[Do depressive symptoms, anxiety and stressful symptoms during pregnancy affect gestational weight gain?] / Sintomas depressivos, ansiedade e os sintomas estressantes durante a gravidez afetam o ganho de peso gestacional?

The scope of this article is to estimate the effects of symptoms of mental disorders during pregnancy (depressive symptoms, anxiety and stress) on gestational weight gain (kg). It is a longitudinal study, carried out with data from the BRISA Birth Cohort, which was launched in 2010 in São Luís, Maranhão. Gestational weight gain was classified according to the Institute of Medicine. The independent variable was a construct (latent variable) referred to as symptoms of mental disorders, made up of the depressive symptoms, anxiety and stressful symptoms variables (all on an ongoing basis). Structural equation modeling was used to investigate the association between mental health and weight gain. Regarding the association between symptoms of mental disorders and weight gain during pregnancy, no total effect was found (PC=0.043; p=0.377). Regarding indirect effects, no effect was found either through risk behaviors (PC=0.03; p=0.368) or through physical activity (PC=0.00; p=0.974). Finally, the data did not show a direct effect of symptoms of mental disorders during pregnancy such as gestational weight gain (PC=0.050; p=0.404). Gestational weight gain had no direct, indirect or total effect on symptoms of mental disorders in pregnant women.

O objetivo deste artigo é estimar os efeitos dos sintomas de transtornos mentais na gravidez (sintomas depressivos, ansiedade e estresse) no ganho de peso gestacional. Estudo longitudinal, realizado com dados da Coorte de nascimento BRISA, iniciada em 2010 em São Luís, Maranhão. O ganho de peso gestacional foi classificado de acordo com Institute of Medicine. A variável independente foi um construto (variável latente) nomeado de sintomas de transtornos mentais, englobando as variáveis sintomas depressivos, a ansiedade e os sintomas estressantes (todas de forma contínua). Utilizou-se modelagem de equações estruturais, a fim de investigar a associação entre a saúde mental e ganho de peso. Em relação a associação entre sintomas de transtornos mentais e ganho de peso na gestação, não se encontrou efeito total (CP=0,043; p=0,377). Em relação aos efeitos indiretos, também não se encontrou efeito através dos comportamentos de risco (CP=0,03; p=0,368) e através da atividade física (CP=0,00; p=0,974). Finalmente os dados não evidenciaram efeito direto dos sintomas de transtornos mentais durante a gravidez como o ganho de peso gestacional (CP=0,050; p=0,404). O ganho de peso gestacional não apresentou efeito direto, indireto e total nos sintomas de transtornos mentais de gestantes.

Challenges in the care of children born to mothers diagnosed with COVID-19 during the pandemic.

OBJECTIVE: To understand the challenges in the care of children born to mothers with COVID-19 during the pandemic. METHOD: Qualitative research, conducted from November 2020 to May 2021, in two public maternity hospitals, with women who had children during the first wave of the pandemic, diagnosed with COVID-19 during pregnancy and/or childbirth. There were nineteen semi-structured interviews with thematic analysis. Symbolic Interactionism was used as a theoretical framework. RESULTS: Changes in the care for newborn children were identified. In the domestic environment, hygiene measures with the newborn children were intensified, social isolation restricted the support network and mothers felt alone and overwhelmed. In terms of health care, there was a setback in neonatal care and interruption of professional care, such as the suspension of appointments. CONCLUSION: The pandemic has restructured traditional models of family care, intensified difficulties in accessing healthcare, and exposed children to inherent risks due to a lack of proper follow-up.

Maternal health during the COVID-19 pandemic: Experiences of health workers in three Brazilian municipalities.

OBJECTIVE: To analyze the experiences of maternal health workers in three Brazilian cities, located in the Northeast (São Luís), Southeast (Niterói), and South (Pelotas) regions during the first year of the COVID-19 pandemic. METHODS: Qualitative research carried out between December 2020 and February 2021. Interviews were conducted, in person or remotely, with 30 health workers, doctors and nurses, working in maternity hospitals of different degrees of complexity. RESULTS: Sociodemographic characteristics, employment relationships and professional qualification of the interviewees were described. Two thematic axes were identified: 1) changes in hospital organization and dynamics in the pandemic; 2) Illness and suffering of health workers. The majority of respondents were women. Most physicians had work relationships in the public and private sectors. In Niterói, health workers had better professional qualifications and more precarious work relationships (as temporary hires), compared to São Luís and Pelotas. In the context of the uncertainties resulting from the pandemic, this situation generated even more insecurity for those workers. The statements at the beginning of the pandemic covered topics such as changes in the organizational dynamics of services, healthcare, telemedicine, and interaction between health workers and users. In the health workers' perception, the initial period of the health emergency, which resulted in intense changes in the provision of services, was marked by an increase in preterm births, perinatal mortality, and fetal losses. Work overload, fear of contamination, concern for family members and uncertainties regarding the new disease caused intense suffering in health workers who had little institutional support in the cities studied. The suffering experienced by health workers went beyond the work dimension, reaching their private life. CONCLUSION: Changes caused by the pandemic required immediate adjustments in professional practices, generating insecurities in healthcare regardless of the location studied. The method of hiring health workers remained the same as the previously practiced one in each city. Due to the risk of disease transmission, measures contrary to humanization practices, and more restrictive in São Luís, were reported as harmful to obstetric care. The Covid-19 pandemic was a huge challenge for the Brazilian health system, aggravating the working conditions experienced by health workers. In addition to the work environment, it was possible to briefly glimpse its effects on private life.

Experiences of women in prenatal, childbirth, and postpartum care during the COVID-19 pandemic in selected cities in Brazil: The resignification of the experience of pregnancy and giving birth.

The COVID-19 pandemic has impacted public and private health systems around the world, impairing good practices in women's health care. However, little is known about the experiences, knowledge, and feelings of Brazilian women in this period. The objective was to analyze the experiences of women, seen at maternity hospitals accredited by the Brazilian Unified Health System (SUS, acronym in Portuguese), regarding health care during pregnancy, childbirth, and postpartum periods, their interpersonal relationships, and perceptions and feelings about the pandemic. This was a qualitative, exploratory research, carried out in three Brazilian municipalities with women hospitalized in 2020, during pregnancy, childbirth, or postpartum period, with COVID-19 or not. For data collection, semi-structured individual interviews (in person, by telephone, or by digital platform) were conducted, recorded and transcribed. The content analysis of thematic modalities was displayed as per the following axes: i) Knowledge about the disease; ii) Search for health care in prenatal, childbirth, and postpartum periods; iii) Experience of suffering from COVID-19; iv) Income and work; and v) Family dynamics and social support network. A total of 46 women were interviewed in São Luís-MA, Pelotas-RS, and Niterói-RJ. Use of media was important to convey information and fight fake news. The pandemic negatively impacted access to health care in the prenatal, childbirth, and postpartum periods, contributing to worsening of the population's social and economic vulnerabilities. Women experienced diverse manifestations of the disease, and psychic disorders were very frequent. Social isolation during the pandemic disrupted the support network of these women, who found social support strategies in communication technologies. Women-centered care-including qualified listening and mental health support-can reduce the severity of COVID-19 cases in pregnant, parturient, and postpartum women. Sustainable employment and income maintenance policies are essential to mitigate social vulnerabilities and reduce risks for these women.

[Childbirth care in health services affiliated with the Stork Network in Brazil: the users' perspective]. / Acolhimento ao parto em estabelecimentos de saúde vinculados à Rede Cegonha no Brasil: a perspectiva das usuárias.

This study aimed to analyze sociodemographic and reproductive factors associated with childbirth care in health services affiliated with the Stork Network in Brazil, from the users' perspective. The sample included 10,540 postpartum women from 606 services. The outcome was the latent variable reception of the patient, consisting of five indicators: healthcare staff members introducing themselves stating their names and roles, calling the pregnant woman by her name, the patient's understanding of the information provided, the patient feeling well treated and respected, and the patient having her needs met by the staff. The explanatory variables were maternal age, schooling, skin color, marital status, type of delivery, parity, and number of services visited before admission for childbirth. Most of the women were 20 to 34 years of age (68.31%), self-identified as brown (56.3%), had 9 to 11 years of schooling (56.1%), and were married or lived with the partner (78.8%). There was a predominance of vaginal delivery (56.6%), with one or two previous children (46%), and reports of not having gone to more than one maternity service to be admitted (91.9%). There was a direct positive effect on reception for childbirth from patient´s higher age (SC = 0.094; p < 0.001) and more schooling (SC = 0.096; p < 0.001). Cesarean delivery had a direct negative effect (SC = -0.059; p < 0.002), and black and brown skin color had direct and indirect negative effects (SC = -0.081; p < 0.001 and SC = -0.014; p < 0.001). Older postpartum women and those with more schooling and vaginal delivery had a more positive perception of their reception by maternity services.

Este estudo objetivou analisar os fatores sociodemográficos e reprodutivos associados ao acolhimento ao parto em estabelecimentos de saúde vinculados à Rede Cegonha no Brasil, na perspectiva das usuárias. Foram selecionados 606 serviços com amostra de 10.540 puérperas. O desfecho foi a variável latente acolhimento da puérpera, composta por cinco indicadores: apresentação dos profissionais com nome e função, chamar a gestante pelo nome, compreensão das informações dadas, se sentir bem tratada e respeitada e ter as necessidades respondidas pela equipe. As variáveis explicativas foram: idade, escolaridade, cor da pele, situação conjugal, tipo de parto, paridade e peregrinação. Foi utilizada modelagem de equações estruturais. Observaram-se maiores percentuais de mulheres com idade de 20 a 34 anos (68,31%), que se autodeclararam como pardas (56,3%), com escolaridade entre 9 e 11 anos de estudo (56,1%) e que tinham companheiro (78,8%). Houve predominância de puérperas que tiveram parto vaginal (56,6%), com um a dois filhos (46%) e que relataram não peregrinar (91,9%). Apresentaram efeito direto positivo sobre o acolhimento mulheres com maior idade (CP = 0,094; p < 0,001) e maior escolaridade (CP = 0,096; p < 0,001). O parto cesáreo apresentou efeito direto negativo (CP = -0,059; p < 0,002) e cor da pele preta e parda apresentou efeitos direto e indireto negativos (CP = -0,081; p < 0,001 e CP = -0,014; p < 0,001). Puérpera com maior idade, maior escolaridade e que tiveram parto vaginal tiveram percepção mais positiva do acolhimento nos serviços de saúde.

El objetivo de este estudio fue analizar los factores sociodemográficos y reproductivos, asociados a la acogida en el parto, en establecimientos de salud vinculados a la Red Cegonha en Brasil, desde la perspectiva de las usuarias. Se seleccionaron 606 servicios en una muestra de 10.540 puérperas. El resultado fue la variable latente de acogida de la puérpera, compuesta por cinco indicadores: presentación de los profesionales con nombre y función, llamar a la gestante por el nombre, comprensión de la información proporcionada, sentirse bien tratada y respetada y contar con las necesidades cubiertas por el equipo. Las variables explicativas fueron: edad, escolaridad, color de piel, situación conyugal, tipo de parto, paridad y desplazamientos largos. Se utilizó un modelado de ecuaciones estructurales. Se observaron mayores porcentajes de mujeres con una edad comprendida entre los 20 a los 34 años (68,31%), que se autodeclararon mestizas (56,3%), con una escolaridad entre 9 y 11 años de estudio (56,1%) y que tenían compañero (78,8%). Hubo una predominancia de puérperas que tuvieron un parto vaginal (56,6%), con de 1 a 2 hijos (46%) y que informaron no realizar grandes desplazamientos (91,9%). Presentaron un efecto directo positivo sobre la acogida mujeres con mayor edad (CP = 0,094; p < 0,001) y mayor escolaridad (CP = 0,096; p < 0,001). El parto por cesárea presentó un efecto directo negativo (CP = -0,059; p < 0,002) y color de la piel negra y mestiza presentó efectos directo e indirecto negativos (CP = -0,081; p < 0,001 e CP = -0,014; p < 0,001). Puérperas con mayor edad, mayor escolaridad y que tuvieran parto vaginal tuvieron una percepción más positiva de acogida en los servicios de salud.

Is sleep time associated with handgrip strength in adolescents from the 1997/1998 São Luís Birth Cohort?

This article aims to analyze the association between sleep time and handgrip strength in adolescents belonging to the 1997/1998 São Luís Birth Cohort. This was a cross-sectional study nested in a birth cohort study. One thousand two hundred sixty-nine individuals (18 and 19 years) wore an Actigraph® GTX3+ accelerometer on their wrist 24 hr/day for 7 consecutive days. Handgrip strength was measured using a digital hand dynamometer. We used directed acyclic graphs (DAG) to identify confounding variables. This sample of adolescents was mostly composed of men, with brown skin color, economic class C, which did not work, did not consume alcohol, did not smoke, and never used drugs. The mean value of handgrip strength was 28.2 (±9.3) kgf, and the mean of sleep time was 6 (±1.0) hours per day. The crude analysis showed an association between sleep time and muscle strength. An increase of one hour of sleep reduced the handgrip strength by 1.95 kgf (95%CI:-2.51;-1.39). However, after adjustment for confounders, the association was not maintained (ß:-0.07; 95%CI:-0.48;0.36). Sleep time is not associated with handgrip strength in adolescents in São Luís.

Prevalence of self-medication and associated factors in adolescents aged 18-19 years: the 1997/1998 cohort in São Luís-MA, Brazil.

This article aims to assess the prevalence and factors associated with self-medication in adolescents. Cross-sectional study, nested in cohort, with 2,515 adolescents aged 18-19 years born in São Luís-MA. The use of medication in the last 15 days without a medical prescription or by a qualified professional was considered self-medication. Factors associated with self-medication were evaluated using Poisson regression with robust variances and hierarchical selection of variables. Medicines were used in the last 15 days by 48.05% of adolescents. Among these, 70.09% use it without a prescription or indication from another health professional. The most used medications for self-medication were "over the counter" (93.68%). Self-medication was positively associated with female gender (PR: 1.41; 95%CI: 1.25-1.59), screen time ≥5h/day (PR: 1.32; 95%CI: 1.05-1.67) and self-reported diagnosis of allergic rhinitis (PR: 1.19; 95%CI: 1.02-1.39); however, negatively associated with self-satisfaction with health (PR: 0.79; 95%CI: 0.67-0.94) and hospitalization in the previous year (PR: 0.70; 95%CI: 0.50-0.97). Self-medication was common among adolescents and to reduce this practice, greater attention should be given to women, individuals with intense exposure to meshes and allergic diseases.

Decline in head circumference growth and associated factors in congenital Zika syndrome.

Little is known about the evolution of head circumference (HC) in children with congenital Zika syndrome (CZS). This study aims to evaluate HC growth in children with CZS in the first three years of life and identify associated factors. HC data obtained at birth and in neuropediatric consultations from 74 children with CZS were collected from the Child's Health Handbook, parents' reports, and medical records. Predictors of HC z-score were investigated using different mixed-effects models; Akaike's information criterion was used for model selection. The HC z-score decreased from -2.7 ± 1.6 at birth to -5.5 ± 2.2 at 3 months of age, remaining relatively stable thereafter. In the selected adjusted model, the presence of severe brain parenchymal atrophy and maternal symptoms of infection in the first trimester of pregnancy were associated with a more pronounced reduction in the HC z-score in the first three years of life. The decrease of HC z-score in CZS children over the first three months demonstrated a reduced potential for growth and development of the central nervous system of these children. The prognosis of head growth in the first 3 years of life is worse when maternal infection occurs in the first gestational trimester and in children who have severe brain parenchymal atrophy.

Physical activity in birth cohorts of three Brazilian cities (Ribeirão Preto, Pelotas, and São Luís): A cross-sectional study.

OBJECTIVE: To describe the prevalence of physical activity among subjects from birth cohorts of three cities located in different regions of Brazil according to sociodemographic characteristics and sex, comparing the relationships within and between cohorts. METHODS: Cross-sectional study involving 12,724 adolescents and young adults who participated in five birth cohorts: Ribeirão Preto [1978/79 (37/39 years old in 2016) and 1994 (22 years in 2016)]; Pelotas [1982 (30 years in 2012) and 1993 (22 years in 2015)], and São Luís [1997/98 (18/19 years in 2016)]. Leisure-time physical activity was evaluated with questionnaires (insufficiently active: <150 min/week and active: ≥150 min/week) and moderate and vigorous physical activity (MVPA) was objectively measured by accelerometry. Those, in each city, were evaluated accordingly to skin color, socioeconomic classification, and study/work activities. RESULTS: The prevalence of leisure-time physical activity ranged from 29.2% at 30 years old in Pelotas to 54.6% among adolescents from São Luís. The prevalence of leisure-time physical activity was higher among younger people (54.6% in São Luís 1997), while the same was not observed for total physical activity. MVPA (3rd tercile) was higher in the cohorts from Pelotas and São Luís. The prevalence of leisure-time physical activity and MVPA was higher in men. The data showed that the variation in physical activity was associated with sex and sociodemographic conditions in all cohorts. CONCLUSION: Sociodemographic characteristics should be considered when promoting leisure-time physical activity and actions aimed at young people, and adults who are more socioeconomically vulnerable should be encouraged.

[Therapeutic itinerary of children with microcephaly due to the Zika virus]. / Itinerário terapêutico de crianças com microcefalia pelo vírus Zika.

In 2015, there was an epidemic of microcephaly in Brazil that was associated with infection by the Zika virus. The condition of these children obliged the parents to embark on a quest in search of treatment. The scope of this study was to establish the therapeutic itinerary pursued in healthcare sectors by parents and/or caregivers of children with microcephaly due to the Zika virus. It involved qualitative research, conducted at a Center of Reference on Neurodevelopment between April 2017 and February 2018, with parents and/or caregivers of children with microcephaly caused by the Zika virus. The sample complied with the criteria of saturation. Twenty semi-structured interviews were conducted, recorded, and transcribed, and content analysis was applied. The results revealed disorientation and uncertainties in the search for care in the health sector. The most sought-after sector was the professional sector, followed by the informal sector. The information conveyed in the media and social networks, which constitute part of the informal sector, helped to clarify the significance of microcephaly and the Zika virus and assisted in the search for treatment. Care in the healthcare network was marked by difficulties and, faced with a new and emergency situation, the route between diagnosis and treatment was arduous.

Em 2015, no Brasil, houve uma epidemia de microcefalia que foi associada à infecção pelo vírus Zika. A condição destas crianças impulsionou os pais a percorrerem um caminho em busca por tratamento. O objetivo deste estudo foi conhecer o itinerário terapêutico percorrido por pais e/ou cuidadores de crianças com microcefalia pelo vírus Zika nos setores de atenção à saúde. Pesquisa de abordagem qualitativa, realizada em um Centro de Referência em Neurodesenvolvimento, no período de abril de 2017 a fevereiro de 2018, com pais e/ou cuidadores de crianças com microcefalia pelo vírus Zika. A amostra obedeceu aos critérios de saturação de sentidos. Foram feitas 20 entrevistas semiestruturadas, gravadas e transcritas. Realizou-se análise de conteúdo, na modalidade temática. Os resultados demostraram desorientação e incertezas na busca pelo cuidado nos setores de saúde. O setor mais procurado foi o profissional, seguido pelo informal e popular. As informações veiculadas na mídia e redes sociais, que fazem parte do setor informal, contribuíram para esclarecer o significado da microcefalia e vírus Zika e auxiliou na busca por tratamento. O cuidado na rede de Atenção à Saúde foi marcado pela peregrinação. Diante de uma situação nova e emergencial, o caminho percorrido, entre o diagnóstico e o tratamento, foi árduo.

[Association between psychological violence and posttraumatic stress disorder in a cohort of Brazilian adolescents]. / Associação entre a violência psicológica e o transtorno de estresse pós-traumático em adolescentes de uma coorte.

The study analyzed the impact of psychological violence on the development of posttraumatic stress disorder (PTSD). This was a cross-sectional study nested in a cohort in which the second follow-up was conducted in 2016. A questionnaire was applied to 2,486 adolescents and approached individual, family, and social aspects and experience with psychological violence. Propensity score was used to create inverse probability weighting (IPW). Thus, a probability was assigned to each adolescent, where 1/IPW represent those in the exposed group and 1/(1-IPW) those in the unexposed group. This procedure made the two groups more homogeneous and mutually comparable. The association between the occurrence of psychological violence and PTSD was estimated by odds ratios (OR) and 95% confidence intervals (95%CI) via crude binary logistic regression and adjusted logistic regression (weighted by IPW). According to the results, 30.3% reported having suffered severe violence. Prevalence of PTSD was 4.8% among exposed and 1.5% in unexposed to psychological violence. An association was observed between severe violence and PTSD in the two analyses, but the magnitude in the model structured by the propensity score (OR = 1.97; 95%CI: 1.08-3.56) indicated an adjustment to the measure from the crude analysis (OR = 3.40; 95%CI: 2.03-5.69). The current study contributes to the scarce literature on exposure to psychological violence and its association with the development of PTSD, confirming the negative impact of this form of abuse on the individual´s mental health.

Este trabalho analisou a influência da ocorrência de violência psicológica no desenvolvimento de transtorno de estresse pós-traumático (TEPT) em adolescentes. Tratou-se de um estudo transversal aninhado a uma coorte, cujo segundo segmento foi realizado em 2016. Aplicou-se um questionário em 2.486 adolescentes, por meio do qual se abordou aspectos individuais, familiares, sociais e da vivência de violência psicológica. Utilizou-se o escore de propensão para se criar o inverso da probabilidade de seleção (IPS). Dessa forma, atribuiu-se uma probabilidade para cada adolescente, sendo 1/IPS aqueles que compõem o grupo dos expostos e 1/(1-IPS) aqueles do grupo dos não expostos. Essa condição tornou os dois grupos mais homogêneos e comparáveis entre si. A associação entre a ocorrência de violência psicológica e de TEPT foi estimada pela odds ratio (OR), enquanto o intervalo de 95% de confiança (IC95%) foi estimado por meio da regressão logística binária bruta e ajustada, ponderada pelo IPS. Verificou-se que 30,3% relataram ter sofrido violência severa. A prevalência do TEPT foi de 4,8% entre os expostos contra 1,5% entre os não expostos à violência psicológica. Observou-se uma associação da violência severa com o TEPT nas duas análises realizadas. Porém, a magnitude no modelo estruturado pelo escore de propensão (OR = 1,97; IC95%: 1,08-3,56) indicou um ajuste da medida de associação da análise bruta (OR = 3,40; IC95%: 2,03-5,69). Nesse sentido, este estudo contribui para a escassa literatura sobre a exposição à violência psicológica e a sua associação com o desenvolvimento de TEPT, confirmando o impacto negativo dessa forma de abuso na saúde mental do indivíduo.

Se analizó la influencia de la ocurrencia de violencia psicológica en el desarrollo de trastorno de estrés postraumático (TEPT). Se trató de un estudio transversal anidado en una cohorte, cuyo segundo seguimiento se realizó en 2016. Se aplicó un cuestionario en 2.486 adolescentes, a través del cual se abordaron aspectos individuales, familiares, sociales, así como de vivencia de violencia psicológica. Se utilizó el marcador de propensión para que se creara el inverso de la probabilidad de selección (IPS). De esta forma, se atribuyó una probabilidad para cada adolescente, siendo 1/IPS para aquellos que componen el grupo de expuestos y 1/(1-IPS) para aquellos del grupo no expuestos. Esta condición hizo los dos grupos más homogéneos y comparables entre sí. La asociación entre ocurrencia de violencia psicológica y TEPT se estimó mediante OR (odds ratio) y el IC95% (intervalo de 95% de confianza) por medio de la regresión logística binaria bruta y ajustada (ponderada por el IPS). Se verificó que un 30,3% informaron haber sufrido violencia severa. La prevalencia del TEPT fue de un 4,8% entre los expuestos contra un 1,5% en no expuestos a la violencia psicológica. Se observó una asociación de la violencia severa con el TEPT en los dos análisis realizados, no obstante, la magnitud en el modelo estructurado por el marcador de propensión (OR = 1,97; IC95%: 1,08-3,56) indicó un ajuste de la medida de asociación del análisis bruto (OR = 3,40; IC95%: 2,03-5,69). Este estudio contribuye a la escasa literatura sobre la exposición de violencia psicológica y su asociación con el desarrollo del TEPT, confirmando el impacto negativo de esa forma de abuso en la salud mental del individuo.

Social participation and self-assessment of health status among older people in Brazil.

To estimate the prevalence of social participation (exposure) and its association with positive self-assessment of overall health status (SAH) (outcome) among 7,712 Brazilian elderly interviewed in the National Health Survey 2013. A cross-sectional study that used Propensity Score (PS) to improve comparability between the group exposed and no exposed to social participation. Poisson regression was performed to determine the prevalence and association of interest using crude and adjusted by inverse probability of selection of PS. Social participation was reported by 25.1% (CI95%: 23.4-26.9) and was lower among poor older people, who depend on public transportation and live in more precarious contexts. Most did not SAH positively, but the proportion was higher when they had social participation (48.0%; CI95%: 46.0-51.0). There was a positive association of social participation with SAH positive. The association using the adjusted model (PR: 1.15; CI95%: 1.08-1.22) attenuated the estimated in the crude model. Elderly exposed were 15% more likely to provide a positive SAH. Despite low levels in Brazil, there was a positive association between of social participation and SAH, confirming that engagement in such activities provides important gains for the health and quality of life.

Racial inequality in obstetric good practices and interventions in labor and birth care in Rede Cegonha. / Desigualdade racial nas boas práticas e intervenções obstétricas no parto e nascimento em maternidades da Rede Cegonha.

This study aimed to evaluate the racial inequality on childbirth care at the Rede Cegonha (Stork Network) using obstetric good practice and interventions indicators. Racial inequality, measured by the total effect of ethnicity/skin color in the crude model, was seen in many indicators. After adjusting for mediators, such as age, schooling, parity, high-risk hospital, and geographic macro-regions, the persistent direct effect suggests racial discrimination against black women with lower partograph completion (PR 0.88; 95% CI 0.80-0.95). Black women stayed less in lithotomy (PR 0.93; 95% CI 0.89-0.98), performed less episiotomy (PR 0.81; 95% CI 0.68 - 0.96), and had less episiotomy suturing pain (PR 0.66; 95% CI 0.51 - 0.87) when compared to white women, suggesting more good practice applied to black women. However, according to the interventionist care model still adopted by many professionals, these practices are routine, and lower achievement in black women would be better interpreted as evidence of racial discrimination against these women. For other outcomes, the ethnicity/skin color effect disappeared after adjusting for mediators, suggesting mitigation or disappearance of the skin color effect in some practices/interventions in childbirth.

O objetivo do presente estudo foi avaliar desigualdade racial na atenção ao parto e ao nascimento na Rede Cegonha utilizando indicadores de boas práticas e intervenções obstétricas. Desigualdade racial, mensurada pelo efeito total da raça/cor no modelo sem ajuste, foi detectada em muitos indicadores. A persistência do efeito direto, após ajuste para os mediadores idade, escolaridade, paridade, hospital de alto risco e região geográfica, sugere discriminação racial contra as pretas, que tiveram menos partograma preenchido (RP 0,88; IC 95% 0,80-0,95). Comparadas às brancas, as pretas ficaram menos em litotomia (RP 0,93; IC95% 0,89-0,98), realizaram menos episiotomia (RP 0,81; IC95% 0,68-0,96) e tiveram menos dor na sutura da episiotomia (RP 0,66; IC95% 0,51-0,87), sugerindo que boas práticas estariam sendo mais realizadas nas pretas. Entretanto, pelo modelo intervencionista de assistência, ainda adotado por muitos profissionais, essas práticas são de rotina e a menor realização delas nas pretas seria melhor interpretada como evidência de discriminação racial a essas mulheres. Para outros desfechos, o efeito da raça/cor desapareceu após o ajuste para mediadores, sugerindo atenuação ou desaparecimento do efeito da cor da pele em algumas práticas/intervenções na assistência ao parto e nascimento.

Prevalence and factors associated with covid-19 vaccine hesitancy in Maranhão, Brazil.

OBJECTIVES: To estimate the prevalence and factors associated with hesitancy in getting the vaccine against SARS-CoV-2 in Maranhão, Brazil. METHODS: This is a cross-sectional population-based study conducted from October 19 to 30, 2020. The estimates were calculated based on clustering, stratification, and non-response. A three-stage sampling was adopted, considering stratum, census tracts, and domicile. After systematic analysis, thirty sectors were selected in each stratum, totaling 150 sectors. Each sector contained a fixed number of 34 households, thus totaling 5,100 households. One individual within each household (resident for at least six months and aged one year or more) was selected by a simple random sampling. We questioned participants about their vaccination intention. Univariate association between independent variables and the outcome were verified using descriptive analysis (weighted frequencies) and Pearson's chi-square test (p < 0.05). Robust multivariate analysis was performed using a three-level hierarchical model. RESULTS: We found 17.5% (95%CI 16.1-19.1%) of the 4,630 individuals interviewed to report hesitancy to be vaccinated against covid-19. After final model adjustment, vaccination hesitancy was statistically higher among residents of the cities of Imperatriz (24.0%; RP = 1.48; IC95% 1.09-2.02) and municipalities of the Grande Ilha de São Luís (20.7%; RP = 1.34; 95%CI 1.02-1.76), female individuals (19.8%; RP = 1.44; 95%CI 1.20-1.75), older adults (22.8%; RP = 1.79; IC95% 1.30-2.46), evangelicals (24.1%; RP = 1.49; 95%CI 1.24-1.79), and those without reported symptoms (18.6%; RP = 1.24; 95%CI 1.02-1.51). We found no statistical differences for other socioeconomic and demographic characteristics, as well as variables related to the labor market, behaviors, and health conditions of the interviewees. CONCLUSION: The prevalence of vaccine hesitancy in Maranhão and its association with individual, contextual, and clinical factors enable us to identify the groups and contexts of greatest resistance, requiring special attention from public strategies to ensure wide vaccination.

Reduction of inequities of access to appropriate childbirth care in Rede Cegonha. / Redução das iniquidades sociais no acesso às tecnologias apropriadas ao parto na Rede Cegonha.

This article compares the findings of "Avaliação da Rede Cegonha" (ARC - Stork Network Assessment), an evaluative study on the Rede Cegonha (RC - Stork Network) program, with Nascer no Brasil (NB - Born in Brazil), a national survey on labor and birth, conducted in 2011-12, before the start implementation of RC. ARC was conducted in 2017, in 606 maternity hospitals involved in RC and NB included a sample with national representation of 266 hospitals. In the current analysis, we included the 136 SUS hospitals that participated in both studies, totaling 3,790 and 12,227 puerperal women. We perform comparisons of best practices and interventions in the management of labor and delivery using Pearson's chi-square test for independent samples. The prevalence of best practices was, on average, 150% higher in ARC than in NB, with a greater relative increase in less developed regions, for older, brown and black women and less educated. Regarding interventions, there was an average reduction of 30% between NB and ARC, with a greater relative reduction in less developed regions and less educated women. There was a significant improvement in the scenario of care for labor and childbirth, with a reduction in regional, educational and racial inequalities in access to appropriate technologies, suggesting that the RC intervention was effective.

Este artigo compara os achados da Avaliação da Rede Cegonha (ARC), estudo avaliativo sobre o programa Rede Cegonha (RC), com o Nascer no Brasil (NB), inquérito nacional sobre parto e nascimento, realizado em 2011-12, antes do início da implementação da RC. A ARC foi conduzida em 2017, em 606 maternidades envolvidas na RC e o NB e empregou uma amostra com representatividade nacional de 266 hospitais. Na análise atual, incluímos os 136 hospitais do SUS que participaram de ambos os estudos, totalizando 3.790 e 12.227 puérperas, respectivamente. Realizamos as comparações de boas práticas e intervenções no manejo do trabalho de parto e de parto utilizando o teste qui-quadrado para amostras independentes. A prevalência das boas práticas foi, em média, 150% maior na ARC que no NB, com maior aumento relativo nas regiões menos desenvolvidas, para mulheres mais velhas, pardas e pretas e menos escolarizadas. Com relação às intervenções, houve redução média de 30% entre o NB e a ARC, com maior redução relativa nas regiões menos desenvolvidas e nas mulheres menos escolarizadas. Houve melhoria significativa no cenário da atenção ao trabalho de parto e parto, com diminuição de iniquidades regionais, de nível de instrução e raciais no acesso às tecnologias apropriadas, sugerindo que a intervenção da RC foi efetiva.

Labor and childbirth care in maternity facilities in Brazil's North and Northeast regions: perceptions of the evaluators of the Stork Network Program. / Atenção ao parto e nascimento em maternidades do Norte e Nordeste brasileiros: percepção de avaliadores da Rede Cegonha.

This article eevaluates delivery and birth care practices in maternity facilities in Brazil's North and Northeast regions. We conducted a qualitative evaluation of 91 facilities in the North and 181 facilities in the Northeast. The data was collected using systematic observation by a team of 44 previously trained evaluators and recorded in a field diary. A thematic analysis of the collected data was performed, resulting in three core themes: challenges of collegial management; challenges for coping with obstetric violence; and the potential of the evaluation process for driving change. Advances were made in the implementation of good labor and childbirth care practices; however, some maternity facilities still reproduce hierarchical models without spaces for collegial management and accounts of obstetric violence were common. Health professionals used the presence of risk to justify the low level of adoption of good practices. However, the findings reveal progress towards the humanization of care. The results also show the potential of the evaluation process for driving change. Although progress has been made towards the adoption of the good practices recommended by the Stork Network Program both in the area of management and care delivery, many challenges remain in view of the dominance of a hierarchical management model associated with an interventionist approach to health care.

O objetivo deste artigo é avaliar práticas de atenção ao parto e nascimento em maternidades do Norte e Nordeste brasileiros. Avaliação qualitativa realizada em 91 maternidades no Norte e 181 no Nordeste do Brasil. A técnica de pesquisa foi a observação sistematizada, realizada por 44 avaliadores previamente treinados e registrada em diário de campo. Foi realizada análise de conteúdo na modalidade temática. Os núcleos temáticos encontrados foram: Desafios da Gestão Colegiada; Desafios para o enfrentamento da Violência Obstétrica; e Potencial do processo avaliativo na indução de mudanças. Foram identificados avanços na implantação de boas práticas na gestão do cuidado e atenção à saúde, embora algumas maternidades ainda reproduzam um modelo hierárquico, sem espaços colegiados de gestão e com práticas de violência obstétrica. Situações de risco em gestantes justificaram menor adesão dos profissionais de saúde às boas práticas, ainda que ações em direção à humanização também tenham sido visibilizadas. Identificou-se a potência do processo avaliativo na indução de mudanças. Foram evidenciadas mudanças em direção às boas práticas preconizadas pela Rede Cegonha, tanto na gestão quanto na atenção, mas são muitos os desafios frente ao predomínio de um modelo de gestão hierárquico associado a um modelo de atenção com práticas intervencionistas.

RPS Brazilian Birth Cohorts Consortium (Ribeirão Preto, Pelotas and São Luís): history, objectives and methods.

This paper describes the history, objectives and methods used by the nine Brazilian cohorts of the RPS Brazilian Birth Cohorts Consortium (Ribeirão Preto, Pelotas and São Luís) Common thematic axes are identified and the objectives, baseline periods, follow-up stages and representativity of the population studied are presented. The Consortium includes three birth cohorts from Ribeirão Preto, São Paulo State (1978/1979, 1994 and 2010), four from Pelotas, Rio Grande do Sul State (1982, 1993, 2004 and 2015), and two from São Luís, Maranhão State (1997 and 2010). The cohorts cover three regions of Brazil, from three distinct states, with marked socioeconomic, cultural and infrastructure differences. The cohorts were started at birth, except for the most recent one in each municipality, where mothers were recruited during pregnancy. The instruments for data collection have been refined in order to approach different exposures during the early phases of life and their long-term influence on the health-disease process. The investigators of the nine cohorts carried out perinatal studies and later studied human capital, mental health, nutrition and precursor signs of noncommunicable diseases. A total of 17,636 liveborns were recruited in Ribeirão Preto, 19,669 in Pelotas, and 7,659 in São Luís. In the studies starting during pregnancy, 1,400 pregnant women were interviewed in Ribeirão Preto, 3,199 in Pelotas, and 1,447 in São Luís. Different strategies were employed to reduce losses to follow-up. This research network allows the analysis of the incidence of diseases and the establishment of possible causal relations that might explain the health outcomes of these populations in order to contribute to the development of governmental actions and health policies more consistent with reality.

The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil.

Introduction: Although economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014-2015 economic recession. Methods: Drawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil's health spending over the 2010-2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of São Paulo and Maranhão. Results: Our analysis shows that Brazil's macroeconomic conditions deteriorated across the board after 2015-2016, with São Paulo's economy experiencing a wider setback than Maranhão's. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhão continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhão were not affected by the crisis, a decrease in public physicians was observed in São Paulo. Conclusion: Our case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.

High consumption of ultra-processed foods is associated with lower muscle mass in Brazilian adolescents in the RPS birth cohort.

OBJECTIVE: The aim of this study was to investigate the association between percent contribution of ultra-processed foods to total dietary energy intake and measurements of body composition obtained using high-validity methods. METHODS: This was a cross-sectional study with 1525 adolescents 18 to 19 y of age from the second follow-up of the 1997/98 São Luís birth cohort, Brazil. To evaluate nutritional status and body composition, the body mass index (BMI)-for-age was used, along with waist circumference, total and android body fat percentage, muscle mass, and the lean mass index (LMI). Food consumption was evaluated by a food frequency questionnaire. Food items were grouped according to the level of processing as per the NOVA classification. Through semi-structured questionnaires, sociodemographic and lifestyle data were abstracted. Adjusted linear regression models were used to evaluate the associations between consumption of ultra-processed foods and body composition measurements. RESULTS: Total average energy consumption was 2919.7 kcal, with 58% (1634.9 kcal) derived from natural or minimally processed foods and 37% (1136.5 kcal) from ultra-processed products. In the adjusted analyses, BMI, muscle mass, and LMI were inversely associated with consumption of ultra-processed foods. A 1% increase in the percent contribution of ultra-processed items to total dietary energy intake was associated with a 0.04 kg decrease in muscle mass (ß = -0.04; 95% confidence interval [CI], -0.06 to -0.02; P < 0.001) and a 0.01 kg/m2 decrease in lean body mass (ß = -0.01; 95% CI, -0.02 to -0.01; P < 0.001). CONCLUSION: The contribution of ultra-processed foods to total dietary energy intake of Brazilian adolescents was associated with body composition, especially with decreasing lean body mass.

[Health of adolescents in the 1997/1998 birth cohort in São Luís, Maranhão State, Brazil]. / Saúde dos adolescentes da coorte de nascimentos de São Luís, Maranhão, Brasil, 1997/1998.

The study aimed to estimate the prevalence of health indicators among adolescents in São Luís, Maranhão State, Brazil, in 2016. The analysis included sociodemographic conditions, life habits, body composition, sleep quality, physical activity, cognitive performance, and suicide risk in 2,515 adolescents 18 to 19 years of age. The adolescents belonged to the 1997/1998 birth cohort or were included retrospectively using the SINASC (Brazilian Information System on Live Births) database. The adolescents were mainly from economic class C (50.1%), 69.5% were in school, 40.3% were working, and 25.2% were neither studying nor working; 60.3% had been robbed, and 48.7% had parents who were separated or divorced; 19.4% showed harmful or excessive alcohol consumption or probable addiction, 19.1% had used or were using illicit drugs, 53.7% reported poor sleep quality, 40.8% reported frequent headaches, 34.3% reported more than five hours of daily screen time, and 4.1% showed high suicide risk. Prevalence of high blood pressure was 12%, and 6% were obese. Girls were more physically inactive (80.7%) and showed greater percentage of high (15.8%) and very high body fat (21.5%), while boys showed greater prevalence of high blood pressure (21.2%) and lower prevalence of physical inactivity (40.9%). High prevalence rates of health risk factors increase the adolescents' vulnerability, exposing these individuals earlier to factors leading to diseases and other health problems.