International Center for Equity in Health The role of ethnicity as a determinant of reproductive, maternal, newborn and child health in Latin America and the Caribbean Marilia Arndt Mesenburg, with collaboration of colleagues from 16 countries International Center for Equity in Health

Background The Sustainable Development Goals (2015-2030) call for disaggregated statistics according to ethnic group Ethnicity is difficult to measure in a consistent or standardized way Three major ethnic groups in LAC region: indigenous, afrodescendants and Europeans Limited information on relation between ethnicity and coverage with reproductive, maternal, newborn and child health (RMNCH) interventions

Research questions 1) Is the coverage with RMNCH interventions different among the three major ethnic groups? 2) To what extent do the differences in terms of wealth, urban-rural residence and formal education explain the ethnic inequalities?

Data source  About 80% of the region´s population 6 Demographic and Health Surveys (DHS) 7 Multiple Indicators Cluster Surveys (MICS) 3 Reproductive Health Surveys (RHS)  We analyzed standardized national surveys carried out in 16 countries (2004 to 2015)

Outcomes: coverage with Women aged 15-49 years Modern contraceptive Antenatal care – four or more visits Skilled birth attendant Children aged 12-23 months Diphtheria, tetanus, and pertussis vaccine (DPT)

Stratification variable Ethnicity Three broad categories Self reported ethnic affiliation, language or skin color Indigenous Afrodescendants Reference category (European descendants, mixed ancestry, etc.) Mediating variables Wealth quintiles Urban-rural residence Women´s education (none, primary or secondary+)

Analysis Individual level Descriptive analysis Crude and adjusted coverage ratios Ethical approval Obtained by the national agencies responsible for each survey CR = indigenous coverage reference coverage CR = afrodescendants coverage reference coverage

Indigenous people are disadvantaged In general, indigenous women and children were poorer more rural received less formal education Median coverage ratio for indigenous Indicator Crude Adjusted Modern contraceptive 0.82 0.85 Antenatal care 0.86 0.89 Skilled birth attendant 0.75 0.90 DPT vaccine 0.95 0.96

Lower coverage among indigenous women in several countries

Similar coverage for DPT vaccination in indigenous children

Afrodescendants: less marked inequalities Median coverage ratios for afrodescendants differences were less marked than for indigenous Indicator Crude Adjusted Modern contraceptive 0.94 Antenatal care 0.96 0.98 Skilled birth attendant 1.00 0.99 DPT vaccine

Limitations Use of three self-reported variables as proxies of ethnic group affiliation Language information hides afrodescendants The reference group varied from country to country and includes many women and children with mixed European, indigenous and African ancestries Use of a single indigenous category Analyses restricted to interventions available for many years, that have reached high coverage in most countries

Summing up Important gaps in RMNCH coverage according ethnic group Marked variability among countries precluded meta-analysis The gaps persist after adjustment for socioeconomic factors Inequalities for afrodescendants are less marked than for indigenous Continued monitoring of ethnic inequalities assessing the impact of inclusive policies guiding future policy and implementation initiatives

Thank you mmesenburg@equidade.org