Fatores associados à morbi-mortalidade perinatal em uma amostra de maternidades públicas e privadas do Município do Rio de Janeiro, 1999-2001

Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool

BACKGROUND

Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce.

OBJECTIVES

We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle.

METHODS

Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits.

RESULTS

At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care.

CONCLUSIONS

A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.

Orientações às gestantes no pré-natal: a importância do cuidado compartilhado na atenção primária em saúde

RESUMO Objetivo Analisar a associação entre a adequação das orientações recebidas durante o pré-natal e o profissional que atendeu a gestante na maioria das consultas na Atenção Primária à Saúde. Método Participaram 3.111 puérperas que realizaram pré-natal pelo Sistema Único de Saúde no Estado de Santa Catarina em 2019, através de questionário aplicado em ambiente hospitalar até 48 horas pós-parto. Analisou-se associação entre a variável de exposição principal e covariáveis, e o desfecho segundo profissional que atendeu no pré-natal. Resultados As orientações mais frequentes foram os sinais de riscos na gestação (80,3%) e riscos de automedicação (76,9%). Observaram-se prevalências abaixo de 50% nas orientações sobre manejo adequado da amamentação (45,9%) e possibilidade de visitar a maternidade antes do parto (38,2%); ter recebido todas as orientações ao menos uma vez durante o pré-natal foi de 18,4%. Gestantes atendidas na maioria das consultas pelos profissionais médico e enfermeiro apresentaram chance 41,0% maior de adequação às orientações, em comparação com aquelas atendidas exclusivamente por médicos. Conclusões e implicações para a prática A prevalência de orientações dadas pelos profissionais de saúde às gestantes foi mais elevada quando o pré-natal foi mais compartilhado entre enfermeiros e médicos, em comparação ao atendimento majoritário por profissional de apenas uma profissão.

[Individual and contextual determinants of infant mortality in Brazilian state capitals: a multilevel approach]

The study sought to identify individual and contextual risk factors in healthcare and their interactions and regional differences in the determination of infant mortality in Brazilian state capitals. This was a case-control study that analyzed 7,470 infant deaths in 2012 in the 27 state capitals, recorded in the Brazilian Mortality Information System (SIM) and matched with the Brazilian Information System on Live Births (SINASC) through linkage and 24,285 controls obtained by sampling the surviving liveborn infants from 2011 to 2012 from the total of 1,424,691 births. The individual explanatory variables corresponded to information available in the SINASC database, and the contextual variable consisted of a quality index for hospital care in the 702 healthcare services where the births occurred. A multilevel logistic model was used to analyze interaction. The principal determinants of infant mortality were biological factors (low birthweight, prematurity, congenital malformations, severe/moderate asphyxia, and race/color), mediated by maternal socioeconomic factors (schooling, marital status, and occupation) and insufficiency of prenatal care. Low number of prenatal visits was a risk factor for infant mortality, independently of the service's quality, except in the state capitals in the South of Brazil. In the interaction between income and prenatal care, few prenatal visits and birth in high-income state capitals showed a higher risk when compared to births in low-income state capitals (OR = 0.68). Multilevel analysis evidenced regional inequalities in the risk models and reiterated the importance of biological determinants in the mediation of socioeconomic and healthcare factors in infant mortality.

PREVALENCE OF CONGENITAL ANOMALIES AND THEIR ASSOCIATED FACTORS IN NEWBORNS IN THE CITY OF SÃO PAULO FROM 2010 TO 2014

OBJECTIVE

To study the prevalence of congenital anomalies in newborns in the city of São Paulo from 2010 to 2014, as well as to analyze other variables associated with the anomalies.

METHODS

Data was collected from the Ministry of Health's Live Births Information System (SINASC) from 2010 to 2014 in São Paulo City. The variables analyzed were length and type of pregnancy, maternal age, and ethnicity and sex of the newborn. The absolute and relative frequencies of congenital anomalies were verified, and the variables associated with them were calculated with the odds ratio (OR) and a 95% confidence interval.

RESULTS

A total of 819,018 live births occurred in the city of São Paulo, and in 14,657 (1.6%) of them, some congenital anomaly was reported. The most frequent congenital anomalies found were those related to osteoarticular system followed by those related to the cardiovascular system. Risks associated with the presence of congenital anomalies were observed in the following factors: maternal age over 40 years (OR=1.59; 95%CI 1.47-1.71), multiple pregnancies (OR=1.28; 95%CI 1.19-3.77), and low birth weight (OR=3.35; 95%CI 3.21-3.49). The female gender was considered a protective variable (OR=0.78; 95%CI 0.75-0.81).

CONCLUSIONS

Congenital anomalies are responsible for morbidity and mortality in the neonatal period. Their early diagnosis is important for planning and resource allocation of specialized health services directed toward the families and infants.

[Characterization of access to normal childbirth care in Bahia State, Brazil, based on graph theory]

Origin-destination flow is a phenomenon that can be modeled as a network. Graph theory is a mathematical tool to characterize a network and thus allows studying the topological properties and temporal and spatial development of a set of related elements. The article aims to estimate the topological evolution of an inter-municipal network of normal deliveries. We selected the admissions for normal deliveries in the Hospital Information System of the Brazilian Unified National Health System, from 2008 to 2014, for women residing in Bahia State, Brazil. The following indices were applied: entry degree (from how many municipalities the women came for childbirth), exit degree (to how many municipalities they left), entry flow (how many women came), exit flow (how many women left), and the mean size of the exit edge (distance traveled). Analyses between macro-regions used the following indicators: proportion of normal deliveries performed outside the municipality of residence and mean size of the exit edge. The results indicate an increase in deliveries performed outside the municipality of residence, in addition to the persistence of concentration of deliveries in the hub municipalities in the Health Regions, and an increase in the distance between the municipality of residence and the municipality where the delivery took place. The organization of networks for normal childbirth poses an on-going challenge. It is important to analyze the flow of women for childbirth care in order to support the establishment of inter-municipal references to guarantee safe labor and childbirth. In conclusion, it is necessary to develop a regionalized network to meet the demand by pregnant women in the territory with universal and equitable coverage.

Access to childbirth care by adolescents and young people in the Northeastern region of Brazil

OBJECTIVE

To identify the factors that interfere with the access of adolescents and young people to childbirth care for in the Northeast region of Brazil.

METHODS

Cross-sectional study with 3,014 adolescents and young people admitted to the selected maternity wards to give birth in the Northeast region of Brazil. The sample design was probabilistic, in two stages: the first corresponded to the health establishments and the second to women who had recently given birth and their babies. The data was collected by means of interviews and consulting the hospital records, from pre-tested electronic form. Descriptive statistics were used for the univariate analysis, Pearson's Chi-square test for the bivariate analysis and multiple logistic regressions for the multivariate analysis. Sociodemographic variables, obstetrical history, and birth care were analyzed.

RESULTS

Half of the adolescents and young people interviewed had not been given guidance on the location that they should go to when in labor, and among those who had, 23.5% did not give birth in the indicated health service. Furthermore, one third (33.3%) had to travel in search of assisted birth, and the majority (66.7%) of the postpartum women came to maternity by their own means. In the bivariate analysis, the variables marital status, paid work, health insurance, number of previous pregnancies, parity, city location, and type of health establishment showed a significant association (p < 0.20) with inadequate access to childbirth care. The multivariate analysis showed that married adolescents and young people (p < 0.015), with no health insurance (p < 0.002) and from the countryside (p < 0.001) were more likely to have inadequate access to childbirth care.

CONCLUSIONS

Adolescents and young women, married, without health insurance, and from the countryside are more likely to have inadequate access to birth care. The articulation between outpatient care and birth care can improve this access and, consequently, minimize the maternal and fetal risks that arise from a lack of systematic hospitalization planning.

Changes in perinatal health in two birth cohorts (1997/1998 and 2010) in São Luís, Maranhão State, Brazil

The objective of this study was to analyze changes in perinatal health in two birth cohorts started in 1997/1998 and 2010, respectively, in São Luís, Maranhão State, Brazil. A total of 2,493 live born infants were included in 1997/1998 and 5,166 in 2010. Low birth weight (LBW) rate did not change (8.5% in 1997/1998 and 8.6% in 2010). Preterm birth (PTB) rate also remained stable (13.2% in 1997/1998 and 13% in 2010). Teenage deliveries and births to single mothers decreased. Maternal schooling and prenatal care coverage increased. Intrauterine growth restriction (IUGR) decreased from 13.3% to 10.6% (p < 0.001). The perinatal mortality rate decreased from 36.6 to 20.7 per 1,000 (p < 0.001) and the infant mortality rate (IMR) dropped from 28.5 to 12.8 per 1,000 (p < 0.001). The cesarean rate increased from 34.1% to 47.5% (p < 0.001). In conclusion, despite favorable changes in socio-demographic, behavioral, and health service factors and decreasing rates of IUGR and perinatal and infant mortality, LBW and PTB remained stable, while the cesarean rate increased.

The study of the mother-child binomium: description and general results

OBJECTIVE: The present study investigated the characteristics of women during pregnancy/immediate postpartum cycles and the product of their pregnancy. METHOD: Data collection was conducted for a period of three months in 2011, in six maternity hospitals in the State of São Paulo. The data were obtained in an interview with the women after the end of the pregnancy and collected from hospital records. The sample included 7,058 women hospitalized for abortion or childbirth in five hospitals from SUS (Unified Health System) and from only one hospital for private health insurance patients and their 6,602 conceptuses (live births and stillborns). Statistical analysis was based on χ2 tests, with a significance level of α = 5%. RESULTS: It was observed that 6,530 women gave birth and 528 showed interruption of pregnancy. Regarding age, 1,448 were teenagers (20.5%). There were no deaths during hospitalization and 99.8% of women received a medical discharge. Maternal morbidity in the current pregnancy was analyzed, showing urinary tract infection, anemia and excessive vomiting as the main problems. The rate of cesarean sections accounted for 31.1% and complications in childbirth and postpartum were shown, respectively, by 834 (12.8%) and 265 (4.1%) women. The characteristics of the conceptuses were also studied: gestation length (9.3% of preterm among live births, and 68% among the stillborn); birth weight (underweight in 8.2% among live births, and 66% among the stillborn) and morbidity, measured by congenital anomalies and other diseases; these diseases were responsible for ICU stay, transfers to better-equipped hospitals (10 cases) and 37 deaths. Thirteen live births were still hospitalized at the end of the investigation.

Prenatal care in Brazil

This study aims to describe prenatal care provided to pregnant users of the public or private health services in Brazil, using survey data from Birth in Brazil, research conducted from 2011 to 2012. Data was obtained through interviews with postpartum women during hospitalization and information from hand-held prenatal notes. The results show high coverage of prenatal care (98.7%), with 75.8% of women initiating prenatal care before 16 weeks of gestation and 73.1% having six or more number of appointments. Prenatal care was conducted mainly in primary health care units (89.6%), public (74.6%), by the same professional (88.4%), mostly physicians (75.6%), and 96% received their hand-held prenatal notes. A quarter of women were considered at risk of complications. Of the total respondents, only 58.7% were advised about which maternity care service to give birth, and 16.2% reported searching more than one health service for admission in labour and birth. Challenges remain for improving the quality of prenatal care, with the provision of effective procedures for reducing unfavourable outcomes.

Atenção ao pré-natal e parto em mulheres usuárias do sistema público de saúde residentes na Amazônia Legal e no Nordeste, Brasil 2010

Objetivos: descrever a adequação da atenção à saúde entre as mulheres que fizeram o pré-natal e/ou parto no Sistema Único de Saúde (SUS), nos municípios prioritários para a redução da mortalidade infantil na Amazônia Legal e no Nordeste. Métodos: análise de dados secundários de inquérito de base populacional com mães e crianças menores de um ano de idade que compareceram à Campanha de vacinação em 2010. A amostra estudada foi de 13.205 mulheres com acompanhamento de pré-natal e de 13.044 mulheres com acompanhamento de parto, em 252 municípios prioritários. A adequação do pré-natal e parto foi classificada em conformidade com indicadores de processo propostos pelo Programa Nacional de Humanização do Pré-natal e Nascimento. Resultados: entre as mulheres investigadas 75,4% realizaram seis ou mais consultas de pré-natal, mas somente 3,4% tiveram acesso a um pré-natal classificado como adequado. O acesso à ultrassonografia foi relatado por 96,1% das mulheres, ao exame de HIV por 91,8% e ao teste de sífilis por 68,7%. Apenas 44,2% das mulheres recebeu indicação da maternidade na qual deveria fazer o parto e a internação no local indicado ocorreu em 8,6% dos casos. A atenção ao parto foi considerada adequada para apenas 1% das entrevistadas. Os resultados variaram entre os estados e níveis socioeconômicos das mulheres. Conclusões: foram identificadas falhas na atenção ao pré-natal e parto, que é inadequada e socialmente iníqua nestas regiões, contribuindo para os precários indicadores de saúde materno infantil na Amazônia Legal e no Nordeste do Brasil.

[Evaluation of data on live birth certificates from the Information System on Live Births (SINASC) in Campinas, São Paulo, 2009]

Objective:

To assess the completeness and reliability of the Information System on Live Births (Sinasc) data.

Methods:

A cross-sectional analysis of the reliability and completeness of Sinasc's data was performed using a sample of Live Birth Certificate (LBC) from 2009, related to births from Campinas, Southeast Brazil. For data analysis, hospitals were grouped according to category of service (Unified National Health System, private or both), 600 LBCs were randomly selected and the data were collected in LBC-copies through mothers and newborns' hospital records and by telephone interviews. The completeness of LBCs was evaluated, calculating the percentage of blank fields, and the LBCs agreement comparing the originals with the copies was evaluated by Kappa and intraclass correlation coefficients.

Results:

The percentage of completeness of LBCs ranged from 99.8%-100%. For the most items, the agreement was excellent. However, the agreement was acceptable for marital status, maternal education and newborn infants' race/color, low for prenatal visits and presence of birth defects, and very low for the number of deceased children.

Conclusion:

The results showed that the municipality Sinasc is reliable for most of the studied variables. Investments in training of the professionals are suggested in an attempt to improve system capacity to support planning and implementation of health activities for the benefit of maternal and child population.

The performance of various anthropometric assessment methods for predicting low birth weight in adolescent pregnant women

Objective: To evaluate the performance of various anthropometric evaluation methods for adolescent pregnant women in the prediction of birth weight. Methods: It is a cross-sectional study including 826 adolescent pregnant women. In the pre-pregnancy body mass index (BMI) classification, the recommendations of the World Health Organization were compared with that of the Brazilian Ministry of Health and the Institute of Medicine (IOM) of 1992 and 2006. The gestational weight gain adequacy was evaluated according to the classification of IOM of 1992, of 2006 and of the Brazilian Ministry of Health. The newborns were classified as low birth weight (LBW) or macrosomic. Multinomial logistic regression was used for statistical analysis and sensibility, specificity, accuracy, positive and negative predictive values were calculated. Results: The evaluation, according to the Brazilian Ministry of Health, showed the best prediction for LBW among pregnant women with low weight gain (specificity = 69.5%). The evaluation according to the IOM of 1992 showed the best prediction for macrosomia among pregnant women with high weight gain (specificity = 50.0%). The adequacy of weight gain according to the IOM of 1992 classification showed the best prediction for LBW (OR = 3.84; 95%CI 2.19 - 6.74), followed by the method of the Brazilian Ministry of Health (OR = 2.88, 95%CI 1.73 - 4.79), among pregnant women with low weight gain. Conclusion: It is recommended the adoption of the Brazilian Ministry of Health proposal, associated with BMI cut-offs specific for adolescents as an anthropometric assessment method for adolescent pregnant women.

Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento

Avaliar aspectos da estrutura de uma amostra de maternidades do Brasil. A estrutura foi avaliada tendo como referências as normas do Ministério da Saúde e englobou: localização geográfica, volume de partos, existência de UTI, atividade de ensino, qualificação de recursos humanos, disponibilidade de equipamentos e medicamentos. Os resultados evidenciam diferenças na qualificação e na disponibilidade de equipamentos e insumos dos serviços de atenção ao parto e nascimento segundo o tipo de financiamento, regiões do país e grau de complexidade. As regiões Norte/Nordeste e Centro-oeste apresentaram os maiores problemas. No Sul/Sudeste, os hospitais estavam melhores estruturados, atingindo proporções satisfatórias em vários dos aspectos estudados, próximas ou mesmo superiores ao patamar da rede privada. O presente estudo traz para o debate a qualidade da estrutura dos serviços hospitalares ofertados no país, e sublinha a necessidade de desenvolvimento de estudos analíticos que considerem o processo e os resultados da assistência.

Adequacy of antenatal care and its relationship with low birth weight in Botucatu, São Paulo, Brazil: a case-control study

BACKGROUND

Birth weight reflects gestational conditions and development during the fetal period. Low birth weight (LBW) may be associated with antenatal care (ANC) adequacy and quality. The purpose of this study was to analyze ANC adequacy and its relationship with LBW in the Unified Health System in Brazil.

METHODS

A case-control study was conducted in Botucatu, São Paulo, Brazil, 2004 to 2008. Data were collected from secondary sources (the Live Birth Certificate), and primary sources (the official medical records of pregnant women). The study population consisted of two groups, each with 860 newborns. The case group comprised newborns weighing less than 2,500 grams, while the control group comprised live newborns weighing greater than or equal to 2,500 grams. Adequacy of ANC was evaluated according to three measurements: 1. Adequacy of the number of ANC visits adjusted to gestational age; 2. Modified Kessner Index; and 3. Adequacy of ANC laboratory studies and exams summary measure according to parameters defined by the Ministry of Health in the Program for Prenatal and Birth Care Humanization.

RESULTS

Analyses revealed that LBW was associated with the number of ANC visits adjusted to gestational age (OR = 1.78, 95% CI 1.32-2.34) and the ANC laboratory studies and exams summary measure (OR = 4.13, 95% CI 1.36-12.51). According to the modified Kessner Index, 64.4% of antenatal visits in the LBW group were adequate, with no differences between groups.

CONCLUSIONS

Our data corroborate the association between inadequate number of ANC visits, laboratory studies and exams, and increased risk of LBW newborns. No association was found between the modified Kessner Index as a measure of adequacy of ANC and LBW. This finding reveals the low indices of coverage for basic actions already well regulated in the Health System in Brazil. Despite the association found in the study, we cannot conclude that LBW would be prevented only by an adequate ANC, as LBW is associated with factors of complex and multifactorial etiology. The results could be used to plan monitoring measures and evaluate programs of health care assistance during pregnancy, at delivery and to newborns, focusing on reduced LBW rates.

Análise espacial dos aglomerados de nascimentos ocorridos em hospitais SUS e não SUS do município de São Paulo, Brasil

O objetivo deste estudo é avaliar a distribuição espacial de nascidos vivos (NV) do município de São Paulo (MSP), verificar se há dependência espacial, identificar possíveis diferenças no perfil dos nascimentos e avaliar as distâncias percorridas entre os domicílios e os hospitais do parto. Foram estudados os NV ocorridos em hospitais de alta complexidade, quatro SUS e quatro da rede não SUS no MSP em 2008. Foram georreferenciados 46.190 NV: 48,8% em hospitais SUS e 51,2% não SUS, estes representaram 27,9% do total de NV do MSP. Os NV de hospitais SUS formaram dois aglomerados com elevada proporção de domicílios com renda de 1/2 a 2SM, concentração de favelas e altas taxas de natalidade. Os NV de hospitais não SUS formaram um aglomerado na região central do MSP, onde há elevada proporção de domicílios com renda > 10 SM e baixa natalidade. Foram encontradas diferenças estaticamente significantes das características maternas, da gestação e do parto entre os NV de hospitais SUS e não SUS e da frequência de gemelaridade. Não houve diferença na prevalência de baixo peso e pré-termo. Os resultados mostraram existir diferenciais no perfil dos aglomerados de NV, que refletem as desigualdades das condições de vida do MSP.

Assessment of urinary infection management during prenatal care in pregnant women attending public health care units in the city of Rio de Janeiro, Brazil

The aim of this study was to assess the sociodemographic risk factors for urinary tract infection and the inadequacy of antenatal care, according to the Kotelchuck index, in pregnant women in the city of Rio de Janeiro. A cross-sectional study was conducted with 1,091 pregnant women, 501 with urinary tract infection, in the public health antenatal care units in Rio de Janeiro, Brazil, in 2007-2008. Demographic and socioeconomic data, obstetric history and adequacy of antenatal care were collected by interviews and antenatal care card. Inadequacy management of urinary tract infection was evaluated by professional performance, health services and women dimensions. Chi-square and multivariate logistic regression were used to compare groups and to identify associated factors with management of urinary tract infection. Pregnant teenagers, anemic and diabetic pregnant women and quality of prenatal partially adequate or inadequate were those with higher odds of urinary tract infection. In the overall assessment, 72% had inadequate management of urinary tract infection. Inadequate management of urinary tract infection was associated with brown skin color compared to white skin color. In the assessment of health professional performance, inadequacy management of urinary tract infection was more common in pregnant women with low weight and overweight and obesity. According to pregnant women evaluation, primiparous women have lower odds of inadequacy management of urinary tract infection compared to those with one or more children.

Comparison of pregnancy characteristics and outcomes between HIV-infected and HIV-non-infected women in Brazil

The aim of this study is to evaluate the characteristics of pregnant women whether they are HIV infected or not and their prenatal care. It is a cross-sectional study. HIV-infected women were derived from a cohort study of all HIV-infected pregnant women followed from 1995 to 2005, at the Instituto de Puericultura e Pediatria Martagão Gesteira - Rio de Janeiro. HIV-non-infected women were derived from a random sample of all pregnant women who gave birth at Rio de Janeiro municipality between 1999 and 2001. All relevant sociodemographic, clinical, and pregnancy outcomes data were retrieved from both studies. To evaluate the prenatal care, we calculated the Kotelchuck Modified Index (KMI). The index is based on the months of initiation of prenatal care and the proportion of visits observed in each trimester, according to gestational age at birth. Comparisons were performed using Student t- and chi-square tests. Variables with p-value < 0.25 were included in an unconditional logistic regression model. There were 713 HIV-infected women and 2145 HIV-non-infected women. Variables independently associated with HIV status were: inadequate KMI (OR=4.08, 95% CI=3.17-5.24); lower educational level (OR=1.32, 95% CI=1.04-1.68); does not live with a partner (OR=3.54, 95% CI=2.66-4.64); lower family income (OR=4.71, 95% CI=3.62-6.14); tobacco use (OR=2.17, 95% CI=1.63-2.88); and hypertension (OR=1.47, 95% CI=1.01-2.17). Prematurity was not independently associated with HIV status. Although in Brazil, the HIV care is free of charge, pregnant women are still having difficulty to reach the specialized care. Better access to care must be offered to this population and studies of prematurity in the HIV-infected women must evaluate their prenatal care.

Sífilis congênita: evento sentinela da qualidade da assistência pré-natal

OBJETIVO: Analisar a assistência pré-natal na prevenção da transmissão vertical da sífilis. MÉTODOS: Estudo transversal representativo para as gestantes de baixo risco atendidas em unidades de saúde do município do Rio de Janeiro, RJ, período de 2007 a 2008. A identificação de gestantes com diagnóstico de sífilis na gestação foi feita por meio de entrevistas, verificação do cartão de pré-natal e busca de casos notificados em sistemas públicos de informação em saúde. Os casos de sífilis congênita foram identificados por meio de busca nos sistemas de informação em saúde: Sistema de Informação de Agravos de Notificação (Sinan), Sistema de Informação sobre Mortalidade (SIM) e Sistema de Informações Hospitalares (SIH) do SUS. RESULTADOS: Foram identificados 46 casos de sífilis na gestação e 16 casos de sífilis congênita com uma prevalência estimada de 1,9% (IC95% 1,3;2,6) de sífilis na gestação e de 6/1.000 (IC95% 3;12/1.000) de sífilis congênita. A taxa de transmissão vertical foi de 34,8% e três casos foram fatais, um abortamento, um óbito fetal e um óbito neonatal, com proporções elevadas de baixo peso e prematuridade. A trajetória assistencial das gestantes mostrou falhas na assistência, como início tardio do pré-natal, ausência de diagnóstico na gravidez e ausência de tratamento dos parceiros. CONCLUSÕES: Estratégias inovadoras, que incorporem melhorias na rede de apoio diagnóstico, são necessárias para enfrentamento da sífilis na gestação, no manejo clínico da doença na gestante e seus parceiros e na investigação dos casos como evento sentinela da qualidade da assistência pré-natal.

Factors associated with physical aggression in pregnant women and adverse outcomes for the newborn

OBJECTIVE

To assess the socioeconomic, demographic, and reproductive factors associated with physical aggression during pregnancy, and the negative outcomes for the newborn in two groups of women: adolescents and young adults.

METHOD

Cross-sectional study with a sample of 8,961 mothers who were admitted to hospitals of the city of Rio de Janeiro during delivery. To test the hypothesis of homogeneity of proportions, the chi-squared test was used. Odds ratio and confidence intervals were estimated using logistic regression.

RESULTS

5.0% of the adolescents and 2.5% of the young adult women suffered physical violence during pregnancy. In both groups, the variables associated with physical abuse were lower educational level, lower support from the child's father, and more attempts to interrupt the pregnancy. The increase in alcohol consumption was associated with physical abuse only in the group of adolescents; illicit drug use was only associated with physical abuse in young adults. The children of abused mothers had a two-fold increased chance of neonatal death, and a three-fold increased chance of post-neonatal death. Conversely, good quality prenatal care reduced the chance of physical aggression during pregnancy.

CONCLUSIONS

The results emphasize the increased chance of neonatal and post-neonatal mortality among children of victims of physical abuse during pregnancy, and indicate the importance of prenatal care to identify women at higher risk of suffering aggression, the appropriate time to provide measures of protection and care for mother and baby.

Gravidez recorrente na adolescência e os desfechos negativos no recém-nascido: um estudo no Município do Rio de Janeiro

O objetivo do estudo foi estimar a magnitude da gravidez recorrente na adolescência verificar os fatores associados ao fenônemo e os principais resultados perinatais. Foram selecionadas 1.986 puérperas adolescentes no pós-parto em maternidades do Município do Rio de Janeiro. A análise estatística consistiu em utilizar testes qui-quadrado (χ²) para testar hipóteses de homogeneidade de proporções. Foram estimadas as associações entre as variáveis pela razão dos produtos cruzados - Odds Ratio (OR) e respectivos intervalos de confiança, utilizando-se procedimentos de regressão logística. Verificou-se que 31,4% já haviam experimentado a maternidade anteriormente e os principais fatores associados foram: idade materna entre 16 e 19 anos e paterna superior a 19 anos, a idade de menarca anterior aos 12 anos, a cor da pele da puérpera preta ou parda, a escolaridade inferior à 5ª série do ensino fundamental e a presença do companheiro durante a gestação. O óbito perinatal foi significativamente maior entre grupo de adolescentes com gestações sucessivas. Os resultados obtidos revelam que as adolescentes com gravidez recorrente apresentam piores condições sociodemográficas do que aquelas na primeira gravidez. Os achados indicam a importância das políticas sociais para as mulheres com gravidez recorrente na adolescência.

Birth in Brazil: national survey into labour and birth

BACKGROUND

Caesarean 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.

METHODS

Nationwide 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.

DISCUSSION

This 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.

Cervical cytological abnormalities and factors associated with high-grade squamous intraepithelial lesions among HIV-infected women from Rio de Janeiro, Brazil

Although cervical cancer remains a major public health problem in Brazil, knowledge of cervical cytological abnormalities among HIV-infected women remains scarce. At baseline evaluation of a cohort followed in Rio de Janeiro, Brazil, 703 HIV-infected women underwent cytology-based cervical cancer screening and human papillomavirus (HPV) DNA testing. Poisson regression analysis was used to evaluate the association of factors with the presence of high-grade squamous intraepithelial lesions (HSIL). Cervical cytology was abnormal in 24.3% of the women; 4.1% had HSIL. Beyond HPV infection, factors independently associated with the presence of HSIL was age (≥25 and ≤40 years, prevalence ratio [PR] 2.60, 95% confidence interval [CI] 1.11-6.10), and more than three pregnancies was protective (PR 0.33, 95% CI 0.11-0.94). High coverage of cervical cancer screening is warranted to prevent morbidity and mortality from cervical cancer in this population.

Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil

A persistência de desfechos perinatais negativos no Município do Rio de Janeiro, Brasil, sugere problemas na qualidade da assistência pré-natal. A última investigação realizada nessa cidade mostrou adequação de apenas 38% dessa assistência. O objetivo deste estudo é avaliar a adequação da assistência pré-natal na rede do SUS do Município do Rio de Janeiro. Foi realizado um estudo transversal, em 2007-2008, por meio de entrevistas com 2.422 gestantes em atendimento nos serviços de pré-natal de baixo risco. Para avaliação da adequação da assistência, foi utilizado o índice PHPN, com as recomendações do Programa de Humanização do Pré-natal e Nascimento, do Ministério da Saúde, e um índice PHPN ampliado, em que foram acrescentados procedimentos clinico-obstétricos, prescrição de sulfato ferroso suplementar e ações educativas. Foi encontrada adequação de 38,5% para o PHPN e 33,3% para o PHPN ampliado. Estratégias de ampliação da captação precoce das gestantes e melhor utilização dos contatos com os serviços para a realização de ações de atenção à saúde são prioritárias para a reversão desse quadro.

A randomised controlled trial of probiotics for the prevention of spontaneous preterm delivery associated with bacterial vaginosis: preliminary results

BACKGROUND

Bacterial vaginosis increases the risk of spontaneous preterm delivery at less than 34 weeks of gestation.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of the early administration of selected lactobacilli strains (probiotics) to pregnant women with asymptomatic bacterial vaginosis/intermediate-degree infections to prevent spontaneous premature delivery and associated neonatal morbidity.

METHODS/DESIGN

Asymptomatic pregnant women at less than 20 weeks of gestation, with no indication of elective preterm delivery, with a vaginal pH ≥ 4.5 and Nugent score > 3 were randomly assigned to the placebo or intervention group (oral administration of selected lactobacilli up to the 24th to 26th week of gestation). The randomisation was stratified for the history of premature delivery (HPD) and blocked. The allocation was concealed, and the participating health professionals and patients were blinded. The primary outcome was preterm delivery (<34 to <32 weeks), and the secondary outcomes were associated neonatal complications.

RESULTS

In total, 4,204 pregnant women were screened; 320 and 324 individuals were respectively randomly assigned to the placebo and intervention groups, and 62% finished the trial. None of the randomised patients were lost to follow-up. For the non-HPD stratum, the intent-to-treat relative risks of spontaneous premature birth at < 34 and < 37 weeks' gestation were 0.33 (0.03, 3.16) and 0.49 (0.17, 1.44), respectively, and they were non-significant (ns) with p = 0.31 and 0.14. The corresponding actual treatment figures were zero and 0.32 (0.09, 1.19), which were ns with p = 0.12 and 0.06. The intent-to-treat relative risk of spontaneous premature birth at < 37 weeks of gestation for the trial as a whole, including HPD and non-HPD participants, was 0.69 (0.26, 1.78), p = 0.30 (ns). The neonatal complications under evaluation occurred in only one infant (< 34 weeks; placebo group) who presented with respiratory distress syndrome and suspected early neonatal sepsis. The recorded adverse events were minor and relatively non-specific.

CONCLUSIONS

The efficacy of the tested probiotics to prevent preterm delivery among women without a history of preterm delivery was not determined because the study sample was insufficient to estimate statistically significant intent-to-treat effects; additional studies are needed to evaluate this intervention among these women.

TRIAL REGISTRATION

Trial registration at NIH register: NCT00303082. Sources of funding: the Brazilian Health Ministry and the State of Rio de Janeiro Research Foundation.

Cuidados pré-natais e avaliação do manejo da hipertensão arterial em gestantes do SUS no Município do Rio de Janeiro, Brasil

Neste estudo, avaliaram-se a adequação e o acompanhamento pré-natal de gestantes com hipertensão arterial e as de baixo risco, além dos fatores associados ao manejo adequado do pré-natal nas hipertensas. Um estudo seccional foi realizado com 1.947 gestantes, 187 com hipertensão arterial, na rede SUS do Rio de Janeiro, Brasil, em 2007/2008. Informações demográficas, socioeconômicas, história obstétrica e adequação do pré-natal foram coletadas através de entrevistas e do cartão pré-natal. O manejo adequado da hipertensão arterial foi avaliado pelas dimensões: profissional de saúde, serviços de saúde e mulher. Utilizou-se o teste Χ ² e regressão logística multivariada para comparação entre os grupos e identificação dos fatores associados ao manejo da hipertensão arterial. A adequação do pré-natal foi de 79% e não diferiu entre os grupos. Apenas 27% das hipertensas tiveram manejo da hipertensão arterial adequado, com pior desempenho do profissional. Gestantes hipertensas com melhor assistência ao pré-natal foram aquelas com antecedentes de nati e/ou neomortalidade e aquelas com 35 ou mais anos de idade. Apesar da adequada utilização do pré-natal, o manejo da hipertensão arterial nas gestantes foi inadequado.

Housing conditions as a social determinant of low birthweight and preterm low birthweight

OBJECTIVE: To assess the relationship between housing conditions and low birthweight and preterm low birthweight among low-income women. METHODS: A case-control study was conducted with post-partum women living in the city of Rio de Janeiro, Southeast Brazil, in 2003-2005. Two groups of cases, low birthweight (n=96) and preterm low birthweight infants (n=68), were compared against normal weight term controls (n=393). Housing conditions were categorized into three levels: adequate, inadequate, and highly inadequate. Covariates included sociodemographic and anthropometric characteristics, risk behaviors, violence, anxiety, satisfaction during pregnancy, obstetric history and prenatal care. RESULTS: Poor housing conditions was independently associated with low birthweight (inadequate - OR 2.3 [1.1;4.6]; highly inadequate - OR 7.6 [2.1;27.6]) and preterm low birthweight (inadequate - OR 2.2 [1.1;4.3]; highly inadequate - OR 7.6 [2.4;23.9]) and factors associated with outcomes were inadequate prenatal care and previous preterm birth. Low income and low maternal body mass index remained associated with low birthweight. CONCLUSIONS: Poor housing conditions were associated with low birthweight and preterm low birthweight.

Factors associated with breastfeeding in the first hour of life

OBJECTIVE

To identify factors associated with breastfeeding in the first hour of life (Step 4 of the Baby-Friendly Hospital Initiative).

METHODS

A cross-sectional study was conducted with a representative sample of mothers who gave birth in maternity wards in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2001. Newborns or mothers with restriction to breastfeeding were excluded, resulting in a sample of 8,397 pairs. A random effect--at maternity hospital level--Poisson model was employed in a hierarchical approach with three levels: distal, intermediate and proximal for characteristics of the mother, of the newborn, and of prenatal and hospital assistance.

RESULTS

Only 16% of the mothers breastfed in the first hour of life. Breastfeeding in this period was less prevalent among neonates with immediate intercurrences after birth (PR = 0.47; CI99% 0.15;0.80); among mothers who did not have contact with their newborns in the delivery room (PR = 0.62; CI99% 0.29;0.95); among mothers submitted to cesarean section delivery (PR = 0.48; CI99% 0.24;0.72); and among mothers who gave birth at private maternity hospitals (PR = 0.06; CI99% 0.01;0.19) or at maternity hospitals contracted out to National Health System (SUS) (PR = 0.16; CI99% 0.01;0.30). The context effect of maternity wards was statistically significant.

CONCLUSIONS

At an individual level, breastfeeding within one hour after birth was constrained by inappropriate practices in private or SUS-contracted maternity hospitals. The group effect of maternity hospitals and the absence of individual maternal-related factors that explain the outcome suggest that mothers have little or no autonomy to breastfeed their babies within the first hour of life, and depend on the institutional practices that prevail at the maternity hospitals.

[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.

Socioeconomic inequities in the health and nutrition of children in low/middle income countries

OBJECTIVE

To describe the effects of social inequities on the health and nutrition of children in low and middle income countries.

METHODS

We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys.

RESULTS

Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished.

CONCLUSIONS

Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.

[Early neonatal mortality according to level of hospital complexity in Greater Metropolitan São Paulo, Brazil]

The aim of this study was to analyze the profile of newborns, mothers, and early neonatal mortality according to the hospital's complexity and affiliation (or lack thereof) with the Unified National Health System (SUS) in Greater Metropolitan São Paulo, Brazil. The study was based on data for live births, deaths, and hospital registries. Factor and cluster analysis were used to obtain the typology of hospital complexity and user profile. The SUS treats more high-risk newborns and mothers with low schooling, insufficient prenatal care, and teenage mothers. The probability of early neonatal death was 5.6 live births (65% higher in the SUS), with no significant differences by level of hospital complexity, except those with extremely high (SUS) and medium (non-SUS) complexity. The difference in early neonatal mortality between the two systems was smaller in the group of newborns with birth weight < 1,500g (22%), but the rate was 131% higher in the SUS for newborns > 2,500g. There was a concentration of high-risk births in the SUS, but the difference in early neonatal mortality between SUS and non-SUS hospitals was smaller in this group of newborns. New studies are needed to elucidate the high mortality rate among newborns with birth weight > 2,500g in the SUS.

Randomized controlled trial of probiotics for the prevention of spontaneous preterm delivery associated with intrauterine infection: study protocol

BACKGROUND

Spontaneous preterm deliveries that occur before the 34th week of gestation, and particularly before the 32nd week of gestation, have been strongly associated to intrauterine infection, ascending from vagina, and represent the largest portion of neonatal deaths and neurological problems. Bacterial vaginosis, characterized by a diminished or absent flora of lactobacilli and increased colonization of several anaerobic or facultative microorganisms, increases two times the risk of preterm delivery before the 34th week. Trials of antibiotics failed to show efficacy and effectiveness against spontaneous preterm birth related to bacterial vaginosis. Some studies indicate benefit from selected probiotics to treat genitourinary infections, including bacterial vaginosis.

OBJECTIVE

The purpose of this study is to evaluate the effectiveness of the early administration of selected probiotics to pregnant women with asymptomatic bacterial vaginosis/intermediate degree infection to reduce the occurrence of spontaneous preterm delivery and related neonatal mortality and morbidity.

METHODS/DESIGN

Women attending public prenatal care services in Rio de Janeiro will be screened to select asymptomatic pregnant women, less than 20 weeks' gestation, with no indication of elective preterm delivery. Those with vaginal pH > = 4.5 and a Nugent score between 4 and 10 (intermediate degree infection or bacterial vaginosis) will be randomized to either the placebo or the intervention group, after written informed consent. Intervention consists in the use of probiotics, Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14, 2 capsules a day, each capsule containing more than one million bacilli of each strain, for 6-12 weeks, up to the 24th-25th wk of gestation. Ancillary analyses include quantification of selected cervicovaginal cytokines and genotyping of selected polymorphisms. The randomization process is stratified for history of preterm delivery and blocked. Allocation concealment was designed as well as blinding of women, caregivers and outcome evaluators. The study will be supervised by an independent monitoring committee. Outcomes under study are preterm delivery (< 34- < 32 weeks of gestation) and associated neonatal complications: early neonatal sepsis, bronchopulmonary dysplasia, periventricular leukomalacia, necrotizing enterocolitis, and prematurity-related retinopathy; definitions were adapted from those recommended by the 2002 version of the Vermont-Oxford Network. Trial registration at NIH register: NCT00303082.

[Risk factors for pre-term birth in Londrina, Paraná State, Brazil]

The objective of this study was to identify risk factors associated with pre-term birth among live births in a hospital in Londrina, Paraná State, Brazil. Cases consisted of 328 pre-term births, and controls were 369 births with gestational age greater than 37 weeks. A multiple hierarchical logistic regression analysis was carried out. There was a significant correlation (p < 0.05) between pre-term birth and the following variables: socioeconomic status (slum residence); low age of head-of-family; maternal BMI < 19 or > 30 kg/m2; history of prematurity; history of assisted reproduction; mothers in a relationship for less than two years; maternal stress; weekly maternal alcohol consumption; insufficient prenatal care; gestational complications such as bleeding, genital tract infection, altered amniotic fluid volume, high blood pressure, and hospital admission; and twin pregnancy. Regular walks during pregnancy were a protective factor. Improved quality of prenatal care and the identification of the above factors during pregnancy may help reduce premature birth.

[Factors that affect time between birth and first breastfeeding]

The current study investigated factors associated with time between birth and first breastfeeding. A representative sample of mothers (10% of deliveries in 47 maternity hospitals in Rio de Janeiro, Brazil) was interviewed (n = 10,077). A random effects proportional risks survival model (at the maternity ward level) was employed, in a three-tier hierarchical approach. Models were fitted separately for normal and cesarean delivery. Time to initiation of breastfeeding in the first 24 hours of life differed between mothers with vaginal delivery (median 4 hours) versus cesarean section (10 hours). Common risk and protective factors were identified: maternal age; neonatal complications; neonatal care considered sub-optimal by the mother; admission of the newborn to the nursery; parity; birth weight. The model predicted 33% of variance in first breastfeeding. In conclusion, time from delivery to first breastfeeding was increased by biological factors, high cesarean rates, and inadequate childbirth and neonatal care practices.

Risk factors for neonatal transfers from the Sapopemba free-standing birth centre to a hospital in São Paulo, Brazil

OBJECTIVE

to identify risk factors associated with neonatal transfers from a free-standing birth centre to a hospital.

DESIGN

epidemiological case-control study.

SETTING

midwifery-led free-standing birth centre in São Paulo, Brazil.

PARTICIPANTS

96 newborns were selected from 2840 births between September 1998 and August 2005. Cases were defined as all newborns transferred from the birth centre to a hospital (n=32), and controls were defined as newborns delivered at the same birth centre, during the same time period, and who had not been transferred to a hospital (n=64).

MEASUREMENTS AND FINDINGS

data were collected from medical records available at the birth centre. Univariate and multivariate analyses were performed using logistic regression. The multivariate analysis included outcomes with p<0.25, specifically: smoking during pregnancy, prenatal care appointments, labour complications, weight in relation to gestational age, and one-minute Apgar score. Of the foregoing outcomes, those that remained in the full regression model as a risk factor associated with neonatal transfer were: smoking during pregnancy [p=0.009, odds ratio (OR)=4.1, 95% confidence interval (CI) 1.03-16.33], labour complications (p<0.001, OR=5.5, 95% CI 1.06-28.26) and one-minute Apgar score ≤ 7 (p<0.001, OR=7.8, 95% CI 1.62-37.03).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

smoking during pregnancy, labour complications and one-minute Apgar score ≤ 7 were confirmed as risk factors for neonatal transfer from the birth centre to a hospital. The identified risk factors can help to improve institutional protocols and formulate hypotheses for other studies.

Baixo peso ao nascer no Brasil de acordo com as informações sobre nascidos vivos do Ministério da Saúde, 2005

Embora seja notório que a cobertura do Sistema de Informação sobre Nascidos Vivos (SINASC) esteja crescendo e que a qualidade da informação venha melhorando, desde a sua implantação, sabe-se que a enumeração de nascidos vivos ainda não é completa no Brasil. Neste trabalho, objetiva-se analisar as desigualdades da proporção do baixo peso ao nascer no Brasil, em 2005, segundo alguns aspectos como o geográfico, o tamanho da população do município e a escolaridade da mãe. Analisou-se, igualmente, a influência da atenção pré-natal. Considerando a totalidade dos nascidos vivos, evidenciou-se o paradoxo do baixo peso ao nascer, ou seja, foram encontrados percentuais mais elevados nas áreas de maior desenvolvimento sócio-econômico. Os resultados paradoxais são explicados, principalmente, pela menor sobrevida e registro inadequado dos prematuros nos municípios mais pobres. Levando-se em conta os nascidos vivos a termo de gestação não-múltipla, foram encontradas desigualdades por grau de escolaridade da mãe. Sugere-se que o atendimento pré-natal abrangente e com qualidade poderia ter um impacto maior na redução dos resultados adversos da gestação, contribuindo para a diminuição das desigualdades sócio-econômicas da saúde perinatal no Brasil.

Qualidade da assistência ao trabalho de parto pelo Sistema Único de Saúde, Rio de Janeiro (RJ), 1999-2001

OBJETIVO: A qualidade da assistência ao trabalho de parto tem sido reconhecida na prevenção de complicações obstétricas que podem levar à morbi-mortalidade materna, perinatal e neonatal. O objetivo do estudo foi analisar a qualidade da assistência ao trabalho de parto segundo o risco gestacional e tipo de prestador. MÉTODOS: Estudo transversal de observação da assistência ao trabalho de parto de 574 mulheres, selecionadas por amostra estratificada em 20 maternidades do Sistema Único de Saúde do Rio de Janeiro (RJ), entre 1999 e 2001. A qualidade da assistência foi analisada segundo o risco gestacional e o tipo de prestador. Utilizaram-se procedimentos estatísticos de análise de variância e de diferença de proporções. RESULTADOS: Do total da amostra, 29,6% das gestantes foram classificadas como de risco. Apesar da hipertensão ser a causa mais importante de morte materna no Brasil, a pressão arterial não foi aferida em 71,6% das gestantes durante a observação no pré-parto. Em média foram feitas cinco aferições por parturiente, sendo o menor número nos hospitais conveniados privados (média de 2,9). Quanto à humanização da assistência, observou-se que apenas 21,4% das parturientes tiveram a presença de acompanhante no pré-parto, 75,7% foram submetidas à hidratação venosa e 24,3% à amniotomia. O único tipo de cuidado que variou segundo o risco obstétrico foi a freqüência da aferição da pressão arterial, em que as gestantes de risco foram monitoradas o dobro de vezes em relação às demais (média de 0,36 x 0,18 aferições/h respectivamente, p=0,006). CONCLUSÕES: De modo geral, as gestantes de baixo risco são submetidas a intervenções desnecessárias e as de alto risco não recebem cuidado adequado. Como conseqüência, os resultados perinatais são desfavoráveis e as taxas de cesariana e de mortalidade materna são incompatíveis com os investimentos e a tecnologia disponível.

[Quality of childbirth data in the Hospital Information System in Rio de Janeiro, Brazil, 1999-2001]

This study aimed to assess the coverage and reliability of the Hospital Admissions Information System (SIH/SUS) in the Municipality of Rio de Janeiro, Brazil. Data for women who gave birth in hospitals belonging to the Unified National Health System (SUS) were compared with data from medical records and interviews from a morbidity and mortality survey. Reliability was almost perfect for age (intraclass correlation coefficient: 0.95) and mode of delivery (kappa = 0.94). The sensitivity and specificity of the SIH/SUS for cesarean section were 98.6% and 99.3%, respectively. Reliability of data on addresses was inversely related to level of data aggregation: 0.76 for programmatic areas and 0.68 for administrative regions. Of 6,835 hospital admissions covered by the SUS, 11.9% showed no records in the SIS-SUS. The high cesarean rate among admissions without prior authorization by the public system appears to be related to regulations setting limits on reimbursement according to mode of delivery.

I, Novaes HMD, Siqueira AAFD, Campbell O, Rodrigues LC. Fatores de risco para mortalidade neonatal precoce

OBJETIVO: Avaliar os fatores de risco da mortalidade neonatal precoce. MÉTODOS: Estudo caso-controle de base populacional com 146 óbitos neonatais precoces e amostra de 313 controles obtidos entre os sobreviventes ao período neonatal, na região sul do município de São Paulo, no período de 1/8/2000 a 31/1/2001. As informações foram obtidas por meio de entrevistas domiciliares e prontuários hospitalares. Foi realizada análise hierarquizada em cinco blocos com características: 1) socioeconômicas das famílias e das mães; 2) psicossociais maternas; 3) biológicas e da história reprodutiva materna; 4) do parto; 5) do recém-nascido. RESULTADOS: Os fatores de risco para a mortalidade neonatal precoce foram: Bloco 1: baixa escolaridade do chefe da família (OR=1,6; IC 95%: 1,1;2,6); domicílio em favela (OR=2,0; IC 95%: 1,2;3,5), com até um cômodo (OR=2,2; IC 95%: 1,1;4,2); Bloco 2: mães com união recente (OR=2,0; IC 95%: 1,0;4,2) e sem companheiro (OR=1,8; IC 95%: 1,1;3,0), presença de maus tratos (OR=2,7;1,1-6,5); Bloco 3: presença de intercorrência na gravidez (OR=8,2; IC 95%: 5,0;13,5), nascimento prévio de baixo peso (OR=2,4; IC 95%: 1,2;4,5); pré-natal ausente (OR=16,1; IC 95%: 4,7;55,4) ou inadequado (OR=2,1; IC 95%: 2,0;3,5); Bloco 4: presença de problemas no parto (OR=2,9; IC 95%: 1,4;5,1), mães que foram ao hospital de ambulância (OR=3,8; IC 95%: 1,4;10,7); Bloco 5: baixo peso ao nascer (OR=17,3; IC 95%: 8,4;35,6), nascimento de pré-termo (OR=8,8; IC 95%: 4,3;17,8). CONCLUSÕES: Além dos fatores proximais (baixo peso ao nascer, gestações de pré-termo, problemas no parto e intercorrências durante a gestação), identificou-se a participação de variáveis que refletem exclusão social e de fatores psicossociais. Esse contexto pode afetar o desenvolvimento da gestação e dificultar o acesso das mulheres aos serviços de saúde. A assistência pré-natal adequada poderia minimizar parte do efeito dessas variáveis.

Higher perinatal mortality in National Public Health System hospitals in Belo Horizonte, Brazil, 1999: a compositional or contextual effect?

OBJECTIVE

In Brazil, it was previously reported that in hospital perinatal, neonatal and infant mortality rates are higher for hospitals contracted to the National Public Health System (SUS) compared with non-SUS hospitals. We analyse whether this reflects a compositional effect (selection of patients) or a contextual effect.

DESIGN

Population-based cohort study.

SETTING

Belo Horizonte, Brazil, 1999.

POPULATION

A total of 36,469 births in 24 hospitals.

METHODS

A multilevel analysis was carried out using information gathered at the individual level on maternal education (used as an indicator of socio-economic status), maternal age, type of pregnancy and delivery, birthweight and sex of the fetus.

MAIN OUTCOME MEASURE

Perinatal death.

RESULTS

Risk factors for perinatal death included male sex (OR = 1.25; 95% CI 1.01-1.55), birthweight of 1500-2500 g (OR = 7.65; 95% CI 5.74-10.20), birthweight of 500-1500 g (OR = 187.54; 95% CI 141.31-248.39), less than 4 years of maternal education (OR = 2.93; 95% CI 1.68-5.10), as well as birth at private-SUS (OR = 2.92; 95% CI 1.87-4.54) or philanthropic-SUS hospitals (OR = 1.81; 95% CI 1.12-2.92). After controlling for individual characteristics, there was still a significant variation in perinatal deaths between hospitals categories.

CONCLUSION

Independent of compositional (or individual) characteristics, hospital factors exert an influence on the risk of perinatal death, primarily hospital category related to SUS. Considering the highest proportion of births in SUS hospitals in Brazil, especially private-SUS hospitals, improving hospital quality of care is an urgent priority for reducing the toll of perinatal and infant mortality, as well as inequalities in these outcomes.

Desigualdades sócio-espaciais da adequação das informações de nascimentos e óbitos do Ministério da Saúde, Brasil, 2000-2002

Neste trabalho, analisam-se as desigualdades sócio-espaciais da adequação das informações de nascimentos (SINASC) e óbitos (SIM) do Ministério da Saúde para o cálculo da mortalidade infantil por município. A análise foi realizada de acordo com o porte populacional do município e região geográfica no período 2000-2002, considerando-se cinco indicadores: coeficiente geral de mortalidade padronizado por idade; razão entre nascidos vivos informados e estimados; desvio médio relativo do coeficiente de mortalidade; desvio médio relativo da taxa de natalidade; percentual de óbitos sem definição da causa básica de morte. Os critérios de adequação foram estabelecidos estatisticamente nas Unidades da Federação com informações consideradas adequadas. Os resultados mostram desigualdades sócio-espaciais importantes: o percentual de adequação é maior no Centro-Sul e entre os municípios de maior porte populacional. Em relação aos três aspectos estudados, o SINASC teve a melhor avaliação. Quanto ao SIM, além de reduzir a subnotificação, é preciso melhorar a qualidade do preenchimento da causa de óbito, para que as informações possam orientar adequadamente os programas de saúde voltados para a redução das iniqüidades da mortalidade infantil no Brasil.

Social inequalities in perinatal mortality in Belo Horizonte, Brazil: the role of hospital care

OBJECTIVES

We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city of Belo Horizonte, Brazil.

METHODS

We used a cohort study of all births (40953) and perinatal deaths (826) in Belo Horizonte in1999. After adjusting for maternal education and birthweight, we compared mortality rates according to hospital category--defined by a hospital's relation to the national Universal Public Health System (SUS)--and quality of care. We used the Wigglesworth Classification to examine perinatal deaths.

RESULTS

After we controlled for birthweight and maternal education, the highest perinatal death rates were observed in private and philanthropic SUS-contracted hospitals (relative to private, non-SUS-contracted hospitals). Hospital quality was also directly associated with perinatal death rates. Mortality rates were especially high for normal-birthweight babies born in private SUS-contracted hospitals. Intrapartum asphyxia was the leading cause of preventable death.

CONCLUSIONS

In a class-segregated health care system, such as Brazil's, disparities in quality of care between SUS-contracted and non-SUS-contracted hospitals contribute to the unacceptably high rates of perinatal mortality.

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.

Mortalidade infantil em uma amostra de nascimentos do município do Rio de Janeiro, 1999-2001: "linkage" com o Sistema de Informação de Mortalidade

OBJETIVOS: estimar as taxas de mortalidade neonatal (TMN) e pós-neonatal (TMPN) em uma amostra de nascimentos do município do Rio de Janeiro, durante o perído de 1999-2001, compará-las segundo o tipo de maternidade e acesso ao parto hospitalar e descrever os óbitos segundo a sua causa básica. MÉTODOS: a identificação dos óbitos infantis no Sistema de Informação sobre Mortalidade (SIM) foi realizada por meio do método de relacionamento probabilístico de registros. A análise foi bivariada, sendo calculados os riscos relativos (RR) e seus respectivos intervalos de confiança 95%. RESULTADOS: as taxas de mortalidade neonatal e pós-neonatal foram sete e seis vezes maiores nas maternidades públicas que nas privadas, respectivamente. Para as puérperas não residentes no município e aquelas que tentaram "parir" em outros estabelecimentos, sem sucesso, a TMN foi duas vezes maior. Observou-se elevada TMN por afecções do período perinatal (APP), mesmo em crianças com mais de 1500 g (2,3 por mil NV). Óbitos neonatais por APP foram seis vezes mais freqüentes nos hospitais públicos que nos privados. CONCLUSÕES: a enorme diferença nas taxas de mortalidade neonatal e pós-neonatal entre os hospitais públicos e privados aponta, como fatores primordiais a sofrerem intervenção para a retomada da redução dessas taxas no município do Rio de Janeiro, a redução das desigualdades sociais e de acesso.

Óbitos neonatais precoces: análise de causas múltiplas de morte pelo método Grade of Membership

Estudo de base populacional para determinar perfis de óbitos neonatais precoces ocorridos em Belo Horizonte, Minas Gerais, Brasil, de 2000 a 2003. A definição dos perfis de causas amplia possibilidade de análise sob enfoque de evitabilidade, justificada pela persistência de altas taxas de mortalidade neonatal precoce. Três perfis foram gerados, a partir do enfoque de causas múltiplas, sob a perspectiva dos conjuntos nebulosos ("fuzzy sets"), utilizando-se técnica Grade of Membership. Relacionaram-se esses perfis ao peso de nascimento e a natureza jurídica do hospital de ocorrência do óbito. Nos hospitais da rede privada ocorreram "óbitos dificilmente preveníveis, com menção de malformação congênita" (perfil 2). Aos hospitais do Sistema Único de Saúde (SUS) associaram-se dois perfis distintos. Nos hospitais contratados/conveniados ocorreram os "óbitos passíveis de prevenção" (perfil 1) e na rede própria os "óbitos de prematuros" (perfil 3). A tipologia observada aponta para necessidade de adoção de políticas diferenciadas na rede SUS: prioritariamente, na rede contratada/conveniada, ações voltadas para credenciamento e avaliação da qualidade da assistência; e, em toda rede, adoção rotineira de protocolos assistenciais e medidas profiláticas, redutores da morbimortalidade neonatal.

Avaliação da qualidade das variáveis sócio-econômicas e demográficas dos óbitos de crianças menores de um ano registrados no Sistema de Informações sobre Mortalidade do Brasil (1996/2001)

Este estudo tem como objetivo avaliar a qualidade da informação sócio-econômica e demográfica, por Unidade Federada (UF) do Sistema de Informações sobre Mortalidade (SIM). A finalidade é reconhecer sua potencialidade no monitoramento da desigualdade da mortalidade infantil no Brasil. Utilizaram-se como indicadores de qualidade a acessibilidade, oportunidade, claridade metodológica, incompletitude e consistência. Selecionaram-se as variáveis: raça da criança, peso ao nascer, semanas de gestação, assistência médica, parturição, escolaridade, idade e ocupação materna. Foram revisadas a documentação do SIM e a literatura sobre indicadores associados com a mortalidade infantil, estimaram-se proporções de incompletitude, por região e UF, e identificaram-se fatores que a influenciam a partir de regressões logísticas. Constatou-se que, apesar da acessibilidade da base de dados e da relevância de suas variáveis, o SIM possui sérios problemas de qualidade que incluem instruções confusas no manual para informação ignorada, má classificação da ocupação materna, ausência de identificação sobre a raça do informante e elevada proporção de incompletitude da informação. Conclui-se que o SIM não é uma fonte de dados adequada para monitorar, avaliar e planejar ações sobre desigualdade em saúde infantil.

Avaliação da peregrinação anteparto numa amostra de puérperas no Município do Rio de Janeiro, Brasil, 1999/2001

Neste estudo foi avaliada a dificuldade de acesso às maternidades do Município do Rio de Janeiro, Brasil. O objetivo do estudo foi identificar os fatores sociais, demográficos e obstétricos associados à peregrinação anteparto. Para tal foram avaliadas 6.652 puérperas que utilizaram os serviços do SUS por ocasião do parto. Foi observado que 1/3 das pacientes busca assistência em mais de um hospital, não sendo raro pacientes peregrinarem por três ou mais unidades. Vale ressaltar que apenas 1/5 dessas mulheres é transferida de ambulância. Os fatores associados a essa peregrinação foram: área programática de residência, peso ao nascer, idade, cor de pele, estado civil e residência em local onde não há coleta de lixo. Não foi encontrada associação de peregrinação anteparto com escolaridade, índice de Kotelchuck modificado, risco obstétrico na internação, fonte de abastecimento de água e residência em favela.

Mortes perinatais e avaliação da assistência ao parto em maternidades do Sistema Único de Saúde em Belo Horizonte, Minas Gerais, Brasil, 1999

Este trabalho analisa a associação entre a morte perinatal e o processo de assistência hospitalar ao parto, considerando-se que grande parte das mortes perinatais pode ser prevenível pela atenção qualificada de saúde e que a avaliação da qualidade da assistência perinatal ao parto é necessária para a redução da morbi-mortalidade perinatal. Realizou-se estudo caso-controle de base populacional dos óbitos perinatais (n = 118) e nascimentos (n = 492), ocorridos em maternidades do Sistema Único de Saúde (SUS) de Belo Horizonte, Minas Gerais, Brasil. Sexo masculino, prematuridade, doenças na gravidez, baixo peso ao nascer, doenças do recém-nascido, não realização de pré-natal, não utilização de partograma e menos de uma avaliação fetal por hora durante o trabalho de parto apresentaram associação estatisticamente significativa com o óbito perinatal. No modelo de regressão logística múltipla, não utilização do partograma durante o trabalho de parto e tipo de maternidade apresentaram-se como fatores de risco independentes para a morte perinatal. O estudo indica que é deficiente a qualidade da assistência hospitalar ao parto e que aspectos da estrutura dos serviços e do processo de assistência relacionam-se com a mortalidade perinatal por causas evitáveis.

Mortalidade perinatal por sífilis congênita: indicador da qualidade da atenção à mulher e à criança

A sífilis permanece como causa importante de mortalidade perinatal no Município do Rio de Janeiro, Brasil, onde o presente estudo foi realizado utilizando os dados do Sistema de Informação de Mortalidade e das Fichas de Notificação e Investigação de Óbitos Fetais e Neonatais, obrigatórias para as maternidades municipais. Entre 1996 e 1998, a sífilis congênita foi responsável por 13,1% dos óbitos fetais e 6,5% dos neonatais nas maternidades municipais. Entre 1999 e 2002, os percentuais foram de 16,2% e 7,9%, respectivamente. Para o Município do Rio de Janeiro, de 1999 a 2002, os percentuais foram 5,4% e 2,2%, para óbitos fetais e neonatais. A taxa de mortalidade perinatal por sífilis congênita permanece estável no Município do Rio de Janeiro apesar dos esforços iniciados com as campanhas para eliminação do agravo em 1999 e 2000. Propomos a utilização da taxa de mortalidade perinatal por sífilis congênita como indicador de impacto das ações de controle e eliminação da sífilis congênita e sugerimos a utilização das fichas de notificação e investigação de óbitos fetais e neonatais para a vigilância de outros agravos evitáveis.