.org/gbd-results-t... - and is fundamental to ensure a healthy pregnancy with positive outcomes³3 Robbins CL, Zapata LB, Farr SL, Kroelinger CD, Morrow B, Ahluwalia I, D'Angelo DV, Barradas D, Cox S, Goodman D, Williams L, Grigorescu V, Barfield WD; Centers for Disease Control and Prevention (CDC). Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009. MMWR Surveill Summ 2014; 63(3):1-62..

International randomized studies evaluating the effects of preconception care have highlighted several benefits, including a reduction in smoking and drinking⁴4 Sijpkens MK, van Voorst SF, Rosman AN, de Jong-Potjer LC, Denktas S, Koch BCP, Bertens LCM, Steegers EAP. Change in lifestyle behaviors after preconception care: a prospective cohort study. Am J Heal Promot 2021; 35(1):116-120., increased folic acid use⁴4 Sijpkens MK, van Voorst SF, Rosman AN, de Jong-Potjer LC, Denktas S, Koch BCP, Bertens LCM, Steegers EAP. Change in lifestyle behaviors after preconception care: a prospective cohort study. Am J Heal Promot 2021; 35(1):116-120.^,55 Lassi ZS, Kedzior SGE, Tariq W, Jadoon Y, Das JK, Bhutta ZA. Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: a systematic review. Campbell Syst Rev 2021; 17(2):e1156., healthier lifestyles during follow-up⁴4 Sijpkens MK, van Voorst SF, Rosman AN, de Jong-Potjer LC, Denktas S, Koch BCP, Bertens LCM, Steegers EAP. Change in lifestyle behaviors after preconception care: a prospective cohort study. Am J Heal Promot 2021; 35(1):116-120., and longer inter-pregnancy intervals⁵5 Lassi ZS, Kedzior SGE, Tariq W, Jadoon Y, Das JK, Bhutta ZA. Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: a systematic review. Campbell Syst Rev 2021; 17(2):e1156.. However, women’s level of knowledge of preconception care remains low, being higher among those with a higher level of education⁶6 Fikadu Id K, Wasihun B, Yimer O. Knowledge of pre-conception health and planned pregnancy among married women in Jinka town, southern Ethiopia and factors influencing knowledge. PLoS One 2022; 17(5):e0268012.. Furthermore, a high prevalence of modifiable risk factors and conditions such as hypertension, diabetes, and depression⁷7 Robbins C, Boulet SL, Morgan I, D'Angelo DV, Zapata LB, Morrow B, Sharma A, Kroelinger CD. Disparities in preconception health indicators - behavioral risk factor surveillance system, 2013-2015, and pregnancy risk assessment monitoring system, 2013-2014. MMWR Surveill Summ 2018; 67(1):1-16. was found in American women of reproductive age and in Australian women planning a pregnancy⁸8 Chivers BR, Boyle JA, Lang AY, Teede HJ, Moran LJ, Harrison CL. Preconception health and lifestyle behaviours of women planning a pregnancy: a cross-sectional study. J Clin Med 2020; 9(6):1701..

Despite maternal and infant health policies, mortality among this group remains high in Brazil⁹9 Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, Victora C. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Cien Saude Colet 2018; 23(6):1915-1928. and half of all pregnancies are not planned¹⁰10 Viellas EF, Domingues RMSM, Dias MAB, da Gama SGN, Filha MMT, Costa JV, Bastos MH, Leal MC. Prenatal care in Brazil. Cad Saude Publica 2014; 30(Supl. 1):S85-S100.. Preconception care can therefore facilitate reproductive planning and reduce the risk of health complications, considering that most women are unaware of this type of care¹¹11 Nascimento NC, Araújo KS, Borges ALV. Preparo pré-concepcional: conhecimento e razões para a não realização entre mulheres usuárias do SUS. Bol Inst Saúde 2016; 17(2):96-104.^,1212 Moura ERF, Evangelista DR, Damasceno AKC. Conhecimento de mulheres com diabetes mellitus sobre cuidados pré-concepcionais e riscos materno-fetais. Rev Esc Enferm USP 2012; 46(1):22-29., even those who have a serious condition such as diabetes¹²12 Moura ERF, Evangelista DR, Damasceno AKC. Conhecimento de mulheres com diabetes mellitus sobre cuidados pré-concepcionais e riscos materno-fetais. Rev Esc Enferm USP 2012; 46(1):22-29.. Studies show that awareness is related to information, which is one of the dimensions of access to health services and a reflection of the level of communication between the health system and individuals¹³13 Sanchez RM, Ciconelli RM. Conceitos de acesso à saúde. Rev Panam Salud Publica 2012; 31(3):260-268.^,1414 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):S190-S198.. Health professionals have also been shown to have low awareness of the need for this type of care¹⁵15 Ferreira FR, Akiba HRR, Júnior EA, Figueiredo EN, Abrahão AR. Prevention of birth defects in the pre-conception period: knowledge and practice of health care professionals (nurses and doctors) in a city of Southern Brazil. Iran J Reprod Med. 2015;13(10):657., which can contribute to the neglect of preconception care and undermine sexual and reproductive rights.

A study in São Paulo showed that only 15.9% of women received preconception care¹⁴14 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):S190-S198.. Furthermore, women who received this type of care still showed a high prevalence of modifiable risk factors¹⁵15 Ferreira FR, Akiba HRR, Júnior EA, Figueiredo EN, Abrahão AR. Prevention of birth defects in the pre-conception period: knowledge and practice of health care professionals (nurses and doctors) in a city of Southern Brazil. Iran J Reprod Med. 2015;13(10):657.. However, these studies were limited to women who planned their pregnancy, reinforcing that women’s preconception health has received little attention and that existing studies in the country on the topic are limited to aspects related to preconception¹¹11 Nascimento NC, Araújo KS, Borges ALV. Preparo pré-concepcional: conhecimento e razões para a não realização entre mulheres usuárias do SUS. Bol Inst Saúde 2016; 17(2):96-104.^,1616 Borges ALV, Santos OA, Nascimento NC, Chofakian CBN, Gomes-Sponholz FA. Preconception health behaviors associated with pregnancy planning status among Brazilian women. Rev Esc Enferm da USP 2016; 50(2):208-215.. Other studies have evaluated specific aspects such as inadequate intake of fruit and vegetables, insufficient physical activity¹⁷17 Mpofu JJ, Moura L, Farr SL, Malta DC, Iser BM, Bernal RTI, Robbins CL, Lobelo F. Associations between noncommunicable disease risk factors, race, education, and health insurance status among women of reproductive age in Brazil - 2011. Prev Med reports 2016; 3:333-337., and NCDs¹⁷17 Mpofu JJ, Moura L, Farr SL, Malta DC, Iser BM, Bernal RTI, Robbins CL, Lobelo F. Associations between noncommunicable disease risk factors, race, education, and health insurance status among women of reproductive age in Brazil - 2011. Prev Med reports 2016; 3:333-337.^,1818 Araújo FG, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence trends of overweight, obesity, diabetes and hypertension among Brazilian women of reproductive age based on sociodemographic characteristics. Health Care Women Int 2019; 40(4):386-406.. The findings show that the prevalence of these factors was higher among black and brown women with a low level of education living in the country’s North and Northeast regions¹⁷17 Mpofu JJ, Moura L, Farr SL, Malta DC, Iser BM, Bernal RTI, Robbins CL, Lobelo F. Associations between noncommunicable disease risk factors, race, education, and health insurance status among women of reproductive age in Brazil - 2011. Prev Med reports 2016; 3:333-337.^,1818 Araújo FG, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence trends of overweight, obesity, diabetes and hypertension among Brazilian women of reproductive age based on sociodemographic characteristics. Health Care Women Int 2019; 40(4):386-406..

Given the situation revealed by research and seeking to gain a more in-depth understanding of women’s health conditions, international studies have proposed a set of preconception health indicators that can be measured using existing public health surveillance systems to provide a more comprehensive evaluation of women’s health¹1 Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011; 15(2):158-168.^,1919 Schoenaker DAJM, Stephenson J, Connolly A, Shillaker S, Fishburn S, Barker M, Godfrey KM, Alwan NA; UK Preconception Partnership. Characterising and monitoring preconception health in England: a review of national population-level indicators and core data sources. J Dev Orig Health Dis 2022; 13(2):137-150.. These indicators can help improve both women’s health and reproductive health²⁰20 Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care - United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 2006; 55(RR-6):1-23.. In addition, women are increasingly having children later in life, when they may exhibit risk factors and disease⁶6 Fikadu Id K, Wasihun B, Yimer O. Knowledge of pre-conception health and planned pregnancy among married women in Jinka town, southern Ethiopia and factors influencing knowledge. PLoS One 2022; 17(5):e0268012., which can influence both general health status and maternal and infant health.

The analysis of preconception health indicators enables the comprehensive monitoring of women’s health at national level, providing benefits beyond reproductive health. Population surveys such as the Pesquisa Nacional de Saúde (PNS), or National Health Survey, enable the evaluation of aspects that extend beyond women’s sexual and reproductive health, including chronic diseases and lifestyle habits. Unlike existing studies, which are conducted mostly at local level¹⁶16 Borges ALV, Santos OA, Nascimento NC, Chofakian CBN, Gomes-Sponholz FA. Preconception health behaviors associated with pregnancy planning status among Brazilian women. Rev Esc Enferm da USP 2016; 50(2):208-215.^,2121 Nascimento NC, Borges ALV, Fujimori E, Tsunechiro MA, Borges do Nascimento Chofakian CBN, Santos OA. Preconception care: adolescents' knowledge and practice. Rev Enferm UFPE 2015; 9(5):7895-7901. and/or limited to specific indicators¹²12 Moura ERF, Evangelista DR, Damasceno AKC. Conhecimento de mulheres com diabetes mellitus sobre cuidados pré-concepcionais e riscos materno-fetais. Rev Esc Enferm USP 2012; 46(1):22-29.^,1818 Araújo FG, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence trends of overweight, obesity, diabetes and hypertension among Brazilian women of reproductive age based on sociodemographic characteristics. Health Care Women Int 2019; 40(4):386-406., national surveys permit the assessment and diagnosis of women’s health conditions at country level, providing a broader picture of indicators, as proposed by international guidelines¹1 Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011; 15(2):158-168.^,1919 Schoenaker DAJM, Stephenson J, Connolly A, Shillaker S, Fishburn S, Barker M, Godfrey KM, Alwan NA; UK Preconception Partnership. Characterising and monitoring preconception health in England: a review of national population-level indicators and core data sources. J Dev Orig Health Dis 2022; 13(2):137-150.. In addition, they allow researchers to identify preconception health inequalities among women.

The aim of this study was therefore to evaluate performance on preconception health indicators among Brazilian women of reproductive age according to sociodemographic characteristics and compare preconception health indicators between 2013 and 2019.

Methods

Study design, data source and population

We conducted a descriptive population-based epidemiological study consisting of two components: a cross-sectional component, using representative secondary data from the 2013 and 2019 PNS (https://www.pns.icict.fiocruz.br/bases-de-dados/); and an ecological time-series component, using data for the period 2010 to 2020 derived from the national health system’s Department of Informatics (DATASUS) (http://indicatorssifilis.aids.gov.br/ and http://indicators.aids.gov.br/). All data used in the study are publicly available.

The PNS is a nationwide household survey and its sampling design has been described by previous studies²²22 Damacena GN, Szwarcwald CL, Malta DC, Souza Júnior PRB, Vieira MLFP, Pereira CA, Morais Neto OL, Silva Júnior JB. O processo de desenvolvimento da Pesquisa Nacional de Saúde no Brasil, 2013. Epidemiol Serv Saude 2015; 24(3):197-206.^,2323 Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Silva GA, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342.. In the 2013 edition, 64,348 household interviews and 60,202 individual interviews with residents aged 18 years and over were conducted²²22 Damacena GN, Szwarcwald CL, Malta DC, Souza Júnior PRB, Vieira MLFP, Pereira CA, Morais Neto OL, Silva Júnior JB. O processo de desenvolvimento da Pesquisa Nacional de Saúde no Brasil, 2013. Epidemiol Serv Saude 2015; 24(3):197-206.^,2323 Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Silva GA, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342.. In 2019, 94,114 household interviews and 90,846 individual interviews with a resident aged 15 years and over were conducted²³23 Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, Damacena GN, Azevedo LO, Silva GA, Theme Filha MM, Lopes CS, Romero DE, Almeida WS, Monteiro CA. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19(2):333-342..

The present study included women of reproductive age based on the definition proposed by the World Health Organization²⁴24 Organização Mundial de Saúde (OMS). Mulheres e saúde: evidências de hoje agenda amanhã. Brasília: OMS; 2009.. Since the 2013 PNS only interviewed people aged 18 and over, 21,645 women aged 18-49 years were included in the sample. Men, women outside this age group, women who were unaware they were pregnant (n = 176), and pregnant women (n = 800) were excluded. A total of 25,228 women aged 18-49 years were included from the 2019 PNS to permit comparison with previous editions. Men, women outside the age group, women who were unaware they were pregnant (n = 108), and pregnant women (n = 735) were excluded. In the 2019 PNS, anthropometric measurements were taken of a subsample, providing body mass index (BMI) estimates for a subpopulation of 1,772 women of reproductive age.

DATASUS compiles epidemiological, morbidity, mortality, service access, and other data derived from the country’s health information systems, such as the national notifiable diseases information system (SINAN). We extracted aggregate data on HIV and syphilis among women aged 15-49 years during the period 2010 to 2020.

Indicators and variables

The preconception health indicators used in this study are based on previous studies that aimed to identify a comprehensive set of indicators to assess women’s health. Available national data sources were a key factor in indicator selection and evaluation¹1 Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011; 15(2):158-168.^,1919 Schoenaker DAJM, Stephenson J, Connolly A, Shillaker S, Fishburn S, Barker M, Godfrey KM, Alwan NA; UK Preconception Partnership. Characterising and monitoring preconception health in England: a review of national population-level indicators and core data sources. J Dev Orig Health Dis 2022; 13(2):137-150..

The following indicators were analyzed based on the available data sources: self-rated health status; education level; access to health insurance; medical and dental consultations during the last 12 months; Pap smear in the last three years among women in the target age group; use of contraceptive methods (CM); CM use up to two years after postpartum; fertility treatment; smoking and passive smoking; alcohol use; fruit and vegetable intake (where adequate intake is at least five portions a day)²⁵25 Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J; American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009; 120(11):1011-1120.; nutritional status based on BMI (malnutrition < 18.5 kg/m², normal weight 18.5-25.0 kg/m², overweight 25.0-29.9 kg/m², and obese ≥ 30 kg/m²)²⁶26 World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Geneva: WHO; 1998.; physical activity (where adequate activity is defined as ≥ 150 minutes of moderate-intensity or ≥ 75 minutes of vigorous activity per week)²⁷27 DC: US Dept of Health and Human Services. Physical Activity Guidelines for Americans [Internet]. 2018. [cited 2021 dez 3]. Available from: https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines
https://health.gov/our-work/nutrition-ph... ; violence committed by someone known to the victim during the last 12 months (2013 PNS), violence suffered during the last 12 months (2019 PNS), intimate partner violence committed during the last 12 months; self-reported depression, diabetes, hypertension (except diabetes and hypertension during pregnancy), and asthma. The above indicators were derived from the 2013 and 2019 PNS. The following indicators were also examined: HIV incidence rate in women of reproductive age; and syphilis incidence rate in pregnant women, both based on the number of cases (taken from DATASUS) and estimated population of women of reproductive age in Brazil during the period 2010 to 2020.

In addition to preconception health indicators, we also considered the following sociodemographic variables: education level (2013 PNS: 0-8, 9-11, or 12 or more years of completed education; 2019 PNS: 0-9, 10-12, or 13 or more years of completed education, both categorized as low, medium, and high education level); self-declared skin color/race (white, black/brown, yellow/indigenous); region of residence (North, Northeast, Southeast, South, Midwest); and parity (none, 1 birth, 2 or 3 births, or 4 or more births).

Data analysis

We characterized Brazilian women of reproductive age according to sociodemographic characteristics using data from the 2013 and 2019 PNS, calculating prevalence and adopting 95% confidence interval (95%CI). We then calculated prevalence and corresponding 95%CI in 2013 and 2019 for each preconception health indicator and according to sociodemographic characteristics. Pearson’s chi-squared test was used to analyze group differences, adopting a 5% significance level. Stata 14 (Survey module) was used to obtain the population estimates, using the complex sample design function. We also performed a subpopulation analysis, which is the indicated method for analyzing complex-sample survey data²⁸28 West BT, Berglund P, Heeringa SG. A closer examination of subpopulation analysis of complex-sample survey data. Stata Journal 2008; 8(4):520-531..

We calculated the proportion of HIV cases (cases among women of reproductive age/cases in Brazil x 100), HIV incidence rates (new cases in women of reproductive age/estimated population of women of reproductive age x 100,000), and syphilis incidence rates (cases of syphilis in pregnant women of reproductive age/live births x 1,000).

Ethical aspects

The aggregate data used in this study are available in the public domain and do not identify the subjects. This study was therefore conducted in accordance with the ethical norms and standards set out in National Health Council Resolution 466 (12 December 2012).

Results

Brazilian women of reproductive age showed the following age distribution in 2013 and 2019: 18-29 years (37.6% and 34.2%); 30-39 years (32.9% and 34.0%); 40-49 years (29.5% and 31.8%). In 2013, 42.2% of these women lived in the Southeast, 28.0% in the Northeast, and 14.1% in the Sul, with a similar distribution being found in 2019 (42.2%, 27.3%, and 13.9%, respectively). Most of the women self-declared black or brown (53.0% in 2013 and 58.1% in 2019). Regarding parity, 35.7% of women had had two or three births in 2013, compared to 35.8% in 2019, and 31.7% had had no births in 2013, compared to 31.2% in 2019 (data not presented).

In both editions of the PNS more than 70% of the women self-reported good/very good health (Table 1). Only 22.3% of the women had studied beyond high school in 2013, rising to 27.1% in 2019. In both editions of the PNS, three in every ten women had health insurance, eight in every ten had visited the doctor during the last 12 months, and five in every ten had visited the dentist during the last 12 months. At least 80% of the women had done a Pap smear in the last three years. The prevalence of CM use was over 80% in both editions. The most common methods were the pill (38.8% in 2013 and 34.1% in 2019), followed by surgical (22.2% in 2013 and 19.8% in 2019), condoms (13.4% in 2013 and 16.9% in 2019), injection (6.4% in 2013 and 7.8% in 2019), and IUD (1.8% in 2013 and 3.8% in 2019) (data not presented). In both editions of the PNS over 3% of women underwent fertility treatment.

In 2013, only 2.7% of women reported having diabetes, 11.7% reported hypertension, and 5.4% reported asthma, compared to 3.4%, 14.0%, and 6.3%, respectively, in 2019 (Table 1). Regarding risk factors, in 2013 and 2019, respectively, 9.7% and 8.4% of women reported smoking, 17.9% and 15.3% reported passive smoking, and 33.7% and 39.4% reported using alcohol, with the latter showing a considerable rise in prevalence. In both editions of the PNS, only two in every 10 women reported adequate daily fruit and vegetable intake. Only two in every 10 women reported practicing enough physical activity in 2013, rising to three in every ten in 2019. In 2013, five in every 10 women were overweight or obese, rising to six in every ten in 2019 (Table 1).

In 2013, 9.5% of women reported having had depression, increasing to 13.4% in 2019. In 2013, 3.9% of women reported having suffered violence during the last 12 months, rising to 2019 in 23.7%. Physical or sexual violence accounted for most cases of violence in 2013 (47.4%), followed by psychological violence (43.9%). In 2019, psychological violence accounted for almost three times as many cases than physical or sexual violence (72.3% and 27.7%, respectively) (data not presented). In 2013, 23.5% of women reported suffering intimate partner violence, compared to 18.7% in 2019. The rate of physical or sexual partner violence was more than twice that of psychological partner violence in 2013 (35.1% and 14.1% respectively). In contrast, in 2019 the prevalence of psychological partner violence was higher than that of physical or sexual violence (15.8% and 25.5%, respectively) (Table 1).

The prevalence of preconception health indicators varied according to education level (Table 2), skin color/race (Table 3), parity, and region of residence (data not presented). Women with a low level of education, who had had more births, and who self-declared black or brown performed worse for preconception health indicators (p-value < 0.05). Women from the North, Northeast, and Midwest performed worse in half of the indicators. Significant differences between regions were not found for prevalence of physical activity, violence, and diabetes (p-value > 0.05).

The HIV incidence rate among women of reproductive age rose between 2010 and 2017, falling thereafter until the end of the period (Figure 1), even though the number of cases in this group as a proportion of overall cases in the general population decreased by 10.0% over the period (Table 4). The syphilis incidence rate in pregnant women rose throughout the period, with a sharper rise from 2013 (Figure 1), increasing seven-fold over the period.

Discussion

The findings of this study show that there was an increase in the prevalence of indicators of health service access and utilization, such as consultations during the last 12 months and having done the Pap smear in the last three years. However, there was also an increase in prevalence of NCDs, such as hypertension, and their risk factors, including alcohol use and obesity. The results also show a rise in the prevalence of depression. The prevalence of other indicators remained stable, notably those related to reproductive health, such as CM use, with the maintenance of an obsolete mix of methods²⁹29 Cavenaghi S, Alves JED. O mix contraceptivo eternamente obsoleto no Brasil e seu legado. Rev Bras Estud Popul 2019; 36:e0103., and fertility treatment. The results also reveal that there was a rise in the syphilis incidence rate over the last decade. Finally, black or brown women living in the North and Northeast with a low level of education and higher number of births had a worse health status.

Our findings reveal that the health of Brazilian women of reproductive age is compromised across various indicators, including NCDs and their risk factors, sexually transmitted infections, and violence, corroborating the results of other national¹²12 Moura ERF, Evangelista DR, Damasceno AKC. Conhecimento de mulheres com diabetes mellitus sobre cuidados pré-concepcionais e riscos materno-fetais. Rev Esc Enferm USP 2012; 46(1):22-29.^,1818 Araújo FG, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence trends of overweight, obesity, diabetes and hypertension among Brazilian women of reproductive age based on sociodemographic characteristics. Health Care Women Int 2019; 40(4):386-406.^,3030 Oliveira LVA, Santos BNS, Machado IE, Malta DC, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence of the metabolic syndrome and its components in the Brazilian adult population. Cien Saude Colet 2020; 25(11):4269-4280. and international studies⁷7 Robbins C, Boulet SL, Morgan I, D'Angelo DV, Zapata LB, Morrow B, Sharma A, Kroelinger CD. Disparities in preconception health indicators - behavioral risk factor surveillance system, 2013-2015, and pregnancy risk assessment monitoring system, 2013-2014. MMWR Surveill Summ 2018; 67(1):1-16.^,3131 Jaacks LM, Vandevijvere S, Pan A, McGowan CJ, Wallace C, Imamura F, Mozaffarian D, Swinburn B, Ezzati M. The obesity transition: stages of the global epidemic. Lancet Diabetes Endocrinol 2019; 7(3):231.^,3232 Vogel B, Acevedo M, Appelman Y, Bairey Merz CN, Chieffo A, Figtree GA, Guerrero M, Kunadian V, Lam CSP, Maas AHEM, Mihailidou AS, Olszanecka A, Poole JE, Saldarriaga C, Saw J, Zühlke L, Mehran R. The Lancet Women and Cardiovascular Disease Commission: reducing the global burden by 2030. Lancet 2021; 397(10292):2385-2438.. It is worth noting that our sample is a group of relatively young women who already exhibit important health problems that extend beyond sexual and reproductive health. Moreover, women’s health status has declined over the years, reaffirming the need to promote health across the life course, implementing wide-ranging policies to encourage the adoption of healthy lifestyle habits, prevent and control disease, and provide psychosocial support, thereby ensuring the effective delivery of comprehensive women’s health care. Despite these findings, most women self-reported good health, revealing a lack of awareness of lifestyle risk factors. The prevalence of other indicators, such as smoking and diabetes, remained stable, indicating lack of progress on the promotion of women’s health.

Our findings also show that women from vulnerable groups have poorer health status and self-reported health, which has been observed by previous studies7,18,33. Our results show that women with a low level of education, black or brown skin color, and who had a higher number of births showed worse health status across various indicators, including diet, physical activity and nutritional status, revealing social inequalities between different groups of Brazilian women. Disparities in preconception health indicators were also observed by a similar study undertaken in the United States⁷7 Robbins C, Boulet SL, Morgan I, D'Angelo DV, Zapata LB, Morrow B, Sharma A, Kroelinger CD. Disparities in preconception health indicators - behavioral risk factor surveillance system, 2013-2015, and pregnancy risk assessment monitoring system, 2013-2014. MMWR Surveill Summ 2018; 67(1):1-16.. The findings indicate that to a certain extent these women are aware of their vulnerability insofar as they were more likely to rate their health negatively than other women. This reinforces the need to continue the pursuit of equity, recognizing differences and guaranteeing rights and access to health services.

Another study in São Paulo reported that women with more children and a lower level of education participated less frequently in preconception care³⁴34 Nascimento N de C, Borges ALV, Fujimori E. Preconception health behaviors among women with planned pregnancies. Rev Bras Enferm 2019; 72(Supl. 3):17-24., reinforcing the need for reproductive health and family planning for women. Despite the high prevalence of CM use, unplanned pregnancies are still common and can have several implications for women, including changes to routine, emotional problems, and abandonment of studies. Changes to life plans and their consequences can be even more drastic in the case of teenage pregnancy³⁵35 Marteleto LJ, Villanueva A. The educational consequences of adolescent childbearing and union formation in Brazil. Stud Fam Plann 2018; 49:1830211.. In addition, these factors can prevent women from attaining better jobs and improving their income, often perpetuating the cycle of poverty³⁵35 Marteleto LJ, Villanueva A. The educational consequences of adolescent childbearing and union formation in Brazil. Stud Fam Plann 2018; 49:1830211..

The results also highlight regional health disparities, with women from the North, Northeast, and Midwest performing more poorly than those from the South and Southeast across preconception health indicators. These findings illustrate that, despite the social and economic development witnessed in the country over recent years, regional inequalities in access to health services persist, both in terms of care complexity³⁶36 Albuquerque MV, Viana ALD, Lima LD, Ferreira MP, Fusaro ER, Iozzi FL. Desigualdades regionais na saúde: mudanças observadas no Brasil de 2000 a 2016. Cien Saude Colet 2017; 22(4):1055-1064. and quality³⁷37 Pinto LF, Quesada LA, D'avila OP, Hauser L, Gonçalves MR, Harzheim E. Primary Care Asssement Tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística. Cien Saude Colet 2021; 26(9):3965-3979..

The prevalence of risk factors and NCDs among women of reproductive age remain high, corroborating the data from another study with a sample of women in São Paulo³⁴34 Nascimento N de C, Borges ALV, Fujimori E. Preconception health behaviors among women with planned pregnancies. Rev Bras Enferm 2019; 72(Supl. 3):17-24.. In addition, our findings show that performance on these indicators declined in 2019, indicating that women’s health status across these dimensions has not improved over the years. NCDs account for 44% of deaths among Brazilian women³⁸38 Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas e agravos não transmissíveis no Brasil 2021-2030 [Internet]. 2020. [citado 2021 mar 7]. Disponível em: https://antigo.saude.gov.br/images/pdf/2020/October/01/Plano-DANT-vers--o-Consulta-p--blica.pdf
https://antigo.saude.gov.br/images/pdf/2... and around half of the female population have metabolic syndrome³⁰30 Oliveira LVA, Santos BNS, Machado IE, Malta DC, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence of the metabolic syndrome and its components in the Brazilian adult population. Cien Saude Colet 2020; 25(11):4269-4280., a group of conditions that can lead to heart disease. A study with diabetic women showed that participants had limited knowledge of potential maternal and fetal health complications caused by chronic diseases and that only one-third of pregnancies were planned. Despite this, only 5% of the women who planned their pregnancy sought antenatal care¹²12 Moura ERF, Evangelista DR, Damasceno AKC. Conhecimento de mulheres com diabetes mellitus sobre cuidados pré-concepcionais e riscos materno-fetais. Rev Esc Enferm USP 2012; 46(1):22-29..

Other studies have reported an upward trend in the prevalence of NCDs and their risk factors among women of reproductive age, including obesity¹⁸18 Araújo FG, Velasquez-Melendez G, Felisbino-Mendes MS. Prevalence trends of overweight, obesity, diabetes and hypertension among Brazilian women of reproductive age based on sociodemographic characteristics. Health Care Women Int 2019; 40(4):386-406.^,3131 Jaacks LM, Vandevijvere S, Pan A, McGowan CJ, Wallace C, Imamura F, Mozaffarian D, Swinburn B, Ezzati M. The obesity transition: stages of the global epidemic. Lancet Diabetes Endocrinol 2019; 7(3):231., hypertension³⁹39 Julião NA, Souza A, Guimarães RRM. Tendências na prevalência de hipertensão arterial sistêmica e na utilização de serviços de saúde no Brasil ao longo de uma década (2008-2019). Cien Saude Colet 2021; 26(9):4007-4019., and alcohol use⁴⁰40 Massaro LTS, Abdalla RR, Laranjeira R, Caetano R, Pinsky I, Madruga CS. Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion. Rev Bras Psiquiatr 2019; 41(2):131-137.^,4141 Munhoz TN, Santos IS, Nunes BP, Mola CL, Silva ICM, Matijasevich A. Tendências de consumo abusivo de álcool nas capitais brasileiras entre os anos de 2006 a 2013: análise das informações do VIGITEL. Cad Saude Publica 2017; 33(7):e00104516.. The high prevalence of hypertension is alarming, given that this condition increases the risk of heart disease among young women³²32 Vogel B, Acevedo M, Appelman Y, Bairey Merz CN, Chieffo A, Figtree GA, Guerrero M, Kunadian V, Lam CSP, Maas AHEM, Mihailidou AS, Olszanecka A, Poole JE, Saldarriaga C, Saw J, Zühlke L, Mehran R. The Lancet Women and Cardiovascular Disease Commission: reducing the global burden by 2030. Lancet 2021; 397(10292):2385-2438.. These findings are a warning sign for preconception health, given the risk of cardiovascular diseases, poor general health status, and potential complications in future pregnancies among this relatively young group of women.

Increased alcohol consumption has been related to changing gender roles and greater participation of women in social settings and activities previously considered to be male⁴¹41 Munhoz TN, Santos IS, Nunes BP, Mola CL, Silva ICM, Matijasevich A. Tendências de consumo abusivo de álcool nas capitais brasileiras entre os anos de 2006 a 2013: análise das informações do VIGITEL. Cad Saude Publica 2017; 33(7):e00104516.. Our results also show an improvement in the physical activity indicator, corroborating the findings of a previous study⁴²42 Ide PH, Martins MSAS, Segri NJ. Tendência dos diferentes domínios da atividade física em adultos brasileiros: dados do Vigitel de 2006-2016. Cad Saude Publica 2020; 36(8):e00142919.. This improvement may be related to behavioral changes and the promotion of healthier lifestyle habits by public health programs⁴²42 Ide PH, Martins MSAS, Segri NJ. Tendência dos diferentes domínios da atividade física em adultos brasileiros: dados do Vigitel de 2006-2016. Cad Saude Publica 2020; 36(8):e00142919..

The data presented show a considerable rise in the prevalence of sexually transmitted infections over the last decade, which have been shown to be persistently endemic worldwide⁴³43 Rowley J, Hoorn S Vander, Korenromp E, Low N, Unemo M, Abu-Raddad LJ, Chico RM, Smolak A, Newman L, Gottlieb S, Thwin SS, Broutet N, Taylor MM. Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016. Bull WHO 2019; 97(8):548-562.. Increased syphilis incidence has been observed in the general population. It is important to note that the exponential increase in cases of syphilis may be related to the fact that the condition was made a notifiable disease in 2010⁴⁴44 Brasil. Ministério da Saúde (MS). Boletim Epidemiológico Sífilis [Internet]. 2021. [acessado 2021 mar 7]. Disponível em: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2021/sifilis/boletim_sifilis_2021_internet.pdf/view
https://www.gov.br/aids/pt-br/central-de... . Preconception care for women with STIs is essential for both maternal and infant health, since it enables the detection and treatment of infections and prevents vertical transmission. Syphilis is detected using a rapid test and treatment is available on the country’s national health service, the Sistema Único de Saúde (SUS) or Unified Health System⁴⁴44 Brasil. Ministério da Saúde (MS). Boletim Epidemiológico Sífilis [Internet]. 2021. [acessado 2021 mar 7]. Disponível em: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2021/sifilis/boletim_sifilis_2021_internet.pdf/view
https://www.gov.br/aids/pt-br/central-de... . All women, regardless of whether they plan to get pregnant or not, can benefit from the prevention and early detection and treatment of STIs.

The present study also showed that violence against women is prevalent. Violence has been shown to be a risk factor for other diseases and adverse health outcomes worldwide⁴⁵45 Institute for Health Metrics and Evaluation. GBD Compare [Internet]. 2019. [cited 2021 nov 29]. Available from: https://vizhub.healthdata.org/gbd-compare/#
https://vizhub.healthdata.org/gbd-compar... and in Brazil⁴⁶46 World Health Organization (WHO). Violence against Women: prevalence estimates, 2018 [Internet]. 2021. [cited 2021 nov 30]. Available from: https://www.who.int/publications/i/item/9789240022256. Aside from being a major human rights violation, violence against women can lead to death and illness⁴⁵45 Institute for Health Metrics and Evaluation. GBD Compare [Internet]. 2019. [cited 2021 nov 29]. Available from: https://vizhub.healthdata.org/gbd-compare/#
https://vizhub.healthdata.org/gbd-compar... . The problem is deeply rooted in gender inequality⁴⁷47 Willie TC, Kershaw TS. An ecological analysis of gender inequality and intimate partner violence in the United States. Prev Med (Baltim) 2019; 118:257-263. and aggravated by conservatism⁴⁸48 Araújo V, Gatto MAC. Can conservatism make women more vulnerable to violence?. Comp Polit Stud 2021; 55(1):122-153.. It is important to note that this study’s results relating to violence, particularly the increase between the two surveys, should be interpreted with caution due to changes made to the questionnaire, meaning that the 2019 survey better captured cases of violence.

Our findings underline a real and urgent need for a comprehensive approach to women’s health in the country, that goes beyond established interventions such as the Pap smear and antenatal and postpartum care. Adopting a comprehensive approach could reduce maternal mortality by around by 28%, given that a large proportion of maternal deaths are attributable to indirect causes, notably pre-existing conditions⁴⁹49 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Heal 2014; 2(6):e323-e333.. While our results show high Pap smear coverage and prevalence of CM use, suggesting women have wide access to specific health services¹⁴14 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):S190-S198., women’s care tends to be fragmented rather than comprehensive, resulting in lost opportunities and a reductionist view of young women’s health. Our study is therefore a step forward as our results provide new insights into young women’s health in the country.

Finally, for decades, public policies and programs have focused on maternal and infant health. However, mortality rates are still a cause for concern⁹9 Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, Victora C. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Cien Saude Colet 2018; 23(6):1915-1928. and it is known that effective preconception care and women’s health care as a whole can improve pregnancy outcomes and reduce health inequities between women. It is worth highlighting that one of the strengths of this study was the fact that the sample was not restricted women who plan to get pregnant and the importance of surveys for assessing women’s health and monitoring indicators among the young female population over the last decade.

Limitations

The study sample did not include adolescents aged 15-17 years. Despite the importance of assessing the health status of this group and the fact that women of reproductive age include these ages, the 2013 PNS only interviewed individuals aged 18 years and over. In contrast, the 2019 PNS included adolescents aged 15-17 years in all modules except violence. A sensitivity analysis of this sample of adolescents showed that the prevalence of the indicators overweight, obese, and alcohol use were underestimated (data not presented) and that the prevalence of the remaining indicators was very similar to those of the present study. Another limitation was that the questionnaire used in the 2019 PNS did not contain a question about salad consumption and changes were made to the questions regarding violence suffered during the last 12 months, meaning it was not possible to compare the two editions.

Another important consideration is that access indicators were restricted to service utilization (consultations, tests, materials) and therefore limited for measuring access across all dimensions¹⁴14 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):S190-S198..

In addition, DATASUS does not stratify new cases of syphilis by age, meaning that it was not possible to analyze the data for non-pregnant women of reproductive age. We therefore analyzed syphilis among pregnant women, given that they account for more than half of the cases of disease reported among women in Brazil and cases are identified in the first trimester of pregnancy. Finally, we did not investigate indicators such as vaccination and stillborn children, among others, due to the lack or unavailability of data.

Conclusion

This study showed that the general health status of Brazilian women of reproductive age is fragile. This is demonstrated by the poor performance of preconception health indicators, notably risk factors, STIs, NCDs, and violence, despite the relatively young age of the sample. The findings reveal an increase in the prevalence of health service access and utilization indicators and a decline in performance on indicators of NCDs and their risk factors, and STIs over time. More socially vulnerable women, such as black and brown women with a low level of education and higher number of births performed worse than other groups, revealing the need to promote health equity and improve health policies and services.

Acknowledgments

BNS Santos is grateful for the Scientific Initiation grant from Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC/CNPq)/Pró-reitoria de Pesquisa/Universidade Federal de Minas Gerais.

References

Publication Dates

History