Indicador de cobertura qualificado pelo conteúdo da atenção pré-natal: uma nova proposta para uso no monitoramento dos países rumo aos objetivos de desenvolvimento sustentável

Abstract

In the continuum of care for reproductive, maternal, newborn, and child health, antenatal care (ANC) is a platform to provide essential services that can prevent, detect, and treat adverse maternal and newborn outcomes. This is why monitoring ANC coverage and quality becomes an important issue, especially in low and middle income countries (LMICs), where despite the progress achieved in the past few decades in increasing coverage in health services, decreasing mortality rates, and the Sustainable Development Goals (SDGs) emphasis on leave no one behind, continue reporting high mortality rates, experiencing difficulties in ANC access, and presenting wide inequalities in access to services between and within countries and world regions. Different proposals have been published on how to assess the ANC quality, but a more standardized definition of an indicator that allows measuring quality considering both ANC contact and content is still needed. This thesis aimed to propose and validate a coverage content-qualified ANC indicator, considering both contact with services and content of care received, comparable between countries, that allows the estimation of inequality between and within countries, and also for monitoring ANC access and quality, using data from national health surveys. As a result, three original articles were produced. The first paper presents the proposal and validation of the new ANC indicator, named ANCq, using national surveys from 63 LMICs. The ANCq was composed of seven variables related with ANC contact and content, considering all women in need of ANC. It was proposed as a score varying from zero, for women with no ANC, to 10 points, for women getting top points for each item. ANCq was validated using a convergent validation exercise exploring the association with neonatal mortality. The results showed that ANCq presented wide variation between and within countries. Latin America and the Caribbean was the region with higher average scores and less variability between countries. Although our results show that globally more than half of women scored between seven and nine points (55%), 7% received no care during pregnancy.Also, ANCq was inversely associated with neonatal mortality, higher scores of ANCq were associated with lower neonatal mortality. In the second paper, we aimed to conduct a global analysis of socioeconomic inequalities in ANC in 63 LMICs using the ANCq. Higher ANCq scores were observed among women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment level in nearly all countries. Countries with higher ANCq mean presented lower inequalities, while countries with average ANCq scores presented wide range of inequality. The third paper aimed to conduct a survival analysis to explore the association between ANC, using the ANCq as indicator, and child mortality in 70 LMICs. We fitted a Cox regression model using a fractional polynomial approach to analyze the association which is not linear. The higher effect on child survival was observed with higher ANCq scores. The predicted hazard ratio showed a reduction of over 60% in child mortality hazard when women obtained 10 points in the ANCq, compared to those with score zero. Overall, our findings suggest that ANCq is an indicator with good validity properties, that showed a positive association with child survival, being a useful tool for assessing ANC coverage and adequacy of care in monitoring exercises in LMICs. The results also highlight the importance of suitable approaches to monitoring ANC inequalities between and within countries are essential to provide evidence for practices, programs and policies aimed at reducing inequities and leave no one behind.