Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries

Abstract

SummaryBackgroundLatin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions.MethodsWe analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15–49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12–23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression.FindingsEthnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66–0·92), antenatal care (0·86, 0·75–0·94), and skilled birth attendants (0·75, 0·68–0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries.InterpretationThe lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level—such as vaccines—show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes.FundingThe Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Ethnic inequalities in child stunting and feeding practices: results from surveys in thirteen countries from Latin America

“…In addition, differential fertility may result in larger proportions of children being classified as indigenous or afrodescendants than would be the case for national censuses that count all individuals. Different types of questions and categories used in each type of survey may lead to the aforementioned discrepancies in the survey samples and the small number of observations when the information is disaggregated into subgroups [34]. Thus, our results must be interpreted carefully, although the fact that our classification showed large and mostly consistent results for indigenous children suggests that the categories included in the analyses are able to discriminate population subgroups.…”

“…There is ample literature on the high rates of several infectious disease among indigenous people [12,47,48]. Survey data from several Latin American countries showed lower health care coverage among indigenous women and children than for the rest of the population, even after adjusting for wealth and residence [34]. Lower coverage has been associated with an organization of health services that is insensitive to the need for intercultural health care [49].…”

“…It is important to note that Suriname and Guyana had special classifications for the reference groups, because it was not possible to identify a subgroup with an European background, and Asians (East Indians and Javanese) were also included in this category. Further information on our classification was published elsewhere [34].…”

How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

“…Recently, several studies have explored the inequalities in maternal, newborn and child health by ethnicity in some countries of Latin America [9][10][11][12]. The criteria used to identify the women as indigenous were selfidentification (SI), spoken indigenous languages (SIL), or indigenous household (IH) (if the head of the household speaks an indigenous language or self-identifies).…”

The Transformative Potential of Strategic Partnerships to Form a Health Equity Network of the Americas

“…4 The region is marked by vast differences in living, as well as social and environmental conditions between the rich and the poor, 5,6 often exacerbated by gender and ethnic/racial inequalities and discrimination. 7 Latin America and the Caribbean are considered among the most unequal regions in the world, 8,9 creating enormous barri-ers to achieving health equity. 9,10 The United States is no exception; a May 2018 report to the United Nations (UN) condemned the United States for the degree of poverty that it tolerates.…”