Mariângela Freitas da Silveira

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.

Congenital Zika virus syndrome in Brazil: a case series of the first 1501 livebirths with complete investigation

BACKGROUND In November, 2015, an epidemic of microcephaly was reported in Brazil, which was later attributed to congenital Zika virus infection. 7830 suspected cases had been reported to the Brazilian Ministry of Health by June 4, 2016, but little is known about their characteristics. We aimed to describe these newborn babies in terms of clinical findings, anthropometry, and survival. METHODS We reviewed all 1501 liveborn infants for whom investigation by medical teams at State level had been completed as of Feb 27, 2016, and classified suspected cases into five categories based on neuroimaging and laboratory results for Zika virus and other relevant infections. Definite cases had laboratory evidence of Zika virus infection; highly probable cases presented specific neuroimaging findings, and negative laboratory results for other congenital infections; moderately probable cases had specific imaging findings but other infections could not be ruled out; somewhat probable cases had imaging findings, but these were not reported in detail by the local teams; all other newborn babies were classified as discarded cases. Head circumference by gestational age was assessed with InterGrowth standards. First week mortality and history of rash were provided by the State medical teams. FINDINGS Between Nov 19, 2015, and Feb 27, 2015, investigations were completed for 1501 suspected cases reported to the Brazilian Ministry of Health, of whom 899 were discarded. Of the remainder 602 cases, 76 were definite, 54 highly probable, 181 moderately probable, and 291 somewhat probable of congenital Zika virus syndrome. Clinical, anthropometric, and survival differences were small among the four groups. Compared with these four groups, the 899 discarded cases had larger head circumferences (mean Z scores -1·54 vs -3·13, difference 1·58 [95% CI 1·45-1·72]); lower first-week mortality (14 per 1000 vs 51 per 1000; rate ratio 0·28 [95% CI 0·14-0·56]); and were less likely to have a history of rash during pregnancy (20·7% vs 61·4%, ratio 0·34 [95% CI 0·27-0·42]). Rashes in the third trimester of pregnancy were associated with brain abnormalities despite normal sized heads. One in five definite or probable cases presented head circumferences in the normal range (above -2 SD below the median of the InterGrowth standard) and for one third of definite and probable cases there was no history of a rash during pregnancy. The peak of the epidemic occurred in late November, 2015. INTERPRETATION Zika virus congenital syndrome is a new teratogenic disease. Because many definite or probable cases present normal head circumference values and their mothers do not report having a rash, screening criteria must be revised in order to detect all affected newborn babies. FUNDING Brazilian Ministry of Health, Pan American Health Organization, and Wellcome Trust.

Heavy alcohol consumption and associated factors: a population-based study

OBJECTIVE To determine the prevalence of heavy alcohol consumption and factors associated with it in a Brazilian adult population. METHODS Cross-sectional population-based study including 2,177 adults (aged 20 to 69), living in the urban area of the municipality of Pelotas, Rio Grande do Sul State, Brazil. The sample was selected in multiple stages. Heavy alcohol consumption was defined as above 30g/day. The adjusted analysis was conducted by logistic regression. RESULTS The prevalence of heavy alcohol consumption was 14.3% (29.2% among men and 3.7% among women). The following groups presented higher prevalences of heavy alcohol consumption after adjusted analysis: men, elderly people, blacks or mulattoes, heavy smokers, and people who present some kind of chronic disease. Men with minor psychiatric disorders showed higher prevalences of heavy alcohol consumption than other men. Among women, association between age and heavy alcohol consumption was inversely related. Furthermore, the study indicates that among hypertensive subjects, those with heavy alcohol consumption presented worse disease management. CONCLUSIONS Heavy alcohol consumption is high and results in countless negative consequences for the individuals health and quality of life. Our results highlight the high prevalence of heavy alcohol consumption and indicate subsections of the whole population more susceptible to alcoholism.

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.

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.

Preterm births, low birth weight, and intrauterine growth restriction in three birth cohorts in Southern Brazil: 1982, 1993 and 2004

Three birth cohort studies from 1982, 1993 and 2004, in Pelotas, Southern Brazil provided the data for this study of trends in preterm births, low birth weight, and intrauterine growth restriction. We found a slight increase in the period in the low birth weight prevalence from 9% to 10%. Intrauterine growth restriction decreased from 14.8% in 1982 to 9.4% in 1993, and subsequently increased to 12% in 2004, whereas preterm births increased markedly, from 6.3% in 1982 to 14.7% in 2004. This striking increment could not be explained by changes in maternal characteristics, as mothers in 2004 were heavier, smoked less during pregnancy and attended antenatal clinics more often and earlier than those of previous cohorts. However, pregnancy interruptions due either to caesarean sections or to inductions significantly increased. Caesareans increased from 28% in 1982 to 45% in 2004, and inductions were 2.5% in 1982 but 11.1% in 2004. The increase in preterms could be partially explained by the growing number of pregnancy interruptions, but there must be other causes since this increase was also observed among babies born by non-induced vaginal deliveries.Tres coortes de nascimentos, de 1982, 1993 e 2004, em Pelotas, Rio Grande do Sul, permitiram o estudo de tendencias em nascimentos prematuros, de baixo peso ao nascer e de restricao do crescimento intrauterino. O estudo mostrou, durante o periodo, um pequeno aumento na prevalencia de baixo peso ao nascer, de 9% para 10%. A restricao do crescimento intrauterino diminuiu, de 14,8% em 1982 para 9,4% em 1993, e aumentou novamente para 12% em 2004, enquanto a proporcao de nascimentos prematuros aumentou de maneira marcante, de 6,3% em 1982 para 14,7% em 2004. Nao foi possivel explicar esse aumento atraves de mudancas nas caracteristicas maternais, ja que as maes em 2004 apresentavam peso corporal mais alto, fumavam menos durante a gestacao e mostravam mais consultas pre-natais e iniciam o atendimento pre-natal mais precocemente, quando comparadas as maes das coortes anteriores. Entretanto, houve um aumento significativo nas interrupcoes da gravidez, seja por cesariana ou inducao. A taxa de cesarianas aumentou de 28% em 1982 para 45% em 2004, e de parto induzido de 2,5% em 1982 para 11,1% em 2004. O aumento nos nascimentos prematuros pode ser explicado parcialmente pelo numero crescente de interrupcoes, mas devem existir outras causas, ja que esse aumento foi observado tambem entre criancas que nasceram de partos vaginais nao-induzidos.

Associated factors and consequences of late preterm births: Results from the 2004 Pelotas birth cohort

Although neonatal and infant mortality rates have fallen in recent decades in Brazil, the prevalence of preterm deliveries has increased in certain regions, especially in the number of late preterm births. This study was planned to investigate: (1) maternal antenatal characteristics associated with late preterm births and (2) the consequences of late preterm birth on infant health in the neonatal period and until age 3 months. A population-based birth cohort was enrolled in Pelotas, Southern Brazil, in 2004. Mothers were interviewed and the gestational age of newborns was estimated through last menstrual period, ultrasound and Dubowitzs method. Preterm births between 34 and 36 completed weeks of gestational age were classified as late preterm births. Only singleton live births from mothers living in the urban area of Pelotas were investigated. Three months after birth, mothers were interviewed at home regarding breast feeding, morbidity and hospital admissions. All deaths occurring in the first year of life were recorded. A total of 447 newborns (10.8%) were late preterms. Associations were observed with maternal age <20 years (prevalence ratio [PR] 1.3 [95% CI 1.1, 1.6]), absence of antenatal care (PR 2.4 [1.4, 4.2]) or less than seven prenatal care visits, arterial hypertension (PR 1.3 [1.0, 1.5]), and preterm labour (PR 1.6 [1.3, 1.9]). Compared with term births, late preterm births showed increased risk of depression at birth (Relative risk [RR] 1.7 [1.3, 2.2]), perinatal morbidity (RR 2.8 [2.3, 3.5]), and absence of breast feeding in the first hours after birth (PR 0.9 [0.8, 0.9]). RRs for neonatal and infant mortality were, respectively, 5.1 [1.7, 14.9] and 2.1 [1.0, 4.6] times higher than that observed among term newborns. In conclusion, in our setting, the prevention of all preterm births must be a priority, regardless of whether early or late.

Autopercepção de vulnerabilidade às doenças sexualmente transmissíveis e Aids em mulheres

OBJETIVO: Investigar comportamentos de risco e autopercepcao de vulnerabilidade as doencas sexualmente transmissiveis (DST) e a Sindrome de imunodeficiencia adquirida (Aids) em mulheres. METODOS: Dos 281 setores censitarios existentes na cidade de Pelotas, RS, foram selecionados 48 a partir de amostragem sistematica. Foi entrevistada uma amostra de 1.543 mulheres, de 15 a 49 anos, por meio de questionario composto de tres partes (informacoes socioeconomicas, perguntas aplicadas em entrevista, questionario auto-aplicado). Para tabulacao dos dados, foi utilizado o programa Epi-Info, versao 6.0. Para analise estatistica dos dados foram usados o teste de Kappa e a razao de odds. RESULTADOS: Na amostra, 64% das mulheres achavam impossivel ou quase impossivel adquirir DST/Aids. Os principais comportamentos de risco foram o nao uso de preservativo na ultima relacao antes do depoimento (72%); inicio das relacoes sexuais com menos de 18 anos (47%); uso de alcool ou drogas pelo parceiro (14%) ou pela mulher (7%) antes da ultima relacao; dois ou mais parceiros nos tres meses que antecederam o depoimento (7%) e sexo anal na ultima relacao (3%); 44% das mulheres apresentaram dois ou mais comportamentos de risco. A sensibilidade da autopercepcao, usando como padrao o escore de risco igual ou superior a dois, foi de 41 %. Sua especificidade de 67%. CONCLUSOES: A autopercepcao de vulnerabilidade nao e um bom indicador, pois as mulheres nao identificam corretamente seu nivel de risco.

Increase in preterm births in Brazil: review of population-based studies

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.

Nascimentos pré-termo no Brasil entre 1994 e 2005 conforme o Sistema de Informações sobre Nascidos Vivos (SINASC)

Monitoring preterm births is essential given their impact on infant morbidity and mortality and their economic and social costs. This article is based on data from the Information System on Live Births (SINASC), implemented in 1990 and expanded gradually to cover 90% of all births in the country. Preterm birth time trends are presented for Brazil, regions, and capitals from 1994 to 2005. At the national level, there was an increase in the preterm birth rate, accompanied by a reduction in the proportion of missing information on gestational age. The Southeast, South, and Central-West regions followed the national trend, while the preterm birth rate fell in the North and Northeast regions. We compared the findings from SINASC with those from population-based studies. The coverage and quality of SINASC has increased over time, but problems with the determination of gestational age still remain, leading to underestimation of preterm birth rates. Due to the importance of SINASC for monitoring, further efforts are needed to improve the systems accuracy.