Prepregnancy maternal BMI and trajectories of BMI-for-age in children up to four years of age: findings from the 2015 Pelotas (Brazil) birth cohort.

BACKGROUND: The aims of the study were to: (a) describe BMI-for-age trajectories in children up to four years of age; (b) evaluate the association between prepregnancy maternal BMI and the BMI-for-age trajectories. METHODS: Data from 3218 (75.3% of the original cohort) children from the Pelotas 2015 Birth Cohort were analyzed. Prepregnancy BMI (kg/m2) was measured on the perinatal interview. Z-scores of BMI-for-age were calculated for children at three months, 1, 2 and 4 years. Trajectories were identified using a semi-parametric group-based modeling approach. Multinomial logistic regression was used to test the association between prepregnancy BMI (weight excess: BMI ≥ 25 kg/m2) and BMI-for-age trajectories. RESULTS: Four trajectories of the BMI-for-age, in z-score, were identified and represent children in the "increasing", "adequate", "stabilized" and "risk for weight excess" group. A total of 196 children (7.1%) belonged to the group that was at risk of weight excess. Adjusted analyses showed that children whose mothers presented prepregnancy weight excess had 2.36 (95%CI 1.71; 3.24) times more risk of belonging to group "risk for weight excess" when compared to those children whose mothers presented underweight/normal weight before pregnancy. CONCLUSION: The risk of weight excess in children up to 4 years of age were greater in mothers who presented prepregnancy weight excess.

Women's multi-partner behavior, multi-partner fertility, and pregnancy outcomes: findings from the 2004 Pelotas Birth Cohort.

STUDY QUESTION: Do women with multi-partner fertility or multi-partner behavior conceive more often than women with a single partner? SUMMARY ANSWER: Women with multi-partner behavior conceived more frequently and had more children than non-multi-partner women and multi-partner fertility women. WHAT IS KNOWN ALREADY: Some women experience having biological children with more than one partner: those women are considered as multi-partner fertility. Women with multi-partner fertility have more children and are substantially less likely to have planned their first birth. Individuals with multi-partner fertility become parents at a younger age, largely with unintended first births, and often do so outside of marriage, compared to parents with two or more children from only one partner. Unmarried women, particularly, are at greater risk of having unintended births. Studies are still scarce and there is a need to assess the contribution of women's multi-partners fertility and multi-partner behavior to family composition, particularly in low- and middle-income countries. STUDY DESIGN, SIZE, DURATION: This longitudinal birth cohort study evaluated 1215 mothers whose children belonging to the 2004 Pelotas Birth Cohort were their first pregnancy, and who attended the perinatal, 48-month, 6-year, and 11-year follow-ups. Information was obtained from responses to a questionnaire. The number of years at risk of having children was treated as the exposure, and woman's multi-partner behavior and multi-partner fertility, dichotomized as 'Yes' or 'No', were considered endogenous treatment variables. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data from mothers with a first pregnancy, and with information available from the perinatal, 48-month, 6-year, and 11-year follow-ups, were evaluated. The exposures studied were women's multi-partner behavior and multi-partner fertility (i.e. conceiving/giving birth), and the outcomes evaluated were the number of pregnancies, the number of children currently alive, and experience of unintended pregnancies from the birth of the child belonging to the 2004 birth cohort until 11 years later. Crude and adjusted risk ratios (RRs) were estimated through Poisson regression with endogenous treatment effects, robust standard errors, and their respective 95% CI. MAIN RESULTS AND THE ROLE OF CHANCE: Multi-partner behavior women had 16% (RR 1.16; 95% CI: 1.08-1.25) and 11% (RR 1.11; 95% CI 1.03-1.19) greater risk of having a new pregnancy and having more children alive, respectively, than those with non-multi-partner behavior. Women with multi-partner fertility had a 23% (RR 1.23; 95% CI: 1.11-1.37) and 20% (RR 1.20; 95% CI: 1.08-1.33) higher risk of having a new pregnancy and having more children alive, respectively, than single-partner fertility mothers. Women who had multiple partners (i.e. behavior), as well as those with multi-partner fertility, showed a lesser proportion of unintended pregnancies when compared to the non-multi-partner ones (34.08%; 95% CI: 28.12-40.60 vs 36.17%; 95% CI: 31.93-40.63), compared to their counterparts' single partners fertility (33.16%; 95% CI: 26.83-40.17 vs 36.26%; 95% CI: 31.85-40.92), although these findings were not statistically significant. LIMITATIONS, REASONS FOR CAUTION: The mothers who were not included in the study owing to missing data for some of the follow-up had 5-11 years of education, a low socio-economic level, and were younger, thus the number of pregnancies may be underestimated because these groups presented a high number of pregnancies and children alive. We did not have information about the complete woman's conjugal history. Therefore, misclassification error of the exposure may be present and, consequently, the measures of association may be underestimated. Furthermore, this study was not truly representative of the Pelotas study female population. WIDER IMPLICATIONS OF THE FINDINGS: In this study of multi-partner behavior and fertility, women who have multiple partners may be less likely to get married and have a stable partner. Compared to single-partner women, multi-partner fertility and multi-partner behavior women may predominantly become pregnant for the purpose of having children, rather than accidentally. STUDY FUNDING/COMPETING INTEREST(S): This article is based on data from the study 'Pelotas Birth Cohort, 2004' conducted by the Postgraduate Program in Epidemiology at the Universidade Federal de Pelotas, with the collaboration of the Brazilian Public Health Association (ABRASCO). From 2009 to 2013, the Wellcome Trust supported the 2004 birth cohort study. The World Health Organization, National Support Program for Centers of Excellence (PRONEX), Brazilian National Research Council (CNPq), Brazilian Ministry of Health, and Children's Pastorate supported previous phases of the study, and also was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES)-Finance Code 001. The authors declare that the supported agencies have no role in any step of performing this study. No conflicts of interest exist. TRIAL REGISTRATION NUMBER: N/A.

Maternal depression in first 1000 days of life and early childhood caries prevalence at 48 months of age.

OBJECTIVES: The aim of this study was to investigate the effect of maternal's depression trajectory in the first 1000 days of the child's life on the prevalence of early childhood dental caries (ECC), in a birth cohort. MATERIALS AND METHODS: All infants born in Pelotas in 2015 were identified, and the mothers were invited to participate in the cohort. A total of 3645 children were included in the study. The outcome was ECC at 48 months of age assessed according to ICDAS. Maternal depression was collected using Edinburgh Postnatal Depression Scale (EPDS) antenatally, at 3, 12, and 24 months of age. Maternal depressive symptom trajectory variables were created using group-based trajectory models and adopting two cutoff points. Poisson regression model with robust variance was used to identify the total effect of maternal depressive symptom trajectories on ECC, adjusting by confounders. RESULTS: A total of 29.2% of the mothers presented a high trajectory for screening of depression, and 18.8% presented a high trajectory of depression diagnosis. The prevalence of ECC was 26.7%. After adjusted analysis, maternal depression trajectories (screening and diagnosis) from pregnancy to 24 months increased the risk for ECC at 48 months of age (RR = 1.14; 95% CI 1.02-1.28 and RR = 1.19; 95% CI 1.05-1.35). CONCLUSIONS: Children from mothers with high depression trajectory had higher risk of having dental caries at 48 months compared to children from mothers with low depression trajectory. CLINICAL RELEVANCE: Strategies of early detection and treatment of maternal mental disorders during the Golden Period should be considered of high priority in health services since it could impact positively in children's life.

Maternal adverse childhood experiences (ACEs) and their associations with intimate partner violence and child maltreatment: Results from a Brazilian birth cohort.

Adverse childhood experiences (ACEs) have been found to predict many negative life outcomes. However, very little evidence exists on Intimate Partner Violence (IPV) and Child Maltreatment (CM). We investigated the impact of maternal ACEs on IPV and CM in three different: cumulative risk, individual adversities and particular groupings of ACEs. The 2015 Pelotas Birth Cohort, Southern Brazil, has followed a population-based sample mothers and children repeatedly until children were aged 4 years, when mothers provided data on ACEs, and current IPV and CM. ACEs were examined in three different ways: (i) as a cumulative risk score; (ii) individual adversities; and (iii) patterns of ACEs (Latent Class Analysis: LCA). One quarter (25.4%) of mothers reported having 5+ ACEs in childhood. Compared to mothers with no ACEs, those who reported 5+ ACEs, had 4.9 (95%CI 3.5; 6.7) times the risk of experiencing IPV and 3.8 (95%CI 2.5; 5.6) times the risk of reporting child maltreatment. LCA results also highlighted the major influence of multiple ACEs on later IPV and CM. However, individual ACEs related to violence (exposure to abuse or domestic violence) showed some specificity for both later IPV and CM, over and above the influence of cumulative childhood adversity. This is the first large study to demonstrate a strong link between maternal ACEs and both IPV and CM. Cumulative ACE exposure and some specificity in effects of childhood violence are important for later IPV and CM. Integrated prevention is essential for reducing the intergenerational transmission of adversity and violence.

Influence of maternal excess weight before pregnancy on breast-feeding and weaning: pooled analyses of four population-based cohorts born between 1982 and 2015.

To investigate the associations of maternal excess weight before pregnancy with (1) weaning at 3 months of age, (2) duration of exclusive breast-feeding at 6 months of age, (3) duration of any breast-feeding at 12 months of age and (4) to compare the magnitude of these associations over four decades. Data were from participants in the Pelotas (Brazil) Birth Cohorts born in 1982 (n 5334), 1993 (n 1442), 2004 (n 4092) and 2015 (n 4102). Maternal pre-pregnancy weight was collected after the delivery and breast-feeding status was assessed when children were 3 and 12 months old. Only in the most recent cohort (2015), women with excess weight (BMI ≥ 25 kg/m2) before pregnancy had higher risk of discontinuing exclusive breast-feeding within the first 6 months postpartum than women with normal weight (hazard ratio = 1·22 (95 % CI 1·15, 1·30)). Duration of any type of breast-feeding until 12 months of age was not affected by pre-pregnancy weight. Excess weight before pregnancy is associated with exclusive breast-feeding only in the most recent birth cohort coinciding with increases in excess weight and breast-feeding over time.

Potential of LARC to recover loss in satisfied demand for modern contraception after the COVID-19 pandemic: a case scenario analysis of Brazil and Mexico.

Objectives: To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic. Methods: National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness. Results: Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs. Conclusions: In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.

Social Distancing, Mask Use, and Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Brazil, April-June 2020.

We assessed the associations of social distancing and mask use with symptomatic, laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection in Porto Alegre, Brazil. We conducted a population-based case-control study during April-June 2020. Municipal authorities furnished case-patients, and controls were taken from representative household surveys. In adjusted logistic regression analyses of 271 case-patients and 1,396 controls, those reporting moderate to greatest adherence to social distancing had 59% (odds ratio [OR] 0.41, 95% CI 0.24-0.70) to 75% (OR 0.25, 95% CI 0.15-0.42) lower odds of infection. Lesser out-of-household exposure (vs. going out every day all day) reduced odds from 52% (OR 0.48, 95% CI 0.29-0.77) to 75% (OR 0.25, 95% CI 0.18-0.36). Mask use reduced odds of infection by 87% (OR 0.13, 95% CI 0.04-0.36). In conclusion, social distancing and mask use while outside the house provided major protection against symptomatic infection.

Quality of antenatal care and its sociodemographic determinants: results of the 2015 Pelotas birth cohort, Brazil.

BACKGROUND: Inadequate antenatal care (ANC) has been associated with adverse pregnancy outcomes. ANC quality is considered a key component of the right to health and a route to equity and dignity for women and their children. Although ANC coverage is relatively high in Brazil, there are revealed some health disparities when coverage is examined by socio-demographic determinants. In this study we evaluated ANC quality and its socio-demographic determinants using data from the 2015 Pelotas birth cohort, Rio Grande do Sul, Brazil. METHODS: This study is part of the 2015 Pelotas population-based birth cohort (n = 3923 pregnant women) conducted in southern Brazil. ANC quality was assessed through 19 content and service utilization indicators recommended by the Brazilian Ministry of Health. Descriptive analyses and associations of each of the ANC indicators and independent variables were performed using the chi-square and linear trend test. ANC indicators were analyzed individually and aggregated as a score. Associations between ANC score quality and socio-demographic variables were assessed with ordinal regressions. Mediation analysis with G-computation was performed to estimate direct and indirect effect of mother's level of education on ANC quality mediated by the number of consultations and timing of ANC initiation. Base and post confounders were included. RESULTS: The results showed that except for breast examination, height measurement, tetanus toxoid vaccination and ANC starting at the first trimester, all ANC indicators showed more than 80% coverage during ANC visits. In the adjusted analysis, inadequate quality ANC was associated with lower maternal education level, not having a partner, being multiparous, being attended by a private provider and by the same professional in all consultations. In the mediation analyses, 6.8% of the association between ANC quality and mother's education was mediated by the trimester in which ANC started, while 12.8% was mediated by the number of ANC visits. CONCLUSIONS: ANC quality is associated with pregnant women's socio-demographic characteristics. Significant efforts are needed to improve the quality of facility-based maternity care.

Introduction to complementary feeding in the first year of life and risk of overweight at 24 months of age: changes from 2004 to 2015 Pelotas (Brazil) Birth Cohorts.

Complementary feeding (CF) and overweight relationships during early childhood are inconsistent in the literature. We described the association of CF during the first year of life with risk of overweight at 24 months of age in the population-based 2004 and 2015 Pelotas (Brazil) Birth Cohorts (2004c and 2015c). CF introduction was evaluated at the 3 and 12 months' follow-ups by asking mothers using a list of foods. Risk of overweight at 24 months of age was BMI-for-age z-score above +1sd from the median of the WHO 2006 growth standards. Our analyses included 3823 (2004c) and 3689 (2015c) children. Early introduction CF (before 6 months of age) prevalence in 2004c was 93·3 (95 % CI 92·5, 94·1) % and in 2015c was 87·2 (95 % CI 86·1, 88·2) %. Tea was the item introduced earlier in both 2004c (68·8 %) and 2015c (55·7 %). At 6 months of age, vegetable mash was the most introduced food in 2004c (33·5 %) and 2015c (47·9 %). Between 2004c and 2015c, the introduction of fresh milk decreased 82·1 to 60·5 % and yogurt from 94·4 to 78·1 % during the first year. Risk of overweight prevalence at 24 months was 33·0 (95 % CI 31·6, 34·5) % in 2004c and 32·0 (95 % CI 30·5, 33·5) % in 2015c. In 2015c, the adjusted odds of risk of overweight at 24 months were increased 1·66 and 1·50 times with the early introduction of fresh/powdered milk: plus water, tea or juice, and plus semi-solid/solid food groups, respectively. It is essential to reinforce the adherence to global recommendations on timely feeding introduction and encourage exclusive breast-feeding until 6 months of age to prevent child overweight.

Phase II trial evaluating the clinical efficacy of cefixime for treatment of active syphilis in non-pregnant women in Brazil (CeBra).

BACKGROUND: Syphilis is a sexually and vertically transmitted infection caused by the bacteria Treponema pallidum for which there are few proven alternatives to penicillin for treatment. For pregnant women infected with syphilis, penicillin is the only WHO-recommended treatment that will treat the mother and cross the placenta to treat the unborn infant and prevent congenital syphilis. Recent shortages, national level stockouts as well as other barriers to penicillin use call for the urgent identification of alternative therapies to treat pregnant women infected with syphilis. METHODS: This prospective, randomized, non-comparative trial will enroll non-pregnant women aged 18 years and older with active syphilis, defined as a positive rapid treponemal and a positive non-treponemal RPR test with titer ≥1:16. Women will be a, domized in a 2:1 ratio to receive the oral third generation cephalosporin cefixime at a dose of 400 mg two times per day for 10 days (n = 140) or benzathine penicillin G 2.4 million units intramuscularly based on the stage of syphilis infection (n = 70). RPR titers will be collected at enrolment, and at three, six, and nine months following treatment. Participants experiencing a 4-fold (2 titer) decline by 6 months will be considered as having an adequate or curative treatment response. DISCUSSION: Demonstration of efficacy of cefixime in the treatment of active syphilis in this Phase 2 trial among non-pregnant women will inform a proposed randomized controlled trial to evaluate cefixime as an alternative treatment for pregnant women with active syphilis to evaluate prevention of congenital syphilis. TRIAL REGISTRATION: Trial identifier: www.Clinicaltrials.gov, NCT03752112. Registration Date: November 22, 2018.

Trajectories of maternal depressive symptoms from the antenatal period to 24-months postnatal follow-up: findings from the 2015 Pelotas birth cohort.

BACKGROUND: Maternal depression may be chronic and recurrent, with negative effects both on the health of mothers and children. Many studies have shown trajectories of postnatal depressive symptoms but few studies in low- and middle-income countries have evaluated the trajectories of depressive symptoms starting during pregnancy. This study aims to identify the different trajectories of depressive symptoms among mothers in the Pelotas 2015 birth cohort, from pregnancy to the second year of the child's life. METHODS: This study used data from the 2015 Pelotas Birth Cohort, a longitudinal study of all live births occurred in 2015 in Pelotas, Brazil. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Mothers who completed the EPDS on at least three follow-up visits beginning to the antenatal follow-up visit were included in the analyses. The trajectory of maternal depressive symptoms was estimated through group-based trajectory modeling. RESULTS: A total of 3040 women were included in the present analysis. We identified five groups of maternal depressive symptoms trajectories, with 23.4% of the mothers presenting persistent depressive symptoms and 3.9% showing chronic high depressive symptoms throughout the study period. The probability of having persistent depressive symptoms increased among mothers with greater socioeconomic vulnerability. CONCLUSIONS: This study shown the persistence of maternal depressive symptoms since pregnancy until 2 years postnatal. Additionally, alongside the known risk factors, pre-gestational depression and antenatal depressive symptoms are important risk factors for the persistence and severity of depressive symptoms. These findings support the need to provide mental health evaluation and care for women from pregnancy to the late postnatal period.

Maternal and child-health outcomes in pregnancies following Assisted Reproductive Technology (ART): a prospective cohort study.

BACKGROUND: Studies comparing the outcome of spontaneous versus assisted reproductive technologies (ART) pregnancies report heterogeneous results. Despite the success of ART to overcome infertility, concern is growing regarding both its safety and its effect on maternal and child health. The objective of this study was to compare maternal and child-health outcomes after ART relative to natural conception. METHODS: A population-based birth cohort study was carried out among pregnant women expected to deliver in 2015 in Pelotas, southern Brazil. Maternal outcomes included pregnancy complications and gestational weight gain. Gestational age, weight, intrauterine growth restriction, length and head circumference, and 1-min and 5-min Apgar, as well as health problems at birth and breastfeeding were defined as offspring outcomes. Statistical analyses were performed using linear and logistic regression. G-formula was used to perform mediation analysis. RESULTS: The study included 4252 babies born by spontaneously pregnancies and 23 babies born after ART. Adjusted analyses showed that children conceived from ART presented lower means of gestational age (p = 0.001), birth weight (p = 0.002), length (p < 0.001), and head circumference at birth (p = 0.02). However, more than 90% of the effect of ART over these outcomes was mediated by multiple pregnancy. CONCLUSION: Our findings suggest that the possible negative effect on the child-health outcomes is due mainly to the higher incidence of multiple pregnancies and not because of ART. The reasons for the increase in adverse pregnancy outcomes associated with ART singleton pregnancies are still uncertain and warrants further research. Further large-population studies are needed to confirm these results.

Lessons about the reliability of congenital syphilis and vertical HIV transmission data learned from case reviews in Uruguay: a cross-sectional study.

BACKGROUND: In Uruguay it is mandatory to review all cases of positive HIV or reactive syphilis tests in pregnancy and peripartum. We compared the rates of mother-to-child transmission of syphilis and HIV detected by case reviews to those obtained from the usual surveillance system and described the characteristic of vertical transmission cases. METHODS: This is a cross-sectional study performed with secondary data obtained from official government sources, for all the country cases of maternal to child transmission of HIV and syphilis from 2012 to 2017, with descriptive analyses. For congenital syphilis analyses, the following pregnancy characteristics were investigated: number of antenatal checks, gestational age at pregnancy diagnosis, gestational age at syphilis test and diagnosis, adequate treatment, and treatment of partners. Sociodemographic characteristics included type of health care (public/private), maternal age, distribution of ethnic minorities, maximum educational attainment, presence of partner, planned pregnancy, drug and alcohol use, domestic violence, previous maternal diagnosis of syphilis, and previous children with congenital syphilis. RESULTS: Coverage of syphilis case reviews increased from 82% in 2014 to 97.4% in 2017. For HIV, this coverage reached 100% in 2017 and elimination of mother to child transmission was achieved. A marked decline in congenital syphilis was noted in the public health care sector, especially in the capital Montevideo, whereas the private sector has remained below the elimination target. Variables related with congenital syphilis in exposed children were late pregnancy diagnosis, < 5 antenatal checks, delayed diagnosis of gestational syphilis, lower rate of correct treatment for gestational syphilis, untreated partner, low maternal schooling, unplanned pregnancy, history of syphilis, and having other children with syphilis. CONCLUSION: The use of case reviews provided knowledge regarding the accurate number of mother-to-child transmission cases and the evolution of elimination of mother to child transmission in the country. The results suggest that rates must be adjusted, providing an opportunity to improve the reliability of surveillance data, and point the need to address specific gaps in order to improve the quality of care during pregnancy, delivery, and the neonatal period.

Agreement of antenatal care indicators from self-reported questionnaire and the antenatal care card of women in the 2015 Pelotas birth cohort, Rio Grande do Sul, Brazil.

BACKGROUND: Studies of healthcare service use during the pregnancy-postpartum cycle often rely on self-reported data. The reliability of self-reported information is often questioned as administrative data or medical records, such as antenatal care cards, are usually preferred. In this study, we measured the agreement of antenatal care indicators from self-reported information and antenatal care cards of pregnant women in the 2015 Pelotas Birth Cohort, Brazil. METHODS: In a sample of 3923 mothers, indicator agreement strengths were estimated from Kappa and prevalence-and-bias-adjusted Kappa (PABAK) coefficients. Maternal characteristics associated with indicator agreements were assessed with heterogeneity chi-squared tests. RESULTS: The self-reported questionnaire and the antenatal care card showed a moderate to high agreement in 10 of 21 (48%) antenatal care indicators that assessed care service use, clinical examination and diseases during pregnancy. Counseling indicators performed poorly. Self-reported information presented a higher frequency data and a higher sensitivity but slightly lower specificity when compared to the antenatal card. Factors associated with higher agreement between both data sources included lower maternal age, higher level of education, primiparous status, and being a recipient of health care in the public sector. CONCLUSIONS: Self-reported questionnaire and antenatal care cards provided substantially different information on indicator performance. Reliance on only one source of data to assess antenatal care quality may be questionable for some indicators. From a public health perspective, it is recommended that antenatal care programs use multiple data sources to estimate quality and effectiveness of health promotion and disease prevention in pregnant women and their offspring.

The use of folic acid, iron salts and other vitamins by pregnant women in the 2015 Pelotas birth cohort: is there socioeconomic inequality?

BACKGROUND: Many low- and middle-income countries recommend micronutrient supplements for pregnant women to improve their nutritional status, prevent possible deficiencies and avoid fetal healgth consequences. This study evaluated the influence of socioeconomic status on the use of folic acid, iron salts and other vitamins and minerals among pregnant women in the 2015 Pelotas Birth Cohort. METHODS: This population-based birth cohort study was carried out with 4270 women. Participants were interviewed during pregnancy and at the maternity hospital about the antenatal period; including the use of iron salts, vitamins and other minerals. Descriptive analyses were performed to characterize the sample. The analyses were adjusted according to socioeconomic variables (maternal education, ethnicity, household income). RESULTS: The overall prevalence of the use of folic acid, iron salts or other vitamins and minerals was 91.0% (95% CI: 90.1-91.8). Specifically, 70.9% (95% CI: 69.5-72.3) used folic acid, 72.9% (95% CI: 71.5-74.3) used iron compounds, and 31.8% (95% CI: 30.3-33.2) used other vitamins or minerals. In the adjusted analysis, the use of iron salts was associated with nonwhite mothers, with ≤4 years of education and whose family income was less than or equal to the monthly minimum wage. The use of folic acid and other vitamins and minerals was associated with white mothers who were more highly educated and had a higher family income. CONCLUSION: Although folic acid and other vitamins and minerals were more frequently used in white, richer and more educated mothers, which indicates inequality, iron supplements were more frequently used in the poorer, less educated nonwhite mothers, suggesting the opposite association for this supplement.

Prevalence and associated factors of supine sleep position in 3-month-old infants: findings from the 2015 Pelotas (Brazil) Birth Cohort.

BACKGROUND: Non-supine infant sleep position is an important modifiable risk factor for sudden unexpected death in infancy. The aim of this study was to assess the prevalence of supine sleep position and associated factors among 3-month-old infants from a birth cohort in the city of Pelotas, southern Brazil. METHODS: The present study evaluated longitudinal data from the 2015 Pelotas Birth Cohort. Study outcome was supine infant sleep position, defined as the appropriate position, among 3-month-old children. Demographic, socioeconomic, behavioral, and health characteristics collected at birth and at the 3-month follow-up were investigated as possible associated factors. The prevalence of each associated factor was investigated, and crude and hierarchical adjusted analyses were performed using Poisson regression. RESULTS: Among the 4108 infants assessed in this study, 2274 (55.4%) slept in supine position at 3 months and only 66 (1.6%) in prone position. Maternal white skin color, higher family income and maternal schooling, advanced maternal age, maternal cohabiting with a partner, receiving counseling from health care professionals and non-bed-sharing were associated with higher prevalence of infants sleeping in supine position at 3 months. All these variables remained associated in our hierarchical adjusted analyses except maternal cohabitation with a partner. Participants with white mothers were more likely to sleep in supine position (PR: 1.23; 95%CI: 0.75-0.89) compared to participants with black mothers. Those belonging to the richest quintile were more likely to sleep in supine position (PR: 1.49; 95%CI: 1.35-1.65) compared to those who belong to the poorest. Mothers aged 31-36 years were more likely to choose supine sleep position (PR: 1.65; 95%CI: 1.42-1.92) compared to mothers younger than 19 years. CONCLUSIONS: The findings of the present study showed the influence of maternal age, socioeconomic status, and counseling on infant sleep habits as predictors of choice of infant sleep position in a Brazilian population. It is recommended to implement informative campaigns and public policies to at-risk population and to improve recommendations from health care professionals.

Reasons for nonuse of contraceptive methods by women with demand for contraception not satisfied: an assessment of low and middle-income countries using demographic and health surveys.

BACKGROUND: Nonuse of contraceptive methods by women in need of contraception may impact their sexual and reproductive health. The aim of this study was to describe the reasons for nonuse of contraception among women with demand for contraception not satisfied in low and middle-income countries (considering both overall countries and various subgroups of women). METHODS: We used the latest Demographic and Health Survey data from 47 countries. A descriptive analysis of the reasons for nonuse of contraceptive methods was performed among sexually active women with demand for contraception not satisfied. The prevalence of each reported reason was also evaluated according to marital status, woman's age and schooling, area of residence, wealth index, and parity. Wealth-related absolute inequality for each reason was also evaluated using the Slope Index of Inequality. A pro-rich inequality pattern means that the reason is more prevalent among the richest women while a pro-poor means the reason is more common among the poorest ones. RESULTS: On average, 40.9% of women in need of contraception were not using any contraceptive methods to avoid pregnancy. Overall, the most prevalent reasons for nonuse of contraceptives were "health concerns" and "infrequent sex," but the prevalence of each reason varied substantially across countries. Nonuse due to "opposition from others" was higher among married than unmarried women; in turn, the prevalence of nonuse due to "lack of access" or "lack of knowledge" was about two times higher in rural areas than in urban areas. Women with less schooling more often reported nonuse due to "lack of access." Pro-rich inequality was detected for reasons "health concerns," "infrequent sex," and "method-related", while the reasons "other opposed," "fatalistic," "lack of access," and "lack of knowledge" were linked to patterns of pro-poor inequality. CONCLUSIONS: Family planning promotion policies must take into account the different reasons for the nonuse of contraceptive methods identified in each country as well as the contextual differences regarding women of reproductive age (such as social norms and barriers that prevent women from accessing and using contraceptives).

Is intrauterine exposure to acetaminophen associated with emotional and hyperactivity problems during childhood? Findings from the 2004 Pelotas birth cohort.

BACKGROUND: Longitudinal studies have consistently reported that prenatal exposure to acetaminophen can to lead to an increased risk of attention deficit-hyperactivity disorder during childhood. This study aimed to investigate the association between intrauterine exposure to acetaminophen and the presence of emotional and behavioral problems at the ages of 6 and 11 years in a low-middle income country. METHODS: We performed a prospective longitudinal population-based study using data from the 2004 Pelotas birth cohort. From the 4231 initial cohort participants, 3722 and 3566 children were assessed at 6 and 11 years of age, respectively. The outcomes were assessed using the parent version of Strengths and Difficulties Questionnaire (SDQ). The cut-off points established for the Brazilian population were used to categorize the outcomes. Crude and adjusted odds ratio were obtained through logistic regression. RESULTS: Acetaminophen was used by 27.5% (95% confidence interval [CI]: 26.1-28.9) of the mothers at least once during pregnancy. The prevalence of emotional problems at 6 and 11 years was 13.6 and 19.9%, respectively. For hyperactivity problems, prevalence was 13.9 and 16.1%, respectively. Intrauterine exposure to acetaminophen increased the odds of having emotional (odds ratio [OR] = 1.47; 95% CI: 1.07-2.02) and hyperactivity/inattention (OR = 1.42; 95% CI: 1.06-1.92) problems in 6-year-old boys. At the age of 11, a small decrease in the effect was observed for both outcomes after adjustment: OR = 1.31 (95% CI: 0.99-1.73) for emotional problems and OR = 1.25 (95% CI: 0.95-1.65) for hyperactivity/inattention in boys. No association for any phenotypes at both ages was observed for girls. CONCLUSION: The effect of intrauterine exposure to acetaminophen in emotional and hyperactivity symptoms was dependent on sex in a Brazilian cohort. While it seemed to be important for boys, mainly at 6 years of age, for girls, no association was observed.

Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort.

BACKGROUND: The disrespect and abuse of women during the process of childbirth is an emergent and global problem and only few studies have investigated this worrying issue. The objective of the present study was to describe the prevalence of disrespect and abuse of women during childbirth in Pelotas City, Brazil, and to investigate the factors involved. METHODS: This was a cross-sectional population-based study of women delivering members of the 2015 Pelotas birth cohort. Information relating to disrespect and abuse during childbirth was obtained by household interview 3 months after delivery. The information related to verbal and physical abuse, denial of care and invasive and/or inappropriate procedures. Poisson regression was used to evaluate the factors associated with one or more, and two or more, types of disrespectful treatment or abuse. RESULTS: A total of 4275 women took part in a perinatal study. During the three-month follow-up, we interviewed 4087 biological mothers with regards to disrespect and abuse. Approximately 10% of women reported having experienced verbal abuse, 6% denial of care, 6% undesirable or inappropriate procedures and 5% physical abuse. At least one type of disrespect or abuse was reported by 18.3% of mothers (95% confidence interval [CI]: 17.2-19.5); and at least two types by 5.1% (95% CI: 4.4-5.8). Women relying on the public health sector, and those whose childbirths were via cesarean section with previous labor, had the highest risk, with approximately a three- and two-fold increase in risk, respectively. CONCLUSIONS: Our study showed that the occurrence of disrespect and abuse during childbirth was high and mostly associated with payment by the public sector and labor before delivery. The efforts made by civil society, governments and international organizations are not sufficient to restrain institutional violence against women during childbirth. To eradicate this problem, it is essential to 1) implement policies and actions specific for this type of violence and 2) formulate laws to promote the equality of rights between women and men, with particular emphasis on the economic rights of women and the promotion of gender equality in terms of access to jobs and education.

A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study.

BACKGROUND: Women are encouraged to be physically active during pregnancy. Despite available evidence supporting antenatal physical activity to bring health benefits for both the mother and child, the most effective way to prevent some maternal and fetal outcomes is still unclear. The purpose of this study was to evaluate the efficacy of an exercise intervention to prevent negative maternal and newborn health outcomes. METHODS: A randomized controlled trial (RCT) nested into the 2015 Pelotas (Brazil) Birth Cohort Study was carried-out with 639 healthy pregnant women, 213 in the intervention group (IG) and 426 in the control (CG) group. An exercise-based intervention was conducted three times/week for 16 weeks from 16-20 to 32-36 weeks' gestation. The main outcomes were preterm birth and pre-eclampsia. Gestational age was calculated based on several parameters, including routine ultrassounds and/or last menstrual period and categorized as < 37 weeks and ≥ 37 weeks for evaluation of preterm birth. Pre-eclampsia was self-reported. Secondary outcomes were gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. Analyses were performed by intention-to-treat (ITT) and per protocol (70% of the 48 planned exercise sessions). Odds ratio were derived using unconditional logistic regression. RESULTS: The IG and CG did not differ at baseline regarding their mean age (27.2 years ± 5.3 vs. 27.1 years ± 5.7) and mean pre-pregnancy body mass index (25.1 ± 3.9 vs. 25.2 ± 4.1 kg/m2). The mean adherence to the exercise intervention was 27 ± 17.2 sessions (out of a potential 48) with 40.4% attending > = 70% of the recommended exercise sessions. A total of 594 participants (IG:198; CG: 396) were included in the ITT and 479 (IG: 83; CG: 396) were included in the per protocol analyses. There were no significant differences in the incidence of preterm birth and pre-eclampsia between groups in the ITT and per protocol analysis. There were also no differences between the two groups in mean gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. CONCLUSIONS: While the RCT did not support the benefits of exercise performed during pregnancy on preeclampsia and preterm birth, the exercise program also did not present adverse impacts on newborn health. Our findings may contribute to promote intervention strategies that motivate health providers to encourage pregnant women to be more physically active. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02148965 , registered on 22 May 2014.