In the past three decades, Brazil has undergone rapid changes in terms of socioeconomic development, urbanisation, medical care, and the health of the population. The first report1 in this Series described how the country evolved in a few decades from a low-income, mostly rural country with multi-tiered health services to a middle-income, urban country with a unified health system. This report addresses how trends in maternal and child health were affected by such changes. We expand on a previous analysis of time trends in inequalities in maternal and child health in Brazil,2 and discuss the health of pregnant women in the context of reproductive rights, which include the right to reproductive choice, safe motherhood, and sexualilty without coercion.3, 4 Our analyses focus on abortion, contraception, pregnancy, and delivery care (see panel 1 for data sources). Injuries (including sexual violence) and infectious and chronic diseases in women will be discussed elsewhere in this Series.18, 19, 20 The discussion of child health is restricted to children younger than 5 years, and focuses on infants because infant deaths account for 90% of all deaths of children younger than 5 years.2
Maternal and child health, which have improved with time, show how Brazil has evolved in terms of health systems, health conditions, and broader social determinants, which are discussed elsewhere in this Series.1, 19, 20, 21 In the past 50 years, Brazil has evolved from a predominantly rural society to one in which more than 80% of the population live in urban areas, fertility rates have decreased from more than six to fewer than two children per woman, primary education became universal, and life expectancy at birth has increased by about 5 years every decade.1, 21 The proportion of all deaths due to infectious diseases decreased substantially—Brazil is successful in the control of vaccine-preventable diseases and HIV/AIDS.18
Key messages
- •
The health and nutrition of Brazilian children has improved rapidly since the 1980s. A key indicator of Millennium Development Goal 1 (a reduction in the number of underweight children by half between 1990 and 2015) has already been met and Millennium Development Goal 4 (a two-thirds reduction in mortality rate of children younger than 5 years by 2015) will probably be met within the next 2 years.
- •
Progress in maternal mortality ratios is difficult to measure because time trends are distorted by improvements in vital statistics, but evidence exists of a decrease in maternal mortality ratios in the past three decades. However, Millennium Development Goal 5 (a reduction in maternal mortality by three-quarters between 1990 and 2015) will probably not be met.
- •
Regional and socioeconomic inequalities in intervention coverage, nutrition, and health outcomes in Brazil have largely decreased.
- •
The main factors that drive such trends probably include improvements in social determinants (ie, poverty, education of women, urbanisation, and fertility), non-health-sector interventions (ie, cash transfers, water, and sanitation), and the creation of a unified national health system with geographical targeting for primary health care (giving previously underserved populations better access to health care), in addition to disease-specific programmes.
- •
Major challenges exist, including a reduction of the high frequency of caesarean section, illegal abortions, and preterm births, in addition to achieving further reductions in regional and socioeconomic inequalities in health.
Brazilian health policies and systems have changed much in the past three decades.1 In the late 1980s, a three-tiered health-care system with private, social security, and charitable institutions was replaced with a universal, tax-funded, national health system. Primary health care became the cornerstone of the system, and geographical targeting of care led to the setting-up of family health teams in the neediest areas of the country. At the same time, investments were made to improve human resources for health and scientific and technological development in the health sector.1, 21 Since the 1990s, governmental policies have become increasingly focused on the provision of social protection mechanisms—not only the well known conditional cash transfer schemes but also the promotion of social inclusion in all sectors of society. As a result of such changes, the long-standing and pronounced differences in access to health care that exist between the wealthy south and southeast regions and the poor north and northeast regions have decreased, as has the financial gap between the wealthiest and poorest families in Brazil.1, 21