Estudo da morbidade e da mortalidade perinatal em maternidades: II - mortalidade perinatal segundo peso ao nascer, idade materna, assistência pré-natal e hábito de fumar da mãe

Analisa-se a influência de variáveis como peso ao nascer, idade materna, assistência pré-natal e tabagismo materno. Do estudo dos 12.999 nascimentos (vivos e mortos) ocorridos em nove maternidades no período de um ano, verificou-se que a mortalidade perinatal é muito maior para os recém-nascidos de baixo peso (665,3 ‰ para peso até 1.500 g), diminuindo à medida que aumenta o peso ao nascer. Também nos casos de mães jovens (menores de 15 anos) ou mães com idade superior a 35 anos esse coeficiente foi mais elevado (45,5 ‰ para mães com menos de 15 anos e 47,0 ‰ para mães entre 35 a 39 anos). A faixa imediatamente superior - 40 a 44 anos - apresentou a mais alta mortalidade perinatal: 61,3 ‰ nascidos vivos e nascidos mortos. O número de consultas realizadas no pré-natal tem importância para a diminuição da gestação de alto risco. Mães que fizeram 7 ou mais consultas no pré-natal tiveram a menor mortalidade no período (17,7‰ nascidos vivos e nascidos mortos). Já o hábito materno de fumar influencia a mortalidade quando a quantidade é de mais de 10 cigarros por dia. A mortalidade perinatal dos produtos de mães que fumavam menos de 10 cigarros por dia não diferiu das taxas de mortalidade para as mães não-fumantes.

Mortality problems in Brazil and in Germany: past-present-future. Learning from each other?

This article was written by a Swiss-German historical demographer after having visited different Brazilian Universities in 1984 as a guest-professor. It aims at promoting a real dialog between developed and developing countries, commencing the discussion with the question: Can we learn from each other? An affirmative answer is given, but not in the superficial manner in which the discussion partners simply want to give each other some "good advice" or in which the one declares his country's own development to be the solely valid standard. Three points are emphasized: 1. Using infant mortality in S. Paulo from 1908 to 1983 as an example, it is shown that Brazil has at its disposal excellent, highly varied research literature that is unjustifiably unknown to us (in Europe) for the most part. Brazil by no means needs our tutoring lessons as regards the causal relationships; rather, we could learn two things from Brazil about this. For one, it becomes clear that our almost exclusively medical-biological view is inappropriate for passing a judgment on the present-day problems in Brazil and that any conclusions so derived are thus only transferable to a limited extent. For another, we need to reinterpret the history of infant mortality in our own countries up to the past few decades in a much more encompassing "Brazilian" sense. 2. A fruitful dialog can only take place if both partners frankly present their problems. For this reason, the article refers with much emprasis to our present problems in dealing with death and dying - problems arising near the end of the demographic and epidemiologic transitions: the superanuation of the population, chronic-incurable illnesses as the main causes of death, the manifold dependencies of more and more elderly and really old people at the end of a long life. Brazil seems to be catching up to us in this and will be confronted with these problems sooner or later. A far-sighted discussion already at this time seems thus to be useful. 3. The article, however, does not want to conclude with the rather depressing state of affairs of problems alternatingly superseding each other. Despite the caution which definitely has a place when prognoses are being made on the basis of extrapolations from historical findings, the foreseeable development especially of the epidemiologic transition in the direction of a rectangular survival curve does nevertheless provide good reason for being rather optimistic towards the future: first in regards to the development in our own countries, but then - assuming that the present similar tendencies of development are stuck to - also in regard to Brazil.

Geographical patterns of proportionate mortality for the most common causes of death in Brazil

Mortality due to chronic diseases has been increasing in all regions of Brazil with corresponding decreases in mortality from infectious diseases. The geographical variation in proportionate mortality for chronic diseases for 17 Brazilian state capitals for the year 1985 and their association with socio-economic variables and infectious disease was studied. Calculations were made of correlation coefficients of proportionate mortality for adults of 30 years or above due to ischaemic heart disease, stroke and cancer of the lung, the breast and stomach with 3 socio-economic variables, race, and mortality due to infectious disease. Linear regression analysis included as independent variables the % of illiteracy, % of whites, % of houses with piped water, mean income, age group, sex, and % of deaths caused by infectious disease. The dependent variables were the % of deaths due to each one of the chronic diseases studied by age-sex group. Chronic diseases were an important cause of death in all regions of Brazil. Ischaemic heart diseases, stroke and malignant neoplasms accounted for more than 34% of the mortality in each of the 17 capitals studied. Proportionate cause-specific mortality varied markedly among state capitals. Ranges were 6.3-19.5% for ischaemic heart diseases, 8.3-25.4% for stroke, 2.3-10.4% for infections and 12.2-21.5% for malignant neoplasm. Infectious disease mortality had the highest (p < 0.001) correlation with all the four socio-economic variables studied and ischaemic heart disease showed the second highest correlation (p < 0.05). Higher socio-economic level was related to a lower % of infectious diseases and a higher % of ischaemic heart diseases. Mortality due to breast cancer and stroke was not associated with socio-economic variables. Multivariate linear regression models explained 59% of the variance among state capitals for mortality due to ischaemic heart disease, 50% for stroke, 28% for lung cancer, 24% for breast cancer and 40% for stomach cancer. There were major differences in the proportionate mortality due to chronic diseases among the capitals which could not be accounted for by the social and environmental factors and by the mortality due to infectious disease.

Fatores associados à assistência pré-natal entre mulheres de baixa renda no Estado de São Paulo, Brasil

São apresentados resultados de pesquisa que avaliou o Programa de Assistência Integral à Saúde da Mulher (PAISM), realizada em 1988, no Estado de São Paulo, Brasil. Foram entrevistadas 3.703 mulheres de baixa renda que tinham entre 15 e 49 anos de idade, utilizando um questionário estruturado e pré-testado. Os resultados referem-se às 669 mulheres grávidas durante 1987 ou 1988 que responderam às questões sobre assistência pré-natal, parto e puerpério. Foi analisada a associação entre algumas de suas características sociodemográficas e comparecimento às consultas pré-natais, a idade gestacional em que foi feita a primeira consulta e o número total de consultas. Os resultados mostraram associação entre características sociodemográficas e comparecimento ao pré-natal. A maior percentagem de grávidas que fizeram pré-natal tinham mais que o primeiro grau de escolaridade. Foi maior a proporção de mulheres que começaram o pré-natal até o terceiro mês de gravidez entre aquelas que não tinham filho vivo (74%), que viviam com um companheiro (70%), que tinham mais que o primeiro grau de escolaridade (88%) e as que moravam no interior do Estado (71%).

Determinantes de utilização do cuidado pré-natal entre famílias de baixa renda no Estado da Paraíba, Brasil

Analisaram-se os determinantes de utilização da assistência pré-natal, entre famílias de baixa renda.. Dados foram coletados de todas as mães com residência permanente no Município de Caaporã, no Estado da Paraíba, Brasil, com filhos até cinco anos de idade na data da entrevista. Através da estatística descritiva e multivariada, analisaram-se os diferenciais de utilização dos serviços e os efeitos de algumas variáveis sociodemográficas sobre o uso do cuidado pré-natal.

Mortality from asthma in the state of S. Paulo, Brazil (1970-1992)

Mortality from asthma has shown important variations over time in several countries. In Brazil, a mortality study performed in the 60s, covering the cities of S.Paulo and Ribeirão Preto, and other ten cities showed that S.Paulo presented the lowest death rate from asthma among of them all. It was decided to study the time trends of deaths from asthma and from the whole set of respiratory diseases from 1970 to 1992, in the population aged 15-34 yrs. old in the State of S.Paulo, as well as to compare them with those of other countries. Asthma mortality rates during the 23 years of observation since 1975, showed an oscillatory declining pattern with a peak of deaths in the initial years. The linearization of the curve allows the calculation of Pearson's correlation coefficient that was significantly negative, suggesting a decline in the mortality over this period, mainly in the 5-9 yrs. old and 30-34 yrs. old strata. The segmentation of data between the period of ICD-9, 1970 to 1978, and of ICD-9, 1979 and subsequent years, shows that there is stability within each period, in all age-groups, except for that of 5-9 yr. olds between 1970-1978. Comparing the rates of the population aged 15-34 yrs. old for the State of S. Paulo, Brazil, with trends observed in 14 other countries, an intermediate pattern for the first triennial period (1970-1972) as well as for the subsequent triennial periods, emerges. A prevalence study of asthma, a follow up program meant for using emergency rooms and a surveillance of deaths due to all respiratory diseases and specifically to asthma are strongly recommended.

Rise and fall in ischemic heart disease mortality: it may have happened before

The rise in ischemic heart disease(IHD) mortality occurring mostly during the first half of the 20th century is usually associated with economic development and its consequences for people's lifestyles. On the basis of historical evidence, it is postulated that a previous IHD epidemic cycle may have occurred in England and Wales towards the turn of the nineteenth century. The implications of this on causal theories and current etiological research on atherosclerosis are discussed.

Mortality among patients with non-affective functional psychoses in a metropolitan area of South-Eastern Brazil

High mortality rates among those suffering from schizophrenia and related psychoses have been consistently described in developed societies. However, to date there is a lack of data on this matter in Brazil. In order to examine this issue, a prospective 2-year follow-up study was carried out in S. Paulo. The sample consisted of 120 consecutive admissions to psychiatric hospitals in a defined catchment area, aged 18 to 44 years old, with clinical diagnoses of non-affective functional psychoses according to the ICD-9. After 2 years, 116 (96.7%) subjects were traced. During the study period there were 7 deaths (6.0% of those traced), 5 (4.3%) due to suicide. All but one of the suicides occurred in the first year after discharge from hospital. Age and sex Standardised Mortality Ratios (relative to rates for the population of the city of Sao Paulo) were 8.4 for overall mortality (95% confidence interval: 4.0-15.9) and 317.9 for deaths due to suicide (95% confidence interval: 125.2-668.3). These results are in agreement with previous studies, and show that in Brazil non-affective functional psychoses are life-threatening illnesses, which need adequate care, particularly when patients go back to live in the community after hospital discharge.

Risk factors for perinatal mortality in an urban area of Southern Brazil, 1993

INTRODUCTION: Although there was a considerable reduction in infant mortality in Pelotas, Rio Grande do Sul in the last decade, its perinatal causes were reduced only by 28%. The associated factors of these causes were analised. MATERIAL AND METHOD: All hospital births and perinatal deaths were assessed by daily visits to all the maternity hospitals in the city, throughout 1993 and including the first week of 1994. RESULTS: The perinatal mortality rate was 22.1 per thousand births. The multivariate analysis showed the following risk factors: low socioeconomic level, male sex and maternal age above 35 years . Among multigravidae women, the fetal mortality rate was significantly increased for mothers with a previously low birthweight and a previous stillbirth. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight. CONCLUSIONS: Main risk factors for perinatal mortality: low socioeconomic level, maternal age above 35 years and male sex. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight.

Disponibilidade de sorologia anti-HIV como um teste voluntário na rotina do atendimento pré-natal em unidades básicas de saúde

São apresentadas, de forma sucinta, as principais etapas cumpridas para a implementação da sorologia anti-HIV no atendimento às gestantes em unidades básicas de saúde. A partir de agosto de 1996, a realização de testes sorológicos para detecção do HIV passou a ser ofertada às gestantes atendidas em unidades básicas de saúde de Ribeirão Preto, SP, integrada a um conjunto de atividades rotineiramente executadas no atendimento pré-natal. Até o final de 1998, o teste sorológico foi aplicado em 68,3% das 17.589 mulheres atendidas em pré-natal, resultando numa positividade de 0,76%.

Breast cancer in Mexican women: an epidemiological study with cervical cancer control

INTRODUCTION: In Mexico, breast cancer (BC) is one of the main causes of cancer deaths in women, with increasing incidence and mortality in recent years. Therefore, the aim of the study is identify possible risk factors related to BC. METHODS: An epidemiological study of hospital cases of BC and controls with cervical uterine cancer (CUCA) was carried out at eight third level concentration hospitals in Mexico City. The total of 353 incident cases of BC and 630 controls with CUCA were identified among women younger than 75 years who had been residents of the metropolitan area of Mexico City for at least one year. Diagnosis was confirmed histologically in both groups. Variables were analyzed according to biological and statistical plausibility criteria. Univariate, bivariate and multivariate analyses were carried out. Cases and controls were stratified according to the menopausal hormonal status (pre and post menopause). RESULTS: The factors associated with BC were: higher socioeconomic level (OR= 2.77; 95%CI = 1.77 - 4.35); early menarche (OR= 1.32; 95%CI= 0.88 - 2.00); old age at first pregnancy (>31 years: OR= 5.49; 95%CI= 2.16 - 13.98) and a family history of BC (OR= 4.76; 95% CI= 2.10 - 10.79). In contrast, an increase in the duration of the breastfeeding period was a protective factor (>25 months: OR= 0.38; 95%CI= 0.20 - 0.70). CONCLUSIONS: This study contributes to the identification of risk factors for BC described in the international literature, in the population of Mexican women. Breastfeeding appears to play an important role in protecting women from BC. Because of changes in women`s lifestyles, lactation is decreasing in Mexico, and young women tend not to breastfeed or to shorten the duration of lactation.

Auditoria médica: programa de pré-natal em posto de saúde na região Sul do Brasil

OBJETIVO: Descreve-se a auditoria médica realizada entre as mulheres que se inscreveram em programa de pré-natal com o objetivo de verificar as características da assistência à gestação e de estabelecer diretrizes de atenção. MÉTODOS: Realizou-se levantamento epidemiológico dos cartões das gestantes inscritas no Programa de Pré-natal do Posto de Saúde da Vila Municipal, Pelotas, RS, com data provável de parto durante 1997 e no primeiro semestre de 1998. Foram incluídas as mulheres ingressadas no Programa até o quarto mês de gestação e que tiveram cinco consultas no mínimo. Foi utilizada a análise bivariada para detectar as condições marcadoras da assistência médica. RESULTADOS: Em 1997, 73 mulheres se inscreveram no Programa de Pré-natal e, em 1998, 75. A média de consultas durante o pré-natal foi de 5,2 em 1997 e 6,2 em 1998. Essa diferença foi significativa (p<0,05). Analisaram-se diversos indicadores de processo médico que traduzem a qualidade da atenção. CONCLUSÃO: Discutiu-se a utilidade do instrumental epidemiológico na organização de um serviço de saúde. Ressaltou-se que esse tipo de estudo é rápido, barato e fornece informações para o direcionamento das atividades dos serviços.

Critérios de escolha de postos de saúde para acompanhamento pré-natal em Pelotas, RS

OBJETIVO: Caracterizar o cuidado pré-natal em uma amostra representativa de mães, identificando o serviço de saúde onde estas realizaram o acompanhamento da gestação e os motivos que as levaram a escolher este local. MÉTODOS: Estudo transversal, realizado nos meses de março e abril de 1997, nas quatro principais maternidades de Pelotas, RS, através de entrevista a 401 mães no pós-parto imediato. RESULTADOS: Fizeram acompanhamento pré-natal, em um posto de saúde 51% das mães, sendo a proximidade geográfica o critério mais freqüentemente referido para tal escolha (46,8%). Para 85% das mães, o serviço de saúde mais próximo de casa era um posto de saúde. No entanto, 52,2% dessas não utilizaram esse local para as consultas pré-natais alegando a má qualidade do atendimento (37,4%). Conforme referido pelas mães, entre os procedimentos de rotina do pré-natal recomendados pelo programa de saúde da rede pública, incluindo a promoção do aleitamento materno, apenas a imunização anti-tetânica foi realizada mais freqüentemente nos postos do que nos demais locais. CONCLUSÕES: Tendo em vista a expressiva utilização da rede pública para o acompanhamento pré-natal, necessitam ser implementados investimentos em educação continuada dos profissionais, com ênfase no cumprimento de normas técnicas pré-estabelecidas.

Tendência secular do crescimento pós-natal na cidade de São Paulo (1974-1996)

OBJETIVO: Caracterizar o crescimento linear nos primeiros cinco anos de vida, conhecer sua distribuição social, estabelecer sua tendência secular e analisar sua determinação, através de dados coletados por três inquéritos domiciliares realizados na cidade de São Paulo, SP, em 1974/75, 1984/85 e 1995/96. MÉTODOS: Os três inquéritos estudaram amostras probabilísticas da população residente na cidade com idades entre zero e 59 meses (1.008 crianças em 1974/75; 1.016 em 1984/85 e 1.280 em 1995/96). Crianças com menos de 24 meses foram medidas na posição deitada e crianças mais velhas na posição em pé. O padrão internacional de crescimento foi utilizado para avaliação da altura segundo a idade e o sexo da criança. O estudo da distribuição social do crescimento levou em conta tercis da renda familiar per capita em cada um dos inquéritos. A estratégia analítica, para estudar os determinantes da tendência secular do crescimento, empregou modelos hierárquicos de causalidade, análises multivariadas de regressão e procedimentos análogos aos utilizados para calcular riscos atribuíveis populacionais. RESULTADOS/CONCLUSÕES: No período de 22 anos, coberto pelos três inquéritos, a tendência secular do crescimento pós-natal na cidade de São Paulo foi positiva, contínua e aparentemente uniforme ao longo do tempo, correspondendo a um ganho médio total de 0,650 escores z da referência internacional de crescimento, ou cerca de 2,3 cm na idade de 30 meses. O maior ganho foi registrado para o terço mais pobre da população -- 3,3 cm ¾ e o menor para o terço mais rico -- 1,7 cm. Mudanças positivas em determinantes distais (renda familiar e escolaridade materna) e intermediárias (condições de moradia, saneamento do meio, acesso a serviços de saúde e antecedentes reprodutivos) do crescimento infantil, justificaram parte substancial do incremento de altura observado entre meados das décadas de 80 e de 90.

Age transition of tuberculosis incidence and mortality in Brazil

OBJECTIVE: Before the Aids pandemic, demographic transition and control programs prompted a shift in the age of incidence of tuberculosis from adults to older people in many countries. The objective of the study is to evaluate this transition in Brazil. METHODS: Tuberculosis incidence and mortality data from the Ministry of Health and population data from the Brazilian Bureau of Statistics were used to calculate age-specific incidence and mortality rates and medians. RESULTS: Among reported cases, the proportion of older people increased from 10.5% to 12% and the median age from 38 to 41 years between the period of 1986 and 1996. The smallest decrease in the incidence rate occurred in the 30--49 and 60+ age groups. The median age of death increased from 53 to 55 years between 1980 and 1996. The general decline in mortality rates from 1986 to 1991 became less evident in the 30+ age group during the period of 1991 to 1996. A direct correlation between age and mortality rates was observed. The largest proportion of bacteriologically unconfirmed cases occurred in older individuals. CONCLUSIONS: The incidence of tuberculosis has begun to shift to the older population. This shift results from the decline in the annual risk of infection as well as the demographic transition. An increase in reactivation tuberculosis in older people is expected, since this population will grow from 5% to 14% of the Brazilian population over the next 50 years. A progressive reduction in HIV-related cases in adults will most likely occur. The difficulty in diagnosing tuberculosis in old age leads to increased mortality.