The integration of social determinants of health in antenatal care policies in Brazil: a content analysis of five federal documents

Abstract

Background Inequities shaped by the Social Determinants of Health (SDH) and intersecting forms of discrimination such as race, age, and socioeconomic status critically influence access to and quality of antenatal care (ANC), a key intervention for preventing maternal mortality. Brazil illustrates this situation: despite universal health coverage and high ANC attendance, territorial, racial, and socioeconomic disparities keep maternal mortality far above the 2030 target. This study aims to investigate how SDH are incorporated into policies and documents related to ANC in Brazil, assessing 1) how these documents acknowledge SDH and 2) how they integrate those determinants into operational objectives and strategies related to ANC. Methods A SDH analytical framework containing the categories of policy goals, recognition of evidence, and system-level objectives/strategies was adapted for the context of antenatal care and used for the analysis. Five documents were selected for analysis: three public policies (the National Policy for Comprehensive Women’s Healthcare, the Program for the Humanization of Prenatal and Birth Care, and Alyne Network), the Pregnant Woman’s Health booklet, and the Joint Technical Note on the Alyne Network. Results Although most documents recognize SDH and frame goals around reducing social inequalities, their strategies focus primarily on health service quality and access, largely targeting individual-level actions rather than broader SDH. Alyne Network stands out by requiring sociodemographic analysis from local authorities and by emphasizing Race / Ethnicity and Cultural / Social norms. Violence against women is the most cited determinant related to ANC utilization across documents, while Age, Wealth / Income, Urban vs. rural residence, Spousal / Family influence, and Cultural / Social norms are mentioned less frequently. Conclusions Documents recognize SDH in objectives and use rights-based language. Future policies could strengthen integration through strategies such as vulnerability assessment, equity indicators, workforce training, cross-sector mechanisms, and community participation.