Intervenções para reduzir a mortalidade infantil pré-escolar e materna no Brasil

Early-onset neonatal sepsis as a risk factor for peri-intraventricular hemorrhage in premature infants

OBJECTIVE

To assess early-onset sepsis as a risk factor of peri-intraventricular hemorrhage in premature infants born at less than or equal to 34 weeks' gestation and admitted to a neonatal intensive care unit (NICU).

METHODS

This retrospective cohort study included premature patients born at less than or equal to 34 weeks' gestation who were admitted to the NICU of a tertiary hospital in southern Brazil, and born from January 2017 to July 2021. Data were collected from patients' medical records. Early-onset sepsis was measured according to the presence or absence of diagnosis within the first 72 hours of life, whereas the outcome, peri-intraventricular hemorrhage, was described as the presence or absence of hemorrhage, regardless of its grade.

RESULTS

Hazard ratios were calculated using Cox regression models. A total of 487 patients were included in the study, of which 169 (34.7%) had some degree of peri-intraventricular hemorrhage. Early-onset sepsis was present in 41.6% of the cases of peri-intraventricular hemorrhage, which revealed a significant association between these variables, with increased risk of the outcome in the presence of sepsis. In the final multivariate model, the hazard ratio for early-onset sepsis was 1.52 (95% confidence interval 1.01-2.27).

CONCLUSION

Early-onset sepsis and the use of surfactants showed to increase the occurrence of the outcome in premature children born at less than or equal to 34 weeks' gestation. Meanwhile, factors such as antenatal corticosteroids and gestational age closer to 34 weeks' gestations were found to reduce the risk of peri-intraventricular hemorrhage.

Quality of Prenatal Care in Brazil: National Health Research 2013

This study aimed to assess the adequacy of prenatal care in Brazil associated with sociodemographic determinants. The study included a data analysis from the National Health Research performed in Brazil in 2013. Two outcomes on the adequacy of prenatal care were assessed: the Kessner index modified by Takeda index that, in addition to the former, assessed whether blood pressure and weight were measured in all appointments, as well as the performance of blood and urine tests and ultrasound. Both quality indicators were assessed for Brazil and for its macro-regions. According to Outcome 1, 80.6% of women received adequate prenatal care. When adding the performance of tests (Outcome 2), the rate dropped to 71.4%. Adequate prenatal care was more frequent among white women who performed prenatal care in the private health sector. The northern region had the lowest rate of adequate prenatal care, while the southeast region showed the highest rates. Despite the extensive coverage, prenatal care in Brazil still presents inequities and low service quality, especially for women from the poorest regions of the country.

Preventable deaths in childhood, according to actions of the Unified Health System, Brazil

OBJECTIVE

To analyze the mortality trend of children under five years of age living in Brazil and regions, using the "Brazilian List of Preventable Causes of Death."

METHOD

Ecological time-series study of mortality rate due to preventable and non-preventable causes, with corrections for ill-defined causes and underreporting of deaths from 2000 to 2013.

RESULTS

In Brazil, preventable death rates (5.1% per year) had a higher decrease compared with non-preventable ones (2.5% per year). Preventable causes associated with proper care during pregnancy had the highest concentration of deaths in 2013 (12,267) and the second lowest average percentage reduction in the year (2.1%) and for the period (24.4%). The South and Southeast regions had the lowest mortality rates in childhood. However, the Northeast region had the highest decrease in reducible child mortality (6.1% per year) and the Midwest, the lowest (3.5% per year).

CONCLUSION

The decrease in childhood mortality rates was expected in the last decade, suggesting the progress in the response of health systems, in addition to improvements in health conditions and social determinants. Special attention should be given to pregnancy-related causes, i.e., expand the quality of prenatal care, in particular, due to fetal and newborn deaths resulted from maternal conditions, which increased significantly in the period (8,3% per year).

Temporal and spatial evolution of maternal and neonatal mortality rates in Brazil, 1997-2012

OBJECTIVE

Maternal and neonatal mortality are important public health issues in low-income countries. This study evaluated spatial and temporal maternal and neonatal mortality trends in Brazil between 1997 and 2012.

METHODS

This study employed spatial analysis techniques using death records from the mortality information system. Maternal mortality rates per 100,000 and neonatal mortality rates (early and late) per 1000 live births were calculated by state, region, and period (1997-2000, 2001-2004, 2005-2008, and 2009-2012). Multivariate negative binomial models were used to explain the risk of death.

RESULTS

The mean Brazilian maternal mortality rate was 55.63/100,000 for the entire 1997-2012 period. The rate fell 10% from 1997-2000 (58.92/100,000) to 2001-2004 (52.77/100,000), but later increased 11% during 2009-2012 (58.69/100,000). Early and late neonatal mortality rates fell 33% (to 7.36/1000) and 21% (to 2.29/1000), respectively, during the 1997-2012 period. Every Brazilian region witnessed a drop in neonatal mortality rates. However, maternal mortality increased in the Northeast, North, and Southeast regions.

CONCLUSION

Brazil's neonatal mortality rate has improved in recent times, but maternal mortality rates have stagnated, failing to meet the Millennium Development Goals. Public policies and intersectoral efforts may contribute to improvements in these health indicators.

Sustained Decrease in Gastroenteritis-related Deaths and Hospitalizations in Children Less Than 5 Years of Age After the Introduction of Rotavirus Vaccination: A Time-Trend Analysis in Brazil (2001-2010)

BACKGROUND

Rotavirus (RV) vaccine, Rotarix, was introduced into the Brazil national immunization program in 2006. To estimate population-level vaccine effect, we conducted a time-trend analysis on all-cause gastroenteritis (GE)-related death certificate-reported deaths (DCRDs), hospital deaths (HDs) and hospitalizations trends in <5-year-olds before and after RV vaccine introduction.

METHODS

National level all-cause GE-related death certificate [Mortality Information System] and admission (Hospital Information System) data were aggregated and analyzed. Negative-binomial regression models (adjusting for age, year and region) compared DCRDs, HDs and hospitalization trends in <5-year-olds between baseline (2001-2005) and postvaccine introduction periods (Mortality Information System: 2007-2009 and Hospital Information System: 2007-2010). Negative-binomial regression models were fitted to data for each outcome before 2006, and the predicted annual frequencies of each outcome were plotted against corresponding observed annual frequencies.

RESULTS

During the postvaccine introduction period, there was an overall age-independent GE-related DCRDs reduction (20.9%, P = 0.04) observed in children <5 years of age; a reduction was also seen in infants <1 year of age (20.8%, P = 0.003). Age-independent GE-related HDs and hospitalizations reductions (57.1%, P < 0.0001 and 26.6%, P < 0.0001, respectively) were observed in <5-year-olds; HDs reductions were also observed for each age group (<1-year-olds: 55.0%, P < 0.0001 and 1- to <5-year-olds: 59.5%, P < 0.0001). Observed annual frequencies of GE-related DCRDs, HDs and hospitalizations were lower than the predicted value in each age group in all years after 2006.

CONCLUSIONS

GE-related DCRDs, HDs and hospitalizations were significantly reduced in <1 and in 1- to <5-year-old Brazilian children after Rotarix introduction, which provides additional evidence of the direct and indirect population-level effect of RV vaccination on GE-related mortality and morbidity in children.

NOSOLOGY OF HAND DISEASES IN CHILDREN AND ADOLESCENTS OPERATED IN PROVISIONAL FACILITIES IN A MODEL HOSPITAL - PERNAMBUCO STATE, BRAZIL

To report the frequencies of congenital hand diseases in patients who underwent surgery on a collective mobilization basis at SOS Hand, Recife, Pernambuco, between 2005 and 2009. Methods: Information was collected from 833 children and adolescents who were examined in eight missions. Results: Among the patients, 306 (36.7%) underwent surgery: 240 (78.4%) because of congenital malformation and 66 (21.6%) because of acquired lesions. The most frequent congenital malformations were: syndactyly, 72 cases (30.0%); polydactyly, 30 cases (12.5%); bifid thumb, 19 cases (7.9%); complex hand malformation, 14 cases (5.8%); cleft hand, 13 cases (5.4%); trigger finger, 12 cases (5.0%); camptodactyly, 11 cases (4.6%); and brachysyndactyly, 9 cases (3.7%). The most frequently acquired injuries were: obstetric traumatic lesions, 26 cases (39.4%); hand trauma sequelae, 18 cases (27.3%); cerebral paralysis sequelae, 7 cases (10.6%); electric shock sequelae, 5 cases (7.6%); and burn sequelae, 4 cases (6.1%). Conclusion: The nosology of hand diseases is similar to that of large series of elective surgery, especially regarding congenital deformities. The frequency of acquired hand lesions seems to be higher than the frequency in international series. The collective mobilization system for hand surgery is important for decreasing the need for this activity in public institutions, and it has been shown to be very efficient. The success of the project may provide support for the Brazilian National Health System to enroll hand surgeons in the on-call system, in emergency units.

Complications in adolescent pregnancy: systematic review of the literature

Sexual activity during adolescence can lead to unwanted pregnancy, which in turn can result in serious maternal and fetal complications. The present study aimed to evaluate the complications related to adolescent pregnancy, through a systematic review using the Medical Subject Headings: “pregnancy complication” AND “adolescent” OR “pregnancy in adolescence”. Only full original articles in English or Portuguese with a clearly described methodology, were included. No qualitative studies, reviews or meta-analyses, editorials, case series, or case reports were included. The sample consisted of 15 articles; in that 10 were cross-sectional and 5 were cohort studies. The overall prevalence of adolescent pregnancy was 10%, and among the Brazilian studies, the adolescent pregnancy rate was 26%. The cesarean delivery rate was lower than that reported in the general population. The main maternal and neonatal complications were hypertensive disorders of pregnancy, prematurity and low birth weight, respectively. Adolescent pregnancy is related to increased frequency of neonatal and maternal complications and lower prevalence of cesarean delivery.

[Perinatal mortality in the municipality of Salvador, Northeastern Brazil: evolution from 2000 to 2009]

OBJECTIVE

To describe and analyze the evolution of perinatal mortality with regards the scale and extent of the problem.

METHODS

A descriptive time trend study with 10,994 perinatal deaths to mothers living in Salvador, Bahia, Northeastern Brazil, with a gestational age of ≥ 22 weeks, newborn age of up to six days and birth weight of 500 grams or more, recorded from 2000 to 2009. Data from the Information Systems on Live Births and Mortality of DATASUS/Ministry of Health available on the website were used. Rates of perinatal and fetal mortality per 1,000 births and early neonatal mortality per 1,000 live births were calculated. The Pearson's Qui-square test for differences in proportions, sequence (runs) test, the calculation of moving averages and linear coefficient of determination (R²) were used for trend analysis. The Wigglesworth classification of causes of death was used.

RESULTS

The rates of perinatal mortality showed a decreasing trend, of -42.0% in the period (from 33.1 (2000) to 19.2 (2009)), with a greater share of rates of neonatal mortality (-56.3%). Fetal mortality accounted for a large proportion (61.9%) of rates of perinatal mortality in 2009. The classification of deaths showed the following most frequent causes of perinatal deaths: intrapartum asphyxia (8.8/1,000), immaturity (7.1/1,000) and congenital malformations (1.3/1,000).

CONCLUSIONS

Perinatal mortality remains high despite the downward trend, and the predominance of fetal mortality indicates recent changes in the profile of causes of death and impact on prevention activities. The quality of prenatal care with risk control and improving care during the delivery may reduce the occurrence of preventable causes of death.

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

BACKGROUND

Over the last decades there has been a reduction of social inequalities in Brazil, as well as a strong expansion of health services, including prenatal care. The objective of the present study was to estimate the rate of inadequate prenatal care utilization and its associated factors in São Luís, Brazil, in 2010 and to determine whether there was a reduction of inequity in prenatal care use by comparing the present data to those obtained from a previous cohort started in 1997/98.

METHODS

Data from the BRISA (Brazilian birth cohort studies of Ribeirão Preto and São Luís) population-based cohort, which started in 2010 (5067 women), were used. The outcome variable was the inadequate utilization of prenatal care, classified according to the recommendations of the Brazilian Ministry of Health. The explanatory variables were organized into three hierarchical levels based on the Andersen's behavioral model of the use of health services: predisposing, enabling and need factors.

RESULTS

Only 2.0% of the women did not attend at least one prenatal care visit. The rate of inadequate prenatal care utilization was 36.7%. Despite an improved adequacy of prenatal care use from 47.3% in 1997/98 to 58.2% in 2010, social inequality persisted: both low maternal schooling (prevalence ratio (PR) = 2.78; 95% confidence interval (95% CI) 2.23-3.47 for 0 to 4 years of study) and low family income, less than 0.5 monthly minimum wage per capita (PR = 1.37; 95% CI 1.22-1. 54), continued to be associated with higher rates of inadequate prenatal care utilization. Racial disparity regarding adequate utilization of prenatal services was detected, with black (PR = 1.19; 95% CI 1.04-1.36) and mulatto (PR = 1.14; 95% CI 1.02-1.26) women showing higher rates of inadequate use. On the other hand, women covered by the FHP - Family Health Program (PR = 0.92; 95% CI 0.85-0.98) showed a lower rate of inadequate prenatal care utilization.

CONCLUSIONS

Despite strong expansion of health services and expressive improvements in adequate prenatal care use and social indicators, inequalities in prenatal care use still persist. The FHP seems to be effective in reducing inadequate prenatal care utilization.

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.

Fatores de risco para mortalidade neonatal no município de Serra, Espírito Santo

Objetivou-se analisar os fatores de risco associados à mortalidade neonatal no município de Serra, ES. Realizou-se estudo de coorte não concorrente, utilizando a técnica de Linkage que pareou os 32.275 nascidos vivos com 273 óbitos neonatais ocorridos no período de 2001 a 2005, utilizando-se dados do SINASC e SIM. Após os ajustes na regressão logística, os fatores associados à mortalidade foram: mães sem instrução, idade materna < 15 anos e > 35 anos, nascer em hospital público, nenhuma consulta de pré-natal, peso ao nascer.

Avoidable deaths in the first four years of life among children in the 2004 Pelotas (Brazil) birth cohort study

Avoidable deaths have been employed as indicators of health care quality. The aim of this study was to identify factors associated with avoidable deaths from birth to four years of age among children from the 2004 Pelotas (Brazil) birth cohort study. From January 1st, 2004, to December 31st, 2005, deaths were monitored on a daily basis and the causes were investigated and classified according to avoidability. After the first year, deaths were monitored through the Mortality Information System. A total of 94 children died during this period. It was possible to classify 92 deaths, 70 of which were preventable. Low family income, fewer prenatal visits and poor-quality prenatal care, preterm birth, low 5-minute Apgar score, and no breastfeeding in the first 24 hours of life were associated with increased risk of death. Prematurity was present in 39 deaths, but only five of these would have been prevented by measures provided during prenatal care. Although limited, compliance with antenatal care program guidelines is still the most important strategy for preventing avoidable deaths in childhood, particularly among the poorest children.

Concentração de sódio e glicose em soro de reidratação oral preparado por Agentes Comunitários de Saúde

A diarreia infantil é importante causa de morbimortalidade, sendo indicativo para terapia de reidratação oral (TRO). Este estudo objetivou avaliar o teor de sódio e glicose em soro de reidratação oral preparado por Agentes Comunitários de Saúde (ACS) que atuam em Unidades Básicas de Saúde (UBS), caracterizando o perfil e o conhecimento destes sobre a TRO. Após responderem questionário com informações profissionais e sobre a TRO, os ACS a prepararam por três métodos. O teor de glicose e de sódio das TRO foi determinado e comparado ao proposto pela OMS. Na análise estatística foram utilizados ANOVA, Tukey e odds ratio. Participaram do estudo 52 ACS, majoritariamente mulheres e com ensino médio completo (90,4%). A adequação da TRO foi de 3,9; 9,8 e 28,9% para a colher caseira, colher medida e punhado pitada, respectivamente. O preparo da TRO com a colher caseira resultou em 88,0% das amostras com teor de sódio perigoso à saúde (>101 mmol/L). Entre os ACS, 38,5% tinham menos de 2 anos de trabalho, com risco 4,8 vezes maior de preparar TRO inadequada em sódio. Os ACS referiram indicar a TRO no tratamento da diarreia infantil, desconhecendo efeitos colaterais do preparo inadequado. A composição da TRO produzida pelos ACS foi inadequada em todos os métodos. É recomendável treinamento dos ACS no preparo da TRO.

Effect of the Family Health Strategy on surveillance of infant mortality

OBJECTIVE

To evaluate the effect of the Family Health Strategy on infant mortality surveillance.

METHODS

An ecologic study was performed with a multiple group design, and the unit of analysis was municipalities in Bahia state (Northeastern Brazil) in 2008. The 3,947 deaths analyzed were obtained from the Mortality Information System, and the minimum acceptable level for death investigation was 25%. Logistic regression models were used for bivariate and multivariate analysis and adjusted for sociodemographic and service organization variables.

RESULTS

In 48.9% of the municipalities at least one infant death was investigated, and 35.5% of municipalities achieved the minimum target for investigation. In the bivariate model, the investigation of at least one infant death was statistically associated with more populous municipalities, higher Human Development Indices, existence of Investigation Committee and obstetric beds in the municipality; there were no associations with Family Health Strategy coverage and existence of a designated person in the municipality. In multivariate models, the investigation of at least one infant death was statistically associated with population size (OR = 4.02) and presence of obstetric beds (OR = 2.68). Achieving the minimum target was associated only with the existence of obstetric beds in the municipality (OR = 1.76).

CONCLUSIONS

The investigation rate for deaths of children less than one year of age was less than the level agreed upon in Bahia in 2008. There was no association between coverage of the Family Health Strategy and death investigations, which suggests that Infant Mortality Surveillance is at an incipient stage, especially in regards to decentralization to local primary care teams.

Iniquidade na assistência à gestação e ao parto em município do semiárido brasileiro

OBJETIVOS: avaliar a iniquidade na assistência à gestação e ao parto para menores de cinco anos residentes no município de Caracol, Piauí, Brasil. MÉTODOS: usando delineamento transversal, amostragem sistemática e aplicação de questionário domiciliar foram coletadas informações sobre características demográficas de mães e crianças, assistência à gestação e ao parto e nível socioeconômico. Por meio da técnica de componentes principais, criou-se um escore em tercis. As associações deste escore com as variáveis relativas à assistência à gestação e ao parto foram avaliadas pelos testes qui-quadrado e Kruskal- Wallis. RESULTADOS: todas as 405 crianças incluídas no estudo eram provenientes de famílias com renda inferior a um salário mínimo mensal; 65% residiam em área rural. Mães pertencentes ao maior tercil socioeconômico realizaram um maior número de consultas de pré-natal; realizaram maior número de exames de urina, hemograma, citopatológico de colo uterino e ultrassonografia, tiveram o parto realizado por médico e foram mais frequentemente submetidas à cesariana. CONCLUSÕES: mesmo entre os mais pobres, há enormes iniquidades em saúde. Combater os determinantes desta pobreza com programas sociais mais agressivos é imperativo, assim como priorizar o atendimento aos mais pobres dentre os pobres.

Público versus privado: avaliando a assistência à gestação e ao parto no extremo sul do Brasil

OBJETIVOS: avaliar a assistência à gestação e ao parto entre o setor público e privado no município de Rio Grande, RS. MÉTODOS: aplicou-se questionário padronizado a todas as gestantes residentes neste município que tiveram filho em 2007. Investigaram-se aspectos relativos a cuidados recebidos desde o início da gestação até o pós-parto imediato. A análise estatística consistiu da comparação de proporções nestes dois grupos através do teste de qui-quadrado. RESULTADOS: dentre os 2584 nascimentos cujas mães residiam no município, foram obtidas informações sobre 2557, o que representa 98,9% do total. Destas mães, 96% realizaram pelo menos uma consulta de pré-natal. Gestantes atendidas no setor privado iniciaram o pré-natal mais cedo, realizaram um maior número de consultas médicas, exame de sangue e ultrassonografia pélvica, exame ginecológico, das mamas e citopatológico de colo uterino. Gestantes do setor público realizaram maior número de exames de urina e sorologia para sífilis e foram mais comumente suplementadas com sulfato ferroso. Todas estas diferenças foram estatisticamente significativas (p<0,05). CONCLUSÕES: gestantes do setor privado receberam de forma sistemática melhor assistência durante o pré-natal em termos de consultas e exames realizados, tiveram seu parto mais comumente realizado por médico, foram mais afetadas por intervenções desnecessárias como cesariana e episiotomia e menos frequentemente suplementadas com ferro.

Desigualdades sociodemográficas e causas de morte em menores de cinco anos no Estado de Pernambuco

OBJETIVOS: caracterizar a mortalidade em menores de cinco anos, no triênio 2004-2006, identificando desigualdades sociodemográficas e nas causas de morte entre as mesorregiões de Pernambuco. MÉTODOS: realizou-se um estudo transversal, com 6721 óbitos em menores de cinco anos residentes em municípios com Sistema de Informação sobre Mortalidade e Sistema de Informação sobre Nascidos Vivos consolidados, agregados em quatro mesorregiões. Para as variáveis estudadas, analisaram-se desigualdades na mortalidade proporcional (qui-quadrado) e nas taxas de mortalidade em menores de cinco anos (TMM5) - razão de taxas e sobremortalidade. RESULTADOS: entre as mesorregiões, a TMM5 variou de 18,3/1000NV (Região Metropolitana do Recife-RMR) a 28,4/1000NV (Sertão), com média de 21,7/1000NV. As maiores TMM5 da Mata, Agreste e Sertão em relação à TMM5 da RMR representaram uma sobremortalidade de 1055 óbitos. A mortalidade proporcional apresentou diferenças (p<0,05) quanto ao local de ocorrência do óbito, características do município de residência (IDH, analfabetismo feminino, taxa de fecundidade) e causas básicas específicas nos capítulos afecções perinatais, doenças infecciosas e parasitárias. No Sertão, as TMM5 reduzíveis por adequada atenção à gestação-parto-RN, por ações de promoção à saúde e por diagnóstico e tratamento adequados foram 1,6; 2,2 e 2,7 vezes superiores às da RMR. CONCLUSÕES: a mortalidade em menores de cinco anos em Pernambuco apresenta desigualdades entre as mesorregiões.

Características sociodemográficas e de assistência à gestação e ao parto no extremo sul do Brasil

Este estudo teve por objetivo comparar a assistência à gestação e ao parto entre mães adolescentes e não adolescentes residentes no Município de Rio Grande, Rio Grande do Sul, Brasil. Entre 1º de janeiro e 31 de dezembro de 2007 aplicou-se questionário padronizado a todas as mães destes recém-nascidos buscando informações sobre cuidados recebidos do inicio da gravidez até momento do parto. Utilizou-se teste do qui-quadrado para comparar proporções. Um quarto (516) dos recém-nascidos era filho de mães adolescentes. Em relação às demais mães, uma menor proporção de adolescentes completou seis ou mais consultas de pré-natal (61% x 75%), iniciou o pré-natal no primeiro trimestre de gravidez (58% x 77%), recebeu vacina antitetânica (81% x 85%) e fez todo o pré-natal com o mesmo profissional (70% x 78%); no entanto, foram mais comumente suplementadas com sulfato ferroso (66% x 57%), submetidas a fórcipe (11% x 6%), à episiotomia (86% x 66%), e atendidas no SUS (92% x 76%). Estes dados mostram que a assistência recebida pelas mães adolescentes foi sistematicamente pior àquela recebida pelas demais mães.

Mortalidade materna no Brasil: o que mostra a produção científica nos últimos 30 anos?

O objetivo deste trabalho foi descrever o perfil epidemiológico e a tendência da mortalidade materna no Brasil, por meio de revisão de estudos sobre o tema. Foi realizada busca eletrônica de artigos científicos publicados entre 1980 e 2010, nas bases de dados LILACS e MEDLINE. Identificaram-se inicialmente 486 artigos. Após aplicação dos critérios de inclusão e exclusão restaram 50 artigos. A comparação dos dados mostrou queda da RMM de forma diferenciada nas regiões brasileiras. Os estudos sobre determinação do óbito materno apontaram desigualdades sociais relacionadas à cor da pele e escolaridade. O preenchimento incompleto da declaração de óbito e a subnotificação ainda persistem. Prevaleceram as causas obstétricas diretas, com predomínio das doenças hipertensivas. Quando analisada, a evitabilidade apontou falhas na assistência pré-natal e ao parto. Apesar de sua relevância, são poucos os artigos sobre mortalidade materna no Brasil. A RMM, embora em declínio, permanece em níveis elevados. Melhorias na qualidade da assistência pré-natal e ao parto são necessárias.

Identificação dos fatores de risco para o transtorno do processamento auditivo (central) em pré-escolares

OBJETIVOS: identificar os fatores de risco para o Transtorno do Processamento Auditivo (Central) TPA(C) em 79 pré-escolares. MÉTODOS: aplicou-se um questionário para 79 pais , de crianças que cursavam a pré-escola ou o primeiro ano do ensino fundamental, das redes municipal, estadual e particular de Porto Alegre. O questionário continha questões referentes ao desenvolvimento infantil. RESULTADOS: a pesquisa mostra como principais resultados a ocorrência do uso de chupeta (73,4%); do tempo de aleitamento materno (36%); da realização dos exames audiológicos (17,8%); do tempo em frente a televisão (59%); e da quantidade de repetições de instruções (54%); Em relação aos testes de correlação o estudo mostrou a utilização da chupeta (p=0,006) e maior ocorrência de otites (p=0,007) por meninas. As crianças mais velhas realizavam leitura espontânea (p=0,007) e recontavam histórias ordenadamente (p=0,035). CONCLUSÃO: Identificou-se as variáveis: maior número de irmãos (p=0,005), maior solicitação de repetições (p<0,001) e dificuldade de compreensão em ambientes competitivos (p=0,002) significativos como fatores de risco para o Transtorno do Processamento Auditivo (Central).

[Avoidable causes of infant mortality in Brazil, 1997-2006: contributions to performance evaluation of the Unified National Health System]

Infant deaths were classified as avoidable, non-avoidable, and resulting from ill-defined conditions, from 1997 to 2006, using the Brazilian List of Avoidable Causes of Mortality. Non-linear regression was used to calculate trends in cause-specific infant mortality rates. There was a significant decline in both avoidable deaths and deaths from ill-defined causes (p < 0.001). Avoidable deaths decreased by 37% overall. Mortality avoidable through adequate intrapartum care and adequate neonatal care decreased by 27.7% and 42.5%, respectively, while mortality avoidable through adequate prenatal care increased by 28.3%. In conclusion, health services contributed to the reduction in infant mortality. The decrease in ill-defined causes of death indicates expanded access to health services. The increase in access to intrapartum and neonatal care contributed to the reduction in infant deaths. The increase in mortality avoidable through adequate prenatal care indicates the need for improvement in prenatal care.

Reducing childhood mortality from diarrhea and lower respiratory tract infections in Brazil

OBJECTIVE

To evaluate the effects of the Family Health Program (FHP), a strategy for reorganization of primary health care in Brazil, on mortality of children younger than 5 years, particularly from diarrheal diseases and lower respiratory tract infections.

METHODS

Mortality rates and the extent of FHP coverage from 2000 to 2005 was evaluated from the 2601 (of 5507) Brazilian municipalities with an adequate quality of vital information. A multivariable regression analysis for panel data was conducted by using a negative binomial model with fixed effects, adjusted for relevant demographic and socioeconomic covariates.

RESULTS

A statistically significant negative association was observed between FHP coverage levels, classified as none (the reference category), low (<30%), intermediate (>or=30% and <70%), or high (>or=70%), and all analyzed mortality rates, with a reduction of 4% (95% confidence interval [CI]: 2%-6%), 9% (95% CI: 7%-12%), and 13% (95% CI: 10%-15%), respectively, on mortality rates or children younger than 5. The greatest effect was on postneonatal mortality. Reductions of 31% (95% CI: 20%-40%) and 19% (95% CI: 8%-28%) in mortality rates from diarrheal diseases and lower respiratory infections, respectively, were found in the group of municipalities with the highest FHP coverage.

CONCLUSIONS

The FHP, one of the largest comprehensive primary health care programs in the world, was effective in reducing overall mortality of children younger than 5, and particularly deaths related to diarrheal diseases and lower respiratory tract infections.

Maternal knowledge on child survival in the poorest areas of North and Northeast Brazil: o caso de áreas pobres nas regiões Norte e Nordeste do Brasil

This study aimed to evaluate knowledge on child survival among mothers of children under five years of age living in nine municipalities in North and Northeast Brazil. A standardized questionnaire was used for home interviews of mothers visited by volunteers from the Pastorate of the Child and mothers not visited by the program (control areas). The association between independent variables and the outcome (visited versus not visited by the Pastorate of the Child) was evaluated using the chi-square test. Among the 752 mothers studied, 386 were visited by Pastorate of the Child volunteers and 366 were not visited. Mothers visited by the Pastorate of the Child, although poorer, showed better knowledge on monitoring child growth and identifying child development difficulties as compared to mothers from the control areas. Despite the better performance of mothers visited by the Pastorate of the Child volunteers, maternal knowledge on child survival in both groups was less than desirable. This hinders the identification of more serious cases, delays seeking medical care, and reduces the impact on child morbidity and mortality.

[Utilization of fully Bayesian modeling to detect patterns in relative risk variation for infant mortality in Rio Grande do Sul State, Brazil]

The infant mortality rate is one of the key indicators used to measure a population's quality of life. The State of Rio Grande do Sul has a social and economic indicator called the Socioeconomic Development Index (IDESE). Most studies analyze the infant mortality rate in relation to risk factors, visually aided by maps. This study presents the methodology and an application of a Spatial Epidemiology method called the ecological correlation, using hierarchical Bayesian procedures. The article discusses the main problems found in ecological correlations, such as spatial autocorrelation and the estimator's instability for small areas. To overcome these difficulties, the relative risk estimate obtained by spatial regression analysis using fully Bayesian estimation is presented. The infant mortality rate is analyzed in all 496 municipalities of Rio Grande do Sul for the years 2001 to 2004. Several models with spatial component and different variables from the IDESE/2003 were compared. The model using spatial structure along with the variable 'education' was considered the best choice. With this methodology, it was possible to obtain a more interpretable pattern of infant mortality risk in Rio Grande do Sul.

Periodontal therapy for pregnant women and cases of low birthweight: an intervention study

BACKGROUND

Over the past decade, strong evidence for an association between maternal periodontitis and low birthweight has started to appear. However, few intervention studies have been proposed for investigating this hypothesis. The aim of this study was to evaluate whether periodontal therapy among pregnant women would reduce the incidence of low birthweight.

METHODS

A nonrandomized intervention study was performed, with two control groups. The sample comprised 339 pregnant women: 141 in the experimental group (treated for periodontitis), 145 in control group 1 (without periodontitis) and 53 in control group 2 (with untreated periodontitis). The experimental group received periodontal treatment throughout pregnancy, whereas control group 1 was only monitored over the same period. After delivery, birthweight information on the newborns was obtained. The analysis procedures consisted of stratified analysis followed by logistic regression.

RESULTS

The frequency of low birthweight among the women with treated periodontitis was 9.22%, while it was 13.10% in the group without periodontal disease. However, the difference was not statistically significant (RR 0.72; 95% CI 0.36-1.45). The occurrence of this outcome in the group with untreated periodontitis (24.53%) was greater than in the other two groups.

CONCLUSION

This suggests that periodontal therapy is a protective factor for birthweight.

Determinants of preterm birth: Pelotas, Rio Grande do Sul State, Brazil, 2004 birth cohort

Prematurity is a leading cause of neonatal mortality and a global health problem that affects high, middle and low-income countries. Several factors may increase the risk of preterm birth. In this article, we test the hypothesis that different risk factors determine preterm birth in different income groups by investigating whether risk factors for preterm deliveries in the 2004 Pelotas (Rio Grande do Sul State, Brazil) birth cohort vary among those groups. A total of 4,142 women were included in the analysis. Preterm births were equally common among women who had spontaneous vaginal deliveries as for those with induced or operative births. In the multivariate analysis the factors that remained significantly associated with preterm birth were black skin color, low education, poverty, young maternal age, primiparity, previous preterm birth, inadequacy of prenatal care and reported hypertension. In the analyses repeated after stratification by family income terciles, there was no evidence of effect modification by income and no clear difference between the socioeconomic groups. No association between cesarean section and preterm delivery was found. Further studies are required to understand the causes of the epidemic of preterm births in Brazil.

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007

OBJECTIVE

To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past.

METHODS

The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34,409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively.

FINDINGS

Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators.

CONCLUSION

In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

SECULAR TREND OF VERY LOW BIRTH WEIGHT RATE IN PORTO ALEGRE, SOUTHERN BRAZIL

The strong association of very low birth weight (VLBW; <1500 g) with infant mortality is well known. There are no data related to VLBW trends in Brazil although findings from some large surveys carried out in small- and medium-sized cities have demonstrated an increase in low birth weight (LBW; <2500 g) rates over the last 30 years. The aim of this study was to evaluate the secular trend of VLBW in the city of Porto Alegre, a large city in a developed area in southern Brazil, and the potential determinants of this trend during the 1990s and early 2000s. This is a registry-based study. Data were obtained from birth certificates of all live births in the city from 1994 to 2005. The variables analysed were: VLBW as the dependent variable and maternal age and schooling, type of delivery, type of hospital, number of live births, gestational age, newborn gender and unemployment rate. The incidence ratio rate (IRR) using Poisson regression was calculated to identify possible trends in VLBW rates. Poisson regressions were performed in order to assess the influence of some independent variables on VLBW. A total of 257,740 singleton newborns were delivered in the city during the period, with a steady reduction in the total number of live births per year from 23,296 in 1994 to 18,325 in 2005. The results showed a small but significant increase in VLBW (p for trend=0.049). There was a significant trend towards adequacy for gestational age per birth weight, suggesting a reduction in rates of intrauterine growth restriction (IUGR) (p<0.001). The findings showed a significant increase of 1% per year in the probability of VLBW. The main risk factors were related to VLBW mothers with low levels of schooling, public hospitals and multiparity and nulliparity. After adjustment, nulliparity remained as a significant risk factor. The interaction between type of hospital and type of delivery indicated that the probability for VLBW was 3.6 times higher (p<0.001) among those born in public hospitals by Caesarean section than those born in private hospitals by vaginal delivery. The results show that southern Brazil is going through a demographic transition characterized by a significant decrease in number of live births associated with a small increase in VLBW rates, a decrease in IUGR rates and stabilization of LBW.

Avaliação da qualidade da informação do Sistema de Informação Perinatal (SIP-CLAP /OPAS) para monitoramento da assistência perinatal hospitalar, Belo Horizonte, 2004

OBJETIVO: avaliar a qualidade da informação do SIP-CLAP/OPAS em maternidades de Belo Horizonte. MÉTODOS: para avaliação da completude foi analisada amostra aleatória sistemática de 562 formulários SIP e prontuários médicos correspondentes, coletados durante a assistência em duas maternidades, em 2004. Uma subamostra de 20% foi utilizada para avaliação da confiabilidade do banco de dados eletrônico do programa. Foram calculadas proporções de completude antes e após resgate da informação disponível em prontuário, e o índice Kappa e o coeficiente de correlação intraclasse (ICC), com nível de significância de 5%, para análise da concordância. RESULTADOS: a completude de variáveis do SIP durante a assistência foi em média 72% no Hospital 1 e 86% no Hospital 2. O ganho médio percentual após busca da informação em prontuários foi de 18% e 7%, respectivamente. Foram observados índices muito bons de concordância nos dois hospitais. CONCLUSÕES: o SIP-CLAP representa uma alternativa para monitoramento da assistência hospitalar perinatal, mas apresenta problemas para sua utilização adequada, pois a completude avaliada durante a assistência não foi satisfatória. São necessários investimentos para o aprimoramento do programa nos hospitais, fundamentais para obtenção de indicadores essenciais para a qualificação da assistência hospitalar ao parto e nascimento.

Increase in preterm births in Brazil: review of population-based studies

OBJECTIVE

The greatest cause of infant mortality in Brazil is perinatal conditions, mostly associated with preterm delivery. The objective of the study was to evaluate the evolution of preterm delivery rates in Brazil.

METHODS

A review was conducted using the Medline and Lilacs databases, including published studies in periodicals, thesis and dissertations since 1950. Exclusion criteria were: studies related to clinical trials and those with complications at gestation and preterm delivery and care. Inclusion criteria were: population-based studies on prevalence of preterm delivery in Brazil, with representative sample of the studied population, and using primary data. Out of 71 studies found, analysis was carried out on 12.

RESULTS

The prevalence of preterm delivery found ranged from 3.4% to 15.0% in the Southern and Southeastern regions between 1978 and 2004, with a rising trend from the 1990s onwards. Studies in the Northeastern region between 1984 and 1998 found prevalences of preterm delivery ranging from 3.8% to 10.2%, also with a rising trend.

CONCLUSIONS

Data from the national live birth information system do not corroborate these trends. Rather, they show differences between the preterm rates given by this system and the rates measured in the studies included in this review. Because of the important role of preterm birth in relation to infant mortality in Brazil, it is important to identify the cause of these increases and to plan interventions that can diminish their occurrence.

The use of maternal and child health services in three population-based cohorts in Southern Brazil, 1982-2004

This study aimed to describe indicators of health care assistance during antenatal care, delivery and in the first year of life in Pelotas, Rio Grande do Sul State, Brazil. In 1982, 1993, and 2004, all hospital newborns from the urban area of Pelotas were enrolled in a cohort study. In this period, the number of pregnant women that did not attend antenatal care fell from 4.9% to 1.9%; the mean number of appointments increased from 6.7 to 8.1; and the number of women who began antenatal care in the third trimester of pregnancy decreased from 14.8% to 7%; caesarean sections increased from 27.7% to 45.2% and the proportion of deliveries assisted by physicians increased from 61.2% to 89.2%. Improvements in immunization rates during the first year of life mainly occurred between 1982 and 1993, while the number of preventive medical appointments improved among those born in 2004. This increase in coverage was greater for low-income mothers and children, which may reflect the implementation of universal coverage in Brazil; however, coverage levels in 1982 were already high for wealthy mothers and children, reducing the scope for further gains.

Impact of the family health program on infant mortality in Brazilian municipalities

OBJECTIVES

We evaluated the effects of the Family Health Program (FHP), a strategy for reorganization of primary health care at a nationwide level in Brazil, on infant mortality at a municipality level.

METHODS

We collected data on FHP coverage and infant mortality rates for 771 of 5561 Brazilian municipalities from 1996 to 2004. We performed a multivariable regression analysis for panel data with a negative binomial response by using fixed-effects models that controlled for demographic, social, and economic variables.

RESULTS

We observed a statistically significant negative association between FHP coverage and infant mortality rate. After we controlled for potential confounders, the reduction in the infant mortality rate was 13.0%, 16.0%, and 22.0%, respectively for the 3 levels of FHP coverage. The effect of the FHP was greater in municipalities with a higher infant mortality rate and lower human development index at the beginning of the study period.

CONCLUSIONS

The FHP had an important effect on reducing the infant mortality rate in Brazilian municipalities from 1996 to 2004. The FHP may also contribute toward reducing health inequalities.

Diferentes estratégias de visita domiciliar e seus efeitos sobre a assistência pré-natal no extremo Sul do Brasil

Este estudo do tipo intervenção comunitária controlada unicega não randomizada teve por objetivo avaliar o impacto das visitas realizadas pelos agentes comunitários de saúde e líderes voluntários da Pastoral da Criança sobre o pré-natal de gestantes pobres em Rio Grande, Rio Grande do Sul, Brasil. Aplicaram-se questionários padronizados antes e depois do parto buscando conhecer suas características demográficas, reprodutivas, assistência recebida durante o pré-natal e nível sócio-econômico e condição de moradia. Estas gestantes foram divididas em três grupos, sendo dois grupos-intervenção e um controle. Dentre as 339 gestantes estudadas, 115 pertenciam ao grupo cuja intervenção foi realizada pelos agentes comunitários de saúde, 116 pelos líderes voluntários da pastoral e 108 pertenciam ao grupo controle. Gestantes visitadas pelos agentes comunitários iniciaram o pré-natal mais precocemente, realizaram maior número de consultas, exames clínicos e testes laboratoriais, foram mais comumente orientadas sobre amamentação e suplementadas com sulfato ferroso. A participação de familiares nas consultas de pré-natal foi maior entre gestantes visitadas pelos líderes voluntários. Visitas domiciliares podem melhorar a qualidade do pré-natal entre gestantes pobres e aumentar a participação de familiares, sobretudo do marido, na gestação.

Associated factors and consequences of late preterm births: results from the 2004 Pelotas birth cohort

Although neonatal and infant mortality rates have fallen in recent decades in Brazil, the prevalence of preterm deliveries has increased in certain regions, especially in the number of late preterm births. This study was planned to investigate: (1) maternal antenatal characteristics associated with late preterm births and (2) the consequences of late preterm birth on infant health in the neonatal period and until age 3 months. A population-based birth cohort was enrolled in Pelotas, Southern Brazil, in 2004. Mothers were interviewed and the gestational age of newborns was estimated through last menstrual period, ultrasound and Dubowitz's method. Preterm births between 34 and 36 completed weeks of gestational age were classified as late preterm births. Only singleton live births from mothers living in the urban area of Pelotas were investigated. Three months after birth, mothers were interviewed at home regarding breast feeding, morbidity and hospital admissions. All deaths occurring in the first year of life were recorded. A total of 447 newborns (10.8%) were late preterms. Associations were observed with maternal age <20 years (prevalence ratio [PR] 1.3 [95% CI 1.1, 1.6]), absence of antenatal care (PR 2.4 [1.4, 4.2]) or less than seven prenatal care visits, arterial hypertension (PR 1.3 [1.0, 1.5]), and preterm labour (PR 1.6 [1.3, 1.9]). Compared with term births, late preterm births showed increased risk of depression at birth (Relative risk [RR] 1.7 [1.3, 2.2]), perinatal morbidity (RR 2.8 [2.3, 3.5]), and absence of breast feeding in the first hours after birth (PR 0.9 [0.8, 0.9]). RRs for neonatal and infant mortality were, respectively, 5.1 [1.7, 14.9] and 2.1 [1.0, 4.6] times higher than that observed among term newborns. In conclusion, in our setting, the prevention of all preterm births must be a priority, regardless of whether early or late.

Assistência à gestação e ao parto: resultados de dois estudos transversais em áreas pobres das regiões Norte e Nordeste do Brasil

Em 2002 e 2005 realizou-se inquérito transversal em áreas pobres das regiões Norte e Nordeste do Brasil visando avaliar a assistência à gestação e ao parto entre mães de menores de cinco anos. Foram estudadas 1.528 e 1.529 crianças em 2002 e 2005, respectivamente. Neste período, a escolaridade média das mães aumentou em 1,5 anos, a renda familiar em R$ 100,00 e o fornecimento de água tratada passou de 23% para 41%; a realização de seis ou mais consultas de pré-natal aumentou de 42% para 52% e a imunização contra tétano neonatal de 54% para 77%; a avaliação da altura uterina de 54% para 77% enquanto a realização de teste para HIV e sífilis duplicou, passando de cerca de 8% para aproximadamente 16% e de ultra-sonografia de 44% para 64%. No entanto, a realização de exames ginecológicos caiu de 41% para 31% e as orientações sobre amamentação de 66% para 55%. Apesar de melhorias expressivas na maioria dos indicadores estudados, verifica-se que ainda estão abaixo das regiões mais desenvolvidas do país. Esforços devem ser feitos visando reduzir estes diferenciais.

Doenças diarréicas em menores de cinco anos no Estado de Pernambuco: prevalência e utilização de serviços de saúde

Objetivou-se, com um estudo transversal de base populacional de 2.074 crianças menores de cinco anos no Estado de Pernambuco (Região Metropolitana do Recife - RMR; Interior Urbano - IU; Interior Rural - IR), avaliar comparativamente a prevalência das diarréias, bem como suas implicações na produção de consultas ambulatoriais e internações hospitalares. Ademais, a pesquisa propõe-se a estabelecer uma linha de base para avaliar tendências temporais do problema. A amostra, de caráter probabilístico, foi distribuída em 18 municípios do Estado, sendo cinco na RMR e os demais nas zonas rurais e urbanas de 13 municípios do interior (Zona da Mata, Agreste e Sertão). A ocorrência mais elevada (22,7% nas últimas duas semanas) e a maior demanda de atendimentos ambulatoriais (8,6% nos últimos 03 meses) foram encontradas no IU, enquanto as internações hospitalares, (4,1% das crianças pesquisadas num retrospecto de 12 meses) predominavam no IR. No conjunto do Estado de Pernambuco, estimou-se que para cada cem casos de diarréia ocorreu uma taxa de 0,44 hospitalizações, com freqüências mais elevadas na RMR. Concluiu-se, tomando como referência os compromissos internacionais assumidos pelo Brasil junto às Nações Unidas (UNICEF 1990) para a década passada, que as diarréias ainda representavam um relevante problema de saúde coletiva em todo Estado de Pernambuco, bem como uma pesada carga de demandas sobre os serviços ambulatoriais e, secundariamente, como demandas hospitalares.

Principais causas de óbitos infantis pós-neonatais em Belo Horizonte, Minas Gerais, Brasil, 1996 a 2004

OBJETIVOS: analisar a evolução das principais causas de mortes infantis pós-neonatais em Belo Horizonte, Minas Gerais, Brasil, entre 1996 e 2004. MÉTODOS: as causas de morte foram agrupadas pelos capítulos e por lista condensada da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10ª revisão - (CID-10). As diarréias, pneumonias, desnutrição e septicemia foram analisadas como grupamento específico de causas evitáveis. Taxas e mortalidade proporcional por causa foram calculadas para períodos trienais. RESULTADOS: foram registrados 2010 óbitos pós-neonatais no período, com tendência decrescente. A taxa de mortalidade infantil passou de 26,6 para 13,3/1000 nascidos vivos (NV), e a pós-neonatal de 8,6 para 4,3/1000 NV de 1996 a 2004, com maior redução nas taxas por doenças respiratórias e doenças infecciosas. Apesar do decréscimo, o grupamento diarréia-pneumonia-desnutrição-septicemia ainda foi responsável por cerca de um quarto dos óbitos em 2002-2004. As malformações congênitas passaram a representar a principal causa de morte pós-neonatal no último triênio e, juntamente com as afecções perinatais, representaram 34% dos óbitos. Observou-se ainda aumento da proporção de óbitos por causas mal definidas e por causas externas. CONCLUSÕES: foram observadas mudanças importantes do perfil de causas de mortalidade pós-neonatal em Belo Horizonte, com aumento da participação das malformações congênitas e afecções perinatais. Esse aumento provavelmente se deveu ao deslocamento de óbitos neonatais para o período pós-neonatal.

[Representation of pregnant smokers on cigarette use: a study carried out at a hospital in the interior of the state of São Paulo]

This study sheds light on the smoking pregnant women's outlook on cigarette use. The Theory of Social Representations was used as a theoretical reference. For data analysis, the Collective Subject Discourse was constructed. Of the 27 women that were interviewed, 18 had finished elementary education, 8 had completed secondary education, and one had college level education; 14 had a stable union and 6 were married. Four themes emerged from the interviews: (1) starting to smoke: a natural, social practice; (2) satisfaction versus guilt; (3) shattering news: effects of smoking on pregnancy; and (4) quitting: between will and ability. Pregnant women revealed negative ideas about smoking, considering smoking the worst of addictions and a potential cause for complications to the fetus and the mother. Smoking was represented in a prejudicial manner, disregarding the existence of treatment and the need for it. Emerging difficulties were related to quitting, for which professionals, information and adequate approaches for treatment and support for achieving success are utmost necessities.

Mortalidade infantil evitável e fatores associados em Porto Alegre, Rio Grande do Sul, Brasil, 2000-2003

Foi realizado um estudo de casos e controles para investigar a associação entre as categorias óbitos evitáveis e não-evitáveis e as variáveis sócio-demográficas, reprodutivas maternas e relacionadas às condições de nascimento da criança. Foram analisados 1.139 casos de óbitos infantis, ocorridos entre 2000 e 2003, com o auxílio da regressão logística multivariada, segundo modelo hierarquizado. As variáveis sexo, idade materna, número de filhos nascidos vivos, tipo de gravidez, local de nascimento e Apgar no 5º minuto não se associaram aos óbitos evitáveis. No entanto, a escolaridade materna < 3 anos (RC = 1,56; IC95%: 1,01-2,45); mãe sem companheiro (RC = 0,65; IC95%: 0,49-0,86) ou com filhos nascidos mortos (RC = 1,59; IC95%: 1,01-2,48); ter malformação congênita (RC = 0,26; IC95%: 0,18-0,37); cesariana (RC = 1,52; IC95%: 1,10-2,11); idade gestacional entre 22 e 36 semanas (RC = 0,47; IC95%: 0,34-0,65); peso inferior a 2.500g (RC = 0,51; IC95%: 0,32-0,79) e ter menos de seis dias de vida (RC = 0,62; IC95%: 0,42-0,89) apresentaram associação significativa com os óbitos evitáveis. Esses achados podem contribuir na identificação de crianças em situação de maior vulnerabilidade.

Reflexos das políticas de saúde sobre as tendências da mortalidade infantil no Brasil: revisão da literatura sobre a última década

A mortalidade infantil tem sido considerada um bom indicador das condições de vida. É simples de ser calculada e reflete o estado de saúde da parcela mais vulnerável da população: os menores de um ano. A divulgação de dados oficiais que estimaram uma queda de 31% no indicador pareceu surpreendente num contexto de deterioração dos níveis de crescimento econômico, renda e trabalho e do aumento da taxa de desemprego. Entretanto, a década foi marcada por decisões políticas importantes, especialmente a implantação da Estratégia de Saúde da Família e dos incentivos da NOB-96. Este estudo objetivou avaliar como a literatura nacional analisou o comportamento da mortalidade infantil na década e sua possível associação com as mudanças na organização e financiamento do SUS. Foi realizada uma revisão sistemática de artigos científicos publicados entre 1998 e 2006. Concluiu-se que os estudos produzidos até o momento não possibilitam avaliar com clareza o possível impacto das alterações produzidas na organização e financiamento do SUS. Ficou evidente a necessidade de monitoramento do indicador e a importância dos estudos locais, especialmente nos municípios com informações incipientes.

Gravidez de alto risco: o desejo e a programação de uma gestação

OBJETIVOS: Considerando a importância das pesquisas em saúde reprodutiva, realizamos este estudo qualitativo com o objetivo de verificar o acontecimento da gestação, a programação e o desejo de ter um filho entre mulheres que vivenciam uma gestação de alto risco em um serviço de pré-natal de referência. MÉTODOS: Optamos pelo método da pesquisa qualitativa de caráter exploratório descritivo. Utilizamos a abordagem metodológica do Discurso do Sujeito Coletivo para organizar os dados verbais obtidos em entrevista semi estruturada, realizada com 12 gestantes. RESULTADOS: As idéias centrais identificadas foram: "Gestação não programada, mas desejada, associada a não utilização ou uso incorreto de método contraceptivo"; "Gestação não programada, mas desejada, associada à questão da crença religiosa"; "Gestação programada e desejada" e "Gestação não programada e não desejada". CONCLUSÃO: Diante das idéias centrais identificadas a carência de educação em saúde, em especial com relação à saúde reprodutiva, foi evidenciada.

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.

[Obstetric delivery and risk of neonatal mortality in Goiânia in 2000, Brazil]

OBJECTIVE

To determine factors associated to vaginal delivery and increased neonatal mortality in cohort studies of newborns.

METHODS

A retrospective cohort study was carried out using linkage data from the Information System on Live Births and Mortality Data System database, which included all newborns in Goiânia for the year 2000. A stratified analysis of delivery routes and maternity hospitals by risk factors of neonatal mortality was conducted through the calculation of relative risk at a 5% significance level. Statistical analyses were carried out using the Chi-square test at a 5% significance level.

RESULTS

Vaginal deliveries were more commonly seen than cesarean sections in situations where there was an increased risk of neonatal mortality. Public hospitals, where vaginal deliveries predominated, were sought by the majority of those pregnant women with an increased risk of neonatal mortality. Private hospitals, not affiliated to the public-funded Brazilian Healthcare System (SUS) and where the incidence of cesarean section was as high as 84.9%, opted for vaginal delivery in situations of greater risk, such as extreme prematurity and very-low-birth-weight infants.

CONCLUSIONS

The association between vaginal delivery and increase neonatal mortality resulted from a selection bias due to the distribution of pregnant women in the hospital network. In addition, this selection bias also resulted from an almost universal preference for cesarean sections in low-risk pregnancies as opposed to vaginal delivery for pregnancies with an increased risk of neonatal mortality.