ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
Institute of Collective Health, Federal University of Bahia (UFBA), Salvador, Brazil.
BMC Med. 2021 Jun 1;19(1):127. doi: 10.1186/s12916-021-01994-7.
Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years.
The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables.
BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07).
Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.
降低贫困和改善医疗保健获取是降低孕产妇死亡率最有效的两项措施，而有条件现金转移（CCT）计划同时作用于这两个方面。本研究旨在评估世界上最大的 CCT 计划之一（巴西家庭补助金计划（BFP））在 11 年间对孕产妇死亡率的影响。
该研究采用生态纵向设计，使用了 2004 年至 2014 年期间所有具有足够质量人口统计数据的 2548 个巴西市政当局。BFP 市政覆盖范围分为低、中、高和巩固四个级别，并根据前几年的平均市政覆盖范围来衡量其持续时间的影响。我们使用固定效应规格的负二项式多变量回归模型，调整了所有相关的人口、社会经济和医疗保健变量。
BFP 与孕产妇死亡率呈显著负相关，与覆盖水平和实施年限成正比，在过去 11 年中，中等、高和巩固 BFP 覆盖的比例分别为 0.88（95%CI 0.81-0.95）、0.84（0.75-0.96）和 0.83（0.71-0.99）。BFP 的持续时间效应在年轻母亲中更强（RR 0.77；95%CI 0.67-0.96）。BFP 还与未进行产前检查的孕妇比例降低（RR 0.73；95%CI 0.69-0.77）、分娩时医院病死率降低（RR 0.78；95%CI 0.66-0.94）以及医院分娩比例增加（RR 1.05；95%CI 1.04-1.07）有关。
我们的研究结果表明，巩固和持久的 CCT 覆盖范围可以降低孕产妇死亡率，并且这些长期影响在儿童和青少年时期接触 CCT 的贫困母亲中更强，这表明 CCT 具有代际效应。持续的 CCT 覆盖范围可以减少健康不平等，有助于实现可持续发展目标 3.1，并应在当前因 COVID-19 大流行而引发的全球经济危机期间得到保留。
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