Social and geographical inequalities in the performance of prenatal care in a metropolitan area of Brazil

Esposti, Carolina Dutra Degli; Santos-Neto, Edson Theodoro dos; Oliveira, Adauto Emmerich; Travassos, Claudia; Pinheiro, Rejane Sobrino

doi:10.1590/1413-81232020255.32852019

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ARTICLE • Ciênc. saúde coletiva 25 (5) • May 2020 • https://doi.org/10.1590/1413-81232020255.32852019 copy

Social and geographical inequalities in the performance of prenatal care in a metropolitan area of Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study analyzed the social and geographical inequalities in the performance of prenatal medical care in the Unified Health System (SUS) in the Metropolitan Region of Grande Vitória, Espírito Santo, Brazil. A cross-sectional study was carried out with 1,209 puerperae living in this region, admitted for childbirth from 2010 to 2011. Data about prenatal care and contextual, enabling, and social characteristics were collected, following the Andersen’s Behavioral Model. The performance of prenatal care was classified into five levels, including information on the number of prenatal visits, initial and repetitive examinations, tetanus vaccination, gestational risk management, and participation in educational activities. The likelihood of different levels of prenatal care performance was analyzed using a multivariate multinomial model, according to maternal social variables. High prenatal coverage (98%) and 4.4% care adequacy were identified. The likelihood of access to prenatal care was increased by enabling, contextual, and social factors. The relationship between prenatal care quality and pregnant women’s social and geographical conditions must be considered in the organization of services to achieve equity and reduce maternal and perinatal morbimortality.

Key words
Equity in access; Quality of health care; Unified Health System; Prenatal care

Variables				Region of residence
		Total (n=1209)		RMGV-ES (n = 849)		Vitória (n = 360)		p-value^* * Chi-square (χ2).
		n	%	n	%	N	%
Predisposing	Age (n = 1,209)							0.242
	≤ 19 years	275	22.7	185	21.8	90	25.0
	20-34 years	837	69.2	600	70.7	237	65.8
	≥ 35 years	97	8.1	64	7.5	33	9.2
	Number of previous deliveries (n = 1,209)							0.229
	0-2	10000000	82.7	695	81.9	305	84.7
	≥3	209	17.3	154	18.1	55	15.3
Enabling	Schooling (n = 1,199)							0.434
	≤ 7 years	367	30.6	266	31.7	101	28.1
	8-10 years	426	35.5	291	34.6	135	31.7
	≥11 years	406	33.9	283	33.7	123	34.3
	Household head (n = 1,201)							0.893
	Pregnant woman herself	126	10.5	88	10.4	38	10.7
	Other	1075	89.5	757	89.6	318	89.3
	General housing conditions (n = 1,161)							0.007
	Highly inadequate	56	4.8	46	5.6	10	2.9
	Inadequate	306	26.4	231	28.2	75	22.0
	Adequate	799	68.8	543	66.2	256	75.1
Contextual	PHC coverage (n = 1,205)							< 0.001
	UBS	525	43.6	476	56.3	49	13.6
	ESF	531	44.1	238	28.1	293	81.6
	PACS	149	12.4	132	15.6	17	4.7
	Oral health coverage (n = 1,205)							< 0.001
	No	290	24.1	284	33.6	06	1.7
	Yes	915	75.9	562	66.4	353	98.3
	MHDI (n = 1,209)							< 0.001
	Medium	38	3.2	38	4.5	-	-
	High	583	48.2	583	68.7	-	-
	Very high	588	48.6	228	26.9	360	100.0

PHPN activities	Total		RMGV-ES		Vitória		p-value^* * Chi-square (χ2) test.
PHPN activities	n^† † In the descriptive analysis, all women with information were included in each of the variables, while only those with information available for the set of variables were included in the regression. ^* * Chi-square (χ2) test. n	%	n	%	n	%
PHPN procedures	1,183	100.0	830	100.0	353	100.0
Onset of prenatal care up to the 4th month	600	55.7	404	52.6	196	63.4	0.001
Prenatal care visits							< 0.001
1-5	425	35.9	349	42.0	76	21.5
6+	758	64.1	481	58.0	277	78.5
Blood typing (ABO-Rh)	762	64.4	511	61.6	251	71.1	0.002
First VDRL	864	73.0	590	71,1	274	77.6	0.020
First EAS	795	67.2	558	67,2	237	67.1	0.976
First blood glucose	861	72.8	596	71.8	265	75.1	0.249
Hemoglobin	844	71.3	585	70.5	259	73.4	0.315
Hematocrit	770	65.1	534	64.3	236	66.9	0.406
Anti-HIV	776	64.8	545	65.7	221	62.6	0.314
Tetanus immunization	427	36.1	304	36.6	123	34.8	0.559
Repetition VDRL	397	33.6	263	31.7	134	38.0	0.037
Repetition EAS	403	34.1	264	31.8	139	39.4	0.012
Repetition blood glucose	427	36.1	278	33.5	149	42.2	0.004
Gestational risk management	1099	93.3	769	92.9	330	94.3	0.376
Educational activities	215	18.2	145	17.5	70	19.9	0.325
Performance levels (n =1072)	1072	100.0	766	100.0	306	100.0	< 0.001
1-5 visits	389	36.3	323	42.2	66	21.6
≥ 6 visits	173	16.1	111	14.5	62	20.3
first level	411	38.3	259	33.8	152	49.7
second level	46	4.3	35	4.6	11	3.6
third level	53	4.9	38	5.0	15	4.9

Variables		Total (n = 1013)		1-5 visits (n = 365)		≥ 6 visits (n = 165)		first level (n = 390)		second level (n = 42)		third level (n = 51)		p-value*
Variables		n	%	n	%	n	%	n	%	n	%	n	%
Predisposing	Age													0.040
	≤ 19 years	224	22.1	94	42.0	41	18.3	76	33.9	08	3.6	05	2.2
	20-34 years	706	69.7	245	34.7	108	15.3	280	39.7	34	4.8	39	5.5
	≥ 35 years	83	8.2	26	31.3	16	19.3	34	41.0	00	0.0	07	8.4
	Number of previous deliveries													0.001
	0-2	843	83.2	282	33.5	135	16.0	343	40.7	38	4.5	45	5.3
	≥ 3	170	16.8	83	48.8	30	17.6	47	12.1	04	2.4	06	3.5
Enabling	Schooling													0.002
	≤ 7 years	302	29.8	128	42.4	54	17.9	98	32.5	08	2.6	14	4.6
	8-10 years	352	34.7	139	39.5	47	13.4	132	37.5	17	4.8	17	4.8
	≥ 11 years	359	35.4	98	27.3	64	17.8	160	44.6	17	4.7	20	5.6
	Household head													0.004
	Pregnant woman herself	112	11.1	50	44.6	20	17.9	29	25.9	02	1.8	11	9.8
	Other	901	88.9	315	35.0	145	16.1	361	40.1	40	4.4	40	4.4
	General housing conditions													0.060
	Highly inadequate	48	4.7	23	47.9	07	14.6	12	25.0	03	6.3	03	6.3
	Inadequate	253	25.0	99	39.1	52	20.6	81	32.0	10	4.0	11	4.3
	Adequate	712	70.3	243	34.1	106	14.9	297	41.7	29	4.1	37	5.2
Contextual	PHC coverage													0.005
	UBS	452	44.6	184	40.7	58	12.8	160	35.4	24	5.3	26	5.8
	ESF	446	44.0	135	30.3	89	20.0	185	41.5	17	3.8	20	4.5
	PACS	115	11.4	46	40.0	18	15.7	45	39.1	01	0.9	05	4.3
	Municipality of residence													< 0.001
	RMGV-ES	729	72.0	302	41.5	105	14.4	251	34.4	33	4.5	38	5.2
	Vitória	284	28.0	63	22.2	60	21.1	139	48.9	09	3.2	13	4.6
	MHDI													0.127
	Medium	29	2.9	11	37.9	03	10.3	13	44.8	02	6.9	00	0.0
	High	493	48.7	197	40.0	75	15.2	171	34.7	22	4.5	28	5.7
	Very high	491	48.5	157	32.0	87	17.7	206	42.0	18	3.7	23	4.7

Variables		≥ 6 or more visits		first level		second level		third level
Variables		Odds Ratio	95%CI	Odds Ratio	95%CI	Odds Ratio	95%CI	Odds Ratio	95%CI
Predisposing	Age
	≤ 19 years	1.00	-	1.00	-	1.00	-	1.00	-
	20-34 years	1.00	0.62-1.60	1.53^* * p-value < 0.05.	1.05-2.24	1.71	0.73-4.01	2.71^* * p-value < 0.05.	1.15-6.41
	≥ 35 years^ there were no observations for age ≥ 35 years in the group that met the second level of performance. Thus, the Odds Ratio and the confidence interval could not be estimated.	1.61	0.71-3.63	2.56^* * p-value < 0.05.	1.29-5.06	-	-	7.72^* * p-value < 0.05.	2.38-25.1
	Number of previous deliveries
	0-2	1.00	-	1.00	-	1.00	-	1.00	-
	≥ 3	0.73	0.43-1.26	0.45^* * p-value < 0.05.	0.29-0.71	0.51	0.17-1.58	0.27^* * p-value < 0.05.	0.11-0.67
Enabling	Schooling
	≤ 7 years	1.00	-	1.00	-	1.00	-	1.00	-
	8-10 years	0.74	0.46-1.19	1.04	0.71-1.51	1.59	0.65-3.90	1.02	0.50-2.11
	≥11 years	1.52	0.94-2.47	1.68^* * p-value < 0.05.	1.13-2.50	1.99	0.78-5.06	1.52	0.74-3.11
	Household head
	Other	1.00	-	1.00	-	1.00	-	1.00	-
	Pregnant woman herself	1.23	0.69-2.19	1.92^* * p-value < 0.05.	1.15-3.22	2.72	0.62-11.8	0.66	0.32-1.37
Contextual	PHC Coverage
	UBS	1.00	-	1.00	-	1.00	-	1.00	-
	ESF	1.59^* * p-value < 0.05.	1.01-2.48	1.17	0.82-1.67	0.99	0.47-2.09	0.84	0.43-1.60
	PACS	1.30	0.70-2.44	1.20	0.74-1.94	0.17	0.22-1.27	0.86	0.33-2.20
	Municipality of residence
	RMGV-ES	1.00	-	1.00	-	1.00	-	1.00	-
	Vitória	2.28^* * p-value < 0.05.	1.43-3.64	2.52^* * p-value < 0.05.	1.70-3.73	1.23	0.51-2.98	2.27^* * p-value < 0.05.	1.13-4.55

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[1] Collaborations

CDD Esposti, C Travassos, and RS Pinheiro participated in all stages of the research, including the design, analysis, and interpretation of data, drafting and review of the paper, and approval of the version to be published. ET Santos Neto participated in the design, analysis, and interpretation of results, critical review, and approval of the version to be published. AE Oliveira collaborated in the interpretation of the data, critical review of the paper, and approval of the version to be published.