Prevalence of children with special healthcare needs: An epidemiological survey in Brazil.

PURPOSE: We aimed to estimate the prevalence and delineate the profile of children with special healthcare needs (CSHCN) in the three municipalities of Brazil's southern and southeastern regions from 2015 to 2017. DESIGN AND METHODS: This cross-sectional study included 6853 children aged 0-11 years. Participants were selected through complex sampling in 32 primary healthcare units. The Brazilian version of the Children with Special Healthcare Needs Screener© and a questionnaire were used to identify sociodemographic and family characteristics, health status, and health services utilization. Simple and multiple logistic regression models were used to evaluate the association between family and child characteristics and prevalence (P < 0.05). RESULTS: The prevalence of CSHCN was 25.3% (95% confidence interval: 21.0-30.0). Most participants required health services or were on long-term medication for a current chronic condition; approximately 53% of CSHCN had no formally recorded diagnoses. The most frequent health problems were respiratory conditions, asthma, and allergies. Approximately 60% of the CSHCN patients underwent follow-up examinations of the specialties pneumology, pediatrics, otorhinolaryngology, speech therapy, neurology, and psychology. Children of school age, of male sex, with premature birth, with a history of recurrent hospitalization, from non-nuclear families, and from underprivileged social classes were identified as risk factors for classification as CSHCN. PRACTICE IMPLICATION: These results contribute to the unprecedented mapping of these children in healthcare networks in Brazil. CONCLUSION: The high prevalence of CSHCN in medium and large municipalities in the southern and southeastern regions was associated with the child's previous health conditions and family structure.

Factors associated with infant formula supplementation in Brazilian hospitals: a cross-sectional study.

OBJECTIVE: To analyze the factors associated with infant formula supplementation in newborns referred to rooming-in in Brazilian hospitals. METHOD: Cross-sectional study with data from 14,531 postpartum women and newborns obtained from the "Birth in Brazil" survey, conducted in 2011-2012. The analysis used a logistic regression model with a hierarchical approach. RESULTS: In total, 21.2% newborns received infant formula during hospital stay. After adjustment, the following factors were associated with the use of infant formula: maternal age ≥ 35 years (OR = 1.51; IC95%:1.30-1.75), prenatal care in a private service (OR = 2,22; IC:1.72-2.85)/public and private service (OR = 1.67; IC:1.24-2.23), cesarean delivery (OR = 1.83; IC:1.41-2.38), multiple pregnancy (OR = 3.786; IC:2.02-7.06), non-breastfeeding in the delivery room (OR = 1.780; IC:1.43-2.21), birth in a private hospital (OR = 1.695; IC:1.02-2.79), prematurity (OR = 1.656; IC:1.32-2.06) and extremes of birth weight (< 2.500 g: OR = 2.084; IC: 1.585-2.741/ ≥4,000g: OR = 1.672; IC:1.31-2.11). Teenage age (OR = 0.651; IC:0.55-0.76), low maternal education (OR = 0.579; IC:0.43-0.77), multiparity (OR = 0.588; IC:0.510-0.678), and lower economic class (OR = 0.565; IC:0.41-0.76) significantly reduced the probability of using infant formula. CONCLUSIONS: Of the associated factors, the authors highlight cesarean delivery and non-breastfeeding in the delivery room, showing that it is necessary to strengthen policies that encourage good practices during childbirth care in order to promote exclusive breastfeeding and protect mothers and newborns from all social classes against the misuse of infant formula.

Burden of early-term birth on adverse infant outcomes: a population-based cohort study in Brazil.

OBJECTIVES: To estimate the national rate of early-term live births in Brazil and to evaluate the effect of birth at 37 and 38 weeks' gestation, as compared with 39 and 40 weeks' gestation on infant outcomes according to precursors of birth and the existence of maternal/fetal medical conditions. DESIGN: National perinatal population-based cohort study. SETTING: 266 maternity services located in the five Brazilian macroregions. PARTICIPANTS: 18 652 singleton live newborns from 37 0/7 to 40 6/7 weeks of gestation. MAIN OUTCOME MEASURES: Resuscitation in delivery room, oxygen therapy, transient tachypnoea, admission to neonatal intensive care unit (NICU), hypoglycaemia, use of antibiotics, phototherapy, phototherapy after hospital discharge, neonatal death and breastfeeding. RESULTS: Early terms accounted for 35% (95% CI 33.4% to 36.7%) of all live births. Among provider-initiated births in women without medical conditions, infants of 37 and 38 weeks' gestation had higher odds of oxygen therapy (adjusted OR (AOR) 2.93, 95% CI 1.72 to 4.98 and AOR 1.92 95% CI 1.18 to 3.13), along with admission to NICU (AOR 2.01, 95% CI 1.18 to 3.41 and AOR 1.56, 95% CI 1.02 to 2.60), neonatal death (AOR 14.40, 95% CI 1.94 to 106.69 and AOR 13.76,95% CI 2.84 to 66.75), hypoglycaemia in the first 48 hours of life (AOR 7.86, 95% CI 1.95 to 31.71 and AOR 5.76, 95% CI 1.63 to 20.32), transient tachypnoea (AOR 2.98, 95% CI 1.57 to 5.65 and AOR 2.12, 95% CI 1.00 to 4.48) and the need for phototherapy within the first 72 hours of life (AOR 3.59, 95% CI 1.95 to 6.60 and AOR 2.29, 95% CI 1.49 to 3.53), yet lower odds of breastfeeding up to 1 hour after birth (AOR 0.67, 95% CI 0.53 to 0.86 and AOR 0.87, 95% CI 0.76 to 0.99) and exclusive breastfeeding during hospital stay (AOR 0.68, 95% CI 0.51 to 0.89 and AOR 0.84, 95% CI 0.71 to 0.99). CONCLUSION: Birth at 37 and 38 weeks' gestation increased the risk of most adverse infant outcomes analysed, especially among provider-initiated births and should be avoided before 39 weeks' gestation in healthy pregnancies.

Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey, 2011/2012.

BACKGROUND: Unintended pregnancy, a pregnancy that have been either unwanted or mistimed, is a serious public health issue in Brazil. It is reported for more than half of women who gave birth in the country, but the characteristics of women who conceive unintentionally are rarely documented. The aim of this study is to analyse the prevalence and the association between unintended pregnancy and a set of sociodemographic characteristics, individual-level variables and history of obstetric outcomes. METHODS: Birth in Brazil is a cross-sectional study with countrywide representation that interviewed 23,894 women after birth. The information about intendedness of pregnancy was obtained after birth at the hospital and classified into three categories: intended, mistimed or unwanted. Multinomial regression analysis was used to estimate the associations between intendedness of a pregnancy, and sociodemographic and obstetric variables, calculating odds ratios and 95 % confidence intervals. All significant variables in the bivariate analysis were included in the multinomial multivariate model and the final model retaining variables that remained significant at the 5 % level. RESULTS: Unintended pregnancy was reported by 55.4 % of postpartum women. The following variables maintained positive and significant statistical associations with mistimed pregnancy: maternal age < 20 years (OR = 1.89, 95 % CI: 1.68-2.14); brown (OR = 1.15, 95 % CI: 1.04-1.27) or yellow skin color (OR = 1.56, 95 % CI: 1.05-2.32); having no partner (OR = 2.32, 95 % CI: 1.99-2.71); having no paid job (OR = 1.15, 95 % CI: 1.04-1.27); alcohol abuse with risk of alcoholism (OR = 1.25, 95 % CI: 1.04-1.50) and having had three or more births (OR = 2.01, 95 % CI: 1.63-2.47). The same factors were associated with unwanted pregnancy, though the strength of the associations was generally stronger. Women with three or more births were 14 times more likely to have an unwanted pregnancy, and complication in the previous pregnancies and preterm birth were 40 % and 19 % higher, respectively. Previous neonatal death was a protective factor for both mistimed (OR = 0.61, 95 % CI: 0.44-0.85) and unwanted pregnancy (OR = 0.44, 95 % CI: 0.34-0.57). CONCLUSIONS: This study confirms findings from previous research about the influence of socioeconomic and individual risk factors on unintended pregnancy. It takes a new approach to the problem by showing the importance of previous neonatal death, preterm birth and complication during pregnancy as risk factors for unintended pregnancy.

Good practices according to WHO's recommendation for normal labor and birth and women's assessment of the care received: the "birth in Brazil" national research study, 2011/2012.

BACKGROUND: The World Health Organization recommends good practices for the conduct of uncomplicated labor and birth, with the aim of improving the quality of and assessment by women of childbirth care. The aim of this study was to evaluate the association between adoption of good practices according to WHO's recommendation for normal labor and birth and assessment by women of the care received. METHODS: Birth in Brazil is a national hospital-based study with countrywide representation consisting of 23,894 mothers and their newborns, conducted between February 2011 and October 2012. The present study analysed a subsample of this national survey. Postpartum women classified as low risk during pregnancy who had experienced either spontaneous or induced labor were included in this study, totalling 4102 mothers. To estimate the association between assessment by women of the childbirth care received (dependent variable) and good practices according to WHO's recommendation during normal labor and birth (independent variables), a multinomial logistic regression analysis was used and crude and adjusted odds ratios calculated with their 95 % confidence intervals. RESULTS: The good practices associated with positive assessment of the care received by women during labor and birth included the partner's presence, privacy in the birthing place, time available to ask questions, clarity of information received, and empathic support from caregivers during labor and birth. Freedom of movement, free nutrition offered, choice of companions, nonpharmacological analgesia, skin-to-skin contact and breastfeeding in the childbirth room were not associated with the assessment by women of the care received. CONCLUSIONS: Our findings reveal the importance to mothers of their relationship with the team of caregivers during labor and birth. Therefore, caregiver teams must be qualified within a more humanistic vision of childbirth health care.

Access to childbirth care by adolescents and young people in the Northeastern region of Brazil.

OBJECTIVE: To identify the factors that interfere with the access of adolescents and young people to childbirth care for in the Northeast region of Brazil. METHODS: Cross-sectional study with 3,014 adolescents and young people admitted to the selected maternity wards to give birth in the Northeast region of Brazil. The sample design was probabilistic, in two stages: the first corresponded to the health establishments and the second to women who had recently given birth and their babies. The data was collected by means of interviews and consulting the hospital records, from pre-tested electronic form. Descriptive statistics were used for the univariate analysis, Pearson's Chi-square test for the bivariate analysis and multiple logistic regressions for the multivariate analysis. Sociodemographic variables, obstetrical history, and birth care were analyzed. RESULTS: Half of the adolescents and young people interviewed had not been given guidance on the location that they should go to when in labor, and among those who had, 23.5% did not give birth in the indicated health service. Furthermore, one third (33.3%) had to travel in search of assisted birth, and the majority (66.7%) of the postpartum women came to maternity by their own means. In the bivariate analysis, the variables marital status, paid work, health insurance, number of previous pregnancies, parity, city location, and type of health establishment showed a significant association (p < 0.20) with inadequate access to childbirth care. The multivariate analysis showed that married adolescents and young people (p < 0.015), with no health insurance (p < 0.002) and from the countryside (p < 0.001) were more likely to have inadequate access to childbirth care. CONCLUSIONS: Adolescents and young women, married, without health insurance, and from the countryside are more likely to have inadequate access to birth care. The articulation between outpatient care and birth care can improve this access and, consequently, minimize the maternal and fetal risks that arise from a lack of systematic hospitalization planning.

Provider-Initiated Late Preterm Births in Brazil: Differences between Public and Private Health Services.

BACKGROUND: A large proportion of the rise in prematurity worldwide is owing to late preterm births, which may be due to the expansion of obstetric interventions, especially pre-labour caesarean section. Late preterm births pose similar risks to overall prematurity, making this trend a concern. In this study, we describe factors associated with provider-initiated late preterm birth and verify differences in provider-initiated late preterm birth rates between public and private health services according to obstetric risk. METHODS: This is a sub-analysis of a national population-based survey of postpartum women entitled "Birth in Brazil", performed between 2011 and 2012. We included 23,472 singleton live births. We performed non-conditional multiple logistic regressions assessing associated factors and analysing differences between public and private health services. RESULTS: Provider-initiated births accounted for 38% of late preterm births; 32% in public health services and 61% in private health services. They were associated with previous preterm birth(s) and maternal pathologies for women receiving both public and private services and with maternal age ≥35 years for women receiving public services. Women receiving private health services had higher rates of provider-initiated late preterm birth (rate of 4.8%) when compared to the ones receiving public services (rate of 2.4%), regardless of obstetric risk-adjusted OR of 2.3 (CI 1.5-3.6) for women of low obstetric risk and adjusted OR of 1.6 (CI 1.1-2.3) for women of high obstetric risk. CONCLUSION: The high rates of provider-initiated late preterm birth suggests a considerable potential for reduction, as such prematurity can be avoided, especially in women of low obstetric risk. To promote healthy births, we advise introducing policies with incentives for the adoption of new models of birth care.

Obstetric, Sociodemographic, and Psychosocial Problems of Postpartum Adolescents of Huambo, Angola.

This study aims to establish a profile of teenage pregnancy (<20 years) at a hospital in Huambo, Angola. Subjects were categorized into two age groups, 10-16 and 17-19 years. We interviewed 381 mothers in the postpartum maternity ward of the Central Hospital of Huambo. Statistical analysis then followed two stages, a descriptive analysis of the study population and analysis through a bivariate 2 × 2 table, using a chi-squared test to evaluate the hypothesis of homogeneity of proportions with a significance level of 5%. Comparing the two groups revealed a more frequent occurrence of problems among mothers under 17 years of age, including a higher frequency of involvement with unemployed parents, more often not living with parents, and fewer prenatal consultations.

Factors associated with postpartum depressive symptomatology in Brazil: The Birth in Brazil National Research Study, 2011/2012.

BACKGROUND: Depression is one of the most common postpartum mental disorders. Many sociodemographic and individuals risk factors are associated with maternal depression but the impact of high levels of birth intervention is unclear. The Brazilian context is characterized by excessive intervention and frequent non-compliance with recommended obstetric protocols. This study therefore examined the impact of sociodemographic, individual, and obstetric risk factors in postpartum depression. METHODS: The Birth in Brazil research study is a national study of 23,894 postpartum women. Information about depression was obtained by telephone interview at 6-18 months after birth and was measured using the Edinburgh Postnatal Depression Scale. RESULTS: The prevalence of probable cases of depression was 26.3%. A multiple logistic regression model identified significant sociodemographic and individual risk factors as: brown skin color (OR=1.15 CI 1.01-1.31), lower economic class (OR=1.70 CI 1.41-2.06), alcohol use (OR=1.41 CI 1.09-1.84) and a history of mental disorders (OR=3.13 CI 1.80-5.44). Significant obstetric factors were unplanned pregnancy (OR=1.22 CI 1.05-1.43 for wanted later and OR=1.38 CI 1.20-1.60 for never wanted), multiparity (OR=1.97 CI 1.58-2.47 for 3 or more children), and poor care during birth (OR=2.02 CI 1.28-3.20) or of the newborn (OR=2.16 CI 1.51-3.10). Obstetric interventions and complications were not associated with maternal depression. LIMITATIONS: Depression was measured only once so we are not able to examine the course over time. The associational and reverse causality cannot be ruled out for some variables. CONCLUSIONS: The prevalence of postpartum depression is high in Brazilian women six months after birth. Poor care of women and babies during birth is more important in postpartum depression than physical obstetric or neonatal intervention and complications.

Determining gestational age based on information from the Birth in Brazil study.

This study aimed at assessing the validity of different measures for estimating gestational age and to propose the creation of an algorithm for gestational age at birth estimates for the Birth in Brazil survey--a study conducted in 2011-2012 with 23,940 postpartum women. We used early ultrasound imaging, performed between 7-20 weeks of gestation, as the reference method. All analyses were performed stratifying by payment of maternity care (public or private). When compared to early ultrasound imaging, we found a substantial intraclass correlation coefficient of ultrasound-based gestational age at admission measure (0.95 and 0.94) and of gestational age reported by postpartum women at interview measure (0.90 and 0.88) for the public and private payment of maternity care, respectively. Last menstrual period-based measures had lower intraclass correlation coefficients than the first two measures evaluated. This study suggests caution when using the last menstrual period as the first measure for estimating gestational age in Brazil, strengthening the use of information obtained from early ultrasound imaging results.

Prevalence and factors associated with nutritional deviations in women in the pre-pregnancy phase in two municipalities of the State of Rio de Janeiro, Brazil.

OBJECTIVE: To assess the prevalence and potential factors associated with pre-pregnancy nutritional status of women. METHODS: This is a cross-sectional study carried out between December 2007 and November 2008 with 1,535 women in the first trimester of pregnancy and randomly selected in health units of the Brazilian public health system (SUS) in the municipalities of Queimados and Petrópolis in the State of Rio de Janeiro. The diagnosis of nutritional deviations was based on the Body Mass Index, according to the classification of the Institute of Medicine, and the following categories were obtained: underweight, normal weight, overweight and obesity. In the statistical analysis, the multinomial logistic regression model was used and an odds ratio and confidence interval of 95% were estimated. RESULTS: The sample included women between 13 and 45 years. The prevalence of underweight, overweight and obesity were 10, 18 and 11%, respectively. Women living in Queimados, adolescents, women who did not live with a partner and smokers had a higher proportion of low pre-pregnancy weight. There was an association between hypertension, overweight and obesity. Adolescents presented lower chance to overweight and obesity. Living in Queimados reduced the odds of overweight. CONCLUSION: The proportion of pre-pregnancy nutritional deviations was high, and recognizing factors that lead to them is very important for an early identification of women at nutritional risk, with view to interventions to reduce the adverse effects of malnutrition on maternal and child health.

Determining gestational age for public health care users in Brazil: comparison of methods and algorithm creation.

BACKGROUND: A valid, accurate method for determining gestational age (GA) is crucial in classifying early and late prematurity, and it is a relevant issue in perinatology. This study aimed at assessing the validity of different measures for approximating GA, and it provides an insight into the development of algorithms that can be adopted in places with similar characteristics to Brazil. A follow-up study was carried out in two cities in southeast Brazil. Participants were interviewed in the first trimester of pregnancy and in the postpartum period, with a final sample of 1483 participants after exclusions. The distribution of GA estimates at birth using ultrasound (US) at 21-28 weeks, US at 29+ weeks, last menstrual period (LMP), and the Capurro method were compared with GA estimates at birth using the reference US (at 7-20 weeks of gestation). Kappa, sensitivity, and specificity tests were calculated for preterm (<37 weeks of gestation) and post-term (>=42 weeks) birth rates. The difference in days in the GA estimates between the reference US and the LMP and between the reference US and the Capurro method were evaluated in terms of maternal and infant characteristics, respectively. RESULTS: For prematurity, US at 21-28 weeks had the highest sensitivity (0.84) and the Capurro method the highest specificity (0.97). For postmaturity, US at 21-28 weeks and the Capurro method had a very high sensitivity (0.98). All methods of GA estimation had a very low specificity (≤0.50) for postmaturity. GA estimates at birth with the algorithm and the reference US produced very similar results, with a preterm birth rate of 12.5%. CONCLUSIONS: In countries such as Brazil, where there is less accurate information about the LMP and lower coverage of early obstetric US examinations, we recommend the development of algorithms that enable the use of available information using methodological strategies to reduce the chance of errors with GA. Thus, this study calls into attention the care needed when comparing preterm birth rates of different localities if they are calculated using different methods.

[Adequacy of weight gain in pregnant women from two municipalities of Rio de Janeiro state (RJ), Brazil, 2008]. / Adequação do ganho ponderal de gestantes em dois municípios do Estado do Rio de Janeiro (RJ), Brasil, 2008.

PURPOSE: To evaluate sociodemographic, behavioral and reproductive factors and morbidities associated with inadequate weight gain during pregnancy. METHODS: Cohort study conducted from December 2007 to August 2008 with women in the first trimester of pregnancy looking for prenatal care in the Public Health System who lived in the cities of Petrópolis or Queimados, Rio de Janeiro state (Brazil). Women with multiple pregnancy, who had a miscarriage in the index pregnancy or who lacked information for the assessment of pregravid nutritional status or weight gain were excluded. Pregravid nutritional status and weight gain during pregnancy were determined according to the criterion established by the Institute of Medicine (IOM). Statistical analysis was performed using a multinomial logistic regression model. RESULTS: A total of 1,287 women were included in the study; 26.6% of them were overweight or obese while 11% were underweight. Inadequate weight gain during pregnancy was observed in 71.4% of pregnant women; 35.6% of them did not gain enough weight while 35.8% gained more weight than recommended by the IOM. In the multivariate analysis, women with hypertension (OR=2.1; 95%CI 1.4-3.1), pregravid overweight (OR=2.5; 95%CI 1.4-4.5) or obesity (OR=2.7; 95%CI 1.8-3.9) and who had a higher educational level were more likely to gain more weight than recommended, while pregravid underweight (OR=0.6; 95%CI 0.4-0.9) represented a protection against excessive gain. CONCLUSION: Pregravid nutritional diagnosis and weight gain monitoring should be actions effectively instituted in the routine of health professionals.

[Repeated pregnancy among adolescents and negative outcomes of the newborn: study in the city of Rio de Janeiro]. / Gravidez recorrente na adolescência e os desfechos negativos no recém-nascido: um estudo no Município do Rio de Janeiro.

The aim of the study was to evaluate the prevalence of repeated pregnancy among adolescents and identify associated factors and perinatal outcomes. A sample of 1,986 post-partum adolescents was selected from public hospitals in the city of Rio de Janeiro, Brazil. To verify the hypothesis of homogeneity of proportions, chi-square tests (χ²) were used. Odds ratios and correspondent confidence intervals were estimated. Logistic regression procedures were used. A repeated pregnancy prevalence of 31.4% was identified and the principal associated factors were: maternal age 15-19 years; paternal age >19 years; early menarche; black or brown maternal skin color; schooling < 5 years; living with partner during pregnancy. Perinatal death was significantly higher in the adolescent mothers group with repeated pregnancy. The results showed that the most disadvantaged socioeconomic conditions were found among adolescent mothers with repeated pregnancy in comparison to mothers on their first pregnancy. The findings sustain the relevance of social policies for adolescent mothers with repeated pregnancy.

Birth in Brazil: national survey into labour and birth.

BACKGROUND: Caesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction. METHODS: Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients' medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson's groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design. DISCUSSION: This study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it's consequences on postnatal health.

[The decision of women for cesarean birth: a case study in two units of the supplementary health care system of the State of Rio de Janeiro]. / Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro.

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.

Congenital malformations in Rio de Janeiro, Brazil: prevalence and associated factors.

This study aims to estimate the prevalence of congenital malformations and their correlation with socioeconomic and maternal variables. The design was cross-sectional, based on a sample of 9,386 postpartum women after admission for childbirth in maternity hospitals in the city of Rio de Janeiro, Brazil. Data were collected through interviews with mothers in the immediate postpartum, as well as by consulting the patient records of both the mothers and newborn infants. Prevalence of congenital malformations at birth was 1.7%, and minor malformations were the most frequent. Neural tube defects were the most frequent major malformations. According to multivariate analysis, congenital malformations were statistically associated with: maternity hospitals belonging to or outsourced by the Unified National Health System (SUS) and inadequate prenatal care (

[Consequences of sociodemographic inequalities on birth weight]. / Desigualdades sociodemográficas e suas conseqüências sobre o peso do recém-nascido.

OBJECTIVE: To analyze sociodemographic inequalities in prenatal and childbirth care and their consequences on birth weight. METHODS: The study was based on a sample of 10,072 postpartum women treated at public (those outsourced by the National Health System) and private maternity hospitals in Rio de Janeiro, Brazil, from 1999 to 2001. To test the association between birth weight and maternal sociodemographic and biological characteristics and prenatal care (modified Kotelchuck index), postpartum women were stratified by level of schooling and two multiple linear regressions were performed. The bootstrap technique was used in addition to accurate confidence intervals for the estimated effects. RESULTS: For nearly all of the variables analyzed in the bivariate analysis, birth weight was lower among children of mothers with low schooling. In the multivariate analysis, among women with low schooling, there was a direct association between birth weight and the modified Kotelchuck index and gestational age. The variables black skin color, smoking, and history of premature birth were negatively associated with birth weight, while maternal age and parity showed distinct behaviors from the central range of data at the extremes. In the group with high schooling, only parity, gestational age, and modified Kotelchuck index were significant and directly associated with birth weight. The protective effect of prenatal care was observed, as well as the negative effect of smoking, regardless of the mother's level of schooling. CONCLUSIONS: The variables associated with neonates' birth weight of mothers with high schooling in Rio de Janeiro were biological, in contrast to the social determinants in the group with low schooling.