Skin color/race as a factor associated with maternal and perinatal morbidity and mortality

Orientador: José Guilherme CecattiTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: Classificar/discriminar a raça ou a origem étnica de um indivíduo pode muitas vezes auxiliar o médico no diagnóstico e tratamento do mesmo. O verdadeiro significado de raça, cor da pele e etnia é complexo. De qualquer forma, nascer, viver, adoecer e morrer são experiências sabidamente desiguais entre brancos, negros e indígenas. Isso seria também aplicável ao processo de gestação e nascimento entre mulheres de diferentes raças/cor de pele e poderia determinar diferenciais na ocorrência de morbidade e mortalidade materna. A identificação precoce e o tratamento adequado das complicações obstétricas são os responsáveis pela queda na morbidade e mortalidade materna. Objetivos: Avaliar a cor da pele materna como um fator associado a eventos de Near Miss Materno (NMM) na Pesquisa Nacional de Demografia e Saúde (PNDS); descrever NMM entre mulheres de diferentes origens raciais que participaram do estudo Chamada Neonatal (CN); e avaliar a associação de complicações maternas graves com a cor da pele materna, e os respectivos resultados perinatais, no estudo da Rede Brasileira de Vigilância de Morbidade Materna Grave (RBVMMG). Métodos: foi realizada uma análise secundária de três estudos já realizados, abordando a cor da pele/raça materna, como fator associado à morbimortalidade materna e perinatal. A primeira análise consiste na avaliação da associação entre cor da pele e Near Miss materno na PNDS. A segunda análise foi a avaliação da associação entre diferenças raciais e a ocorrência de Near Miss materno nas regiões Amazônica e Nordeste do Brasil, no estudo Chamada Neonatal. E a terceira análise consiste na avaliação da ocorrência de desfecho materno grave (near miss materno + morte materna) nos diferentes grupos de mulheres determinados pela cor da pele, no estudo da RBVMMG. Resultados: No PNDS 5.025 mulheres constituíram a população avaliada, 59% das mulheres eram negras ou pardas, cerca de 23% destas tiveram alguma complicação, e 2% tinham pelo menos um critério pragmático de NMM; a razão de NMM foi de 31 por 1.000 nascidos vivos, e sua ocorrência não foi estatisticamente diferente entre os grupos de cor da pele. A ocorrência de NMM esteve associada à maior idade e menor escolaridade maternas. No estudo da CN 16.783 mulheres foram entrevistadas, aproximadamente 76% dessas eram negras, 6% relataram alguma complicação relacionada à gravidez, e a razão NMM foi maior entre as indígenas (53,1/1000NV) e negras (28,4) do que entre as brancas (25,7). A ocorrência de NMM esteve associado ao menor número de consultas de pré-natal, à cesariana, à primeira gestação e ao maior tempo para se chegar ao hospital. No estudo da RBVMMG, foram avaliadas 7.139 mulheres, 57,1% dessas eram negras e 42,8% eram brancas, a razão de mortalidade foi de 1 para cada 5,2 casos de Near Miss materno, independente da cor da pele materna. A ocorrência de desfecho materno grave (DMG) foi maior entre o grupo de mulheres brancas. Conclusão: os três estudos mostraram diferentes resultados da associação entre cor de pele/raça com a ocorrência de morbidade materna grave. É possível que esses resultados discordantes possam ser devidos a uma importante miscigenação na população brasileira, como também influência de diversos fatores sociais, econômicos e de acesso das mulheres aos serviços de saúde modulados pela cor da pele/raça das mulheresAbstract: Introduction: Classifying / discriminating the race or ethnic origin of an individual can often assist the physician in its diagnosis and treatment. The true meaning of race, skin color and ethnicity is complex. Anyway, being born, living, falling ill and dying are known unequal experiences among whites, blacks and indigenous. This could also be applicable to the processes of pregnancy and childbirth among women of different races/skin colors and could determine differentials in the occurrence of maternal morbidity and mortality. The early identification and adequate treatment of obstetric complications are responsible for the decrease in maternal morbidity and mortality. Objectives: To evaluate maternal skin color as a factor associated with maternal Near Miss (MNM) events in the Brazilian National Demographic and Health Survey (DHS); to describe MNM among women of different racial backgrounds, who participated in the Neonatal Call (NC) study; and to evaluate the association of severe maternal complications with maternal skin color, and the respective perinatal results, in the study of the Brazilian Network for Surveillance of Severe Maternal Morbidity. Methods: a secondary analysis of three already implemented studies was performed addressing maternal skin color/race as a factor associated with maternal and perinatal morbidity and mortality. The first analysis consists of the evaluation of the association of skin color and MNM in the DHS. The second analysis was the evaluation of the association between racial differences and the occurrence of MNM in the Amazonian and Northeast regions of Brazil, in the study NC. And the third analysis consists of evaluating the occurrence of severe maternal outcome (maternal near miss + maternal death) in the different group of women determined by skin color in the study of the Network. Results: In DHS 5,025 women constituted the population evaluated, 59% of them were black or mixed, about 23% of them had complications, and 2% had at least one pragmatic MNM criterion; the MNM rate was 31 per 1,000 live births, and its occurrence was not statistically different between ethnic of skin color. The occurrence of MNM was associated to the higher maternal age and lower schooling. In the NC study 16,783 women were interviewed, approximately 76% of these were black women, 6% reported any complication related to pregnancy, and the MNM ratio was higher among indigenous (53.1/1000LB) and black women (28.4) than in white women (25.7). The occurrence of MNM was associated to the low number of prenatal visits, to C-section, primigravity and to the longer time to reach the hospital. In the Network study, 7,139 women were evaluated, 57.1% were black and 42.8% were white, the mortality index was 1 for every 5.2 cases of MNM, regardless of maternal skin color. The occurrence of severe maternal outcome (SMO) was higher among the group of white women. Conclusion: The three studies showed different results regarding the association between skin color/race and the occurrence of severe maternal morbidity. It is possible that these discordant results may be due to an important miscegenation in the Brazilian population and also to several social, economic and access to health services factors, that are modulated by the skin color/race of womenDoutoradoSaúde Materna e PerinatalDoutora em Ciências da SaúdeCAPE

The food patterns of a multicenter cohort of Brazilian nulliparous pregnant women

Assessment of human nutrition is a complex process, in pregnant women identify dietary patterns through mean nutrient consumption can be an opportunity to better educate women on how to improve their overall health through better eating. This exploratory study aimed to identify a posteriori dietary patterns in a cohort of nulliparous pregnant women. The principal component analysis (PCA) technique was performed, with Varimax orthogonal rotation of data extracted from the 24-h dietary recall, applied at 20 weeks of gestation. We analysed 1.145 dietary recalls, identifying five main components that explained 81% of the dietary pattern of the sample. Dietary patterns found were: Obesogenic, represented by ultra-processed foods, processed foods, and food groups rich in carbohydrates, fats and sugars; Traditional, most influenced by natural, minimally processed foods, groups of animal proteins and beans; Intermediate was similar to the obesogenic, although there were lower loads; Vegetarian, which was the only good representation of fruits, vegetables and dairy products; and Protein, which best represented the groups of proteins (animal and vegetable). The obesogenic and intermediate patterns represented over 37% of the variation in food consumption highlighting the opportunity to improve maternal health especially for women at first mothering

Proposal of MUAC as a fast tool to monitor pregnancy nutritional status : results from a cohort study in Brazil

Objective: In Brazil, although the assessment of maternal nutritional status is recommended using body mass index (BMI), this is only possible in settings adequately prepared. Midupper arm circumference (MUAC) is another biological variable identified as a tool for rapid assessment of nutritional status that is correlated with BMI. Therefore, we aim to surrogate BMI by MUAC cut-offs for rapid screening of maternal nutritional status starting at midpregnancy. Design: Analysis of the multicentre cohort study entitled ‘Preterm SAMBA’ using an approach of validation of diagnostic test. Setting: Outpatient prenatal care clinics from five tertiary maternity hospitals from three different Brazilian regions. Participants: 1165 pregnant women attending prenatal care services from 2015 to 2018 and with diverse ethnic characteristics who were enrolled at midpregnancy and followed in three visits at different gestational weeks. Primary and secondary outcome measures: Sensitivity, specificity, positive and negative predictive values, likelihood ratio and accuracy of MUAC being used instead of BMI for the assessment of nutritional status of women during pregnancy. Results: We found a strong correlation between MUAC and BMI, in the three set points analysed (r=0.872, 0.870 and 0.831, respectively). Based on BMI categories of nutritional status, we estimated the best MUAC cut-off points, finding measures according to each category: underweight 30.15 cm (19–21 weeks), >30.60 cm (27–29 weeks) and >30.25 cm (37–39 weeks) per gestational week. Therefore, we defined as adequate between 25.75–28.10 cm (19–21 weeks), 25.75–28.70 cm (27–29 weeks) and 25.75–29.45 cm (37–39 weeks) of MUAC. Conclusion: We conclude that MUAC can be useful as a surrogate for BMI as a faster screening of nutritional status in pregnant women

Head circumference as an epigenetic risk factor for maternal nutrition

Nutrition indicators for malnutrition can be screened by many signs such as stunting, underweight or obesity, muscle wasting, and low caloric and nutrients intake. Those deficiencies are also associated with low socioeconomic status. Anthropometry can assess nutritional status by maternal weight measurements during pregnancy. However, most studies have focused primarily on identifying changes in weight or Body Mass Index (BMI), and their effects on neonatal measures at present time. Whereas head circumference (HC) has been associated with nutrition in the past. When the mother was exposed to poor nutrition and unfavorable social conditions during fetal life, it was hypothesized that the intergenerational cycle was potentially mediated by epigenetic mechanisms. To investigate this theory, maternal head circumference (MHC) was associated with neonatal head circumference (NHC) in pregnant women without preexisting chronic conditions, differentiated by sociodemographic characteristics. A multiple linear regression model showed that each 1 cm-increase in MHC correlated with a 0.11 cm increase in NHC (β95% CI 0.07 to 0.15). Notwithstanding, associations between maternal and neonatal anthropometrics according to gestational age at birth have been extensively explained. Path analysis showed the influence of social status and the latent variable was socioeconomic status. A model of maternal height and head circumference was tested with effects on neonatal HC. The social variable lacked significance to predict neonatal HC in the total sample (p = 0.212) and in the South/Southeast (p = 0.095), in contrast to the Northeast (p = 0.047). This study highlights the potential intergenerational influence of maternal nutrition on HC, suggesting that maternal nutrition may be more relevant in families with major social vulnerability

Pessary plus progesterone to prevent preterm birth in women with short cervixes. A randomized controlled trial

OBJECTIVE: To test the effectiveness of cervical pessary in addition to vaginal progesterone for the prevention of preterm birth in women with midpregnancy short cervixes. METHODS: We performed a multicenter, open-label, randomized controlled trial in 17 perinatal centers. Asymptomatic women with singleton or twin pregnancies and cervical lengths of 30 mm or less, measured at 18 0/7– 22 6/7 weeks of gestation, were randomized to cervical pessary plus vaginal progesterone (pessary plus progesterone group) or vaginal progesterone only (progesteroneonly group) (200 mg/day). Treatments were used from randomization to 36 weeks of gestation or delivery. The primary outcome was a composite of neonatal mortality and morbidity. Secondary outcomes were delivery before 37 weeks and before 34 weeks of gestation. Analysis was performed according to intention to treat. RESULTS: Between July 9, 2015, and March 29, 2019, 8,168 women were screened, of whom 475 were randomized to pessary and 461 to progesterone only. The composite perinatal outcome occurred in 19.2% (89/463) of the women in the pessary group compared with 20.9% (91/436) of the women in the progesterone-only group (adjusted risk ratio [aRR] 0.88, 95% CI 0.69–1.12). Delivery rates before 37 weeks of gestation were 29.1% compared with 31.4% (aRR 0.86, 95% CI 0.72–1.04); delivery rates before 34 weeks were 9.9% compared with 13.9% (aRR 0.66, 95% CI 0.47–0.93). Women in the pessary group had more vaginal discharge (51.6% [245/476] vs 25.4% [117/479] [P,.001]), pain (33.1% [157/476] vs 24.1% [111/479] [P5.002]), and vaginal bleeding (9.7% [46/476] vs 4.8% [22/479] [P5.004]). CONCLUSION: In asymptomatic women with short cervixes, the combination of pessary and progesterone did not decrease rates of neonatal morbidity or mortality when compared with progesterone only.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Bill & Melinda Gates Foundation [OPP1107597], the Brazilian Ministry of Health, and the Brazilian National Council for Scientific and Technological Development (CNPq) [401615/20138]

A randomized controlled trial on the use of pessary plus progesterone to prevent preterm birth in women with short cervical length (P5 trial)

Background: Preterm birth is the leading cause of mortality and disability in newborn and infants. Having a short cervix increases the risk of preterm birth, which can be accessed by a transvaginal ultrasound scan during the second trimester. In women with a short cervix, vaginal progesterone and pessary can both reduce this risk, which progesterone more established than cervical pessary. The aim of this study is to compare the use of vaginal progesterone alone versus the association of progesterone plus pessary to prevent preterm birth in women with a short cervix. Methods: This is a pragmatic open-label randomized controlled trial that will take place in 17 health facilities in Brazil. Pregnant women will be screened for a short cervix with a transvaginal ultrasound between 18 0/7 until 22 6/7 weeks of gestational age. Women with a cervical length below or equal to 30mm will be randomized to the combination of progesterone (200 mg) and pessary or progesterone (200 mg) alone until 36 + 0 weeks. The primary outcome will be a composite of neonatal adverse events, to be collected at 10 weeks after birth. The analysis will be by intention to treat. The sample size is 936 women, and a prespecified subgroup analysis is planned for cervical length (= 25 mm). Categorical variables will be expressed as a percentage and continuous variables as mean with standard deviation. Time to delivery will be assessed with Kaplan-Meier analysis and Cox proportional hazard analysis. Discussion: In clinical practice, the combination of progesterone and pessary is common however, few studies have studied this association. The combination of treatment might act in both the biochemical and mechanical routes related to the onset of preterm birth. Trial registration: Brazilian Clinical Trial Registry (ReBec) RBR-3t8prz, UTN: U1111–1164-2636, 2014/11/18.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Bill & Melinda Gates Foundation [OPP1107597], the Brazilian Ministry of Health, and the Brazilian National Council for Scientific and Technological Development (CNPq) [401615/20138]