Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil.

OBJECTIVE: To investigate inequalities in cesarean delivery rates in Brazil according to ethnic group and level of access to hospital delivery. METHODS: Cross-sectional analysis of data for primiparous women with singleton deliveries between 2003 and 2004 from the National Information System of Live-Births (6,064,799 live births). Robust Poisson regression modeling was applied to estimate prevalence ratios of cesarean deliveries for ethnic group and level of access to hospital delivery according to residence. RESULTS: There were 2,438,180 primiparous deliveries and the cesarean rate was 45.8%. Ethnic inequalities in cesarean delivery rates showed lower rates for all ethnic groups compared with white women, with the lowest rates recorded for indigenous women. The association between ethnicity and cesarean delivery was higher in states with lower access to hospital (P<0.001). Multiple regression models showed that this association was, in part, explained by older maternal age and higher levels of education and prenatal care. CONCLUSIONS: Overuse of cesarean delivery and strong evidence of ethnic inequalities in cesarean rates exist in Brazil. The inequalities are greater in states with lower access to hospital and were partially explained by socioeconomic factors and prenatal care, suggesting a misuse of medical technology at birth.

Effects of the home environment on unintentional domestic injuries and related health care attendance in infants.

AIMS: To examine the effects of the home environment on unintentional domestic injuries and related health care attendance in infants from deprived families. METHODS: Ten mechanisms that caused unintentional domestic injury during the first year were investigated in a population-based study of 1-year-old children in southern Brazil. Odds ratios of injury-related health care attendance were estimated by number of injury mechanisms reported. Variation in number of mechanisms (in the whole sample) and odds ratios of care attendance (in children with reported injuries) were estimated for socioeconomic and psychosocial variables. RESULTS: Among all children (394) 86% had injuries; 10.9% care attendance and 0.5% hospitalisation were reported, and 14.5% presented dental trauma. Injury-related care attendance increased with the number of injury mechanisms (linear trend OR = 1.34, 95% CI = 1.09-1.66). In multivariable linear regression, injury mechanisms increased with the number of home hazards (p = 0.047) and decreased with duration of exclusive breastfeeding (p = 0.039), maternal involvement-responsiveness (p = 0.037) and mother's paid work (p = 0.018). Injury-related health care attendance among children with reported injuries was positively associated with maternal involvement-responsiveness (OR = 2.27, 95% CI = 1.11-4.67) and home organization (OR = 2.25, 95% CI = 1.09-4.65). CONCLUSION: Injury control can benefit from policy and practice that improve housing, reduce home hazards and promote breastfeeding, maternal bonds, safety practices and injury care.

A continuous-scale measure of child development for population-based epidemiological surveys: a preliminary study using Item Response Theory for the Denver Test.

A method for translating research data from the Denver Test into individual scores of developmental status measured in a continuous scale is presented. It was devised using the Denver Developmental Screening Test (DDST) but can be used for Denver II. The DDST was applied in a community-based survey of 3389 under-5-year-olds in Porto Alegre, Brazil. The items of success were standardised by logistic regression on log chronological age. Each child's ability age was then estimated by maximum likelihood as the age in this reference population corresponding to the child's success and failures in the test. The score of developmental status is the natural logarithm of this ability age divided by chronological age and thus measures the delay or advance in the child's ability age compared with chronological age. This method estimates development status using both difficulty and discriminating power of each item in the reference population, an advantage over scores based on total number of items correctly performed or failed, which depend on difficulty only. The score corresponds with maternal opinion of child developmental status and with the 3-category scale of the DDST. It shows good construct validity, indicated by symmetrical and homogeneous variability from 3 months upwards, and reasonable results in describing gender differences in development by age, the mean score increasing with socio-economic conditions and diminishing among low-birthweight children. If a standardised measure of development status (z-scores) is required, this can be obtained by dividing the score by its standard deviation. Concurrent and discriminant validity of the score must be examined in further studies.

Social inequalities in maternal opinion of child development in southern Brazil.

AIMS AND METHODS: Concurrent validity of maternal opinion of child development was estimated in a cross-sectional, population-based survey of 6-59-mo children (n=3025), using a standard measure devised from the Denver Developmental Screening Test. RESULTS: Sensitivity, specificity and negative predictive value increased with maternal education and family income. Positive predictive value was higher in low-income families and children with impairments, low birthweight and long hospital stays. CONCLUSION: Children at social and clinical risk should be assessed more carefully, even if maternal report is normal or advanced.

Measuring blood pressure: the importance of understanding variation

Blood pressure is intrinsically variable. Because of this measured blood pressure shows a degree of random variation. In an individual patient, random variation in measured blood pressure causes chance variation in the diagnosis of hypertension. This means that decisions about whether to star treatment of high blood pressure are in part determined by chance. In particular it means that in population groups with a low prevalence of hypertension, the number who are incorrectly diagnosed may be greater than the number who are correctly diagnosed. In an individual patient who is started on treatment, random variation in measured blood pressure causes very significant chance variation when we try to determine whether a treatment is effectively reducing blood pressure. This means that decisions about whether to change treatments are in large part determined by chance. Random variation in measured blood pressure is much greater than the difference between a low dose and a high dose treatment or the difference between one drug treatment and another. Variation in blood pressure measurement therefore causes all subsequent decisions about to be subject to a great deal of arbitrary variation. Neither using the average of many blood pressure monitoring fully resolve this problem. The most satisfactory solution to he diagnostic problem is to follow the lad of New Zealand and European hypertension guidelines and base the decision to treat on the patient’s cardiovascular risk. Cardiovascular risk correlates better with potential benefit to he patient and because it is determined in large part by age and sex, it is a measurement that is less affected by chance variation in measured blood pressure. The solution to he problem of follow up is more radical. Many clinical trials have demonstrated the drugs are effective in lowering blood pressure. We do not need to confirm this fact in every one of our patients

Desigualdade social e outros determinantes da altura em crianças: uma análise multinível / Social inequalities and other determinants of height in children: a multi-level analysis

Estudo transversal de base populacional sobre altura de crianças de 12 a 59 meses (n = 2.632) foi realizado em Porto Alegre, Brasil. Usou-se regressão linear multinível para investigar o efeito de condições sócio-econômicas, demográficas, de saúde e dos ambientes físico e social sobre a altura, medida em escores-z do padrão de altura para idade do National Center for Health Statisrics. A área de localização do domicílio foi classificada como bem e mal provida em infra-estrutura habitacional. A altura foi, em média, -0,18 escore-z, estando positivamente associada a escolaridade e qualificação ocupacional dos pais, renda, qualidade de moradia, idade materna, intervalo interpartal e peso de nascimento, e negativamente relacionada a prematuridade, número de menores de cinco anos no domicílio e hospitalização nos dois primeiros anos de vida. O efeito da educação materna foi o dobro nas áreas mal providas em infra-estrutura habitacional. O efeito positivo da qualificação ocupacional dos pais foi evidente apenas nas áreas mal providas. Provavelmente, a área de residência modifica o efeito das condições sócio-econômicas sobre o crescimento. Programas habitacionais e de saneamento são potencialmente úteis para diminuir o efeito de condições sócio-econômicas desfavoráveis sobre o crescimento da criança.

[Social inequalities and other determinants of height in children: a multi-level analysis]. / Desigualdade social e outros determinantes da altura em crianças: uma análise multinível.

A cross-sectional household survey of height among children under five years of age (n = 2,632) was conducted in the city of Porto Alegre, Rio Grande do Sul State, Brazil. Multi-level linear regression was applied to investigate the effect of socioeconomic and demographic factors, physical and social environment, and health conditions on children s height, measured by the height-for-age z-scores of the National Center for Health Statistics standards. Area of residence (census tract) was classified as good versus poor in terms of housing and sanitation standards. On average, children s height was -0.18 z-score. Average height increased with maternal and paternal schooling, parents work skills, per capita family income, improved housing, maternal age, birth intervals, and birth weight. Height decreased with hospitalization in the first two years of life, number of under-five children in the household, and preterm birth. In the poor residential areas, the effect of maternal schooling was twice as great as in the better-off areas. The effect of parental work skills was only evident in the more deprived areas. Area of residence modified the effects of socioeconomic conditions on children s growth. Housing and sanitation programs are potentially beneficial to offset the negative effect of social disadvantage on children's growth.

Out-patient drug treatment of pneumonia among children under two years of age in Fortaleza, Brazil

Estudou-se a aderência ao tratamento de pneumonia em crianças, em serviço ambulatorial de hospital pediátrico em Fortaleza, Brazil. Foram investigadas 171 crianças com diagnóstico de pneumonia. Através de questionário foram coletadas informaçöes referentes à prescriçäo médica e estimada a aderência ao tratamento de 149 crianças. Os antimicrobianos mais comumente prescritos foram penicilina procaína (33 por cento), penicilina benzatina (31 por cento), ampicilina ou amoxacilina (12 por cento) e cotrimoxazol (8 por cento). Embora tenha sido freqüente a associaçäo de antimicrobianos com outros medicamentos, tratamento exclusivo com penicilina procaína foi prescrito para 31 crianças. A aderência ao uso de antimicrobianos foi de 52 por cento, tendo sido mais elevada para os pacientes tratados exclusivamente com medicaçäo injetável. As prescriçöes médicas combinaram, muitas vezes, diferentes antimicrobianos durante o mesmo tratamento. A análise das diferentes associaçöes antimicrobianas revelou que apenas 81 (54 por cento) crianças receberam tratamento apropriado, por período de cinco ou mais dias. Concluiu-se que a identificaçäo de antimicrobianos que possam resultar na maior aderência ao tratamento permanece como um dos principais desafios no manejo ambulatorial das pneumonias nas crianças. Outros medicamentos incluíram os analgésicos e broncodilatadores.