The current and future costs of colorectal cancer attributable to red and processed meat consumption in Brazil.

BACKGROUND: Compelling evidence supports the association between red and processed meat consumption and increased risk of colorectal cancer. Herein, we estimated the current (2018) and future (2030) federal direct healthcare costs of colorectal cancer in the Brazilian Unified Health System attributable to red and processed meat consumption. Considering reduced red and processed meat consumption, we also projected attributable costs of colorectal cancer in 2040. METHODS: We retrieved information on red and processed meat consumption from two nationally representative dietary surveys, the Household Budget Survey 2008-2009 and 2017-2018; relative risks for colorectal cancer from a meta-analysis; direct healthcare costs of inpatient and outpatient procedures in adults ≥ 30 years with colorectal cancer (C18-C20) from 2008-2019 by sex. RESULTS: Attributable costs of colorectal cancer were calculated via comparative risk assessment, assuming a 10-year lag. In 2018, US$ 20.6 million (8.4%) of direct healthcare costs of colorectal cancer were attributable to red and processed meat consumption. In 2030, attributable costs will increase to US$ 86.6 million (19.3%). Counterfactual scenarios of reducing red and processed meat consumption in 2030 suggested that US$ 2.2 to 11.9 million and US$ 13 to 74 million could be saved in 2040, respectively. CONCLUSION: Red and processed meat consumption has an escalating economic impact on the Brazilian Unified Health System. Our findings support interventions and policies focused on primary prevention and cancer.

Correction: Current and future costs of cancer attributable to insufficient leisure-time physical activity in Brazil.

[This corrects the article DOI: 10.1371/journal.pone.0287224.].

Current and future costs of cancer attributable to insufficient leisure-time physical activity in Brazil.

OBJECTIVES: Cancer is an increasing cause of death and disability in Brazil and a pivotal vector for growing health expenditures. Lower levels of leisure-time physical activity are associated with a higher risk of some cancers. We quantified the current and future cancer direct healthcare costs attributable to insufficient leisure-time physical activity in Brazil. METHODS: We performed a macrosimulation model using: (i) relative risks from meta-analyses; (ii) prevalence data of insufficient leisure-time physical activity in adults ≥ 20 years; (iii) national registries of healthcare costs of adults ≥ 30 years with cancer. We used simple linear regression to predict cancer costs as a function of time. We calculated the potential impact fraction (PIF) considering the theoretical-minimum-risk exposure and other counterfactual scenarios of physical activity prevalence. RESULTS: We projected that the costs of breast, endometrial, and colorectal cancers may increase from US$ 630 million in 2018 to US$ 1.1 billion in 2030 and US$ 1.5 billion in 2040. The costs of cancer attributable to insufficient leisure-time physical activity may increase from US$ 43 million in 2018 to US$ 64 million in 2030. Increasing leisure-time physical activity could potentially save US$ 3 million to US$ 8.9 million in 2040 by reducing the prevalence of insufficient leisure-time physical activity in 2030. CONCLUSION: Our results may be helpful to guide cancer prevention policies and programs in Brazil.

Agreement between maternal self-report of birth-related information and medical records in Brazil: A comparison study between public, mixed, and private hospitals.

BACKGROUND: The study aims to assess agreement between data obtained from interviews with postpartum women and their health records about labor and birth characteristics, newborn care, and reasons for cesarean birth. METHODS: The present study analyzes the Birth in Brazil study dataset, a nationwide hospital-based survey that included 23,894 postpartum women. Reliability was assessed using kappa coefficients and 95% confidence intervals. We also calculated the proportion of specific agreement: the observed proportion of positive agreement (Ppos) and the observed proportion of negative agreement (Pneg). RESULTS: In terms of labor and birth characteristics, more significant discrepancies in prevalence were observed for fundal pressure (1.4%-42.6%), followed by amniotomy, and augmentation. All of these variables were reported more frequently by women. Reliability was nearly perfect only for mode of delivery (kappa 0.99-1.00, Ppos and Pneg >99.0%). Higher discrepancies in reasons for cesarean prevalence were observed for previous cesarean birth (CB) (3.9%-10.4%) and diabetes mellitus (0.5%-8.5%). Most kappa coefficients for CB reasons were moderate to substantial. Lower coefficients were seen for diabetes mellitus, induction failure, and prelabor rupture of membranes and Pneg was consistently higher than Ppos. DISCUSSION: Our findings raise relevant questions about the quality of information shared with women during and after the process of care for labor and birth, as well as the information recorded in medical charts. Not having access to full information about their own health status at birth may impair women's health promotion behaviors or clear disclosure of risk factors in future interactions with the healthcare system.

Nutritional status at hospital admission and prediction of clinical outcomes in children and adolescents with cancer: Results of the Brazilian survey on oncological nutrition in paediatrics.

BACKGROUND: Changes in nutritional status are recognised as predictors of unfavourable outcomes in children and adolescents with cancer, particularly in developing countries. There have been no studies on children and adolescents with cancer from every region of Brazil or on the impact of nutritional status on clinical outcomes. The aim of this study is to assess the association between the nutritional status of children and adolescents with cancer and the prediction of clinical outcomes. METHODS: This was a longitudinal, multicentre, hospital-based study. An anthropometric nutritional assessment was performed, and the Subjective Global Nutritional Assessment (SGNA) was administered within 48 h of admission. Seven hundred and twenty-three patients (aged 2-18 years) were included in the sample, undergoing cancer treatment. They were recruited in 13 reference centres in the five macro-regions of Brazil between March 2018 and August 2019. The outcomes evaluated were readmission within 30 days and death within 60 days of admission. To identify predictors of 60-day survival, Cox regression and log-rank statistics were used to compare Kaplan-Meier curves between the strata. RESULTS: About 36.2% (n = 262) of the samples were malnourished according to the SGNA. Severe malnutrition by the SGNA (relative risk [RR] = 8.44, 95% confidence interval [CI]: 3.35-21.3, P = 0.001) and living in the North region (RR = 11.9, 95% CI: 3.34-42.7, P = 0.001) were associated with the poorest survival. The North (RR = 5.77, 95% CI: 1.29-25.8, P = 0.021), Northeast (RR = 1.46, 95% CI: 1.01-2.11, P = 0.041), Midwest (RR = 0.43, 95% CI: 0.20-0.095, P = 0.036), age group 10-18 years (RR = 0.65, 95% CI: 0.45- 0.94, P = 0.022) and haematologic malignancy (RR = 1.52, 95% CI: 1.10-2.10, P = 0.011) were predictors of readmission within 30 days. CONCLUSIONS: The prevalence of malnutrition was high and related to death. These results highlight the need to use the SGNA in clinical practice alongside classic anthropometric methods for the diagnosis of malnutrition, and the need to standardise care across all Brazilian regions, which should include nutritional care for children and adolescents with cancer.

Performance of subjective global nutritional assessment in predicting clinical outcomes: Data from the Brazilian survey of pediatric oncology nutrition.

BACKGROUND: Methods for assessing nutritional status in children and adolescents with cancer is a difficult in clinical practice. The study aimed to evaluate the performance of Subjective Global Nutritional Assessment (SGNA) in predicting clinical outcomes in children and adolescents with cancer in Brazil. METHODS: This was a prospective cohort multicenter study. It was included 723 children and adolescents with cancer aged 2-18 years between March 2018 and August 2019. Nutritional assessment was performed according to World Health Organization recommendations and using SGNA within 48h of hospitalization. Unplanned readmission, length of hospital stay, and post-discharge death were analyzed. Cohen's kappa coefficient was used to ascertain the agreement between body mass index for age (BMI/A) and SGNA. The sensitivity, specificity, positive and negative predictive values, and accuracy of SGNA were estimated. Odds ratios (ORs) with 95% confidence intervals (CIs) were evaluated using multiple logistic regression. RESULTS: The mean patient age was 9.4 ± 4.9 years. SGNA showed that 29.7% (n = 215) and 6.5% (n = 47) patients had moderate and severe malnutrition, respectively. Considering the concurrent validity criterion, SGNA had an OR (95% CI) of 6.8 (3.1-14.9) for predicting low and very low weight for age at admission, with a sensitivity and specificity of 72.4% (59%-82.1%) and 72% (64.2%-78.9%), respectively. SGNA could predict death in children with severe/moderate malnutrition, with an accuracy of 63.8% (63%-65.1%). Logistic multivariate analysis showed that the adjusted effect of death; hematological tumor; living in the northeast, southeast, and midwest regions of Brazil; and older age was associated with malnutrition according to SGNA. CONCLUSION: Based on concurrent validity between SGNA and anthropometry, SGNA performed well and had a good ability to predict death in Brazilian children with cancer.

The future costs of cancer attributable to excess body weight in Brazil, 2030-2040.

BACKGROUND: Excess body weight (EBW), herein defined as body mass index (BMI) ≥25 kg/m2, is a well-known modifiable risk factor for cancer and a pivotal vector for growing healthcare costs. We estimated the future (2030) federal direct healthcare costs of cancer in the Brazilian Unified Health System (SUS) attributable to EBW. We also projected direct healthcare costs of cancer that could be potentially saved in 2040, considering counterfactual (alternative) scenarios of population-wide reductions in the BMI to be achievedin 2030. METHODS: We developed a macrosimulation model by sex using self-reported BMI data in adults ≥ 20 years who relied exclusively on the public health system from the Brazilian National Health Survey (PNS) 2019; relative risks for 12 types of cancer from the World Cancer Research Fund/American Institute Cancer Research (WCRF/AICR) meta-analysis; and nationwide registries of federal direct healthcare costs of inpatient and outpatient procedures in adults ≥30 years with cancer from 2008-2019. We calculated the attributable costs of cancer via comparative risk assessment, assuming a 10-year lag between exposure and outcome. We used the potential impact fraction (PIF) equation and the Monte Carlo simulation method to estimate the attributable costs and 95% uncertainty intervals, considering the theoretical-minimum-risk exposure and other counterfactual (alternative) scenarios of the EBW prevalence. We assessed the cancer costs attributable to EBW, multiplying PIF by the direct healthcare costs of cancer. RESULTS: In 2030, 2.4% or US$ 62.8 million in direct healthcare costs of cancer may be attributable to EBW. We projected potential savings of approximately US$ 10.3 to 26.6 million in 2040 by reducing the prevalence of EBW in 2030. CONCLUSIONS: We estimated high future costs of cancer attributable to EBW in Brazil. Our findings may support interventions and policies focused on the primary prevention of EBW and cancer.

Low body mass index is associated with reduced intratumoral CD4+ T-lymphocyte infiltration in laryngeal squamous cell carcinoma patients.

Tumor size, inflammation, and nutritional status may be correlated with the immune response to cancer. Our hypothesis is that there is an interrelationship among tumor size, inflammatory response, and body mass index (BMI), and that these variables could alter T-lymphocyte infiltration in patients with laryngeal squamous cell carcinoma (LSCC). A retrospective cohort of 91 surgical LSCC patients treated at a Brazilian National Cancer Reference Center was followed for 5 years. We collected data regarding BMI, clinical factors, patients' lifestyle, C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR). Data were obtained in the medical records within a maximum interval of 7 days before surgery. The stromal and intratumoral CD4+ and CD8+ T-cell infiltrations were obtained by immunohistochemistry. Our results demonstrated a significant correlation among tumor size and BMI, NLR, PLR, and LMR. Similarly, PLR and LMR were significantly correlated with BMI. Tumor size and inflammatory parameters were not associated with changes in T-cell infiltrations. However, patients with low BMIs had a significantly lower density of intratumoral CD4+ T lymphocytes infiltrated when compared with normal/high BMI patients (odds ratio, 0.14; 95% confidence interval, 0.03-0.58; P = .007). CD8+ T-lymphocyte infiltration did not change in low-BMI patients. In conclusion, we observed a correlation among tumor size, inflammation, and BMI. Tumor size/inflammation axis may be responsible for the change in BMI and, therefore, may have influenced the reduction of intratumoral CD4+ T-lymphocyte infiltration in LSCC patients.

Body Mass Index Alters the Predictive Value of the Neutrophil-to-Lymphocyte Ratio and Systemic Inflammation Response Index in Laryngeal Squamous Cell Carcinoma Patients.

Laryngeal squamous cell carcinoma (LSCC) is a frequent cancer subtype among head and neck cancers. Exacerbated inflammation and nutritional deficit are common features in this type of cancer and can be used as a prognostic marker. This study aimed to investigate the relationship between body mass index (BMI), neutrophil-to-lymphocyte ratio (NLR), and systemic inflammation response index (SIRI) on overall survival (OS) of LSCC patients. In this retrospective cohort study, 168 patients were followed for 5 years. Data on clinical factors, patients' life habits, height, weight, and hematological parameters were collected. BMI, NLR, and SIRI were calculated. Pretreatment NLR≥ 2.02 and SIRI≥ 1160.85 were independent prognostic factors for poor OS. Low BMI did not significantly affect the OS. However, the inflammatory parameters had their predictive capacity altered when stratified by the BMI classification. NLR≥ 2.02 + Low BMI or SIRI≥ 1160.85 + Low BMI increased in 8.6 and 3.8 times the risk of death, respectively. In contrast, stratification by normal/high BMI classification eliminated the predictive capacity of NLR and SIRI. Here, we demonstrated the possible ability of BMI to change the prognostic capacity of inflammatory markers NLR and SIRI in patients with LSCC.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2021.1952447.

Can the sustainable development goals for cancer be met in Brazil? A population-based study.

Background: A one-third reduction in premature mortality (30-69 years) from chronic noncommunicable diseases is goal 3.4 of the United Nations Sustainable Development Goals (UN SDG). The burden of NCDs is expected to continue to increase in low- and middle-income countries, including Brazil. Objectives: The aim of this study was to assess geographical and temporal patterns in premature cancer mortality in Brazil between 2001 and 2015 and to predict this to 2030 in order to benchmark against the 3.4 SDG target. Methods: We used data on deaths from cancer in those aged 30-69, by age group, sex and cancer site, between 2001 and 2015 from the National Mortality Information System of Brazil (SIM). After correcting for ill-defined causes, crude and world age-standardised mortality rates per 100,000 inhabitants were calculated nationally and for the 5 regions. Predictions were calculated using NordPred, up to 2030. Results: The difference in observed (2011-2015) and predicted (2026-2030) mortality was compared against the SDG 3.4 target. Between 2011-2015 and 2026-2030 a 12.0% reduction in premature cancer age-standardised mortality rate among males and 4.6% reduction among females is predicted nationally. Across regions this varied from 2.8% among females in North region to 14.7% among males in South region. Lung cancer mortality rates are predicted to decrease among males but not among females nationally (men 28%, females 1.1% increase) and in all regions. Cervical cancer mortality rates are projected to remain very high in the North. Colorectal cancer mortality rates will increase for both sexes in all regions except the Southeast. Conclusions and recommendation: Cancer premature mortality is expected to decrease in Brazil, but the extent of the decrease will be far from the SDG 3.4 target. Nationally, only male lung cancer will be close to reaching the SDG 3.4 target, reflecting the government's long-term efforts to reduce tobacco consumption. Projected colorectal cancer mortality increases likely reflect the epidemiological transition. This and, cervical cancer control will continue to be major challenges. These results will help inform strategic planning for cancer primary prevention, early detection and treatment programs; such initiatives should take cognizance of the regional differences highlighted here.

Costs of cancer attributable to excess body weight in the Brazilian public health system in 2018.

OBJECTIVES: The prevalence of excess body weight (EBW) has increased over the last decades in Brazil, where 55.4% of the adult population was overweight in 2019. EBW is a well-known risk factor for several types of cancer. We estimated the federal cost of EBW-related cancers in adults, considering the medical expenditures in the Brazilian Public Health System. METHODS: We calculated the costs related to 11 types of cancer considering the procedures performed in 2018 by all organizations that provide cancer care in the public health system. We obtained data from the Hospital and Ambulatory Information Systems of the Brazilian Public Health System. We calculated the fractions of cancer attributable to EBW using the relative risks from the literature and prevalence from a nationally representative survey. We converted the monetary values in Reais (R$) to international dollars (Int$), considering the purchasing power parity (PPP) of 2018. RESULTS: In Brazil, the 2018 federal cost for all types of cancers combined was Int$ 1.73 billion, of which nearly Int$ 710 million was spent on EBW-related cancer care and Int$ 30 million was attributable to EBW. Outpatient and inpatient expenditures reached Int$ 20.41 million (of which 80% was for chemotherapy) and Int$ 10.06 million (of which 82% was for surgery), respectively. Approximately 80% of EBW-attributable costs were due to breast, endometrial and colorectal cancers. CONCLUSION: A total of 1.76% of all federal cancer-related costs could be associated with EBW, representing a substantial economic burden for the public health system. We highlight the need for integrated policies for excess body weight control and cancer prevention.

Dados do Inquérito Brasileiro de Nutrição Oncológica em Pediatria: Estudo Multicêntrico e de Base Hospitalar / Data from the Brazilian Survey of Pediatric Oncology Nutrition: Multicenter, Hospital-Based Study / Datos de Encuesta Brasileña de Nutrición en Oncología Pediátrica: Estudio Multicéntrico Hospitalario

Introdução: A desnutrição é observada em crianças com câncer e está associada a desfechos clínicos negativos. Objetivo: Descrever a prevalência de inadequação do estado nutricional de crianças e adolescentes com neoplasia maligna na admissão hospitalar em Centros de Referência do câncer infantil no Brasil. Método: Estudo transversal aninhado a um estudo de coorte, multicêntrico, de base hospitalar. A amostra probabilística foi feita em dois estágios em cada estrato por Macrorregião pelo método de probabilidade proporcional ao tamanho com um ano de coleta em cada instituição. Foram coletados em 13 instituições de referência dados clínicos, antropométricos, de composição corporal e sobre o questionário de Avaliação Nutricional Subjetiva Global Pediátrica (ANSGP), em até 48 horas da admissão hospitalar, entre março de 2018 e agosto de 2019. Resultados: O estudo totalizou 723 pacientes nas cinco regiões do Brasil. A prevalência de desnutrição moderada e grave foi de 25,9% na faixa etária de 2 a 5 anos, 40,1% de 5 a 10 anos e 39,7% de 10 a 19 anos, de acordo com ANSGP. Segundo o Índice de Massa Corporal/Idade (IMC/I), magreza e magreza acentuada totalizaram 13%, risco de sobrepeso, sobrepeso e obesidade apresentaram uma prevalência de 26,7% de 2 a 5 anos; 24,9% de 5 a 10 anos; e 25,7% de 10 a 19 anos. Conclusão: Evidenciou-se alta prevalência de inadequação nutricional pela ANSGP, sugerindo que a desnutrição pode ser subdiagnosticada quando utilizado somente o IMC/I, fortalecendo a necessidade de utilização de métodos complementares na avaliação nutricional de crianças com câncer

Introduction: Malnutrition is found in children with cancer and is associated with negative clinical outcomes. Objective: To describe the prevalence of inadequate nutritional status of children and adolescents with malignant neoplasm at hospital admission in childhood cancer reference centers in Brazil. Method: Cross-sectional study nested in a multicenter, hospital-based cohort study. The probabilistic sample was carried out in two stages in each stratum by macro-region using the probability method proportional to the size with one year of collection in each institution. Clinical, anthropometric, body composition data and the Pediatric Subjective Global Nutritional Assessment (SGNA) questionnaire were collected from 13 reference institutions within 48 hours of hospital admission, from March 2018 to August 2019. Results: The study totaled 723 patients in the 5 regions of Brazil. The prevalence of moderate and severe malnutrition was 25.9% in the age group of 2 to 5 years, 40.1% in 5 to 10 years and 39.7% in 10 to 19 years, according to the SGNA. According to the Body Mass/Age Index (BMI/I), thinness and marked thinness totaled 13%, risk of overweight, overweight and obesity showed a prevalence of 26.7% from 2 to 5 years, 24.9% from 5 to 10 years and 25.7% from 10 to 19 years. Conclusion: There was a high prevalence of nutritional inadequacy by the SGNA, suggesting that malnutrition can be underdiagnosed when using only the BMI/I, strengthening the need to use complementary methods in the nutritional assessment of children with cancer

Introducción: La desnutrición se observa en niños con cáncer y se asocia con resultados clínicos negativos. Objetivo: Describir la prevalencia del estado nutricional inadecuado de niños y adolescentes con neoplasia maligna al ingreso hospitalario en centros de referencia de cáncer infantil en Brasil. Método: Estudio transversal anidado en un estudio de cohorte hospitalario multicéntrico. La muestra probabilística se realizó en dos etapas en cada estrato por macrorregión utilizando el método de probabilidad proporcional al tamaño con un año de recolección en cada institución. Se recopilaron datos clínicos, antropométricos, de composición corporal y el cuestionario Global Pediatric Subjective Nutritional Assessment (ANSGP) de 13 instituciones de referencia dentro de las 48 horas posteriores al ingreso hospitalario, desde marzo de 2018 hasta agosto de 2019. Resultados: El estudio totalizó 723 pacientes en las 5 regiones de Brasil. La prevalencia de desnutrición moderada y severa fue de 25,9% en el grupo de edad de 2 a 5 años, 40,1% de 5 a 10 años y 39,7% de 10 a 19 años, según la ANSGP. Según el Índice de Masa Corporal/ Edad (IMC/I), la delgadez y la delgadez marcada totalizaron 13%, el riesgo de sobrepeso, sobrepeso y obesidad mostró una prevalencia de 26,7% de 2 a 5 años, 24,9% de 5 a 10 años y 25,7% de 10 a 19 años. Conclusión: Hubo una alta prevalencia de insuficiencia nutricional por parte de la ANSGP, lo que sugiere que la desnutrición puede ser infradiagnosticada cuando se utiliza solo el IMC/I, fortaleciendo la necesidad de utilizar métodos complementarios en la evaluación nutricional de los niños con cáncer

Advanced Stage of Disease and Systemic Inflammation as Factors Associated With Referral of Patients With Colorectal Cancer to a Palliative Care Unit.

OBJECTIVE: To identify factors associated with referral to an exclusive palliative care unit (PCU) in patients with colorectal cancer (CRC). METHODS: Retrospective cohort study with patients having CRC of both sexes treated at a hospital unit, aged ≥20 years. Data were extracted from the medical records of pretreatment patients between January 2008 and August 2014. The outcome was referral to the PCU within 5 years. Logistic regression analyses were performed to assess whether sociodemographic, clinical, nutritional, and biochemistry data were associated to referral, generating odds ratios (OR), and 95% confidence intervals (CI). RESULTS: Four hundred fifteen patients were evaluated. The Patient-Generated Subjective Global Assessment demonstrated a prevalence of malnutrition of 57.3%. One hundred one (24.3%) patients were referred to the PCU after 16.3 months (interquartile range: 7.2-33.5). These patients were more likely to be at an advanced stage of the disease and have malnutrition and exacerbated systemic inflammation. Tumor stage III and IV (OR: 2.05; 95% CI: 1.12-3.76) and neutrophil-to-lymphocyte ratio (NLR) ≥3 (OR: 1.89; 95% CI: 1.12-3.17) were predictors of an increased chance of referral to the PCU. CONCLUSION: Advanced disease stage and NLR were associated with referral of patients with CCR to a PCU.

Neutrophil-lymphocyte ratio and nutritional status are clinically useful in predicting prognosis in colorectal cancer patients.

Background: Neutrophil-lymphocyte ratio (NLR) and nutritional status may provide a prognostic value in colorectal cancer (CRC). Thus, aim of this study was to evaluate the prognostic value of nutritional status and NLR in CRC patients.Methods: A retrospective analysis was conducted in CRC patients. The independent variables were body mass index (BMI), weight loss (WL) and NLR. Logistic regression was used to estimate the odds chance of low NLR. Kaplan-Meier curves and Cox regression were used to evaluate the overall survival at 5 years old.Results: In the 148 patients evaluated, the most prevalent nutritional status was overweight/obesity (43.2%) and 27.0% had severe WL. Sixty-seven subjects (45.3%) had NLR ≥ 3 that was associated with the lower OS (P < 0.001). There was a higher OS for overweight/obese patients (P = 0.002) and a lower among subjects with severe WL (P = 0.009). The NLR ≥3 (HR: 3.639; 95% CI, 1.708-7.771) was an independent poor prognostic factor for OS. Patients without WL (HR: 0.367, 95% CI, 0.141-0.954) and classified as overweight/obesity (HR: 0.260; 95% CI, 0.106-0.639) presented better prognostic.Conclusion: NLR, WL, BMI assessments are promising prognostic indicators in the CRC.

Labor and birth care by nurse with midwifery skills in Brazil.

BACKGROUND: The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections. METHODS: Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births. RESULTS: 16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower. CONCLUSIONS: The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices.

Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012.

BACKGROUND: Maternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil. METHODS: The study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011-2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI). RESULTS: The estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5-13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51-14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12-9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69-12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67-3.88) and forceps (OR: 9.37; 95 % CI: 4.01-21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services. CONCLUSION: The high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births.

Factors associated with cesarean delivery during labor in primiparous women assisted in the Brazilian Public Health System: data from a National Survey.

BACKGROUND: The rate of cesarean delivery (CD) in Brazil has increased over the past 40 years. The CD rate in public services is three times above the World Health Organization recommended values. Among strategies to reduce CD, the most important is reduction of primary cesarean. This study aimed to describe factors associated with CD during labor in primiparous women with a single cephalic pregnancy assisted in the Brazilian Public Health System (SUS). METHODS: This study is part of the Birth in Brazil survey, a national hospital-based study of 23,894 postpartum women and their newborns. The rate of CD in primiparous women was estimated. Univariate and multivariable logistic regression was performed to analyze factors associated with CD during labor in primiparous women with a single cephalic pregnancy, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals. RESULTS: The analyzed data are related to the 2814 eligible primiparous women who had vaginal birth or CD during labor in SUS hospitals. In adjusted analyses, residing in the Southeast region was associated with lower CD during labor. Occurrence of clinical and obstetric conditions potentially related to obstetric emergencies before delivery, early admission with < 4 cm of dilatation, a decision late in pregnancy for CD, and the use of analgesia were associated with a greater risk for CD. Favorable advice for vaginal birth during antenatal care, induction of labor, and the use of any good practices during labor were protective factors for CD. The type of professional who attended birth was not significant in the final analyses, but bivariate analysis showed a higher use of good practices and a smaller proportion of epidural analgesia in women cared for by at least one nurse midwife. CONCLUSIONS: The CD rate in primiparous women in SUS in Brazil is extremely high and can compromise the health of these women and their newborns. Information and support for vaginal birth during antenatal care, avoiding early admission, and promoting the use of good practices during labor assistance can reduce unnecessary CD. Considering the experience of other countries, incorporation of nurse midwives in childbirth care may increase the use of good practices during labor.

Determinants of gestational night blindness in pregnant women from Rio de Janeiro, Brazil.

OBJECTIVE: To describe the prevalence and determinants of gestational night blindness in pregnant women receiving care in a hospital in Rio de Janeiro, Brazil. DESIGN: Cross-sectional study of pregnant and postpartum women receiving care in a public hospital in Rio de Janeiro from 1999 to 2001 (group I; n 225) or from 2005 to 2008 (group II; n 381). Night blindness was identified through a standardized and validated interview (WHO, 1996). The determinants of gestational night blindness were identified through a hierarchical logistic regression model. SETTING: Public maternity hospital in Rio de Janeiro, RJ, Brazil. SUBJECTS: Adult pregnant and postpartum women (n 606), aged ≥20 years. RESULTS: The prevalence of gestational night blindness was 9·9 %. The final model revealed that not living in the South Zone of Rio de Janeiro (distal level: adjusted OR=1·846; 95 % CI 1·002, 3·401), belonging to group I (intermediate level: adjusted OR=2·183; 95 % CI 1·066, 4·471) and for the proximal level, having a history of abortion (adjusted OR=2·840; 95 % CI 1·134, 7·115) and having anaemia during the first and second trimesters of pregnancy (adjusted OR=3·776; 95 % CI 1·579, 9·029) were determinants of gestational night blindness. CONCLUSION: Gestational night blindness should be assessed for during the prenatal care of all pregnant women, especially those living in deprived areas of the city and/or who have a history of abortion or anaemia. Nutritional monitoring is recommended during pregnancy to control gestational night blindness.

Differences in utility scores obtained through Brazilian and UK value sets: a cross-sectional study.

BACKGROUND: Multiple sclerosis (MS) is a chronic disease associated with several impacts; especially regarding patients' health-related quality of life (HRQL). EuroQol 5 Dimensions questionnaire (EQ-5D) provides self-reported analysis of HRQL and utility scores. Although the British algorithm to convert EQ-5D responses into utility is the most used in the literature, national settings is more appropriate for health policy decision makers. A Brazilian algorithm is available, but not used in MS patients yet. Primarily, this study aimed to address potential differences in utility scores obtained through Brazilian and British value sets. Secondary objective was to determine the role of disability, fatigue and patients socio-demographic and clinical characteristics relevant to MS on the utility scores reported by Brazilian patients. METHODS: Cross-sectional study with MS patients treated in 8 Brazilian sites. Patients were interviewed about socio-demographic and clinical characteristics, self-reported disability level, HRQL and impact of fatigue on daily living. Disability level, HRQL and impact of fatigue were assessed using the Expanded Disability Status Scale (EDSS) and the Brazilian versions of EQ-5D-3 L and Modified Fatigue Impact Scale (MFIS-BR), respectively. Patients were classified in subgroups according to EDSS (mild: 0-3; moderate: 4-6.5; severe: >7) and the self-perceived impact of fatigue (absent: ≤ 38 points; low: 39-58; high: ≥ 59). EQ-5D-3 L data was converted into a utility index using an algorithm developed by a Brazilian research group (QALY Brazil) and also the UK algorithm. Differences between utility scores were analysed through Wilcoxon test. RESULTS: Two hundred and ten patients were included in the study. Utility index mean scores of 0.59 (SD = 0.22) and 0.56 (SD = 0.32) for the Brazilian and UK algorithms were observed, respectively, without statistically significant difference for the distribution of data (p = 0.586). However, when utility scores were lower than 0.5, Brazilian algorithm provided higher estimates than UK with a better agreement between the scores found closer to 1. The same trend was observed when data was stratified for EDSS and impact of fatigue, with statistically significant difference between scores in categories of mild/severe disabilities and absent/high impact of fatigue. CONCLUSIONS: Results suggest that Brazilian value set provided higher utility scores than the UK, particularly for measures below 0.5.

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth.

The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.