Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries

BACKGROUND

Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs.

METHODS

National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions.

RESULTS

The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest.

CONCLUSION

Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.

Role of Adiponectin in Coronary Heart Disease Risk: A Mendelian Randomization Study

Supplemental Digital Content is available in the text.

Rationale:

Hypoadiponectinemia correlates with several coronary heart disease (CHD) risk factors. However, it is unknown whether adiponectin is causally implicated in CHD pathogenesis.

Objective:

We aimed to investigate the causal effect of adiponectin on CHD risk.

Methods and Results:

We undertook a Mendelian randomization study using data from genome-wide association studies consortia. We used the ADIPOGen consortium to identify genetic variants that could be used as instrumental variables for the effect of adiponectin. Data on the association of these genetic variants with CHD risk were obtained from CARDIoGRAM (22 233 CHD cases and 64 762 controls of European ancestry) and from CARDIoGRAMplusC4D Metabochip (63 746 cases and 130 681 controls; ≈ 91% of European ancestry) consortia. Data on the association of genetic variants with adiponectin levels and with CHD were combined to estimate the influence of blood adiponectin on CHD risk. In the conservative approach (restricted to using variants within the adiponectin gene as instrumental variables), each 1 U increase in log blood adiponectin concentration was associated with an odds ratio for CHD of 0.83 (95% confidence interval, 0.68–1.01) in CARDIoGRAM and 0.97 (95% confidence interval, 0.84–1.12) in CARDIoGRAMplusC4D Metabochip. Findings from the liberal approach (including variants in any locus across the genome) indicated a protective effect of adiponectin that was attenuated to the null after adjustment for known CHD predictors.

Conclusions:

Overall, our findings do not support a causal role of adiponectin levels in CHD pathogenesis.

Missed opportunities in full immunization coverage: findings from low- and lower-middle-income countries

Background

An estimated 23 million infants are still not being benefitted from routine immunization services. We assessed how many children failed to be fully immunized even though they or their mothers were in contact with health services to receive other interventions.

Design

Fourteen countries with Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out after 2000 and with coverage for DPT (Diphtheria-tetanus-pertussis) vaccine below 70% were selected. We defined full immunization coverage (FIC) as having received one dose of BCG (bacille Calmette-Guérin), one dose of measles, three doses of polio, and three doses of DPT vaccines. We tabulated FIC against: antenatal care (ANC), skilled birth attendance (SBA), postnatal care for the mother (PNC), vitamin A supplementation (VitA) for the child, and sleeping under an insecticide-treated bed-net (ITN). Missed opportunities were defined as the percentage of children who failed to be fully immunized among those receiving one or more other interventions.

Results

Children who received other health interventions were also more likely to be fully immunized. In nearly all countries, FIC was lowest among children born to mothers who failed to attend ANC, and highest when the mother had four or more ANC visits Côte d'Ivoire presented the largest difference in FIC: 54 percentage points (pp) between having four or more ANC visits and lack of ANC. SBA was also related with higher FIC. For instance, the coverage in children without SBA was 36 pp lower than for those with SBA in Nigeria. The largest absolute difference on FIC in relation to PNC was observed for Ethiopia: 31 pp between those without and with PNC. FIC was also positively related with having received VitA. The largest absolute difference was observed in DR Congo: 41 pp. The differences in FIC among whether or not children slept under ITN were much smaller than for other interventions. Haiti presented the largest absolute difference: 16 pp.

Conclusions

Our results show the need to develop and implement strategies to vaccinate all children who contact health services in order to receive other interventions.

Body shape and size in 6-year old children: assessment by three-dimensional photonic scanning

Background:

Body shape and size are typically described using measures such as body mass index (BMI) and waist circumference, which predict disease risks in adults. However, this approach may underestimate the true variability in childhood body shape and size.

Objective:

To use a comprehensive three-dimensional photonic scan approach to describe variation in childhood body shape and size.

Subjects/Methods:

At age 6 years, 3350 children from the population-based 2004 Pelotas birth cohort study were assessed by three-dimensional photonic scanner, traditional anthropometry and dual X-ray absorptiometry. Principal component analysis (PCA) was performed on height and 24 photonic scan variables (circumferences, lengths/widths, volumes and surface areas).

Results:

PCA identified four independent components of children's body shape and size, which we termed: Corpulence, Central:peripheral ratio, Height and arm lengths, and Shoulder diameter. Corpulence showed strong correlations with traditional anthropometric and body composition measures (r>0.90 with weight, BMI, waist circumference and fat mass; r>0.70 with height, lean mass and bone mass); in contrast, the other three components showed weak or moderate correlations with those measures (all r<0.45). There was no sex difference in Corpulence, but boys had higher Central:peripheral ratio, Height and arm lengths and Shoulder diameter values than girls. Furthermore, children with low birth weight had lower Corpulence and Height and arm lengths but higher Central:peripheral ratio and Shoulder diameter than other children. Children from high socio-economic position (SEP) families had higher Corpulence and Height and arm lengths than other children. Finally, white children had higher Corpulence and Central:peripheral ratio than mixed or black children.

Conclusions:

Comprehensive assessment by three-dimensional photonic scanning identified components of childhood body shape and size not captured by traditional anthropometry or body composition measures. Differences in these novel components by sex, birth weight, SEP and skin colour may indicate their potential relevance to disease risks.

Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect

The importance of breastfeeding in low-income and middle-income countries is well recognised, but less consensus exists about its importance in high-income countries. In low-income and middle-income countries, only 37% of children younger than 6 months of age are exclusively breastfed. With few exceptions, breastfeeding duration is shorter in high-income countries than in those that are resource-poor. Our meta-analyses indicate protection against child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes. We did not find associations with allergic disorders such as asthma or with blood pressure or cholesterol, and we noted an increase in tooth decay with longer periods of breastfeeding. For nursing women, breastfeeding gave protection against breast cancer and it improved birth spacing, and it might also protect against ovarian cancer and type 2 diabetes. The scaling up of breastfeeding to a near universal level could prevent 823,000 annual deaths in children younger than 5 years and 20,000 annual deaths from breast cancer. Recent epidemiological and biological findings from during the past decade expand on the known benefits of breastfeeding for women and children, whether they are rich or poor.

Sex differences in the association between foetal growth and child attention at age four: specific vulnerability of girls

BACKGROUND

Recent evidence suggests that impaired foetal growth may provide an early indication of increased risk of child attention problems. However, despite both foetal growth and child attention problems differing by sex, few studies have examined sex differences in this association. Furthermore, no studies have been conducted in low- and middle-income countries, where there are higher rates of perinatal problems. This study aimed to test for sex differences in the association between foetal growth indices and attention problems at age four, in a large, prospective birth cohort from a middle-income country.

METHODS

A total of 3,749 neonates from the 2004 Pelotas birth cohort (Brazil) with foetal growth indices collected at birth [low birthweight (LBW), small-for-gestational age (SGA), head circumference (HC), head circumference-to-abdominal circumference ratio (HC/AC) and ponderal index (PI)], were assessed for attention problems using the Child Behaviour Checklist at age four. Ordinal logistic regression with successive adjustment for maternal, demographic, gestational, perinatal and child nutrition/mother-child morbidity, was conducted separately for girls and boys.

RESULTS

In girls, attention difficulties were associated with being born SGA (OR = 1.40, CI = 1.08-1.82, p = .012), with a small HC (OR = 1.52, CI = 1.11-2.08, p = .009), or with a low PI (OR = 1.29, CI = 1.08-1.54, p = .005). There were no associations identified between attention difficulties and any foetal growth indices in boys.

CONCLUSIONS

Our results show that girls with impaired foetal growth may be particularly at risk of attention difficulties in childhood. This is consistent with emerging research that female foetuses may be more vulnerable to certain suboptimal intrauterine environments, inducing epigenetic changes that lead to disturbed growth and long-term developmental impairment.

[Poor dad, poor child? An investigation of intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State, Brazil]

Brazil is one of the countries with the lowest intergenerational income mobility. This article aimed to analyze intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State. Two methods were used, intergenerational income elasticity and quantile regressions, in order to measure heterogeneity in income mobility as a function of different levels of parents' past income. The results show relatively high income mobility for Brazilian standards. The main explanation is that the data cover the children's income at a younger age (about 23 years). Quantile regressions show higher social mobility in the intermediary social stratum. The results reinforce the notion of two opposite "traps", poverty and wealth.

Progress in reducing inequalities in reproductive, maternal, newborn,' and child health in Latin America and the Caribbean: an unfinished agenda

OBJECTIVE

To expand the "Countdown to 2015" analyses of health inequalities beyond the 75 countries being monitored worldwide to include all countries in Latin America and the Caribbean (LAC) that have adequate data available.

METHODS

Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to monitor progress in health intervention coverage and inequalities in 13 LAC countries, five of which are included in the Countdown (Bolivia, Brazil, Guatemala, Haiti, and Peru) and eight that are not (Belize, Colombia, Costa Rica, Dominican Republic, Guyana, Honduras, Nicaragua, and Suriname). The outcomes included neonatal and under-5 year mortality rates, child stunting prevalence, and the composite coverage index-a weighted average of eight indicators of coverage in reproductive, maternal, newborn, and child health. The slope index of inequality and concentration index were used to assess absolute and relative inequalities.

RESULTS

The composite coverage index showed monotonic patterns over wealth quintiles, with lowest levels in the poorest quintile. Under-5 and neonatal mortality as well as stunting prevalence were highest among the poor. In most countries, intervention coverage increased, while under-5 mortality and stunting prevalence fell most rapidly among the poor, so that inequalities were reduced over time. However, Bolivia, Guatemala, Haiti, Nicaragua, and Peru still show marked inequalities. Brazil has practically eliminated inequalities in stunting.

CONCLUSIONS

LAC countries presented substantial progress in terms of reducing inequalities in reproductive, maternal, newborn, and child health interventions, child mortality, and nutrition. However, the poorest 20% of the population in most countries is still lagging behind, and renewed actions are needed to improve equity.

Determinants of out-of-pocket health expenditure on children: an analysis of the 2004 Pelotas Birth Cohort

Background

The present study aimed to examine the impact of socioeconomic, demographic, and health status-related factors on out-of-pocket expenditure on health care for children.

Methods

Data were obtained from a birth cohort study conducted in the city of Pelotas, state of Rio Grande do Sul (RS), southern Brazil, in 2004. The final sample is a result of adjusts made in order to keep in the analysis only those that attended to 3 follow-ups (at 12, 24 and 48 months of age). Estimates were carried out using the Panel Data Tobit Model with random effects.

Results

The study showed that expenditure on medicines was 20 % less likely in those considered healthy children by their mothers and, if there was any expenditure with healthy children, the expected expenditure was reduced by 58 %. A 1 % increase in household income increased the expected expenditure on medicines by 16 %, and by 23 % in children with private health insurance coverage.

Conclusions

All types of health care expenditures examined were higher for children covered by private health insurance. Although total health care expenditure was higher for children of better-off families, it represented a lower share of these families’ income evidencing income inequality in health care expenditures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-015-0180-0) contains supplementary material, which is available to authorized users.

Genetic causes of intellectual disability in a birth cohort: a population-based study

Intellectual disability affects approximately 1–3% of the population and can be caused by genetic and environmental factors. Although many studies have investigated the etiology of intellectual disability in different populations, few studies have been performed in middle‐income countries. The present study estimated the prevalence of genetic causes related to intellectual disability in a cohort of children from a city in south Brazil who were followed from birth. Children who showed poor performance in development and intelligence tests at the ages of 2 and 4 were included. Out of 4,231 liveborns enrolled in the cohort, 214 children fulfilled the inclusion criteria. A diagnosis was established in approximately 90% of the children evaluated. Genetic causes were determined in 31 of the children and 19 cases remained unexplained even after extensive investigation. The overall prevalence of intellectual disability in this cohort due to genetic causes was 0.82%. Because this study was nested in a cohort, there were a large number of variables related to early childhood and the likelihood of information bias was minimized by collecting information with a short recall time. This study was not influenced by selection bias, allowing identification of intellectual disability and estimation of the prevalence of genetic causes in this population, thereby increasing the possibility of providing appropriate management and/or genetic counseling. © 2015 The Authors. American Journal of Medical Genetics Part A Published by Wiley Periodicals, Inc.

Early life determinants of low IQ at age 6 in children from the 2004 Pelotas Birth Cohort: a predictive approach

Background

Childhood intelligence is an important determinant of health outcomes in adulthood. The first years of life are critical to child development. This study aimed to identify early life (perinatal and during the first year of life) predictors of low cognitive performance at age 6.

Methods

A birth cohort study started in the city of Pelotas, southern Brazil, in 2004 and children were followed from birth to age six. Information on a broad set of biological and social predictors was collected. Cognitive ability—the study outcome—was assessed using the Wechsler Intelligence Scale for Children (WISC). IQ scores were standardized into z-scores and low IQ defined as z < −1. We applied bootstrapping methods for internal validation with a multivariate logistic regression model and carried out external validation using a second study from the 1993 Pelotas Birth Cohort.

Results

The proportion of children with IQ z-score < −1 was 16.9% (95% CI 15.6–18.1). The final model included the following early life variables: child’s gender; parents’ skin color; number of siblings; father’s and mother’s employment status; household income; maternal education; number of persons per room; duration of breastfeeding; height-for-age deficit; head circumference-for-age deficit; parental smoking during pregnancy; and maternal perception of the child’s health status. The area under the ROC curve for our final model was 0.8, with sensitivity of 72% and specificity of 74%. Similar results were found when testing external validation by using data from the 1993 Pelotas Birth Cohort.

Conclusions

The study results suggest that a child’s and her/his family’s social conditions are strong predictors of cognitive ability in childhood. Interventions for promoting a healthy early childhood development are needed targeting children at risk of low IQ so that they can reach their full cognitive potential.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-014-0308-1) contains supplementary material, which is available to authorized users.

Effectiveness of motivational interviewing at improving oral health: a systematic review

OBJECTIVE

To analyze the effectiveness of motivational interviewing (MI) at improving oral health behaviors (oral hygiene habits, sugar consumption, dental services utilization or use of fluoride) and dental clinical outcomes (dental plaque, dental caries and periodontal status).

METHODS

A systematic search of PubMed, LILACS, SciELO, PsyINFO, Cochrane and Google Scholar bibliographic databases was conducted looking for intervention studies that investigated MI as the main approach to improving the oral health outcomes investigated.

RESULTS

Of the 78 articles found, ten met the inclusion criteria, all based on randomized controlled trials. Most studies (n = 8) assessed multiple outcomes. Five interventions assessed the impact of MI on oral health behaviors and nine on clinical outcomes (three on dental caries, six on dental plaque, four on gingivitis and three on periodontal pockets). Better quality of evidence was provided by studies that investigated dental caries, which also had the largest population samples. The evidence of the effect of MI on improving oral health outcomes is conflicting. Four studies reported positive effects of MI on oral health outcomes whereas another four showed null effect. In two interventions, the actual difference between groups was not reported or able to be recalculated.

CONCLUSIONS

We found inconclusive effectiveness for most oral health outcomes. We need more and better designed and reported interventions to fully assess the impact of MI on oral health and understand the appropriate dosage for the counseling interventions.

Body composition assessment using DXA in six-year-old children: the 2004 Pelotas Birth Cohort, Rio Grande do Sul State, Brazil

The aim of this study was to describe fat (FM) and lean body mass (LBM) in six-year-old children from the 2004 Pelotas Birth Cohort, stratified by gender. Dual-Energy X-ray Absorptiometry was used to measure FM and LBM, FM and LBM indexes, and percentage (%) of FM and LBM. Mean measures of adiposity were higher among girls (6.3kg, 4.2kg/m2 and 23.4% vs. 5kg, 3.3kg/m2 and 18%) while LBM measures were higher among boys (19.3kg, 13kg/m2 and 78.5% vs. 17.7kg, 12.2kg/m2 and 73.2%). In both boys and girls mean measures of adiposity increased with socioeconomic status and maternal education. Mean measures of adiposity were higher among white-skinned children while %LBM was higher among black-skinned children. Preterm compared to full-term children showed lower mean measures of adiposity and LBM. Female sex, white skin color and higher socioeconomic conditions are associated with higher adiposity in childhood.

[Prevalence of preterm birth according to birth weight group: a systematic review]

OBJECTIVE

To estimate the prevalence of preterm birth by categories of birth weight, and to obtain an equation to correct the estimates.

METHODS

Systematic review of the Brazilian literature published from 1990 to 2012, to identify studies with primary collection of data on birth weight and gestational age. Twelve studies were selected and contributed for tabulations of preterm prevalence according to 100 g birth weight categories. These results were combined using sex-specific fractional polynomial equations and the resulting curves were compared with results from the Live Birth Information System for the years 2000, 2005, 2010 and 2011.

RESULTS

For all birth weight categories, preterm prevalence estimates based on primary studies had a higher prevalence than those of the the Live Birth Information System. The prevalence reported by the Live Birth Information System was of 7.2% in 2010, about 38.0% lower than the estimated prevalence of 11.7% obtained with the correctional equation.

CONCLUSIONS

Information reported by the Live Birth Information System on preterm prevalence does not reflect the true magnitude of the problem in Brazil, and should not be used without the correction factors proposed in the present analyses.

Cohort profile update: 2004 Pelotas (Brazil) Birth Cohort Study. Body composition, mental health and genetic assessment at the 6 years follow-up

This is an update of the 2004 Pelotas Birth Cohort profile, originally published in 2011. In view of the high prevalence of overweight and mental health problems among Brazilian children, together with the availability of state-of-the-art equipment to assess body composition and diagnostic tests for mental health in childhood, the main outcomes measured in the fifth follow-up (mean age 6.8 years) included child body composition, mental health and cognitive ability. A total of 3722 (90.2%) of the original mothers/carers were interviewed and their children examined in a clinic where they underwent whole-body dual X-ray absorptiometry (DXA), air displacement plethysmography and a 3D photonic scan. Saliva samples for DNA were obtained. Clinical psychologists applied the Development and Well-Being Assessment questionnaire and the Wechsler Intelligence Scale for Children to all children. Results are being compared with those of the two earlier cohorts to assess the health effects of economic growth and full implementation of public policies aimed at reducing social inequalities in the past 30 years. For further information visit the programme website at [http://www.epidemio-ufpel.org.br/site/content/coorte_2004/questionarios.php]. Applications to use the data should be made by contacting 2004 cohort researchers and filling in the application form available at [http://www.epidemio-ufpel.org.br/site/content/estudos/formularios.php].

[Place and type of meals consumed by adults in medium sized cities]

OBJECTIVE

To describe the meals consumed by adults living in a midsize city in the South of Brazil, according to the place and preparation.

METHODS

A population-based cross-sectional study was conducted in Pelotas, Southern Brazil, in 2012. The two-stage sampling design used the 2010 census tracts as primary sampling units. Data were collected on the place of meals (at home or out) and on the kind of preparations consumed at home (homemade, snacks, take away food) covering the two days prior to the interview, using a standardized questionnaire.

RESULTS

The study included 2,927 adults, of which 59.0% were female, 60.0% were below 50 years of age and 58.0% were in work. Data were collected on 11,581 meals consumed on the two days preceding the interview, 25.0% were consumed outside of the home at lunchtime, and 10.0% at dinnertime. Considering home meals, most participants reported eating food prepared at home at both lunch and dinner. The majority of out-of-home meals (64.0% for lunch and 61.0% for dinner) were consumed in the work place, mostly based on food prepared at home. Individuals eating out of home were mostly male, young and highly educated. The occupational categories that ate at restaurants more often were trade workers, businessmen, teachers and graduate professionals.

CONCLUSIONS

Despite the changes in eating patterns described in Brazil in recent years, residents of medium-sized towns still mostly eat at home, consuming homemade food.

[Methodological description of accelerometry for measuring physical activity in the 1993 and 2004 Pelotas (Brazil) birth cohorts]

The aim of this study was to characterize the methodology of data collection on physical activity using accelerometry in two birth cohorts (2004 and 1993) in Pelotas, Rio Grande do Sul State, Brazil, at the 6-7 and 18-year follow-up visits, respectively. During visits to the study headquarters for a health evaluation, cohort subjects received the accelerometer to be worn on the wrist for 5 to 8 days, after which the device was retrieved at their homes. Genea and GENEActiv triaxial estimators of gravity (g) acceleration were employed. Accelerometry data were collected from 3,331 children (93.7% of those included in follow-up) and 3,816 adolescents (99% of those in follow-up). The study characterizes the data collection methodology in more than 7,000 individuals and discusses issues in its implementation. It thus provides a methodological framework aimed at helping to plan future population-based studies with the use of such technology and to improve understanding of physical activity in the context of epidemiological studies.

Prevalence and comorbidity of psychiatric disorders among 6-year-old children: 2004 Pelotas Birth Cohort

PURPOSE

Most studies published on the prevalence of psychiatric disorders in children were conducted in high-income countries despite the fact that nearly 90 % of the world's population aged under 18 live in low- and middle-income countries. The study aimed to assess the prevalence of psychiatric disorders among children of 6 years of age, to examine the distribution of psychiatric disorders by gender and socioeconomic status and to evaluate the occurrence of psychiatric comorbidities.

METHODS

The 2004 Pelotas Birth Cohort originally comprised 4,231 live births from Pelotas, southern Brazil. A total of 3,585 (84.7 % of 4,231 births) children aged 6 years were assessed using the Development and Well-Being Assessment (DAWBA).

RESULTS

Nearly 13 % of the children presented a psychiatric diagnosis according to DSM-IV, being more prevalent among males than females (14.7 and 11.7 %, respectively, p = 0.009). Anxiety disorders were the most prevalent of all disorders (8.8 %) and specific phobias (5.4 %) and separation anxiety disorder (3.2 %) were the most common subtypes. Attention deficit hyperactivity disorder (2.6 %), oppositional defiant disorder/conduct disorder (2.6 %), and depression (1.3 %) were also diagnosed. More than one psychiatric disorder was presented by 17 % of children. Socioeconomically disadvantaged children had a higher prevalence of psychiatric disorders.

CONCLUSION

Our findings underline the early onset of psychiatric disorders among children and the frequent occurrence of psychiatric comorbidity. Early prevention is needed in the field of mental health in Brazil and should start during infancy.

Maternal smoking in successive pregnancies and recurrence of low birthweight: the 2004 Pelotas birth cohort study, Brazil

To evaluate the frequency of maternal smoking in successive pregnancies and its association with repetition of low birthweight, a study was conducted of a subsample of mothers from the 2004 Pelotas Birth Cohort in Brazil. Only women with previous histories of low birthweight newborns were included. Women with ≥ 2 previous births were eligible only if at least one of the two births immediately preceding the 2004 birth had low birthweight. From 4,458 births, 565 were included in this study. Frequency of smoking was 32.4%. Considering past pregnancies, 67.1% of mothers never smoked, 21.4% smoked during all pregnancies, 6.5% were ex-smokers, and 5% smoked only during the current pregnancy. In the adjusted analyses, when compared to mothers who never smoked, those who smoked during all pregnancies had 2.5 times greater probability of low birthweight recurrence in 2004 (PR = 2.5; 95%CI: 1.32-4.80). Smoking persistence is an important factor for the recurrence of low birthweight in successive pregnancies.

Padrões alimentares e fatores associados entre crianças de um a seis anos de um município do Sul do Brasil

O estudo teve como objetivos descrever padrões alimentares e investigar a associação com fatores demográficos e socioeconômicos entre crianças de um a seis anos na cidade de Pelotas, Rio Grande do Sul, Brasil. Foi utilizada a correlação de Pearson para agrupar os alimentos. Os padrões alimentares foram construídos por meio da análise de componentes principais. As associações foram verificadas usando-se o teste de KruskalWallis (α = 0,05). Foram avaliadas 667 crianças. Identificou-se cinco padrões alimentares: "vegetais", "tradicional" (pão, margarina/margarina, arroz/massa, café, açúcar), "guloseimas e embutidos", "lanches" (laticínios, achocolatados, biscoitos e sucos) e "frutas". Os padrões "vegetais" e "frutas"tiveram maior adesão entre as crianças cujas mães tinham maior escolaridade e renda familiar. O padrão "tradicional" foi o mais observado entre crianças cujas mães tinham menor escolaridade e renda familiar. Os padrões "vegetais" e "tradicional" apresentaram o maior percentual de variância. As condições socioeconômicas das famílias exercem um papel fundamental na determinação do padrão alimentar das crianças.

Measuring coverage in MNCH: determining and interpreting inequalities in coverage of maternal, newborn, and child health interventions

To monitor progress towards the Millennium Development Goals, it is essential to monitor the coverage of health interventions in subgroups of the population, because national averages can hide important inequalities. In this review, we provide a practical guide to measuring and interpreting inequalities based on surveys carried out in low- and middle-income countries, with a focus on the health of mothers and children. Relevant stratification variables include urban/rural residence, geographic region, and educational level, but breakdowns by wealth status are increasingly popular. For the latter, a classification based on an asset index is the most appropriate for national surveys. The measurement of intervention coverage can be made by single indicators, but the use of combined measures has important advantages, and we advocate two summary measures (the composite coverage index and the co-coverage indicator) for the study of time trends and for cross-country comparisons. We highlight the need for inequality measures that take the whole socioeconomic distribution into account, such as the relative concentration index and the slope index of inequality, although simpler measures such as the ratio and difference between the richest and poorest groups may also be presented for non-technical audiences. Finally, we present a framework for the analysis of time trends in inequalities, arguing that it is essential to study both absolute and relative indicators, and we provide guidance to the joint interpretation of these results.

Factors associated to medicine use among children from the 2004 Pelotas Birth Cohort (Brazil)

OBJECTIVE

To identify factors associated to medicine use among children from the 2004 Pelotas Birth Cohort, Brazil.

METHODS

Prospective study to evaluate medicine use in children aged 3, 12 and 24 months regardless of the reasons, therapeutic indication or class. The study included 3,985 children followed up at three months of age, 3,907 at 12 months, and 3,868 at the last follow-up time of 24 months. Mothers were interviewed to collect information on medicine use during the recall period of 15 days prior to the interview. The outcome was studied according to sociodemographic and perinatal variables, mother's perception of child's health and breastfeeding status. Crude and adjusted analyses were performed by Poisson regression following a hierarchical model.

RESULTS

The prevalence of medicine use ranged from 55% to 65% in the three follow-ups. After controlling for confounders, some variables remained associated to medicine use only at the three-month follow-up with greatest use among children of younger mothers, those children who had intrapartum complications, low birthweight, were never breastfed and were admitted to a hospital. Greatest medicine use was also associated with being a firstborn child at 3 and 12 months; mother's perception of their child health as fair or poor and children whose mothers have private health insurance at 12 and 24 months; highest maternal education level at all follow-up times.

CONCLUSIONS

Different variables influence medicine use among children during the first two years of life and they change as the child ages especially maternal factors and those associated to the child's health problems.

Caries is the main cause for dental pain in childhood: findings from a birth cohort

AIM

The aim of the study was to evaluate the prevalence of dental pain in preschool children and its association with socioeconomic, demographic, clinical, and behavior variables.

SUBJECTS AND METHODS

The study was nested in a population-based birth cohort from Pelotas, Brazil, started in 2004. A sample of 1,129 children aged 5 years was dentally examined, and their mothers were interviewed. Exploratory variables included demographics, socioeconomic status, mothers' oral health status and associated behaviors, and caries in primary teeth. Data were analyzed using multivariable Poisson regression.

RESULTS

The prevalence of dental pain was 16.5% (95% CI: 14.4-18.8). Multivariate analysis showed that dark-skinned children (prevalence ratio, PR = 1.6, 95% CI: 1.1-2.4) from low socioeconomic level (PR 1.9, 1.2-3.0) whose mothers had less than 4 years of education (PR 1.9, 1.0-3.6), from mothers with less than 10 teeth in at least one arch (PR 1.7, 1.2-2.5) and less than 10 in two arches (PR 1.6, 1.0-2.6), and those with high caries prevalence at the age of 5 years (PR 4.8, 3.3-7.1) were more likely to experience dental pain.

CONCLUSIONS

Unrestored caries is the main factor associated with dental pain in childhood. Socioeconomic aspects and family context in which dental pain occurs should also be taken into account when dental pain preventive measures are implemented.

Trends in socioeconomic inequalities in anthropometric status in a population undergoing the nutritional transition: data from 1982, 1993 and 2004 Pelotas birth cohort studies

BACKGROUND

Socioeconomic inequalities in child nutrition may change rapidly over time, particularly in populations undergoing the nutrition transition. Yet, the few available studies are repeated cross-sectional surveys. By studying three prospective birth cohorts in the same city over a period of more than two decades, we describe secular trends in overweight and stunting at different ages, according to socioeconomic position.

METHODS

Population-based birth cohort studies were launched in the city of Pelotas (Brazil) in 1982, 1993 and 2004, with follow-up visits at twelve, 24 and 48 months. Children were weighed and measured at every visit. Z-scores of length/height-for-age and body mass index-for-age were calculated using the WHO Child Growth Standards. The slope and relative indices of inequality, based on family income quintiles, were estimated for each follow-up visit.

RESULTS

Between the 1982 and 2004 cohorts, stunting among four-year-olds declined (from 10.9% to 3.6%), while overweight increased (from 7.6% to 12.3%). In every visit, stunting prevalence was inversely related to income. Both absolute and relative inequalities declined over time; among four-year-olds stunting dropped from 26.0% in the 1982 cohort to 6.7% in the 2004 cohort in the poorest group, while in the richest group stunting prevalence dropped from 2.7% in 1982 to 1.1% in the 2004 cohort study. The secular trend towards increased overweight was evident for four-year-olds, in almost all socioeconomic groups, but not among one and two-year-olds. Among four-year old children, overweight prevalence increased in all income quintiles, by 130% in the middle-income group, 64% in the poorest and 41% in the richest group.

CONCLUSIONS

The decline in stunting is remarkable, but the increase in overweight among four-year olds - particularly among the poorest and the middle-income groups- requires concerted efforts to prevent the long term consequences of child overweight.