Maternal-child health in Pelotas, Rio Grande do Sul State, Brazil: major conclusions from comparisons of the 1982, 1993, and 2004 birth cohorts

Primary Health Care as a guide for assistance to infants at risk of neurodevelopmental disorders

Purpose Characterize infants at risk of neurodevelopmental disorders according to sociodemographic and health profiles and describe their monitoring in Basic Health Units (UBS) under different management models. Methods Data were collected from medical records of infants at risk of neurodevelopmental disorders in the west region of the city of Sao Paulo from August 2013 to February 2014 (phase 1 - characterization; phase 2 - monitoring). Results Of the 225 individuals assessed in the first phase of the study, 51.1% were female and 7.11% were twins. Adolescent (45.2%), brown (50.56%), single (46.09%), complete primary education (47.60%) mothers were predominant. The mean number of prenatal visits was 7.12. Most mothers had vaginal delivery (62.22%) at mean gestational age of 37.05 weeks. Mean Apgar scores at the 1st and 5th minutes were 7.13 and 8.80, respectively. Mean weight at birth was 2597.21g., with 50.22% of newborns weighting ≤2500g. In its second phase, the study describes and compares the follow-up of 55 infants according to the UBS management model: 28 in UBS/"Estratégia Saúde da Família" (UBS/ESF) and 27 in traditional UBS (UBS/T). UBS/ESF presented higher mean of consultations (p=0.006). Longer interval between consultations was observed at UBS/T. No records of development milestones were found in 56% of the sample. Growth measures were better registered at UBS/ESF. In both management models, the number of consultations was smaller and the interval between them was shorter than those recommended by the Brazilian Ministry of Health. Conclusion According to the recommended guidelines of the "Rede Cegonha" public policy, gaps in the monitoring of infants at risk of neurodevelopmental disorders are still observed.

Characteristics and factors associated with hospitalization in early childhood: 2004 Pelotas (Brazil) birth cohort

Hospitalization is a frequent event in early childhood. In Brazil, the National Household Sample Survey of 2008 showed a 9% hospitalization rate among children in the first four years of life. The study aimed to describe the characteristics of hospitalization in the first six years of life and analyze the early factors associated with hospitalization in a birth cohort in southern Brazil. A zero-inflated Poisson model was used to simultaneously examine the effects of co-variables for the occurrence of a given event and to count events. The frequency of at least one episode of hospitalization during the study period was 33.4% (95%CI: 31.8-34.9), and was highest in the first year (19.1%; 95%CI: 17.9-20.4), remaining stable at approximately 10% between the first and fourth years, decreasing to 8.4% (95%CI: 7.6-9.4) between the fourth and sixth years. diseases of the respiratory system were among the leading causes of hospitalization, followed by infectious and parasitic diseases. History of prior hospitalization was one of the most important predictors of odds of hospitalization and risk of multiple hospitalizations. In early childhood, birth weight, gestational age, Apgar score, sex, and type of pregnancy were inversely associated with hospitalization, and environmental characteristics such as maternal smoking in pregnancy, mother's skin color, and low family income were associated statistically with number of hospitalizations. The results point to the importance of focusing efforts on reducing hospitalizations from diseases of the respiratory system, especially in children under one year.

Antenatal depressive symptoms among pregnant women: Evidence from a Southern Brazilian population-based cohort study

BACKGROUND

Antenatal depression (AD) is a major public health issue but evidence regarding its prevalence and associated factors in low and middle-income countries (LMICs) is limited. The aim of the study was to estimate the prevalence and identify risk factors for AD among Brazilian pregnant women.

METHODS

All women living in the urban area of the city of Pelotas, Southern Brazil, with confirmed pregnancy and estimated delivery date in the year 2015, were invited to take part. Eligible pregnant women were recruited from health services. Symptoms of antenatal depression were assessed using the Edinburgh Postnatal Depression Scale (EPDS) by face-to-face interviews. A cutoff-point of 13 or more was used to define probable AD.

RESULTS

EPDS scores were available for 4130 women. The prevalence of AD was 16% (95%CI 14·9-17·1). After adjustment for potential confounders, the factors most strongly associated with higher EPDS scores were a previous history of depression (PR 2·81; 95%CI 2·44-3·25), high parity (PR 1·72; 95%CI 1·38-2·15 - ≥2 children vs. 1 child) and maternal education (PR 5·47; 95%CI 4·22-7·09 - 0-4 vs. ≥12 years of formal education).

LIMITATIONS

EPDS was administered through face-to-face interviews rather than questionnaires and some women may have felt uncomfortable reporting their symptoms leading to underreporting and consequently underestimation of the prevalence found.

CONCLUSION

AD prevalence is substantially higher in Brazil than in high-income countries (HICs) but similar to other LMICs. Our study identified relevant risk factors that may be potential targets to plan interventions, particularly a history of depression.

Does vaginal delivery mitigate or strengthen the intergenerational association of overweight and obesity? Findings from the Boston Birth Cohort

BACKGROUND/OBJECTIVES

The intergenerational association of obesity may be driven by mother-to-newborn transmission of microbiota at birth. Yet cesarean delivery circumvents newborn acquisition of vaginal microbiota, and has been associated with greater childhood adiposity. Here we examined the independent and joint associations of maternal pre-pregnancy body mass index (BMI; kg m^-2) and delivery mode with childhood overweight or obesity.

SUBJECTS/METHODS

We prospectively followed 1441 racially and ethnically diverse mother-child dyads in the Boston Birth Cohort until age 5 years (range: 2.0-8.0 years). We used logistic regression to examine the independent and joint associations of delivery mode (cesarean and vaginal delivery) and pre-pregnancy BMI with childhood overweight or obesity (age-sex-specific BMI ⩾85th percentile).

RESULTS

Of 1441 mothers, 961 delivered vaginally and 480 by cesarean. Compared with vaginally delivered children, cesarean delivered children had 1.4 (95% confidence interval (CI) 1.1-1.8) times greater odds of becoming overweight or obese in childhood, after adjustment for maternal age at delivery, race/ethnicity, education, air pollution exposure, pre-pregnancy BMI, pregnancy weight gain and birth weight. Compared with children born vaginally to normal weight mothers, after multivariable adjustment, odds of childhood overweight or obesity were highest in children born by cesarean delivery to obese mothers (odds ratio (OR): 2.8; 95% CI: 1.9-4.1), followed by children born by cesarean delivery to overweight mothers (OR: 2.2; 95% CI: 1.5-3.2), then children born vaginally to obese mothers (OR: 1.8; 95% CI: 1.3-2.6) and finally children born vaginally to overweight mothers (OR: 1.7; 95% CI: 1.2-2.3).

CONCLUSIONS

In our racially and ethnically diverse cohort, cesarean delivery and pre-pregnancy overweight and obesity were associated with childhood overweight or obesity. Needed now are prospective studies that integrate measures of the maternal and infant microbiome, and other potentially explanatory covariates, to elucidate the mechanisms driving this association and to explore whether exposure to vaginal microbiota in cesarean delivered newborns may be an innovative strategy to combat the intergenerational cycle of obesity.

Birth mode-dependent association between pre-pregnancy maternal weight status and the neonatal intestinal microbiome

The intestinal microbiome is a unique ecosystem that influences metabolism in humans. Experimental evidence indicates that intestinal microbiota can transfer an obese phenotype from humans to mice. Since mothers transmit intestinal microbiota to their offspring during labor, we hypothesized that among vaginal deliveries, maternal body mass index is associated with neonatal gut microbiota composition. We report the association of maternal pre-pregnancy body mass index on stool microbiota from 74 neonates, 18 born vaginally (5 to overweight or obese mothers) and 56 by elective C-section (26 to overweight or obese mothers). Compared to neonates delivered vaginally to normal weight mothers, neonates born to overweight or obese mothers had a distinct gut microbiota community structure (weighted UniFrac distance PERMANOVA, p < 0.001), enriched in Bacteroides and depleted in Enterococcus, Acinetobacter, Pseudomonas, and Hydrogenophilus. We show that these microbial signatures are predicted to result in functional differences in metabolic signaling and energy regulation. In contrast, among elective Cesarean deliveries, maternal body mass index was not associated with neonatal gut microbiota community structure (weighted UniFrac distance PERMANOVA, p = 0.628). Our findings indicate that excess maternal pre-pregnancy weight is associated with differences in neonatal acquisition of microbiota during vaginal delivery, but not Cesarean delivery. These differences may translate to altered maintenance of metabolic health in the offspring.

Use of a monitoring tool for growth and development in Brazilian children – systematic review

Objective:

To assess the use of a health monitoring tool in Brazilian children, with emphasis on the variables related to growth and development, which are crucial aspects of child health care.

Data source:

A systematic review of the literature was carried out in studies performed in Brazil, using the Cochrane Brazil, Lilacs, SciELO and Medline databases. The descriptors and keywords used were “growth and development”, “child development”, “child health record”, “child health handbook”, “health record and child” and “child handbook”, as well as the equivalent terms in Portuguese. Studies were screened by title and summary and those considered eligible were read in full.

Data synthesis:

Sixty-eight articles were identified and eight articles were included in the review, as they carried out a quantitative analysis of the filling out of information. Five studies assessed the completion of the Child's Health Record and three of the Child's Health Handbook. All articles concluded that the information was not properly recorded. Growth monitoring charts were rarely filled out, reaching 96.3% in the case of weight for age. The use of the BMI chart was not reported, despite the growing rates of childhood obesity. Only two studies reported the completion of development milestones and, in these, the milestones were recorded in approximately 20% of the verified tools.

Conclusions:

The results of the assessed articles disclosed underutilization of the tool and reflect low awareness by health professionals regarding the recording of information in the child's health monitoring document.

The association of maternal age with birthweight and gestational age: a cross-cohort comparison

BACKGROUND

We examined the associations of maternal age with low birthweight (LBW) and preterm birth in four cohorts from a middle- and a high-income country, where the patterning of maternal age by socio-economic position (SEP) is likely to differ.

METHODS

Population-based birth cohort studies were carried out in the city of Pelotas, Brazil in 1982, 1993, and 2004, and in Avon, UK in 1991 [Avon Longitudinal Study of Parents and Children (ALSPAC)]. Adjustment for multiple indicators of SEP were applied.

RESULTS

Low SEP was associated with younger age at childbearing in all cohorts, but the magnitudes of these associations were stronger in ALSPAC. Inverse associations of SEP with LBW and preterm birth were observed in all cohorts. U-shaped associations were observed between maternal age and odds of LBW in all cohorts. After adjustment for SEP, increased odds of LBW for young mothers (<20 years) attenuated to the null but remained or increased for older mothers (≥ 35 years). Very young (<16 years) maternal age was also associated with both outcomes even after full SEP adjustment. SEP adjusted odds ratio of having a LBW infant in women <16 years and ≥ 35 years, compared with 25-29 years, were 1.48 [95% confidence interval (CI) 1.00, 2.20] and 1.66 [95% CI 1.36, 2.02], respectively. The corresponding results for preterm birth were 1.80 [95% CI 1.23, 2.64)] and 1.38 [95% CI 1.15, 1.67], respectively.

CONCLUSION

Confounding by SEP explains much of the excess risk of LBW and preterm among babies born to teenage mothers as a whole, but not for mothers aged <16 or ≥ 35 years. Given that the proportion of women becoming pregnant at <16 years is smaller than for those ≥ 35 years, the population burden is greater for older age.

Independent risk factors associated with infant deaths

OBJECTIVE: Identifying the independent risk factors associated with infant deaths registered in Brazilian public information systems.METHODS: A cross-sectional study using secondary data recorded in public information systems for eleven years. The association of mortality rates was observed according to death periods using univariate and multivariate regression tests.RESULTS: The infant mortality rate decreased by 20.7 % in the study period. The list of independent factors associated with infant deaths shows the necessity for measures to increase public actions aimed at the early onset of prenatal care, continuing until the postpartum, puerperal period and in the growth and development of the newborn.CONCLUSION: The independent risk factors for infant death were low birth weight, gestation duration of less than 37 weeks, multiple pregnancy, maternal educational level lower than eight years, Apgar score and less than seven antenatal pregnancy.

Determinants of neonatal death with emphasis on health care during pregnancy, childbirth and reproductive history

OBJECTIVE

To identify risk factors for neonatal mortality, focusing on factors related to assistance care during the prenatal period, childbirth, and maternal reproductive history.

METHODS

This was a case-control study conducted in Maceió, Northeastern Brazil. The sample consisted of 136 cases and 272 controls selected from official Brazilian databases. The cases consisted of all infants who died before 28 days of life, selected from the Mortality Information System, and the controls were survivors during this period, selected from the Information System on Live Births, by random drawing among children born on the same date of the case. Household interviews were conducted with mothers.

RESULTS

The logistic regression analysis identified the following as determining factors for death in the neonatal period: mothers with a history of previous children who died in the first year of life (OR=3.08), hospitalization during pregnancy (OR=2.48), inadequate prenatal care (OR=2.49), lack of ultrasound examination during prenatal care (OR=3.89), transfer of the newborn to another unit after birth (OR=5.06), admittance of the newborn at the ICU (OR=5.00), and low birth weight (OR=2.57). Among the socioeconomic conditions, there was a greater chance for neonatal mortality in homes with fewer residents (OR=1.73) and with no children younger than five years (OR=10.10).

CONCLUSION

Several factors that were associated with neonatal mortality in this study may be due to inadequate care during the prenatal period and childbirth, and inadequate newborn care, all of which can be modified.

Diferenciais nos fatores de risco para a mortalidade infantil em cinco cidades brasileiras: um estudo de caso-controle com base no SIM e no SINASC

O estudo buscou identificar diferenciais entre os fatores de risco para mortalidade infantil em cinco cidades, sendo uma de cada macrorregião brasileira. Realizou-se um estudo caso-controle, considerando casos os óbitos de menores de um ano registrados no Sistema de Informações sobre Mortalidade (SIM) e no Sistema de Informações sobre Nascidos Vivos (SINASC) e controles os nascidos vivos que não foram a óbito, registrados no SINASC. Os fatores de risco foram estimados por meio de análises univariadas e multivariadas, adotando-se os modelos logísticos hierarquizados. Os principais determinantes da mortalidade infantil foram os fatores biológicos (Apgar, baixo peso ao nascer, prematuridade e presença de malformação congênita) mediados pelos fatores socioeconômicos (escolaridade, estado civil e raça/cor) e as condições da assistência (consultas de pré-natal). Embora se verifique concordância em parte dos determinantes da mortalidade infantil entre as cidades analisadas, alguns diferenciais regionais puderam ser observados expressando a condição iníqua da mortalidade infantil associada às desigualdades nas condições socioeconômicas e de acesso aos serviços de saúde.

Evolução da assistência materno-infantil e do peso ao nascer no Estado de Pernambuco em 1997 e 2006

Avaliar a evolução e a influência da assistência materno-infantil na variação do peso ao nascer no estado de Pernambuco. Os dados analisados provêm de duas pesquisas transversais da população de crianças menores de cinco anos, estudadas por inquéritos domiciliares em 1997 (n = 1906) e 2006 (n = 1555). A amostra foi calculada para assegurar a representatividade de dois estratos geoeconômicos: setores urbano e rural. Estudou-se a assistência ao pré-natal e parto e o peso ao nascer. Utilizou-se o teste do qui-quadrado para comparar as variáveis categóricas e calculou-se a diferença da média de peso ao nascer nos anos pesquisados, e os respectivos intervalos de confiança de 95%. Verificou-se importante melhora na assistência ao pré-natal e aumento do parto cesáreo. Houve uma redução significante de 112g na diferença da média de peso ao nascer no meio rural. Em 2006 o acesso a pelo menos 1 consulta de pré-natal ocorreu independente da escolaridade materna, no entanto, o acesso ao pré-natal mais adequado foi maior entre as mães de maior escolaridade, tanto em 1997, como em 2006. Apesar da expansão da assistência no pré-natal e no parto, o acesso iníquo, o excesso de intervenções médicas e o aumento da sobrevida de recém nascidos podem estar contribuindo para as variações da média de peso ao nascer no estado de Pernambuco.

Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature

BACKGROUND

The rate of exclusive breastfeeding remains low in many countries. Furthermore, cesarean delivery (CD) is increasing and may affect breastfeeding success.

OBJECTIVE

The objective was to conduct a systematic review and meta-analysis of observational studies to determine whether CD (prelabor or in-labor) is associated with a lower rate of breastfeeding compared with vaginal delivery (VD).

DESIGN

Studies published before January 2011 that reported breastfeeding up to 6 mo postpartum and compared outcomes after CD or VD, including foreign language publications, were identified through PubMed and bibliographic review. Prespecified data were extracted independently by multiple observers. The types of CD [prelabor (elective/scheduled) or in-labor (emergency)] were compared by subgroup analyses. Potential sources of study-level bias were analyzed by using meta-regression and sensitivity analyses.

RESULTS

The systematic review included 53 studies (554,568 subjects, 33 countries); 25 authors contributed additional data (245,455 subjects), and 48 studies (553,306 subjects, 31 countries) were included in the meta-analysis. Rates of early breastfeeding (any initiation or at hospital discharge) were lower after CD compared with after VD (pooled OR: 0.57; 95% CI: 0.50, 0.64; P < 0.00001) and lower after prelabor but not after in-labor CD (prelabor OR: 0.83; 95% CI: 0.80, 0.86; P < 0.00001; in-labor OR: 1.00; 95% CI: 0.97, 1.04; P = 0.86). In mothers who initiated breastfeeding, CD had no significant effect on any breastfeeding at 6 mo (OR: 0.95; 95% CI: 0.89, 1.01; P = 0.08).

CONCLUSIONS

There was a negative association between prelabor CD and early breastfeeding. If breastfeeding is initiated, mode of delivery has no apparent effect on the number of mothers still breastfeeding at 6 mo. Women and health care workers should be aware of the negative associations between CD and early breastfeeding and consequent implications for infants' well-being.

Análise de tendências das taxas de mortalidade infantil e de seus fatores de risco na cidade de Porto Alegre, Rio Grande do Sul, Brasil, no período de 1996 a 2008

Objetiva-se determinar as tendências de mortalidade infantil e de seus fatores de risco em Porto Alegre. Este é um estudo baseado nas informações do registro de nascidos vivos e de óbitos infantis no período de 1996-2008. Foi analisada a tendência temporal das taxas de mortalidade infantil (TMI) e de seus componentes, de acordo com a escolaridade materna, o número de consultas de pré-natal, idade materna, número de filhos vivos e mortos, sexo do recém-nascido, o tipo de parto, a idade gestacional, o peso de nascimento e o tipo de hospital. Foi utilizada a regressão sequencial de Poisson para estimar a influência da condição socioeconômica e os demais fatores de risco. A TMI decaiu entre os nascidos de mães com escolaridade inferior a 11 anos. Entre os nascidos de mães com 12 ou mais anos de escolaridade, não houve alterações significativas. A condição socioeconômica materna foi o fator que mais se associou à redução da mortalidade infantil. Contudo, a tendência de redução não atingiu todo o potencial devido ao aumento do baixo peso ao nascer.

Impacto do incentivo ao aleitamento materno entre mulheres trabalhadoras formais

Investigar se programas de incentivo ao aleitamento materno ajudam a prevenir o desmame precoce entre filhos de mães trabalhadoras. Foi realizado um estudo de intervenção não randomizado, por meio de inquérito entre mães que voltaram a trabalhar após o parto, participantes e não-participantes de um programa de incentivo ao aleitamento. A amostra consistiu de 200 mães de filhos com idades entre 6 e 10 meses. Para avaliar fatores associados ao desmame precoce, os resultados foram analisados por meio dos testes estatísticos de qui-quadrado, exato de Fisher e análise de regressão logística múltipla (α = 0,05). Os resultados mostraram que houve diferença estatística nas taxas de aleitamento materno exclusivo (p < 0,0001) e de aleitamento materno (p < 0,0001) entre os grupos. Apresentou diferença estatística (p = 0,0056) em relação à época de retorno ao trabalho entre os grupos. Não houve diferença entre o fim da licença-maternidade e a época de desmame. As mães que não conseguem amamentar seus filhos durante a jornada de trabalho têm 4,98 (IC95%: 1,27-19,61) vezes mais chances de desmamá-los antes do quarto mês.