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Linda S Adair,
Caroline Hd Fall,
Clive Osmond,
Aryeh D Stein,
Reynaldo Martorell,
Manuel Ramirez-Zea,
Harshpal Singh Sachdev,
Darren L Dahly,
Isabelita Bas,
Shane A Norris,
Lisa Micklesfield,
Pedro Hallal, Cesar G Victora
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ABSTRACT: BACKGROUND: Fast weight gain and linear growth in children in low-income and middle-income countries are associated with enhanced survival and improved cognitive development, but might increase risk of obesity and related adult cardiometabolic diseases. We investigated how linear growth and relative weight gain during infancy and childhood are related to health and human capital outcomes in young adults. METHODS: We used data from five prospective birth cohort studies from Brazil, Guatemala, India, the Philippines, and South Africa. We investigated body-mass index, systolic and diastolic blood pressure, plasma glucose concentration, height, years of attained schooling, and related categorical indicators of adverse outcomes in young adults. With linear and logistic regression models, we assessed how these outcomes relate to birthweight and to statistically independent measures representing linear growth and weight gain independent of linear growth (relative weight gain) in three age periods: 0-2 years, 2 years to mid-childhood, and mid-childhood to adulthood. FINDINGS: We obtained data for 8362 participants who had at least one adult outcome of interest. A higher birthweight was consistently associated with an adult body-mass index of greater than 25 kg/m(2) (odds ratio 1·28, 95% CI 1·21-1·35) and a reduced likelihood of short adult stature (0·49, 0·44-0·54) and of not completing secondary school (0·82, 0·78-0·87). Faster linear growth was strongly associated with a reduced risk of short adult stature (age 2 years: 0·23, 0·20-0·52; mid-childhood: 0·39, 0·36-0·43) and of not completing secondary school (age 2 years: 0·74, 0·67-0·78; mid-childhood: 0·87, 0·83-0·92), but did raise the likelihood of overweight (age 2 years: 1·24, 1·17-1·31; mid-childhood: 1·12, 1·06-1·18) and elevated blood pressure (age 2 years: 1·12, 1·06-1·19; mid-childhood: 1·07, 1·01-1·13). Faster relative weight gain was associated with an increased risk of adult overweight (age 2 years: 1·51, 1·43-1·60; mid-childhood: 1·76, 1·69-1·91) and elevated blood pressure (age 2 years: 1·07, 1·01-1·13; mid-childhood: 1·22, 1·15-1·30). Linear growth and relative weight gain were not associated with dysglycaemia, but a higher birthweight was associated with decreased risk of the disorder (0·89, 0·81-0·98). INTERPRETATION: Interventions in countries of low and middle income to increase birthweight and linear growth during the first 2 years of life are likely to result in substantial gains in height and schooling and give some protection from adult chronic disease risk factors, with few adverse trade-offs. FUNDING: Wellcome Trust and Bill & Melinda Gates Foundation.
The Lancet 03/2013; · 38.28 Impact Factor
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Christian Kieling,
Mara H Hutz,
Júlia P Genro,
Guilherme V Polanczyk,
Luciana Anselmi,
Suzi Camey,
Pedro C Hallal,
Fernando C Barros, Cesar G Victora,
Ana M B Menezes,
Luis Augusto Rohde
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ABSTRACT: Background: The study of gene-environment interactions (G × E) is one of the most promising strategies to uncover the origins of mental disorders. Replication of initial findings, however, is essential because there is a strong possibility of publication bias in the literature. In addition, there is a scarcity of research on the topic originated from low- and middle-income countries (LMIC). The aim of this study was to replicate G × E hypotheses for externalizing problems among adolescents in a middle-income country. Methods: As part of the Pelotas 1993 Birth Cohort Study, 5,249 children were enrolled at birth and followed up to the age of 15 years, with an 85.7% retention rate. We sought an interaction between the homozygosity of the 10-repeat allele at the dopamine transporter (DAT1) gene and prenatal maternal smoking in the development of hyperactivity problems during adolescence assessed by the Strengths and Difficulties Questionnaire. We also tested for an interaction between the uVNTR polymorphism at the monoamine oxidase A (MAOA) and the experience of childhood maltreatment in the occurrence of conduct problems among adolescent boys. Results: Although there was a clear association between prenatal maternal smoking and hyperactivity scores in adolescence (p < 0.001), no main genetic or interaction effects for the DAT1 gene were detected. Similarly, childhood maltreatment showed to be associated with conduct problems among boys (p < 0.001), with no observable main genetic or interaction effects for the MAOA gene. Conclusions: In the largest mental health G × E study performed in a LMIC to date, we did not replicate previous positive findings from the literature. Despite the presence of main environmental effects, there was no evidence of effect modification by genotype status. Additional replication efforts to measure G × E are needed to better understand the origins of mental health and illness, especially in LMIC.
Journal of Child Psychology and Psychiatry 12/2012; · 4.28 Impact Factor
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ABSTRACT: BACKGROUND: We assessed anthropometric status, breastfeeding duration, morbidity, and mortality outcomes during the first four years of life according to gestational age, in three populationbased birth cohorts in the city of Pelotas, Southern Brazil. METHODS: Total breastfeeding duration, neonatal mortality, infant morbidity and mortality, and anthropometric measures taken at 12 and 48 months were evaluated in children of different gestational ages born in 1982, 1993 and 2004 in Southern Brazil. RESULTS: Babies born <34 weeks of gestation and those born between 34-36 weeks presented increased morbidity and mortality, were breastfed for shorter periods, and were more likely to be undernourished at 12 months of life, in comparison with the 39-41 weeks group. Children born with 37 weeks were more than twice as likely to die in the first year of life, and were also at increased risk of hospitalization and underweight at 12 months of life. Post-term infants presented an increased risk of neonatal mortality. CONCLUSION: The increased risks of morbidity and mortality among preterm (<37 weeks of gestation) and post-term (>41 weeks) are well known. In our population babies born at 37 also present increased risk. As the proportion of preterm and early term babies has increased markedly in recent years, this is a cause for great concern.
BMC Pediatrics 10/2012; 12(1):169. · 1.88 Impact Factor
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ABSTRACT: BACKGROUND: Socioeconomic inequalities in child nutrition may change rapidly over time, particularly in populations undergoing the nutrition transition. Yet, the few available studies are repeated cross-sectional surveys. By studying three prospective birth cohorts in the same city over a period of more than two decades, we describe secular trends in overweight and stunting at different ages, according to socioeconomic position. METHODS: Population-based birth cohort studies were launched in the city of Pelotas (Brazil) in 1982, 1993 and 2004, with follow-up visits at twelve, 24 and 48 months. Children were weighed and measured at every visit. Z-scores of length/height-for-age and body mass index-for-age were calculated using the WHO Child Growth Standards. The slope and relative indices of inequality, based on family income quintiles, were estimated for each follow-up visit. RESULTS: Between the 1982 and 2004 cohorts, stunting among four-year-olds declined (from 10.9% to 3.6%), while overweight increased (from 7.6% to 12.3%). In every visit, stunting prevalence was inversely related to income. Both absolute and relative inequalities declined over time; among four-year-olds stunting dropped from 26.0% in the 1982 cohort to 6.7% in the 2004 cohort in the poorest group, while in the richest group stunting prevalence dropped from 2.7% in 1982 to 1.1% in the 2004 cohort study. The secular trend towards increased overweight was evident for four-year-olds, in almost all socioeconomic groups, but not among one and two-year-olds. Among four-year old children, overweight prevalence increased in all income quintiles, by 130% in the middle-income group, 64% in the poorest and 41% in the richest group. CONCLUSIONS: The decline in stunting is remarkable, but the increase in overweight among four-year olds - particularly among the poorest and the middle-income groups- requires concerted efforts to prevent the long term consequences of child overweight.
BMC Public Health 07/2012; 12(1):511. · 2.00 Impact Factor
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ABSTRACT: OBJECTIVE: To investigate the association of family income at birth with BMI among young adults who have been followed since birth. DESIGN: A birth cohort study. SETTING: In 1982, all children born in Pelotas, southern Brazil, were included in a perinatal survey and visited at ages 1, 2, 4, 15, 18-19 and 23 years. SUBJECTS: Cohort members (n 4297) were traced and interviewed in 2004-2005. In all follow-ups, participants were weighed and measured, and BMI and prevalence of obesity were calculated for each age. Family income was obtained in minimum wages in 1982 and as a continuous variable, in reais, in later follow-ups. Skin colour was self-reported in 2004-2005. RESULTS: Mean BMI and prevalence of obesity differed between males and females. In males, a direct relationship was found throughout life and among females this relationship was modified by age. During childhood, BMI was higher among girls from higher income groups and this association was inversed at age 23 years. At this same age, mean BMI among black women was 1·3 kg/m2 higher than among white women, even after adjustment for current family income. CONCLUSIONS: The findings show in men that the relationship between income and BMI is similar to that seen in less developed areas, whereas among adult women the relationship is similar to that observed in developed countries. In addition to the effect of socio-economic status, skin colour also has an influence on the BMI of adult women.
Public Health Nutrition 07/2012; · 2.17 Impact Factor
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ABSTRACT: The Developmental Origins of Health and Disease hypothesis suggests that intrauterine, infancy and early childhood variables play a key role at programming later health. However, little is known on the programming of behavioral variables, because most studies so far focused on chronic disease-related and human capital outcomes. The aim of the present study was to evaluate the effects of prenatal, infancy and childhood weight and length/height gains on objectively-measured physical activity (PA) in adolescence.
This is a prospective birth cohort study in Pelotas, Brazil, including 457 adolescents (mean age: 13.3 years) with weight and length/height data at birth, one, three and six months, one and four years of age. PA was measured using a GT1M Actigraph accelerometer, and expressed as (a) minutes per day spent on sedentary, light, moderate, vigorous and very-vigorous activities; (b) total counts per day.
61.3% of the adolescents accumulated 60+ minutes of moderate-to-vigorous PA per day. Weight and length/height trajectories in infancy and childhood were similar between those classified as active or inactive at 13.3 years. However, those classified as inactive were heavier and taller at all ages; differences were statistically significant only in terms of length at three, six and 12 months.
Weight gain in infancy and childhood did not predict variability in adolescent PA, but those active in adolescence showed somewhat smaller average gains in length in infancy. These findings suggest that PA may partially be sensitive to early hormonal programming, or that genetic factors may affect both early growth and later metabolism or predisposition for PA.
International Journal of Behavioral Nutrition and Physical Activity 07/2012; 9:82. · 3.83 Impact Factor
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ABSTRACT: To verify the impact of flour fortification on anaemia in Brazilian children. The survey also investigated the role of Fe deficiency as a cause of anaemia and estimated the bioavailability of the Fe in the children's diet. This local study was complemented by a nationwide survey of the types of Fe compounds added to flour.
Series of population-based surveys conducted in 2004 (baseline study), 2005, 2006 and 2008.
Pelotas, Rio Grande do Sul, Brazil.
Children under 6 years of age residing in the urban area of the city of Pelotas, Southern Brazil (n 507 in 2004; n 960 in 2005; n 893 in 2006; n 799 in 2008). In 2008, a sub-sample of children (n 114) provided venous blood samples to measure body Fe reserve parameters (ferritin and transferrin saturation).
We found no impact of fortification, with an increase in anaemia prevalence among children under 24 months of age. Hb levels decreased by 0·9 g/dl in this age group between 2004 and 2008 (10·9 g/dl to 10·0 g/dl; P < 0·001). Roughly 50 % of cases of anaemia were estimated to be due to Fe deficiency. Half of the mills surveyed used reduced Fe to fortify wheat flour. Total Fe intake from all foodstuffs was adequate for 88·6 % of the children, but its bioavailability was only 5 %.
The low bioavailability of the Fe compounds added to flours, combined with the poor quality of children's diets, account for the lack of impact of mandatory fortification.
Public Health Nutrition 06/2012; 15(10):1796-801. · 2.17 Impact Factor
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ABSTRACT: Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition.
Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure
Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted.
Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions.
Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.
Food and nutrition bulletin 06/2012; 33(2 Suppl):S6-26. · 1.92 Impact Factor
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ABSTRACT: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country.
We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality.
Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals.
We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent.
Bill & Melinda Gates Foundation, Norad, The World Bank.
The Lancet 03/2012; 379(9822):1225-33. · 38.28 Impact Factor
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ABSTRACT: We assessed the influence of season of birth on duration of breastfeeding and other feeding patterns in three population-based birth cohort studies in the city of Pelotas, Southern Brazil.
In 1982, 1993 and 2004, all hospital-born children in the city were enrolled in three cohort studies (n = 5914, 5249 and 4287, respectively). Children and their mothers were periodically visited in the first 2 years of life, to collect information on the duration of breastfeeding and the ages at which different types of foods were introduced on a regular basis. Two independent variables were studied: month of birth and mean environmental temperature in the first month of life. Survival analyses and chi-squared tests were used to evaluate the associations. Temperature-based slope indices of inequality were also calculated.
Duration of breastfeeding was lower among children born from April to June (months preceding winter) and spending their first month of life in colder temperatures. The influence of season of birth on breastfeeding patterns and the introduction of cow's milk differed according to maternal education, with the strongest effects among children belonging to less educated mothers. Early introduction of fruits (1982 and 1993 cohorts) and vegetables (1982 cohort) were also associated with lower environmental temperature in the first month of life, but not with trimester of birth.
Colder temperatures adversely affect duration of breastfeeding and feeding patterns in infancy, especially among the poorest. This finding should be considered in breastfeeding promotion programmes.
International Journal of Epidemiology 02/2012; 41(3):743-52. · 6.41 Impact Factor
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ABSTRACT: The number of cesarean sections (CSs) is increasing in many countries, and there are concerns about their short- and long-term effects. A recent Brazilian study showed a 58% higher prevalence of obesity in young adults born by CS than in young adults born vaginally. Because CS-born individuals do not make contact at birth with maternal vaginal and intestinal bacteria, the authors proposed that this could lead to long-term changes in the gut microbiota that could contribute to obesity.
We assessed whether CS births lead to increased obesity during childhood, adolescence, and early adulthood in 3 birth cohorts.
We analyzed data from 3 birth-cohort studies started in 1982, 1993, and 2004 in Southern Brazil. Subjects were assessed at different ages until 23 y of age. Poisson regression was used to estimate prevalence ratios with adjustment for ≤15 socioeconomic, demographic, maternal, anthropometric, and behavioral covariates.
In the crude analyses, subjects born by CS had ∼50% higher prevalence of obesity at 4, 11, and 15 y of age but not at 23 y of age. After adjustment for covariates, prevalence ratios were markedly reduced and no longer significant for men or women. The only exception was an association for 4-y-old boys in the 1993 cohort, which was not observed in the other 2 cohorts or for girls.
In these 3 birth cohorts, CSs do not seem to lead to an important increased risk of obesity during childhood, adolescence, or early adulthood.
American Journal of Clinical Nutrition 02/2012; 95(2):465-70. · 6.67 Impact Factor
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ABSTRACT: The aim of this study was to investigate the cross-sectional and prospective associations between physical activity and body composition in adolescence. This is a prospective study, including 4,103 adolescents belonging to the Pelotas (Brazil) 1993 birth cohort, who were followed up at the mean ages of 11.3 and 14.7 years. Subsample analyses included 511 individuals with accelerometry and deuterium dilution data at 13.3 years. Sum of skinfolds at age 11.3 years was highly correlated with skinfolds at age 14.7 years (rho = 0.74, P < 0.001). More than 85% of participants remained in the same quintile or changed by not more than one quintile during the 3.4 year period. Tracking of physical activity was considerably lower, although still significant; the correlation was 0.24 (P < 0.001) and 61.4% of the adolescents moved one or less quintiles. In fully-adjusted models, no significant cross-sectional or longitudinal associations were found between physical activity and body composition, neither in boys nor in girls. These null results were confirmed in the 511 individuals with accelerometry and deuterium data. We provide evidence of tracking of physical activity and particularly body composition during adolescence. Our results do not support the hypothesis that physical activity and fatness are strongly related in adolescents.
Journal of Sports Sciences 12/2011; 30(2):183-90. · 1.93 Impact Factor
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International Journal of Epidemiology 12/2011; 40(6):1461-8. · 6.41 Impact Factor
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ABSTRACT: To measure within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators in sub-Saharan Africa and quantify its contribution to the national health service coverage gap.
Coverage data for child and maternal health services in 28 sub-Saharan African countries were obtained from the 2000-2008 Demographic Health Survey. For each country, the national coverage gap was determined for an overall health service coverage index and select individual health service indicators. The data were then additively broken down into the coverage gap in the wealthiest quintile (i.e. the proportion of the quintile lacking a required health service) and the population attributable risk (an absolute measure of within-country wealth-related inequality).
In 26 countries, within-country wealth-related inequality accounted for more than one quarter of the national overall coverage gap. Reducing such inequality could lower this gap by 16% to 56%, depending on the country. Regarding select individual health service indicators, wealth-related inequality was more common in services such as skilled birth attendance and antenatal care, and less so in family planning, measles immunization, receipt of a third dose of vaccine against diphtheria, pertussis and tetanus and treatment of acute respiratory infections in children under 5 years of age.
The contribution of wealth-related inequality to the child and maternal health service coverage gap differs by country and type of health service, warranting case-specific interventions. Targeted policies are most appropriate where high within-country wealth-related inequality exists, and whole-population approaches, where the health-service coverage gap is high in all quintiles.
Bulletin of the World Health Organisation 12/2011; 89(12):881-90. · 4.64 Impact Factor
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Christopher W Kuzawa,
Pedro C Hallal,
Linda Adair,
Santosh K Bhargava,
Caroline H D Fall,
Nanette Lee,
Shane A Norris,
Clive Osmond,
Manuel Ramirez-Zea,
Harshpal Singh Sachdev,
Aryeh D Stein, Cesar G Victora
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ABSTRACT: To evaluate the associations between birth weight (BW), infancy, and childhood weight gain and adult body composition.
Subjects included participants of five birth cohort studies from low and middle income nations (Brazil, Guatemala, India, Philippines, and South Africa; n = 3432). We modeled adult body composition as a function of BW and conditional weight gain (CW), representing changes in weight trajectory relative to peers, in three age intervals (0-12 months, 12-24 months, 24 months-mid childhood).
In 34 of 36 site- and sex-specific models, regression coefficients associated with BW and CWs were higher for adult fat-free than for fat mass. The strength of coefficients predicting fat-free mass relative to those predicting fat mass was greatest for BW, intermediate for CWs through 24 months, and weaker thereafter. However, because fat masses were smaller and showed larger variances than fat-free masses, weaker relationships with fat mass still yielded modest but significant increases in adult % body fat (PBF). CW at 12 months and mid-childhood tended to be the strongest predictors of PBF, whereas BW was generally the weakest predictor of PBF. For most early growth measures, a 1 SD change predicted less than a 1% change in adult body fat, suggesting that any health impacts of early growth on changes in adult body composition are likely to be small in these cohorts.
BW and weight trajectories up to 24 months tend to be more strongly associated with adult fat-free mass than with fat mass, while weight trajectories in mid-childhood predict both fat mass and fat-free mass.
American Journal of Human Biology 11/2011; 24(1):5-13. · 2.27 Impact Factor
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ABSTRACT: Birth weight has been inversely associated with later blood pressure. Firstborns tend to have lower birth weight than their later-born peers, but the long-term consequences remain unclear. The study objective was to investigate differences between firstborn and later-born individuals in early growth patterns, body composition, and blood pressure in Brazilian adolescents. The authors studied 453 adolescents aged 13.3 years from the prospective 1993 Pelotas Birth Cohort. Anthropometry, blood pressure, physical activity by accelerometry, and body composition by deuterium were measured. Firstborns (n = 143) had significantly lower birth weight than later borns (n = 310). At 4 years, firstborns had significantly greater weight and height, indicating a substantial overshoot in catch-up growth. In adolescence, first borns had significantly greater height and blood pressure and a lower activity level. The difference in systolic blood pressure could be attributed to variability in early growth and that in diastolic blood pressure to reduced physical activity. The magnitude of increased blood pressure is clinically significant; hence, birth order is an important developmental predictor of cardiovascular risk in this population. Firstborns may be more sensitive to environmental factors that promote catch-up growth, and this information could potentially be used in nutritional management to prevent catch-up "overshoot."
American journal of epidemiology 09/2011; 174(9):1028-35. · 5.59 Impact Factor
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ABSTRACT: This study was aimed at assessing the effect of maternal smoking during pregnancy on metabolic cardiovascular risk factors in early adulthood in a Brazilian birth cohort, after controlling for possible confounding variables and health behaviors in early adulthood.
In 1982, the maternity hospitals in Pelotas, southern Brazil, were visited and all births were identified. Those livebirths whose family lived in the urban area of the city were studied prospectively. In 2004-2005, we attempted to follow the whole cohort, the subjects were interviewed, examined and blood sample was collected. The following outcomes were studied: blood pressure; HDL cholesterol; triglycerides; random blood glucose and C-reactive protein. To explore the effect of maternal smoking, we adjusted the coefficients for the following possible mediators: perinatal factors (low birthweight and preterm births); adult behavioral factors (physical activity, dietary pattern, intake of fat and fiber, and tobacco smoking) and adult anthropometry (body mass index and waist circumference).
In 2004-2005, we interviewed 4297 subjects, with a follow-up rate of 77.4%. The only significant finding in the unadjusted analyses was lower HDL cholesterol among females. After adjustment for lifestyle variables in early adulthood, birthweight and waist circumference, the difference in HDL levels between offspring of smokers and non-smokers reduced from -2.10mg/dL (95% confidence interval: -3.39; -0.80) to -1.03 mg/dL (-2.35; 0.30).
Evidence that maternal smoking during pregnancy programs offspring metabolic cardiovascular risk factors are scarce, and reported associations are likely due to postnatal exposure to lifestyle patterns.
Atherosclerosis 08/2011; 219(2):815-20. · 3.79 Impact Factor
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Cesar G Victora
Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 08/2011; 27(8):1456-1457. · 0.83 Impact Factor
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Cesar G Victora,
Mauricio L Barreto,
Maria do Carmo Leal,
Carlos A Monteiro,
Maria Ines Schmidt,
Jairnilson Paim,
Francisco I Bastos,
Celia Almeida,
Ligia Bahia,
Claudia Travassos,
Michael Reichenheim,
Fernando C Barros
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ABSTRACT: Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.
The Lancet 06/2011; 377(9782):2042-53. · 38.28 Impact Factor
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ABSTRACT: To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries.
All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing - either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, Χ² tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used.
The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients.
C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor's schedule. Drastic action is called for to change the current situation.
Revista de saude publica 06/2011; 45(4):635-43. · 1.01 Impact Factor
