Cynthia Braga da Cunha

Desigualdades raciais, sociodemográficas e na assistência ao pré-natal e ao parto, 1999-2001

OBJETIVO: Analisar as desigualdades sociais e no acesso e utilizacao dos servicos de saude em relacao a cor da pele em amostra representativa de puerperas que demandaram atencao hospitalar ao parto. METODOS: Trata-se de estudo transversal, realizado no Municipio do Rio de Janeiro, no qual foram amostradas 9.633 puerperas, sendo 5.002 brancas (51,9%), 2.796 pardas (29,0%) e 1.835 negras (19,0%), oriundas de maternidades publicas, conveniadas com o Sistema Unico de Saude e particulares no periodo de 1999 a 2001. Os dados foram coletados de prontuarios medicos e por entrevistas com as maes no pos-parto imediato, aplicando questionarios padronizados. Foram utilizados os testes de chi² para analisar a homogeneidade das proporcoes e t de Student para comparacao de medias. A analise foi estratificada segundo o grau de instrucao materna. RESULTADOS: Observou-se persistente situacao desfavoravel das mulheres de pele preta e parda em relacao as brancas. Nas mulheres pretas e pardas sao maiores as proporcoes de puerperas adolescentes, com baixa escolaridade, sem trabalho remunerado e vivendo sem companheiro. Sofrer agressao fisica, fumar, tentar interromper a gravidez e peregrinar em busca de atencao medica foram mais frequentes nas negras seguidas das pardas e das brancas com baixa escolaridade. O grupo de elevado nivel de escolaridade tem melhores indicadores, mas repete o mesmo padrao. Esse gradiente se mantem, em sentido inverso, quanto a satisfacao com a assistencia prestada no pre-natal e no parto. Constata-se a existencia de duas formas de discriminacao, por nivel educacional e cor da pele. CONCLUSOES: Verificaram-se dois niveis de discriminacao, a educacional e a racial, que perpassam a esfera da atencao oferecida pelos servicos de saude a populacao de puerperas do Municipio do Rio de Janeiro.

Avaliação da qualidade das variáveis epidemiológicas e demográficas do Sistema de Informações sobre Nascidos Vivos, 2002

This study evaluates the quality of data in the Brazilian Live Births Information System (SINASC), focusing on the methodological clarity of documentation and adequate data completeness and consistency at the national, regional, and State levels in 2002. The variables analyzed were: skin color/race of newborn, maternal schooling, maternal marital status, maternal occupation, maternal age, prenatal visits, live births, stillbirths, and birth weight. For most of the variables, SINASC shows good data completeness and consistency, but there were serious problems with the quality of data on previous children and maternal occupation. Related to race, there were some methodological problems in the definition and incomplete filling-in for the Federal District (Brasilia) and the States of Sao Paulo, Bahia, and Sergipe. Statistical analysis confirmed a significant association between data completeness and indicators of poverty and inequality. The study showed that improvements in SINASC data quality could make this system a good epidemiological source for identifying risk factors and socioeconomic conditioning factors.

Uso do índice de Kotelchuck modificado na avaliação da assistência pré-natal e sua relação com as características maternas e o peso do recém-nascido no Município do Rio de Janeiro

The Kotelchuck index (KI) was modified and used to evaluate prenatal care provided in the City of Rio de Janeiro, Brazil, in a sample of 9,920 post-partum women following singleton deliveries. Ordinal logistic regression (OLR) and multivariate linear regression (LMR) were used to estimate the importance of demographic, psychosocial, and obstetric factors for modified KI and the effects on birth weight (BW), respectively. Only 38.5% of the sample was classified as having received adequate or intensive prenatal care. After adjusting for other predictors, the explanatory variables for KI were: mothers schooling, living with the newborns father, attempted abortion, diabetes mellitus, satisfaction with pregnancy, skin color, parity, age, and place of residence. BW was associated with the modified KI, even after controlling for socio-demographic, behavioral, and biological variables. Adequate utilization of prenatal care in the City of Rio de Janeiro contributed to the prevention of low BW, and the mothers who used prenatal services less presented worse conditions in terms of socioeconomic status, schooling, family support, and obstetric risk.

Avaliação da qualidade das variáveis sócio-econômicas e demográficas dos óbitos de crianças menores de um ano registrados no Sistema de Informações sobre Mortalidade do Brasil (1996/2001)

This study aimed to evaluate the quality of socioeconomic and demographic data in the Brazilian Mortality Information System (SIM), in relation to infant mortality. The article assesses the systems potential for monitoring inequalities in infant mortality in various States in the country. Accessibility, timeliness, methodological clarity, incompleteness, and consistency were explored as quality indicators. Selected variables were: race, birth weight, gestational age, medical care, parity, and maternal schooling, age, and occupation. The study also reviewed the systems working documentation and the scientific literature on infant mortality. Proportions of data incompleteness were calculated by region and State, identifying factors that might influence (in)completeness using logistic regression. Despite the databases accessibility and the relevance of most of its variables, the system has serious quality problems: confusing instructions in the information manual concerning missing data, misclassification of maternal occupation, lack of data on the informants race/ethnicity, and high proportions of incomplete information. The system does not appear to be a reliable source for monitoring, evaluating, and planning measures to minimize infant health inequalities.

The decline in mortality from circulatory diseases in Brazil

OBJECTIVES Cardiovascular diseases are the leading cause of death in the world. Although mortality rates have declined gradually in developed countries, the scenario is less clear in developing countries. We describe the trends in cardiovascular mortality in Brazil over 24 years and investigate differences according to groups of diseases, sociopolitical region, gender, and age. METHODS We retrieved official data on mortality and population estimates to calculate standardized mortality rates in six age strata and in the five political regions from 1980 through 2003. The negative binomial distribution model was used to estimate trends for mortality separately for each gender, age group, and geopolitical region during this period. RESULTS Total cardiovascular standardized mortality rates decreased consistently over 24 years, from 287.3 to 161.9 per 100,000 inhabitants, with a mean annual decrease of 3.9%. Reductions in cardiovascular standardized mortality rates were detected in all strata and for all groups of diseases, with stroke exhibiting the largest average decline, from 95.2 to 52.6 per 100,000 inhabitants (mean 4.0% per year), followed by coronary disease, from 80.3 to 49.2 per 100,000 inhabitants (3.6% per year); the decrease was especially marked in the most developed regions. CONCLUSIONS Cardiovascular disease standardized mortality rates consistently decreased in Brazil during the study period. The reduction is apparently related to indices of increasing social development. Despite these encouraging findings, a gradual increase in the deaths from cardiovascular disease is expected in the next decades, and additional efforts in prevention are needed.

Progressive Decline in Stroke Mortality in Brazil From 1980 to 1982, 1990 to 1992, and 2000 to 2002

Background and Purpose— We describe the trends in stroke mortality in Brazil during 3 decades and investigate their differences according to regional disparities, sex, and age distributions. Methods— Official data on mortality and population estimates were retrieved to calculate standardized mortality rates (with the 1980 Brazilian population as a reference) in 6 age strata and in the 5 political regions for the initial period (3 first years) of the 1980, 1990, and 2000 decades. Data were corrected for undefined causes of death. The Poisson model was used to estimate risk reduction during the 3 decades and to study the interaction between those rates and sex, age strata, and regions. Results— The stroke standardized mortality rate decreased consistently in the last 20 years, from 68.2 to 40.9 per 100 000 habitants. This reduction paralleled a decrease in total cardiovascular mortality rates in the same period, from 208.2 to 126.1 per 100 000 habitants. The reduction in stroke standardized mortality rate was detected in men and women and in all age strata. The reduction was evident in all geopolitical regions of the country, with the wealthiest regions’ exhibiting higher initial rates and more marked standardized mortality rate reductions. The risk of dying of stroke in the period 2000 to 2002 was 0.45 (95% CI, 0.44 to 0.45) of that found in the period 1980 to 1982. Conclusions— The risk of dying of stroke in Brazil declined dramatically between the initial period in the early 1980s and the early 2000s. The decline was especially marked in the most developed regions and may reflect an improvement in general health conditions during the study period.

Consequences of sociodemographic inequalities on birth weight

OBJETIVO: Analisar as desigualdades sociodemograficas, na assistencia pre-natal e ao parto e suas consequencias sobre o peso ao nascer. METODOS: Estudo realizado em amostra de 10.072 puerperas atendidas em maternidades publicas, conveniadas com o Sistema Unico de Saude, e particulares do Municipio do Rio de Janeiro, no periodo de 1999-2001. Para verificar a associacao entre peso ao nascer e caracteristicas maternas, sociodemograficas, biologicas e da assistencia pre-natal (indice de Kotelchuck modificado), realizaram-se regressoes lineares multiplas, estratificando as puerperas segundo nivel de instrucao. Foi utilizada a tecnica de bootstrap com intervalos de confianca acurados para as estimativas dos efeitos. RESULTADOS: Na analise bivariada, para quase todas as variaveis estudadas, as medias de peso ao nascer foram menores entre as maes de escolaridade mais baixa. Na analise da regressao multipla para o grupo de baixa escolaridade, o peso ao nascer associou-se diretamente com o indice de Kotelchuck modificado e a idade gestacional, e inversamente com as variaveis cor da pele preta, habito de fumar e a experiencia de filhos prematuros anteriores. Idade materna e paridade tiveram comportamentos distintos nos extremos e na faixa central dos dados. No grupo de maior escolaridade somente a paridade, a idade gestacional e o indice de Kotelchuck modificado foram significativos e se associaram diretamente com o peso ao nascer. Verificou-se o papel protetor da assistencia pre-natal, assim como o efeito negativo do habito de fumar independente do nivel de escolaridade das maes. CONCLUSOES: As variaveis que explicaram o peso ao nascer dos neonatos de maes com elevada escolaridade foram de natureza biologica, em contraste com os determinantes sociais encontrados no grupo de baixa escolaridade.The objective was to analyze sociodemographic inequalities in prenatal and childbirth care and their consequences on birth weight. The study was based on a sample of 10072 postpartum women treated at public (those outsourced by the National Health System) and private maternity hospitals in Rio de Janeiro Brazil from 1999 to 2001. To test the association between birth weight and maternal sociodemographic and biological characteristics and prenatal care (modified Kotelchuck index) postpartum women were stratified by level of schooling and two multiple linear regressions were performed. The bootstrap technique was used in addition to accurate confidence intervals for the estimated effects. For nearly all of the variables analyzed in the bivariate analysis birth weight was lower among children of mothers with low schooling. In the multivariate analysis among women with low schooling there was a direct association between birth weight and the modified Kotelchuck index and gestational age. The variables black skin color smoking and history of premature birth were negatively associated with birth weight while maternal age and parity showed distinct behaviors from the central range of data at the extremes. In the group with high schooling only parity gestational age and modified Kotelchuck index were significant and directly associated with birth weight. The protective effect of prenatal care was observed as well as the negative effect of smoking regardless of the mothers level of schooling. The variables associated with neonates birth weight of mothers with high schooling in Rio de Janeiro were biological in contrast to the social determinants in the group with low schooling. (authors)OBJECTIVE: To analyze sociodemographic inequalities in prenatal and childbirth care and their consequences on birth weight. METHODS: The study was based on a sample of 10,072 postpartum women treated at public (those outsourced by the National Health System) and private maternity hospitals in Rio de Janeiro, Brazil, from 1999 to 2001. To test the association between birth weight and maternal sociodemographic and biological characteristics and prenatal care (modified Kotelchuck index), postpartum women were stratified by level of schooling and two multiple linear regressions were performed. The bootstrap technique was used in addition to accurate confidence intervals for the estimated effects. RESULTS: For nearly all of the variables analyzed in the bivariate analysis, birth weight was lower among children of mothers with low schooling. In the multivariate analysis, among women with low schooling, there was a direct association between birth weight and the modified Kotelchuck index and gestational age. The variables black skin color, smoking, and history of premature birth were negatively associated with birth weight, while maternal age and parity showed distinct behaviors from the central range of data at the extremes. In the group with high schooling, only parity, gestational age, and modified Kotelchuck index were significant and directly associated with birth weight. The protective effect of prenatal care was observed, as well as the negative effect of smoking, regardless of the mother’s level of schooling. CONCLUSIONS: The variables associated with neonates’ birth weight of mothers with high schooling in Rio de Janeiro were biological, in contrast to the social determinants in the group with low schooling.

Defeitos congênitos no Município do Rio de Janeiro, Brasil: uma avaliação através do SINASC (2000-2004)

To evaluate the occurrence of birth defects in the city of Rio de Janeiro, Brazil, using the Live Birth Information System (SINASC), we performed a cross-sectional study on all live newborns with birth defects from January 1, 2000, to December 31, 2004. The variables referred to birth defects (presence and system affected), type of health service, mothers, gestations, live births, and deliveries. Prevalence of birth defects was 83/10,000 live births. The most frequent birth defects involved the musculoskeletal system, central nervous system, cleft lip and palate, and chromosomal anomalies. The majority of cases were born in public (municipal) and private maternity hospitals, with the highest prevalence in the Fernandes Figueira Insitute, Oswaldo Cruz Foundation. Older women and those with less schooling had more live born infants with birth defects. The proportion of reports with missing information was high, reaching 21% in some institutions. Wider dissemination of SINASC data on birth defects should be encouraged. Reliability studies are recommended for better use of these reports.

Confiabilidade das informações das declarações de nascido vivo com registro de defeitos congênitos no Município do Rio de Janeiro, Brasil, 2004

This study assessed the reliability of birth certificate data related to birth defects in Brazils Live Birth Information System (SINASC). We selected 24 maternity hospitals in the Unified National Health System (SUS) and compared the reports of birth defects from birth certificates with medical records of mothers and live born infants in the city of Rio de Janeiro for the year 2004. After transposing the data to a specific form, the birth defects were coded by types and organ systems and compared to the SINASC data. The most commonly affected organs involved the central nervous and musculoskeletal systems. Agreement was more than 50% for the digestive, genitourinary, and musculoskeletal systems and chromosomal anomalies. Prevalence-adjusted kappa varied according to 2 or 3-digit ICD-10 analysis, with better results for the musculoskeletal, digestive, and genitourinary systems and congenital anomalies, and worse for the central nervous and cardio-circulatory systems, eye, neck, and ear malformations, and cleft lip and palate. The results were unsatisfactory, suggesting the need for more investments to train the persons responsible for completing birth certificates in maternity hospitals and develop a model for coding birth defects on these documents.

Consumo alimentar na gestação e no pós-parto segundo cor da pele no município do Rio de Janeiro

OBJETIVO: Avaliar o consumo alimentar durante a gestacao e pos-parto, segundo cor da pele. METODOS: Estudo longitudinal prospectivo que incluiu 467 mulheres entre 15 e 45 anos no periodo pos-parto, no municipio do Rio de Janeiro, entre 1999 e 2001. Foi aplicado um questionario de frequencia de consumo de alimentos aos 15 dias pos-parto (consumo referente ao periodo da gestacao) e aos seis meses (consumo referente ao periodo pos-parto). Foi utilizada analise de covariância para analisar diferencas no consumo alimentar, segundo cor da pele, controlada pela escolaridade. RESULTADOS: Durante a gestacao, pretas e pardas apresentaram consumo de energia 13,4% e 9,1% (p=0,009 e p=0,028) e consumo de carboidrato 15,1% e 10,5% maior que brancas (p=0,005 e p=0,014), respectivamente. Mulheres pretas e brancas apresentaram consumo energetico 34% e 20% acima das recomendacoes nutricionais, respectivamente (p=0,035). Durante o periodo pos-parto, as pretas apresentaram consumo de energia 7,7% maior e consumo de lipidios 14,8% maior que as brancas; consumo de acidos graxos saturados 23,8% maior que brancas (p=0,003) e 13% maior que pardas (p=0,046). A adequacao de consumo de lipidios e acidos graxos saturados foi maior em pretas que em brancas (p=0,024 e p=0,011, respectivamente). CONCLUSOES: Os resultados mostram ser necessario revisar estrategias de intervencao nutricional no pre-natal e implementar assistencia nutricional no pos-parto, para ajustar o consumo alimentar a niveis adequados, considerando as diferencas por cor/raca identificadas.