Perinatal health and mother-child
health care in the municipality of São Luís,
M aranhão State, Brazil
Saúd e p e rinatal e ate nç ão à saúd e
d a mãe e d a c rianç a no Munic íp io d e São Luís,
Maranhão , Brasil
1 Departam en to de Saú de Pú blica, Un iversid ad e Fed eral d o M aran h ão. Ru a Barão d e Itap ary 155, São Lu ís, M A
65020-070, Brasil. 2 Departam en to de En ferm agem , Un iversid ad e Fed eral d o M aran h ão. Ru a Vian a Vaz s/n , São Lu ís, M A 65020-660, Brasil. 3 Departam en to de Medicin a III, Un iversid ad e Fed eral d o M aran h ão. Ru a d os Praz eres 215, 5oan d ar (cobertu ra), São Lu ís, M A 65020-460, Brasil. 4 Hospital Un iversitário, Un iversid ad e Fed eral d o M aran h ão. Ru a d os Praz eres 215, São Lu ís, M A 65020-460, Brasil. 5 Departam en to de Pu ericu ltu ra e Ped iatria, Facu ld ad e d e Med icin a d e Ribeirão Preto, Un iversid ad e d e São Pau lo. Av. Ban d eiran tes 3900, Ribeirão Preto, SP 14049-900, Brasil.
An tôn io Au gu sto M . d a Silva 1 Liberata Cam p os Coim bra 2 Raim u n d o An tôn io d a Silva 1 M aria Teresa S. S. d e B. e Alves 1 Fern an d o Lam y Filh o 3
Zen i Carvalh o Lam y 4 Elba Gom id e Moch el 2 Vân ia M aria d e F. Aragão 3 Vald in ar Sou sa Ribeiro 3 Su eli Rosin a Ton ial 1 M arco An tôn io Barbieri 5
Abstract Th e p u rp ose of th is article w as to evalu ate socioecon om ic an d d em ograp h ic in d icators, rep rod u ctive h ealth , u se of p ren atal, ch ild birth , an d n eon atal services, an d an th rop om etric d ata for m oth ers an d in fan ts. Th e au th ors p erform ed a cross-section al an alysis of a system atic sam p le of 2,831 h osp ital birth s in São Lu ís, M aran h ão State, from M arch 1997 to Febru ary 1998 at ten p u blic an d p rivate m atern ity h osp itals. Th e sam p le w as stratified p rop ortion ally accord in g to th e n u m ber of birth s in each m atern ity h osp ital. Moth ers an sw ered a stan d ard qu estion n aire. Of th e total, 97.9% w ere live birth s an d 98% w ere sin gleton s. Pren atal coverage w as 89.5%, an d p reva-len ce of cesarean section s w as 33.8%. A p h ysician p rovid ed p ren atal care in 75.7% of cases an d p erform ed 73.8% of th e d eliveries. Th e Un ified Health System covered th e costs of 76.4% of th e p ren a t a l v isit s a n d 89.7% of t h e d eliveries. A p ed ia t ricia n w a s p resen t in t h e d elivery room in 50.2% of cases. Th e low birth w eigh t rate w as 9.6% an d th e p reterm birth rate 13.9%. Reason s for con cern in clu d ed a h igh p ercen tage of ad olescen t m oth ers, sin gle m oth ers (or w ith ou t p artn ers), th e h igh cesarean rate, an d th e h igh p ercen tage of birth s atten d ed by u n qu alified p erson n el. Key words Low Birth Weigh t; Prem atu re; Fetal Grow th Retard ation ; Pren atal Care; Cesarean Section
Resumo Est e a rt igo t ev e o ob jet iv o d e est im a r in d ica d ores sócio- econ ôm icos, d em ográ ficos, saú d e rep rod u tiva, u tiliz ação d e serviços p ré-n atais e d e aten ção ao p arto e ao recém -n ascid o, d ad os an trop om étricos d a m ãe e d a crian ça. Foi realiz ad o estu d o tran sversal em am ostra sis-t em á sis-t ica d e 2.831 n a scim en sis-t os h osp isis-t a la res ocorrid os em Sã o Lu ís, essis-t ra sis-t ifica d a p or m a sis-t er-n id ad es, com p artilh a p rop orcioer-n al ao er-n ú m ero d e er-n ascim eer-n tos em cad a u er-n id ad e, er-n o p eríod o d e m arço d e 1997 a fevereiro d e 1998. Utilizou -se qu estion ário p ad ron iz ad o resp on d id o p ela p u ér-p era . An a lisa ra m - se n a scim en t os em d ez u n id a d es d e sa ú d e, ér-p ú b lica s e ér-p riv a d a s, d os q u a is, 97,9%, eram n ascid os vivos e 98% d e p arto ú n ico. A cobertu ra d o p ré-n atal foi d e 89,5%. A p re-valên cia d e cesarian as 33,8%. O m éd ico realiz ou 75,7% d o aten d im en to p ré-n atal e 73,5% d os p artos. O Sistem a Ún ico d e Saú d e cu steou 76,4% d o aten d im en to p rén atal e 89,7% d a assistên -cia ao p arto. O aten d im en to p or p ed iatra em sala d e p arto foi d e 50,2%. A taxa d e baixo p eso ao n ascer foi d e 9,6% e d e p rem atu rid ad e 13,9%. Alta p orcen tagem d e m ães ad olescen tes e sem com -p a n h eiro, a lt a t a x a d e cesá rea s e d e -p a rt os a ssist id os -p or -p essoa l n ã o q u a lifica d o, sã o ra z ões p ara p reocu p ação.
Introduction
Mo th e rch ild h e a lth p ro b le m s h a ve b e e n a p -p roach ed by several e-p id em iological stu d ies in Bra zil (Ba rb ieri et a l., 1989; Ba rros et a l., 1996; Bettio l et a l., 1998; Victo ra et a l., 1996), b u t in th e State of Maran h ão th e few availab le stu d ies h ave failed to u se a su fficien tly system atic ap -p ro a ch , a n d fe w in ve st iga t io n s h a ve b e e n con d u cted on rep resen tative sam p les of d iffer-en t m u n icip alities or cou n ties (Coim b ra et al., 1996; Estad o d o Maran h ão/ UNICEF, 1992; Silva e t a l., 1999; To n ia l & Silva , 1997). Fe w stu d ie s are availab le assessin g th e coverage an d q u ality o f h e a lth ca re se r vice s (Esta d o d o Ma ra n -h ão/ UNICEF, 1992; Silva et al., 1999).
Kn owled ge is in su fficien t o n ra tes o f p reg-n a reg-n cy o u tco m e s su ch a s low b irth we igh t, p re te rm b irth , a n d in tra u te rin e growth re ta r-d ation in Brazil. Registry sou rces are gen erally u n relia b le. Sp ecifica lly, th e SINASC (Na tio n a l Live Birth In form ation System ) lacks su fficien t cove ra ge in so m e p la ce s to a llow va lid e sti-m ates. In ad d ition , p erin atal sti-m ortality rates are u n kn own for m ost settin gs d u e to lack of p rop -er record s, esp ecially con c-ern in g stillb irth s.
La ck o f re lia b le in fo rm a tio n fo r m o th e r-ch ild h e a lth in d ica to rs h in d e rs th e p la n n in g a n d e va lu a tio n o f m e a su re s to im p rove livin g sta n d a rd s. It is th u s e xtre m e ly im p o rta n t to p erform su rveys to evalu ate h ealth con d ition s an d th e u se of p reven tive an d cu rative services. We th u s u n d e rto o k th e p re se n t cro ss-se c-tio n a l su r ve y b a se d o n a sa m p le o f h o sp ita l b irth s in m atern ity h osp itals in th e m u n icip ali-ty o f Sã o Lu ís fro m Ma rch 1997 to Fe b ru a r y 1998 in ord er to assess m atern al an d p erin atal h ealth con d ition s in th is city.
M ethodology
Th e stu d y u sed th e sa m e m eth o d o lo gy a s two oth er p erin atal stu d ies, con d u cted in Rib eirão Preto, São Pau lo State, in 1978-79 an d 1994 (Bar-bieri et al., 1989; Bettiol et al., 1998; Gom es et al., 1999; Silva et al., 1998) as p art of a m u lticen ter p roject on p erin atal h ealth in Brazilian cities.
Th e m u n icip a lity o f Sã o Lu ís is lo ca ted o n th e islan d of São Lu ís in th e n orth ern p art of th e Sta te o f Ma ra n h ã o a n d h a s a n a rea o f 518km2.
Total p op u lation is 781,068 (IBGE, 1997). Pren a-ta l ca re is p rovid ed b y 35 m u n icip a l h ea lth u n its, 7 Sta te u n its, a n d 1 Fed era l u n it, a s well as by h ealth services con tracted ou t by th e Un i-fied Hea lth System (SUS) a n d p riva te u n its. Ch ildbirth care is p rovided by 18 p u blic an d p ri-vate m atern ity services.
Sampling
Th e stu d y u sed a cross-section al ap p roach . We u sed a sam p le of h osp ital b irth s in São Lu ís, in -clu d in g m oth ers resid in g in th e city, n on -resi-d e n ts, live b irth s, stillb irth s, sin gle to n s, a n -resi-d m u ltip le b irth s. Ho sp ita l b irth s re p re se n te d 96.3% (95% CI: 94.1-98.6) o f a ll b irth s in 1996, th u s en su rin g th at th e h osp ital b irth sam p le is rep resen tative (Ton ial & Silva, 1997). Th e stu d y was con d u cted at 10 u n its con sistin g of p u b lic, co n tra cted -o u t, a n d / o r p riva te fa cilities fro m March 1, 1997, to Feb ru ary 28, 1998. Matern ity se r vice s wh e re le ss th a n 100 d e live rie s we re p erform ed in 1996, i.e., on ly 2.2% of th e d eliv-e rieliv-e s th a t o ccu rreliv-e d d u rin g th a t yeliv-e a r, weliv-e reliv-e eliv-e x-clu d ed from th e stu d y.
Th e sa m p le wa s stra tifie d p ro p o rtio n a lly a cco rd in g to th e n u m b er o f d eliveries in ea ch m atern ity h osp ital. All b irth s in each u n it were listed in ord er of occu rren ce. System a tic sa m p lin g was p erform ed in each u n it, with a sam -p lin g in terva l o f seven . A ra n d o m n u m b er b e-twe e n 1 a n d 7 wa s p icke d to d e te rm in e th e startin g p oin t for each stu d y u n it.
Calcu lation of sam p le size for th e estim ate of a p rop ortion con sid erin g th e p op u lation size o f 20,092 b irth s fo r th e ye a r p re ce d in g th e stu d y, with 2% p re cisio n , 5% typ e I e rro r, a n d wo rkin g with a m a xim u m p xq p ro d u ct (50% even t p rop ortion ) d em on strated th at 2,145 in -te r vie ws we re n e ce ssa r y. Sin ce th e stu d y a lso a im e d to co m p a re p ro p o rtio n s co n sid e rin g a 5% typ e I erro r a n d 80% stu d y p ower, wo rkin g with a m axim u m p xq p rod u ct (50% even t p ro-p o rtio n ) a n d se ttin g th e m in im u m d iffe re n ce to b e d e te cte d a s sign ifica n t a t 4%, th e m in i-m u i-m sai-m p le size was calcu lated at 2,499 b irth s. Co n sid e rin g stu d y lo sse s, we o p te d to wo rk with a sam p lin g in terval of seven , wh ich wou ld p e rm it a sa m p le size o f a p p roxim a te ly 2,870 b irth s (Kalton , 1983).
Instruments
th e m o th e r wa s in te r vie we d a t h o m e if sh e resid ed in th e m u n icip ality of São Lu ís. Losses d u e to refu sal or in ab ility to locate th e m oth er occu rred in 5.8% of cases.
Variab les in clu d ed in th e q u estion n aire are d escrib ed b elow.
Qu estio n s co n cern in g id en tification were: qu estion n aire n u m b er, n am e of h osp ital, n am e o f ch ild a n d m o th er, a d d ress, referen ce p o in t, n eigh b orh ood , city an d State, an d area of resi-d en ce (u rb an or ru ral).
Th e fo llowin g d em ograp h ic an d socioeco-n om ic data were stu d ied : wh eth er m oth er an d fa th e r live d in th e h o m e, n u m b e r o f sib lin gs a n d n u m b er o f p erso n s resid in g in th e h o u se-h old , m atern al an d p atern al ed u cation al level, fa m ily a n d p er cap ita in co m e in m in im u m wages, m oth er workin g ou tsid e th e h om e, an d o ccu p a tio n o f th e h e a d o f th e fa m ily (co n sid -ered to b e th e p erson with th e h igh est in com e), h o u sin g co n d itio n s, a n d p re se n ce o f ru n n in g wa ter a n d sewa ge d isp osa l. Th e occu p a tion of th e h ead of fam ily was u sed for socioecon om ic classification b ased on th e In tern ation al Clas-sifica tio n o f Occu p a tio n s (ISCO) (Silva e t a l., 1998).
Da ta co n cern in g rep rod u ctive h ealth were b irth d ate of th e in fan t’s m oth er, age of th e in -fa n t’s -fa th e r, n u m b e r o f p re gn a n cie s, p a rity, n u m b er of live-b orn s an d stillb orn s, n u m b er of a b o rtio n s, a n d n u m b e r o f low b irth we igh t n e wb o rn s. All p re vio u s p re gn a n cie s a n d th e cu rre n t o n e we re d e fin e d in te rm s o f d a te o f term in ation , len gth of gestation , an d age of fe-tal or n eon afe-tal d eath wh en ap p licab le.
In fo rm a tio n wa s o b ta in ed a b o u t sm ok in g,
wh e th e r th e m o th e r sm o ke d , a t wh a t a ge sh e sta rte d sm o kin g, fo r h ow m a n y ye a rs sh e h a d b e e n sm o kin g, wh a t sh e sm o ke d (ciga re tte s, cigars, or p ip e), an d n u m ber of tim es th e m oth er sm oked p er d ay b efore an d d u rin g p regn an -cy. Th e q u e stio n n a ire a lso a ske d wh e th e r th e fath er was cu rren tly sm okin g, wh at h e sm oked , a n d h ow m a n y tim e s a d a y h e sm o ke d d u rin g th e m oth er’s resp ective gestation .
Con cern in g u tilization of p ren atal services, th e m oth er was asked ab ou t p ren atal care, th e m o n th sh e h a d sta rte d , n u m b e r o f visits, a n d te ta n u s im m u n iza tio n . Th e m o th e r wa s a lso a ske d wh e th e r sh e h a d h e a lth in su ra n ce a n d wh ich ca te go r y o f p re n a ta l ca re sh e h a d re -ce ive d (gove rn m e n t h e a lth cove ra ge, p riva te h e a lth p la n , o r o u t-o f-p o cke t). Da te o f la st m e n stru a l p e rio d a n d ge sta tio n a l le n gth in we e ks we re re co rd e d , a n d th e o ccu rre n ce o f p ren atal d iseases was in vestigated . With resp ect to u tiliza tio n o f ch ild b irth ca re se r vice s, we record ed th e n u m b er of fetu ses, wh o p rovid ed
ca re a t d e live r y, typ e o f d e live r y, ca te go r y o f ca re, a n d (in th e ca se o f m a tern a l d ea th ) d a te of d eath an d p rim ary an d associated cau ses.
Ad e q u a cy o f p re n a ta l ca re u tiliza tio n wa s m e a su re d u sin g th e in d e x o f th e sa m e n a m e (APNCU) (Ko telch u ck, 1994) a n d b y a n ew in d ex created on th e b asis of th e m in im u m n u m -b er of sch ed u led visits as recom m en d ed -by th e Brazilian Health Min istry an d tim in g of in itia-tion (Coim b ra, 1999). Both in d ices are ad ju sted on th e b asis of total gestation al len gth , con sid -e rin g th a t m o th -e rs o f p r-e m a tu r-e in fa n ts t-e n d to h ave fewer p ren atal visits.
Ge sta tio n a l a ge wa s ca lcu la te d fro m th e d a te o f th e la st n o rm a l m e n stru a l p e rio d re -p o rte d b y th e m o th e r. At first, th e 15th o f th e m o n th wa s co n sid e re d fo r a ll ca se s in wh ich on ly th e d ay (n ot m on th ) of th e last m en stru a-tion was u n kn own . Cases of weigh t in com p ati-b le with d ate of last m en stru al p eriod rep orted a n d lo ca te d a b ove th e 99th p e rce n tile fo r th e En glish cu rve were record ed as u n kn own (Alt-m a n &a(Alt-mp; Co le s, 1980). Th e sa (Alt-m e p ro ce d u re wa s u se d fo r ca se s o f im p ro b a b le ge sta tio n a l a ge (less th an 20 or m ore th an 50 weeks). Fin ally, a p ro ce ss o f im p u ta tio n wa s ca rrie d o u t fo r a ll ca se s o f m issin g d a ta o r d a ta re co rd e d a s ig-n o re d iig-n a re gre ssio ig-n m o d e l iig-n clu d iig-n g b irth we igh t, p a rity, fa m ily in co m e, a n d se x o f th e n ewb orn (Stata Corp oration , 1997).
Cla ssifica tio n o f weigh t b y gesta tio n a l a ge wa s b a se d o n th e Willia m s cu r ve ( Willia m s e t a l., 1982). In fa n ts were co n sid ered to b e la rge for gestation al age wh en th eir weigh t was ab ove th e 90th p ercen tile for th is cu rve, ad eq u ate for gestation al age wh en th eir weigh t was b etween th e 10th an d 90th p ercen tile, an d sm all for ges-ta tio n a l a ge wh e n th e ir we igh t wa s b e low th e 10th p ercen tile, th e latter rep resen tin g cases of in trau terin e growth retard ation .
With re sp e ct to th e n ew born, we re co rd e d se x, live -b o rn o r stillb o rn sta tu s, b irth d a te, n eon atal d iseases an d , in case of fetal or n eon a-tal d eath , th e d ate an d tim e of d eath as well as th e p rim ary an d associated cau ses.
Anthropometric data
Birth weigh t was m easu red u sin g in fan t scales a d ju sted to 10 gra m s. Th e in fa n t wa s weigh ed sh ortly after b irth with ou t cloth es. Scales u sed in th e h osp ita ls were verified p eriod ica lly a n d rep laced wh en ever defects were detected. New-b o rn s we re m e a su re d a t New-b e twe e n 12 a n d 24 h o u rs o f life u sin g a n ARTH AGtyp e a n th ro -p om eter. Moth er’s h eigh t was d eterm in ed with a U NICEF (Un ite d Na tio n s Ch ild re n’s Fu n d ) p o rta b le wa ll a n th ro p o m e te r, a n d a rm girth wa s m e a su re d with a sta n d a rd ta p e m e a su re. Th e m o th er wa s a sked to rep o rt h er weigh t a t th e b egin n in g an d en d of p regn an cy.
Statistical analysis
In th e p resen t p ap er we rep ort th e calcu lation of p ercen tages for th e m ajor in d icators in vesti-ga ted a n d so m e o f th eir resp ective 95% co n fi-d en ce in tervals.
Results
A total of 2,831 b irth s were an alyzed , in clu d in g live-b orn s an d stillb orn s an d sin gle an d m u lti-p le b irth s. Most d eliveries (84.9%) occu rred in th e 4 largest h osp itals (p u b lic or con tracted ou t by th e SUS); 89.8% of d eliveries in volved fam i-lie s re sid in g in th e m u n icip a lity o f Sã o Lu ís, a n d 90.1% in vo lve d fa m ilie s fro m th e gre a te r m etrop olitan area.
So cio e co n o m ic a n d d e m o gra p h ic ch a ra c-te ristics o f fa m ilie s a re lisc-te d in Ta b le 1. Mo st fa m ilie s (52.7%) h a d a n in co m e o f le ss th a n 3 tim e s th e m in im u m wa ge, a n d m o st h e a d s o f fa m ilie s (71%) we re se m i-skille d o r u n skille d h a n d la b o re rs; 24.2% o f th e m o th e rs a lso wo rke d o u tsid e th e h o m e. Mo st h o u se h o ld s (61.1%) con tain ed 5 or m ore m em b ers.
Th e h igh est p ercen tage of m oth ers h ad 5 to 8 yea rs o f sch o o lin g (42.2%), n ea rly 30% were u n d e r 20 ye a rs o f a ge, a n d 13.4% we re u n d e r 18. Ne a rly h a lf (47.2%) we re in co m m o n -la w m a rria ge s, a n d 24.4% h a d n o p a rtn e r. Mo st were h a vin g th eir first ch ild (47.8%). Sm o kin g p re va le n ce a m o n g wo m e n in th is p o p u la tio n gro u p wa s low, o n ly 5.9%. Am o n g sm o ke rs, 65% sm oked u p to 10 cigarettes p er d ay d u rin g p regn an cy, con sid ered a low figu re. Prevalen ce o f p re vio u s stillb irth (s) wa s 3.1%, a n d p re va -le n ce o f p rio r a b o rtio n wa s 20.8%. Prio r low b irth weigh t wa s rep o rted b y 7.8% o f m o th ers (Tab le 2).
Pre n a ta l ca re cove ra ge wa s 89.5%, b u t th e u se o f p re n a ta l ca re is still n o t u n ive rsa l. Ap
-p roxim a tely 25% o f m o th ers h a d fewer th a n 4 p re n a ta l visits, b u t m o re th a n h a lf (54.9%) started p ren atal care d u rin g th e first trim ester of pregn an cy. More than 75% of pren atal care was cove re d b y th e SU S. Acco rd in g to th e APNCU in d e x, o n ly 13% o f t h e p re gn a n t wo m e n h a d received ad eq u ate p ren atal care. However, ac-cord in g to th e n ew in d ex, n early h alf th e p reg-n a reg-n t wo m e reg-n h a d re ce ive d a d e q u a t e ca re (Tab le 3).
Ap p roxim ately 75% of th e wom en received p re n a ta l ca re e xclu sive ly fro m a p h ysicia n , wh ile 10.8% re ce ive d ca re so le ly fro m n u rse s. Mu ltip ro fessio n a l p ren a ta l ca re wa s o b ser ved in 13.5% of cases. Most wom en (84.1%) sh owed ad eq u ate tetan u s im m u n ization , ad d in g th ose wh o received 2 or 3 d oses of vaccin es an d th ose wh o h a d b e e n p re vio u sly im m u n ize d . Blo o d te sts fo r d e te ctio n o f syp h ilis we re o rd e re d in 77.7% o f ca se s, a n d b lo o d typ in g wa s p e r-form ed in 87.5%.
Th e cesa rea n ra te wa s 33.8% (95%CI: 32.0-35,5). Alth o u gh a ll b irth s o ccu rred in th e h o s-p ita l, o n ly 73.5% we re s-p e rfo rm e d b y s-p h ysi-cian s, d em on stratin g th at a sign ifican t p rop or-tion of p atien ts (19%) received care from n u rs-in g a tten d a n ts. SUS covered n ea rly 90% of th e d e live rie s. Acco rd in g to th e re co rd s, 10.1% o f wom en received tu b a l liga tion s in a ssocia tion with th e cesarean section (Tab le 4). Th u s, tu b al ligation was p erform ed in 29.8% of th e cesare-an d eliveries. Con sid erin g p rim ary cesare-an d rep eat ce sa re a n d e live rie s se p a ra te ly, tu b a l liga tio n was p erform ed in 16.7% an d 57.1% of cases, re-sp ectively. On ly 12.6% o f th e wo m en were a ccom p an ied by th e sam e h ealth care p rofession -al d u rin g th e p ren at-al p eriod an d at d elivery.
So m e ch a ra cteristics o f th e n ewb o rn s a n d ca re p rovid e d ca n b e se e n in Ta b le 5. Of a ll b irth s, 55% we re m a le s. Th e low b irth we igh t rate was 9.6% (95%CI: 8.5-10.7) an d th e p reterm b irth ra te wa s 13.9% (95%CI: 12.715.2). In -trau terin e growth retard ation was ob served in 14.6% o f ca ses (95%CI: 13.3-15.9). Mea n b irth weigh t was 3,142 gram s.
Discussion
In th e m u n icip ality of São Lu ís, 85% of all birth s occu rred in th e fou r la rge p u b lic or SUScon -tracted m atern ity h osp itals. Ten p ercen t of d eliveries in São Lu ís in volved fam ilies n ot resid -in g -in th e m u n icip a lity, m ostly from th e th ree oth er m u n icip a lities on th e isla n d of Sã o Lu ís wh ich are p art of Greater Metrop olitan São Lu ís. So cio e co n o m ic in d ica to rs ge n e ra lly re -ve a le d b irth s in a p o p u la tio n o f low m o n th ly in co m e, p re d o m in a n tly co n sistin g o f se m i-skille d o r u n i-skille d h a n d la b o re rs, th e typ ica l re a lity o f m o st ca p ita l citie s in th e No rth e a st regio n o f Bra zil. In a d d itio n , h o u seh o ld s with n u m erou s m em b ers were com m on . Socioecon om ic d ata sh owed th at m ost m oth ers h ad iSocioecon -term ed iate sch oolin g.
Am o n g th e m o st releva n t in d ica to rs in th e p resen t su rvey was th e h igh p rop ortion of ad o-le sce n t m o th e rs, in clu d in g m a n y u n d e r 18 years of age. Th is was also reflected in th e h igh p ro p o rtio n o f p rim ip a ro u s m o th e rs. An o th e r o u t st a n d in g in d ica t o r wa s t h e h igh p e rce n t -a ge o f m o th ers with o u t -a p -a rtn er (24%). Bo th te e n a ge p re gn a n cy a n d n o t livin g with th e ch ild ’s fa th er h a ve b een d escrib ed a s risk fa c-to rs fo r p o o r p e rin a ta l o u tco m e s su ch a s low b irth weigh t a n d in tra u terin e growth reta rd a -tion (Lekea-Karan ika et al., 1999).
An o th e r ite m th a t d e se r ve s co m m e n t wa s t h e low p ro p o r t io n o f sm o ke r s in t h is p o p u -la t io n , a n d t h e low n u m b e r o f ciga re t t e s sm o ke d b y t h o se wh o d id sm o ke. Th is fa ct m ay reflect th e low m ean in com e of th e p op u -la tio n stu d ied o r m a y b e d u e to o th er rea so n s Tab le 1
So c io e c o no mic and d e mo g rap hic c harac te ristic s o f familie s. São Luís, Maranhão State , Brazil, 1997/ 1998.
Variables f %
Family income (times minimum wage)
≥1 486 17.2
1.1-1.9 459 16.2
2-2.9 545 19.3
3-4.9 464 16.4
5-9.9 413 14.6
≥10 262 9.3
Unkno wn 202 7.1
Per capita family income (times minimum wage)
< 0.25 520 18.4
0.25-0.49 805 28.4
0.50-0.99 695 24.6
≥1 608 21.5
Unkno wn 203 7.2
O ccupation of head of family
Manag e rs and up p e r le ve l p ro fe ssio nals 255 9.0
Mid d le le ve l ad ministrato rs 313 11.1
Skille d wo rke rs 162 5.7
Se mi-skille d wo rke rs 1,075 38.0
Unskille d wo rke rs 935 33.0
Une mp lo ye d 17 0.6
Unkno wn 74 2.6
N umber of persons per household
1-4 1,100 38.9
≥5 1,729 61.1
M other working outside the home
Ye s 684 24.2
No 2,146 75.8
t o b e in ve st iga t e d in m o re d e t a il in su b se -q u en t stu d ies.
Pren atal coverage is good , b u t a sign ifican t p e rce n ta ge o f m o th e rs a re still n o t cove re d , an d qu ality of care is in su fficien t, with a sign if-ica n t p ro p o rtio n o f p re cise ly th o se p re gn a n t wo m e n wh o a re p ro b a b ly a t gre a te r p e rin a ta l risk still receivin g n o care. Th e ad eq u acy in d ex ca lcu la te d o n th e b a sis o f two in d ica to rs wa s
low. Th e n u m b e r o f visit s is in su fficie n t a n d t h e p ro p o rt io n o f p a t ie n t s wh o d o n o t st a rt p ren atal care d u rin g th e first trim ester of p reg-n a reg-n cy is h igh . Mu ltip rofessioreg-n a l p rereg-n a ta l ca re is low. Th e th ree selected q u ality in d icators also d e m o n stra te d th a t m u ch is n e e d e d to im -p rove -p re n a ta l ca re in th e m u n ici-p a lity. On ly 12.6% o f m o th e rs we re se e n b y th e sa m e p ro -fession al d u rin g th e p ren atal p eriod an d at d e-Tab le 2
Births ac c o rd ing to so me mate rnal c harac te ristic s. São Luís, Maranhão State , Brazil, 1997/ 1998.
Variables f %
M aternal schooling (years)
No sc ho o ling 199 7.1
1-4 314 11.1
5-8 1,192 42.2
9-11 994 35.2
≥12 124 4.4
M aternal age (years)
< 18 380 13.4
18-19 466 16.5
20-24 1,072 37.9
25-29 548 19.4
30-34 235 8.3
35-39 104 3.7
≥40 24 0.9
M arital status
Marrie d 803 28.4
Co hab iting 1,337 47.2
No p artne r 639 22.6
Se p arate d , wid o we d , d ivo rc e d 51 1.8
Parity
1 1,353 47.8
2 836 29.5
3-4 503 17.8
≥5 139 4.9
M aternal smoking
Ye s 166 5.9
No 2,665 94.1
Previous stillbirth
Ye s 87 3.1
No 2,744 96.9
Previous abortion
Ye s 588 20.8
No 2,243 79.2
Previous low birth weight
Ye s 219 7.8
No 2,591 92.2
live r y, a lth o u gh th is is a wid e sp re a d wish o f m o th e rs a n d a n in d ica to r o f h u m a n iza tio n o f h ealth care.
Th e cesarean rate was h igh an d risin g in th e m u n icip a lity (Esta d o d o Ma ra n h ã o / U NICEF, 1992). On e o f th e p ro b a b le ca u se s o f th is ce sarean rate is tu b al ligation , p erform ed togeth -er with n early 30% of cesarean s.
Th e p ersisten ce of a h igh p ercen tage of h os-p ita l d e live rie s n o t a ssiste d b y q u a lifie d os-p e r-son n el (p h ysician or registered n u rse) is a p h e-n o m e e-n o e-n th a t m u st b e e va lu a te d ie-n gre a te r d ep th . Th e p ercen ta ge of n ewb orn s exa m in ed by a p ed ia tricia n in th e d elivery ro o m co n tin -u e s to b e low d e sp ite a r-u lin g b y Min istr y o f Health in stitu tin g reim b u rsem en t for th is p
ro-ce d u re (Bra sil, 1993). It is n e ro-ce ssa r y to d e te r-m in e b y a u d it wh e th e r th is p a yr-m e n t is b e in g m ad e to p rofession als wh o are in fact failin g to p rovid e th e service, sin ce in m an y cases we d e-te ce-te d n e o n a ta l m e d ica l re co rd s sign e d b y a p e d ia tricia n , wh ile in th e q u e stio n n a ire th e m o th e rs sta te d th a t n o p e d ia tricia n wa s p re -sen t in th e d elivery room .
Neo n a ta l ca re still lea ves m u ch to b e d e-sired . Ro o m in g-in fo r n o rm a l in fa n ts is n o t p racticed in all cases. In som e h osp itals, in fan ts h ad still n ot begu n breastfeedin g after 24 h ou rs.
Co m p a riso n o f so m e d e m o gra p h ic a n d m e d ica l ca re ch a ra cte ristics re p o rte d in th e th ree p erin a ta l stu d ies co n d u cted in Bra zil in th e 1990s sh owed th a t Pelota s h a d th e h igh est Tab le 3
Pre natal c are . São Luís, Maranhão State , Brazil, 1997/ 1998.
Variables f %
N umber of prenatal visits
0 263 9.3
1-3 449 15.9
4-5 703 24.8
≥6 1,381 48.8
Unkno wn 35 1.2
Trimester when prenatal care was started
No p re natal c are 263 9.3
First 1,547 54.9
Se c o nd 904 32.1
Third 102 3.6
Category of prenatal care
No p re natal c are 263 9.3
Unifie d He alth Syste m (SUS) 1,903 67.2
Co ntrac te d o ut b y SUS 259 9.2
He alth insuranc e p lan 309 10.9
O ut-o f-p o c ke t 97 3.4
Professional who provided prenatal care
Physic ian 1,945 75.7
Re g iste re d nurse 276 10.8
Physic ian and re g iste re d nurse 347 13.5
Kotelchuck’s adequacy of prenatal care utilization index
Inte nsive 84 3.0
Ad e q uate 282 10.0
Inte rme d iate 1,072 37.9
Inad e q uate 1,393 49.1
Adequacy based on Health M inistry recommendations
Ad e q uate 1,403 49.6
Inte rme d iate 430 15.2
Inad e q uate 998 35.3
p ercen tage of fam ilies with an in com e of u p to on e m in im u m wa ge. Th e p ercen ta ge of m oth -e rs with o u t a p a rtn -e r wa s 12.3% in P-e lo ta s, 11.4% in Ribeirão, an d 24.4% in São Lu ís. Moth -ers u n d er 20 years of age rep resen ted 17.4% of b irth s in Pelo ta s, 17.5% in Rib eirã o Preto, a n d 29.9% in Sã o Lu ís (Bettiol et a l., 1998; Costa et al., 1996; Victora et al., 1996).
An o th e r m a jo r d iffe re n ce wa s in th e p e r-cen tage of sm okin g m oth ers: 5.7% in São Lu ís, 33.5% in Pelo ta s, a n d 20.3% in Rib eirã o Preto. Prim ip a ra e re p re se n te d 35.1% o f b irth s in Pelota s, 36.8% in Rib eirã o Preto, a n d 47.8% in São Lu ís (Bettiol et al., 1998; Tom asi et al., 1996). Wh ile in Rib eirão Preto on ly 2.4% of m oth -ers failed to receive p ren atal care, th is p ercen tage was h igh er in Pelotas (4.9%) an d even h igh -e r in Sã o Lu ís (9.3%). Th -e c-e sa r-e a n ra t-e a lso va ried a m o n g th e th ree m u n icip a lities: 30.5% in Pelo ta s, 53.2% in Rib eirã o Preto, a n d 33.8% in Sã o Lu ís. In Pelo ta s, 88.3% o f th e d eliveries we re a tte n d e d b y p h ysicia n s, wh ile th e p e r-cen tage was lower in São Lu ís (73.5%). Th e SUS re im b u rse d th e co st o f 55.1% o f d e live rie s in
Rib e irã o a n d 89.7% in Sã o Lu ís (Co sta e t a l., 1996; Silva et al., 1998; Victora et al., 1996).
Co n sid erin g o n ly sin gleto n live b irth s, th e low birth weight rate was lower in São Luís (7.6%) than in Pelotas (9.1%) an d Ribeirão Preto (10.6%). A h igh er p reterm b irth ra te wa s a lso o b served in Rib eirão (14.8%), wh ile an in term ed iate rate was observed in São Luís (12.4%) an d a lower rate was observed in Pelotas (8.0%) (data n ot shown ). As observed in São Lu ís, m ost p rem atu re in fan ts sh owed n o low b irth weigh t in Rib eirã o Preto. In Pelotas th is p h en om en on d oes n ot ap p ear to occu r. São Lu ís p resen ted a m u ch h igh er p reva-le n ce o f in tra u te rin e growth re ta rd a tio n th a n Pelotas (Silva et al., 1998; Victora et al., 1996).
Prevalen ce of low b irth weigh t an d p reterm b irth was ap p roxim ately th e sam e as d escrib ed fo r th e e n tire Un ite d Sta te s p o p u la tio n in re -ce n t ye a rs (NCH S, 1999), a n in trigu in g fa ct if we con sid er th at th e kn own risk factors for low b irth we igh t a re m u ch m o re p re va le n t in th e São Lu ís p op u lation .
Sim ilarly, com p arison of th e statistical d ata with th ose of oth er Brazilian cities (Pelotas an d Tab le 4
De live ry c are . São Luís, Maranhão State , Brazil, 1997/ 1998.
Variables f %
Type of delivery
Vag inal 1,875 66.2
Primary c e sare an se c tio n 646 22.8
Re p e at c e sare an se c tio n 310 11.0
Tubal ligation during cesarean section
Ye s 285 10.1
No 2,546 89.9
Professional who performed the delivery
Physic ian 2,080 73.5
Re g iste re d nurse 94 3.3
Nursing atte nd ant 537 19.0
Mid wife o r he alth ag e nt 98 3.5
O the r 3 0.1
No info rmatio n 19 0.7
Category of admission
Unifie d He alth Syste m (SUS) 1,667 58.9
Co ntrac te d o ut b y SUS 873 30.8
He alth insuranc e p lan 247 9.1
O ut-o f-p o c ke t 34 1.2
Same professional providing prenatal and delivery care
Ye s 324 12.6
No 2,244 87.4
Tab le 5
Charac te ristic s o f ne wb o rns and typ e o f c are p ro vid e d to the m.
São Luís, Maranhão State , Brazil, 1997/ 1998.
Variables f %
Low birth weight
Ye s 270 9.6
No 2,548 90.4
Preterm birth
Ye s 394 13.9
No 2,437 86.1
Weight for gestational age classification
Small 411 14.6
Ad e q uate 2,195 77.9
Larg e 212 7.5
Professional assisting newborn
Pe d iatric ian 1,420 50.2
O b ste tric ian 32 1.1
Ane sthe sio lo g ist 6 0.2
Re g iste re d nurse 204 7.2
Nursing atte nd ant 946 33.4
Mid wife 33 1.2
O the r 5 0.2
No info rmatio n 185 6.2
Type of lodging for newborn
Be d sid e c rad le 1,304 46.1
Co lle c tive nurse ry 324 11.4
Inte rme d iate nurse ry 351 12.4
In b e d with the mo the r 736 26.0
Inte nsive c are unit 56 2.0
NA 60 2.2
Beginning of breastfeeding in the first 24 hours of life
Ye s 2,160 76.3
No 480 17.0
No info rmatio n 191 6.7
Apgar measured
Ye s 1,355 47.9
No 1,365 48.2
No info rmatio n 111 3.9
Capurro measured
Ye s 1,000 35.3
No 1,745 61.7
No info rmatio n 86 3.0
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Acknowledgements
We wish to th a n k th e m o th e rs o f Sã o Lu ís, th e sta ff a n d a d m in istra to rs o f th e m a te rn ity h o sp ita ls, a n d stu d e n ts in te rn s wh o o b ta in e d th e a n th ro p o m e tric d ata an d con d u cted th e in terviews. We are also grate-fu l to Nilza Nu n e s d a Silva fro m th e De p a rtm e n t o f Ep id em iology, Sch ool of Pu b lic Health , Un iversity of São Pau lo, wh o assisted u s in d rawin g sam p lin g p ro-ced u res. We wish to exp ress ou r th an ks to th e Brazil-ia n Na tio n a l Re se a rch Co u n cil (CNPq ) fo r fu n d in g th is stu d y, u n d er gran t 523474/ 96-2.
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