Monitoring trends in socioeconomic, maternal and child health inequalities

This is the authors' abstract. We don't add key points for this paper.

Socioeconomic inequalities are greatest in low-income countries.1 African and Latin American countries manifest the highest rates of inequalities, whereas Scandinavia and Eastern Europe exhibit the lowest.2 Poverty is associated with worse physical and mental health. Less equal societies have lower child well-being indicators and higher infant mortality rates compared with more equal countries.1 Socioeconomic inequalities decreased in most developed countries from 1910 to 1950 and then levelled off, but from 1980 onwards, inequalities in rich nations started to increase again.3 Brazil has one of the most unequal income distributions in the world. Inequalities rose in the 1970s and 1980s but decreased steadily thereafter.4 The GINI coefficient (a measure of statistical dispersion intended to represent a nation’s income distribution—the most commonly used measurement of inequality) fell from a high of 63.3% in 1989 to a low of 51.3% in 2015.2 During these decades, Brazil built more inclusive institutions, driving the country towards more equity, democracy and a better income distribution. Political power was less and less controlled by the elites. The minimum wage increased. Public funds targeted to the poor increased, including social security payments (pensions and safety payments to the elderly and disabled), and conditional cash transfers. Both the coverage and average benefits increased.5 Over the past several decades, Brazil embarked on policies that reduced health inequalities. Among the political and societal changes was the creation of the Unified Health System (SUS is the Portuguese acronym) in 1989, which entitled all Brazilian people to free health care funded by taxes and social contributions,6 and the establishment of the Family Health Strategy (FHS), a community-based approach aimed at providing primary care. Access to health care for the poor increased sharply.7 The FHS was associated with decreased infant mortality,8 and the Brazilian conditional cash transfer programme (called Bolsa Familia, through which poor women receive welfare payments as long as their children are kept in school and receive all basic vaccines) was also linked with decreasing infant mortality9 and better nutritional outcomes.10 Infant mortality in Brazil decreased by 68% from 1990 to 2015, thus reaching the target reduction established by the Millennium Development Goals.11 However in 2016, after the zika virus epidemic and spending cuts due to economic recession, infant mortality increased by 5%.12 Monitoring time trends in health inequities over time is not an easy undertaking, but is important to help identify whether a society is changing in a way that may lead to better living standards. In this supplement to the IJE, time trends in maternal and child health and socioeconomic inequalities were examined over the past four decades in the Brazilian city of Pelotas, covering maternal reproductive history and anthropometry, antenatal care and caesarean sections, low birthweight and preterm birth, stillbirth, newborn and infant mortality, hospital admissions in the first week of life, breastfeeding exclusivity and duration and infant nutrition and growth. Watching closely what happened in Pelotas may help us understand changes in a middle-income country and how rapid epidemiological and nutritional transitions unfolded. It may also shed light on how a free universal health care system affected maternal and child health. Four population-based birth cohorts were started in Pelotas in 1982, 1993, 2004 and 2015. All included nearly all city births, with very low rates of losses and refusals. Data were collected from the time of birth to each child’s first birthday. Follow-up rates were high. Socioeconomic indicators of inequities in health were abstracted, thus allowing the researchers to apply an equity lens to time trends in maternal and child health.13 The picture that emerges from the following pages reflects how health inequities evolved over the past 33 years in a society transitioning to a middle-income country that was able to create and foster a universal public health system.8,9 Overall, most trends in maternal and child health indicators were positive. There were improvements in socioeconomic determinants of health (family income, parental education and access to clean water).13 Median birth interval14 and maternal underweight decreased and maternal height increased.15 Antenatal care improved greatly16 and stillbirths and neonatal and infant mortality declined sharply.17 Both the hospitalization rate in the first year of life18 and undernutrition decreased19 and exclusive breastfeeding became more prevalent.20 There were also negative changes. The prevalence of overweight and obesity among pregnant women increased.15 Preterm birth (PTB) and low birthweight (LBW) rates rose21 and hospital admissions due to complications of PTB increased.18 Particularly worrisome was the sharp increase in the caesarean section rate.16 The authors pointed out that ‘the most likely explanation for the increasing PTB and LBW is the extremely high prevalence of caesarean section, particularly among rich women, with a resulting increase in preterm and early term deliveries due to schedule deliveries’.21 Time trends in inequalities also showed both positive and negative changes. On the plus side, income-related inequalities in most social and environmental conditions13 and in hospital admissions decreased.18 Inequalities in the number of antenatal care visits16 and absolute socioeconomic inequalities in infant mortality decreased,17 as did socioeconomic inequalities in undernutrition.19 On the negative side, some inequities persisted or worsened. Inequalities in age at childbearing and schooling inequalities according to maternal skin colour remained unchanged.13 Low-income women still have shorter birth intervals than their wealthier counterparts,14 and maternal underweight decreased faster among high-income mothers.15 Infants born to non-White mothers were more likely to be hospitalized in the first year of life,18 and women from the low-income group showed lower rates of exclusive breastfeeding.20 Most positive trends followed the inverse-equity hypothesis, which postulates that new effective public health interventions first reach the better off and only later reach the poor.22 However, there were negative trends (increases in the caesarean section, PTB and LBW rates), in which inequalities have diminished due to worsening among the better off, contrary to the inverse-equity hypothesis. The main message is that most indicators of maternal and child health improved. Given recent increases in infant mortality,12 decreased spending in some social programmes that have contributed to reduce health inequalities in Brazil and a recent change in Government,23 it remains to be seen whether current trends of diminishing inequalities will persist or reverse as they did in most high-income countries from 1980 onwards.3