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date: 11 December 2019

Child Health in Latin America

Summary and Keywords

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis.

Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.

Keywords: child health, Latin America, maternal health, health equity, Millennium Development Goals

Child Health in Latin America

International development initiatives such as the Millennium Development Goals (MDG) and the Sustainable Development Goals have propelled worldwide actions to improve maternal and child health as well as to monitor their impact at regional and national levels (Arnesen et al., 2016; Grove et al., 2015). Since the 1990s, increasing focus has been given to effective interventions to prevent child deaths (Sacks et al., 2017).

The Latin American region made substantial progress in reducing child mortality since the 1990s, with a sharp decrease in the number of under-five deaths. Because of the social and health-care investments in the majority of LA countries, the number of children affected by undernutrition, diarrheal diseases, and pneumonia has significantly decreased (PAHO, 2017).

However, despite the accelerated decline in childhood mortality, rates in the neonatal period remain high and deaths within the first 28 days of life represent an increasingly large proportion of under-five deaths. In the region, for every 100 newborns, approximately one dies during the neonatal period (UN IGME, 2017). The majority of these deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions (Thompson, Land, Camacho-Hubner, & Fullerton, 2015).

Early childhood interventions are among the most relevant strategies to reduce health inequalities because efforts during these initial years are more likely to break the cycle of poverty (Engle et al., 2011). For properly investing in Latin American children, it is essential to understand the diversity of contexts in which childhood development takes place. Efforts and resources should focus on improving survival and on promoting early child development, taking into account the different experiences of social, ethnic, religious, and cultural processes within countries (Wehby & López-Camelo, 2017).

The present study addresses the health of children living in the Latin American region, as defined by the Pan American Health Organization (PAHO, 2016). According to PAHO’s definition, the region comprises the following French, Portuguese, and Spanish-speaking countries of the American continent: Mexico, Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Guadeloupe, Haiti, Cuba, Dominican Republic, French Guiana, Martinique, Puerto Rico, Bolivia, Colombia, Ecuador, Peru, Venezuela, Brazil, Argentina, Chile, Paraguay, and Uruguay. The study was restricted to under-five children due to their relevance and to the analysis of available information from major data sources, such as Pan American Health Organization (PAHO), The World Bank Group, United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), Institute for Health Metrics and Evaluation (IHME), and from the Demographic and Health Surveys (DHS).

The data analyzed provide information not only on the temporal trends of child mortality but also on the improvements in the coverage of some relevant maternal and child health interventions. An attempt was made to outline the progresses achieved in the period 1990 to 2015 and to show the challenges still to overcome regarding the different social contexts of the Latin American nations.

Pregnancy and Childbirth

In 2017, more than 10 million children were born in Latin American (LA) countries (PAHO/PLISA), which indicates an even greater number of pregnancies that year. During the gestational period, all women should receive continuous care for the prevention, diagnosis, treatment of diseases or deficiencies, as well as health information and support from social, cultural, and psychological perspectives. Adequate antenatal care should include at least eight consultations, according to the World Health Organization (WHO, 2016). In addition to the number of consultations, regularity and quality of care are associated with better perinatal outcomes for both the mother and the newborn (Domingues et al., 2015).

In the Latin American region, there is great variation in antenatal coverage as measured by the percentage of women with four or more consultations, ranging from 43% in Guatemala to more than 90% in Cuba, Puerto Rico, and Uruguay. El Salvador, Nicaragua, Haiti, and Bolivia have antenatal coverage of between 50% and 80%, and all other countries between 80 and 90%. When analyzed by LA subregions, the lowest proportions are observed for countries in the Central American Isthmus and the Andean Area while the highest are observed in Mexico, Brazil, Southern Cone (with the exception of Paraguay), and Latin Caribbean (with the exception of Haiti) (Figure 1).

The graph in Figure 1 also shows the proportion of births attended by skilled personnel. Of the 25 countries in the region, 60% provide hospital-based delivery care to more than 95% of their pregnant women, although some countries have very low coverage, such as Haiti (less than 50%) and Bolivia (less than 80%).

Child Health in Latin America

Figure 1. Proportion (%) of pregnancy women who have received 4+ antenatal care visits (per 100 live births) and proportion of births attended by trained personnel. Latin America countries, last year with information available.

These data show that, in general, countries in the LA region have been committed to providing antenatal care and hospital-based delivery for their pregnant women and newborns. In addition, these data draw attention to the fact that hospital care has higher coverage than antenatal care, which is less technologically complex and costs less. However, the four-visits antenatal indicator implies program adherence, which, in turn, is contingent on socioeconomic barriers, women’s perception, and satisfaction with the care received (Wehby & López-Camelo, 2017). It should also be noted that had data been available for evaluating this indicator according to the WHO recommendation (eight or more consultations), the results would be worse.

Currently, LA has the highest cesarean rate among all regions of the world (Betran et al., 2016). In the late 1990s, rates of cesarean sections were already extremely high in some countries such as Brazil, Colombia, and the Dominican Republic (Figure 2). Presently, these countries present 55%, 45%, and 58% cesarean rates, respectively. In addition, Guatemala and Peru, which initially had rates below the WHO-recommended minimum, currently have rates above of those observed in developed countries (Betran et al., 2015). The only exception is Haiti, which maintained very low cesarean rates, below the level that is considered safe to meet the needs of childbirth complications.

Cesarean rates according to the highest and lowest quintiles of wealth are also presented in Figure 2. In some of the countries, such as Bolivia, Guatemala, and Peru, cesarean rates among the poorest women are below the safety level, while among the richest women cesarean rates are greater than 50%. Current rates of C-section in the wealthiest 20% of the population in Brazil and the Dominican Republic reach extreme values of more than 80%.

Child Health in Latin America

Figure 2. C-section rate by lowest and highest wealth quintile in selected countries of Latin American region, 1995 to 1997 and 2013 to 2015.

Source: ICF International (2015). Funded by USAID.

The simultaneous lack and excess of cesarean deliveries in these countries reflects a model of care that excludes a considerable portion of the population and at the same time promotes iatrogenic care, which has been associated with preterm births among the richest. This seems to be narrowing the gap in maternal and neonatal complications between rich and poor (Ye, Betran, Guerrero Vela, Souza, & Zhang, 2014; Villar et al., 2007; Leal et al., 2016).

Low birth weight (LBW) is a consequence of multiple factors that affect fetal growth during pregnancy and is highly correlated with the gestational age of the fetus. Maternal nutritional status during pregnancy and gestation, birth-spacing interval, infections, and other previous maternal or gestational pathologies, lifestyle (smoking, use of alcohol and illicit drugs), multiple pregnancy, and lack of access to health services are among the main determinants of LBW (De Souza Buriol, Hirakata, Goldani, & da Silva, 2016). All these factors are also associated with the mother’s living conditions, including maternal education and other indicators of poverty (Houweling et al., 2017). Together with prematurity, LBW constitutes a risk factor for child health not only during the perinatal period but also during childhood, adolescence, and adulthood (Engle, Thomashek, & Wallman, 2007).

According to data from the Pan American Health Organization (PAHO), in the period 2011–2015, there was large variation in the percentage of LBW among LA countries, from 7% in Cuba, Chile, and Mexico, to 14% in Guatemala and the Dominican Republic. However, it is important to note the contradictory results in some counties, such as Haiti and Bolivia—these countries have low estimated prevalence of LBW but also have the highest infant mortality rates in the region. This paradoxical situation is also found in Brazil. The poorest regions of the country have the highest infant mortality rates but the lowest LBW prevalence estimates, indicating the inconsistency of LBW data (Silva et al., 2010).

Breastfeeding

Breastfeeding offers countless benefits for children and women and is the intervention with the greatest potential to reduce infant mortality (Jones et al., 2003). Optimal levels of breastfeeding could prevent more than 820,000 deaths of children under five years old per year worldwide, as well as prevent 20,000 deaths of women from breast cancer (Victora et al., 2016).

To assess the main indicators of breastfeeding in LA—prevalence of exclusive breastfeeding, median duration (in months) of any breastfeeding and exclusive breastfeeding in the first six months, data obtained from Demographic and Health Surveys (DHS) were used. The last available DHS surveys for eight LA countries were considered: Bolivia, 2008; Colombia, 2010; Dominican Republic, 2013; Guatemala, 2014–2015; Haiti, 2012; Honduras, 2011–2012; Nicaragua, 2001; Peru, 2012. Data from Brazil was obtained from a DHS-like survey.

Regarding median duration of exclusive breastfeeding, Peru and Bolivia had the highest duration in Latin America, both with more than three months of exclusive breastfeeding. The lowest estimates were observed in Honduras, Nicaragua, and the Dominican Republic, all with a duration of 0.7 months or less. Guatemala and Peru are the two LA countries with longest median duration of any breastfeeding (21.7 and 20.2 months, respectively) while Colombia and Brazil have estimates of nearly 15 months.

In terms of prevalence of exclusive breastfeeding in the first six months, estimates higher than 50% were achieved only by Peru (67.8%), Bolivia (61.2%), and Guatemala (53.2%). In Colombia, Haiti, and Brazil, the exclusive breastfeeding rates were close to 40%, while the estimates in Bolivia, Honduras, and Nicaragua were at the 30% level. The Dominican Republic showed the lowest duration of any breastfeeding (of only seven months) and the lowest prevalence of exclusive breastfeeding (6.7%).

One of the World Health Organization’s (WHO) targets included in the Implementation Plan on Maternal Infant and Young Child Nutrition (IYCN) is to “Increase exclusive breastfeeding rates in the first six months up to at least 50% by 2025.” Only 3 out of the 10 LA countries considered in this analysis (Peru, Bolivia, and Guatemala) have reached this relatively modest target.

Having in mind that the success of breastfeeding is not the sole responsibility of women but is shared by all society (Rollins et al., 2016), to achieve optimal levels of breastfeeding it is necessary to ensure political will and advocacy actions at the country, community, and individual levels for breastfeeding promotion. Additionally, monitoring and evaluation of the interventions are needed to examine progresses and remaining challenges (Pérez-Escamilla, Curry, Minhas, Taylor, & Bradley, 2012).

Child Nutrition

Since the 1980s, prevalence of undernutrition has been decreasing and prevalence of obesity and overweight has been increasing globally. This phenomenon called “nutritional transition” is related to a complex combination of rapid sociodemographic transformations with dietary changes towards ultra-processed foods and increasingly sedentary lifestyles, also affecting children and adolescents (Popkin, 2001). Obesity prevalence has increased substantially among the youngest in developed and developing countries (Ng et al., 2014; NCD-RisC, 2017).

In Latin America, countries have experienced a marked reduction in underweight among under-five children. Data from a systematic review that identified official sources for monitoring nutritional status among LA countries showed an overall improvement of undernutrition in the past 30 years (Galicia, Grajeda, & de Romaña, 2016).

Based on data from recent national representative surveys between 1985 and 2014, childhood underweight (z-score weight for age < −2 standard deviations) decreased in the majority of LA countries. The relative decline in underweight ranged from 67% in Brazil to 44% in Guatemala. The exception was the Dominican Republic, which was the only country in the region with an increase in undernutrition. Despite the overall improvement in the nutritional status, some LA countries still show a high prevalence of stunting and anemia in children (Galicia et al., 2016).

Regarding the most recent information on wasting in each country (2006–2013), under-five prevalence of wasting (z-score weight for height < −2 standard deviations) was below 5% for all countries, a satisfactory level according to the WHO criteria. Low prevalence of wasting has been historically the rule throughout the region (Victora, 1992). On the other hand, overweight in this age group achieved levels greater than 5% for most of the countries, with high proportions in Panama, 2008 (11.3%), Argentina, 2007 (9.8%), and Mexico, 2012 (9.7%) as well (Galicia et al., 2016).

The current scenario documented in the 2017 WHO report stated that in Latin America there are 6 million children stunted, 1 million wasted, and 4 million overweight, representing a double burden for the LA countries, with the simultaneous presence of undernutrition and overweight (UNICEF, WHO, The World Bank Group, 2017).

Some LA countries are conducting interventions and public health programs to prevent childhood obesity. The initiatives include excise taxes on sugar-sweetened beverages and energy-dense foods; food label legislation including warnings around sugar, saturated fat, sodium, and calories; restrictions on marketing, advertising, and sales of unhealthy foods to children; trans fatty acids removal from processed foods; and construction of recreational bikeways or open streets for physical activities. However, continued monitoring of these recent initiatives is needed to understand health implications (Pérez-Escamilla et al., 2017).

Childhood Mortality

Under-five mortality (or childhood mortality) measures the probability of dying in the first five years of life and is one of the most important health indicators due to its high sensitivity to the living and health conditions of populations. Its inclusion in the Millennium Development Goals (MDGs) for the period 1990 to 2015 and later in the Sustainable Development Goals for 2030 endorses the relevance of monitoring this indicator.

Several countries have accepted the challenge of improving maternal and child health, representing a great opportunity for the development of preventive strategies aimed at reducing the risk of death before the age of five (Marchant et al., 2016). Moreover, this effort raised issues with estimating health indicators used to assess the achievement of goals (Mathers & Boerma, 2010). An adequate evaluation of the progress achieved through monitoring coverage with life-saving interventions would ensure accountability among country members toward the commitment made with the United Nations (AbouZahr et al., 2015).

In this context, the growing recognition of the importance of vital statistics has led to initiatives to improve vital registration data, prioritizing disadvantaged areas with incomplete information (Szwarcwald et al., 2014; Finkelstein, Duhau, & Speranza, 2016; You et al., 2015). Nevertheless, not all LA countries have high-quality health statistics. According to estimates of childhood mortality provided by the Pan American Health Organization (PAHO) (PAHO/PLISA), comparison between reported and estimated rates of under-five mortality rates in 2015 indicates that some countries in the LA region still have a high proportion of underreporting of vital events. Out of the 17 countries with data available for analysis, six were shown to have incomplete vital statistics data.

The under-five mortality estimates presented in this section are derived from different sources of information (PAHO/PLISA; UN IGME/CME Info; GBD, 2016), in which vital statistics data are used in countries with adequate information, while estimates by indirect demographic methods based on census and household surveys are used in countries with insufficient vital data.

Under-Five Mortality Rates

According to data from the World Bank (The World Bank Group/UN IGME), in 2015, under-five mortality in the LA region was 18.1 per 1,000 live births, ranging from 5.6 in Cuba to 68.9 in Haiti (Table 1).

In the period 1995 to 2015, there was a significant decline in under-five mortality in LA countries. The goal of reducing childhood mortality by two-thirds between 1990 and 2015 was attained by half the countries. The largest declines were evidenced in Peru, Brazil, and Mexico, all of them with annual reduction rates of more than 3%. Only Venezuela, Panama, Costa Rica, and the Dominican Republic showed annual reduction rates lower than 2%.

Table 1. Under-Five Mortality Rate, Infant Mortality Rate, and Neonatal and Post-Neonatal Mortality Rate (/1000 Live Births). Latin American Countries, 1990, 2000, 2015

Country

Under-Five Mortality Rate

Infant Mortality Rate

Neonatal Mortality Rate

Post-Neonatal Mortality Rate

1990

2000

2015

1990

2000

2015

1990

2000

2015

1990

2000

2015

Argentina

28.8

19.4

11.6

25.5

17.3

10.3

14.8

11.2

6.6

10.7

6.1

3.7

Belize

39.0

24.1

15.6

31.7

20.4

13.4

19.6

14.4

10.7

12.1

6.0

2.7

Bolivia

123.8

79.8

38.2

85.2

58.5

30.5

41.7

30.2

19.5

43.5

28.3

11

Brazil

64.2

35.8

15.7

53.4

31.3

14.0

25.7

17.1

8.2

27.7

14.2

5.8

Chile

19.1

10.9

8.4

16.0

9.2

7.3

8.6

5.7

5.4

7.4

3.5

1.9

Colombia

35.1

25.0

15.8

28.9

21.2

13.6

17.6

13.7

8.7

11.3

7.5

4.9

Costa Rica

16.8

12.9

9.1

14.3

11.1

7.9

8.9

7.6

6.0

5.4

3.5

1.9

Cuba

13.3

8.3

5.6

10.6

6.4

4.3

6.8

4.2

2.4

3.8

2.2

1.9

Dominican Rep.

59.9

41.0

31.5

46.3

33.1

26.1

24.7

23.7

21.3

21.6

9.4

4.8

Ecuador

56.7

34.5

21.5

44.1

28.4

18.3

24.4

17.2

11.5

19.7

11.2

6.8

El Salvador

59.6

32.5

15.5

46.1

26.9

13.3

23.0

14.5

7.8

23.1

12.4

5.5

French Guiana

13.5b

12.8

10.2a

12.4

8.2

9.0

5.4

5.6

2.8

Guadaloupe

9.8d

7.3a

6.7

8.4

4.3

6.6

2.4

1.8

Guatemala

81.8

51.9

29.5

60.4

40.8

24.6

28.7

21.2

14.4

31.7

19.6

10.2

Haiti

144.9

104.5

68.9

100.4

74.8

52.2

38.9

30.4

25.0

61.5

44.4

27.2

Honduras

58.1

37.3

19.4

45.1

30.5

16.6

21.9

17.4

10.8

23.2

13.1

5.8

Martinique

9.3c

9.0

6.8a

7.5

8.2

6.6

2.7

Mexico

45.7

26.8

15.0

36.5

22.5

12.9

22.3

12.9

7.8

14.2

9.6

5.1

Nicaragua

67.5

40.4

20.3

51.3

32.7

17.3

23.9

17

9.1

27.4

15.7

8.2

Panama

31.0

26.0

16.9

25.8

21.9

14.5

17.6

15.2

9.9

8.2

6.7

4.6

Paraguay

46.6

33.6

20.6

37.1

27.7

17.6

22.1

17.5

11.5

15.0

10.2

6.1

Peru

80.4

38.5

16.0

56.7

29.5

12.4

28.0

16

7.8

28.7

13.5

4.6

Puerto Rico

8.8b

7.9

12.7a

9.9

7.1

6.3

5.0

2.5

2.1

Uruguay

23.4

17.0

9.3

20.6

14.8

8.0

12.2

8.4

5.1

8.4

6.4

2.9

Venezuela

29.7

21.7

16.6

24.8

18.5

14.3

12.8

12

10.5

12.0

6.5

3.8

Latin America

55.3

33.4

18.1

43.8

27.7

15.3

22.7

15.6

9.4

21.1

12.1

5.9

North America

10.9

8.2

6.5

9.2

7.0

5.6

5.7

4.5

3.8

3.5

2.4

1.8

OECD members

21.4

13.0

7.2

17.1

10.8

6.1

10.3

6.6

3.9

6.8

4.2

2.2

World

93.4

77.5

42.2

64.8

53.9

31.4

36.8

30.7

19.1

28.0

23.2

12.3

Notes: (a) 1995;

(b) 2005;

(c) 2010;

(d) 2013.

Source: The World Bank Data. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, The World Bank, UN DESA Population Division) and Pan American Health Organization (PAHO), Health Information Platform for the Americas (PLISA).

Despite the reduction, the 1990–2015 map of the change in the under-five mortality rate in the world shows that only a few Latin American countries (Chile, Costa Rica, Cuba, Uruguay) have achieved mortality levels similar to those observed in high income countries, while the majority of the region lags well behind (Table 1 and Figure 3).

Child Health in Latin America

Figure 3. Under-five mortality rate, 1990 and 2015.

Source: The World Bank Data. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population Division).

Infant Mortality Rates

Most deaths occurring during childhood are concentrated in the first year of life, especially in the first month of life (Table 1). In 2015, all LA countries presented higher rates in the neonatal than in the post-neonatal period, except for Haiti. In LA, the neonatal mortality rate was 9.4 per 1,000 LB, almost twice the post-neonatal mortality rate, of 5.9 per 1,000 LB. The high proportion of deaths occurs during the early neonatal period evidences the importance of factors related to gestation, delivery, and postpartum, generally preventable through quality health care (Lansky, Franca, & Kawachi, 2007).

The infant mortality rate declined from 43.8 infant deaths per 1,000 live births (LV) in 1990 to 27.7 in 2000, and to 15.3 in 2015 (Table 1). Annual rates of decline were 3.7% in the 1990s, decreasing to 3.0% in the period 2000–2015. In the latter period, the decline in neonatal mortality (2.7% per year) was smaller than the decline in post-neonatal mortality (3.4%), and neonatal deaths accounted for more than 60% of all infant deaths.

In addition, the intraregional inequality in infant mortality rates (IMR) decreased over the period 1990–2015. In 1990 the group of countries in the worst quintile had a median IMR 4.8 times higher than the countries in the best quintile—ranging from 15.2 to 72.8 per 1,000 live births (LB). By 2015, the ratio of the worst to the best quintile decreased to 3.7, with median IMR varying from 7.6 to 28.3 per 1,000 LB. In 1990 as well as in 2015, Cuba, Chile, Costa Rica, and Uruguay were in the lowest IMR quintile. Peru and El Salvador had such a significant drop in infant mortality rates that they moved from the worst quintile in 1990 to the second-lowest IMR quintile in 2015. Bolivia, Guatemala, and Haiti remained in the group of countries with the highest IMR.

In terms of infant mortality variation by per capita Gross Domestic Product (GDP) in LA countries, the graphic presented in Figure 4 shows the strong correlation between the two indicators. Some countries in the region, such as Bolivia, Dominican Republic, Ecuador, Guatemala, and Panama, are situated above the line, with higher rates than expected according to their GDP per capita. On the other hand, poor countries such as Honduras and Nicaragua have IMRs lower than expected, which can be a reflection of investments made in health care and social programs in these countries (Figure 4).

In Nicaragua, despite the greater reduction in mortality and inequality in urban areas, under-five mortality in all areas has declined at a rate sufficient to achieve the Millennium Development Goals (Pérez et al., 2014). In Guatemala, which is one of the least developed countries in Latin America, specific health initiatives have been implemented in rural areas and indigenous communities with community facilitators performing health prevention, promotion, and care. As well as the achievement of important growth in medical consultations, the project has shown significant decreases in maternal and child mortality (Martínez-Fernández et al., 2015). Cuba’s position well below the regression line evidences its remarkable achievement (Panel 1) even when compared to other countries with similar GDP per capita.

Child Health in Latin America

Figure 4. Infant mortality rate by Gross Domestic Product (GDP) per capita (log-log) 2015.

Source: The World Bank Data through Gapminder.

Time trends of socioeconomic inequalities in infant mortality were analyzed in selected countries. The inequalities are represented in the equiplot (Figure 5), where rates are shown by wealth quintiles in two different years during the period 1990–2015, the oldest and the most recent year with available DHS data. In all countries except for Haiti, there were reductions in absolute inequalities, expressed as the difference in IMR between poor and rich. Progress in terms of relative inequalities—the ratio of IMR between poor and rich—was mixed, however. In Peru, there is a clear reduction in relative inequities over a period of approximately 20 years, with the IMR decreasing faster in the poorest than in the wealthiest quintile. In Colombia, the inequality reduction occurred to a lesser extent between 1990 and 2010, but the inequality ratio increased from 1.7 to 2.5, meaning a largest reduction among the wealthiest. In the Dominican Republic and Bolivia, the reduction in inequality was not clear, with infant mortality in the three poorest quintiles still far apart from the first two. In Haiti, between 1991 and 2012, the IMR mostly decreased in the wealthiest quintile, and therefore the IMR inequality increased.

The significant reduction of inequality in Peru is noteworthy and is the most likely explanatory factor for the remarkable IMR drop in this country since the 1990s (Huicho et al., 2016). Peru’s progress has been attributed to a comprehensive, multisectoral, antipoverty agenda with child health and nutrition goals as explicit indicators for progress. On the other hand, the worst performance was found in Haiti, probably due to the many difficulties experienced in this period, such as conflicts and earthquakes.

Child Health in Latin America

Figure 5. Infant mortality rate by wealthy quintiles in selected LA countries.

Source: The World Bank Data. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population Division).

Causes of Death Among Under-Five Children

To identify the main causes of childhood mortality in the LA region, the cause-specific mortality rates were based on the estimates of deaths and live births after the redistribution of ill-defined causes and non-specific causes of death (garbage codes) and correction of classification errors for HIV/AIDS according to the Global Burden of Disease methodology (Global Burden of Disease, 2016).

Figure 6 shows the main causes of mortality in under-five children in 1990 and 2015. The main causes of death changed in important ways. Part of this change was the result of a considerable reduction in mortality rates due to respiratory infections and diarrheal diseases, which in 1990 represented the two main causes of death in under-five children and in 2015 moved to third and seventh in the rankings, respectively. Congenital anomalies, the fourth main group of causes in 1990, became the main group in 2015. Prematurity was the second most significant cause of death in 2015, but the mortality rate due to prematurity declined in the period analyzed. On the other hand, neonatal sepsis had only a small decline and moved from seventh position in 1990 to fifth in 2015.

Childhood mortality due to malnutrition moved from sixth position in 1990 to ninth in 2015. There was also a decline in the mortality rate due to meningitis, which ranked 10th in 2015, whooping cough, which was in 17th position and moved to 20th, and other infectious diseases such as sexually transmitted diseases excluding HIV, ranked 11th in 1990 but moving to 14th in 2015.

In addition, among the first 20 rankings of under-five causes of death in 2015, there are some external causes; aspiration of foreign bodies, traffic accidents, drowning, and interpersonal violence, which were classified in 8th, 11th, 12th, and 15th positions, respectively. As infectious causes of death are reduced, further prevention of child mortality will require strategies aimed at reducing injuries.

Regarding foreign body aspiration, prevention solutions are largely dependent on public policies regulating the safety of toys, such as legislation banning unsafe products or warning labels with the specific hazard description. Another strategy is launching educational campaigns to promote adult awareness of the risk of food or nonorganic product aspiration. Those interventions should be in line with health care, especially at the primary-care level, by raising awareness of the seriousness of the problem by health-care providers, and the indications for bronchoscopy when necessary (Lluna et al., 2017). As to road injuries, legislation concerning speed control, alcohol consumption, and adequacy of children’s vehicular transportation have been shown to be effective at reducing deaths due to road traffic accidents among children (García et al., 2014), and strategies should be strengthened to reduce the still high number of deaths.

Child Health in Latin America

Figure 6. Under-five mortality rates (per 1000 live births) for leading causes of death. Latin America, 1990 and 2015.

Source: Based on death and live birth data from the LA and Caribbean region of the GBD2015 study.

Diseases Preventable by Immunization

From Edward Jenner’s early studies of smallpox vaccination in the second half of the 18th century to the 21st century, vaccines significantly reduced deaths from infectious diseases worldwide and are estimated to be responsible for an increase of more than 10 years in the average life expectancy in the 20th century (Andre et al., 2008).

One of the milestones in combating vaccine-preventable diseases was the implementation of the Expanded Program on Immunization, approved by the World Health Organization (WHO) Council in 1974. The program established global guidelines in the area and encouraged the development of new vaccines leading to eradication or near eradication of various diseases. By 2015, 116 million children worldwide had received three doses of diphtheria, tetanus, and pertussis vaccine, and annually 2 to 3 million deaths from these diseases are prevented by the availability of vaccines.

The success of national immunization programs in the Americas is particularly evident. In 1970, when the Pan American Health Organization (PAHO) convened the International Conference on Vaccines against viral, rickettsial, and bacterial diseases, vaccine coverage was less than 10% for diphtheria, pertussis, and tetanus (DPT), BCG, and poliomyelitis. Today, the average coverage is between 80% and 90%, and Latin America is widely regarded as a global success story for immunization coverage with a similar performance to that of developed countries (Table 2).

The analysis of population coverage for DPT, BCG, measles, and poliomyelitis in selected countries in Latin America shows that while there have been various successful policies implemented over the years, difficulties to maintain a high coverage over time remain. In 2005, 60.8% of the 23 countries analyzed had coverage greater than 90% for DPT (Table 2). Some countries such as Haiti and Bolivia, despite not reaching the 90% goal, had considerable growth in DPT coverage between 2005 and 2015. However, some countries that started out with high DPT coverages dropped to below 90% in 2015 (Mexico, Ecuador, Guatemala, and Honduras). Guatemala and Honduras also had a decline in BCG and anti-polio coverages between 2005 and 2015. Currently, almost all countries except Ecuador, Honduras, and Haiti have met the 90% coverage goal for measles vaccine.

Table 2. DPT, BCG, Anti-Polio and Anti-Measles Vaccination Coverage

Country

DPT

BCG

Anti-Polio

Anti-Measles

2005

2015

2005

2015

2005

2015

2005

2015

Argentina

100.0

94.0

100.0

95.0

93.0

100.0

89.0

Belize

96.0

94.0

98.0

96.0

94.0

95.0

96.0

Bolivia

85.0

89.0

88.0

99.0

84.0

88.0

89.0

95.0

Brazil

96.0

96.0

100.0

100.0

98.0

98.0

100.0

96.0

Chile

91.0

96.0

95.0

93.0

92.0

96.0

90.0

96.0

Colombia

93.0

91.0

94.0

90.0

93.0

91.0

94.0

94.0

Costa Rica

91.0

92.0

88.0

83.0

91.0

92.0

89.0

93.0

Cuba

100.0

100.0

99.0

99.0

100.0

98.0

98.0

100.0

Dominican Rep.

87.0

85.0

100.0

100.0

86.0

87.0

100.0

90.0

Ecuador

94.0

78.0

100.0

88.0

93.0

84.0

93.0

84.0

El Salvador

89.0

91.0

89.0

92.0

99.0

95.0

French Guiana

Guadaloupe

Guatemala

92.0

74.0

97.0

89.0

92.0

84.0

95.0

99.0

Haiti

68.0

72.0

62.0

72.0

65.0

76.0

59.0

64.0

Honduras

98.0

85.0

98.0

88.0

98.0

85.0

96.0

87.0

Martinique

Mexico

98.0

87.0

99.0

100.0

98.0

87.0

96.0

100.0

Nicaragua

88.0

100.0

100.0

100.0

87.0

100.0

96.0

100.0

Panama

88.0

73.0

100.0

100.0

90.0

72.0

99.0

100.0

Paraguay

87.0

80.0

88.0

84.0

87.0

80.0

90.0

Peru

89.0

90.0

93.0

91.0

85.0

88.0

80.0

92.0

Puerto Rico

Uruguay

96.0

95.0

100.0

98.0

96.0

95.0

95.0

95.0

Venezuela

87.0

87.0

95.0

99.0

80.0

87.0

76.0

92.0

Latin America (*)

93.6

90.1

92.7

92.7

North America (*)

95.8

94.6

92.2

91.8

OECD members (*)

95.5

94.4

92.9

94.5

World (*)

78.0

85.3

77.8

84.7

Source:Pan American Health Organization (PAHO). Health Information Platform for the Americas (PLISA). The World Bank Data. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF. WHO. The World Bank. UN DESA Population Division).

Due to successful Immunization Programs in Latin America countries, some vaccine-preventable diseases have been eliminated from the region. In 1994 the International Commission for Certification of the Eradication of Poliomyelitis declared that the Americas have interrupted transmission of wild poliovirus; this victory was attributed in large part to the implementation of national polio vaccination day for under-five children. As the poliovirus is not eradicated in all continents, it is important to routinely maintain high coverage of oral poliovirus vaccine (Levine, 2007).

In September of 2017, the Pan American Health Organization declared measles was eliminated within the Americas as well. On the other hand, transmission of pertussis is still active. Despite the decline in pertussis incidence in recent years, numerous outbreaks of the disease have been reported (McCormick & Czachor, 2013).

In 1989, the WHO launched the Neonatal Tetanus Elimination Initiative to reduce the numbers of cases to a level in which the disease would no longer be a major public health problem. Although tetanus cannot be eradicated due to the presence of spores in the environment, tetanus can be reduced through immunization of reproductive-age and pregnant women, promotion of clean delivery practices, and treatment of the umbilical stump. After drastic reduction of neonatal tetanus cases since the late 1980s, the goal of less than one case of neonatal tetanus per 1,000 live births in every district of priority countries has recently been achieved in Latin America. This achievement was documented in September 2017 by PAHO.

Mother-to-Child Transmission Diseases

Infectious diseases can be transmitted from mother to fetus during pregnancy, delivery, and breastfeeding. Among them, syphilis, HIV, and Zika virus are of great concern due to their impact on perinatal outcomes. Untreated maternal syphilis is associated with negative outcomes, represented by foetal losses, neonatal deaths, preterm newborns, or low birth weight (Newman et al., 2013). Mother to child transmission (MTCT) of HIV, which may happen during pregnancy, childbirth, and through breastfeeding, is the main cause of childhood infections (WHO, 2014). Microcephaly and other central nervous system malformations, placental insufficiency, intra-uterine growth restriction, intra-uterine fetal death, and spontaneous abortion have been reported as potential outcomes of Zika virus infection during pregnancy (WHO, 2016).

It is estimated that globally in 2012, 950,000 pregnant women were infected with syphilis (WHO, 2014), with 7.8% of world cases concentrated in the American region (Newman et al., 2013). In 2013, there were still more than 1.4 million (1.3 million to 1.6 million) pregnant women with HIV in low- and middle-income countries with 1% of children who were newly infected with HIV in the region of the Americas (WHO, 2014). The first case of Zika virus in the continental region of the Americas was reported in May 2015 in the northeast of Brazil, and the causal link with microcephaly was rapidly suggested by Brazilian researchers (Schuler-Faccini et al., 2016). As of March 2017, 48 countries and territories in the region of the Americas have reported autochthonous, vector-borne transmission of the Zika virus, and 23 countries and territories have reported cases of congenital syndrome associated with Zika infection (Etienne, Santos, & Espinal, 2017). The epidemic Zika virus in the Americas and the severe effects of mother-to-child transmission have led the World Health Organization to declare a state of international emergency (Panel 2).

Chikungunya virus was confined in the African and Asian continents until 2013, when it was introduced in the Latin Caribbean and established the first human cycle in the Americas. Subsequently, cases of autochthonous transmission were reported in South and Central America, with fast spread in the LA region around late 2014 (Weaver & Forrester, 2015). The occurrence of the Chikungunya virus during pregnancy is of additional concern, due to the possibility of vertical transmission and fetal involvement, progressing to neonatal encephalopathy and microcephaly in a few cases (Marinho, Cunha, Amim, & Prata-Barbosa, 2017). A two-year follow-up study of children exposed to the Chikungunya virus during the perinatal period showed effects on neurocognitive development (Gérardin et al., 2014).

MTCT of both syphilis and HIV infection can be prevented through timely screening and treatment of pregnant women during antenatal care. The last Pan American Health Organization (PAHO) report on the progress toward elimination of syphilis and HIV in the Americas has shown improvement in antenatal care coverage in testing for HIV, in use of antiretroviral therapy during pregnancy, and in screening for syphilis; meanwhile, the syphilis treatment coverage has been stagnant since 2011. In line with the reported progresses for HIV screening and treatment, the rate of MTCT of HIV in Latin America decreased 53%, from 15% (11% to 20%) in 2010 to 8% (6% to 10%) in 2015 and the number of new HIV infections in children aged 0 to 14 years declined by 55% between 2010 and 2015. On the other hand, there is a growing rate of congenital syphilis of 1.7 per 1,000 live births in 2015 influenced by Brazil’s growing rates. In 2015, Brazil accounted for 85% of the estimated regional cases. The regional congenital syphilis rates are stable since 2009 when Brazil is excluded from the analysis. In 2015, 18 countries in the region reported data indicating the elimination of both MTCT HIV and syphilis. In 2015, Cuba became the first country in the world to receive validation from the WHO of the elimination of mother-to-child-transmitted HIV and syphilis. Table 3 presents the indicators for the elimination of MTCT of HIV and syphilis in Latin America.

Table 3. Indicators for the Elimination of Mother to Child Transmission of Syphilis and HIV, Latin America, 2015

Countries

% Pregnant Women Tested for

% ART to Prevent the MTCT of HIV

% Pregnant Women Treated for Syphilis

HIV MTCT Rate (2013–2014)

Pediatric HIV Rate Per 1,000 lb

Congenital Syphilis Rate Per 1,000 lb

HIV

Syphilis

Reported

UNAIDS estimates

Argentina

>95

78c

93

93

82

4.5c

0.06c

1.21

Belize

82

93b

>95c

63

91b

0.0c

0.00c

0.00b

Bolivia

>95

>95

63c

76

>95

19.3c

0.10c

Brazil

84

90b

87

>95

86

4.4c

0.09c

6.49

Chile

79

95c

>95

93

2.7c

0.02c

0.17c

Colombia

55

62

87

49

94c

3.8

0.03

1.24c

Costa Rica

>95

85

82

41

73a

6.4c

0.04c

0,64

Cuba

>95

>95

>95

>95

>95

1.9

0.03

0.04

Dominican Rep.

49

17c

50c

72

68

5.1

0.24

0.07b

Ecuador

58

60

El Salvador

69

>95

55

56

1.3

0.02

0.20

French Guiana

Guadeloupe

Guatemala

40

21c

13

>95c

4.6

0.01

0.01

Haiti

94

88

96

88

5.6

0.79

Honduras

>95

57c

50

53

>95c

2.8

0.02

0.27

Martinique

Mexico

55

61c

81c

76

0.06

Nicaragua

>95

88c

76

>95

>95

3.5

0.03

0.06

Panama

>95

33c

78

61

3.3

0.09

1.10

Paraguay

60

69

56

57

3.8

0.02

2.90

Peru

74

85

86c

79

83

7.5b

0.07b

0.34

Puerto Rico

>95b

0.0b

0.00

0.14

Uruguay

>95

>95

>95

>95

>95c

2.9c

0.08c

1.97c

Venezuela

27

28b

43

0.05b

PAHO and WHO Elimination Goals

≥ 95

≥ 95

≥ 95

≥ 95

≥ 95

≤ 2

≤0.3

≤ 0.5

Notes: (a) 2011,

(b) 2013,

(c) 2014.

Source: Pan American Health Organization. Elimination of Mother-to-Child Transmission of HIV and Syphilis in the Americas. Update 2016. Washington, DC (PAHO, 2017).

Despite the progress, failures of syphilis and HIV screening during pregnancy persist. Testing is a vital first step for identifying infected women and linking them into care. There are still about 2.7 million pregnant women in Latin America who did not receive any tests for syphilis during pregnancy and 3.1 million pregnant women who did not have access to an HIV test in 2015. Other barriers include the late access or lack of access to antenatal care, mainly affecting the most vulnerable groups; limited use of rapid tests at the point of care, syphilis reinfection of pregnant women due to the lack of treatment of intimate partners, and shortages in treatment provision in primary health care to pregnant women and their partners. For Zika and Chikungunya virus infection control, the main challenges are related to vector control, access to reproductive services, and access to health and social services for mother and children affected by the disease.

Early Childhood Development

Due to the significant reduction in under-five mortality, focus is gradually moving to other emerging issues, including public policies that enable children to develop to their full potential. Efforts and resources are being invested into promoting intellectual, emotional, and social early child development.

In some Latin American countries, children face enormous challenges to achieve full development. Many of these children live in poor conditions, often associated with social disadvantage and vulnerability such as exposure to violence, abuse or neglect, abandonment, among others (Walker et al., 2011). These barriers are reflected in the larger percentage of children living in extreme poverty as compared to older age groups, because the elder are those who have survived and experienced social protection (Rossel, 2013).

Since the beginning of the year 2000, the life-course approach has been recognized as an essential framework for understanding adult health. Twenty-first-century studies have reached the consensus on the importance of early childhood development for improving health and reducing health disparities across the entire life course (Braveman & Barclay, 2009; Shonkoff, Boyce, & McEwen, 2009).

In some Latin American countries, interventions aimed at early childhood development have been in place for decades. Examples are “Educate your child” developed in Cuba in 1992 and the Chilean initiative “Chile grows with you” created in 2006 (Aulicino & Langou, 2016). In other Latin American countries, increased child survival was the result of initiatives aligned with the Millennium Development Goals (MDGs) and other national and international agreements. Initiatives to promote child development in the region were adopted on a large scale, especially in the 21st century. Panel 3 presents a summary of interventions in the various LA countries and their main focuses (Aulicino & Langou, 2016). The greater visibility of early child development in the Sustainable Development Goals will likely help expand such programs throughout the region.

In September 2015, a group of Latin American organizations met in São Paulo, Brazil, to define a regional policy agenda for early childhood development. One of the central themes of the agenda was the need to adopt a participatory approach in the definition of goals and monitoring indicators. The agenda also included the need to support families by creating new or strengthening existing national and local programs based on successful evidences or actions recognized as best practices (Aulicino & Langou, 2016). The agenda aims to stimulate leadership, cooperative spirit, and solidarity, respecting the different cultures (Temporão et al., 2010).

Final Considerations

Since the late 1990s, Latin American countries have undergone major changes in terms of socioeconomic development, urbanization, and health care. Besides economic growth, advances in national health systems and progress toward universal coverage have contributed to improve child and maternal health outcomes (Andrade et al., 2015).

Under-five mortality in LA has fallen by a third between 1990 and 2015, with sharp declines in diarrheal diseases and lower respiratory infections. Due to the successful immunization programs in Latin America, vaccine-preventable diseases such as poliomyelitis and measles have been virtually eliminated. Many LA countries have attained near universal coverage of childbirths attended by skilled personnel and have reached over 80% coverage for antenatal care, as measured by the percentage of women with four or more consultations.

However, there are still issues to be resolved. While under-five mortality rates have quickly declined in LA countries, neonatal mortality rates have shown slower progress. The concentration of newborn deaths mostly in the first hours after childbirth calls attention to the importance of extending the scope of child health indicators to address a broader set of outcomes, such as the perinatal mortality rate and the prevalence of preterm and low-birth weight newborns. Reliable data on stillbirths, gestational age, and birth weight, which are still unavailable in most LA countries, are essential to monitor pregnancy outcomes and reduce the burden of the neonatal component (Lawn et al., 2011).

In addition to the invisibility of stillbirths and circumstances of their occurrence (Målqvist, 2011; Frøen et al., 2009), underreporting of live births and children deaths in deprived areas has been documented in Mexico (Hernández et al., 2012) and Brazil (Szwarcwald et al., 2014). Yet, the lack of reliable information on vital events is usually associated with inadequate health care resulting from sociocultural and geographical barriers at community levels and unequal provision of health resources (Victora, Rubens, & GAPPS Review Group, 2010). A proactive search of infant deaths was conducted in rural areas of Amazonas State, on the border between Brazil and Colombia, in 2014, designed to capture deaths not reported to the mortality information system (Almeida et al., 2017). In many of the municipalities included in the proactive search of deaths, the majority of the population lives along the rivers and is composed by acculturated indigenous people. The difficulties in transportation (which is exclusively by boat), the lack of infrastructure, and the extreme climatic conditions of high temperatures and rainfall result in a scenario of geographic isolation in which access to health care is poor. The search for unofficial cemeteries hidden in the forests allowed the identification of several burial sites previously unknown to health authorities (Figure 7).

Child Health in Latin America

Figure 7. Cemetery of the indigenous community Marí-Marí, Tonantins, Amazon, Brazil.

Photo: Marcelle Lemos.

Other studies in Latin American countries have also shown that access to preventive and curative care remains inadequate in low socioeconomic settings. Indigenous women and children systematically show lower coverage with essential health interventions (Castro, Savage, & Kaufman, 2015). In Argentina and Ecuador, unequal use of antenatal care mostly explained ethnic and socioeconomic inequalities in preterm births (Wehby, Pawluk, Nyarko, & Lopez-Camelo, 2016). In Brazil, late access or inadequate antenatal care limits the uptake of syphilis tests during pregnancy, increasing the chance of congenital syphilis and avoidable stillbirths and neonatal deaths (Domingues & Leal, 2016).

Continued failures to address gaps in access to immunization have been documented as well (Velandia-González et al., 2015). Recent studies in Colombia and Guatemala found that the majority of the population considers vaccines important and effective but identified a range of barriers pointing to the need for tailored interventions to improve routine vaccine coverage and achieve universal immunization (García et al., 2014; Barrera et al., 2014).

Considerable evidence supports the expansion of primary health care as a crucial step for progress toward maternal and child universal health coverage. Improvements are obtained by providing essential care to mothers and newborns in the community at primary care facilities while addressing the social determinants of health (Macinko & Harris, 2015). In Brazil, in the late 1990s, the Family Health Strategy was implemented as a national policy for primary care, giving priority to deprived municipalities, especially those located in the less developed regions (Paim, Travassos, Almeida, Bahia, & Macinko, 2011). The expansion of primary care in disadvantaged areas showed important impacts such as the significant reduction in the historic regional gap in infant mortality rates (Szwarcwald et al., 2014) and the decrease in under-five mortality rates due to ill-defined causes and unattended deaths (Rasella, Aquino, & Barreto, 2010). The impact of the Family Health Strategy on child mortality has shown to be even stronger when taking into account the combined effect of Bolsa Familia—the main conditional cash transfer (Panel 4) in Brazil (Bastos, Menzies, Hone, Dehghani, & Trajman, 2017).

In contrast, institutional deliveries have become part of LA culture, bringing about an important discussion on the excessive medicalization of childbirth. Latin America in the 21st century has the highest cesarean rate in the world (Boatin et al., 2018) with an excess of cesarean sections without medical indication, which have been associated with increased preterm and early term rates (Betran et al., 2016; Leal et al., 2016), leading to harmful effects on child health and development (Magne, Puchi Silva, Carvajal, & Gotteland, 2017).

Another problem to be faced by the LA region is the dual burden of malnutrition during childhood (Galicia et al., 2016). Regarding breastfeeding, coverage of exclusive breastfeeding in the first six months is far below the WHO´s goal of at least 50% in many countries. At the same time, consumption of unhealthy foods starts early, and prevalence of obesity in childhood is increasing (Jaime et al., 2016). Because of the established health risks of obesity and of the strong association between weight gain after two years of life and adult obesity (Adair et al., 2013), concern on the rise of childhood obesity in Latin America is growing. In response, many countries are implementing obesity prevention programs aimed at modifying known risk factors. There is a clear need to establish the current state of the problem, to monitor and evaluate ongoing interventions, and to document successful strategies to support the development and implementation of effective actions across the region (Caballero, Vorkorper, Anand, & Rivera, 2017).

Although the advances in the public agenda aimed at promoting child health and development in Latin American countries in recent years are undeniable, weaknesses persist with important gaps and inequalities in the region and challenges are no less significant. The latter include the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support socially disadvantaged families. When planning interventions, knowledge and experience should constitute the basis for implementing effective evidence-based programs, and patterns of inequality should be taken into account to make sure the resources are targeted to the most deprived populations (Bryce, Victora, & Black, 2013). It is necessary to focus on overcoming inequities by creating strategies to guarantee children’s rights to a healthy, safe, and protected life, with access to basic needs such as education, adequate nutrition, housing, and health care.

Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health care is at the heart of sustainable development and must be an absolute priority.

Further Reading

Colchero, M. A., Salgado, J. C., Unar-Munguía, M., Molina, M., Ng, S., & Rivera-Dommarco, J. A. (2015). Changes in prices after an excise tax to sweetened sugar beverages was implemented in Mexico: Evidence from urban areas. PLoS One, 10(12), e0144408.Find this resource:

Domingues, R. M. S., Dias, M. A. B., Schilithz, A. O. C., & Leal, M. C. (2016). Factors associated with maternal near miss in childbirth and the postpartum period: Findings from the birth in Brazil National Survey, 2011–2012. Reproductive Health, 13(3), 115.Find this resource:

Dos Santos, R. R., Niquini, R. P., Bastos, F. I., & Domingues, R. M. S. M. (2017). Diagnostic and therapeutic knowledge and practices in the management of congenital syphilis by pediatricians in public maternity hospitals in Brazil. International Jounal of Health Services, 20731417722088.Find this resource:

França, G. V. A., Restrepo-Méndez, M. C., Maia, M. F. S., Victora, C. G., & Barros AJD. (2016). Coverage and equity in reproductive and maternal health interventions in Brazil: Impressive progress following the implementation of the Unified Health System. International Journal for Equity in Health, 15, 149.Find this resource:

Galicia, L., de Romaña, D. L., Harding, K. B., De-Regil, L. M., & Grajeda, R. (2016). Tackling malnutrition in Latin America and the Caribbean: Challenges and opportunities. Pan American Journal of Public Health, 40(2), 138–146.Find this resource:

GBD. (2016). Mortality collaborators: Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet, 390(10100), 1084–1150.Find this resource:

Holzmann, H., Hengel, H., Tenbusch, M., & Doerr, H. W. (2016). Eradication of measles: Remaining challenges. Medical Microbiology and Immunology, 205(3), 201–208.Find this resource:

Mikkelsen, L., Phillips, D. E., AbouZahr, C., Setel, P. W., Savigny, D., Lozano R., & Lopez, A. D. (2015). A global assessment of civil registration and vital statistics systems: Monitoring data quality and progress. Counting births and deaths 3. Series. Lancet, 386(10001), 1395–1406.Find this resource:

Victora, C. G., Requejo, J. H., Barros, A. J., Berman, P., Bhutta, Z., Boerma, T., . . . Bryce, J. (2016). Countdown to 2015: A decade of tracking progress for maternal, newborn, and child survival. Lancet, 387(10032), 2049–2059.Find this resource:

World Health Organization. (2014). Global guidance on criteria and processes for validation: elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. Geneva, Switzerland: World Health Organization.Find this resource:

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