Márcia Lazaro de Carvalho

Fatores associados à amamentação na primeira hora de vida

OBJECTIVE To identify factors associated with breastfeeding in the first hour of life (Step 4 of the Baby-Friendly Hospital Initiative). METHODS A cross-sectional study was conducted with a representative sample of mothers who gave birth in maternity wards in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2001. Newborns or mothers with restriction to breastfeeding were excluded, resulting in a sample of 8,397 pairs. A random effect--at maternity hospital level--Poisson model was employed in a hierarchical approach with three levels: distal, intermediate and proximal for characteristics of the mother, of the newborn, and of prenatal and hospital assistance. RESULTS Only 16% of the mothers breastfed in the first hour of life. Breastfeeding in this period was less prevalent among neonates with immediate intercurrences after birth (PR = 0.47; CI99% 0.15;0.80); among mothers who did not have contact with their newborns in the delivery room (PR = 0.62; CI99% 0.29;0.95); among mothers submitted to cesarean section delivery (PR = 0.48; CI99% 0.24;0.72); and among mothers who gave birth at private maternity hospitals (PR = 0.06; CI99% 0.01;0.19) or at maternity hospitals contracted out to National Health System (SUS) (PR = 0.16; CI99% 0.01;0.30). The context effect of maternity wards was statistically significant. CONCLUSIONS At an individual level, breastfeeding within one hour after birth was constrained by inappropriate practices in private or SUS-contracted maternity hospitals. The group effect of maternity hospitals and the absence of individual maternal-related factors that explain the outcome suggest that mothers have little or no autonomy to breastfeed their babies within the first hour of life, and depend on the institutional practices that prevail at the maternity hospitals.OBJETIVO: Identificar fatores associados a amamentacao na primeira hora de vida (Passo 4 da Iniciativa Hospital Amigo da Crianca). METODOS: Foi realizado estudo transversal com amostra representativa de parturientes em maternidades do Rio de Janeiro, RJ, entre 1999 e 2001. Foram excluidos recem-nascidos ou maes com restricao ao aleitamento materno, resultando em amostra de 8.397 binomios. Foi adotado modelo Poisson com efeitos aleatorios ao nivel das maternidades, em abordagem hierarquizada com tres niveis: distal, intermediario e proximal para caracteristicas maternas, do recem-nascido, e de assistencia ao pre-natal e hospitalar. RESULTADOS: Amamentaram na primeira hora de vida 16% das maes. O aleitamento materno nesse periodo foi menos prevalente entre os recem-nascidos com intercorrencias imediatas apos o parto (RP = 0,47; IC99% 0,15;0,80); entre as maes que nao tiveram contato com os recem-nascidos na sala de parto (RP = 0,62; IC99% 0,29;0,95), as que tiveram parto cesariano (RP = 0,48; IC99% 0,24;0,72); e cujo parto ocorreu em maternidade privada (RP = 0,06; IC99% 0,01;0,19) ou conveniada com o Sistema Unico de Saude (RP = 0,16; IC99% 0,01;0,30). O efeito de contexto das maternidades foi estatisticamente significativo. CONCLUSOES: Em nivel individual, a amamentacao na primeira hora de nascimento foi prejudicada por praticas inadequadas nas maternidades, em particular as privadas e conveniadas com o Sistema Unico de Saude. O efeito de grupo das maternidades e a ausencia de fatores individuais maternos que expliquem o desfecho sugerem que as maes tem pouco ou nenhum poder de decisao sobre essa amamentacao e dependem das praticas institucionais vigentes nas maternidades.

Fatores que interferem no tempo entre o nascimento e a primeira mamada

The current study investigated factors associated with time between birth and first breastfeeding. A representative sample of mothers (10% of deliveries in 47 maternity hospitals in Rio de Janeiro, Brazil) was interviewed (n = 10,077). A random effects proportional risks survival model (at the maternity ward level) was employed, in a three-tier hierarchical approach. Models were fitted separately for normal and cesarean delivery. Time to initiation of breastfeeding in the first 24 hours of life differed between mothers with vaginal delivery (median 4 hours) versus cesarean section (10 hours). Common risk and protective factors were identified: maternal age; neonatal complications; neonatal care considered sub-optimal by the mother; admission of the newborn to the nursery; parity; birth weight. The model predicted 33% of variance in first breastfeeding. In conclusion, time from delivery to first breastfeeding was increased by biological factors, high cesarean rates, and inadequate childbirth and neonatal care practices.

Breastfeeding during the first hour of life and neonatal mortality

OBJECTIVE To analyze the correlation between breastfeeding in the first hour of life with neonatal mortality rates. METHODS The present study used secondary data from 67 countries, obtained from the Demographic and Health Surveys. Initially, for data analysis, Spearman Correlation (95% CI) and Kernel graphical analysis were employed, followed by a Negative Binomial Pois- son regression model, adjusted for potential confounders. RESULTS Breastfeeding within the first hour of life was negatively correlated with neo- natal mortality (Spearmans Rho = -0.245, p = 0.046), and this correlation was stronger among countries with more than 29 neonatal deaths per 1000 newborns (Spearmans Rho = -0.327, p = 0.048). According to the statistical model, countries with the lowest breastfeeding tertiles had 24% higher neonatal mortality rates (Rate ratio = 1.24, 95% CI = 1.07-1.44, p < 0.05), even when adjusted for potential confounders. CONCLUSION The protective effect of breastfeeding during the first hour of life on neo- natal mortality in this ecological study is consistent with findings from previous observa- tional studies, indicating the importance of adopting breastfeeding within the first hour as a routine neonatal care practice.

Proposta de modelo hierarquizado aplicado à investigação de fatores de risco de óbito infantil neonatal

Theoretical-conceptual models aim to integrate social, biological, behavioral, and other factors and to explain their interrelations in the determination of health outcomes. In the case of determination of neonatal death in Brazil, few studies have analyzed the mechanisms by which numerous variables and constructs interrelate. This article offers a theoretical discussion of the possible components of a hierarchical framework for studying neonatal mortality. The proposed model sought to include factors that have traditionally been identified as relevant to the occurrence of neonatal death and others that have been studied more recently (like race, social support, and violence during pregnancy). The components were distributed in 11 dimensions allocated to four hierarchical levels (one distal, two intermediary, and one proximal). The proposed framework should be adjusted to the Brazilian reality for neonatal death in large cities and raises various aspects for discussion that have not been explored previously in Brazil.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliacao de prontuarios de 23.940 puerperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para analise dos potenciais fatores de risco para o obito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regioes Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condicoes do recem-nascido foram os principais fatores associados ao obito neonatal. A inadequacao do pre-natal e da atencao ao parto indicaram qualidade nao satisfatoria da assistencia. A peregrinacao de gestantes para o parto e o nascimento de criancas com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organizacao da rede de saude. Obitos de recem-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos obitos. A qualificacao da atencao, em especial da assistencia hospitalar ao parto se configura como foco prioritario para maiores avancos nas politicas publicas de reducao das taxas e das desigualdades na mortalidade infantil no Brasil.This study examined neonatal deaths in the live-births cohort in the Birth in Brazil survey, which interviewed and examined medical records of 23,940 mothers from February 2011 to October 2012. Potential risk factors were analyzed using hierarchical modeling. Neonatal mortality rate was 11.1/1,000, the highest rates occurring in the North and Northeast regions and in lower social classes. Low birth weight, risks during pregnancy and conditions of the newborn were the main factors associated with neonatal death. Inadequate prenatal and childbirth care point to unsatisfactory quality of health care. Difficulty in gaining hospital admission for delivery, and children with birth weight<1,500g born at hospitals without a neonatal intensive care unit, indicate gaps in health system organization. Deaths from intra-partum asphyxia in term babies and late prematurity express preventable neonatal mortality. Better quality health care, especially hospital care during labor and birth, poses the main public policy challenge to progress in reducing mortality and inequalities in Brazil.

Fatores de risco para morte por pneumonia em menores de um ano em uma região metropolitana do sudeste do Brasil: um estudo tipo caso-controle

In a case-control study, a sample of post-neonatal deaths from pneumonia occurring in the Metropolitan Area of Rio de Janeiro, Brazil (1986-1987) were compared with healthy controls who lived in the same neighborhood. Risk factors investigated were variables related to the mothers pregnancy history and the childs birth, to the familys social condition and to the use of health services. Using the univariate logistic regression model, the coefficients of each independent variable, the relative risk and its confidence limits were first estimated. Birth weight and age of weaning were strongly associated with the dependent variable. After adjustment by means of the multiple logistic regression model, only 4 variables remained statistically associated with mortality: age of weaning, birth weight, over crowding, and BCG vaccination. Based on the available data, it was concluded that mortality from pneumonia in children under 1 year of age is significantly related to the social condition of the family, particularly to that of the mother.Atraves de um estudo tipo caso-controle, foi comparada uma amostra de obitos pos-neonatais por pneumonia ocorridos na Regiao Metropolitana do Rio de Janeiro, Brasil (1986-1987) e controles sadios, moradores na vizinhanca. Os fatores de risco investigados foram variaveis relacionadas a historia gestacional da mae e ao nascimento da crianca, as condicoes sociais da familia e a utilizacao de servicos de saude. Na primeira etapa de analise, atraves de um modelo de regressao logistica univariada, foram estimados os coeficientes de cada variavel independente, o risco relativo e seus limites de confianca. O peso ao nascer e a idade do desmame mostraram-se das mais fortemente associadas com a variavel dependente. Na segunda etapa, foi feito o ajuste pelo modelo de regressao logistica multipla e somente 4 variaveis permaneceram estatisticamente associadas com a mortalidade: idade do desmame, peso ao nascer, numero de moradores da casa e aplicacao da vacina BCG. Conclui-se que a mortalidade por pneumonia em menores de um ano esta fortemente associada as condicoes sociais da familia, em particular da mae.

Factors associated with exclusive breastfeeding in the first six months of life in Brazil: a systematic review

ABSTRACT OBJECTIVE To identify factors associated with exclusive breastfeeding in the first six months of life in Brazil. METHODS Systematic review of epidemiological studies conducted in Brazil with exclusive breastfeeding as outcome. Medline and LILACS databases were used. After the selection of articles, a hierarchical theoretical model was proposed according to the proximity of the variable to the outcome. RESULTS Of the 67 articles identified, we selected 20 cross-sectional studies and seven cohort studies, conducted between 1998 and 2010, comprising 77,866 children. We identified 36 factors associated with exclusive breastfeeding, being more often associated the distal factors: place of residence, maternal age and education, and the proximal factors: maternal labor, age of the child, use of a pacifier, and financing of primary health care. CONCLUSIONS The theoretical model developed may contribute to future research, and factors associated with exclusive breastfeeding may subsidize public policies on health and nutrition.

Concordância na determinação da causa básica de óbito em menores de um ano na região metropolitana do Rio de Janeiro, 1986

An evaluation was undertaken, during the assessment of the quality of the filling up of death certificates, with the purpose of evaluating the agreement, in the determination of the basic cause of death, between the physician who certified the death and a medical team which examined the information provided by hospital records. This survey included the analysis of a sample of deaths among children under one year of age which occurred in the Metropolitan Region of Rio de Janeiro (Brazil) in the period from May 1986 to April 1987. As regards neonatal deaths, the greatest concentration of causes of death is perinatal and, despite the changes that have been observed, the composition of the main groups of causes presented no significant alteration. However, within the perinatal group, those generically classified or poorly defined causes were reduced by about 50% and new certificates were made out. Among post-neonatal deaths, we found significant changes, particularly for deaths caused by pneumonia and malnutrition. Given the great interrelation observed among the major causes of death within this group (pneumonia, diarrhoea, malnutrition), it is believed that the investigation of multiple causes of death would provide a more accurate, overall notion of the process that led to death, thus allowing the formulation of a more comprehensive view.No âmbito de um estudo sobre a qualidade do preenchimento da Declaracao de Obito, avaliou-se a concordância na determinacao da causa basica da morte entre o medico que atestou o obito e a equipe de medicos que avaliou informacoes do prontuario hospitalar. Estudou-se uma amostra de obitos de menores de um ano ocorridos na Regiao Metropolitana do Rio de Janeiro, RJ (Brasil), de maio de 1986 a abril de 1987. Para os obitos neonatais, as causas perinatais concentraram a maior parte dos obitos e apesar das mudancas observadas, a composicao entre os principais grupos nao se alterou de modo importante. No interior do grupo de causas perinatais, conseguimos reduzir as causas classificadas de maneira generica ou mal definidas em cerca de 50% com o preenchimento do novo atestado. Para os obitos pos-neonatais, foram encontradas alteracoes significativas, em especial para os obitos causados por pneumonia e desnutricao. Dado o grande inter-relacionamento observado entre as principais causas de morte neste grupo (pneumonia, diarreia, desnutricao), considerou-se que a apuracao das causas multiplas de morte daria uma ideia mais ampla e correta do processo que resultou na morte, permitindo uma visao mais globalizante da questao.

Breastfeeding can prevent hospitalization for pneumonia among children under 1 year old

OBJECTIVE To evaluate the relationship between breastfeeding and hospitalization for pneumonia among children under 1 year old. METHODS Ecological study using secondary data of hospitalizations for pneumonia (outcome) and breastfeeding prevalence data (exposure) among children under 1 year old living in the Brazilian state capital cities and the Federal District in 2008. A negative binomial model of hospitalization was used to estimate the rate ratio (95% confidence interval), adjusted according to the Gini Index, and the prevalence rates of smokers in the general population and low birth weight individuals in the population investigated. RESULTS Breastfeeding prevalence among children between 9 and 12 months old and exclusive breastfeeding prevalence among children under 6 months old were associated with a lower rate ratio of hospitalization for pneumonia (RR = 0.62; 95%CI 0.51-0.74 and RR = 0.52; 95%CI 0.39-0.69, respectively). CONCLUSION Increased prevalence rates of breastfeeding during the first year of life and exclusive breastfeeding during the first 6 months of life can reduce the number of hospitalizations for pneumonia.

Factors associated with breastfeeding in the first hour of life

OBJECTIVE To identify factors associated with breastfeeding in the first hour of life (Step 4 of the Baby-Friendly Hospital Initiative). METHODS A cross-sectional study was conducted with a representative sample of mothers who gave birth in maternity wards in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2001. Newborns or mothers with restriction to breastfeeding were excluded, resulting in a sample of 8,397 pairs. A random effect--at maternity hospital level--Poisson model was employed in a hierarchical approach with three levels: distal, intermediate and proximal for characteristics of the mother, of the newborn, and of prenatal and hospital assistance. RESULTS Only 16% of the mothers breastfed in the first hour of life. Breastfeeding in this period was less prevalent among neonates with immediate intercurrences after birth (PR = 0.47; CI99% 0.15;0.80); among mothers who did not have contact with their newborns in the delivery room (PR = 0.62; CI99% 0.29;0.95); among mothers submitted to cesarean section delivery (PR = 0.48; CI99% 0.24;0.72); and among mothers who gave birth at private maternity hospitals (PR = 0.06; CI99% 0.01;0.19) or at maternity hospitals contracted out to National Health System (SUS) (PR = 0.16; CI99% 0.01;0.30). The context effect of maternity wards was statistically significant. CONCLUSIONS At an individual level, breastfeeding within one hour after birth was constrained by inappropriate practices in private or SUS-contracted maternity hospitals. The group effect of maternity hospitals and the absence of individual maternal-related factors that explain the outcome suggest that mothers have little or no autonomy to breastfeed their babies within the first hour of life, and depend on the institutional practices that prevail at the maternity hospitals.OBJETIVO: Identificar fatores associados a amamentacao na primeira hora de vida (Passo 4 da Iniciativa Hospital Amigo da Crianca). METODOS: Foi realizado estudo transversal com amostra representativa de parturientes em maternidades do Rio de Janeiro, RJ, entre 1999 e 2001. Foram excluidos recem-nascidos ou maes com restricao ao aleitamento materno, resultando em amostra de 8.397 binomios. Foi adotado modelo Poisson com efeitos aleatorios ao nivel das maternidades, em abordagem hierarquizada com tres niveis: distal, intermediario e proximal para caracteristicas maternas, do recem-nascido, e de assistencia ao pre-natal e hospitalar. RESULTADOS: Amamentaram na primeira hora de vida 16% das maes. O aleitamento materno nesse periodo foi menos prevalente entre os recem-nascidos com intercorrencias imediatas apos o parto (RP = 0,47; IC99% 0,15;0,80); entre as maes que nao tiveram contato com os recem-nascidos na sala de parto (RP = 0,62; IC99% 0,29;0,95), as que tiveram parto cesariano (RP = 0,48; IC99% 0,24;0,72); e cujo parto ocorreu em maternidade privada (RP = 0,06; IC99% 0,01;0,19) ou conveniada com o Sistema Unico de Saude (RP = 0,16; IC99% 0,01;0,30). O efeito de contexto das maternidades foi estatisticamente significativo. CONCLUSOES: Em nivel individual, a amamentacao na primeira hora de nascimento foi prejudicada por praticas inadequadas nas maternidades, em particular as privadas e conveniadas com o Sistema Unico de Saude. O efeito de grupo das maternidades e a ausencia de fatores individuais maternos que expliquem o desfecho sugerem que as maes tem pouco ou nenhum poder de decisao sobre essa amamentacao e dependem das praticas institucionais vigentes nas maternidades.