Social inequality and perinatal health: comparison of three Brazilian cohorts

The objective of the present study was to estimate and compare social inequality in terms of three indicators, i.e., low birth weight (LBW), preterm birth (PTB) and small for gestational age (SGA) birth, in three birth cohorts. Two cohorts were from the city of Ribeirão Preto, where data were collected for all 6748 live born singletons in 1978/79 and for one third of live born singletons (2846) in 1994. The third cohort consisted of 2443 singletons born in São Luís over a period of one year (1997/98). In Ribeirão Preto, LBW and PTB rates increased in all social strata from 1978/79 to 1994. Social inequalities regarding LBW and PTB disappeared since the increase in these rates was more accelerated in the groups with higher educational level. The percentage of SGA infants increased over the study period. Social inequality regarding SGA birth increased due to a more intense increase in SGA births in the strata with lower schooling. In São Luís, in 1997/98 there was no social inequality in LBW or PTB rates, whereas SGA birth rate was higher in mothers with less schooling. We speculate that the more accelerated increase in medical intervention, especially due to the increase in cesarean sections in the more privileged groups, could be the main factor explaining the unexpected increase in LBW and PTB rates in Ribeirão Preto and the decrease or disappearance of social inequality regarding these perinatal indicators in the two cities

Why are the rates of cesarean section in Brazil higher in more developed cities than in less developed ones?

The objective of the present study was to investigate factors associated with cesarean sections in two cities located in different regions of Brazil and to determine factors that explain the higher cesarean section rate in the more developed city, Ribeirão Preto, compared to the less developed one, São Luís. Data from two cohort studies comprising 2846 women in Ribeirão Preto in 1994, and 2443 women in São Luís in 1997/1998 were used. Adjusted and non-adjusted risk estimates were calculated using a Poisson regression model. The cesarean section rate was 33.7% in São Luís and 50.8% in Ribeirão Preto. Adjusted analysis in a joint sequential model revealed a 51% higher risk of cesarean section in Ribeirão Preto compared to São Luís (prevalence rate ratio (PRR) = 1.51). Adjustment for category of hospital admission reduced the PRR to 1.09, i.e., this variable explained 82% of the difference in the cesarean section rate between the two cities. Adjustment for the variable "the same physician for prenatal care and delivery" reduced the PRR to 1.07, with the "physician" factor explaining 86% of the difference between rates. When simultaneously adjusted for the two variables, the PRR decreased to 1.05, with these two variables explaining 90% of the difference in the cesarean section rate between the two cities, and the difference was no longer significant. The difference in the cesarean section rate between the two Brazilian cities, one more and one less developed, was mainly explained by the physician factor and, to a lesser extent, by the category of hospital admission

Evaluation Of The Neonatal Outcomes Of The Kangaroo Mother Method In Brazil [avaliação Dos Resultados Neonatais Do Método Canguru No Brasil]

Objective: To evaluate the results of the kangaroo mother method in Brazil. Methods: A prospective cohort study comparing 16 units that have or do not have the second phase of the kangaroo mother method: eight were national centers of excellence for the kangaroo mother method (study group) and eight were part of the Brazilian Neonatal Research Network (control group). A total of 985 newborn infants with birth weights of 500 to 1,749 g were enrolled. Multivariate analyses employedmultiple linear regression and Poisson regression with robust adjustment. Results: The adjusted analysis (controlled for birth weight, gestational age, Score for Neonatal Acute Physiology Perinatal Extension II, Neonatal Therapeutic Intervention Scoring System, and maternal age and educational level) demonstrated that mean length of hospital stay (p = 0.14) and intercurrent clinical conditions in the intermediate or kangaroo unit were equal for both groups. Weight (p = 0.012), length (p = 0.039) and head circumference (p = 0.006) at 36 weeks' corrected gestational age were all lower at the kangaroo units. The kangaroo units exhibited superior performance in relation to exclusive breastfeeding at discharge (69.2 vs. 23.8%, p=0.022). Conclusions: The evidence suggests that the humanization strategy adopted by the Brazilian Ministry of Health is a safe alternative to conventional treatment and a good strategy for promoting breastfeeding. Copyright © 2008 by Sociedade Brasileira de Pediatria.845428435Mathelin, C., (1999) Osorriso da Gioconda: Clínica psicanalí ticacombebês prematuros, , Rio de Janeiro: Companhia de Freud;Lamy, Z.C., (2000) Unidade neonatal: Um espaço de conflitos e negociações [Tese], , Rio de Janeiro, RJ: Fundação Oswaldo Cruz;Walsh-Sukys M, Reitenbach A, Hudson-Barr D, DePompei P. Reducing light and sound in the neonatal intensive care unit: an evaluation of patient safety, staff satisfaction, and costs. J Perinatol. 2001;21:230-5. Erratum in: J Perinatol. 2001;21:572Martín Ancel, A., Iriondo Sanz, M., Fina Martí, A., Roqués Serradilla, V., García Del Río, M., López Sastre, J.B., On recommendations, protocols, and clinical guidelines (2001) An Esp Pediatr, 55, pp. 99-100Brasil. Ministério da Saúde. Norma da atenção humanizada ao recém-nascido de baixo peso - Método Canguru. Brasília, DF: MS1999Brasil. Ministério da Saúde. Norma da atenção humanizada ao recém-nascido de baixo peso - Método Canguru. Brasília, DF: MS2000Rey, E., Martínez, H., Manejo racional del niño prematuro (1983) Bogotá, (Colombia): Universidad NacionalCurso de Medicina FetalAnderson GC, Marks EA, Wahlberg V. Kangaroo care for premature infants. AmJ Nurs. 1986;86:807-9. Erratum in: Am J Nurs. 1986;86:1000Anderson, G.C., Current knowledge about skin-to-skin (kangaroo) care for preterm infants (1991) J Perinatol, 11, pp. 216-226Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Mãe canguru para reduzir morbidade e mortalidade em recém-nascidos com baixo peso ao nascer (Cochrane Review). In: Resumos de Revisões Sistemáticas em Português, Issue 2, 2007. Oxford: Update SoftwareFeldman, R., Weller, A., Sirota, L., Eidelman, A.I., Skin-to-Skin contact (Kangaroo care) promotes self-regulation in premature infants: Sleep-wake cyclicity, arousal modulation, and sustained exploration (2002) Dev Psychol, 38, pp. 194-207Kirsten, G.F., Bergman, N.J., Hann, K.M., Kangaroo mother care in the nursery (2001) Pediatr Clin North Am, 48, pp. 443-452Ramanathan, K., Paul, V.K., Deorari, A., Taneja, U., George, G., Kangaroo Mother Care in very low birth weight infants (2001) Indian J Pediatr, 68, pp. 1019-1023Ludington-Hoe, S.M., Johnson, M.W., Morgan, K., Lewis, T., Gutman, J., Wilson, P.D., Neurophysiologic assessment of neonatal sleep organization: Preliminary results of a randomized, controlled trial of skin contact with preterm infants (2006) Pediatrics, 117, pp. e909-e923Gray, L., Watt, L., Blass, E.M., Skin-to-skin contact is analgesic in healthy newborns (2000) Pediatrics, 105, pp. e14Charpak, N., Ruiz-Pelaez, J.G., Figueroa de, C.Z., Charpak, Y., A randomized, controlled trial of kangaroo mother care: Results of follow-up at 1 year of corrected age (2001) Pediatrics, 108, pp. 1072-1079Penalva, O., Schwartzman, J.S., Descriptive study of the clinical and nutritional profile and follow-up of premature babies in a Kangaroo Mother Care Program (2006) J Pediatr (Rio J), 82, pp. 33-39Charpak, N., Ruiz-Pelaez, J.G., Figueroa de, C.Z., Charpak, Y., Kangaroo mother versus traditional care for newborn infants >/= 2,000 grams: A randomized, controlled trial (1997) Pediatrics, 100, pp. 682-688Ruiz-Peláez, J.G., Charpak, N., Cuervo, L.G., Kangaroo Mother Care, an example to follow from developing countries (2004) BMJ, 329, pp. 1179-1181Venancio, S.I., Almeida, H., Método Mãe Canguru: Aplicação no Brasil, evidências científicas e impacto sobre o aleitamento materno. (2004) J Pediatr (Rio J), 80, pp. S173-S180Richardson, D.K., Corcoran, J.D., Escobar, G.J., Lee, S.K., SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores (2001) J Pediatr, 138, pp. 92-100Gray, J.E., Richardson, D.K., McCormick, M.C., Workman-Daniels, K., Goldmann, D.A., Neonatal therapeutic intervention scoring system: A therapy-based severity-of-illness index (1992) Pediatrics, 90, pp. 561-567Barros, A.J., Hirakata, V.N., Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio (2003) BMC Med Res Methodol, 3, p. 21Roberts, K.L., Paynter, C., McEwan, B., A comparison of kangaroo mother care and conventional cuddling care (2000) Neonatal Netw, 19, pp. 31-35Cattaneo, A., Davanzo, R., Worku, B., Surjono, A., Echeverria, M., Bedri, A., Kangaroo mother care for low birth weight infants: A randomised controlled trial in different settings (1998) Acta Paediatr, 87, pp. 976-985Kadam, S., Binoy, S., Kanbur, W., Mondkar, J.A., Fernandez, A., Feasibility of kangaroo mother care in Mumbai (2005) Indian J Pediatr, 72, pp. 35-38Sloan, N.L., LeonCamacho, L.W., PintoRojas, E., Stern, C., Maternidad IsidroAyora Study Team. Kangaroo mother method: Randomised controlled trial of an alternative method of care for stabilised low-birthweight infants. Maternidad Isidro Ayora Study Team (1994) Lancet, 344, pp. 782-78