title: Inadequate prenatal care utilization and associated factors in São Luís, Brazil.
abstract: BACKGROUND
  Over the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care. The objective of the present study was to estimate the rate of inadequate prenatal care utilization and its associated factors in São Luís, Brazil, in 2010 and to determine whether there was a reduction of inequity in prenatal care use by comparing the present data to those obtained from a previous cohort started in 1997/98.
  
  
  METHODS
  Data from the BRISA (Brazilian birth cohort studies of Ribeirão Preto and São Luís) population-based cohort, which started in 2010 (5067 women), were used. The outcome variable was the inadequate utilization of prenatal care, classified according to the recommendations of the Brazilian Ministry of Health. The explanatory variables were organized into three hierarchical levels based on the Andersen's behavioral model of the use of health services: predisposing, enabling and need factors.
  
  
  RESULTS
  Only 2.0% of the women did not attend at least one prenatal care visit. The rate of inadequate prenatal care utilization was 36.7%. Despite an improved adequacy of prenatal care use from 47.3% in 1997/98 to 58.2% in 2010, social inequality persisted: both low maternal schooling (prevalence ratio (PR) = 2.78; 95% confidence interval (95% CI) 2.23-3.47 for 0 to 4 years of study) and low family income, less than 0.5 monthly minimum wage per capita (PR = 1.37; 95% CI 1.22-1. 54), continued to be associated with higher rates of inadequate prenatal care utilization. Racial disparity regarding adequate utilization of prenatal services was detected, with black (PR = 1.19; 95% CI 1.04-1.36) and mulatto (PR = 1.14; 95% CI 1.02-1.26) women showing higher rates of inadequate use. On the other hand, women covered by the FHP - Family Health Program (PR = 0.92; 95% CI 0.85-0.98) showed a lower rate of inadequate prenatal care utilization.
  
  
  CONCLUSIONS
  Despite strong expansion of health services and expressive improvements in adequate prenatal care use and social indicators, inequalities in prenatal care use still persist. The FHP seems to be effective in reducing inadequate prenatal care utilization.
authors.forename: Ariane Cristina Ferreira
authors.initials: AC
authors.lastname: Bernardes
authors.forename: Raimundo Antonio
authors.initials: RA
authors.lastname: da Silva
authors.forename: Liberata Campos
authors.initials: LC
authors.lastname: Coimbra
authors.forename: Maria Teresa Seabra Soares de Britto
authors.initials: MT
authors.lastname: Alves
authors.forename: Rejane Christine de Sousa
authors.initials: RC
authors.lastname: Queiroz
authors.forename: Rosângela Fernandes Lucena
authors.initials: RF
authors.lastname: Batista
authors.forename: Heloisa
authors.initials: H
authors.lastname: Bettiol
authors.affiliation: Department of Puericulture and Pediatrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil, Avenida Bandeirantes, 3900, Hospital das Clínicas de Ribeirão Preto, Monte Alegre, Ribeirão Preto, São Paulo 14049-900, Brazil. mabarbieri@fmrp.usp.br.
authors.forename: Marco Antônio
authors.initials: MA
authors.lastname: Barbieri
authors.forename: Antônio Augusto Moura
authors.initials: AA
authors.lastname: da Silva
mesh_terms: D000328:Adult; D000428:Alcohol Drinking; D044383:Black People / Q000706:statistics & numerical data; D001938:Brazil; D003430:Cross-Sectional Studies; D005260:Female; D006078:Government Programs; D054625:Healthcare Disparities / Q000208:ethnology / Q000639:trends*; D006801:Humans; D007182:Income; D009035:Mothers / Q000193:education; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data* / Q000639:trends*; D012907:Smoking; D055815:Young Adult
references.citation: Braz J Med Biol Res. 2007 Sep;40(9):1195-202
references.pmid: 17713666
references.citation: Rev Saude Publica. 2006 Jun;40(3):466-73
references.pmid: 16810371
references.citation: BMC Pregnancy Childbirth. 2009 Jul 22;9:31
references.pmid: 19622174
references.citation: Cad Saude Publica. 2011 May;27(5):1021-34
references.pmid: 21655852
references.citation: Br J Obstet Gynaecol. 1980 Feb;87(2):81-6
references.pmid: 7362807
references.citation: Cad Saude Publica. 2004;20 Suppl 1:S63-72
references.pmid: 16636736
references.citation: Cad Saude Publica. 2012 Nov;28(11):2106-14
references.pmid: 23147952
references.citation: Rev Bras Ginecol Obstet. 2010 Nov;32(11):563-9
references.pmid: 21271168
references.citation: Lancet. 2000 Sep 23;356(9235):1093-8
references.pmid: 11009159
references.citation: J Epidemiol Community Health. 2006 Jan;60(1):13-9
references.pmid: 16361449
references.citation: Lancet. 2011 May 28;377(9780):1863-76
references.pmid: 21561656
references.citation: Milbank Mem Fund Q. 1966 Jul;44(3):Suppl:94-127
references.pmid: 5967464
references.citation: Rev Bras Ginecol Obstet. 2009 Jul;31(7):335-41
references.pmid: 19838578
references.citation: BMC Pregnancy Childbirth. 2008 May 01;8:15
references.pmid: 18452623
references.citation: Soc Sci Med. 1986;23(7):721-35
references.pmid: 3775454
references.citation: J Adv Nurs. 2008 Feb;61(3):244-60
references.pmid: 18197860
references.citation: Lancet. 2001 May 19;357(9268):1551-64
references.pmid: 11377642
references.citation: Health Policy Plan. 2010 Jul;25(4):253-61
references.pmid: 20123940
references.citation: Cad Saude Publica. 1998 Jul-Sep;14(3):487-92
references.pmid: 9761601
references.citation: Rev Bras Enferm. 2010 Nov-Dec;63(6):1005-9
references.pmid: 21308236
references.citation: Cad Saude Publica. 2008 Jul;24(7):1609-18
references.pmid: 18670685
references.citation: J Health Soc Behav. 1995 Mar;36(1):1-10
references.pmid: 7738325
references.citation: Lancet. 2013 Jul 6;382(9886):57-64
references.pmid: 23683599
references.citation: Am J Public Health. 2008 Apr;98(4):692-68
references.pmid: 17761568
references.citation: Rev Panam Salud Publica. 2005 Jan;17(1):15-25
references.pmid: 15720877
references.citation: Rev Saude Publica. 2006 Jun;40(3):402-13
references.pmid: 16810363
references.citation: Cad Saude Publica. 2012 Apr;28(4):789-800
references.pmid: 22488324
references.citation: Am J Public Health. 1994 Sep;84(9):1414-20
references.pmid: 8092364
references.citation: Am J Public Health. 2009 Jan;99(1):87-93
references.pmid: 19008516
references.citation: Rev Saude Publica. 2003 Aug;37(4):456-62
references.pmid: 12937706
references.citation: Lancet. 2001 May 19;357(9268):1565-70
references.pmid: 11377643
references.citation: Cochrane Database Syst Rev. 2010 Oct 06;(10):CD000934
references.pmid: 20927721
references.citation: Public Health Rep. 1996 Sep-Oct;111(5):408-18; discussion 419
references.pmid: 8837629
references.citation: Cad Saude Publica. 2004 Sep-Oct;20(5):1281-9
references.pmid: 15486671
references.citation: Am J Public Health. 2004 Aug;94(8):1366-71
references.pmid: 15284045
references.citation: Lancet. 2005 Mar 5-11;365(9462):847-54
references.pmid: 15752528