Iniquidades em gestações de alto risco no Brasil, análise interseccional: Pesquisa Nacional de Saúde (2013-2019)

Abstract

This study aimed to analyze how intersectional barriers to obstetric care are structured by social markers such as race, gender, class and territory, based on an adjusted version of the theoretical-conceptual model adapted from Góes (2018), grounded in Krieger’s ecosocial theory (2002). Self-reported conditions of gestational diabetes mellitus (srGDM) and gestational hypertension (srGH) were used as proxy measures for high-risk pregnancies, due to limitations in measuring all relevant obstetric conditions. The objective was to assess healthcare inequities in high-risk prenatal and delivery care from an intersectional perspective, based on data from the Brazilian National Health Survey (PNS) for the years 2013 and 2019. The study population consisted of 3,903,309 individuals in the PNS-2013 (n = 1,918) and 4,163,574 individuals in the PNS-2019 (n = 2,245). The results are presented in two manuscripts. The first identified an increase in the prevalence of srGDM over the study period: from 1.74% (95% CI: 1.72%–1.75%) in 2013 to 2.82% (95% CI: 2.81%–2.84%) in 2019. The most significant increase was observed among Black women and other Black pregnant people, with a 1.99 percentage point rise (0.33% in 2013; 2.32% in 2019). Higher prevalence rates were found among individuals aged 40 or older, those living in urban areas and in the South macro-region, those with a partner, those who received guidance about referral maternity hospitals, and those who had recently monitored their blood glucose. In both PNS editions, Brown (“Parda”) respondents showed the poorest care indicators, with higher proportions of inadequate prenatal and delivery care, both among those with srGDM and among those without the condition. The second manuscript examined the experience of respondents with srGH. The statistical analysis identified statistically significant interactions between race, education level, and urban residency in relation to inadequate care outcomes. In PNS-2019, Black urban residents had a Relative Excess Risk due to Interaction (RERI) of 1.66 (95% CI: 0.07–3.25) for the outcome of inadequate access to timely and complete prenatal care (initiation by the 12th gestational week and ≥7 consultations), with a Risk Ratio (RR) of 4.71 (95% CI: 0.49–44.99), indicating relevant additive interaction despite the RR not being statistically significant on its own. In PNS-2013, Brown (“Parda”) individuals with low education levels showed a RERI of 1.07 (95% CI: 0.14–2.00) and RR of 1.35 (95% CI: 0.56–3.24) for incomplete completion of basic laboratory tests (such as blood count, VDRL, HIV, and urinalysis), indicating greater difficulty in accessing essential tests. Regarding inadequate guidance on the referral maternity hospital for delivery, PNS-2019 data revealed a RERI of 1.75 (95% CI: 0.90–2.59) among urban Black respondents, although the RR was 0.98 (95% CI: 0.35–2.72), suggesting a gap in access to information. The findings underscore the need to incorporate the intersectionality of social markers into prenatal care policies in order to address structural inequities and advance toward building a more equitable future within Brazil’s healthcare services.