Health Equity Report 2016 Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking © United Nations Children’s Fund, UNICEF Health Equity Report 2016: Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking November 2016 Panama City, Panama Cover photo: © UNICEF/UNI100388/LeMoyne UNICEF Latin America and Caribbean Regional Office Alberto Tejada street, Building 102, City of Knowledge Panama, Republic of Panama P.O. Box 0843-03045 Phone: (507) 301-7400 www.unicef.org/lac Twitter: https://twitter.com/uniceflac Facebook: https://www.facebook.com/UnicefLac ISBN: 978-92-806-4842-3 This joint report reflects the activities of individual agencies around an issue of common concern. The principles and policies of each agency are governed by the relevant decisions of its governing body. Each agency implements the interventions described in this document in accordance with these principles and policies and within the scope of its mandate. This publication may be reproduced for use in research, advocacy and education only, provided the source is acknowledged (UNICEF). This publication may not be reproduced for other purposes without the prior written permission of UNICEF. Permissions will be requested to Communication Unit, [email protected]. Health Equity Report 2016 Analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking Acknowledgement This report was prepared jointly by a team from Tulane University and UNICEF, with inputs from members of the A Promise Renewed for the Americas (APR-LAC) Metrics and Monitoring Working Group. For UNICEF, Luisa Brumana led the team, which included Liliana Carvajal-Vélez, Miguel González, Gladys Hauck, Andrés A. López and Vicente Terán. Key contributors from UNICEF Headquarters included, Agbessi Amouzou, Robert Bain, Claudia Cappa, Lucia Hug, Priscilla Idele, Julia Krasevec, Holly Newby, Nicole Petrowski, Tyler Andrew Porth, Tom Slaymaker, Chiho Suzuki, Nicole Tai and Danzhen You. For the Tulane University Collaborative Group for Health Equity in Latin America (CHELA), Arachu Castro led the writing and conducted the quantitative data analysis, and Virginia Savage, Hannah Kaufman and Alejandra Leytón drafted sections of the report. The authors wish to thank Madeline Noble, Mai Do and Erin Brock for their contributions to data collection as well as Ludovico Feoli, who provided overall support from the Center for Inter-American Policy and Research at Tulane University. From APR-LAC, in addition to the UNICEF team, Marcela Barrios, Pablo Duran, José Antonio Escamilla, Isabel Espinosa, Oscar Mujica and Antonio Sanhueza contributed from PAHO, Amparo Gordillo from the World Bank, Emma Iriarte and Paola Zúñiga from IDB and Jennifer Slotnick from USAID. Contents Figures vii Tables x Boxes x Foreword 1 Executive summary 3 Key findings on health equity 6 1. Key findings about equity in reproductive health 7 2. Key findings about equity in maternal health 8 3. Key findings about equity in neonatal health 10 4. Key findings about equity in child health 12 5. Key findings about equity in adolescent health 14 6. Key findings about equity in violence and health 16 Introduction 17 1. Health equity and social inequality 18 2. The relevance of health equity for the achievement of 19 universal health care, the human right to health and the sustainable development goals 3. Methodology and limitations of the report 20 1. Reproductive health 23 1.1 Contraception use and access to safe abortion 24 1.2 Social drivers of sexually transmitted infections 26 1.3 Cancer prevention and treatment 27 • Pap tests and the prevention of cervical cancer 27 • Breast cancer and access to treatment 28 2. Maternal health 29 2.1 Antenatal care and skilled birth attendance 30 • Antenatal care 30 • Skilled birth attendance 32 • The rise of caesarean sections 35 ii Contents 2.2 Maternal mortality and morbidity 38 • Direct and indirect causes and the quality of health care 39 • Unsafe abortion and social conditions 41 • Anaemia 42 2.3 Foetal deaths, stillbirth and the health of the pregnant 43 woman 2.4 Diagnosis and treatment of hiv and syphilis during 45 pregnancy 3. Neonatal health 47 3.1 Neonatal mortality, low birth weight and access to 48 perinatal care 3.2 Breastfeeding and the alternatives 55 3.3 Birth registration and the right to an identity 60 3.4 Postnatal care for mothers and newborns 63 4. Child health (0 to 9 years old) 65 4.1 Mortality in children 66 4.2 Child growth and malnutrition 69 • Stunting, wasting and underweight 69 • Overweight and obesity 71 • Micronutrient deficiencies and anaemia 72 4.3 Immunization and immuno-preventable diseases 73 4.4 Water, sanitation, hygiene and diarrhoea 74 • Treatment of diarrhoea 78 4.5 Pneumonia, asthma, other respiratory conditions and 79 the environment • Pneumonia 79 • Asthma 81 4.6 Disabilities and opportunities 82 4.7 The differential risk for tuberculosis, chagas disease, dengue 83 and hiv among children 5. Adolescent health (10 to 19 85 years old) 5.1 Health, access to education and sexuality education 86 in schools 5.2 Early marriage and sexual initiation 87 Contents iii 5.3 Sexual and reproductive health services for adolescents 89 5.4 Adolescent pregnancy, agency and the perpetuation of poverty 90 5.5 Vulnerability, agency and lifestyle 95 5.6 Vulnerability, agency and HIV among youth 96 • Challenges of transition from childhood to adolescence for youth with hiv 97 5.7 LGBT adolescents and discrimination 99 6. Implications of violence on 101 health equity 6.1 Physical, sexual and verbal abuse of women and children 102 • Violence and abuse of children with disabilities 102 • The impact of landmines on children 102 • Sexual abuse of adolescents and mental health conditions 102 • Intimate partner violence during pregnancy 104 6.2 Discrimination and violence in health facilities 106 6.3 Health implications of urban poverty, violence and forced 107 migration 7. Conclusions 110 7.1 Indicators recommended to measure health inequity 111 7.2 Areas in which more research on health equity is needed 112 • Reproductive health 112 • Maternal health 113 • Neonatal health 114 • Child health 114 • Adolescent health 115 • Violence 117 7.3 Priorities in the implementation of equitable policies 118 to improve reproductive, maternal, neonatal, child and adolescent health • Reproductive health • Maternal health 118 • Neonatal health 119 • Child health 119 • Adolescent health 120 • Violence 120 120 References 122 iv Contents Figures, tables & boxes Figures Figure 1. Gaps in the percentage of women aged 15-49 years with an unmet need 24 for contraception (for spacing and limiting) in Latin America and the Caribbean by wealth, place of residence and educational attainment, household surveys 2007-2014 Figure 2. Gaps in the percentage of women aged 15–49 years with a live birth in the last 30 2-5 years with at least four antenatal visits by any provider in Latin American and Caribbean countries, by wealth, place of residence and educational attainment, household surveys 2007-2014 Figure 3. Gaps in the percentage of women aged 15–49 years with a live birth in the 32 last two years with at least four antenatal visits by any provider, by language spoken, Paraguay 2008 Figure 4. Percentage of women aged 15–49 years with a live birth in the last two years 32 by type of birth attendance among those attended at least four times during pregnancy in Bolivia, Colombia, Dominican Republic, Guyana, Haiti, Honduras and Peru, 2008-2013 household surveys Figure 5. Gaps in the percentage of live births in the last 2-5 years attended by skilled 33 birth attendants in Latin American and Caribbean countries, by wealth, place of residence and educational attainment, Household surveys 2007-2014 Figure 6. Percentage of Indigenous and non-Indigenous women with skilled birth 33 attendance in Bolivia, Colombia, Ecuador, Guatemala, Mexico, Nicaragua, Paraguay and Peru, 2004–2012 Figure 7. Percentage of indigenous and non-indigenous pregnant women in Bolivia, 34 Ecuador, Guatemala, Nicaragua and Peru who attended antenatal care, gave birth in a health facility and received follow-up care, 2000–2004 Figure 8. Percentage of women with skilled birth attendance in Mexico and Peru, by 34 indigenous status, 2000-2012 Figure 9. Gaps in the percentage of live births in the 2-5 years preceding the survey 35 delivered by caesarean section in Latin American and Caribbean countries, by wealth, place of residence and educational attainment, household surveys 2007- 2014 Figure 10. Maternal mortality ratio with upper- and lower-level estimates in Latin 38 American and Caribbean countries, 2015 Figure 11. Maternal mortality ratio in Chile by place of residence and education, 2010 38 Figure 12. Distribution of maternal deaths by cause in Latin America and globally, 2013 39 Figure 13. Neonatal mortality rate (deaths per 1,000 live births) in Latin American and 48 Caribbean countries, 2015 Figure 14. Gaps in the perinatal mortality rate for the five-year period preceding the 49 survey, defined as the sum of stillbirths and early neonatal deaths per 1,000 pregnancies in Latin American and Caribbean countries, by wealth, place of residence and educational attainment of the mother, household surveys 2008-2012 vi Figures, tables & boxes Figure 15. Gaps in the neonatal mortality rate (neonatal deaths per 1,000 live births) 50 in Latin American and Caribbean countries by wealth, place of residence and educational attainment of the mother, household surveys 2007-2012 Figure 16. Gaps in the percentage of most recent live births in the last two years who 52 were weighed at birth per total number of most recent live births in the last two years in Latin American and Caribbean countries, by wealth, place of residence and educational attainment of the mother, household surveys 2007-2014 Figure 17.