Evaluating the relationship between conditional cash transfer programme on preterm births: a retrospective longitudinal study using the 100 million Brazilian cohort.

BACKGROUND: Preterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management. METHODS: A retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32-36), (iii) severe (28-31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management. RESULTS: 1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63-0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59-0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43-0.74). CONCLUSIONS: An income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.

Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020.

OBJECTIVE: We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020. DESIGN: Population-based, multi-country study. SETTING: National healthcare systems. POPULATION: Liveborn infants. METHODS: We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population. MAIN OUTCOME MEASURES: Prevalence and neonatal mortality risks. RESULTS: Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life. CONCLUSIONS: In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021.

OBJECTIVE: To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021. DESIGN: Population-based, multi-country analysis. SETTING: National data systems in 23 middle- and high-income countries. POPULATION: Liveborn infants. METHODS: Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types. MAIN OUTCOME MEASURES: Prevalence of six newborn types. RESULTS: We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries. CONCLUSIONS: The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

Cesarean sections and early-term births according to Robson classification: a population-based study with more than 17 million births in Brazil.

BACKGROUND: Cesarean section (CS) rates are increasing worldwide and are associated with negative maternal and child health outcomes when performed without medical indication. However, there is still limited knowledge about the association between high CS rates and early-term births. This study explored the association between CSs and early-term births according to the Robson classification. METHODS: A population-based, cross-sectional study was performed with routine registration data of live births in Brazil between 2012 and 2019. We used the Robson classification system to compare groups with expected high and low CS rates. We used propensity scores to compare CSs to vaginal deliveries (1:1) and estimated associations with early-term births using logistic regression. RESULTS: A total of 17,081,685 live births were included. Births via CS had higher odds of early-term birth (OR 1.32; 95% CI 1.32-1.32) compared to vaginal deliveries. Births by CS to women in Group 2 (OR 1.50; 95% CI 1.49-1.51) and 4 (OR 1.57; 95% CI 1.56-1.58) showed the highest odds of early-term birth, compared to vaginal deliveries. Increased odds of an early-term birth were also observed among births by CS to women in Group 3 (OR 1.30, 95% CI 1.29-1.31), compared to vaginal deliveries. In addition, live births by CS to women with a previous CS (Group 5 - OR 1.36, 95% CI 1.35-1.37), a single breech pregnancy (Group 6 - OR 1.16; 95% CI 1.11-1.21, and Group 7 - OR 1.19; 95% CI 1.16-1.23), and multiple pregnancies (Group 8 - OR 1.46; 95% CI 1.40-1.52) had high odds of an early-term birth, compared to live births by vaginal delivery. CONCLUSIONS: CSs were associated with increased odds of early-term births. The highest odds of early-term birth were observed among those births by CS in Robson Groups 2 and 4.

Association between food environments and fetal growth in pregnant Brazilian women.

INTRODUCTION: Birth weight is described as one of the main determinants of newborns' chances of survival. Among the associated causes, or risk factors, the mother's nutritional status strongly influences fetal growth and birth weight outcomes of the concept. This study evaluates the association between food deserts, small for gestational age (SGA), large for gestational age (LGA) and low birth weight (LBW) newborns. DESIGN: This is a cross-sectional population study, resulting from individual data from the Live Birth Information System (SINASC), and commune data from mapping food deserts (CAISAN) in Brazil. The newborn's size was defined as follows: appropriate for gestational age (between 10 and 90th percentile), SGA (< 10th percentile), LGA (> 90th percentile), and low birth weight < 2,500 g. To characterize food environments, we used tertiles of the density of establishments which sell in natura and ultra-processed foods. Logistic regression modeling was conducted to investigate the associations of interest. RESULTS: We analyzed 2,632,314 live births in Brazil in 2016, after appropriate adjustments, women living in municipalities with limited availability of fresh foods had a higher chance of having newborns with SGA [OR2nd tertile: 1.06 (1.05-1.07)] and LBW [OR2nd tertile: 1.11 (1.09-1.12)]. Conversely, municipalities with greater availability of ultra-processed foods had a higher chance of having newborns with SGA [OR3rd tertile: 1.04 (1.02-1.06)] and LBW [OR2nd tertile: 1.13 (1.11-1.16)]. Stratification by race showed that Black and Mixed/Brown women had a higher chance of having newborns with SGA [OR3rd tertile: 1.09 (1.01-1.18)] and [OR3rd tertile: 1.06 (1.04-1.09)], respectively, while Mixed-race women also had a higher chance of having newborns with LBW [OR3rd tertile: 1.17 (1.14-1.20)]. Indigenous women were associated with LGA [OR3rd tertile: 1.20 (1.01-1.45)]. CONCLUSION: The study found that living in areas with limited access to healthy foods was associated with an increased risk of SGA and low birth weight among newborns, particularly among Black and Mixed/Brown women. Therefore, urgent initiatives aimed at reducing social inequalities and mitigating the impact of poor food environments are needed in Brazil.

Time trends and social inequalities in infant and young child feeding practices: national estimates from Brazil's Food and Nutrition Surveillance System, 2008-2019.

OBJECTIVE: To describe the time trends and socio-economic inequalities in infant and young child feeding practices in accordance with the Brazilian deprivation index (BDI). DESIGN: This time-series study analysed the prevalence of multiple breast-feeding and complementary feeding indicators based on data from the Brazilian Food and Nutrition Surveillance System, 2008-2019. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. SETTING: Primary health care services, Brazil. PARTICIPANTS: Totally, 911 735 Brazilian children under 2 years old. RESULTS: Breast-feeding and complementary feeding practices differed between the extreme BDI quintiles. Overall, the results were more favourable in the municipalities with less deprivation (Q1). Improvements in some complementary feeding indicators were observed over time and evidenced such disparities: minimum dietary diversity (Q1: Δ 47·8-52·2 %, APC + 1·44, P = 0·006), minimum acceptable diet (Q1: Δ 34·5-40·5 %, APC + 5·17, P = 0·004) and consumption of meat and/or eggs (Q1: Δ 59·7-80·3 %, APC + 6·26, P < 0·001; and Q5: Δ 65·7-70·7 %, APC + 2·20, P = 0·041). Stable trends in exclusive breast-feeding and decreasing trends in the consumption of sweetened drinks and ultra-processed foods were also observed regardless the level of the deprivation. CONCLUSIONS: Improvements in some complementary food indicators were observed over time. However, the improvements were not equally distributed among the BDI quintiles, with children from the municipalities with less deprivation benefiting the most.

Differences in risk factors for incident and recurrent preterm birth: a population-based linkage of 3.5 million births from the CIDACS birth cohort.

BACKGROUND: Preterm birth (PTB) is a syndrome resulting from a complex list of underlying causes and factors, and whether these risk factors differ in the context of prior PTB history is less understood. The aim of this study was to explore whether PTB risk factors in a second pregnancy were different in women with versus without previous PTB. METHODS: We conducted a population-based cohort study using data from the birth cohort of the Center for Data and Knowledge Integration for Health (CIDACS) for the period 2001 to 2015. We used longitudinal transition models with multivariate logistic regression to investigate whether risk factors varied between incident and recurrent PTB. RESULTS: A total of 3,528,050 live births from 1,764,025 multiparous women were analyzed. We identified different risk factors (Pdifference <0.05) between incident and recurrent PTB. The following were associated with an increased chance for PTB incidence, but not recurrent: household overcrowding (OR 1.09), maternal race/ethnicity [(Black/mixed-OR 1.04) and (indigenous-OR 1.34)], young maternal age (14 to 19 years-OR 1.16), and cesarean delivery (OR 1.09). The following were associated with both incident and recurrent PTB, respectively: single marital status (OR 0.85 vs 0.90), reduced number of prenatal visits [(no visit-OR 2.56 vs OR 2.16) and (1 to 3 visits-OR 2.44 vs OR 2.24)], short interbirth interval [(12 to 23 months-OR 1.04 vs OR 1.22) and (<12 months, OR 1.89, 95 vs OR 2.58)], and advanced maternal age (35-49 years-OR 1.42 vs OR 1.45). For most risk factors, the point estimates were higher for incident PTB than recurrent PTB. CONCLUSIONS: The risk factors for PTB in the second pregnancy differed according to women's first pregnancy PTB status. The findings give the basis for the development of specific prevention strategies for PTB in a subsequent pregnancy.

Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017.

OBJECTIVE: In Brazil, national estimates of childhood malnutrition have not been updated since 2006. The use of health information systems is an important complementary data source for analysing time trends on health and nutrition. This study aimed to examine temporal trends and socio-demographic inequalities in the prevalence of malnutrition in children attending primary health care services between 2009 and 2017. DESIGN: Time trends study based on data from Brazil's Food and Nutrition Surveillance System. Malnutrition prevalence (stunting, wasting, overweight and double burden) was annually estimated by socio-demographic variables. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. SETTING: Primary health care services, Brazil. PARTICIPANTS: Children under 5 years old. RESULTS: In total, 15,239,753 children were included. An increase in the prevalence of overweight (APC = 3·4 %; P = 0·015) and a decline in the prevalence of wasting (-6·2 %; P = 0·002) were observed. The prevalence of stunting (-3·2 %, P = 0·359) and double burden (-1·4 %, P = 0·630) had discrete and non-significant reductions. Despite the significant reduction in the prevalence of undernutrition among children in the most vulnerable subgroups (black, conditional cash transfer's recipients and residents of poorest and less developed areas), high prevalence of stunting and wasting persist alongside a disproportionate increase in the prevalence of overweight in these groups. CONCLUSIONS: The observed pattern in stunting (high and persistent prevalence) and increase in overweight elucidate setbacks in advances already observed in previous periods and stresses the need for social and political strategies to address multiple forms of malnutrition.

Factors associated with low birth weight at term: a population-based linkage study of the 100 million Brazilian cohort.

BACKGROUND: Factors associated with low birth weight at term (TLBW), a proxy for intrauterine growth restriction (IUGR), are not well-elucidated in socioeconomically vulnerable populations. This study aimed to identify the factors associated with TLBW in impoverished Brazilian women. METHODS: Records in the 100 Million Brazilian Cohort database were linked to those in the National System of Information on Live Births (SINASC) to obtain obstetric, maternal, birth and socioeconomic data between 2001 and 2015. Multivariate logistic regression was performed to investigate associations between variables of exposure and TLBW. RESULTS: Of 8,768,930 term live births analyzed, 3.7% presented TLBW. The highest odds of TLBW were associated with female newborns (OR: 1.49; 95% CI: 1.47-1.50), whose mothers were black (OR: 1.20; 95% CI: 1.18-1.22), had a low educational level (OR: 1.57; 95% CI: 1.53-1.62), were aged ≥35 years (OR: 1.44; 95% CI: 1.43-1.46), had a low number of prenatal care visits (OR: 2.48; 95% CI: 2.42-2.54) and were primiparous (OR: 1.62; 95% CI: 1.60-1.64). Lower odds of TLBW were found among infants whose mothers lived in the North, Northeast and Center-West regions of Brazil compared to those in the South. CONCLUSION: Multiple aspects were associated with TLBW, highlighting the need to comprehensively examine the mechanisms underlying these factors, especially in more vulnerable Brazilian populations, in order to contribute to the elaboration of health policies and promote better conditions of life for poor and extremely poor mothers and children.

Perinatal health outcomes of international migrant women in Brazil: A nationwide data linkage study of the CIDACS birth cohort (2011-2018).

BACKGROUND: We investigated perinatal outcomes among live births from international migrant and local-born mothers in a cohort of low-income individuals in Brazil. METHODS: We linked nationwide birth registries to mortality records and socioeconomic data from the CIDACS Birth Cohort and studied singleton live births of women aged 10-49 years from 1st January 2011 to 31st December 2018. We used logistic regressions to investigate differences in antenatal care, adverse pregnancy outcomes, and neonatal (i.e., ≤28 days) mortality among international migrants compared to non-migrants in Brazil; and explored the interaction between migration, race/ethnicity and living in international border municipalities. RESULTS: We studied 10,279,011 live births, of which 9469 (0.1 %) were born to international migrants. Migrant women were more likely than their Brazilian-born counterparts to have a previous foetal loss (ORadj: 1.16, 1.11-1.22), a delayed start of antenatal care (i.e., beyond 1st trimester) (1.22, 95%CI:1.16-1.28), a newborn who is large for gestational age (1.29, 1.22-1.36), or a newborn with congenital anomalies (1.37, 1.14-1.65). Conversely, migrant women were less likely to deliver prematurely (0.89, 0.82-0.95) or have a low birth weight infant (0.74, 0.68-0.81). There were no differences in neonatal mortality rates between migrants and non-migrants. Our analyses also showed that, when disparities in perinatal outcomes were present, disparities were mostly concentrated among indigenous mothers in international borders and among live births of Black mothers in non-borders. CONCLUSION: Although live births of international migrants generally have lower rates of adverse birth outcomes, our results suggest that indigenous and Black migrant mothers may face disproportionate barriers to accessing antenatal care.

Prenatal exposure to ambient air pollution and subsequent risk of lower respiratory tract infections in childhood and adolescence: A systematic review.

BACKGROUND: Pregnancy represents a critical window of vulnerability to the harmful effects of air pollution on health. However, long-term consequences such as risk of having lower respiratory tract infections (LRTIs) are less explored. This systematic review aims to synthesize previous research on prenatal exposure to ambient (outdoor) air pollution and LRTIs in childhood and adolescence. METHODS: We systematically searched Embase, MEDLINE, Web of Science Core Collection, CINAHL, and Global Health up to May 17, 2024. We included peer-reviewed publications of studies which investigated the association between prenatal exposure to ambient air pollution and LRTIs up to the age of 19. We excluded conference abstracts, study protocols, review articles, and grey literature. Screening and data extraction was conducted by two reviewers independently. We used the Office of Health Assessment and Translation tool to assess risk of bias and conducted a narrative synthesis. RESULTS: The search yielded 6056 records, of which 16 publications describing 12 research studies were eligible for the synthesis. All studies were conducted in high- or upper-middle-income countries in Europe or Asia. Half (6) of the studies focused on LRTIs occurring within the first three years of life, and the others also included LRTIs in older children (up to age 14). Air pollutants investigated included nitrogen dioxide, sulphur dioxide, particulate matter (PM2.5: diameter ≤2.5 µm and PM10: diameter ≤10 µm), carbon monoxide, ozone, and benzene. Findings on a potential association between prenatal ambient air pollution exposure and LRTIs were inconclusive, without a clear and consistent direction. There was some suggestion of a positive association with prenatal PM2.5 exposure. The small number of studies identified, their poor geographical representation, and their methodological limitations including concerns for risk of bias preclude more definitive conclusions. CONCLUSION: The available published evidence is insufficient to establish whether prenatal exposure to ambient air pollution increases risk of LRTIs in children and adolescents. With many populations exposed to high levels of air pollution, there is an urgent need for research in more diverse settings, more transparent reporting of methods, and exploring how, when, and for whom prenatal exposure to ambient air pollution leads to the greatest health risks. PROSPERO REGISTRATION NUMBER: CRD42023407689.

Social Inequalities in Child Development: Analysis of Low-Birth-Weight Trends in Brazil, 2010-2020.

INTRODUCTION: Low birth weight (LBW) is a global issue prevalent in low-income countries. Economic assessments of interventions to reduce this burden are crucial to guide health policies. However, there is a relative scarcity of research that illustrates the magnitude of LBW by country and region to support the design of public policies. OBJECTIVE: This study aimed to analyze the temporal trend of fetal growth in newborns in Brazil between 2010 and 2020. METHODS: A time series study was conducted using data from the Live Births Information System (SINASC), which is managed by the Department of Information and Informatics of the Unified Health System (DATASUS) of the Brazilian Ministry of Health. The Prais-Winsten linear model was applied to analyze the annual proportions of LBW. The annual percentage changes (APC) and their respective 95% confidence intervals (95%CI) were calculated. Prevalence rate averages of LBW were calculated and displayed on thematic maps to visualize the evolution dynamics in each Federation Unit (FU). RESULTS: A total of 31,887,329 women from all Federative Units of Brazil were included in the study from 2010 to 2020. The Southeast region had the largest proportion of participants, with records from 2015 accounting for 9.5% of the total. Among the women in the study, 49.6% were between the ages of 20 and 29, and the majority (75.5%) had between 8 and 12 years of schooling. The newborns of these women were predominantly male (58.8%) and non-white (59.5%). The study found that there was a trend towards stabilization of increasing proportions of LBW in the North, Northeast, and Centre-West regions between 2010 and 2020. In Brazil and other regions, these tendencies remained stable. CONCLUSION: To improve living conditions and reduce social inequalities and health inequities, public policies and actions are necessary. Strengthening the Unified Health System (SUS), income transfer programs, quota policies for vulnerable groups, and gender equality measures such as improving access to education for women and the labor sector are among the suggested approaches.

Ethno-racial inequalities on adverse birth and neonatal outcomes: a nationwide, retrospective cohort study of 21 million Brazilian newborns.

Background: Ethno-racial inequalities are critical determinants of health outcomes. We quantified ethnic-racial inequalities on adverse birth outcomes and early neonatal mortality in Brazil. Methods: We conducted a cohort study in Brazil using administrative linked data between 2012 and 2019. Estimated the attributable fractions for the entire population (PAF) and specific groups (AF), as the proportion of each adverse outcome that would have been avoided if all women had the same baseline conditions as White women, both unadjusted and adjusted for socioeconomics and maternal risk factors. AF was also calculated by comparing women from each maternal race/skin colour group in different groups of mothers' schooling, with White women with 8 or more years of education as the reference group and by year. Findings: 21,261,936 newborns were studied. If all women experienced the same rate as White women, 1.7% of preterm births, 7.2% of low birth weight (LBW), 10.8% of small for gestational age (SGA) and 11.8% of early neonatal deaths would have been prevented. Percentages preventable were higher among Indigenous (22.2% of preterm births, 17.9% of LBW, 20.5% of SGA and 19.6% of early neonatal deaths) and Black women (6% of preterm births, 21.4% of LBW, 22.8% of SGA births and 20.1% of early neonatal deaths). AF was higher in groups with fewer years of education among Indigenous, Black and Parda for all outcomes. AF increased over time, especially among Indigenous populations. Interpretation: A considerable portion of adverse birth outcomes and neonatal deaths could be avoided if ethnic-racial inequalities were non-existent in Brazil. Acting on the causes of these inequalities must be central in maternal and child health policies. Funding: Bill & Melinda Gates Foundation and Wellcome Trust.

Association of interpregnancy interval with adverse pregnancy outcomes according to the outcomes of the preceding pregnancy: a longitudinal study with 4.7 million live births from Brazil.

Background: Earlier studies have proposed a link between the Interpregnancy Interval (IPI) and unfavorable birth outcomes. However, it remains unclear if the outcomes of previous births could affect this relationship. We aimed to investigate whether the occurrence of adverse outcomes-small for gestational age (SGA), preterm birth (PTB), and low birth weight (LBW)-at the immediately preceding pregnancy could alter the association between IPI and the same outcomes at the subsequent pregnancy. Methods: We used a population-based linked cohort from Brazil (2001-2015). IPI was measured as the difference, in months, between the preceding birth and subsequent conception. Outcomes included SGA (<10th birthweight percentile for gestational age and sex), LBW (<2500 g), and PTB (gestational age <37 weeks). We calculated risk ratios (RRs), using the IPI of 18-22 months as the reference IPI category, we also stratified by the number of adverse birth outcomes at the preceding pregnancy. Findings: Among 4,788,279 births from 3,804,152 mothers, absolute risks for subsequent SGA, PTB, and LBW were higher for women with more adverse outcomes in the preceding delivery. The RR of SGA and LBW for IPIs <6 months were greater for women without previous adverse outcomes (SGA: 1.44 [95% Confidence Interval (CI): 1.41-1.46]; LBW: 1.49 [1.45-1.52]) compared to those with three previous adverse outcomes (SGA: 1.20 [1.10-1.29]; LBW: 1.24 [1.15-1.33]). IPIs ≥120 months were associated with greater increases in risk for LBW and PTB among women without previous birth outcomes (LBW: 1.59; [1.53-1.65]; PTB: 2.45 [2.39-2.52]) compared to women with three adverse outcomes at the index birth (LBW: 0.92 [0.78-1.06]; PTB: 1.66 [1.44-1.88]). Interpretation: Our study suggests that women with prior adverse outcomes may have higher risks for adverse birth outcomes in subsequent pregnancies. However, risk changes due to differences in IPI length seem to have a lesser impact compared to women without a prior event. Considering maternal obstetric history is essential in birth spacing counseling. Funding: Wellcome Trust225925/Z/22/Z.

Maternal and child nutrition programme of investigation within the 100 Million Brazilian Cohort: study protocol.

INTRODUCTION: There is a limited understanding of the early nutrition and pregnancy determinants of short-term and long-term maternal and child health in ethnically diverse and socioeconomically vulnerable populations within low-income and middle-income countries. This investigation programme aims to: (1) describe maternal weight trajectories throughout the life course; (2) describe child weight, height and body mass index (BMI) trajectories; (3) create and validate models to predict childhood obesity at 5 years of age; (4) estimate the effects of prepregnancy BMI, gestational weight gain (GWG) and maternal weight trajectories on adverse maternal and neonatal outcomes and child growth trajectories; (5) estimate the effects of prepregnancy BMI, GWG, maternal weight and interpregnancy BMI changes on maternal and child outcomes in the subsequent pregnancy; and (6) estimate the effects of maternal food consumption and infant feeding practices on child nutritional status and growth trajectories. METHODS AND ANALYSIS: Linked data from four different Brazilian databases will be used: the 100 Million Brazilian Cohort, the Live Births Information System, the Mortality Information System and the Food and Nutrition Surveillance System. To analyse trajectories, latent-growth, superimposition by translation and rotation and broken stick models will be used. To create prediction models for childhood obesity, machine learning techniques will be applied. For the association between the selected exposure and outcomes variables, generalised linear models will be considered. Directed acyclic graphs will be constructed to identify potential confounders for each analysis investigating potential causal relationships. ETHICS AND DISSEMINATION: This protocol was approved by the Research Ethics Committees of the authors' institutions. The linkage will be carried out in a secure environment. After the linkage, the data will be de-identified, and pre-authorised researchers will access the data set via a virtual private network connection. Results will be reported in open-access journals and disseminated to policymakers and the broader public.

Impact of cash transfer programs on birth and child growth outcomes: systematic review.

To investigate the impact of cash transfer (CTs) on birth outcomes, including birth weight, low birth weight and prematurity, as well as child physical growth were included, as assessed by anthropometric indices in children under five years of age. Searching was performed using the PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus and Web of Science databases. Quantitative observational, experimental and quasi-experimental. Eleven studies were included in the review. The majority (81.8%) were carried out in low-and middle-income countries and most involved conditional CTs (63.6%). Four were clinical trials and seven were observational studies. Conditional CTs were found to be associated with a reduction in height-for-age (-0.14; 95%CI -0.27, -0.02); (OR 0.85; 95%CI 0.77-0.94); (OR = 0.44; 95%CI 0.19-0.98), a significantly reduced chance of low weight-for-age (OR = 0.16; 95%CI -0.11-0.43), low weight-for-height (OR = -0.68; 95%CI -1.14, -0.21), and low weight-for-age (OR = 0.27; 95%CI 0.10; 0.71). Unconditional CTs were associated with reduced birth weight (RR = 0.71; 95%CI 0.63-0.81; p < 0.0001) and preterm births (RR = 0.76; 95%CI 0.69-0.84; p < 0.0001). Conditional CTs can positively influence birth outcomes and child growth.

Participation in Conditional Cash Transfer Program During Pregnancy and Birth Weight-Related Outcomes.

Importance: There is limited evidence of the association of conditional cash transfers, an important strategy to reduce poverty, with prevention of adverse birth-related outcomes. Objective: To investigate the association between receiving benefits from the Bolsa Família Program (BFP) and birth weight indicators. Design, Setting, and Participants: This cohort study used a linked data resource, the Centro de Integracao de Dados e Conhecimentos Para Saude (CIDACS) birth cohort. All live-born singleton infants born to mothers registered in the cohort between January 2012 and December 2015 were included. Each analysis was conducted for the overall population and separately by level of education, self-reported maternal race, and number of prenatal appointments. Data were analyzed from January 3 to April 24, 2023. Exposure: Live births of mothers who had received BFP until delivery (for a minimum of 9 months) were classified as exposed and compared with live births from mothers who did not receive the benefit prior to delivery. Main Outcomes and Measures: Low birth weight (LBW), birth weight in grams, and small for gestational age (SGA) were evaluated. Analytical methods used included propensity score estimation, kernel matching, and weighted logistic and linear regressions. Race categories included Parda, which translates from Portuguese as "brown" and is used to denote individuals whose racial background is predominantly Black and those with multiracial or multiethnic ancestry, including European, African, and Indigenous origins. Results: A total of 4 277 523 live births (2 085 737 females [48.8%]; 15 207 among Asian [0.4%], 334 225 among Black [7.8%], 29 115 among Indigenous [0.7%], 2 588 363 among Parda [60.5%], and 1 310 613 among White [30.6%] mothers) were assessed. BFP was associated with an increase of 17.76 g (95% CI, 16.52-19.01 g) in birth weight. Beneficiaries had an 11% lower chance of LBW (odds ratio [OR], 0.89; 95% CI, 0.88-0.90). BFP was associated with a greater decrease in odds of LBW among subgroups of mothers who attended fewer than 7 appointments (OR, 0.85; 95% CI, 0.84-0.87), were Indigenous (OR, 0.73; 95% CI, 0.61-0.88), and had 3 or less years of education (OR, 0.76; 95% CI, 0.72-0.81). There was no association between BFP and SGA, except among less educated mothers, who had a reduced risk of SGA (OR, 0.83; 95% CI, 0.79-0.88). Conclusions and Relevance: This study found that BFP was associated with increased birth weight and reduced odds of LBW, with a greater decrease in odds of LBW among higher-risk groups. These findings suggest the importance of maintaining financial support for mothers at increased risk of birth weight-related outcomes.

Association of Conditional Cash Transfers With Maternal Mortality Using the 100 Million Brazilian Cohort.

Importance: Conditional cash transfers (CCTs) have been consistently associated with improvements to the determinants of maternal health, but there have been insufficient investigations regarding their effects on maternal mortality. Objective: To evaluate the association between being a Bolsa Família program (BFP) beneficiary and maternal mortality and to examine how this association differs by duration of BFP receipt, maternal race, living in rural or urban areas, the Municipal Human Development Index (MHDI), and municipal primary health care coverage. Design, Setting, and Participants: This cross-sectional analysis was nested within the 100 Million Brazilian Cohort. Girls and women aged 10 to 49 years (hereinafter referred to as women) who had at least 1 live birth were included, using data from Brazilian national health databases linked to the 100 Million Brazilian Cohort (January 1, 2004, to December 31, 2015). Propensity score kernel weighting was applied to control for sociodemographic and economic confounders in the association between BFP receipt and maternal mortality, overall and stratified by different subgroups (race, urban or rural area, and MHDI), and duration of BFP receipt. Data were analyzed from July 12, 2019, to December 31, 2022. Main Outcome(s) and Measures: Maternal death. Results: A total of 6 677 273 women aged 10 to 49 years were included in the analysis, 4056 of whom had died from pregnancy-related causes. The risk of maternal death was 18% lower in women who received BFP (weighted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]). A longer duration receiving BFP was associated with an increased reduction in maternal mortality (OR for 1-4 years, 0.85 [95% CI, 0.75-0.97]; OR for 5-8 years, 0.70 [95% CI, 0.60-0.82]; OR for ≥9 years, 0.69 [95% CI, 0.53-0.88]). Receiving BFP was also associated with substantial increases in the number of prenatal appointments and interbirth intervals. The reduction was more pronounced in the most vulnerable groups. Conclusions and Relevance: This cross-sectional analysis nested within the 100 Million Brazilian Cohort found an association between BFP receipt and maternal mortality. This association was of greater magnitude in women with longer exposure to BFP and in the most vulnerable groups. These findings reinforce evidence that programs such as BFP, which have already proven effective in poverty reduction, have great potential to improve maternal survival.

Social inequalities and their impact on children's health: a current and global perspective.

OBJECTIVE: To describe the consequences of social inequalities on children's health as a global and persistent problem, demonstrating its historical and structural roots in different societies. DATA SOURCES: Relevant articles in the PubMed/MEDLINE database, in addition to those found in a manual search and in the bibliographic references of selected studies and consultation to the websites of international organizations to obtain relevant data and documents. DATA SYNTHESIS: To understand how inequities affect health, it is necessary to know the unequal distribution of their social determinants among population groups. In the case of children, the parental pathway of determinants is central. The non-equitable way in which many families or social groups live, determined by social and economic inequalities, produces unequal health outcomes, particularly for children. This is observed between and within countries. Children from the most vulnerable population groups consistently have worse health conditions. Interventions aimed at children's health must go beyond care and act in an integrated manner on poverty and on social and economic inequalities, aiming to end systematic and unfair differences. CONCLUSIONS: Despite the considerable advances observed in children's health in recent decades at a global level, the inequalities measured by different indicators show that they persist. This scenario deserves attention from researchers and decision-makers, especially in the context of the global health crisis caused by the COVID-19 pandemic, which has further intensified the situation of vulnerability and social inequalities in health around the world.

Determinants of preterm birth: proposal for a hierarchical theoretical model. / Determinantes do nascimento prematuro: proposta de um modelo teórico hierarquizado.

Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.

O nascimento prematuro (NP) é uma síndrome resultante de uma complexa relação entre múltiplos fatores que não possuem relações e causalidade totalmente compreendidas. Esse artigo traz uma discussão de um modelo teórico hierarquizado dos determinantes de NP, considerando características maternas como aspectos sociodemográficos, psicossociais, nutricionais, comportamentais e biológicos, tradicionalmente associados ao risco aumentado de NP. As variáveis foram distribuídas em seis dimensões, alocadas em três níveis hierárquicos (distal, intermediário e proximal). Nesse modelo, os determinantes socioeconômicos da mãe, da família, do domicílio e do bairro exercem efeitos indiretos sobre o NP por meio de variáveis no nível intermediário, que por sua vez afetam fatores biológicos de risco no nível proximal, os quais apresentam um efeito direto sobre o NP. O estudo adota um modelo teórico hierarquizado dos fatores envolvidos na cadeia de determinação do NP e suas inter-relações. O entendimento dessas inter-relações é um passo importante na tentativa de interromper a cadeia causal que torna algumas mulheres vulneráveis ao parto prematuro.