Silvana Granado Nogueira da Gama

Desigualdades raciais, sociodemográficas e na assistência ao pré-natal e ao parto, 1999-2001

OBJETIVO: Analisar as desigualdades sociais e no acesso e utilizacao dos servicos de saude em relacao a cor da pele em amostra representativa de puerperas que demandaram atencao hospitalar ao parto. METODOS: Trata-se de estudo transversal, realizado no Municipio do Rio de Janeiro, no qual foram amostradas 9.633 puerperas, sendo 5.002 brancas (51,9%), 2.796 pardas (29,0%) e 1.835 negras (19,0%), oriundas de maternidades publicas, conveniadas com o Sistema Unico de Saude e particulares no periodo de 1999 a 2001. Os dados foram coletados de prontuarios medicos e por entrevistas com as maes no pos-parto imediato, aplicando questionarios padronizados. Foram utilizados os testes de chi² para analisar a homogeneidade das proporcoes e t de Student para comparacao de medias. A analise foi estratificada segundo o grau de instrucao materna. RESULTADOS: Observou-se persistente situacao desfavoravel das mulheres de pele preta e parda em relacao as brancas. Nas mulheres pretas e pardas sao maiores as proporcoes de puerperas adolescentes, com baixa escolaridade, sem trabalho remunerado e vivendo sem companheiro. Sofrer agressao fisica, fumar, tentar interromper a gravidez e peregrinar em busca de atencao medica foram mais frequentes nas negras seguidas das pardas e das brancas com baixa escolaridade. O grupo de elevado nivel de escolaridade tem melhores indicadores, mas repete o mesmo padrao. Esse gradiente se mantem, em sentido inverso, quanto a satisfacao com a assistencia prestada no pre-natal e no parto. Constata-se a existencia de duas formas de discriminacao, por nivel educacional e cor da pele. CONCLUSOES: Verificaram-se dois niveis de discriminacao, a educacional e a racial, que perpassam a esfera da atencao oferecida pelos servicos de saude a populacao de puerperas do Municipio do Rio de Janeiro.

Experiência de gravidez na adolescência, fatores associados e resultados perinatais entre puérperas de baixa renda

This paper compares socioeconomic characteristics, prenatal care, and life styles of three groups of post-partum women, one consisting of adolescents (< 20 years) and the other two of women 20-34 years old, classified according to their history of pregnancy during adolescence. A sample of 3,508 post-partum women was selected from public hospitals in the city of Rio de Janeiro, Brazil, and interviewed just after childbirth. To verify the hypothesis of homogeneity of proportions, chi-square tests (c2) were used. Comparing the three groups, the most adverse conditions were found among the 20-34-year-old mothers with a history of pregnancy during adolescence. These women have the least schooling, the highest rates of smoking and use of illegal drugs during pregnancy, and the fewest prenatal appointments. According to this study, prenatal care proved to be an effective compensatory policy for the prevention of prematurity and low birth weight, especially among adolescent mothers.

Birth in Brazil: national survey into labour and birth

BackgroundCaesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.MethodsNationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.DiscussionThis study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health.

Uso do índice de Kotelchuck modificado na avaliação da assistência pré-natal e sua relação com as características maternas e o peso do recém-nascido no Município do Rio de Janeiro

The Kotelchuck index (KI) was modified and used to evaluate prenatal care provided in the City of Rio de Janeiro, Brazil, in a sample of 9,920 post-partum women following singleton deliveries. Ordinal logistic regression (OLR) and multivariate linear regression (LMR) were used to estimate the importance of demographic, psychosocial, and obstetric factors for modified KI and the effects on birth weight (BW), respectively. Only 38.5% of the sample was classified as having received adequate or intensive prenatal care. After adjusting for other predictors, the explanatory variables for KI were: mothers schooling, living with the newborns father, attempted abortion, diabetes mellitus, satisfaction with pregnancy, skin color, parity, age, and place of residence. BW was associated with the modified KI, even after controlling for socio-demographic, behavioral, and biological variables. Adequate utilization of prenatal care in the City of Rio de Janeiro contributed to the prevention of low BW, and the mothers who used prenatal services less presented worse conditions in terms of socioeconomic status, schooling, family support, and obstetric risk.

Gravidez na adolescência como fator de risco para baixo peso ao nascer no Município do Rio de Janeiro, 1996 a 1998

OBJECTIVE: To identify the role of pregnancy during adolescence as a risk factor to low birth weight (LBW). METHODS: A stratified sample of live births from the Information System of Live Births in the municipality of Rio de Janeiro, in the period 1996-98, was selected. The risk factors of LBW were analyzed for the two strata composed by the mother age, 15-19 and 20-24 years old. For the statistical analysis, odds ratios and correspondent confidence intervals were estimated. Logistic regression procedures were used. RESULTS: The LBW was significantly greater among the adolescent mothers group than the 20-24 years one. Regarding prenatal care, adolescents had a lower number of appointments and a higher percentage of no attendance. More than 50% of the older mothers completed high school, but only 31.5% among the younger mothers had the same level of instruction. The percentage of premature live births in this group was significantly greater. Differences were observed by type of hospital (public or private) and there was a predominant use of public hospitals by the adolescents. The logistic regression analysis showed a significant effect of the mother age on LBW, even when controlled for other variables. CONCLUSIONS: The results suggest that further investigation on the mechanisms that underlie the association between LBW and pregnancy during adolescence should be carried out, taking into consideration sociocultural factors such as poverty and social deprivation, as well as biological and nutritional factors during pregnancy.

Perfil sócio-demográfico e psicossocial de puérperas adolescentes do Município do Rio de Janeiro, Brasil - 1999-2001

This study aimed to describe the socioeconomic and psychosocial characteristics of a sample of teenage mothers classified according to marital status and age group. A sample of 1,228 adolescent mothers was interviewed in the immediate post-partum, selected from public and private hospitals in the City of Rio de Janeiro, Brazil. The chi-square test (chi2) was used to verify the hypothesis of homogeneity of proportions. Comparing the groups, we found that single and younger adolescents were at increased risk of unwanted pregnancy, less family support, and more abortions. Fathers of the infants also tended to be adolescents and unemployed. Adherence to prenatal care was influenced by the adolescents marital status. The results showed that the most disadvantaged socioeconomic and psychosocial conditions were found among single and younger adolescents.

Fatores associados à assistência pré-natal precária em uma amostra de puérperas adolescentes em maternidades do Município do Rio de Janeiro, 1999-2000

This study characterizes the women receiving precarious prenatal care according to socio-demographic variables, mothers reproductive history, family support, satisfaction with pregnancy, and risk behavior during pregnancy. A total of 1,967 adolescents were interviewed in the immediate post-partum in public and outsourced maternity hospitals in the City of Rio de Janeiro. The dependent variable was the number of prenatal appointments (0-3; 4-6; 7 or more). The statistical analysis aimed to test the hypothesis of homogeneity of proportions, including bi- and multivariate analysis, using multinomial logistic regression, in which the reference category for the response variable was 7 or more prenatal visits. Higher (and statistically significant) proportions of insufficient number of prenatal visits (0-3) were associated with: precarious sanitation conditions; not living with the childs father; attempted abortion; and smoking, drinking, and/or drug use during pregnancy. The results strongly indicate that mothers with worse living conditions and risk behavior during pregnancy were the same who lacked access to prenatal care.

Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.

Congenital malformations in Rio de Janeiro, Brazil: prevalence and associated factors

This study aims to estimate the prevalence of congenital malformations and their correlation with socioeconomic and maternal variables. The design was cross-sectional, based on a sample of 9,386 postpartum women after admission for childbirth in maternity hospitals in the city of Rio de Janeiro, Brazil. Data were collected through interviews with mothers in the immediate postpartum, as well as by consulting the patient records of both the mothers and newborn infants. Prevalence of congenital malformations at birth was 1.7%, and minor malformations were the most frequent. Neural tube defects were the most frequent major malformations. According to multivariate analysis, congenital malformations were statistically associated with: maternity hospitals belonging to or outsourced by the Unified National Health System (SUS) and inadequate prenatal care (<or= 3 visits). This study highlights the importance of measures for health promotion and disease prevention in childbearing-age women, with special attention to prenatal care and childbirth, which can directly influence neonatal indicators and prevention of birth defects.

Teenage pregnancy and other risk factors for fetal and infant mortality in the city of Rio de Janeiro, Brazil

This article analyzes teenage pregnancy and other risk factors for fetal and infant mortality in the city of Rio de Janeiro, Brazil. The study included a sample of births in Rio de Janeiro, and exposure variables were organized hierarchically. For fetal death, the results showed the protective effect of adequate prenatal care, while maternal morbidity increased the risk. For neonatal death, adequate prenatal care and female gender in the newborn were protective factors, while black or brown maternal skin color, history of stillbirth, maternal morbidity, and physical aggression during the index pregnancy increased the risk. Low birth weight and prematurity were corroborated as determinants of fetal and neonatal death. Risk of post-neonatal death was highest with increased parity, intra-gestational morbidity, and low birth weight. Teenage pregnancy itself was an independent factor for post-neonatal death. The findings reaffirm the relevance of social and health policies targeting adolescents, as well as improvements in prenatal care.