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

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

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

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

Impact of cash transfer programs on birth and child growth outcomes: systematic review / Impacto dos programas de transferência de renda nos desfechos de nascimento e crescimento infantil: revisão sistemática

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

Resumo Investigar o impacto dos programas de tranferência de renda (CTs) nos desfechos ao nascer, incluindo peso ao nascer, baixo peso ao nascer e prematuridade, e crescimento físico infantil, avaliado pelos índices antropométricos de crianças menores de cinco anos. Revisão sistemática realizada nas bases de dados PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus e Web of Science. Foram incluídos estudos quantitativos observacionais, experimentais e quasi-experimentais, com um total de 11 estudos na revisão. A maioria (81,8%) foi realizada em países de baixa e média rendas. Também na modalidade CT condicionais (63,6%). Quatro eram ensaios clínicos, e sete observacionais. Os CT condicionais estiveram associados a uma redução nos índices de altura-para-idade (-0,14; IC95% -0,27, -0,02); (OR 0,85; IC95% 0,77-0,94); (OR = 0,44; IC95% 0,19-0,98), redução significativa na chance de baixo peso-para-idade (OR = 0,16; IC95% -0,11-0,43), baixo peso-para-altura (OR = -0,68; IC95% -1,14, -0,21), e redução de peso para idade (OR = 0,27; IC95% 0,10; 0,71). CTs não condicionais foram associados à redução do baixo peso as nascer (RR = 0,71; IC95% 0,63-0,81; p < 0,0001), e de prematuros (RR = 0,76; IC95% 0,69-0,84; p < 0,0001). Os CTs condicionais podem influenciar positivamente os desfechos ao nascer e o crescimento infantil.

The impact of social drivers, conditional cash transfers and their mechanisms on the mental health of the young; an integrated retrospective and forecasting approach using the 100 million Brazilian Cohort: A study protocol.

BACKGROUND: Physical, emotional, and social changes, including exposure to poverty, abuse, or violence, increases youth vulnerability to mental illness. These factors interfere with development, limit opportunities, and hamper achievement of a fulfilling life as adults. Addressing these issues can lead to improved outcomes at the population level and better cost-effectiveness for health services. Cash transfer programs have been a promising way to address social drivers for poor mental health. However, it is still unclear which pathways and mechanisms explain the association between socioeconomic support and lower mental illness among youth. Therefore, we will evaluate the effect of social drivers on youth mental health-related hospitalizations and suicide, test mechanisms and pathways of a countrywide socioeconomic intervention, and examine the timing of the intervention during the life course. METHODS: We will combine individual-level data from youth national hospitalization, mental health disorders and attempted suicide, suicide registries and notifications of violence, with large-scale databases, including "The 100 Million Brazilian Cohort", over an 18-year period (2001-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Designs, Propensity Score Matching and difference-in-differences, combined with multivariable regressions for cohort analyses. We will run multivariate regressions based on hierarchical analysis approach to evaluate the association between important social drivers (mental health care, demographic and economic aspects) on mental health-related hospitalizations and suicide among youth. Furthermore, we will perform microsimulations to generate projections regarding how mental health-related hospitalizations and suicide trends will be in the future based on the current state, and how BFP implementation scenarios will affect these trends. DISCUSSION: The results of this project will be of vital importance to guide policies and programs to improve mental health and reduce mental health-related hospitalizations and suicide in youth. It will provide information to improve the effectiveness of these programs worldwide. If cash transfers can decrease mental health problems among youth and reduce suicide.

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

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

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

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

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

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

Evaluating the effect of Bolsa Familia, Brazil's conditional cash transfer programme, on maternal and child health: A study protocol.

BACKGROUND: Conditional Cash Transfer Programs have been developed in Latin America in response to poverty and marked social inequalities on the continent. In Brazil, the Bolsa Familia Program (BFP) was implemented to alleviate poverty and improve living conditions, health, and education for socioeconomically vulnerable populations. However, the effect of this intervention on maternal and child health is not well understood. METHODS: We will evaluate the effect of BFP on maternal and child outcomes: 1. Birth weight; 2. Preterm birth; 3. Maternal mortality; and 4. Child growth. Dynamic retrospective cohort data from the 100 Million Brazilian Cohort (2001 to 2015) will be linked to three different databases: Live Birth Information System (2004 to 2015); Mortality Information System (2011 to 2015); and Food and Nutritional Surveillance System (2008 to 2017). The definition of exposure to the BFP varies according to the outcome studied. Those who never received the benefit until the outcome or until the end of the follow-up will be defined as not exposed. The effects of BFP on maternal and child outcomes will be estimated by a combination of propensity score-based methods and weighted logistic regressions. The analyses will be further stratified to reflect changes in the benefit entitlement before and after 2012. DISCUSSION: Harnessing a large linked administrative cohort allows us to assess the effect of the BFP on maternal and child health, while considering a wide range of explanatory and confounding variables.

CoronaVac vaccine is effective in preventing symptomatic and severe COVID-19 in pregnant women in Brazil: a test-negative case-control study.

BACKGROUND: More doses of CoronaVac have been administered worldwide than any other COVID-19 vaccine. However, the effectiveness of COVID-19 inactivated vaccines in pregnant women is still unknown. We estimated the vaccine effectiveness (VE) of CoronaVac against symptomatic and severe COVID-19 in pregnant women in Brazil. METHODS: We conducted a test-negative design study in all pregnant women aged 18-49 years with COVID-19-related symptoms in Brazil from March 15, 2021, to October 03, 2021, linking records of negative and positive SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) tests to national vaccination records. We also linked records of test-positive cases with notifications of severe, hospitalised or fatal COVID-19. Using logistic regression, we estimated the adjusted odds ratio and VE against symptomatic COVID-19 and against severe COVID-19 by comparing vaccine status in test-negative subjects to test-positive symptomatic cases and severe cases. RESULTS: Of the 19,838 tested pregnant women, 7424 (37.4%) tested positive for COVID-19 and 588 (7.9%) had severe disease. Only 83% of pregnant women who received the first dose of CoronaVac completed the vaccination scheme. A single dose of the CoronaVac vaccine was not effective at preventing symptomatic COVID-19. The effectiveness of two doses of CoronaVac was 41% (95% CI 27.1-52.2) against symptomatic COVID-19 and 85% (95% CI 59.5-94.8) against severe COVID-19. CONCLUSIONS: A complete regimen of CoronaVac in pregnant women was effective in preventing symptomatic COVID-19 and highly effective against severe illness in a setting that combined high disease burden and marked COVID-19-related maternal deaths.

Methods to evaluate COVID-19 vaccine effectiveness, with an emphasis on quasi-experimental approaches. / Métodos para avaliação da efetividade de vacinas para COVID-19 com ênfase em abordagens quase-experimentais.

The evaluation of vaccine effectiveness is conducted with real-world data. They are essential to monitor the performance of vaccination programmes over time, and in the context of the emergence of new variants. Until now, the effectiveness of COVID-19 vaccines has been assessed based on classic methods, such as cohort and test-negative case-control studies, which may often not allow for adequate control of inherent biases in the assignment of vaccination campaigns. The aim of this review was to discuss the study designs available to evaluate vaccine effectiveness, highlighting quasi-experimental studies, which seek to mimic randomized trials, by introducing an exogenous component to allocate to treatment, in addition to the advantages, limitations, and applicability in the context of Brazilian data. The use of quasi-experimental approaches, such as interrupted time series, difference-in-differences, propensity scores, instrumental variables, and regression discontinuity design, are relevant due to the possibility of providing more accurate estimates of COVID-19 vaccine effectiveness. This is especially important in scenarios such as the Brazilian, which characterized by the use of various vaccines, with the respective numbers and intervals between doses, applied to different age groups, and introduced at different times during the pandemic.

A avalição da efetividade de vacinas é feita com dados do mundo real e é essencial para monitorar o desempenho dos programas de vacinação ao longo do tempo bem como frente a novas variantes. Até o momento, a avaliação da efetividade das vacinas para COVID-19 tem sido baseada em métodos clássicos como estudos de coorte e caso controle teste-negativo, que muitas vezes podem não permitir o adequado controle dos vieses intrínsecos da alocação das campanhas de vacinação. O objetivo dessa revisão foi discutir os desenhos de estudo disponíveis para avaliação de efetividade das vacinas, enfatizando os estudos quase-experimentais, que buscam mimetizar os estudos aleatorizados ao introduzir um componente exógeno para atribuição ao tratamento, bem como suas vantagens, limitações e aplicabilidade no contexto dos dados brasileiros. O emprego de métodos quase-experimentais, incluindo as séries temporais interrompidas, o método de diferença em diferenças, escore de propensão, variáveis instrumentais e regressão descontínua, são relevantes pela possibilidade de gerar estimativas mais acuradas da efetividade de vacinas para COVID-19 em cenários como o brasileiro, que se caracteriza pelo uso de várias vacinas, com respectivos número e intervalos entre doses, aplicadas em diferentes faixas etárias e em diferentes momentos da pandemia.

Risk of mortality for small newborns in Brazil, 2011-2018: A national birth cohort study of 17.6 million records from routine register-based linked data.

BACKGROUND: Preterm birth (<37 weeks), low birth weight (LBW,<2500g), and small for gestational age (SGA,<10th centile of birth weight for gestational age and sex) are markers of newborn vulnerability with a high risk of mortality. We estimated the prevalence of phenotypes combining these three markers and quantified the mortality risk associated with them. METHODS: Population-based cohort study using routine register-based linked data on all births and deaths in Brazil from January 1, 2011, to December 31, 2018. We estimated the prevalence of preterm, LBW, and SGA individually and for phenotypes combining these characteristics. The mortality risk associated with each phenotype: early neonatal, late neonatal, neonatal, post-neonatal, infant, 1-4 years, and under five years was quantified using mortality rates and hazard ratios (HRs) with 95% confidence interval (CI) were estimated using Cox proportional hazard models. FINDINGS: 17,646,115 live births were included. Prevalence of preterm birth, LBW and SGA were 9.4%, 9.6% and 9.2%, respectively. Neonatal mortality risk was 16-fold (HR=15.9; 95% CI:15.7-16.1) higher for preterm compared to term, 3 times higher (HR=3.4; (95% CI:3.3-3.4) for SGA compared to adequate for gestational age (AGA), and >25 times higher for LBW (HR=25.8; (95% CI:25.5-26.1) compared to normal birth weight (NBW). 18% of all live births were included in one of the small vulnerable newborn phenotypes. Of those 8.2% were term-SGA (4.7%NBW, 3.5%LBW), 0.6% were term-AGA-LBW, 8.3% preterm-AGA (3.8%NBW, 4.5%LBW) and 1.0% preterm-SGA-LBW. Compared to term-AGA-NBW, the highest mortality risk was for preterm-LBW phenotypes (HR=36.2(95%CI 35.6-36.8) preterm-AGA-LBW, HR=62.0(95%CI 60.8-63.2) preterm-SGA-LBW). The increased mortality risk associated with vulnerable newborn phenotypes was highest in the first month of life, with attenuated but continued high risk in the post-neonatal period and 1-4 years of age. INTERPRETATION: Our findings support the value of using more detailed phenotypes to identify those at highest risk. More granular data can inform care at the individual level, advance research, especially for prevention, and accelerate progress towards global targets such as the Sustainable Development Goals. FUNDING: Wellcome Trust.

Métodos para avaliação da efetividade de vacinas para COVID-19 com ênfase em abordagens quase-experimentais / Methods to evaluate COVID-19 vaccine effectiveness, with an emphasis on quasi-experimental approaches

Resumo A avalição da efetividade de vacinas é feita com dados do mundo real e é essencial para monitorar o desempenho dos programas de vacinação ao longo do tempo bem como frente a novas variantes. Até o momento, a avaliação da efetividade das vacinas para COVID-19 tem sido baseada em métodos clássicos como estudos de coorte e caso controle teste-negativo, que muitas vezes podem não permitir o adequado controle dos vieses intrínsecos da alocação das campanhas de vacinação. O objetivo dessa revisão foi discutir os desenhos de estudo disponíveis para avaliação de efetividade das vacinas, enfatizando os estudos quase-experimentais, que buscam mimetizar os estudos aleatorizados ao introduzir um componente exógeno para atribuição ao tratamento, bem como suas vantagens, limitações e aplicabilidade no contexto dos dados brasileiros. O emprego de métodos quase-experimentais, incluindo as séries temporais interrompidas, o método de diferença em diferenças, escore de propensão, variáveis instrumentais e regressão descontínua, são relevantes pela possibilidade de gerar estimativas mais acuradas da efetividade de vacinas para COVID-19 em cenários como o brasileiro, que se caracteriza pelo uso de várias vacinas, com respectivos número e intervalos entre doses, aplicadas em diferentes faixas etárias e em diferentes momentos da pandemia.

Abstract The evaluation of vaccine effectiveness is conducted with real-world data. They are essential to monitor the performance of vaccination programmes over time, and in the context of the emergence of new variants. Until now, the effectiveness of COVID-19 vaccines has been assessed based on classic methods, such as cohort and test-negative case-control studies, which may often not allow for adequate control of inherent biases in the assignment of vaccination campaigns. The aim of this review was to discuss the study designs available to evaluate vaccine effectiveness, highlighting quasi-experimental studies, which seek to mimic randomized trials, by introducing an exogenous component to allocate to treatment, in addition to the advantages, limitations, and applicability in the context of Brazilian data. The use of quasi-experimental approaches, such as interrupted time series, difference-in-differences, propensity scores, instrumental variables, and regression discontinuity design, are relevant due to the possibility of providing more accurate estimates of COVID-19 vaccine effectiveness. This is especially important in scenarios such as the Brazilian, which characterized by the use of various vaccines, with the respective numbers and intervals between doses, applied to different age groups, and introduced at different times during the pandemic.

Combined association of obesity and other cardiometabolic diseases with severe COVID-19 outcomes: a nationwide cross-sectional study of 21 773 Brazilian adult and elderly inpatients.

OBJECTIVES: To investigate the combined association of obesity, diabetes mellitus (DM) and cardiovascular disease (CVD) with severe COVID-19 outcomes in adult and elderly inpatients. DESIGN: Cross-sectional study based on registry data from Brazil's influenza surveillance system. SETTING: Public and private hospitals across Brazil. PARTICIPANTS: Eligible population included 21 942 inpatients aged ≥20 years with positive reverse transcription-PCR test for SARS-CoV-2 until 9 June 2020. MAIN OUTCOME MEASURES: Severe COVID-19 outcomes were non-invasive and invasive mechanical ventilation use, intensive care unit (ICU) admission and death. Multivariate analyses were conducted separately for adults (20-59 years) and elders (≥60 years) to test the combined association of obesity (without and with DM and/or CVD) and degrees of obesity with each outcome. RESULTS: A sample of 8848 adults and 12 925 elders were included. Among adults, obesity with DM and/or CVD showed higher prevalence of invasive (prevalence ratio 3.76, 95% CI 2.82 to 5.01) and non-invasive mechanical ventilation use (2.06, 1.58 to 2.69), ICU admission (1.60, 1.40 to 1.83) and death (1.79, 1.45 to 2.21) compared with the group without obesity, DM and CVD. In elders, obesity alone (without DM and CVD) had the highest prevalence of ICU admission (1.40, 1.07 to 1.82) and death (1.67, 1.00 to 2.80). In both age groups, obesity alone and combined with DM and/or CVD showed higher prevalence in all outcomes than DM and/or CVD. A dose-response association was observed between obesity and death in adults: class I 1.32 (1.05 to 1.66), class II 1.41 (1.06 to 1.87) and class III 1.77 (1.35 to 2.33). CONCLUSIONS: The combined association of obesity, diabetes and/or CVD with severe COVID-19 outcomes may be stronger in adults than in elders. Obesity alone and combined with DM and/or CVD had more impact on the risk of COVID-19 severity than DM and/or CVD in both age groups. The study also supports an independent relationship of obesity with severe outcomes, including a dose-response association between degrees of obesity and death in adults.

Abortion and the COVID-19 pandemic: insights for Latin America.

The COVID-19 pandemic may accentuate existing problems, hindering access to legal abortion, with a consequent increase in unsafe abortions. This scenario may be even worse in low- and middle-income countries, especially in Latin America, where abortion laws are already restrictive and access to services is already hampered. Our objective was to understand how different countries, with an emphasis on Latin Americans, have dealt with legal abortion services in the context of the COVID-19. Thus, we conducted a narrative review on abortion and COVID-19. The 75 articles included, plus other relevant references, indicate that the pandemic affects sexual and reproductive health services by amplifying existing problems and restricting access to reproductive rights, such as legal abortion. This impact may be even stronger in low- and middle-income countries, especially in Latin America, where access to legal abortion is normally restricted. The revision of sources in this article underlines the urgent need to maintain legal abortion services, both from women's perspective, in support of their reproductive rights, but also from that of the international commitment to achieving the Millennium Development Goals. Thereby, Latin American countries must place reproductive rights as a priority on their agendas and adapt legislation to accommodate alternative models of abortion care. Furthermore, our results underscore the need for clear information on the functioning of sexual and reproductive health services as essential for understanding the impact of the pandemic on legal abortion and to identify the groups most affected by the changes.

Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data.

BACKGROUND: Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS: The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS: BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION: Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.

The relationship between nutritional deficiencies and mental health

ABSTRACT The objective of this mini review was to discuss the relationship between nutritional deficiencies and mental health, and to present a structure that helps to visualize these associations based on a literature review and the scenarios of the COVID-19 pandemic. The study was conducted to demonstrate the effect of the nutritional deficiencies on the occurrence and/or worsening of mental health problems, mainly related to the most drastic measures of social distance during the COVID-19 pandemic. Studies have already shown that a nutritionally unbalanced diet may be associated with greater chances of mental health problems. Insufficient levels of micronutrients can, by regulating the stress response, immune and oxidative systems, negatively affect brain functions and, consequently, cognitive functions and mental health of individuals. The current pandemic of COVID-19 reveals an increase in food and nutritional insecurity, and a worsening of this situation among already vulnerable populations. Micronutrient deficiencies may be exacerbated in a context of increased food insecurity and the COVID-19 pandemic, which may contribute to increased mental health problems.

RESUMEN El objetivo de esta revisión fue discutir la relación entre las deficiencias nutricionales y la salud mental, y presentar una estructura que ayude a visualizar estas asociaciones con base en la revisión de la literatura y en los escenarios de la pandemia de COVID-19. El estudio se realizó para demostrar el efecto de las deficiencias nutricionales sobre la ocurrencia y/o agravamiento de problemas de salud mental, principalmente relacionados con las medidas más drásticas de distanciamiento social durante la pandemia COVID-19. Los estudios ya han demostrado que una dieta nutricionalmente desequilibrada puede estar asociada con mayores posibilidades de problemas de salud mental. Los niveles insuficientes de micronutrientes pueden, al regular la respuesta al estrés, los sistemas inmunológico y oxidativo, afectar negativamente las funciones cerebrales y, en consecuencia, las funciones cognitivas y la salud mental de las personas. La actual pandemia de COVID-19 revela un aumento de la inseguridad alimentaria y nutricional, y un agravamiento de esta situación entre poblaciones ya vulnerables. Las deficiencias de micronutrientes pueden agravarse en un contexto de mayor inseguridad alimentaria y la pandemia de COVID-19, lo que puede contribuir a un aumento de los problemas de salud mental.

Shifts towards overweight and double burden of malnutrition among socio-economically vulnerable children: a longitudinal ecological analysis of Brazilian municipalities.

OBJECTIVE: To investigate the shifts and factors associated with different scenarios resulting from the prevalence of child stunting and overweight in Brazilian municipalities. DESIGN: This is an ecological study using municipality-level panel data of stunting and overweight prevalence and socio-economic characteristics from 2008 to 2014. The municipalities were classified according to the WHO-UNICEF prevalence thresholds for stunting and overweight and were categorised into four nutritional scenarios: no burden (prevalence of stunting < 20 % and overweight < 10 %), stunting burden (prevalence of stunting ≥ 20 % and overweight < 10 %), overweight burden (prevalence of stunting < 20 % and overweight ≥ 10 %) and double burden (prevalence of stunting ≥ 20 % and overweight ≥ 10 %). SETTING: Totally, 4443 Brazilian municipalities. PARTICIPANTS: Aggregated data of children under 5 years old enrolled in the Brazil's conditional cash transfer programme (Bolsa Família). RESULTS: A mean reduction from 14·2 % to 12·7 % in the prevalence of stunting and an increase from 17·2 % to 18·4 % in the prevalence of overweight were observed. The predominant scenarios were overweight burden and double burden. The odds of both scenarios increased with higher gross domestic product (GDP) per capita and decreased with higher unemployment rates. Stunting and double burden decreased with higher expected years of schooling, and stunting burden increased with household crowding. CONCLUSION: Our findings indicate an advanced nutrition transition stage in Brazil, associated mainly with municipal GDP per capita growth, which has contributed to increasing the burden of overweight alone or coexisting with stunting (double burden) among children in the most socio-economically vulnerable strata of the population.

Abortion and the COVID-19 pandemic: insights for Latin America / Aborto e a pandemia da COVID-19: lições para América Latina / Aborto y pandemia de COVID-19: reflexiones para Latinoamérica

The COVID-19 pandemic may accentuate existing problems, hindering access to legal abortion, with a consequent increase in unsafe abortions. This scenario may be even worse in low- and middle-income countries, especially in Latin America, where abortion laws are already restrictive and access to services is already hampered. Our objective was to understand how different countries, with an emphasis on Latin Americans, have dealt with legal abortion services in the context of the COVID-19. Thus, we conducted a narrative review on abortion and COVID-19. The 75 articles included, plus other relevant references, indicate that the pandemic affects sexual and reproductive health services by amplifying existing problems and restricting access to reproductive rights, such as legal abortion. This impact may be even stronger in low- and middle-income countries, especially in Latin America, where access to legal abortion is normally restricted. The revision of sources in this article underlines the urgent need to maintain legal abortion services, both from women's perspective, in support of their reproductive rights, but also from that of the international commitment to achieving the Millennium Development Goals. Thereby, Latin American countries must place reproductive rights as a priority on their agendas and adapt legislation to accommodate alternative models of abortion care. Furthermore, our results underscore the need for clear information on the functioning of sexual and reproductive health services as essential for understanding the impact of the pandemic on legal abortion and to identify the groups most affected by the changes.

A pandemia da COVID-19 pode agravar problemas existentes, dificultando o acesso ao aborto legal e resultando em um aumento dos abortos inseguros. O cenário pode ser ainda pior nos países de renda média e baixa, principalmente na América Latina, onde as leis sobre aborto já são restritivas e o acesso aos serviços é dificultado. Tivemos como objetivo, compreender como os diferentes países, com ênfase nos latino-americanos, têm lidado com os serviços de aborto legal no contexto da COVID-19. Para tal, foi realizada uma revisão narrativa sobre aborto e COVID-19. Os 75 artigos incluídos, além de outras referências relevantes, indicam que a pandemia impacta os serviços de saúde sexual e reprodutiva, ao agravar os problemas existentes e restringir o acesso aos direitos reprodutivos, incluindo o direito ao aborto legal. O impacto pode ser ainda mais sério nos países de renda baixa e média, principalmente na América Latina, onde o acesso ao aborto legal costuma ser restrito. A revisão das fontes no artigo destaca a necessidade urgente de manter em funcionamento os serviços de aborto legal, tanto da perspectiva das mulheres, em apoio aos seus direitos reprodutivos, quanto do compromisso internacional para atingir os Objetivos de Desenvolvimento do Milênio. Assim, os países da América Latina devem priorizar os direitos reprodutivos nas agendas nacionais e adaptar suas legislações para acomodar modelos alternativos de assistência ao aborto. Nossos resultados também destacam a necessidade de informações precisas sobre o funcionamento dos serviços de saúde sexual e reprodutiva, essenciais para compreender o impacto da pandemia sobre o aborto legal e para identificar os grupos mais afetados pelas mudanças.

La pandemia de COVID-19 puede acentuar problemas existentes, impidiendo el acceso al aborto legal, con el consiguiente incremento de abortos inseguros. Este escenario es quizás incluso peor en los países de bajos y medios ingresos, especialmente en Latinoamérica, donde las leyes del aborto son de por sí restrictivas y el acceso a los servicios ya se encuentra obstaculizado. Nuestro objetivo fue comprender cómo han lidiado diferentes países, poniendo énfasis en los latinoamericanos, con servicios legales de aborto en el contexto de la COVID-19. Por lo tanto, realizamos una revisión narrativa sobre el aborto y el COVID-19. Se incluyeron 75 artículos, así como otras referencias relevantes, indicando que la pandemia impacta en los servicios de salud sexual y reproductiva, lo que amplifica los problemas existentes y restringe el acceso a derechos reproductivos, tales como el aborto legal. Este impacto quizás fue incluso más fuerte en los países con ingresos bajos y medios, especialmente en Latinoamérica, donde el acceso al aborto legal se encuentra restringido normalmente. La revisión de fuentes en este artículo subraya la necesidad urgente de mantener los servicios de aborto legal, tanto desde la perspectiva de las mujeres, apoyando sus derechos reproductivos, así como también desde el compromiso internacional, con el fin de alcanzar las Objetivos de Desarrollo del Milenio. De este modo, los países latinoamericanos deben situar los derechos reproductivos como prioridad en sus agendas y adaptar su legislación para incorporar modelos alternativos de atención al aborto. Nuestros resultados también destacam la necesidad de información precisa para el funcionamiento de los servicios de salud sexuales y reproductivos, como algo esencial para entender el impacto de la pandemia en el aborto legal, así como para identicar a los grupos más afectados por los cambios.