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Abstract

Background:

During the COVID-19 pandemic in Peru, primary health care services redistributed personnel to hospitals. In this context, Antenatal care (ANC) could have been limited in the general population, especially among indigenous communities.

Objective:

To determine differences in compliance with adequate ANC based on ethnic groups in Peru prior to and throughout the COVID-19 pandemic.

Methods:

Observational, retrospective study, secondary analysis of the Demographic and Family Health Survey conducted in the course the period 2017–2022. The sample consisted of women of childbearing age from 15 to 49 years and considered the variables of ethnicity, ANC, and sociodemographic factors. For statistical analysis, generalized linear models from the Poisson family utilizing a logarithmic link function were used. Crude and adjusted Prevalence Ratios were calculated along with their 95% confidence intervals.

Results:

A total of 20,165 records were reviewed. Before the pandemic, the frequency of inadequate ANC was 57.91%, and during the pandemic, it increased to 64.91%. Compared to mestizos, belonging to the Quechua ethnic group (PR: 1.08; 95% CI: 1.04–1.13), Aymara (PR: 1.21; 95% CI: 1.12–1.30), natives of the Amazon (PR: 1.15; 95% CI: 1.04–1.27), and those belonging to other races (PR: 1.15; 95% CI: 1.02–1.29) had a higher prevalence of inadequate ANC. During the pandemic, only Aymara women maintained a higher prevalence of inadequate ANC (PR: 1.18; 95% CI: 1.06–1.31).

Conclusions:

Before the pandemic, there were ethnic differences in the prevalence of inadequate ANC, and during the pandemic, only Aymara pregnant women maintained a higher prevalence of inadequate ANC.

Keywords

pregnant women pregnancy antenatal care pandemics indigenous population

Introduction

Antenatal care (ANC) is characterized as a series of scheduled appointments or visits to a healthcare center where a healthcare team monitors the progress of gestation to ensure optimal health conditions for both the mother and the child, aiming to reduce maternal and perinatal morbidity and mortality.^1–3 The recommended number of ANC visits varies among countries, with Peru advocating for a minimum of six visits, ideally initiated before the 14th week of gestation.⁴

In 2020, although 88.4% of Peruvian pregnant women received at least six ANC, there are still disparities in compliance.⁵ A study using a nationally representative questionnaire found that only 35% of pregnant Peruvian women were adequately adhering to ANC, with the lowest compliance observed in the content of care that included all essential services recommended by the WHO,⁶ such as clinical assessments, laboratory tests, supplementation, and counseling.⁷ This study revealed that, compared to pregnant women residing on the coast, those living in the Andes exhibited inadequate adherence to ANC. Similarly, inadequate compliance was identified among pregnant women belonging to a native ethnic group compared to non-native counterparts. This is significant as it highlights another aspect of disparities in care and certain health indicators within a vulnerable population, such as indigenous communities.^8–10

Peru, a multiracial and multiethnic country, comprises 55 indigenous persons and 48 indigenous languages, with 25.8% of the population self-identifying as part of an indigenous community.^11,12 Nevertheless, despite coexisting with socio-economic disadvantages, not all indigenous communities share identical characteristic. Previous research has demonstrated ethnic differences in various health conditions.^12,13 For instance, research has shown that being a Quechua-speaking or native language-speaking individual doubled the likelihood of not seeking health services due to mistreatment, and being of Aymara ethnicity tripled this probability. Similarly, during the pandemic, compared to indigenous peoples from the jungle, patients from Andean indigenous communities faced almost eight times the risk of dying from COVID-19.¹³

For perinatal care-related outcomes, several studies have highlighted the impact of pandemic-related challenges on achieving adequate ANC.^14,15 Similarly, various studies in other countries have shown ethnic differences, including variations in compliance with ANC.^16–19 However, because the impact of social determinants of health varies among countries, these results may not be applicable to our country. On the other hand, the burden of these social determinants also varied during the pandemic, possibly explaining differences in mortality among Peruvian ethnic minorities during the pandemic,¹³ or compliance with ANC in other countries.²⁰ In this regard, understanding these differences will allow quantifying a problem and proposing improvement strategies, taking into account an intercultural approach in public health policies. Consequently, the objective of this study was to determine the differences in compliance with ANC based on the ethnic group in Peru prior to and during the COVID-19 pandemic.

Methods

Study design

Secondary analysis of the Demographic and Family Health Survey (ENDES, acronym in Spanish) during the period 2017–2022. ENDES is a cluster-stratified, nationally representative sample survey conducted yearly by the National Institute of Statistics and Informatics (INEI in Spanish). The survey includes three questionnaires (household, individual, and health) and is conducted with the aim of updating knowledge on health indicators for the Peruvian population.²¹

Population, sample, and sampling

The study population included women of reproductive age (WRA), ranging from 15 to 49 years old. The sampling method used in ENDES is a balanced, two-phase, stratified, and independent probabilistic sampling at the departmental level, distinguishing between urban and rural regions. ENDES estimates are annually representative at the national level, urban/rural breakdown, by geographical domain (Lima Metropolitan Area, Coast, Highlands, and Jungle), and for all 24 regions of Peru and the constitutional province of Callao.²¹

Peru is an Andean–Amazonian country with pronounced geographic and cultural diversity. Most referral obstetric hospitals are clustered in coastal cities, whereas the highlands and jungle regions depend on lower-level facilities that offer basic prenatal care and refer high-risk pregnancies to higher-tier centers.²² Household incomes follow a similar gradient, being highest in urban coastal areas and lowest in rural Andean and Amazonian communities, which further widens disparities in access to and quality of maternal care nationwide.^23,24

Eligibility criteria

Women of childbearing age (15–49 years) who had given birth within the last year prior to the survey application were included. Pregnant women and those with incomplete information in our variables of interest were excluded.

Variables

The dependent variable was inadequate ANC. This variable was constructed based on non-compliance with any of the recommendations from the World Health Organization (WHO).⁶ Additionally, the methodology used in earlier studies was taken into account for its construction.^7,25 The construction of the variable involved the assessment of four aspects: (i) First ANC visit during the first trimester; (ii) Number of ANC visits during pregnancy; (iii) Adherence to the programs featured in each ANC visit, and (iv) ANC provided by trained personnel. Non-compliance with any of these four aspects was considered inadequate ANC. ENDES does not include medical-record abstraction; therefore, compliance is based on self-report.

Regarding the first ANC visit in the first trimester, it was assessed with the question: “How many months pregnant were you when you had your first antenatal care visit?” an ANC visit during the first trimester was considered appropriate.

The number of ANC care visits was assessed with the question: “How many ANC visits did you attend during your pregnancy with (child’s name)?” A number of visits six times or more was considered adequate according to the guidelines of the Technical Standard of the Ministry of Health (MINSA) of Peru.⁴

To comply with the programs featured in each antenatal visit, the guidelines provided by the World Health Organization (WHO) for the care of expectant mothers during each antenatal visit⁶ and previous studies²⁶ were considered. These programs included: HIV/AIDS analysis, syphilis screening, blood and urine analysis to clarify issues that arise during pregnancy, guidance on where to seek help in the event of complications, blood pressure measurement, taking iron supplements as advised by healthcare professionals, and tetanus vaccination.

ANC provided by trained personnel was assessed with the question: “Who attended to you during the delivery of (child’s name)?,” with possible responses working as a doctor, nurse, obstetrician, nursing technician, or midwife. Trained personnel were considered to be doctors, nurses, obstetricians, and nursing technicians.

The main independent variable was the ethnicity of the mother (mestizo, Quechua, Amazon native, member of another indigenous group, or black, white, and other races). This variable was constructed based on the respondent’s answers to the question: “According to your ancestors and according to your customs, do you feel or consider yourself to be:.” Potential responses were Quechua, Aymara, indigenous people of the Amazon, associated with or part of another native group, Black/moreno/zambo/mulato/Afro-Peruvian or Afro-descendant, white, mestizo, other races. Responses of “Don’t know/No response” were excluded.

Additionally, we included covariates such as age (15–25, 26–35, and 36–49 years), education level (primary or lower, secondary, non-university higher education, university), marital status (single, married, cohabiting, widowed, divorced/separated), number of children (one child, two children, three children, four children or more), health insurance coverage (no, yes), wealth index (very poor, poor, middle, rich, very rich), area of residence (urban, rural), and geographic region of residence (Lima Metropolitan Area, remaining areas of the coast, highlands, and jungle).

Statistical analysis

The databases of the ENDES for the period 2017–2022 were downloaded in SAV format, subsequently exported and analyzed using STATA v16.0 (TX, StataCorp LP). All sampling patterns were evaluated based on stratum and weighting factor., considering the intricate sampling design of the ENDES, using the svy command.

In the descriptive analysis, categorical variables were presented as frequencies and percentages along with their 95% confidence intervals (CI). Numeric variables were presented as means with their respective 95% CIs. To determine if there were significant differences between categorical variables according to the proposed outcomes, the Chi-square test with Rao Scott correction for complex sampling was used. Wald test was employed to assess differences between numeric variables.

To evaluate the association between ethnicity and inadequate ANC, generalized linear models from the Poisson family with a logarithmic link function were constructed. Crude Prevalence Ratios (PRc) and adjusted Prevalence Ratios (PRa) were calculated with their respective 95% CIs. The crude model was a bivariate regression, whereas the adjusted model included variables that reported a p-value < 0.20 according to a backward selection model. Multicollinearity was assessed using variance inflation factors, considering a cutoff point greater than 5. A p-value less than 0.05 was established as statistically significant for all analyses.

Ethical considerations

We analyzed secondary data from the ENDES, which is freely available on the INEI website (http://iinei.inei.gob.pe/microdatos/). The databases can be downloaded without including identifiers, thereby ensuring the confidentiality of the respondents’ information. It is important to highlight that all participants provided informed consent to be surveyed.

Results

We identified a total of 125,452 reproductive events (WRA) during the period 2017–2022. About 93,188 participants were excluded for not having had any children in the last year, and 116 participants were excluded due to pregnancy. Subsequently, 11,982 participants were excluded due to incomplete or inconsistent information in the variables of interest. Finally, 20,165 (WRA) records were analyzed, representing a population of 1,560,371 individuals (Figure 1).

Figure 1.

Participant selection flowchart included in the analysis, ENDES 2017–2022.

The mean age was 28.7 (28.6–28.8) years, with 47.36% having secondary education, and 64.14% being in a cohabiting relationship. The average number of children was 2.19 (2.17–2.22) children. About 24.22% were classified as very poor, 74.43% lived in urban areas, and 29.43% resided in Lima Metropolitan Area. Concerning ethnicity, 48.77% identified as mestizo, followed by Quechua at 25.52%, and Aymara at 1.69%. The frequency of inadequate ANC in the last pregnancy was 61.17%. Regarding ANC, 77.17% had their first check-up during the first trimester, 85.05% had six or more check-ups, only 0.01% were not attended by trained personnel, and 51.41% reported adequate compliance with ANC components (Table 1).

Table 1.

General characteristics of sample included in the analysis, ENDES 2017–2022 (n = 20,165; N = 1,560,371).

Characteristics	Absolute frequency	Weighted proportion^a
Characteristics	n	%	95% CI
Age (years)
Mean (95% CI)	28.69	28.56–28.82
15–25	6401	30.67	30.06–31.75
26–35	9347	46.87	45.94–47.80
36–49	4417	22.23	21.44–23.04
Education level
Complete elementary education or below	3452	15.42	14.75–16.11
High school	9816	47.36	46.38–48.34
Non-university higher education	3721	19.35	18.56–20.16
University education	3176	17.88	17.02–18.76
Status marital
Single	1324	6.58	6.14–7.06
Live-in-partner only	13,258	64.14	63.19–65.08
Married	3900	20.96	20.10–21.85
Widow	9	0.06	0.03–0.15
Divorced/separated	1674	8.25	7.78–8.75
Number of children
Mean (95% CI)	2.19	2.17–2.22
One child	7099	36.71	35.81–37.63
Two children	6215	31.24	30.38–32.12
Three children	3820	18.58	17.87–19.30
Four children or more	3031	13.47	12.88–14.08
Health insurance
No	2529	14.57	13.85–15.32
Yes	17,636	85.43	84.68–86.15
Wealth index
Very poor	5955	24.22	23.38–25.09
Poor	5412	23.67	22.84–24.52
Medium	3964	20.18	19.40–20.98
High	2875	17.18	16.41–17.98
Very high	1959	14.74	13.86–15.66
Area of residence
Urban	13,964	74.43	73.51–75.32
Rural	6201	25.57	24.68–26.49
Geographic region of residency
Metropolitan Lima	2467	29.43	28.21–30.68
Other areas of Coast region	5875	25.95	24.94–26.98
Highlands	6761	27.29	26.30–28.30
Jungle	5062	17.33	16.57–18.13
Ethnicity
Mestiza	8838	48.77	47.78–49.75
Quechua	6247	25.52	24.67–26.39
Aymara	664	1.69	1.47–1.93
Native from Amazon	494	1.74	1.48–2.04
Part of another indigenous people	59	0.23	0.15–0.34
Afro-Peruvian	2163	12.12	11.50–12.77
White	1502	8.78	8.25–9.35
Other races	198	1.16	0.97–1.38
First prenatal care visit in the first trimester
No	4827	22.83	22.06–23.62
Yes	15,338	77.17	76.38–77.94
Number of prenatal care visits
Less than 6	2906	14.95	14.29–15.63
Equal or more than 6	17,259	85.05	84.37–85.71
Prenatal care by trained personnel
No	1	0.01	0.00–0.08
Yes	20,164	99.99	99.92–100.00
Compliance with prenatal care programs
Inadequate	9608	48.59	47.62–49.57
Adequate	10,557	51.41	50.43–52.38
Prenatal care
Adequate	7980	38.83	37.91–39.75
Inadequate	12,185	61.17	60.25–62.09

95% CI: 95% confidence intervals.

Weights and the design effect of the complex survey sampling were included.

In the bivariate analysis of general characteristics according to ethnicity, statistically significant differences were found for all variables (Table 2).

Table 2.

General characteristics of the sample included in the study according to ethnicity.

Characteristics	Ethnicity
	Mestiza		Quechua		Aymara		Native from Amazon		Part of another indigenous people		Afro-Peruvian		White		Other races		p-Value^a
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	p-Value^a
Prenatal care																	<0.001
Adequate	3964	42.67	2082	32.91	163	26.97	182	33.50	28	53.30	886	39.16	608	38.22	67	30.99
Inadequate	4874	57.33	4165	67.09	501	73.03	312	66.50	31	46.70	1277	60.84	894	61.78	131	69.01
Age (years)																	<0.001
15–25	2629	28.01	1911	29.41	176	28.44	221	43.64	29	50.23	826	38.79	551	35.43	58	29.53
26–35	4262	48.97	2861	46.60	318	49.76	199	39.43	21	32.58	942	43.03	655	44.27	89	45.74
36–49	1947	23.03	1475	23.99	170	21.80	74	16.93	9	17.19	395	18.18	296	20.30	51	24.73
Education level																	<0.001
Complete elementary education or below	842	8.37	1354	19.05	76	10.09	180	35.97	23	41.22	577	27.94	356	21.97	44	23.31
High school	3965	44.18	3235	50.60	380	60.32	252	47.10	27	47.73	1116	50.12	754	49.08	87	49.23
Non-university higher education	2046	23.29	946	17.08	126	17.48	42	11.20	8	9.12	308	14.32	204	13.98	41	13.90
University education	1985	24.16	712	13.28	82	12.10	20	5.73	1	1.93	162	7.62	188	14.98	26	13.57
Status marital																	<0.001
Single	587	6.72	425	6.43	17	2.98	38	9.34	3	1.19	134	6.26	111	7.08	9	6.05
Live-in-partner only	5604	61.04	4135	66.97	458	63.62	371	69.34	45	77.88	1510	69.35	1010	64.39	125	66.24
Married	1836	23.39	1263	19.71	132	23.89	47	15.35	6	16.13	331	16.35	244	18.76	41	16.35
Widow	4	0.06	4	0.12	1	0.36	0	0.00	0	0.00	0	0.00	0	0.00	0	0.00
Divorced/separated	807	8.79	420	6.77	56	9.15	38	5.97	5	4.80	188	8.04	137	9.77	23	11.36
Number of children																	<0.001
One child	3290	38.72	2093	34.34	205	32.33	139	29.89	17	25.32	701	33.22	594	40.59	60	30.71
Two children	2852	32.05	1835	30.48	239	37.22	110	25.62	15	29.97	684	31.86	419	28.27	61	29.98
Three children	1639	17.90	1225	20.04	145	20.44	79	13.66	11	17.82	423	19.64	255	16.73	43	22.37
Four children or more	1057	11.33	1094	15.15	75	10.01	166	30.82	16	26.90	355	15.28	234	14.40	34	16.93
Health insurance																	0.027
No	1261	15.39	622	12.44	104	15.98	43	13.38	4	15.20	259	14.15	211	16.20	25	18.56
Yes	7577	84.61	5625	87.56	560	84.02	451	86.62	55	84.80	1904	85.85	1291	83.80	173	81.44
Wealth index																	<0.001
Very poor	1475	13.90	2676	33.99	109	26.22	389	70.94	46	76.59	750	34.21	467	28.96	43	19.73
Poor	2209	20.54	1814	28.66	232	32.29	68	13.55	8	9.75	639	27.17	384	21.72	58	29.07
Medium	2004	21.88	994	18.98	180	20.96	21	5.71	2	2.44	434	19.79	289	17.61	40	22.98
High	1757	21.72	519	11.82	106	15.54	5	2.08	2	4.43	245	13.50	211	16.65	30	14.11
Very high	1393	21.95	244	6.54	37	4.98	11	7.72	1	6.79	95	5.33	151	15.06	27	14.11
Area of residence																	<0.001
Urban	7306	85.44	3366	62.13	527	68.13	136	34.87	19	31.49	1432	65.87	1034	70.98	144	74.13
Rural	1532	14.56	2881	37.87	137	31.87	358	65.13	40	68.51	731	34.13	468	29.02	54	25.87
Geographic region of residency																	<0.001
Metropolitan Lima	1567	38.54	453	21.02	12	7.13	19	14.80	2	13.76	195	17.79	199	27.90	20	22.00
Other areas of Coast region	3224	29.59	551	8.49	424	33.06	8	3.52	1	2.61	998	43.90	576	33.90	93	37.29
Highlands	1296	12.02	4351	60.36	205	57.08	9	2.78	2	3.54	470	22.14	369	22.33	59	31.00
Jungle	2751	19.85	892	10.14	23	2.73	458	78.90	54	80.09	500	16.18	358	15.86	26	9.71

Weights and the design effect of the complex survey sampling were included.

The bold font in Table 2 indicates values where the p-value is statistically significant.

Refers to the statistical significance obtained from the comparison of the proportions between the categories of the variables considering the complex sampling of the survey.

The frequency of inadequate ANC during the COVID-19 pandemic saw a notable increase compared to the period before it (64.95% vs 57.91%; p < 0.001). These differences were observed among mestizo women (62.86% vs 52.68%; p < 0.001), Quechua women (69.02% vs 65.50%; p = 0.025), and white women (64.96% vs 58.64%; p = 0.045; Table 3).

Table 3.

Frequencies of prenatal care in the pre-pandemic period and during the COVID-19 pandemic by ethnic group.

Exposure		Prenatal care
		Adequate			Inadequate			p-Value^a
		n	%	95% CI	n	%	95% CI	p-Value^a
All sample								<0.001
Pre-pandemic COVID-19		4491	42.09	40.79–43.41	6090	57.91	56.69–59.21
Pandemic COVID-19		3489	35.05	33.78–36.35	6095	64.95	63.65–66.22
Stratification by ethnicity
Ethnicity
Mestiza	Pre-pandemic COVID-19	2298	47.32	45.32–49.34	2365	52.68	50.66–54.68	<0.001
	Pandemic COVID-19	1666	37.14	35.24–39.08	2509	62.86	60.92–64.76
Quechua	Pre-pandemic COVID-19	1155	34.50	32.40–36.67	2201	65.50	63.33–67.60	0.025
	Pandemic COVID-19	927	30.98	28.80–33.25	1964	69.02	66.75–71.20
Aymara	Pre-pandemic COVID-19	98	30.07	23.86–37.12	255	69.93	62.88–76.14	0.137
	Pandemic COVID-19	65	23.40	16.85–31.51	246	76.60	68.49–83.14
Native from Amazon	Pre-pandemic COVID-19	94	35.11	27.44–43.63	150	64.89	56.37–72.56	0.488
	Pandemic COVID-19	88	31.69	24.20–40.26	162	68.31	59.74–75.80
Part of another indigenous people	Pre-pandemic COVID-19	9	42.11	25.20–61.10	12	57.89	38.91–74.80	0.114
	Pandemic COVID-19	19	63.16	40.42–81.24	19	36.84	18.76–59.58
Afro-Peruvian	Pre-pandemic COVID-19	470	41.22	37.55–44.99	602	58.78	55.01–62.44	0.112
	Pandemic COVID-19	416	37.01	33.36–40.82	675	62.99	59.18–66.64
White	Pre-pandemic COVID-19	328	41.36	36.94–45.92	434	58.64	54.08–63.06	0.045
	Pandemic COVID-19	280	35.04	30.92–39.40	460	64.96	60.60–69.08
Other races	Pre-pandemic COVID-19	39	31.60	22.84–41.89	71	68.40	58.11–77.16	0.847
	Pandemic COVID-19	28	30.26	19.52–43.71	60	69.74	56.29–80.48

95% CI: 95% confidence intervals.

Weights and the design effect of the complex survey sampling were included.

The bold font in Table 3 indicates values where the p-value is statistically significant.

p-Values from survey-adjusted Rao–Scott χ² tests comparing the distribution of adequate versus inadequate care between the pre-pandemic and pandemic periods within each ethnic group (and for the entire sample).

In the bivariate analysis of general characteristics concerning ANC, all variables were significant except for health insurance (Table 4).

Table 4.

General characteristics of the sample included in the study according to prenatal care.

Characteristics	Prenatal care
	Adequate			Inadequate			p-Value^a
	n	%	95% CI	n	%	95% CI	p-Value^a
Ethnicity							<0.001
Mestiza	3964	42.67	41.27–44.08	4874	57.33	55.92–58.73
Quechua	2082	32.91	31.38–34.48	4165	67.09	65.52–68.62
Aymara	163	26.97	22.28–32.25	501	73.03	67.75–77.72
Native from Amazon	182	33.50	27.83–39.70	312	66.50	60.30–72.17
Part of another indigenous people	28	53.30	37.60–68.38	31	46.70	31.62–62.40
Afro-Peruvian	886	39.16	36.54–41.85	1277	60.84	58.15–63.46
White	608	38.22	35.16–41.38	894	61.78	58.62–64.84
Other races	67	30.99	23.88–39.13	131	69.01	60.87–76.12
Age (years)							<0.001
15–25	2448	37.11	35.55–38.70	3953	62.89	61.30–64.45
26–35	3888	41.10	39.76–42.46	5459	58.90	57.54–60.20
36–49	1644	36.39	34.51–38.31	2773	63.61	61.69–65.49
Education level							<0.001
Complete elementary education or below	1153	32.36	30.50–34.28	2299	67.64	65.72–69.50
High school	3830	38.77	37.48–40.07	5986	61.23	59.93–62.52
Non-university higher education	1649	44.06	41.86–46.29	2072	55.94	53.71–58.14
University education	1348	38.89	36.55–41.28	1828	61.11	58.71–63.45
Status marital							0.009
Single	453	34.18	30.85–37.69	871	65.82	62.31–69.15
Live-in-partner only	5419	40.00	38.89–41.13	7839	60.00	58.87–61.11
Married	1501	37.64	35.56–39.77	2399	62.36	60.23–64.44
Widow	3	35.01	8.78–75.10	6	64.99	24.90–91.22
Divorced/separated	604	36.42	33.47–39.48	1070	63.58	60.52–66.53
Number of children							<0.001
One child	3194	44.44	42.91–45.98	3905	55.56	54.02–57.09
Two children	2434	37.50	35.91–39.11	3781	62.50	60.89–64.09
Three children	1414	35.94	33.93–38.00	2406	64.06	62.00–66.06
Four children or more	938	30.60	28.54–32.74	2093	69.40	67.26–71.46
Health insurance							0.379
No	960	37.75	35.21–40.37	1569	62.25	59.63–64.79
Yes	7020	39.01	38.02–40.01	10,616	60.99	59.99–61.98
Wealth index							<0.001
Very poor	1991	32.18	30.70–33.70	3964	67.82	66.30–69.30
Poor	2253	40.61	38.87–42.37	3159	59.39	57.63–61.13
Medium	1688	42.59	40.47–44.74	2276	57.41	55.26–59.53
High	1257	42.81	40.44–45.20	1618	57.20	54.80–59.55
Very high	791	37.10	34.21–40.07	1168	62.90	59.92–65.79
Area of residence							<0.001
Urban	5821	40.63	39.51–41.76	8143	59.37	58.24–60.49
Rural	2159	33.58	32.11–35.09	4042	66.42	64.91–67.89
Geographic region of residency							<0.001
Metropolitan Lima	968	38.04	35.83–40.30	1499	61.96	59.70–64.17
Other areas of Coast region	2479	43.32	41.65–45.01	3396	56.68	54.99–58.35
Highlands	2181	30.61	29.31–31.95	4580	69.39	68.05–70.69
Jungle	2352	46.36	44.58–48.16	2710	53.64	51.84–55.42

95% CI: 95% confidence intervals.

Weights and the design effect of the complex survey sampling were included.

The bold font in Table 4 indicates values where the p-value is statistically significant.

Refers to the statistical significance obtained from the comparison of the proportions between the categories of the variables considering the complex sampling of the survey.

In the multivariate analysis adjusted to assess the association between ethnicity and ANC in the last pregnancy, it was found that, compared to mestizo women, belonging to the Quechua ethnicity (PR: 1.08; 95% CI: 1.04–1.13; p < 0.001), Aymara ethnicity (PR: 1.21; 95% CI: 1.12–1.30; p < 0.001), Amazonian natives (PR: 1.15; 95% CI: 1.04–1.27; p < 0.001), and those belonging to other races (PR: 1.15; 95% CI: 1.02–1.29; p = 0.021) had a higher prevalence of inadequate ANC (Table 5).

Table 5.

Crude and adjusted models to evaluate the association between the ethnicity and the inadequate prenatal care in the sample included in the analysis.

Exposure		Inadequate prenatal care
		Crude model^a			Adjusted model^b
		PR	95% CI	p-Value	PR	95% CI	p-Value
All sample
Ethnicity	Mestiza	Ref.	–	–	Ref.	–	–
	Quechua	1.17	1.13–1.21	<0.001	1.08	1.04–1.13	<0.001
	Aymara	1.27	1.18–1.37	<0.001	1.21	1.12–1.30	<0.001
	Native from Amazon	1.16	1.06–1.27	0.002	1.15	1.04–1.27	0.007
	Part of another indigenous people	0.81	0.58–1.15	0.239	0.79	0.54–1.14	0.204
	Afro-Peruvian	1.06	1.01–1.11	0.021	1.02	0.97–1.08	0.362
	White	1.08	1.02–1.14	0.008	1.04	0.99–1.10	0.122
	Other races	1.20	1.07–1.35	0.001	1.15	1.02–1.29	0.021
Stratification by pre-pandemic/pandemic period
Pre-pandemic COVID-19
Ethnicity	Mestiza	Ref.	–	–	Ref.	–	–
	Quechua	1.24	1.18–1.31	<0.001	1.11	1.05–1.18	<0.001
	Aymara	1.33	1.20–1.47	<0.001	1.23	1.10–1.36	<0.001
	Native from Amazon	1.23	1.08–1.40	0.002	1.21	1.05–1.38	0.008
	Part of another indigenous people	1.10	0.79–1.52	0.570	1.01	0.71–1.44	0.949
	Afro-Peruvian	1.12	1.04–1.20	0.003	1.07	0.99–1.15	0.070
	White	1.11	1.02–1.21	0.014	1.07	0.98–1.16	0.136
	Other races	1.30	1.12–1.50	<0.001	1.21	1.04–1.40	0.014
Pandemic COVID-19
Ethnicity	Mestiza	Ref.	–	–	Ref.	–	–
	Quechua	1.10	1.05–1.15	<0.001	1.05	0.99–1.10	0.086
	Aymara	1.22	1.10–1.35	<0.001	1.18	1.06–1.31	0.002
	Native from Amazon	1.09	0.96–1.23	0.183	1.09	0.95–1.25	0.212
	Part of another indigenous people	0.59	0.33–1.05	0.074	0.57	0.30–1.10	0.093
	Afro-Peruvian	1.00	0.94–1.07	0.952	0.97	0.90–1.03	0.327
	White	1.03	0.96–1.11	0.362	1.00	0.93–1.08	0.901
	Other races	1.11	0.93–1.33	0.256	1.07	0.89–1.29	0.492

PR: prevalence ratio; 95% CI: 95% confidence intervals.

The bold font in Table 5 indicates values where the p-value is statistically significant.

A generalized linear model of the Poisson family with a log link was made considering the effect of the design and the weights of the complex sampling of the survey.

Adjusted for age, number of children, health insurance, wealth index, area of residence, geographic region of residence.

In the adjusted analysis to assess the prevalence of inadequate ANC before and during the pandemic, it was found that, before the pandemic, compared to mestizo women, belonging to the Quechua ethnicity (PR: 1.11; 95% CI: 1.05–1.18; p < 0.001), Aymara ethnicity (PR: 1.23; 95% CI: 1.10–1.36; p < 0.001), Amazonian natives (PR: 1.21; 95% CI: 1.05–1.38; p = 0.008), and those belonging to other races (PR: 1.21; 95% CI: 1.04–1.40; p = 0.014) had a higher prevalence of inadequate ANC. On the other hand, during the pandemic, only Aymara women (PR: 1.18; 95% CI: 1.06–1.31; p = 0.002) had a higher prevalence of inadequate ANC (Table 5).

Discussion

Our main results show that 6 out of 10 pregnant women had inadequate ANC, and, compared to mestizo pregnant women, those of Quechua, Aymara, Amazonian native, and other ethnicities had a higher prevalence of inadequate ANC. Likewise, during the pandemic, only Aymara pregnant women had a higher prevalence of inadequate ANC.

Overall, national ANC coverage improved. A study found that the number of ANC visits increased from 77.22% to 87.52% from 2009 to 2019.²⁷ During the same period, the relative difference between women in rural and urban areas shrank from 15% to 3%, while the percentage of pregnant women lacking access to quality visits dropped from 45.16% to 29.35%.²⁷ Regarding access to quality check-ups, absolute inequality by wealth quintile also nearly halved, from 55.96% to 25.95%.²⁷ Despite these improvements, barriers persist that hinder compliance with visits or the quality of ANC. Using the 2017 ENDES data, another study demonstrated that receiving more ANC increased the likelihood of receiving quality ANC.²⁶ Furthermore, it was found that being a pregnant woman from the highlands, living in a rural area, and belonging to a native ethnicity were associated with a lower likelihood of receiving quality ANC.²⁶ Having secondary and higher education, being in the wealth quintile 2–5, belonging to the rest of the Coastal and Jungle regions, having health insurance affiliation, and receiving ANC in the first trimester were associated with a higher likelihood of receiving quality ANC.²⁶ Subsequently, a study utilizing the 2019 ENDES data revealed that being in the age groups of 20–34 and 35–49, with secondary or higher education, being in a wealth quintile above the poorest, coming from the Amazon region, not identifying as indigenous, experiencing a second or third pregnancy, along with having a planned pregnancy, raised the likelihood of achieving adequate compliance with ANC.⁷

These results demonstrate that, in addition to certain obstetric conditions, sociodemographic aspects influence the proper fulfillment of ANC, including ethnic origin and other characteristics common among indigenous peoples that predefine them as vulnerable populations. In this regard, originating from rural areas, being from the highlands or the Amazon, and the condition of poverty found in these studies are common characteristics among pregnant women from indigenous communities and could explain our results.^7,26

Indeed, a nationwide survey in 2015 aimed at illustrating ethnic dynamics in our country showed that individuals who self-identified as mestizo reported living in urban areas to a greater extent than those who identified as indigenous (57.1% vs 56.2%).²⁸ Similarly, Andean households were 80% more likely, and Amazonian households were 170% more likely to live in poverty compared to “white-mestizo” households.²⁸ Descriptive variables regarding labor market characteristics indicated that education allows for achieving better goals and living conditions. Again, the Amazonians, Quechuas, and Aymaras showed lower levels of education attainment, with fewer chances of accessing the labor market In the case of the Aymaras and Quechuas, especially those in the remote areas of the country, distance from productive niches and lack of infrastructure make it challenging to attain higher educational levels compared to mestizos or whites, diminishing opportunities to access the productive job market.²⁸

Much like in the case of ANC, these characteristics potentially explain the poorer health indicators in these populations,^29,30 alongside factors hindering access to health services. These factors include linguistic barriers, distance to health centers, lack of transportation, discrimination, and mistreatment in healthcare establishments in Peru.^12,31 Similar to our country, other studies have also suggested that ethnic minorities or indigenous peoples face disadvantages in terms of social determinants of health, making them susceptible to less antenatal attention or overall obstetric care. This warrants the design of specific strategies considering their unique characteristics.^16–19,32 During the pandemic, these social determinants worsened for ethnic minorities,³³ which, in the case of Peru, led to variations in mortality among indigenous peoples¹³ and potentially could have also affected ANC compliance.

In the United States, a study found that, during the pandemic, while most racial and ethnic groups in Medicaid expansion states experienced a decrease in inadequate ANC, the odds of lacking ANC increased for some ethnicities.²⁰ Specifically, they increased by 15% for non-Hispanic whites, 9% for non-Hispanic Blacks, 33% for Native American Alaskan Natives, 25% for Asians/Pacific Islanders, and 13% for Hispanics in states without Medicaid expansion.²⁰ Peru was one of the countries most affected during the pandemic due to various factors, including structural issues in its healthcare system.³⁴ The pandemic led to an overload of hospital systems focused on caring for COVID-19-infected patients, sidelining aspects such as ANC because pregnant women faced difficulties accessing health services.³⁵ These conditions likely explain the 7% decrease in adequate ANC during the pandemic nationwide. However, the use of teleconsultations and mobile devices represented an alternative to improve care for pregnant women during this period.^36,37 Although their coverage by ethnicity or geographical region was not studied in our country, their variations could possibly also influence the variation in inadequate ANC in our country.

The Aymara people are one of the largest indigenous groups in Peru, and according to the national census of 2017, 548,311 individuals self-identified as Aymara, primarily residing in six provinces in Puno and some rural districts in Moquegua and Tacna.³⁸ Puno, a mountainous region, experienced a rise in the number of pregnant women receiving six ANC visits before the pandemic.²⁸ Although not one of the regions in Peru with the highest number of COVID-19 deaths,³⁹ Puno is among the less privileged regions in the country. While our study does not aim to describe why, during the pandemic, only Aymara pregnant women persisted with a higher prevalence of inadequate ANC, these explanations may lie in the limitations of the healthcare system in this region. For example, during the first wave, the first level of care was non-operational, leading to the entire demand for care of infected patients being shifted to the second level of care.⁴⁰ In this sense, pregnant women may not have had a place to undergo ANC. However, despite evidence of teleconsultation implementation for ANC,⁴¹ there is no data on its effectiveness, and there is no evidence of cultural adaptations of teleconsultation to the customs and practices of the Aymara nation that may limit its implementation.

Our results have implications for public health. Firstly, despite existing public initiatives that include interculturality,¹² our findings show that ethnic differences persist in the healthcare of pregnant women. Therefore, considering the consequences of inadequate ANC on perinatal morbidity and mortality in our country,⁴² this should prompt the development of strategies that reinforce the intercultural competencies of healthcare professionals. Additionally, due to the challenges of access to healthcare services for individuals belonging to indigenous peoples,^8,30,31 the reinforcement of telemedicine,^36,37 should continue, taking into account the cultural relevance of care. In this regard, policies to promote better adherence to ANC, institutionalized childbirth,⁴³ vertical delivery, and other strategies, unfortunately, regressed during the pandemic.

Our research has some limitations. First, although our study is based on secondary data and thus subject to potential recall or social desirability bias, it is important to note that ENDES employs validated questionnaires developed by expert panels to ensure clarity and cultural appropriateness. Furthermore, data collection is carried out by trained health personnel using standardized protocols under strict supervision, which helps to minimize measurement errors and enhance the reliability of the self-reported information. Additionally, the survey applies a complex, probabilistic, and stratified sampling design, which ensures national and regional representativeness and reduces the likelihood of selection bias. Second, the definition of adequate ANC was based exclusively on the frequency and timing of antenatal visits, without incorporating aspects of quality of care such as the type of health professional providing the service, the availability of screening tests (double test, triple test, or Non-Invasive Prenatal Test (NIPT)), or the performance of morphologic ultrasound examinations. Third, the ENDES does not collect information on maternal clinical history or risk factors that could influence the number of ANC visits, such as maternal comorbidities (hypertension, diabetes), previous obstetric complications, nutritional status, or contextual barriers (socioeconomic, cultural, and geographic). Although we used multivariable regression models to control for potential confounders, residual confounding due to unmeasured variables cannot be ruled out. Addressing these aspects in future studies would provide a more comprehensive understanding of the determinants of ANC utilization. Fourth, it is not possible to establish cause-and-effect relationships; only associations can be determined.

It is also essential to deepen the understanding of how much of the inadequate antenatal care disproportionately affecting different ethnic groups actually translates into adverse outcomes during pregnancy and the neonatal period. The marked cultural, social, and geographic diversity of Peru suggests that this relationship is unlikely to be homogeneous, making it relevant to promote research that examines how ANC adequacy may mediate the link between ethnicity and maternal-perinatal outcomes, thereby providing more contextualized evidence to design culturally appropriate interventions.

Despite these limitations, the ENDES is a nationally and regionally representative survey with quality control processes and extensive use for studying health topics in the Peruvian population. Furthermore, it records data used to assess the adequate fulfillment of ANC based on WHO recommendations and is regulated by the Ministry of Health (MINSA).

Conclusion

In conclusion, there are ethnic differences in ANC compliance among Peruvian pregnant women, which persisted during the pandemic for some indigenous peoples. A continued intercultural approach in ANC and reinforcing cultural relevance in telemedicine is necessary to improve health system coverage.

Footnotes

Acknowledgements

Not applicable.

Author contributions

Agueda Muñoz-del-Carpio-Toia, Percy Herrera-Añazco, Jerry K. Benites-Meza, and Vicente A. Benites-Zapata: Conceptualization and study design, data acquisition, formal analysis and interpretation, drafting the original manuscript, and final approval of the version to be submitted.

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: The study was funded by the project “Importancia de la vacunación y el autocuidado de la salud COVID-19” from the internal fund of the Vicerrectorado de Investigación of Universidad Católica de Santa María, Arequipa, Peru.

ORCID iDs

Percy Herrera-Añazco

Jerry K. Benites-Meza

Vicente A. Benites-Zapata

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Antenatal care adequacy before and during the COVID-19 pandemic in indigenous populations in Peru

Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Study design

Population, sample, and sampling

Eligibility criteria

Variables

Statistical analysis

Ethical considerations

Results

Discussion

Conclusion

Footnotes

Acknowledgements

Author contributions

Declaration of conflicting interests

Funding

ORCID iDs

References