Álvaro Jorge Madeiro Leite

Birth in Brazil: national survey into labour and birth

BackgroundCaesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.MethodsNationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.DiscussionThis study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health.

Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil

A multi-country evaluation is being carried out in Brazil and four other countries to determine the effectiveness, cost, and impact of the Integrated Management of Childhood Illness (IMCI). We examine the effect of IMCI on the quality of health care provided to children under five visiting health facilities. A health facility survey was conducted at 24 facilities (12 with IMCI) in each of four States in the Northeast. We assessed the quality of care provided to children between 2 months and 5 years attending the facilities. Health workers trained in IMCI provided significantly better care than those not trained. Significant differences between health workers who were trained or not trained in IMCI were found in the assessment of the child, disease classification, treatment, and caretaker communication. Nurses trained in IMCI performed as well as, and sometimes better than, medical officers trained in IMCI. We conclude that while there is room for further improvement, IMCI case management training significantly improves health worker performance, and that parts of Brazil that have not yet introduced IMCI should be encouraged to do so.

Prevalência de sobrepeso e obesidade em adolescentes escolares do município de Fortaleza, Brasil

OBJECTIVES: to determine overweight and obesity prevalence in adolescent students in the Municipality of Fortaleza, Brazil and to estimate prevalence rates of public and private schools according to gender and age group (early and late adolescence). METHODS: a cross sectional study performed in the period of March to May 2003 comprised of 1158 adolescents, 571 from public schools and 587 from private schools. Overweight was defined when body mass index (BMI) was determined to be equal or above percentile 85 and under percentile 95; obesity was defined when BMI was determined as equal or over percentile 95, regardless of age and gender. RESULTS: total prevalence of overweight and obesity was of 19.5%. In private schools, overweight/obesity reached 23.9%, a rate higher than in public schools (18.0%) (p = 0.018). Overweight/ obesity prevalence in the male gender (19.6%) was similar to the female gender (19.0%) p = 0.80), in early adolescence, prevalence was (24.1%) higher than in late adolescence (15.0%) (p < 0.0001). CONCLUSIONS: overweight and obesity prevalence in adolescent students of the city of Fortaleza was determined to be high, in private schools and higher in early adolescence with no difference between genders.

Biomarkers of environmental enteropathy, inflammation, stunting, and impaired growth in children in Northeast Brazil

Critical to the design and assessment of interventions for enteropathy and its developmental consequences in children living in impoverished conditions are non-invasive biomarkers that can detect intestinal damage and predict its effects on growth and development. We therefore assessed fecal, urinary and systemic biomarkers of enteropathy and growth predictors in 375 6–26 month-old children with varying degrees of malnutrition (stunting or wasting) in Northeast Brazil. 301 of these children returned for followup anthropometry after 2-6m. Biomarkers that correlated with stunting included plasma IgA anti-LPS and anti-FliC, zonulin (if >12m old), and intestinal FABP (I-FABP, suggesting prior barrier disruption); and with citrulline, tryptophan and with lower serum amyloid A (SAA) (suggesting impaired defenses). In contrast, subsequent growth was predicted in those with higher fecal MPO or A1AT and also by higher L/M, plasma LPS, I-FABP and SAA (showing intestinal barrier disruption and inflammation). Better growth was predicted in girls with higher plasma citrulline and in boys with higher plasma tryptophan. Interactions were also seen with fecal MPO and neopterin in predicting subsequent growth impairment. Biomarkers clustered into markers of 1) functional intestinal barrier disruption and translocation, 2) structural intestinal barrier disruption and inflammation and 3) systemic inflammation. Principle components pathway analyses also showed that L/M with %L, I-FABP and MPO associate with impaired growth, while also (like MPO) associating with a systemic inflammation cluster of kynurenine, LBP, sCD14, SAA and K/T. Systemic evidence of LPS translocation associated with stunting, while markers of barrier disruption or repair (A1AT and Reg1 with low zonulin) associated with fecal MPO and neopterin. We conclude that key noninvasive biomarkers of intestinal barrier disruption, LPS translocation and of intestinal and systemic inflammation can help elucidate how we recognize, understand, and assess effective interventions for enteropathy and its growth and developmental consequences in children in impoverished settings.

Determinantes da mortalidade neonatal: estudo caso-controle em Fortaleza, Ceará, Brasil

This case-control study with 132 cases and 264 controls aimed to determine predictors of neonatal mortality using hierarchical modeling. Cases were defined as newborns that died within 28 days of birth, and controls as the survivors, among infants of mothers living in Fortaleza, Ceara State, Brazil. Hierarchical logistic regression identified factors associated with neonatal death: maternal race, with brown/black race showing a protective effect (OR = 0.23; IC95%: 0.09-0.56), time spent from home to the hospital > 30 minutes (OR = 3.12; 95%CI: 1.34-7.25), time 10 hours between hospital admission and delivery (OR = 2.43; 95%CI: 1.24-4.76), inadequate prenatal care (OR = 2.03; 95%CI: 1.03-3.99), low birth weight (OR = 14.75; 95%CI: 5.26-41.35), prematurity (OR = 3.41; 95%CI: 1.29-8.98), and male gender (OR = 2.09; 95%CI: 1.09-4.03). In this case series, neonatal deaths were associated with the quality of prenatal care and direct care during labor.

Fatores de risco para mortalidade infantil em município do Nordeste do Brasil: linkage entre bancos de dados de nascidos vivos e óbitos infantis - 2000 a 2002

OBJETIVO: Analisar fatores de risco para a morte de criancas menores de um ano de idade, do municipio de Maracanau, Estado do Ceara, entre os anos de 2000 e 2002, atraves de linkage das informacoes do Sistema de Informacao sobre Nascidos Vivos e Sistema de Informacao sobre Mortalidade. METODOS: Coorte retrospectiva de 11.127 nascimentos vivos com declaracao de nascido vivo preenchida, ocorridos entre 01/01/2000 e 31/12/2002 e 119 obitos infantis relacionados a essa coorte de nascidos vivos, com declaracao de obito ou instrumento de investigacao de obito infantil preenchidos, ocorridos entre 01/01/2000 e 31/12/2003. Os fatores de risco para a mortalidade infantil foram estimados utilizando-se as analises bivariada e multivariada atraves da regressao logistica. RESULTADOS: Foram encontradas odds ratio (OR) estatisticamente significativas para nascidos vivos com baixo peso ao nascer (OR=3,16; IC95% 1,58-6,35), nascidos vivos prematuros (OR=2,70 ; IC95% 1,25-5,86), nascidos vivos de maes com consultas pre-natal igual ou menores a 6 (OR=2,05; IC95% 1,15-3,64) e nascidos vivos cujo escore de Apgar no primeiro (OR=4,40 IC95% 2,48-7,81) e quinto (OR=5,5; IC95% 2,75-11,20) minutos de vida foram inferiores a sete. CONCLUSOES: Esse estudo possibilitou o uso das bases de dados de nascimentos e obitos, sugerindo a vigilância continua e oferta de assistencia adequada ao subgrupo de recem-nascidos com maior risco de morte e a garantia de assistencia pre-natal de qualidade.

Effectiveness of home-based peer counselling to promote breastfeeding in the northeast of Brazil: a randomized clinical trial.

AIMS To evaluate the effectiveness of home-based peer counselling to increase breastfeeding rates for unfavourably low birthweight babies. METHODS Randomized clinical trial carried out in maternity hospitals and households in Fortaleza, one of the regions in Brazil with very low income; 1003 mothers and their newborns were selected in eight maternity hospitals. Newborns needed were healthy and weighed less than 3000 g. INTERVENTION Breastfeeding counselling, conducted by lay counsellors from the community, during home visits carried out on days 5, 15, 30, 60, 90 and 120 after birth. MAIN OUTCOME MEASURE Feeding methods in the fourth month of life. RESULTS The intervention increased exclusive breastfeeding (24.7% vs 19.4%; p=0.044), delayed the introduction of formula and increased the time infants substituted breastfeeding to bottle milk (bottle milk 33.4% in the control group and 20.1% in the intervention group; p=0.00002). When comparing the frequency of artificial breastfeeding versus all other forms of breastfeeding (exclusive+predominant+partial), the intervention increased breastfeeding rates in 39% (RR=0.61; CI 95%: 0.50-0.75); 15% of children were free from artificial feeding (absolute risk reduction). The number of families to be visited to avoid one child receiving artificial feeding (NNT) was 7 (CI 95%: 5-13). CONCLUSIONS Breastfeeding counselling, promoted by lay counsellors, can impact favourably on exclusive breastfeeding rates and contribute to delaying the utilization of milk formula and weaning. The intervention has great application potential because most cities in the northeast of Brazil count on community health workers that could do the counselling.

Hospital mortality rates of infants with birth weight less than or equal to 1,500 g in the northeast of Brazil

Objective: To obtain information on the hospital mortality of infants born in Fortaleza with birth weight less than or equal to 1,500 g, and to compare it with data from the Vermont Oxford Network, a center of excellence for neonatal care. Results: A total of 774 newborn infants were analyzed. The neonatal mortality coefficient was 477‰, and the postneonatal mortality coefficient was 35‰, taking the hospital mortality coefficient to 512‰. The coefficient of early neonatal mortality was 335‰, and the coefficient of late neonatal mortality was 142‰. Mortality coefficients were higher in Fortaleza for all weight ranges than on the Vermont Oxford Network and were also, with the exception of the less than or equal to 600 g weight range, higher than in Montevideo. Conclusions: The results demonstrate high rates of hospital mortality among very low birth weight infants, with a greater concentration during the first week of life, suggesting that not only the care provided at the neonatal intensive care units is deficient, but also that prenatal and delivery-room care is inadequate.OBJECTIVE To obtain information on the hospital mortality of infants born in Fortaleza with birth weights less than or equal to 1,500 g, and to compare it with data from the Vermont Oxford Network, a center of excellence for neonatal care. METHODS Prospective cohort study, enrolling all infants with birth weight less than or equal to 1,500 g born in Fortaleza between March 1, 2002 and February 28, 2003 from all the hospitals and maternity units with neonatal intensive care units. Infants were followed from birth until hospital discharge or hospital death, using the Vermont Oxford Network questionnaire. RESULTS A total of 774 newborn infants were analyzed. The neonatal mortality coefficient was 477 per thousand, and the postneonatal mortality coefficient was 35 per thousand, taking the hospital mortality coefficient to 512 per thousand. The coefficient of early neonatal mortality was 335 per thousand, and the coefficient of late neonatal mortality was 142 per thousand. Mortality coefficients were higher in Fortaleza for all weight ranges than on the Vermont Oxford Network and were also, with the exception of the less than or equal to 600 g weight range, higher than in Montevideo. CONCLUSIONS The results demonstrate high rates of hospital mortality among very low birth weight infants, with a greater concentration during the first week of life, suggesting that not only the care provided at the neonatal intensive care units is deficient, but also that prenatal and delivery-room care is inadequate.

Nível socioeconômico e sua influência sobre a prevalência de sobrepeso e obesidade em escolares adolescentes do município de Fortaleza

Foi encontrada maior prevalencia de sobrepeso/obesidade nas classes de maior nivel socioeconomico (24,8%)em relacao as de menor nivel (17,4%). Os rapazes de maior nivel socioeconomico tiveram maiores taxas deprevalencia de sobrepeso/obesidade do que os de menor nivel, fato que nao foi observado entre as adolescentes.Constatou-se que, na fase de 10 a 14 anos, o excesso de peso era mais frequente nas classes mais altas, naoacontecendo essa diferenca entre 15 a 19 anos.

Quality of life in children with sleep-disordered breathing: evaluation by OSA-18

UNLABELLED Sleep-disordered breathing (SDB) is prevalent. There is evidence of their effect on quality of life. AIM To assess the quality of life in children with SDB before and after adenoidectomy or adenotonsillectomy. METHODS A prospective before and after interventional study, with a component for assessment. A consecutive sample of children referred to adenoidectomy or adenotonsillectomy was recruited from the otolaryngology clinic; guardians answered a specific survey for the evaluation of quality of life in children with SDB, the OSA-18, before and at least 30 days after surgery. Nasofibroscopic and otolaryngological exams and a semi-structured survey on the childs social and clinical profile were done on both appointments. RESULTS 48 children with a mean age of 5.93 years (SD=2.43) were evaluated. The mean number of schooling years for guardians was 8.29 years (SD=3.14). The most frequent symptoms were: agitated sleep, apnea and snoring. The total mean score of the initial OSA-18 was 82.83 (major impact); following surgery, the total mean score was 34.15. The differences in the total scores and in the domains between the initial OSA-18 and post-surgery scores were all significant (p<0.00). CONCLUSION SDB has a relevant impact on quality of life, and patients show dramatic improvements after surgical treatment.