Maria Teresa Seabra Soares de Britto e Alves

Factors associated with inadequacy of prenatal care utilization

OBJECTIVE To identify factors associated with inadequacy of prenatal care utilization in urban community. METHODS A cross-sectional study of a systematic sample stratified by maternity hospital, consisting of hospital births in the municipality of São Luís, Brazil, was carried out from March 1997 to February 1998. Socioeconomic and demographic factors, reproductive health, morbidity during pregnancy, and utilization of prenatal care services were studied. Mothers answered a standardized questionnaire before hospital discharge. The adequacy of prenatal care utilization was analyzed by means of two indexes: APNCU (Adequacy of Prenatal Care Utilization) and a new index based on the recommendations of the Brazilian Ministry of Health. RESULTS There were interviewed 2,831 women who delivered at 10 public and private maternity hospitals. The inadequacy of prenatal care utilization was 49.2% according to the APNCU index and 24.5% when determined by the Brazilian index. Prenatal care at public services, low maternal schooling, low income, having no partner, and absence of maternal diseases during pregnancy were associated with inadequacy of prenatal care use according to both indexes. High parity and maternal age of 35 years or more were also associated with inadequacy, whereas primiparity, morbidity, and young maternal age (<20 years) seemed to protect from inadequacy when the Brazilian index was used. CONCLUSIONS Prenatal care showed low coverage in the municipality of São Luís. The inadequacy of prenatal care utilization was associated with several factors linked to social inequality.

Early Growth and Neurologic Outcomes of Infants with Probable Congenital Zika Virus Syndrome

We report the early growth and neurologic findings of 48 infants in Brazil diagnosed with probable congenital Zika virus syndrome and followed to age 1–8 months. Most of these infants had microcephaly (86.7%) and craniofacial disproportion (95.8%). The clinical pattern included poor head growth with increasingly negative z-scores, pyramidal/extrapyramidal symptoms, and epilepsy.

Qualidade da atenção ao aborto no Sistema Único de Saúde do Nordeste brasileiro: o que dizem as mulheres?

Abortion is a serious health problem in Brazil and complications can be avoided by adequate and timely care. The article evaluates the quality of care given to women admitted for abortion in hospitals operated by the Unified Health System, in Salvador, Recife and Sao Luis, the benchmarks being Ministry of Health norms and user satisfaction. The article analyzes 2804 women admitted to hospital for abortion complications in 19 hospitals, between August and December 2010. Four dimensions were defined: reception and guidance; inputs and physical environment; technical quality and continuity of care. There was a closer fit to norms on reception and guidance. Social support and the right to information were not well rated in all three cities. The technical quality of care was rated poor. With respect to inputs and physical environment, cleanliness was the least adequate criterion. Continuity of care was the most critical situation in all three cities, due to the lack of scheduled follow-up appointments, information about care available after hospital discharge, the risk of further pregnancy and family planning. Abortion care falls short of that advocated under Brazilian norms and by international agencies.

Prevalencia e fatores associados a desnutricao e ao excesso de peso em menores de cinco anos nos seis maiores municipios do Maranhao

Prevalences of malnutrition and overweight among children under five years and its association with socioeconomic, demographic and health indicators were estimated for the six largest municipalities of Maranhao, in 2006/2007. By means of a household survey, a sample of 1214 children under five years of age was randomly selected. Two-stage cluster sampling was used, representing the six municipalities of Maranhao with over one hundred thousand inhabitants. Standardized questionnaire was administered to mothers or guardians and trained personnel measured weight and height or length. For classification of malnutrition cutoff points of +2 z score, following World Health Organization guidelines. By weight-for-age malnutrition prevalence was 4.5, by length/height-for-age 8.5% were stunted and by the weight-for-length/height 3.9% were malnourished (wasting), while 6.7% were overweight. Children of families headed by women had lower prevalence of malnutrition (prevalence ratio=0.4). Socioeconomic variables were not associated with malnutrition or overweight. Participation in money transfer programs from the government was not associated with malnutrition or overweight. The prevalence of malnutrition was low, but being overweight was more prevalent than malnutrition. Social inequality was not detected in relation to malnutrition in children under five years of age, suggesting a favorable trend towards greater equity.

The variability and predictors of quality of AIDS care services in Brazil.

BackgroundSince establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery.MethodsThe survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality.ResultsThe questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities.ConclusionThe survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Water-contact patterns and risk factors for Schistosoma mansoni infection in a rural village of Northeast Brazil

Schistosomiasis mansoni in the Serrano village, municipality of Cururupu, state of Maranhão, Brazil, is a widely spread disease. The PECE (Program for the Control of Schistosomiasis), undertaken since 1979 has reduced the prevalence of S. mansoni infection and the hepatosplenic form of the disease. Nevertheless piped water is available in 84% of the households, prevalence remains above 20%. In order to identify other risk factors responsible for the persistence of high prevalence levels, a cross-sectional survey was carried out in a systematic sample of 294 people of varying ages. Socioeconomic, environmental and demographic variables, and water contact patterns were investigated. Fecal samples were collected and analyzed by the Kato-Katz technique. Prevalence of S. mansoni infection was 24.1%, higher among males (35.5%) and between 10-19 years of age (36.6%). The risk factors identified in the univariable analysis were water contacts for vegetable extraction (Risk Ratio--RR = 2.92), crossing streams (RR = 2.55), bathing (RR = 2.35), fishing (RR = 2.19), hunting (RR = 2.17), cattle breeding (RR = 2.04), manioc culture (RR = 1.90) and leisure (RR = 1.56). After controlling for confounding variables by proportional hazards model the risks remained higher for males, vegetable extraction, bathing in rivers and water contact in rivers or in periodically inundated parts of riverine woodland (swamplands).

Avaliação de serviços de assistência ambulatorial em aids, Brasil: estudo comparativo 2001/2007

OBJETIVO: Avaliar os servicos do Sistema Unico de Saude brasileiro de assistencia ambulatorial a adultos vivendo com aids em 2007 e comparar com a avaliacao de 2001. METODOS: Os 636 servicos cadastrados no Ministerio da Saude em 2007 foram convidados a responder a um questionario previamente validado (Questionario Qualiaids) com 107 questoes de multipla escolha sobre a organizacao da assistencia prestada. Analisaram-se as frequencias das respostas de 2007 comparando-as com as obtidas em 2001 na forma de variacao percentual (VP). RESULTADOS: Responderam o questionario 504 (79,2%) servicos. Cerca de 100,0% dos respondentes relataram ter pelo menos um medico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. Varios aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de numero de faltas a consulta medica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no inicio da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participacao organizada do usuario (de 5,9 para 16,7%, VP: 183,1%). Houve manutencao de dificuldades: pequena variacao na disponibilidade de exames especializados em ate 15 dias, como endoscopia (31,9 para 34,5%, VP: 8,1%), e a piora de indicadores como tempo ideal de acesso a consultas especializadas (55,9 para 34,5% em cardiologia, VP negativa de 38,3%). O tempo medio despendido nas consultas medicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%). CONCLUSOES: A avaliacao de 2007 mostrou que os servicos contam com os recursos essenciais para a assistencia ambulatorial. Houve melhoras em muitos aspectos em relacao a 2001, mas persistem desafios. Pouco tempo dedicado a consulta medica pode estar vinculado ao numero insuficiente de medicos e/ou a baixa capacidade de escuta e dialogo. A acessibilidade prejudicada a consultas especializadas mostra a dificuldade das infraestruturas locais do Sistema Unico de Saude.OBJECTIVE To assess Brazilian Unified Health System outpatient services delivering care to adults living with AIDS in 2007 and to compare with the assessment conducted in 2001. METHODS The 636 health services registered in the Ministry of Health in 2007 were invited to respond to a previously validated questionnaire (Qualiaids Questionnaire) with 107 multiple-choice questions about the organization of care delivery. It analyzed the frequencies of responses to the 2007 questionnaire compared with those found in that of 2001 through percent variation (PV). RESULTS 504 (79.2%) of the services responded to the questionnaire. Almost 100.0% of the respondents reported having essential resources for outpatient care: having at least one doctor, sufficient supplies of antiretroviral drugs, CD4 and viral load tests. Many aspects displayed improvement in 2007 compared to 2001: registry of missed medical appointments (from 18.3 to 27.0%, PV: 47.5%), follow-up appointment within 15 days of starting antiretroviral treatment (from 55.3 to 66.2%, PV: 19.7%) and users organized participation (from 5.9 to 16.7%, PV: 183.1%). However, some difficulties remained: little change in the availability of specialized exams, such as endoscopy, within 15 days, (31.9 to 34.5%, PV: 8.1%) and decreases in indicators such as optimal time access to specialized appointments (55.9 to 34.5% in cardiology, negative PV: 38.3%). Mean time spent in follow-up medical appointments remained low: about 15 minutes (52.5 to 49.5%, negative PV: 5.8%). CONCLUSIONS The 2007 assessment revealed that services have essential resources for ambulatory assistance. There was some improvement in many aspects compared to 2001, although some challenges still remain. Little time dedicated to medical appointments may be linked to insufficient number of doctors and/or due to reduced capacity of listening and dialogue. Impaired access to specialized appointments reveals the difficulty local Brazilian Unified Health System facilities have regarding infrastructure.

[Trends in AIDS incidence and mortality in Brazil, 1985 to 1998].

INTRODUCTION AIDS mortality is decreasing in Brazil, especially after the introduction of anti-retroviral therapy. A study was conducted to evaluate AIDS incidence and mortality in a certain area of Brazil. METHODS The number of AIDS deaths according to sex in the study period, obtained from registry sources, were used as the numerator of mortality rates. From 1985 to 1995, deaths with underlying cause classified as code 279/1 in the 9th International Classification of Diseases (ICD) and, from 1996 onwards, B20 to B24 codes in the 10th Review were considered AIDS cases. SINAN/MS disease compulsory notification data were used as the numerator of incidence rates. Percentage of variation of the incidence and mortality rates were calculated using a Poisson regression model. RESULTS In the study period, there were 1,211 AIDS cases and 501 deaths. AIDS incidence increased 21.6% during this period (p<0.05) in both sexes, though higher among women. The mortality rates increased exponentially (122.5%) from 1985 to 1991. From 1991 to 1998, mortality remained steady among men but continued to rise among women. CONCLUSIONS Stabilization of AIDS mortality in men may be a reflection of large utilization of anti-retroviral therapy. Increasing mortality rate among women could be due to different epidemic dynamics according to sex. This trend is different from the observed in the rest of Brazil, where there has been a fall in AIDS mortality for both sexes since 1991.

Mental health and physical inactivity during pregnancy: a cross-sectional study nested in the BRISA cohort study

The aim of this study was to investigate the association between mental health and physical inactivity in 1,447 pregnant women in the second trimester of pregnancy. Subjects answered the short version of the International Physical Activity Questionnaire. Symptoms of depression and anxiety, and stress levels were assessed using the Center for Epidemiological Studies Depression Scale, the Beck Anxiety Inventory and the Perceived Stress Scale, respectively. The rate of physical inactivity was low (39.8%). The prevalence rates of symptoms of severe depression and severe levels of anxiety were 28.8% and 16.9%, respectively. The average perceived stress score was 24.9. An association was found between physical inactivity and not living with a partner (OR = 1.28), having a manual occupation (OR = 0.71) and, unexpectedly, normal and low levels of anxiety (OR = 1.46 and OR = 1.44, respectively). No association was observed between physical inactivity and symptoms of severe depression and perceived stress. It is plausible to assume that the majority of physical activity practiced by these women was attributable to housework or occupation which may in turn be associated with high levels of anxiety.

Secular trends in the rate of low birth weight in Brazilian State Capitals in the period 1996 to 2010

Epidemias de malaria ocorrem anualmente nos municipios da Regiao Amazonica, Brasil, no entanto os servicos de saude nao adotam, de maneira sistematica, instrumentos para deteccao e contencao oportunas desses eventos. O objetivo foi caracterizar as epidemias de malaria na regiao segundo duracao, especie de Plasmodium e vulnerabilidade das populacoes. Foi avaliado um sistema de monitoramento automatizado da incidencia da malaria, com base no diagrama de controle segundo quartis, para identificar as epidemias da doenca. Em 2010, ocorreram epidemias em 338 (41,9%) municipios da regiao. Houve epidemias por P. falciparum e por P. vivax, separadamente, e tambem por ambas as especies. Epidemias com duracao de um a quatro meses ocorreram em 58,3% dos municipios epidemicos; de cinco a oito meses, em 24,3%; e de nove a 12 meses, em 17,4%. O monitoramento automatizado da variacao da incidencia da malaria podera contribuir para deteccao precoce das epidemias e melhorar o seu controle oportuno.Malaria epidemics occur annually in various municipalities (counties) in the Brazilian Amazon. However, health services do not systematically adopt tools to detect and promptly control these events. This article aimed to characterize malaria epidemics in the Brazilian Amazon Region based on their duration, the Plasmodium species involved, and the populations degree of vulnerability. An automatic malaria incidence monitoring system based on quartiles was assessed for prompt identification of malaria epidemics. In 2010, epidemics were identified in 338 (41.9%) of the counties in the Brazilian Amazon. P. falciparum and P. vivax epidemics were detected, both singly and in combination. Epidemics lasted from 1 to 4 months in 58.3% of the counties, 5 to 8 months in 34.5%, and 9 to 12 months in 17.4%. Systematic monitoring of malaria incidence could contribute to early detection of epidemics and improve the effectiveness of control measures.