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

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

Regional and social inequalities in the performance of Pap test and screening mammography and their correlation with lifestyle: Brazilian national health survey, 2013.

BACKGROUND: Mass population screening for the early detection of cervical and breast cancer has been shown to be a safe and effective strategy worldwide and has reduced the incidence and mortality rates of these diseases. The aim of this study is to analyse the reach of screening tests for cervical and breast cancer according to sociodemographic variables and to analyse their correlation with a healthy lifestyle. METHODS: We have analysed data collected from 31.845 women aged 18 and over, who were interviewed for the Brazilian National Health Survey, a nationwide household inquiry, which took place between August 2013 and February 2014. The Pap tests performed in the last 3 years in women aged between 25 and 64 and screening mammogram performed in the last 2 years in women aged between 50 and 69 were considered adequate. We identified habits that constitute a healthy lifestyle, such as the consumption of five or more daily servings of fruits and vegetables, 30 min or more of leisurely physical activity and not smoking. RESULTS: We observed that the Pap test (78.8 %) was more widespread than the screening mammogram (54.5 %), with significant geographical and social differences concerning access to health care. Access for such screening was higher for women living in more developed regions (Southeast and South), who were white-skinned, better educated, living with a partner and, especially, who were covered by private health insurance. Those who underwent the tests according to established protocols also had a healthy lifestyle, which corroborates the healthy behaviour pattern of damage prevention. CONCLUSION: Despite the progress made, social disparity still defines access to screening tests for cervical and breast cancer, with women covered by private health insurance tending to benefit the most. It is necessary to reduce social and regional inequalities and ensure a more uniform provision and access to the tests, especially for socially disadvantaged women, in order to reduce the incidence and mortality rate resulting from the aforementioned diseases.

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

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

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

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

Factors associated with the use of supplemental oxygen or positive pressure ventilation in the delivery room, in infants born with a gestational age ≥ 34 weeks.

BACKGROUND: Approximately 5-10 % of newborns require some form of resuscitationupon delivery; several factors, such as maternal abnormal conditions, gestational age and type of delivery could be responsible for this trend. This study aimed to describe the factors associated with the need for positive pressure ventilation (PPV) via a mask or endotracheal tube and the use of supplemental O2 in newborns with a gestational age greater than 34 weeks in Brazil. METHODS: We performed a cross-sectional study and obtained data from the Birth in Brazil Survey. The inclusion criterion was a gestational age ≥34 weeks. Exclusion criteria were newborns with congenital malformations, and cases with undetermined gestational age or type of delivery (vaginal, pre labor cesarean section and cesarean section during labor). The primary outcomes were need of PPV via a mask or endotracheal tube and the use of supplemental oxygen without PPV. Confounding variables, including maternal age, source of birth payment, years of maternal schooling, previous birth, newborn presentation, multiple pregnancy, and maternal obstetric risk, were analyzed. RESULTS: We included 22,720 newborns. Of these, 2974 (13.1 %) required supplementary oxygen. PPV with a bag and mask was used for 727 (3.2 %) newborns and tracheal intubation for 192 (0.8 %) newborns. Chest compression was necessary for 136 (0.6 %) newborns and drugs administered in 114 (0.5 %). 51.3 % of newborns were delivered by cesarean section, with the majority of cesarean sections (88.7 %) being performed prior to labor. Gestational age (late preterm infants: (Relative Risk-(RR) 2.46; 95 % (Confidence interval-CI 1.79-3.39), maternal obstetric risk (RR 1.59; 95 % CI1.30-1.94), and maternal age of 12-19 years old (RR 1.36; 95 % CI1.06-1.74) contributed to rates of PPV in the logistic regression analysis. Newborns aged between 37-38 weeks of gestaional age weren´t less likely to require PPV compared with those aged 39-41 weeks of gestational age. CONCLUSIONS: Late preterm infants, previous maternal obstetric risks and maternal age contributed to the higher needs of PPV and use of O2 in the delivery room. These variables need to be considered in planning care in the delivery room.

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

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

Prevalence and risk factors related to preterm birth in Brazil.

BACKGROUND: The rate of preterm birth has been increasing worldwide, including in Brazil. This constitutes a significant public health challenge because of the higher levels of morbidity and mortality and long-term health effects associated with preterm birth. This study describes and quantifies factors affecting spontaneous and provider-initiated preterm birth in Brazil. METHODS: Data are from the 2011-2012 "Birth in Brazil" study, which used a national population-based sample of 23,940 women. We analyzed the variables following a three-level hierarchical methodology. For each level, we performed non-conditional multiple logistic regression for both spontaneous and provider-initiated preterm birth. RESULTS: The rate of preterm birth was 11.5 %, (95 % confidence 10.3 % to 12.9 %) 60.7 % spontaneous - with spontaneous onset of labor or premature preterm rupture of membranes - and 39.3 % provider-initiated, with more than 90 % of the last group being pre-labor cesarean deliveries. Socio-demographic factors associated with spontaneous preterm birth were adolescent pregnancy, low total years of schooling, and inadequate prenatal care. Other risk factors were previous preterm birth (OR 3.74; 95 % CI 2.92-4.79), multiple pregnancy (OR 16.42; 95 % CI 10.56-25.53), abruptio placentae (OR 2.38; 95 % CI 1.27-4.47) and infections (OR 4.89; 95 % CI 1.72-13.88). In contrast, provider-initiated preterm birth was associated with private childbirth healthcare (OR 1.47; 95 % CI 1.09-1.97), advanced-age pregnancy (OR 1.27; 95 % CI 1.01-1.59), two or more prior cesarean deliveries (OR 1.64; 95 % CI 1.19-2.26), multiple pregnancy (OR 20.29; 95 % CI 12.58-32.72) and any maternal or fetal pathology (OR 6.84; 95 % CI 5.56-8.42). CONCLUSION: The high proportion of provider-initiated preterm birth and its association with prior cesarean deliveries and all of the studied maternal/fetal pathologies suggest that a reduction of this type of prematurity may be possible. The association of spontaneous preterm birth with socially-disadvantaged groups reaffirms that the reduction of social and health inequalities should continue to be a national priority.

[Adequacy of prenatal care according to maternal characteristics in Brazil]. / Adequação da assistência pré-natal segundo as características maternas no Brasil.

OBJECTIVE: To verify the degree of adequacy of prenatal care in Brazil and to determine whether it is associated with sociodemographic characteristics of women. METHODS: This nationwide hospital-based study was performed with 23 894 women in 2011 and 2012. Data were obtained from interviews with puerperal women and from the prenatal card recording prenatal care appointments. Adequate prenatal care was defined as that started no later than the 12th gestational week, with performance of at least six consultations (with number of consultations adjusted for gestational age at delivery), record in the prenatal card of at least one result for each of the recommended routine prenatal tests, and guidance regarding the maternity hospital for delivery. Multivariate logistic regression was performed to verify the association between maternal characteristics and the adequacy of prenatal care. RESULTS: Early onset of prenatal care was observed in 53.9% of participants, adequate number of consultations in 73.2%, record of at least one of each recommended test in 62.9%, guidance regarding maternity hospital in 58.7%, and overall adequate prenatal care in 21.6%. Less adequate prenatal care was observed in women who were younger, black, multiparous, who did not have a partner, without paid employment, having fewer years of formal schooling, belonging to lower socioeconomic classes, and living in the North and Northeast of Brazil. After adjustment of maternal characteristics, no differences were observed between public or private health care services regarding adequacy of prenatal care. CONCLUSIONS: Even though the coverage of prenatal care is virtually universal in Brazil, regional and social differences in the access and adequacy of care still persist. The implementation of strategies to facilitate early access to prenatal care is essential.

High-risk space-time clusters of mortality in children 5 to 14 years of age in Mato Grosso state, Brazil. / Clusters Espaço-Temporais de Alto Risco da Mortalidade Infantojuvenil em Mato Grosso, Brasil.

The study aimed to detect high-risk areas for deaths of children and adolescents 5 to 14 years of age in the state of Mato Grosso, Brazil, from 2009 to 2020. This was an exploratory ecological study with municipalities as the units of analysis. Considering mortality data from the Mortality Information System (SIM) and demographic data from the Brazilian Institute of Geography and Statistics (IBGE), the study used multivariate statistics to identify space-time clusters of excess mortality risk in this age group. From 5 to 9 years of age, two clusters with high mortality risk were detected; the most likely located in the state's southern mesoregion (RR: 1.6; LRT: 8,53). Among the 5 clusters detected in the 10-14-year age group, the main cluster was in the state's northern mesoregion (RR: 2,26; LRT: 7,84). A reduction in mortality rates was observed in the younger age group and an increase in these rates in the older group. The identification of these clusters, whose analysis merits replication in other parts of Brazil, is the initial stage in the investigation of possible factors associated with morbidity and mortality in this group, still insufficiently explored, and for planning adequate interventions.

O objetivo deste estudo é detectar as áreas de maior risco para óbitos de crianças e adolescentes de 5 a 14 anos no estado de Mato Grosso entre os anos de 2009 e 2020. Estudo ecológico, tipo exploratório, cuja unidade de análise foram os municípios. Considerando dados de mortalidade do SIM e os demográficos do IBGE, o estudo utilizou a estatística multivariada para a identificação dos clusters espaço-temporais de sobrerrisco de mortalidade nesta faixa etária. Dos 5 aos 9 anos, dois clusters de alto risco de mortalidade foram detectados; o mais provável localizado na mesorregião sul (RR: 1,6; LRV: 8,53). Dentre os 5 clusters detectados na faixa etária dos 10 aos 14 anos, o principal foi localizado na mesorregião norte (RR: 2,26; LRV: 7,84). Foi identificada redução das taxas de mortalidade na faixa etária mais jovem e aumento destas taxas na faixa etária mais velha. A identificação destes clusters, cuja análise merece ser replicada a outras partes do território nacional, é a etapa inicial para a investigação de possíveis fatores associados à morbi-mortalidade deste grupo ainda pouco explorado e para o planejamento de intervenções adequadas.

[Factors associated with breastfeeding at birth in maternity hospitals linked to the Rede Cegonha, Brazil, 2016-2017]. / Fatores associados ao aleitamento materno ao nascer em maternidades vinculadas à Rede Cegonha, Brasil, 2016-2017.

Breastfeeding (BF) is a human right, and it must start from birth. The adequacy of Rede Cegonha (RC) strategies can contribute to the promotion of BF. The objective was to identify factors associated with BF in the first and 24 hours of live births at full-term maternity hospitals linked to CR. Cross-sectional study with data from the second evaluation cycle 2016-2017 of the RC that covered all of Brazil. Odds ratios were obtained through binary logistic regression according to a hierarchical model, with 95% confidence intervals and p-value < 0.01. The prevalence of BF in the first hour was 31% and in the 24 hours 96.6%. The chances of BF in the first hour increased: presence of a companion during hospitalization, skin-to-skin contact, vaginal delivery, delivery assistance by a nurse and accreditation of the unit in the Baby-Friendly Hospital Initiative. Similar results at 24 hours, and association with maternal age below 20 years. BF in the first hour was less satisfactory than in the 24 hours, probably due to the high prevalence of cesarean sections, a factor associated with a lower chance of early BF. Continuous training of professionals about BF and the presence of an obstetric nurse during childbirth are recommended to expand BF in the first hour.

O aleitamento materno (AM) é um direito humano e deve ser iniciado desde o nascimento. A adequação das estratégias da Rede Cegonha (RC) pode contribuir na promoção do AM. O objetivo foi identificar os fatores associados ao AM na primeira e nas 24 horas de nascidos vivos a termo em maternidades vinculadas à RC. Estudo transversal com dados do segundo ciclo avaliativo 2016-2017 da RC, que abrangeu todo o Brasil. Foram obtidas razões de chance por meio de regressão logística binária segundo modelo hierarquizado, com intervalos de confiança a 95% e p-valor < 0,01. A prevalência de AM na primeira hora foi de 31%, e nas 24 horas, de 96,6%. Aumentaram as chances de AM na primeira hora: presença de acompanhante na internação, contato pele a pele, parto vaginal, assistência ao parto por enfermeira e acreditação da unidade na Iniciativa Hospital Amigo da Criança. Resultados semelhantes nas 24 horas, e associação com idade materna inferior a 20 anos. O AM na primeira hora foi menos satisfatório do que nas 24h, provavelmente pela elevada prevalência de cesariana, fator associado à menor chance de AM precoce. A capacitação dos profissionais sobre AM de forma contínua e a presença de enfermeiro obstetra no parto são recomendadas para ampliar o AM na primeira hora.