Paulo Germano de Frias

HIV testing during pregnancy: use of secondary data to estimate 2006 test coverage and prevalence in Brazil

This paper describes a methodological proposal based on secondary data and the main results of the HIV-Sentinel Study among childbearing women, carried out in Brazil during 2006. A probabilistic sample of childbearing women was selected in two stages. In the first stage, 150 health establishments were selected, stratified by municipality size (<50,000; 50,000-399,999; 400,000+). In the second stage, 100-120 women were selected systematically. Data collection was based on HIV-test results registered in pre-natal cards and in hospital records. The analysis focused on coverage of HIV-testing during pregnancy and HIV prevalence rate. Logistic regression models were used to test inequalities in HIV-testing coverage during pregnancy by macro-region of residence, municipality size, race, educational level and age group. The study included 16,158 women. Results were consistent with previous studies based on primary data collection. Among the women receiving pre-natal care with HIV-test results registered in their pre-natal cards, HIV prevalence was 0.41%. Coverage of HIV-testing during pregnancy was 62.3% in the country as a whole, but ranged from 40.6% in the Northeast to 85.8% in the South. Significant differences according to race, educational level and municipality size were also found. The proposed methodology is low-cost, easy to apply, and permits identification of problems in routine service provision, in addition to monitoring compliance with Ministry of Health recommendations for pre-natal care.

Cobertura do teste de Papanicolaou e fatores associados à não-realização: um olhar sobre o Programa de Prevenção do Câncer do Colo do Útero em Pernambuco, Brasil

This research aimed to assess coverage of Pap smear screening in the State of Pernambuco, Brazil, during the three years prior to the study, among women 18 to 69 years of age, and to identify factors associated with womens lack of participation in screening. This was a cross-sectional, population-based study, using data from a survey in 2005-2006 with 640 women, selected by three-stage cluster sampling. Information on 258 women was analyzed. Pap smear coverage was 58.7% for women 18 to 69 years of age and 66.2% for those 25 to 59. Single marital status, no history of childbirth, and not having consulted a physician in the previous year were associated with lack of Pap smear screening. In the multivariate analysis, low schooling also showed a significant effect. Pap smear coverage in Pernambuco was satisfactory, but insufficient to impact the epidemiological profile of cervical cancer. It is necessary to strengthen and upgrade health promotion activities in order to reduce the inequalities and encourage womens active participation in cervical cancer prevention.

Sistema de Informações sobre Mortalidade: estudo de caso em municípios com precariedade dos dados

The study was part of a survey conducted in clusters of Brazilian municipalities (counties) characterized by serious underreporting of deaths, with the objective of estimating infant mortality in these areas in 2000. The article discusses the principal sources of information on infant deaths in these municipalities, as well as some problems related to the implementation of the Mortality Data System (SIM). The methodology included an active search for deaths in previously registered official and unofficial sources, which identified 344 deaths not processed in the SIM (66% of total deaths). There were a low percentage of deaths processed in the SIM and coming from official sources (notary public offices and healthcare facilities), thus highlighting problems with reporting of deaths, issuing of death certificates, and data flows. The important contribution by the Community Health Agents Program/ Family Health Program points to the need for active data search in this source as a routine activity in municipalities with underreporting of data. Insufficient training of professionals and high staff turnover were major issues in the systems deficient implementation.

Healthy lifestyles and access to periodic health exams among Brazilian women

Using data from the World Health Survey carried out in Brazil in 2003, this paper has the objective of describing the sociodemographic profile of Brazilian women (age 18-69 years of age) that have adequate health care, not only with respect to health service utilization but also to healthy lifestyles. Sociodemographic variables (age, marital status, race, education level, number of household assets, and occupation), health care variables (periodic gynecologic exam with Papanicolaou, mammography among women aged 40-69 years, body mass index, smoking, alcohol, physical activity, dental care, private health insurance), and self-rated health were analyzed by municipality size strata. Logistic regression models were used to identify the characteristics of women that have adequate health care. Coverage of periodic gynecologic exam with Papanicolaou was 65.0% and mammography coverage was 47.0%. Less than 20.0% of Brazilian women have adequate care, and the most associated factors were: being younger than 40 years old, having higher educational level, having private health insurance and being married. The results indicate the need to develop health promotion policies focused on modifying the risk habits and risk practices to health, and to stimulate preventive periodic health exams.

Avaliação da adequação das informações de mortalidade e nascidos vivos no Estado de Pernambuco, Brasil

The Brazilian Ministry of Health has made important investments to improve the quality of information systems on mortality and live births. However, in most Brazilian States the infant mortality rate is still estimated by indirect methods, thus overlooking the progress in this area. The current article aimed to evaluate the adequacy of mortality and live birth data using indicators of coverage and regularity for both systems. Analysis of temporal trends in infant mortality coverage estimated by indirect methods revealed major inconsistencies in the temporal series. The adequacy indicators showed an important improvement in the coverage and regularity of vital information systems. The proportion of deaths from ill-defined causes also decreased, although at a slower rate. The improvement in recording of live births and deaths in the State of Pernambuco highlights the importance of reflecting on the use of direct methods to calculate infant mortality, at least in municipalities with adequate vital statistics.

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.

Avaliação da completitude das variáveis da Declaração de Nascido Vivo de residentes em Pernambuco, Brasil, 1996 a 2005

An evaluative, descriptive, time series study was conducted to evaluate the completeness of data on certificates of live birth. The study population consisted of all live births of residents in Pernambuco State, Brazil, from 1996 to 2005, contained in the database of the Live Birth Information System (SINASC), provided by the Information Technology Department of the Unified National Health System (DATASUS). We calculated each variables incompleteness (blank/unknown data) by municipality of residence. Based on these data, we calculated the percentage of municipalities with excellent completeness (> 95%), constructed a simple linear regression model, and calculated the determination coefficient. An important increase was observed in the percentage of municipalities with excellent completeness, highlighting the following variables: race/color, maternal schooling, maternal marital status, and number of prenatal visits. The study emphasizes the importance and relevance of using the SINASC database for analyzing maternal and child health conditions.

Fatores de risco para mortalidade neonatal em coorte hospitalar de nascidos vivos

Endereco para correspondencia: Instituto Materno-infantil Professor Fernando Figueira, Nucleo de Epidemiologia, Rua dos Coelhos, 300, 6 Andar, Boa Vista, Recife-PE, Brasil. CEP: 50070-550 E-mail: pripera@cpqam.fiocruz.br Resumo Este estudo analisou os fatores de risco associados a mortalidade neonatal hospitalar na maternidade-escola do Instituto Materno-infantil Professor Fernando Figueira, entre 2001 e 2003. Os dados foram coletados das declaracoes de nascimento e obito; para a identificacao dos fatores associados a mortalidade, foi realizada analise bivariada e multivariada. A taxa de mortalidade neonatal hospitalar foi de 49,4 obitos por mil nascidos vivos. A analise multivariada mostrou que os efeitos das variaveis – indice de Apgar no quinto minuto abaixo de tres ou entre quatro e sete; baixa escolaridade da mae; idade gestacional ate 36 semanas; numero de consultas de pre-natal abaixo de tres; baixo peso ao nascer; e raca preta/parda – foram significativos para a mortalidade. A assistencia pre-natal e pos-natal deve se organizar para prevenir alguns desses fatores e reduzir as iniquidades originadas nas diferencas sociais. Palavras-chave: mortalidade neonatal; fatores de risco; atencao hospitalar.

Óbitos infantis evitáveis em hospital de referência estadual do Nordeste brasileiro

OBJETIVOS: classificar os obitos de menores de um ano ocorridos de janeiro a dezembro de 2000, em hospital de referencia em Pernambuco, segundo criterios de evitabilidade da causa basica. METODOS: estudo descritivo de corte transversal, utilizando-se como fonte de dados o Sistema de Informacao sobre Mortalidade, processado na instituicao. As causas basicas presentes nas Declaracoes de Obitos, corrigidas a partir do prontuario medico e codificadas segundo as regras da 10 revisao da Classificacao Internacional de Doencas, foram agrupadas segundo os criterios de evitabilidade de obitos propostos pela Fundacao SEADE em 1991. Calculou-se o coeficiente de mortalidade infantil hospitalar. RESULTADOS: a maioria dos obitos estava classificada entre as causas reduziveis por medidas de atencao a saude, com mortalidade proporcional de 77,4% (infantil), 75,3% (neonatal) e 60,1% (pos-neonatal) representando um coeficiente de mortalidade infantil hospitalar de 103,7 obitos por 1.000 internacoes. Quase metade era neonatos, desses, 31% eram reduziveis por diagnostico e tratamento precoces. No grupo pos-neonatal, 44% foram causadas principalmente pelas doencas infecciosas intestinais e do aparelho respiratorio. CONCLUSOES: os altos percentuais de mortes por causas evitaveis, sugerem problemas de acesso aos servicos de saude, cobertura e/ou na qualidade da assistencia prestada.

[Infant death surveillance as an indicator of health care system effectiveness--a study conducted in northeastern Brazil].

OBJECTIVE To evaluate the access to and quality of health care administered to infants based on postmortem data. METHODS A descriptive cross-sectional census-based study was carried out to assess the infant deaths that occurred in the town of Bom Conselho, state of Pernambuco, between January 1st 1999 and December 31st 1999. Home interviews and inspection of medical records were used for data collection. Deaths were identified by consulting the Mortality Information System, health centers, public notary services, cemeteries, health workers, and midwives. RESULTS Seventy-one of 72 deaths were investigated, with a loss of 1.4%. The majority (69.4%) of deaths occurred in the postneonatal period and 67.6% of them occurred at home. In 77.5% of the cases medical help was sought at least once, most frequently at emergency units (65.1%). However, 22.5% of the patients were not taken to any kind of health care service. Most health care services (90.9%) were less than one hour away from the patients home, 78.5% were located in the town of residence and 97% of the consultations were carried out by doctors. Of 88 consultations, 39.8% resulted in hospitalization and 27.3% in discharge without arrangement of a follow-up appointment. In 84% of the cases the medication was provided free of charge. CONCLUSIONS Death surveillance revealed restricted access to medical care and poor quality of health care administered to infants living in the referred town. The high rate of home deaths is related to access, whilst the journeys made by some of the mothers to health care units, during the illness that caused the death of their infants, points to the precarious organization of those services.