The baby-friendly hospital initiative and breastfeeding at birth in Brazil: a cross sectional study.

BACKGROUND: Breastfeeding in the first hour after birth is important for the success of breastfeeding and in reducing neonatal mortality. Government policies are being developed in this direction, highlighting the accreditation of hospitals in the Baby-Friendly Hospital (BFH) initiative. The aim of this study was to analyze the association between delivery in a BFH (main exposure), compared to non BFH, and timely initiation of breastfeeding (outcome). METHODS: Data came from the "Birth in Brazil" survey, a nationwide hospital-based study of postpartum women and their newborns, coordinated by the Oswaldo Cruz Foundation. A sample of 22,035 mothers/babies was analyzed through a hierarchical theoretical model on three levels, and all analyzes considered the complex sample design. Odds ratios were obtained by logistic regression, with a 99 % CI. RESULTS: Among all births, 40 % occurred in hospitals accredited or in accreditation process for the BFHI and 52 % of women underwent caesarean section. In the final model, at the distal level, mothers less than 35 years old, and those who lived in the North Region, had a higher chance of timely initiation of breastfeeding. At the intermediate level, prenatal care in the public sector and advice on breastfeeding during pregnancy were directly associated with the outcome. At the proximal level, being born in a Baby-Friendly Hospital and vaginal delivery increased the chance of timely initiation of breastfeeding, while prematurity and low birth weight reduced the chance of the outcome. CONCLUSIONS: The chance of being breastfed in the first hour after birth in Baby-Friendly hospitals was twice as high as at non-accredited hospitals, which shows the importance of this initiative for timely initiation of breastfeeding.

Factors associated with exclusive breastfeeding in the first six months of life in Brazil: a systematic review.

OBJECTIVE: To identify factors associated with exclusive breastfeeding in the first six months of life in Brazil. METHODS: Systematic review of epidemiological studies conducted in Brazil with exclusive breastfeeding as outcome. Medline and LILACS databases were used. After the selection of articles, a hierarchical theoretical model was proposed according to the proximity of the variable to the outcome. RESULTS: Of the 67 articles identified, we selected 20 cross-sectional studies and seven cohort studies, conducted between 1998 and 2010, comprising 77,866 children. We identified 36 factors associated with exclusive breastfeeding, being more often associated the distal factors: place of residence, maternal age and education, and the proximal factors: maternal labor, age of the child, use of a pacifier, and financing of primary health care. CONCLUSIONS: The theoretical model developed may contribute to future research, and factors associated with exclusive breastfeeding may subsidize public policies on health and nutrition.

Factors associated with exclusive breastfeeding in the first six months of life in Brazil: a systematic review / Fatores associados ao aleitamento materno exclusivo nos primeiros seis meses de vida no Brasil: revisão sistemática

ABSTRACT OBJECTIVE To identify factors associated with exclusive breastfeeding in the first six months of life in Brazil. METHODS Systematic review of epidemiological studies conducted in Brazil with exclusive breastfeeding as outcome. Medline and LILACS databases were used. After the selection of articles, a hierarchical theoretical model was proposed according to the proximity of the variable to the outcome. RESULTS Of the 67 articles identified, we selected 20 cross-sectional studies and seven cohort studies, conducted between 1998 and 2010, comprising 77,866 children. We identified 36 factors associated with exclusive breastfeeding, being more often associated the distal factors: place of residence, maternal age and education, and the proximal factors: maternal labor, age of the child, use of a pacifier, and financing of primary health care. CONCLUSIONS The theoretical model developed may contribute to future research, and factors associated with exclusive breastfeeding may subsidize public policies on health and nutrition.

RESUMO OBJETIVO Identificar fatores associados ao aleitamento materno exclusivo nos primeiros seis meses de vida no Brasil. MÉTODOS Revisão sistemática de estudos epidemiológicos conduzidos no Brasil com o aleitamento materno exclusivo como desfecho. Foram utilizadas as bases de dados Medline e Lilacs. Após a seleção de artigos, foi proposto um modelo teórico hierarquizado, segundo a proximidade da variável com o desfecho. RESULTADOS Dos 67 artigos identificados, foram selecionados 20 estudos transversais e sete de coorte, conduzidos entre 1998 e 2010, compreendendo 77.866 crianças. Foram identificados 36 fatores associados ao aleitamento materno exclusivo, sendo mais frequentemente associados os fatores distais: local de residência, idade e escolaridade maternas, e os fatores proximais: trabalho materno, idade da criança, uso de chupeta e financiamento da atenção primária em saúde. CONCLUSÕES O modelo teórico desenvolvido pode contribuir para a condução de futuras pesquisas e os fatores associados ao aleitamento materno exclusivo podem subsidiar políticas públicas em saúde e nutrição.

A amamentação na primeira hora de vida e mortalidade neonatal / Breastfeeding during the first hour of life and neonatal mortality

Objetivo: Analisar a correlação entre o percentual de amamentação na primeira hora de vida e as taxas de mortalidade neonatal. Métodos: Foram utilizados dados secundários de 67 países obtidos das pesquisas realizadas com a metodologia do Demographic and Health Surveys. Inicialmente, para a análise dos dados, foram empregadas a Correlação de Spearman (IC 95%) e a análise gráfica com modificação de Kernel, seguidas de regressão de Poisson Binomial Negativa, ajustando para possíveis fatores de confundimento. Resultados: O percentual de aleitamento materno na primeira hora de vida esteve negativamente associado com as taxas de mortalidade neonatal (Rho = -0,245, p = 0,046), e esta correlação foi mais forte entre os países com mortalidade neonatal superior a 29 mortes/1.000 nascidos vivos (Rho = -0,327, p = 0,048). Os países com os menores tercis de aleitamento materno na primeira hora de vida tiveram uma taxa 24% maior de mortalidade neonatal (razão de taxa = 1,24, IC 95% = 1,07-1,44), mesmo ajustando para fatores de confundimento. Conclusão: O efeito protetor da amamentação na primeira hora de vida sobre a mortalidade neonatal encontrado nesse estudo ecológico é consistente com o de estudos observacionais, e aponta para a importância de se adotar a amamentação na primeira hora de vida como prática de atenção neonatal.

Objective: To analyze the correlation between breastfeeding in the first hour of life with neonatal mortality rates. Methods: The present study used secondary data from 67 countries, obtained from the Demographic and Health Surveys. Initially, for data analysis, Spearman Correlation (95% CI) and Kernel graphical analysis were employed, followed by a Negative Binomial Poisson regression model, adjusted for potential confounders. Results: Breastfeeding within the first hour of life was negatively correlated with neonatal mortality (Spearman's Rho = -0.245, p = 0.046), and this correlation was stronger among countries with more than 29 neonatal deaths per 1000 newborns (Spearman's Rho = -0.327, p = 0.048). According to the statistical model, countries with the lowest breastfeeding tertiles had 24% higher neonatal mortality rates (Rate ratio = 1.24, 95% CI = 1.07-1.44, p < 0.05), even when adjusted for potential confounders. Conclusion: The protective effect of breastfeeding during the first hour of life on neonatal mortality in this ecological study is consistent with findings from previous observational studies, indicating the importance of adopting breastfeeding within the first hour as a routine neonatal care practice.

Factors associated with caesarean section among primiparous adolescents in Brazil, 2011-2012.

This paper presents the factors associated with caesarean section in primiparous adolescents in Brazil using data from a national hospital-based survey conducted between 2011 and 2012. Information was obtained from postpartum women through face-to-face and telephone interviews and a theoretical model with three levels of hierarchy was used to analyze associations with the dependent variable mode of delivery (caesarean or vaginal). The results show that the caesarean section rate among primiparous teenagers is high (40%). The most significant contributing factors for caesarean section were: considering this mode of delivery safer (OR=7.0; 95%CI: 4.3-11.4); giving birth under the private health system (OR=4.3; 95%CI: 2.3-9.0); being attended by the same health care professional throughout prenatal care and delivery (OR=5.7; 95%CI: 3.3-9.0) and clinical history of risk and complications during pregnancy (OR=10.8; 95%CI: 8.5-13.7). Adolescent pregnancy continues to be an important concern on the reproductive health agenda and the rates observed by this study are worrying given the effects of early exposure to caesarean section.

Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care.

This study examined neonatal deaths in the live-births cohort in the Birth in Brazil survey, which interviewed and examined medical records of 23,940 mothers from February 2011 to October 2012. Potential risk factors were analyzed using hierarchical modeling. Neonatal mortality rate was 11.1/1,000, the highest rates occurring in the North and Northeast regions and in lower social classes. Low birth weight, risks during pregnancy and conditions of the newborn were the main factors associated with neonatal death. Inadequate prenatal and childbirth care point to unsatisfactory quality of health care. Difficulty in gaining hospital admission for delivery, and children with birth weight<1,500g born at hospitals without a neonatal intensive care unit, indicate gaps in health system organization. Deaths from intra-partum asphyxia in term babies and late prematurity express preventable neonatal mortality. Better quality health care, especially hospital care during labor and birth, poses the main public policy challenge to progress in reducing mortality and inequalities in Brazil.

Fatores associados à cesariana entre primíparas adolescentes no Brasil, 2011-2012 / Factores asociados a la cesárea en adolescentes primíparas en Brasil, 2011-2012 / Factors associated with caesarean section among primiparous adolescents in Brazil, 2011-2012

Nesse artigo são apresentados os fatores associados à realização de cesariana em primíparas adolescentes no Brasil, utilizando-se dados de pesquisa nacional de base hospitalar realizada entre 2011 e 2012. As informações foram obtidas por meio de entrevista com a puérpera durante a internação hospitalar. Um modelo teórico conceitual foi estabelecido com três níveis de hierarquia e a variável dependente foi a via de parto – cesariana ou vaginal. Os resultados mostram proporção elevada de cesariana entre primíparas adolescentes (40%) e os fatores mais fortemente associados à cesariana foram considerar esta via de parto mais segura (OR = 7,0; IC95%: 4,3-11,4); parto financiado pelo setor privado (OR = 4,3; IC95%: 2,3-9,0); mesmo profissional de saúde assistindo pré-natal e parto (OR = 5,7; IC95%: 3,3-9,0) e apresentar antecedentes clínicos de risco e intercorrências na gestação (OR = 10,8; IC95%: 8,5-13,7). A gravidez na adolescência permanece em pauta no campo da saúde reprodutiva, sendo preocupante a proporção do parto cirúrgico encontrada nesse estudo, haja vista a exposição precoce aos efeitos da cesariana.

This paper presents the factors associated with caesarean section in primiparous adolescents in Brazil using data from a national hospital-based survey conducted between 2011 and 2012. Information was obtained from postpartum women through face-to-face and telephone interviews and a theoretical model with three levels of hierarchy was used to analyze associations with the dependent variable mode of delivery (caesarean or vaginal). The results show that the caesarean section rate among primiparous teenagers is high (40%). The most significant contributing factors for caesarean section were: considering this mode of delivery safer (OR = 7.0; 95%CI: 4.3-11.4); giving birth under the private health system (OR = 4.3; 95%CI: 2.3-9.0); being attended by the same health care professional throughout prenatal care and delivery (OR = 5.7; 95%CI: 3.3-9.0) and clinical history of risk and complications during pregnancy (OR = 10.8; 95%CI: 8.5-13.7). Adolescent pregnancy continues to be an important concern on the reproductive health agenda and the rates observed by this study are worrying given the effects of early exposure to caesarean section.

En este artículo se propone el estudio de los factores asociados a la cesárea en adolescentes primíparas en Brasil, utilizando los datos de una encuesta de base hospitalaria, realizada en 2011 y 2012. La información se obtuvo mediante entrevistas con mujeres después del parto, durante la hospitalización. Se estableció un modelo conceptual teórico con tres niveles de jerarquía, donde la variable dependiente fue el tipo de parto: cesárea o vaginal. Los resultados muestran una alta proporción de cesáreas en adolescentes primíparas (40%) y los factores más fuertemente asociados a la cesárea son: la consideraban más segura (OR = 7,0; IC95%: 4,3-11,4); era un parto financiado por el sector privado (OR = 4,3; IC95%: 2,3-9,0); o el hecho de que un mismo profesional de salud prestara atención en el periodo prenatal y parto (OR = 5,7; IC95%: 3,3-9,0), así como la historia clínica de los riesgos y complicaciones (OR = 10,8; IC95%: 8,5-13,7). El embarazo adolescente sigue estando en la agenda de la salud reproductiva, siendo preocupante la proporción de partos operatorios encontrados en este estudio, teniendo en cuenta la exposición temprana a los efectos de la cesárea.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido / Investigación Nacer en Brasil: perfil de mortalidad neonatal, evaluación de la maternidad y cuidado del recién nacido / Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliação de prontuários de 23.940 puérperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para análise dos potenciais fatores de risco para o óbito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regiões Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condições do recém-nascido foram os principais fatores associados ao óbito neonatal. A inadequação do pré-natal e da atenção ao parto indicaram qualidade não satisfatória da assistência. A peregrinação de gestantes para o parto e o nascimento de crianças com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organização da rede de saúde. Óbitos de recém-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos óbitos. A qualificação da atenção, em especial da assistência hospitalar ao parto se configura como foco prioritário para maiores avanços nas políticas públicas de redução das taxas e das desigualdades na mortalidade infantil no Brasil.

Se trata de un estudio de cohorte sobre la mortalidad neonatal en la investigación Nacer en Brasil, con entrevistas y revisión de los registros médicos de 23.940 mujeres durante el posparto, entre febrero de 2011 y octubre de 2012. Se utilizó el modelado jerárquico con el fin de analizar los factores de riesgo potenciales para la muerte neonatal. La tasa de mortalidad fue de 11,1/1.000; mayor en las regiones Norte y Nordeste y en las clases sociales más bajas. El bajo peso al nacer, el riesgo gestacional y la condición del recién nacido fueron los principales factores asociados a la mortalidad neonatal. Una asistencia prenatal y al parto inadecuados indican una calidad insuficiente de atención. La peregrinación de las mujeres embarazadas durante el parto y el nacimiento de niños con peso < 1.500g en un hospital sin unidad de cuidado intensivo neonatal demostró deficiencias en la organización de la red de salud. El motivo final de las muertes de los recién nacidos por asfixia intraparto y la prematuridad tardía expresan la posibilidad de que las muertes podrían haber sido evitadas. La cualificación en la atención, especialmente en la prestación de atención hospitalaria se configura como un foco prioritario para la política pública y el progreso en la reducción de la mortalidad infantil y las desigualdades.

This study examined neonatal deaths in the live-births cohort in the Birth in Brazil survey, which interviewed and examined medical records of 23,940 mothers from February 2011 to October 2012. Potential risk factors were analyzed using hierarchical modeling. Neonatal mortality rate was 11.1/1,000, the highest rates occurring in the North and Northeast regions and in lower social classes. Low birth weight, risks during pregnancy and conditions of the newborn were the main factors associated with neonatal death. Inadequate prenatal and childbirth care point to unsatisfactory quality of health care. Difficulty in gaining hospital admission for delivery, and children with birth weight < 1,500g born at hospitals without a neonatal intensive care unit, indicate gaps in health system organization. Deaths from intra-partum asphyxia in term babies and late prematurity express preventable neonatal mortality. Better quality health care, especially hospital care during labor and birth, poses the main public policy challenge to progress in reducing mortality and inequalities in Brazil.

Breastfeeding during the first hour of life and neonatal mortality.

OBJECTIVE: To analyze the correlation between breastfeeding in the first hour of life with neonatal mortality rates. METHODS: The present study used secondary data from 67 countries, obtained from the Demographic and Health Surveys. Initially, for data analysis, Spearman Correlation (95% CI) and Kernel graphical analysis were employed, followed by a Negative Binomial Pois- son regression model, adjusted for potential confounders. RESULTS: Breastfeeding within the first hour of life was negatively correlated with neo- natal mortality (Spearman's Rho = -0.245, p = 0.046), and this correlation was stronger among countries with more than 29 neonatal deaths per 1000 newborns (Spearman's Rho = -0.327, p = 0.048). According to the statistical model, countries with the lowest breastfeeding tertiles had 24% higher neonatal mortality rates (Rate ratio = 1.24, 95% CI = 1.07-1.44, p < 0.05), even when adjusted for potential confounders. CONCLUSION: The protective effect of breastfeeding during the first hour of life on neo- natal mortality in this ecological study is consistent with findings from previous observa- tional studies, indicating the importance of adopting breastfeeding within the first hour as a routine neonatal care practice.

Factors associated with physical aggression in pregnant women and adverse outcomes for the newborn.

OBJECTIVE: To assess the socioeconomic, demographic, and reproductive factors associated with physical aggression during pregnancy, and the negative outcomes for the newborn in two groups of women: adolescents and young adults. METHOD: Cross-sectional study with a sample of 8,961 mothers who were admitted to hospitals of the city of Rio de Janeiro during delivery. To test the hypothesis of homogeneity of proportions, the chi-squared test was used. Odds ratio and confidence intervals were estimated using logistic regression. RESULTS: 5.0% of the adolescents and 2.5% of the young adult women suffered physical violence during pregnancy. In both groups, the variables associated with physical abuse were lower educational level, lower support from the child's father, and more attempts to interrupt the pregnancy. The increase in alcohol consumption was associated with physical abuse only in the group of adolescents; illicit drug use was only associated with physical abuse in young adults. The children of abused mothers had a two-fold increased chance of neonatal death, and a three-fold increased chance of post-neonatal death. Conversely, good quality prenatal care reduced the chance of physical aggression during pregnancy. CONCLUSIONS: The results emphasize the increased chance of neonatal and post-neonatal mortality among children of victims of physical abuse during pregnancy, and indicate the importance of prenatal care to identify women at higher risk of suffering aggression, the appropriate time to provide measures of protection and care for mother and baby.

A amamentação na primeira hora de vida e mortalidade neonatal / Breastfeeding during the first hour of life and neonatal mortality

OBJETIVO: Analisar a correlação entre o percentual de amamentação na primeira hora de vida e as taxas de mortalidade neonatal. MÉTODOS: Foram utilizados dados secundários de 67 países obtidos das pesquisas realizadas com a metodologia do Demographic and Health Surveys. Inicialmente, para a análise dos dados, foram empregadas a Correlação de Spearman (IC 95%) e a análise gráfica com modificação de Kernel, seguidas de regressão de Poisson Binomial Negativa, ajustando para possíveis fatores de confundimento. RESULTADOS: O percentual de aleitamento materno na primeira hora de vida esteve negativamente associado com as taxas de mortalidade neonatal (Rho = -0,245, p = 0,046), e esta correlação foi mais forte entre os países com mortalidade neonatal superior a 29 mortes/1.000 nascidos vivos (Rho = -0,327, p = 0,048). Os países com os menores tercis de aleitamento materno na primeira hora de vida tiveram uma taxa 24% maior de mortalidade neonatal (razão de taxa = 1,24, IC 95% = 1,07-1,44), mesmo ajustando para fatores de confundimento. CONCLUSÃO: O efeito protetor da amamentação na primeira hora de vida sobre a mortalidade neonatal encontrado nesse estudo ecológico é consistente com o de estudos observacionais, e aponta para a importância de se adotar a amamentação na primeira hora de vida como prática de atenção neonatal.

OBJECTIVE: To analyze the correlation between breastfeeding in the first hour of life with neonatal mortality rates. METHODS: The present study used secondary data from 67 countries, obtained from the Demographic and Health Surveys. Initially, for data analysis, Spearman Correlation (95% CI) and Kernel graphical analysis were employed, followed by a Negative Binomial Poisson regression model, adjusted for potential confounders. RESULTS: Breastfeeding within the first hour of life was negatively correlated with neonatal mortality (Spearman's Rho = -0.245, p = 0.046), and this correlation was stronger among countries with more than 29 neonatal deaths per 1000 newborns (Spearman's Rho = -0.327, p = 0.048). According to the statistical model, countries with the lowest breastfeeding tertiles had 24% higher neonatal mortality rates (Rate ratio = 1.24, 95% CI = 1.07-1.44, p < 0.05), even when adjusted for potential confounders. CONCLUSIONS: The protective effect of breastfeeding during the first hour of life on neonatal mortality in this ecological study is consistent with findings from previous observational studies, indicating the importance of adopting breastfeeding within the first hour as a routine neonatal care practice.

Fatores associados à agressão física em gestantes e os desfechos negativos no recém-nascido / Factors associated with physical aggression in pregnant women and adverse outcomes for the newborn

OBJETIVO: Verificar os fatores socioeconômicos, demográficos e reprodutivos associados à agressão física na gestação e os desfechos negativos para o recém-nascido em dois grupos de mulheres: adolescentes e adultas jovens. MÉTODO: Estudo transversal com uma amostra de 8.961 puérperas que se hospitalizaram em maternidades do município do Rio de Janeiro por ocasião do parto. Para testar hipótese de homogeneidade de proporções foi utilizado o teste χ². A razão de chances e os intervalos de confiança foram estimados através de regressão logística. RESULTADOS: Foi apontado que 5% das adolescentes e 2,5% das adultas jovens sofreram agressão física na gravidez. Em ambos os grupos, as variáveis associadas com o abuso físico foram: menor nível de escolaridade, menor apoio do pai da criança e maior tentativa de interrupção da gestação. O aumento no consumo de bebida alcoólica mostrou associação com o abuso físico apenas no grupo de adolescentes, e o uso de drogas ilícitas somente entre as adultas jovens. Os filhos das puérperas agredidas tiveram duas vezes mais chances de óbito neonatal, e três vezes mais de óbito pós-neonatal. Por outro lado, a assistência pré-natal de boa qualidade reduziu a chance de agressão física durante a gestação. CONCLUSÕES: Os resultados alertam para o aumento da chance de óbito neonatal e pós-neonatal entre os filhos das vítimas de agressão física durante a gestação e apontam para a importância do pré-natal na identificação de mulheres sob maior risco de episódios violentos, momento oportuno para o desenvolvimento de ações de proteção e cuidado à mãe e ao bebê.

OBJECTIVE: To assess the socioeconomic, demographic, and reproductive factors associated with physical aggression during pregnancy, and the negative outcomes for the newborn in two groups of women: adolescents and young adults. METHOD: Cross-sectional study with a sample of 8,961 mothers who were admitted to hospitals of the city of Rio de Janeiro during delivery. To test the hypothesis of homogeneity of proportions, the chi-squared test was used. Odds ratio and confidence intervals were estimated using logistic regression. RESULTS: 5.0% of the adolescents and 2.5% of the young adult women suffered physical violence during pregnancy. In both groups, the variables associated with physical abuse were lower educational level, lower support from the child's father, and more attempts to interrupt the pregnancy. The increase in alcohol consumption was associated with physical abuse only in the group of adolescents; illicit drug use was only associated with physical abuse in young adults. The children of abused mothers had a two-fold increased chance of neonatal death, and a three-fold increased chance of post-neonatal death. Conversely, good quality prenatal care reduced the chance of physical aggression during pregnancy. CONCLUSIONS: The results emphasize the increased chance of neonatal and post-neonatal mortality among children of victims of physical abuse during pregnancy, and indicate the importance of prenatal care to identify women at higher risk of suffering aggression, the appropriate time to provide measures of protection and care for mother and baby.

Risk factors for cognitive impairment in school-age children born preterm: application of a hierarchical model.

The purpose was to analyze factors associated with cognitive impairment in very low birth weight (VLBW) children born preterm. A prospective cohort of 65 VLBW children was assessed at the age of eight years using the Wechsler Intelligence Scale for Children. A model for the relationship of variables with the cognitive impairment outcome attributed hierarchical levels: distal (socioeconomic variables), intermediate I and II (perinatal and neonatal variables, post-neonatal variables) and proximal (child health and psychosocial stimulation). A multivariate logistic regression was performed. In the multivariate hierarchical logistic regression, the maternal education (OR=0.77, 95%CI 0.63-0.94) and number of prenatal visits (OR=0.73, 95%CI 0.54-0.99) showed a protective association, but the male (OR=7.3, 95%CI 1.54-35.3) was associated with worse results. The VLBW children cognitive performance in the age of eight years benefits from more educated mothers, better prenatal care, and the baby gender as female.

Risk factors for cognitive impairment in school-age children born preterm: application of a hierarchical model / Fatores de risco para alteração cognitiva em escolares nascidos pré-termo: aplicação de modelo hierarquizado

The purpose was to analyze factors associated with cognitive impairment in very low birth weight (VLBW) children born preterm. A prospective cohort of 65 VLBW children was assessed at the age of eight years using the Wechsler Intelligence Scale for Children. A model for the relationship of variables with the cognitive impairment outcome attributed hierarchical levels: distal (socioeconomic variables), intermediate I and II (perinatal and neonatal variables, post-neonatal variables) and proximal (child health and psychosocial stimulation). A multivariate logistic regression was performed. In the multivariate hierarchical logistic regression, the maternal education (OR=0.77, 95%CI 0.63-0.94) and number of prenatal visits (OR=0.73, 95%CI 0.54-0.99) showed a protective association, but the male (OR=7.3, 95%CI 1.54-35.3) was associated with worse results. The VLBW children cognitive performance in the age of eight years benefits from more educated mothers, better prenatal care, and the baby gender as female.

O objetivo foi analisar fatores associados à alteração cognitiva na idade escolar de crianças nascidas prematuras de muito baixo peso (PMBP). Uma coorte prospectiva de 65 crianças PMBP foi avaliada aos oito anos através da Escala de Inteligência Wechsler para Crianças. Um modelo para relação das variáveis com o desfecho alteração cognitiva reconheceu níveis hierárquicos: distal (variáveis socioeconômicas), intermediário I e II (variáveis perinatais e neonatais; variáveis pós-neonatais) e proximal (saúde da criança e estímulo psicossocial). Foi realizada análise de regressão logística multivariada. Na regressão logística hierarquizada multivariada, a escolaridade materna (OR=0,77; IC95% 0,63-0,94) e o número de consultas no pré-natal (OR=0,73; IC95% 0,54-0,99) mostraram uma associação protetora; porém o sexo masculino (OR=7,3; IC95% 1,54-35,3) foi associado a piores resultados. O desempenho cognitivo dos PMBP na idade de oito anos é beneficiado pela maior escolaridade das mães, melhor assistência pré-natal e pelo bebê ser do sexo feminino.

Padrões de aleitamento materno exclusivo e internação por diarréia entre 1999 e 2008 em capitais brasileiras / Exclusive breastfeeding and diarrhea hospitalization patterns between 1999 and 2008 in Brazilian State Capitals

A prevalência do aleitamento materno tem aumentado nas duas últimas décadas como resultado das políticas públicas de incentivo a esta prática. Trata-se de estudo epidemiológico ecológico, com base em dados secundários das Capitais Brasileiras e Distrito Federal. As prevalências de aleitamento materno, a população de nascidos vivos e os casos de internação hospitalar por diarreias foram comparados entre os anos de 1999 e 2008. Foi utilizado o teste não-paramétrico de Spearman para correlacionar as variáveis. Foram estudados 1.329.618 nascidos vivos no período. O aumento da prevalência de aleitamento materno exclusivo em crianças com menos de 4 meses de vida teve correlação negativa com as taxas de internação por diarreias (r = -0,483, p = 0,014), sendo essa correlação mais forte para meninas (r = -0,521, p = 0,016) que para os meninos (r = -0,476, p = 0,008). O aumento da prevalência de aleitamento materno exclusivo entre 1999 e 2008 parece estar correlacionado com a diminuição das taxas de internação hospitalar por diarreias no mesmo período, corroborando a importância das políticas públicas de promoção, proteção e apoio do aleitamento materno.

The prevalence of breastfeeding has increased over the past two decades in Brazil, as a result of public breastfeeding policies. The scope of this paper is to analyze the correlation between the increase in the prevalence of breastfeeding and hospitalization rates due to diarrhea. It is an epidemiological ecological study, based on secondary data from Brazilian Capital Cities and the Federal District. The prevalence of breastfeeding, the number of live births, and cases of hospitalization due to diarrhea were compared for the years 1999 and 2008 and the Spearman non-parametric test was used to correlate the variables. During the period, 1,329,618 children under one year of age in 1999 and 2008 were studied. The increase in the prevalence of exclusive breastfeeding among children under 4 months old had a negative correlation with hospitalization rates due to diarrhea (Rho=-0.483, p=0.014). This correlation was stronger for girls (Rho=-0.521, p=0.008) than for boys (Rho=-0.476, p=0.016). The increase in the prevalence of breastfeeding between 1999 and 2008 appears to be correlated to a reduction in hospitalization rates due to diarrhea over the same period, corroborating the importance of public policies to protect, support and promote breastfeeding.

Breastfeeding can prevent hospitalization for pneumonia among children under 1 year old.

OBJECTIVE: To evaluate the relationship between breastfeeding and hospitalization for pneumonia among children under 1 year old. METHODS: Ecological study using secondary data of hospitalizations for pneumonia (outcome) and breastfeeding prevalence data (exposure) among children under 1 year old living in the Brazilian state capital cities and the Federal District in 2008. A negative binomial model of hospitalization was used to estimate the rate ratio (95% confidence interval), adjusted according to the Gini Index, and the prevalence rates of smokers in the general population and low birth weight individuals in the population investigated. RESULTS: Breastfeeding prevalence among children between 9 and 12 months old and exclusive breastfeeding prevalence among children under 6 months old were associated with a lower rate ratio of hospitalization for pneumonia (RR = 0.62; 95%CI 0.51-0.74 and RR = 0.52; 95%CI 0.39-0.69, respectively). CONCLUSION: Increased prevalence rates of breastfeeding during the first year of life and exclusive breastfeeding during the first 6 months of life can reduce the number of hospitalizations for pneumonia.

[Cognitive development of premature children at school age: a proposal for a hierarchical model to investigate risk factors]. / Desenvolvimento cognitivo de prematuros à idade escolar: proposta de modelo hierarquizado para investigação dos fatores de risco.

Cognitive impairment is a neurodevelopmental sequela that is more prevalent in very low birth weight (VLBW) premature children. There are few Brazilian studies on this group's cognitive development at school age. The current study proposes a theoretical discussion on the determinants of cognitive development at school age in VLBW preterm children, using a hierarchical analytical model. According to this model, biological and environmental factors interrelate on several levels (distal, intermediate, and proximal), resulting in changes in cognitive development. The aim is to investigate the possible mediation of variables and their interrelationships and the resulting events that could lead to cognitive impairment as the outcome. Selection of risk factors was based on a literature review of factors associated with adverse cognitive outcomes. Better understanding of the interrelationships between these factors could lead to more appropriate prevention and intervention in this group, thereby increasing their chances of educational and social inclusion.

Desenvolvimento cognitivo de prematuros à idade escolar: proposta de modelo hierarquizado para investigação dos fatores de risco / Cognitive development of premature children at school age: a proposal for a hierarchical model to investigate risk factors

O déficit cognitivo é a sequela do neurodesenvolvimento mais prevalente na população de prematuros de muito baixo peso. Poucos são os trabalhos nacionais sobre o desenvolvimento desta população na idade escolar. Este estudo propõe uma discussão teórica sobre os fatores determinantes do desenvolvimento cognitivo na idade escolar de prematuros de muito baixo peso ao nascer, utilizando o modelo hierarquizado de análise. Neste modelo, fatores biológicos e ambientais se relacionariam em diversos níveis: distal, intermediário e proximal, resultando em alterações no desenvolvimento cognitivo. Pretende-se, desta forma, aprofundar a questão das mediações possíveis das variáveis e suas inter-relações e consequentes eventos que podem levar ao desfecho. Para a seleção dos fatores de risco foi realizada uma revisão da literatura sobre fatores associados a resultados cognitivos desfavoráveis. Pressupõe-se que o melhor conhecimento das inter-relações destes fatores auxiliaria na prevenção e intervenção mais adequada nesta população, aumentando suas chances de inclusão escolar e social.

Cognitive impairment is a neurodevelopmental sequela that is more prevalent in very low birth weight (VLBW) premature children. There are few Brazilian studies on this group's cognitive development at school age. The current study proposes a theoretical discussion on the determinants of cognitive development at school age in VLBW preterm children, using a hierarchical analytical model. According to this model, biological and environmental factors interrelate on several levels (distal, intermediate, and proximal), resulting in changes in cognitive development. The aim is to investigate the possible mediation of variables and their interrelationships and the resulting events that could lead to cognitive impairment as the outcome. Selection of risk factors was based on a literature review of factors associated with adverse cognitive outcomes. Better understanding of the interrelationships between these factors could lead to more appropriate prevention and intervention in this group, thereby increasing their chances of educational and social inclusion.

Fatores associados à amamentação na primeira hora de vida / Factores asociados al amamantamiento en la primera hora de vida / Factors associated with breastfeeding in the first hour of life

OBJETIVO: Identificar fatores associados à amamentação na primeira hora de vida (Passo 4 da Iniciativa Hospital Amigo da Criança). MÉTODOS: Foi realizado estudo transversal com amostra representativa de parturientes em maternidades do Rio de Janeiro, RJ, entre 1999 e 2001. Foram excluídos recém-nascidos ou mães com restrição ao aleitamento materno, resultando em amostra de 8.397 binômios. Foi adotado modelo Poisson com efeitos aleatórios ao nível das maternidades, em abordagem hierarquizada com três níveis: distal, intermediário e proximal para características maternas, do recém-nascido, e de assistência ao pré-natal e hospitalar. RESULTADOS: Amamentaram na primeira hora de vida 16 por cento das mães. O aleitamento materno nesse período foi menos prevalente entre os recém-nascidos com intercorrências imediatas após o parto (RP = 0,47; IC99 por cento 0,15;0,80); entre as mães que não tiveram contato com os recém-nascidos na sala de parto (RP = 0,62; IC99 por cento 0,29;0,95), as que tiveram parto cesariano (RP = 0,48; IC99 por cento 0,24;0,72); e cujo parto ocorreu em maternidade privada (RP = 0,06; IC99 por cento 0,01;0,19) ou conveniada com o Sistema Único de Saúde (RP = 0,16; IC99 por cento 0,01;0,30). O efeito de contexto das maternidades foi estatisticamente significativo. CONCLUSÕES: Em nível individual, a amamentação na primeira hora de nascimento foi prejudicada por práticas inadequadas nas maternidades, em particular as privadas e conveniadas com o Sistema Único de Saúde. O efeito de grupo das maternidades e a ausência de fatores individuais maternos que expliquem o desfecho sugerem que as mães têm pouco ou nenhum poder de decisão sobre essa amamentação e dependem das práticas institucionais vigentes nas maternidades.

OBJETIVO: Identificar factores asociados al amamantamiento en la primera hora de vida (Paso 4 de la Iniciativa Hospital Amigo del Niño).MÉTODOS: Se realizó estudio transversal con muestra representativa de parturientas en maternidades de Rio de Janeiro, Sureste de Brasil, entre 1999 y 2001. Se excluyeron recién nacidos o madres con restricción a la lactancia materna, resultando en muestra de 8.397 binomios. Se adoptó modelo Poisson con efectos aleatorios al nivel de las maternidades, en abordaje jerarquizado con tres niveles: distal, intermedio y proximal para características maternas, del recién nacido, y de asistencia al prenatal y hospitalario.RESULTADOS: Amamantaron en la primera hora de vida 16% de las madres. La lactancia materna en ese período fue menos prevalente entre los recién nacidos con intercorrencias inmediatas posterior al parto (RP=0,47; IC99% 0,15;0,80); entre las madres que no tuvieron contacto con los recién nacidos en la sala de parto (RP=0,62; IC99% 0,29;0,95); que tuvieron parto por cesárea (RP = 0,48; IC99% 0,24;0,72); y cuyo parto ocurrió en maternidad privada (RP = 0,06; IC99% 0,01;0,19) o por convenio con el Sistema Único de Salud (RP = 0,16; IC99% 0,01;0,30). El efecto de contexto de las maternidades fue estadísticamente significativo.CONCLUSIONES: En nivel individual, el amamantamiento en la primera hora de nacimiento fue perjudicado por prácticas inadecuadas en las maternidades, en particular las privadas y con convenio con el Sistema Único de Salud. El efecto de grupo de las maternidades y la ausencia de factores individuales maternos que expliquen el resultado, sugieren que las madres tienen poco o ningún poder de decisión sobre tal amamantamiento y dependen de las prácticas institucionales vigentes en las maternidades.

Factors associated with breastfeeding in the first hour of life.

OBJECTIVE: To identify factors associated with breastfeeding in the first hour of life (Step 4 of the Baby-Friendly Hospital Initiative). METHODS: A cross-sectional study was conducted with a representative sample of mothers who gave birth in maternity wards in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2001. Newborns or mothers with restriction to breastfeeding were excluded, resulting in a sample of 8,397 pairs. A random effect--at maternity hospital level--Poisson model was employed in a hierarchical approach with three levels: distal, intermediate and proximal for characteristics of the mother, of the newborn, and of prenatal and hospital assistance. RESULTS: Only 16% of the mothers breastfed in the first hour of life. Breastfeeding in this period was less prevalent among neonates with immediate intercurrences after birth (PR = 0.47; CI99% 0.15;0.80); among mothers who did not have contact with their newborns in the delivery room (PR = 0.62; CI99% 0.29;0.95); among mothers submitted to cesarean section delivery (PR = 0.48; CI99% 0.24;0.72); and among mothers who gave birth at private maternity hospitals (PR = 0.06; CI99% 0.01;0.19) or at maternity hospitals contracted out to National Health System (SUS) (PR = 0.16; CI99% 0.01;0.30). The context effect of maternity wards was statistically significant. CONCLUSIONS: At an individual level, breastfeeding within one hour after birth was constrained by inappropriate practices in private or SUS-contracted maternity hospitals. The group effect of maternity hospitals and the absence of individual maternal-related factors that explain the outcome suggest that mothers have little or no autonomy to breastfeed their babies within the first hour of life, and depend on the institutional practices that prevail at the maternity hospitals.