Abstract
In 2020, the Brazilian federal government launched the “Prevent Brazil” program to incentivize cities to improve their performance across 7 health care indicators, including prenatal dental care. Our study examines the impact of this policy on the use of oral health care among pregnant women in Brazil. We used a series of cross-sectional data from the Brazilian Public Health System from 2018 to 2023. We linked publicly available data from the Brazilian Ministry of Health and the Brazilian Institute of Geography and Statistics. Our outcome was the proportion of pregnant women receiving prenatal care who had at least 1 dental visit during the past year. Covariates included city-level socioeconomic (income and literacy), demographic (gender, race, and urban areas), and workforce variables (number of dentists working in the public health system per city/year). We estimated the impact of the policy on prenatal dental visits nationwide and stratified by geographic region using interrupted time-series analysis. Our analyses included 99.9% of all Brazilian cities (n = 5,562). The use of oral health care among pregnant women increased from 15% in 2018 to 69% in 2023. Adjusted estimates show that, after initiation of the Prevent Brazil, dental care use among pregnant women increased nationally at a rate of 4.6 percentage points per 4-mo period (95% confidence interval [CI] 4.5; 4.7). The policy’s largest impact was in the North and Northeast regions, which have the lowest socioeconomic profiles (adjusted time-series rate 5.7 [95% CI 5.3; 6.1] and 5.2 [5.0; 5.4] percent points, respectively). Our findings support the positive impact of the Prevent Brazil policy on prenatal dental care in Brazil. The policy was associated with a countrywide improvement in prenatal dental care use, with a greater impact in socioeconomically disadvantaged regions.
Keywords
Introduction
Pregnancy and childbirth are an excellent window of opportunity for health interventions since women interact more frequently with the health system, providing a chance to promote preventive health services and improve future engagements (Kerber et al. 2007). However, persistent inequities exist globally in maternal access to care and maternal outcomes between and within populations (Graham et al. 2016). In Brazil, trends from 1982 to 2015 indicate persistent income and race inequalities in maternal and child health (Matijasevich et al. 2019; Silva 2019, Wehrmeister et al. 2019). Similarly, national surveys from 1998 to 2019 indicated there were continued but decreasing disparities in health care use in Brazil, with the largest disparities in preventive health services (Coube et al. 2023).
Dental care accessibility and oral health promotion are critical during the prenatal period. Even though the causal relationship is yet to be confirmed, there is a plethora of evidence of the correlation between prenatal oral health problems, mainly periodontal disease, and later adverse outcomes, such as preterm delivery, low birth weight, and preeclampsia (Bobetsis et al. 2020; Xu and Han 2022). Furthermore, prenatal oral health promotion and education may improve oral health outcomes and the pattern of dental care of offspring (Paglia 2017; Xiao et al. 2019).
Public policies promoting prenatal dental care can benefit mother and baby. They may have lifelong effects, particularly for those facing barriers to access and use of health services, such as people from a low socioeconomic position and racialized communities. In Brazil, the Unified Health System (from the Brazilian Portuguese, Sistema Único de Saúde [SUS]) provides national free health care, including dental care. Dental care within SUS grew substantially after 2004, with the launch of the “Smiling Brazil” national policy (Pucca et al. 2015). Data from the 2019 Brazilian National Health Survey indicated that 12.7% of the Brazilian population had private dental insurance and 22.9% relied on the public system for their dental visits. In addition, there were regional and socioeconomic disparities to oral health care. While 16.5% in Southeast Brazil had their dental care in SUS, this number was higher in the Northeast region (34.9%). Similarly, those with less than primary education were more likely to rely on the public system for their dental care (42%) compared with those with tertiary education (6.2%) (Brazilian Institute of Geography and Statistics 2019). Potential barriers to accessing prenatal dental care within the Brazilian SUS include a shortage of dentists, compared with physicians and nurses, particularly in rural areas (Rodrigues et al. 2023).
The Brazilian Ministry of Health (2019) established a new financing policy for primary health care (PHC) in SUS, “Prevent Brazil.” The policy had 3 components: (1) the number and profile of the population served by the city; (2) specific strategic actions, such as Timely Health, expanding health center working hours; and (3) performance indicators. The policy did not change access or coverage, but performance indicators financially incentivize cities that meet predefined targets across 7 health care indicators. These indicators are related to prenatal care (3 indicators), chronic diseases (2 indicators), women’s health (1 indicator), and child health (1 indicator). The city’s overall performance summarizes its performance in all 7 indicators, and prenatal dental care corresponds to 20% of its overall performance score. For example, the prenatal dental care target for 2020 was set at 60%, meaning that at least 60% of women receiving prenatal care in SUS should have had a dental visit in the last year for the city to score the maximum in this performance indicator. Performance indicators are measured and reported at the city level every 4 mo (January-April, May-August, and September-December). The Prevent Brazil Policy aimed to facilitate use of those in vulnerable health and had potential to improve pregnant and prenatal oral health. This study aims to examine trends of prenatal dental care use in SUS before and after the implementation of Prevent Brazil.
Methods
Population and Data
Our unit of analysis is the city. We used a series of cross-sectional data from all 5,570 Brazilian municipalities. We linked publicly available data from the Brazilian Ministry of Health and the Brazilian Institute of Geography and Statistics (IBGE; from the acronym in Brazilian Portuguese “Instituto Brasileiro de Geografia e Estatística”).
We evaluated performance metrics of the prenatal dental care component of the Prevent Brazil policy before (years 2018 and 2019 and January-April 2020) and after its implementation (May-December 2020 and years 2021, 2022, and 2023). Because data are collected every 4 mo, we had 7 data points in the prepolicy phase and 11 data points in the postpolicy phase. Even though the policy was implemented in May 2020, the Brazilian Federal Government opted to start payments at the maximum amount for all cities as if they achieved the target goal because of the COVID-19 pandemic. The financial incentive began to reflect the city’s actual performance in 2022. The transition from the total payment to using the actual performance metrics as the indicator for funding was gradual, and prenatal dental care’s actual performance affected the funding from the second period (May-August) of 2022 forward (Brazilian Ministry of Health 2019).
Outcome
The outcome was prenatal dental care use among the population using SUS during pregnancy. We defined the use of prenatal dental care at the city level as the proportion of pregnant women receiving prenatal care in the Public Health System who had a dental visit in the past 12 mo, regardless of the reason for the visit or the procedures performed. Therefore, the outcome was calculated per city as follows:
Prenatal dental care use was collected from the Ministry of Health’s Health Information System for Primary Care (SISAB; acronym in Brazilian Portuguese; Health Information System for Primary Care 2023). We evaluated trends in prenatal dental care nationwide and stratified by region. Regions were defined based on the Brazilian Constitution (1988): North, Northeast, Midwest, Southeast, and South.
Covariates
Models were adjusted for city-level socioeconomic, demographic, and workforce variables. For socioeconomic variables, we included income and literacy. Income was measured as the proportion of households living below the federal minimum wage per month, which, at the time, was 510 Brazilian reals, the equivalent of USD 290. Literacy rate at age 10 y or older was defined as the proportion of the city’s population of that age who could write and read. For demographic characteristics, we used the sex and race distribution and the proportion of the population living in urban areas. Race was defined as the proportion of the population, per city, who self-identified as non-White (Black, mixed–Pardo, Asian, and Indigenous people). All city-level data were assessed from the 2010 national census (Brazilian Institute of Geography and Statistics 2023). We also included the number of dentists working in the public health system per city/year, using data from the National Registry of Health Facilities from the Brazilian Ministry of Health (Brazilian Ministry of Health, 2023).
Statistical Analysis
We performed a single-group interrupted time-series analysis (ITS) to evaluate prenatal dental care use in Brazil before and after the policy implementation. The ITS is a quasi-experimental approach for evaluating health interventions for population-level health outcomes (Bernal et al. 2017). The underlying trend is modeled from a time series based on sequential measures of the outcome before and after the intervention. We used linear regression models with generalized estimating equations to fit the population-averaged effects, considering the panel data at the city level. Our adjusted models can be expressed as:
where Y is the outcome, the proportion of prenatal dental care; i represents the individual cities; and t is the time. Xit is a dummy variable for the intervention (0 = before and 1 = after the intervention). In this equation, β1 captures the preintervention trend, β2 captures the level change in the outcome immediately after the intervention, and β3 captures the treatment effect over time, meaning the trend difference in the periods before and after the intervention. We also calculated postintervention trend estimates, computed with the lincom command in Stata to combine the linear parameters obtained in the main model. Our estimate of interest is the postintervention trend, which estimates the adjusted changes over time. Finally, we included vectors of state and year fixed effects; Xi represents city-level covariates (city-level income, literacy, sex, race, and urban areas distribution, and number of dentists/year) and εit is the error term (Linden 2021).
We used the Cumby-Huizinga test for autocorrelation, and our models were reestimated to account for it.
Because the policy was implemented during the COVID-19 pandemic, we excluded years 2020 and 2021 from the sensitivity analysis to test whether our main estimates would change.
In addition, we performed a falsification test using a placebo outcome. In the falsification analysis, we selected an outcome that was (1) unaffected by the Prevent Brazil policy, (2) not directly affected by the COVID-19 pandemic, (3) measured as a city-level proportion, and (4) reported during the same period as our main outcome. We used the proportion of health care facilities at the city level that provide primary care as our placebo outcome. Data on the proportion of health care facilities was from the National Registry of Health Facilities from the Brazilian Ministry of Health (Brazilian Ministry of Health).
All analyses were performed in Stata/MP. The package xtitsa was used for the ITS analysis (Linden 2021).
We used city-level, publicly available data. The project was submitted to the Institutional Review Board of Harvard University, which determined it to be not human subjects research and the data to be nonsensitive. This article follows the Strengthening the Report of Observational Studies in Epidemiology (STROBE) statement.
Results
This study includes 99.9% of all Brazilian cities (n = 5,562 out of 5,570) with complete data on all variables of interest. Table 1 presents the sociodemographic profile and prenatal oral health care use countrywide and by region. The Northeast region comprised 32.3% of all municipalities in our study (n = 1,794), followed by the Southeast (29.9%, n = 1,665), South (21.4%, n = 1,188), Midwest (8.4%, n = 466), and North (8.1%, n = 449). Descriptive statistics show high literacy in the cities, with 85.2% of the population on average being able to read and write at age 10 y. In addition, on average, three-quarters of the population of the cities lived with an income below the minimum wage. There are evident disparities by region, with the Northeast showing the worst profile of literacy and income, while the South had the best socioeconomic condition. The municipalities presented a well-balanced sex distribution, with a mean of 49.5% of women. On average, 63.8% of the population lived in urban areas, and 53.1% self-identified as non-White.
Characteristics of the Brazilian municipalities.
Prenatal dental care use in SUS, or the proportion of pregnant women receiving prenatal care in the Brazilian Public Health System who had a dental visit in the past year, increased from 15.3% in the first period of evaluation, in the beginning of 2018, to an average of 69.3% in the end of 2023 (data not shown in tables). When comparing the average pre- and postintervention, the proportion of pregnant women in SUS with a prenatal dental visit increased countrywide from 18.4% to 49.2% (Table 2). The Northeast region had the highest rates, before and after the intervention, while the Southeast had the lowest use rates in both periods.
Outcome trends before and after the Intervention.
Data were collected in 4-mo periods, totaling 7 data points in the prepolicy phase and 11 in the postpolicy phase.
SUS, Brazilian Unified Health System, from the acronym in Brazilian Portuguese “Sistema Único de Saúde.”
Proportion of pregnant women receiving prenatal care in SUS who had a prenatal dental visit.
After initiation of Prevent Brazil, dental care use among pregnant women increased nationally at a rate of 4.6 percentage points per period (95% confidence interval [CI] 4.5; 4.7), as shown in Table 2. Prior to the implementation of the policy, prenatal oral health care was already on a slightly upward trend, increasing at a rate of 0.9 percentage points (95% CI 0.8; 1.1) per 4 mo. However, the periodic trend showed a consistent increase of 3.7 (95% CI 3.5; 3.9) per 4 mo in the postpolicy period, compared with the prepolicy trend. In the first period after implementation, May to August 2020, there was a decrease in prenatal dental care coverage countrywide and in all but the Midwest region.
Figure 1 displays findings from the interrupted time-series analysis in prenatal dental care use nationally and by region before and after the policy implementation. The policy’s largest impact was observed in the North and Northeast regions, with the adjusted rates increasing periodically at a rate of 5.7 (95% CI 5.3; 6.1) and 5.2 (5.0; 5.4) percent points, respectively (also in Table 2). Comparatively, the time-series rate in the Midwest region was 5.1 points (95% CI 4.6; 5.6) every 4 mo. The Southeast and South regions benefited the least by the policy, with adjusted time-series rates of 3.7 (95% CI 3.5; 4.0) and 4.3 percentage points (95% 3.9; 4.6), respectively.
Prenatal oral health care use in Brazilian municipalities before and after the implementation of the Prevent Brazil policy, countrywide and by region. A. Countrywide; B. North; C. Northeast; D. Midwest; E. Southeast; F. South.
Figure 2 and Appendix Figure 1 represent the geographical distribution of the outcomes in the periods before and after the policy implementation and the city-level covariates. Clear disparities were observed in the income, literacy, and race covariates, with the North and Northeast regions concentrated with cities with lower incomes and lower literacy rates as well as with more people self-identified as non-White. The expansion in prenatal dental care coverage over time is also evident from the maps.
Distribution of the prenatal dental visits at the city level.
Appendix Tables 2 and 3 presents the results from the sensitivity and the falsification analysis. A significant improvement in prenatal dental care was observed countrywide and in all regions in the postpolicy trend, even after excluding the COVID-19 period. In addition, a very small increase was identified in the period-adjusted change for the falsification analysis, and the postpolicy trend for the placebo outcome did not show any difference when compared with the prepolicy trend.
Discussion
Using a quasi-experimental approach and national data from 5,562 Brazilian municipalities, our findings suggest that the Prevent Brazil policy was associated with improved use of oral health services among pregnant women, particularly in the North and Northeast regions, which had the lowest socioeconomic conditions. Public policies such as Prevent Brazil can mitigate socioeconomic inequities in health for the historically socially disadvantaged population served by SUS, contributing toward equity in health care use in Brazil.
The divisions in Brazilian regions are historical and are more than just geographic. The Northeast region, followed by the North region, has the lowest gross domestic product per capita, and their cities have the lowest Human Development Index on average. In contrast, the Southeast and South have the best socioeconomic profile (United Nations Development Programme 2016). This pattern is also observed in health, including health care coverage, and health-related public expenses. It is encouraging that prenatal dental care use increased nationally and in the Northern regions at higher rates, indicating that the Prevent Brazil public policy contributed toward reducing inequities in Brazil.
The Brazilian National Health Survey data indicated that more than 70% of pregnant Brazilian women had most of their prenatal health visits at a public health facility (Brazilian Institute of Geography and Statistics 2019). In Brazil, Black women use SUS for their prenatal care more often (84.1%) than White women do (58.9%) (Lessa et al. 2022). Providing universal health coverage is a core mechanism to promote equity but is not sufficient to address socioeconomic inequities in prenatal dental care (Silva et al. 2020). Addressing the deeply rooted causes of maternal health inequities requires multiple and sustained interventions at every level (Crear-Perry et al. 2021).
To fully maximize the potential benefits of early life interventions, it is crucial to embrace an integrated approach that optimizes the health of mother and baby (Kinney et al. 2016). Connecting the delivery of health services to both mother and offspring could increase efficiency, reduce the duplication of resources, and affect the quality and continuity of care (Kerber et al. 2007). The integrated approach of Prevent Brazil may provide pregnant women with comprehensive care, because ideally, they would be cared for by all health professionals in the same health care facility, promoting collaboration between providers and facilitating women’s participation. This may also build trust and improve the relationship between the family and the health care personnel, improving maternal and child postnatal care.
Significant disparities were observed between cities, with some achieving excellent prenatal dental care use, while others had minimal reach. These disparities are similarly observed in other countries, even those with different health care systems. In the United States, for example, there is a concern about areas that lack maternity care resources (Noursi et al. 2021). Qualitative and quantitative studies sharing successful strategies from cities performing well can inform other cities and future policies. Further studies should also evaluate the adequacy and quality of the care provided since it is paramount to ensure that the maternity care offered is of the highest quality and delivered in a respectful, culturally competent manner (Crear-Perry et al. 2021). Furthermore, even though we expect this facilitated use of oral health care to affect maternal and child health outcomes positively, this is beyond the objectives of this research project. Future studies should investigate the effects of improved prenatal dental care in general and of Prevent Brazil specifically on perinatal and later health outcomes.
The Prevent Brazil policy was introduced in November 2019. However, it was implemented in May 2020, which coincided with the COVID-19 pandemic. COVID-19 affected all aspects of health care, particularly preventive care and populations at increased risk for severe illness from COVID-19, such as pregnant women (National Center for Immunization and Respiratory Diseases et al. 2022). In Brazil, there was a greater than 95% decrease in the number of preventive dental procedures performed in SUS from April to August 2020, compared with the same period in 2019 (Chisini et al. 2021). Therefore, it is not possible to disentangle the effect of the Prevent Brazil policy from the impact of the pandemic on health and health care outcomes. Given the timing of the Prevent Brazil implementation, we would expect a delayed and gradual change in the trend of prenatal dental care coverage. For the same reason, an immediate improvement in the level of the outcome was not expected, and this hypothesis was confirmed by our findings.
Furthermore, our study lacked a control group, since the policy was implemented nationwide. However, we conducted a falsification analysis using an outcome unrelated to the policy and expressed as a city-level proportion. Although we observed a significant decrease in the proportion per city of public health care centers that provide primary care, the magnitude of the estimates was very small (−0.4% per 4 mo). This did not change in the postpolicy trend (adjusted postpolicy trend: 0.0).
We had information only on dental care use, without information on diagnosis, procedures, or quality of the services, which are likely to differ, given the countrywide heterogeneity in workforce profile and material infrastructure. Finally, we assessed only dental visits within the public health system. It would be relevant to also analyze trends in prenatal dental care in the private health system, but this information is not publicly available. However, our study included more than 99% of all cities in the largest and most populous country in South America, and the evaluation was stratified by the official regions.
Conclusion
Our findings suggest a positive impact of the Prevent Brazil policy on prenatal dental care in Brazil. The policy was associated with improvement in prenatal dental care use, with a greater impact in socioeconomically disadvantaged regions.
Author Contributions
H.S. Schuch, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; M. Furtado contributed to data analysis and interpretation, and critically revised the manuscript. A.C. Filho contributed to data interpretation, and critically revised the manuscript; H.W. Elani, contributed to conception, design, data interpretation, drafted and critically revised the manuscript. All authors gave their final approval and agree to be accountable for all aspects of work.
Supplemental Material
sj-docx-1-jdr-10.1177_00220345241258459 – Supplemental material for Changes in Use of Prenatal Dental Care After Brazil’s Incentive Policy
Supplemental material, sj-docx-1-jdr-10.1177_00220345241258459 for Changes in Use of Prenatal Dental Care After Brazil’s Incentive Policy by H.S. Schuch, M. Furtado, A.D.P. Chiavegatto Filho and H.W. Elani in Journal of Dental Research
Footnotes
A supplemental appendix to this article is available online.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: H.S. Schuch, M. Furtado, and H.W. Elani were supported by a pilot grant from Harvard School of Dental Medicine.
References
Supplementary Material
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