Rodriguez-Lopez Merida, Botero Jaramillo Daniela, Prada Sergio, Merlo Juan, Leckie George
School of Health Sciences, Universidad Icesi, Cali, Colombia
Unit for Social Epidemiology, Lund University, Lund, Sweden.
BMJ Glob Health. 2025 Aug 14;10(8):e019608. doi: 10.1136/bmjgh-2025-019608.
Access to adequate antenatal care (ANC) is crucial for improving maternal and neonatal health outcomes. Despite high national ANC coverage, Colombia still faces regional and socioeconomic disparities. This study aims to estimate geographical and intersectional inequalities in ANC coverage and evaluate the contribution of social determinants to these disparities.
We conducted a cross-sectional observational study using data from live birth certificates of singleton pregnancies in Colombia during 2022. Multilevel analysis of individual heterogeneity and discriminatory accuracy was performed using logistic regression models. Two approaches were applied: (1) geographical, with departments as the second level and (2) intersectional, with strata as the second level, defined by the combination of health insurance, area of residency, ethnicity and maternal age. The variance partition coefficients (VPCs) from the random-intercept versions of the models were used as the disparity measure. Random slopes were included to allow for variations in the effects of ethnicity and insurance across departments.
A total of 552 284 singleton pregnancies were analysed. National ANC coverage was 95.96%. However, 15 of the 33 departments and 24 of the 36 intersectional strata reported ANC coverage below the national average. For the geographical analysis, the VPC dropped from 24.45% to 10.02%, after accounting for population compositional effects. For the intersectional analysis, the VPC dropped from 39.43% to 3.64%, after adjusting for the additive effects of the individual characteristics used to define the strata. Ethnicity and health insurance were the most significant determinants of both geographical and intersectional heterogeneity. The effect of both factors varied significantly across departments.
Colombia faces significant geographical and intersectional inequalities, primarily driven by inequities in ethnicity and health insurance coverage. Policies targeting these social determinants are needed to ensure equitable access to maternal health services.
获得充分的产前护理（ANC）对于改善孕产妇和新生儿健康结局至关重要。尽管全国范围内的ANC覆盖率较高，但哥伦比亚仍面临地区和社会经济差异。本研究旨在估计ANC覆盖率的地理和交叉不平等情况，并评估社会决定因素对这些差异的影响。
我们使用2022年哥伦比亚单胎妊娠活产证明的数据进行了一项横断面观察性研究。使用逻辑回归模型对个体异质性和判别准确性进行多水平分析。应用了两种方法：（1）地理层面，以部门为第二层级；（2）交叉层面，以阶层为第二层级，由医疗保险、居住地区、种族和孕产妇年龄的组合定义。模型随机截距版本的方差分解系数（VPC）用作差异度量。纳入随机斜率以考虑不同部门中种族和保险效应的变化。
共分析了552284例单胎妊娠。全国ANC覆盖率为95.96%。然而，33个部门中的15个以及36个交叉阶层中的24个报告的ANC覆盖率低于全国平均水平。对于地理分析，在考虑人口构成效应后，VPC从24.45%降至10.02%。对于交叉分析，在调整用于定义阶层的个体特征的累加效应后，VPC从39.43%降至3.64%。种族和医疗保险是地理和交叉异质性的最主要决定因素。这两个因素的效应在不同部门间差异显著。
哥伦比亚面临显著 的地理和交叉不平等，主要由种族和医疗保险覆盖方面的不公平所驱动。需要针对这些社会决定因素制定政策，以确保公平获得孕产妇保健服务。
