Iná S. Santos

Cohort Profile: The 2004 Pelotas (Brazil) Birth Cohort Study

The last decades of the 20th century witnessed a major epidemiological and nutritional transition in Latin America. Mortality due to infectious diseases and malnutrition declined in most countries and neonatal deaths now account for a growing proportion of infant deaths. In Brazil, infant mortality fell from 82.8 per 1000 live births in 1980 to 27.4 per 1000 in 2000. There were also marked improvements in undernutrition: 37.1% of Brazilian children <5 years of age were stunted in 1974 compared with 10.5% in 1996. Because of the speed of epidemiological and nutritional changes, and motivated by the successful implementation and follow-up of two previous population-based birth cohorts in 1982 and 1993, the research team decided to start a new cohort in 2004 to assess the magnitude of changes in maternal and child health status and their determinants. The existence of three prospective birth cohorts in the same population would provide a unique opportunity to study time trends over a 22-year span.

The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004

BACKGROUND Middle-income countries will need to drastically reduce neonatal deaths to achieve the Millennium Development Goal for child survival. The evolution of antenatal and perinatal care indicators in the Brazilian city of Pelotas from 1982 to 2004 provides a useful case study of potential challenges. METHODS We prospectively studied three birth cohorts representing all urban births in 1982, 1993, and from January to July, 2004. The same methods were used in all three studies. FINDINGS Despite improvements in maternal characteristics, prevalence of preterm births increased from 6.3% (294 of 4665) in 1982 to 16.2% (342 of 2112) in 2004, corresponding to a 47 g reduction in mean birthweight. Average number of antenatal visits in 2004 was 8.3 per woman, but quality of care was still inadequate--97% of women had an ultrasound scan, but only 1830 (77%) had a vaginal examination and 559 of 1748 non-immunised women did not receive tetanus toxoid. Rate of caesarean sections increased greatly, from 28% (1632 of 5914) in 1982 to 43% (1039 of 2403) in 2004, reaching 374 of 456 (82%) of all private deliveries in 2004. The increased rate of preterm births seemed to result largely from caesarean sections or inductions. Newborn care improved, and gestational-age-specific mortality rates had fallen by about 50% since 1982. As a result, neonatal mortality rates had been stable since 1990, despite the increase in preterm deliveries. INTERPRETATION Excessive medicalisation--including labour induction, caesarean sections, and inaccurate ultrasound scans--led by an unregulated private sector with spill-over effects to the public sector, might offset the gains resulting from improved maternal health and newborn survival. These challenges will have to be faced by middle-income countries striving to achieve the child survival Millennium Development Goal.

Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case›control study

Abstract Objective: To determine whether breast feeding protects infants against pneumonia and whether the protection varies with age. Design: Nested case-control study. Setting: Pelotas, southern Brazil. Subjects: Cases were 152 infants aged 28-364 days who had been admitted to hospital for pneumonia. Controls were 2391cases in a population based case-control study. Main outcome measure: Odds ratio of admission for pneumonia according to type of milk consumed (breast milk alone, breast and formula milk, or formula milk and other fluids only), use of fluid supplements apart from formula milk, and use of solid supplements. Results: Infants who were not being breast fed were 17 times more likely than those being breast fed without formula milk to be admitted to hospital for pneumonia (95% confidence interval 7.7 to 36.0). This relative risk was 61 (19.0 to 195.5) for children under 3 months old, decreasing to 10 (2.8 to 36.2) thereafter. Supplementation with solids was associated with a relative risk of 13.4 (7.6 to 23.5) for all infants and 175 (21.8to 1405.1) for those under 3 months old. Conclusion: Breast feeding protects young children against pneumonia, especially in the first months of life. These results may be used for targeting intervention campaigns at the most vulnerable age groups.

The 2004 Pelotas birth cohort: methods and description

OBJECTIVE To describe a birth cohort which started in 2004, aiming to assess pre and perinatal conditions of the newborns, infant morbimortality, early life characteristics and outcomes, and access, use and financing of health care. METHODS All children born in the urban area of Pelotas and Capão do Leão municipalities (Southern Brazil) in 2004 were identified and their mothers invited to join the study. In the first year of the study the children were seen at birth, at three and 12 months of age. These visits involved the application of a questionnaire to the mothers including questions on health; life style; use of health services; socioeconomic situation; estimation of gestational age; anthropometric measurements on the newborn (weight, length, head, chest and abdominal circumferences); anthropometric measurements on the mother (weight and height) and assessment of infant development. RESULTS Out of the eligible infants (4,558), more than 99% were recruited to the study at birth. Follow-up rates were 96% at three months and 94% at 12 months of age. Among the initial results we highlight the following. Infant mortality rate was 19.7 per thousand, with 66% of infant deaths occurring in the neonatal period. There were frequencies of 15% premature babies and 10% low birthweight. Cesarean sections represented 45% of deliveries. CONCLUSIONS The third Pelotas birth cohort showed an infant mortality rate similar to that of 11 years ago, with most deaths occurring in the neonatal period. The rates of prematurity and cesarean sections increased substantially.

Fatores individuais associados à utilização de consultas médicas por adultos

OBJETIVO: Identificar caracteristicas individuais associadas a maior probabilidade de consultar o medico e o fazer em excesso. METODOS: Estudo de base populacional com 3.100 adultos (>20 anos), moradores de Pelotas, Estado do Rio Grande do Sul, de outubro a dezembro de 2003. Foi utilizada amostragem por conglomerados em multiplos estagios. Foi realizada entrevista para obter dados socioeconomicos, demograficos e de saude, alem do numero de consultas no periodo de tres meses anteriores. A referencia de >4 consultas foi considerada superutilizacao. As analises multivariadas foram realizadas por regressao de Poisson baseadas em um modelo conceitual e apresentados em razoes de prevalencia e respectivos intervalos de confianca de 95%. RESULTADOS: A prevalencia de consulta ao medico foi de 55,1%. A maior probabilidade de consultar um medico esteve associada as mulheres, hospitalizacao no ano anterior, ex-tabagismo, diabetes e hipertensao arterial. Verificou-se tendencia de consultas conforme o avanco da idade (p<0,001) e piora da autopercepcao de saude (p<0,001). A prevalencia de superutilizacao de consultas foi de 9%, associada positivamente ao sexo feminino, hospitalizacao no ano anterior e historia de hipertensao. A tendencia de consultas em excesso esteve associada com aumento do indice de massa corporal (p=0,01), avanco da idade (p=0,006) e piora da autopercepcao de saude (p<0,001). CONCLUSOES: Estiveram associados a consulta e sua superutilizacao ser do sexo feminino, ser hipertenso e ter estado hospitalizado no ano anterior, alem do aumento de idade e piora da autopercepcao de saude.

Validation of the Edinburgh Postnatal Depression Scale (EPDS) in a sample of mothers from the 2004 Pelotas Birth Cohort Study

The aim of this study was to evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening and diagnosis of postpartum depression. Three months after delivery, EPDS was administered to 378 mothers from the 2004 Pelotas Birth Cohort Study, Rio Grande do Sul State, Brazil. Up to 15 days later, mothers were re-interviewed by mental health care professionals using a semi-structured interview based on ICD-10 (gold standard). We calculated the sensitivity and specificity of each cutoff point, and values were plotted as a receiver operator characteristic curve. The best cutoff point for screening postpartum depression was > 10, with 82.6% (75.3-89.9%) sensitivity and 65.4% (59.8-71.1%) specificity. For screening moderate and severe cases, the best cutoff point was > 11, with 83.8% (73.4-91.3%) sensitivity and 74.7% (69.4-79.5%) specificity. For diagnosis, EPDS was valid only for prevalence of postpartum depression in the 20-25% range, with 60% PPV for the > 13 cutoff point (59.5% sensitivity; 88.4% specificity). The specificities and PPVs for all cutoff points were below those reported by other authors. Small numbers and the calculation of PPV in samples with overrepresentation of cases in the majority of studies appear to account for these differences.

Aumento da prematuridade no Brasil: revisão de estudos de base populacional

OBJECTIVE The greatest cause of infant mortality in Brazil is perinatal conditions, mostly associated with preterm delivery. The objective of the study was to evaluate the evolution of preterm delivery rates in Brazil. METHODS A review was conducted using the Medline and Lilacs databases, including published studies in periodicals, thesis and dissertations since 1950. Exclusion criteria were: studies related to clinical trials and those with complications at gestation and preterm delivery and care. Inclusion criteria were: population-based studies on prevalence of preterm delivery in Brazil, with representative sample of the studied population, and using primary data. Out of 71 studies found, analysis was carried out on 12. RESULTS The prevalence of preterm delivery found ranged from 3.4% to 15.0% in the Southern and Southeastern regions between 1978 and 2004, with a rising trend from the 1990s onwards. Studies in the Northeastern region between 1984 and 1998 found prevalences of preterm delivery ranging from 3.8% to 10.2%, also with a rising trend. CONCLUSIONS Data from the national live birth information system do not corroborate these trends. Rather, they show differences between the preterm rates given by this system and the rates measured in the studies included in this review. Because of the important role of preterm birth in relation to infant mortality in Brazil, it is important to identify the cause of these increases and to plan interventions that can diminish their occurrence.OBJETIVO: A maior causa de mortalidade infantil no Brasil sao condicoes perinatais, associadas em sua maioria a prematuridade. O objetivo do estudo foi avaliar a evolucao das taxas de prematuridade no Brasil. METODOS: Foi realizada revisao nas bases de dados Medline e Lilacs, incluindo estudos publicados em periodicos, teses e dissertacoes, desde 1950. Os criterios de exclusao foram: estudos que se referiam a temas clinicos, com complicacoes da prematuridade e gestacao, bem como cuidados com prematuros. Os criterios de inclusao foram: estudos de base populacional sobre prevalencia de prematuridade com dados do Brasil, com amostra representativa do local do estudo e com dados primarios. De 71 estudos encontrados, a analise foi realizada com 12. RESULTADOS: A prevalencia de prematuridade variou de 3,4% a 15,0% nas regioes Sul e Sudeste, entre 1978 e 2004, sugerindo tendencia crescente a partir da decada de 1990. Estudos na regiao Nordeste, entre 1984 e 1998, encontraram prevalencias de prematuridade de 3,8% a 10,2%, tambem com tendencia a aumentar. CONCLUSOES: Dados do Sistema de Informacoes de Nascidos Vivos nao corroboram este aumento, pois mostram diferencas entre as taxas de prematuridade informadas por esse Sistema e as taxas medidas nos estudos incluidos nesta revisao. Devido ao importante papel da prematuridade na mortalidade infantil no Brasil e importante identificar as causas deste aumento e planejar intervencoes que diminuam sua ocorrencia.

Atenção pré-natal na rede básica: uma avaliação da estrutura e do processo

Realizou-se estudo transversal descritivo e auditoria de registros medicos para avaliar a estrutura e o processo de atendimento pre-natal nas unidades de atencao primaria a saude em Pelotas, Sul do Brasil. Para a investigacao da estrutura, foram incluidas todas as 31 unidades da zona urbana. No estudo do processo revisou-se os registros de pre-natal das maes com data provavel de parto nos 6 meses anteriores ao inicio do trabalho de campo, num total de 839 formularios. A estrutura foi considerada precaria (70% da ideal), principalmente devido a deficiencias da planta fisica. Quanto ao processo, observaram-se uma baixa cobertura (53%) e media de consultas de 5,3. O pre-natal foi adequado em somente 37% dos registros (Indice de Kessner). Adicionando-se exames laboratoriais e procedimentos da consulta como criterios complementares, 31% e 5% dos registros foram considerados adequados, respectivamente. De um modo geral, a qualidade do cuidado pre-natal oferecido foi precaria. Mecanismos que aumentem a aderencia das equipes de saude aos procedimentos e a logica do programa, necessitam ser desenvolvidos.

Socio-economic and ethnic group inequities in antenatal care quality in the public and private sector in Brazil

BACKGROUND Socio-economic inequalities in maternal and child health are ubiquitous, but limited information is available on how much the quality of care varies according to wealth or ethnicity in low- and middle-income countries. Also, little information exists on quality differences between public and private providers. METHODS Quality of care for women giving birth in 2004 in Pelotas, Brazil, was assessed by measuring how many of 11 procedures recommended by the Ministry of Health were performed. Information on family income, self-assessed skin colour, parity and type of provider were collected. RESULTS Antenatal care was used by 98% of the 4244 women studied (mean number of visits 8.3), but the number of consultations was higher among better-off and white women, who were also more likely to start antenatal care in the first trimester. The quality of antenatal care score ranged from 0 to 11, with an overall mean of 8.3 (SD 1.7). Mean scores were 8.9 (SD 1.5) in the wealthiest and 7.9 (SD 1.8) in the poorest quintiles (P < 0.001), 8.4 (SD 1.6) in white and 8.1 (SD 1.9) in black women (P < 0.001). Adjusted analyses showed that these differences seemed to be due to attendance patterns rather than discrimination. Mean quality scores were higher in the private 9.3 (SD 1.3) than in the public sector 8.1 (SD 1.6) (P < 0.001); these differences were not explained by maternal characteristics or by attendance patterns. CONCLUSIONS Special efforts must be made to improve quality of care in the public sector. Poor and black women should be actively encouraged to start antenatal care early in pregnancy so that they can fully benefit from it. There is a need for regular monitoring of antenatal attendances and quality of care with an equity lens, in order to assess how different social groups are benefiting from progress in health care.

Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off

OBJETIVO: Describir el padron de los partos en una cohorte de nacimientos, comparando partos normales y cesareos. METODOS: Todos los recien nacidos de moradoras de area urbana de Pelotas (Sur de Brasil) en 2004 fueron reclutados para una cohorte de nacimientos. Las madres fueron entrevistadas aun en el hospital, cuando informaciones detalladas de la gestacion, el parto y el recien nacido, junto con una historia de salud materna y caracteristicas de la familia fueron colectadas. Caracteristicas maternas y el financiamiento del parto fueron los principales factores estudiados. Tambien se hizo descripcion de la distribucion de las cesareas por hora del dia y dia de la semana. Tecnicas de padron de analisis descriptivo y pruebas chi-cuadrado para comparar proporciones y regresion Poisson para explorar el efecto independiente de predictores de la cesarea fueron los metodos utilizados. RESULTADOS: La tasa global de cesareas fue de 45%, 36% entre pacientes del servicio publico y 81% en el servicio privado, donde se relato que 35% de las cesareas fueron electivas. Las cesareas fueron mas frecuentes martes y miercoles, con una reduccion de cerca de un tercio los domingos, mientras que los partos normales presentaron distribucion uniforme a lo largo de la semana. El horario de las cesareas en el servicio publico y en el privado fue muy diferente. La escolaridad materna se asocio positivamente con la cesarea entre las madres del servicio publico, pero no del privado. CONCLUSIONES: La cesarea fue muy frecuente entre las madres mas ricas, y fuertemente asociada con la escolaridad materna entre pacientes del servicio publico. Los padrones descritos son compatibles con la hipotesis de que las cesareas son hechas, en gran parte, para atender la conveniencia de las agendas de los medicos. La situacion actual solo sera revertida con politicas radicales.OBJECTIVE To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries. METHODS All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing - either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, Χ² tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used. RESULTS The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients. CONCLUSIONS C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctors schedule. Drastic action is called for to change the current situation.