Raimundo Antonio da Silva

Perinatal health and mother-child health care in the municipality of São Luís, Maranhão State, Brazil

The purpose of this article was to evaluate socioeconomic and demographic indicators, reproductive health, use of prenatal, childbirth, and neonatal services, and anthropometric data for mothers and infants. The authors performed a cross-sectional analysis of a systematic sample of 2,831 hospital births in São Luís, Maranhão State, from March 1997 to February 1998 at ten public and private maternity hospitals. The sample was stratified proportionally according to the number of births in each maternity hospital. Mothers answered a standard questionnaire. Of the total, 97.9% were live births and 98% were singletons. Prenatal coverage was 89.5%, and prevalence of cesarean sections was 33.8%. A physician provided prenatal care in 75.7% of cases and performed 73.8% of the deliveries. The Unified Health System covered the costs of 76.4% of the prenatal visits and 89.7% of the deliveries. A pediatrician was present in the delivery room in 50.2% of cases. The low birth weight rate was 9.6% and the preterm birth rate 13.9%. Reasons for concern included a high percentage of adolescent mothers, single mothers (or without partners), the high cesarean rate, and the high percentage of births attended by unqualified personnel.

Cobertura vacinal e fatores de risco associados à não-vacinação em localidade urbana do Nordeste brasileiro, 1994

INTRODUCTION The assessment of vaccination coverage and risk factors for non-vaccination is important to evaluate vaccination programs and to identify children not properly vaccinated. METHODS A cross-sectional household survey was carried out in the municipality of S. Luís, Maranhão, Brazil by means of a standardized questionnaire. Multistage cluster sampling was used to identify children of 12-59 months of age residing in the city in 1994. The mother or other person responsible for the children was interviewed. Fifty census clusters were visited and 40 households were sampled in each. On average, 15 children were found in each cluster. Design effect was calculated for each estimate. Health service utilization was analyzed according to socioeconomic and demographic indicators, and perceived morbidity using proportional hazard modeling (Coxs regression). RESULTS Vaccination coverage levels were 72.4% for BCG, 59.9% for three doses of polio vaccine, 57% for three doses of DTP vaccine and 54.7% for measles vaccine. Vaccination levels have remained statistically unchanged over the last three years. Lower maternal schooling continues to be associated with increased risk of non-vaccination in the multivariable analysis. CONCLUSION Vaccination levels were low. Health education activities are one of the suggested strategies to increase vaccination coverage.INTRODUCAO: A identificacao da cobertura vacinal e dos fatores responsaveis pelo retardo ou pela falta de imunizacoes e fundamental para a adequada monitorizacao dos programas de vacinacao e para se identificar e atingir as criancas que nao sao vacinadas adequadamente. METODOS: Foi realizado inquerito domiciliar transversal, em amostra aleatoria por conglomerados em multiplos estagios de criancas de 12 a 59 meses de idade, no Municipio de Sao Luis, Maranhao, Brasil, em 1994. Utilizou-se questionario padronizado respondido pela mae ou responsavel pela crianca. Foram visitados 50 setores censitarios; em cada um foram amostrados 40 domicilios, onde foram encontradas, em media, 15 criancas. O efeito de desenho foi calculado para cada estimativa. A nao-vacinacao foi analisada em relacao a indicadores socioeconomicos, demograficos e a morbidade referida pela regressao de Cox. RESULTADOS: A cobertura vacinal foi de 72,4% para BCG, 59,9% para 3 doses da vacina Sabin, 57% para 3 doses de vacina DPT (difteria, coqueluche e tetano) e 54,7% para a vacina anti-sarampo. A baixa escolaridade materna foi o principal fator de risco para a nao-vacinacao apos o controle dos fatores de confusao. CONCLUSAO: As coberturas vacinais foram baixas. Uma das estrategias sugeridas para o aumento das coberturas e o incremento das atividades de educacao em saude.

Morbimortalidade infantil por diarréia aguda em área metropolitana da região Nordeste do Brasil, 1986-1989

Six cross-sectional studies involving children under five years of age in three places on S. Luiz island, i.e., Vila Palmeira, Anjo da Guarda and S. Jose de Ribamar, were performed. A standardized questionnaire on the presence of diarrhoea in the previous 2 weeks was answered by the mothers or by those responsible for the children. Two population based studies (in May 1986 and May 1989) and four sample based surveys (in November of 1986, 1987 and 1988 and in May 1989) were carried out. The prevalence of diarrhoea was highest in May, 1986 and November, 1987. The highest prevalence occurred in S. Jose de Ribamar. The distribution of cases according to age showed a higher prevalence among children of 6-11 months and between 1 and 2 years of age. The prevalence of diarrhoea was highest among the families: that excreted directly into the sea or a latreen; that used water from uncovered wells; that threw their garbage into the sea; and whose bread-winners were unemployed. Diarrhoea was the principal cause of death in both surveys. Infant mortality, in May 1986, was 44.0 per thousand in children under 1 year of age and 12.8 in children under 5 years old; in May 1989 it was 7.9 per thousand and 4.9 per thousand respectively. The decrease in child morbidity and mortality due to diarrhoea between 1986 and 1989 was statistically significant.Foi realizado inquerito domiciliar do tipo transversal abrangendo criancas menores de cinco anos residentes em 3 areas da ilha de Sao Luis (Brasil): Vila Palmeira, Anjo da Guarda e Sao Jose de Ribamar. Aplicou-se um questionario onde se perguntou a mae ou a pessoa responsavel pela crianca sobre a presenca de diarreia nas duas ultimas semanas. Foram realizados dois estudos censitarios (maio de 1986 e 1989) e quatro amostragens sazonais (novembro de 1986, 1987 e 1988 e maio de 1989). A prevalencia de diarreia foi maior em maio de 1986 e novembro de 1987; Sao Jose de Ribamar foi o local de maior prevalencia; a distribuicao dos casos por idade mostrou maior prevalencia entre criancas de 6 a 11 meses e de 1 a 2 anos de idade; a prevalencia da diarreia foi maior nas familias que tinham como destino dos dejetos a mare e fossa negra; que se abasteciam de agua de poco descoberto, nas familias cujos pais eram desempregados e nas que depositavam o lixo na mare. A diarreia foi a principal causa de morte nos dois estudos censitarios; a taxa de mortalidade infantil em maio de 1986 foi, respectivamente, de 44,0 por mil em menores de um ano e 12,8 por mil em menores de cinco anos; em maio de 1989 foi de 7,9 por mil e 4,9 por mil. As reducoes na morbidade e mortalidade infantil por diarreia aguda entre 1986 e 1989 foram estatisticamente significantes.: Six cross-sectional studies involving children under five years of age in three places on S. Luiz island, i.e., Vila Palmeira, Anjo da Guarda and S. Jose de Ribamar, were performed. A standardized questionnaire on the presence of diarrhoea in the previous 2 weeks was answered by the mothers or by those responsible for the children. Two population based studies (in May 1986 and May 1989) and four sample based surveys (in November of 1986, 1987 and 1988 and in May 1989) were carried out. The prevalence of diarrhoea was highest in May, 1986 and November, 1987. The highest prevalence occurred in S. Jose de Ribamar. The distribution of cases according to age showed a higher prevalence among children of 6-11 months and between 1 and 2 years of age. The prevalence of diarrhoea was highest among the families: that excreted directly into the sea or a latreen; that used water from uncovered wells; that threw their garbage into the sea; and whose bread-winners were unemployed. Diarrhoea was the principal cause of death in both surveys. Infant mortality, in May 1986, was 44.0 per thousand in children under 1 year of age and 12.8 in children under 5 years old; in May 1989 it was 7.9 per thousand and 4.9 per thousand respectively. The decrease in child morbidity and mortality due to diarrhoea between 1986 and 1989 was statistically significant.

Fatores de risco para hospitalização de crianças de um a quatro anos em São Luís, Maranhão, Brasil

Os fatores de risco para hospitalizacao infantil foram estudados por inquerito domiciliar transversal, em amostra aleatoria por conglomerados em multiplos estagios de 596 criancas de um a quatro anos de idade, em Sao Luis, Maranhao, Brasil, em 1994. A taxa de hospitalizacao foi de 24,4%, sendo as maiores por pneumonia (7,3%) e diarreia (7,1%). A maioria das internacoes foi custeada pelo SUS (78,1%) e apenas 18,2% pelo seguro-saude. Apos o ajuste para fatores de confusao pela regressao de Cox modificada para estudos transversais, criancas de familias de renda familiar de ate um salario minimo e as que possuiam seguro-saude tiveram maior risco de serem hospitalizadas em relacao as demais. A maioria das hospitalizacoes em Sao Luis ocorreu por causas evitaveis ou sensiveis a atencao ambulatorial. O padrao de hospitalizacao em U levanta questoes acerca da baixa qualidade da atencao ambulatorial para os segmentos mais pobres da populacao e indica, provavelmente, a ocorrencia de internacoes desnecessarias e iatrogenicas entre os usuarios de seguro-saude.

Inadequate prenatal care utilization and associated factors in São Luís, Brazil

BackgroundOver the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care. The objective of the present study was to estimate the rate of inadequate prenatal care utilization and its associated factors in São Luís, Brazil, in 2010 and to determine whether there was a reduction of inequity in prenatal care use by comparing the present data to those obtained from a previous cohort started in 1997/98.MethodsData from the BRISA (Brazilian birth cohort studies of Ribeirão Preto and São Luís) population-based cohort, which started in 2010 (5067 women), were used. The outcome variable was the inadequate utilization of prenatal care, classified according to the recommendations of the Brazilian Ministry of Health. The explanatory variables were organized into three hierarchical levels based on the Andersen’s behavioral model of the use of health services: predisposing, enabling and need factors.ResultsOnly 2.0% of the women did not attend at least one prenatal care visit. The rate of inadequate prenatal care utilization was 36.7%. Despite an improved adequacy of prenatal care use from 47.3% in 1997/98 to 58.2% in 2010, social inequality persisted: both low maternal schooling (prevalence ratio (PR) = 2.78; 95% confidence interval (95% CI) 2.23-3.47 for 0 to 4 years of study) and low family income, less than 0.5 monthly minimum wage per capita (PR = 1.37; 95% CI 1.22-1. 54), continued to be associated with higher rates of inadequate prenatal care utilization. Racial disparity regarding adequate utilization of prenatal services was detected, with black (PR = 1.19; 95% CI 1.04-1.36) and mulatto (PR = 1.14; 95% CI 1.02-1.26) women showing higher rates of inadequate use. On the other hand, women covered by the FHP - Family Health Program (PR = 0.92; 95% CI 0.85-0.98) showed a lower rate of inadequate prenatal care utilization.ConclusionsDespite strong expansion of health services and expressive improvements in adequate prenatal care use and social indicators, inequalities in prenatal care use still persist. The FHP seems to be effective in reducing inadequate prenatal care utilization.

Perfil da assistência odontológica pública para a infância e adolescência em São Luís (MA)

This profile of public dental care for children/adolescents in Sao Luis, Maranhao State, Brazil, is based on a survey conducted through interviews, designed to identify these services and help upgrade Health Services available in this city. It describes the pediatric dental care available and the age groups attended, the qualifications of the practitioners involved, the types of treatment for primary and permanent teeth and oral health education programs run at the Municipal Healthcare Units with dental facilities, analyzed through visits and structured interviews. The findings show that dental care was available for children/adolescents (mainly between 6 and 12 years old) at 91.1% of the Healthcare Units offering daily and universal care (65.75%), as well as at those whose services are limited to certain specialties and/or specific days (34.15%). All the public Healthcare Units offered surgical treatment for permanent teeth. Fillings are used more for permanent teeth than primary teeth. Among the public Healthcare Units, 25 (55.5%) did not offer or run oral health programs. At most (75.5%) of the Units visited, dental treatment for children and adolescents is limited to basic care and directed mainly to permanent teeth. The traditional welfare model of providing care as freely demanded remains in place.Descreve existencia de atendimento para criancas, as faixas etarias atendidas, a qualificacao do profissional, os tipos de procedimentos realizados para a denticao decidua e permanente e a existencia de programas educativos de promocao de saude bucal nas Unidades de Saude do Municipio de Sao Luis com assistencia odontologica, por meio de visitas e entrevistas estruturadas. Os resultados mostram que o atendimento odontologico para criancas e adolescentes e disponibilizado em 91,1% das unidades de saude, se concentrando na faixa etaria de 6 a 12 anos, tanto nas unidades que prestam assistencia diaria e universal (65,75%) quanto naquelas (34,15%) onde o atendimento e feito em consultorio restrito, especifico e/ou em dias especificos. Todas as unidades visitadas oferecem tratamento cirurgico para a denticao permanente. O tratamento restaurador e mais disponibilizado para os dentes permanentes do que para os dentes deciduos. Vinte e cinco (55,5%) das unidades de saude nao apresentam ou nao desenvolvem programas de educacao em saude bucal. Na maioria das unidades (75,5%) visitadas, o tratamento odontologico para criancas e adolescentes e restrito a atencao basica e voltado para a denticao permanente. O modelo assistencial tradicional de atendimento de livre demanda permanece.

Racial inequalities and perinatal health in the southeast region of Brazil

Few studies are available about racial inequalities in perinatal health in Brazil and little is known about whether the existing inequality is due to socioeconomic factors or to racial discrimination per se. Data regarding the Ribeirão Preto birth cohort, Brazil, whose mothers were interviewed from June 1, 1978 to May 31, 1979 were used to answer these questions. The perinatal factors were obtained from the birth questionnaire and the ethnic data were obtained from 2063 participants asked about self-reported skin color at early adulthood (23-25 years of age) in 2002/2004. Mothers of mulatto and black children had higher rates of low schooling (< or = 4 years, 27.2 and 38.0%) and lower family income (< or = 1 minimum wage, 28.6 and 30.4%). Mothers aged less than 20 years old predominated among mulattos (17.0%) and blacks (14.0%). Higher rates of low birth weight and smoking during pregnancy were observed among mulatto individuals (9.6 and 28.8%). Preterm birth rate was higher among mulattos (9.5%) and blacks (9.7%) than whites (5.5%). White individuals had higher rates of cesarean delivery (34.9%). Skin color remained as an independent risk factor for low birth weight (P < 0.001), preterm birth (P = 0.01), small for gestational age (P = 0.01), and lack of prenatal care (P = 0.02) after adjustment for family income and maternal schooling, suggesting that the racial inequalities regarding these indicators are explained by the socioeconomic disadvantage experienced by mulattos and blacks but are also influenced by other factors, possibly by racial discrimination and/or genetics.

The association between skin color/race and health indicators in elderly Brazilians: a study based on the Brazilian National Household Sample Survey (2008)

This study analyzed racial inequalities in health in 18,684 elderly Brazilians 65 years or older, interviewed in the National Household Sample Survey in 2008 (PNAD 2008), and who reported their color/race as white, brown, or black. Associations were estimated between self-rated health status, functional incapacity, and number of chronic conditions according to crude and adjusted regression analyses (α = 0.01). The majority of the elderly were white (56.2%). In the adjusted analysis, brown color/races was associated with worse self-rated health status (OR = 1.11; 95%CI: 1.03-1.18) and black color/race was associated with more chronic diseases (PR = 1.07; 95%CI: 1.02-1.13). Brown color/race appeared as a protective factor against functional incapacity. When brown and black elderly were combined in one category (“black”), “black” elderly continued to show worse self-rated health status (OR = 1.09; 95%CI: 1.02-1.16) and lower odds of functional incapacity (OR = 0.83; 95%CI: 0.76-0.92). “Black” color/race lost the association with number of chronic diseases. Color/race explained part of the health inequalities in elderly Brazilians, but other socioeconomic variables had a more striking effect.

Early life, current socioeconomic position and serum lipids in young adulthood of participants in a cohort study initiated in 1978/1979

The association between socioeconomic position (SEP) and serum lipids has been little studied and the results have been controversial. A total of 2063 young adults born in 1978/79 were evaluated at 23-25 years of age in the fourth follow-up of a cohort study carried out in Ribeirão Preto, SP, Brazil, corresponding to 31.8% of the original sample. Total serum cholesterol (TC), triglycerides, high-density cholesterol (HDL cholesterol) and low-density cholesterol (LDL cholesterol) were analyzed according to SEP at birth and during young adulthood. SEP was classified into tertiles of family income and a cumulative score of socioeconomic disadvantage was created. TC was 11.85 mg/100 mL lower among men of lower SEP in childhood (P < 0.01) but no difference was found in women, whereas it was 8.46 lower among men (P < 0.01) and 8.21 lower among women of lower SEP in adulthood (P < 0.05). Individuals of lower SEP had lower LDL and HDL cholesterol, with small differences between sexes and between the two times in life. There was no association between SEP and triglyceride levels. After adjustment of income at one time point in relation to the other, some associations lost significance. The greater the socioeconomic disadvantage accumulated along life, the lower the levels of TC, LDL and HDL cholesterol (P < 0.05). The socioeconomic gradient of TC and LDL cholesterol was inverse, representing a lower cardiovascular risk for individuals of lower SEP, while the socioeconomic gradient of HDL cholesterol indicated a lower cardiovascular risk for individuals of higher SEP.

Terapia de reidratação oral para diarréia aguda em região do nordeste do Brasil, 1986-1989

Foi estudada a utilizacao da Terapia de Reidratacao Oral (TRO) no tratamento da diarreia infantil aguda em menores de cinco anos de idade, atraves de inquerito domiciliar transversal nos anos de 1986 e 1989, em tres localicadades da ilha de Sao Luis, MA, Brasil. A prevalencia da doenca diarreica foi alta (16,8% e 7,8%) e a utilizacao da TRO baixa (31% e 25,3%), em 1986 e 1989, havendo decrescimo estatisticamente significante desta taxa entre esses anos. A utilizacao da TRO foi maior entre 6 e 23 meses de idade da crianca, entre as maes com segundo grau, quando a indicacao do tratamento foi feita por agentes de saude e quando a mae nao usou medicamento para diarreia. O uso da TRO nao mostrou associacao com a renda familiar e com a relacao do chefe de familia no emprego. Entre as intervencoes propostas para melhor promocao do uso da TRO, sugeriu-se uma politica de educacao em saude direcionada as comunidades mais carentes, progamas de reciclagem dos profissionais de saude no tratamento da diarreia infantil e programas de treinamento para agentes de saude.