Publications by authors named "Cesar G Victora"

379 Publications

[Maternal and child health inequalities among migrants: the case of Haiti and the Dominican RepublicDesigualdades na saúde materno-infantil entre migrantes: o caso do Haiti e da República Dominicana].

Rev Panam Salud Publica 2021 16;45:e100. Epub 2021 Sep 16.

Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil.

Objective: To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans.

Methods: Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition.

Results: Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups.

Conclusion: Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.
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http://dx.doi.org/10.26633/RPSP.2021.100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442708PMC
September 2021

Sociedades justas: una nueva visión de la equidad en la salud en la Región de las Américas después de la COVID-19.

Rev Panam Salud Publica 2021 31;45:e99. Epub 2021 Aug 31.

Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil.

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http://dx.doi.org/10.26633/RPSP.2021.99DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407600PMC
August 2021

SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveys.

BMJ Open 2021 08 19;11(8):e047779. Epub 2021 Aug 19.

International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.

Objectives: Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored.

Setting: We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016 PARTICIPANTS: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries.

Outcome Measures: Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures.

Results: In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries.

Conclusions: Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.
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http://dx.doi.org/10.1136/bmjopen-2020-047779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378377PMC
August 2021

Time-dependent decay of detectable antibodies against SARS-CoV-2: A comparison of ELISA with two batches of a lateral-flow test.

Braz J Infect Dis 2021 Jul-Aug;25(4):101601. Epub 2021 Aug 5.

Universidade Federal de Pelotas, Pelotas, RS, Brazil.

Background: Large-scale epidemiological studies of seroprevalence of antibodies against SARS-CoV-2 often rely on point-of-care tests that provide immediate results to participants. Yet, little is known on how long rapid tests remain positive after the COVID-19 episode, or how much variability exists across different brands and even among batches of the same test.

Methods: In November 2020, we assessed the sensitivity of three tests applied to 133 individuals with a previous positive PCR result between April and October. All subjects provided finger prick blood samples for two batches (A and B) of the Wondfo lateral-flow IgG/IgM test, and dried blood spot samples for the S-UFRJ ELISA test.

Results: Overall sensitivity levels were 92.5% (95% CI 86.6-96.3), 63.2% (95% CI 54.4-71.4) and 33.8% (95% CI 25.9-42.5) for the S-UFRJ test, Wondfo A and Wondfo B tests, respectively. There was no evidence of a decline in the positivity of S-UFRJ with time since the diagnosis, but the two Wondfo batches showed sharp reductions to as low as 41.9% and 19.4%, respectively, for subjects with a positive PCR in June or earlier. Positive results for batch B of the rapid test were 35% to 54% lower than for batch A at any given month of diagnosis.

Interpretation: Whereas the ELISA test showed high sensitivity and stability of results over the five months of the study, both batches of the rapid test showed substantial declines, with one of the batches consistently showing lower sensitivity levels than the other. ELISA tests based on dried-blood spots are an inexpensive alternative to rapid lateral-flow tests in large-scale epidemiological studies.

Funding: The study was funded by the "Todos Pela Saúde" initiative, Instituto Serrapilheira, Brazilian Ministry of Health, Brazilian Collective Health Association (ABRASCO) and the JBS S.A. initiative 'Fazer o Bem Faz Bem'.
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http://dx.doi.org/10.1016/j.bjid.2021.101601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339571PMC
October 2021

The nutrition agenda must include tobacco control - Authors' reply.

Lancet 2021 07;398(10297):301

Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.

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http://dx.doi.org/10.1016/S0140-6736(21)01249-6DOI Listing
July 2021

Vaccination coverage in children up to 2 years old, receiving financial support from the Family Income Transfer Program, Brazil.

Epidemiol Serv Saude 2021 9;30(3):e2020983. Epub 2021 Jul 9.

Universidade Federal de Pelotas, Programa de Pós-graduação em Epidemiologia, Pelotas, RS, Brasil.

Objective: To assess vaccination coverage, based on the National Immunization Program schedule, among children receiving financial support from the Family Income Transfer Program, Brazil, according to the family socioeconomic status and maternal characteristics.

Methods: 3,242 children under 12 months old were assessed between August/2018 and April/2019, of whom 3,008 were reassessed between September/2019 and January/2020. The analyses were performed using multilevel models (level 3, Federative Unit; level 2, municipality; level 1, children).

Results: Vaccination coverage was 2.5 fold higher in the first follow-up (61.0% - 95% CI 59.3;62.6%), compared to the second follow-up (24.8% - 95% CI 22.8;25.9%) (p<0.001). In the first follow-up, coverage was higher in the richest quintile (67.9%) and in children whose mothers had ≥9 years of schooling (63.3%). In the second follow-up, there were no differences. The highest coverage occurred between 0.5-2.5 (93.5%) and 12.5-15.5 months (34.4%), respectively, first and second follow-ups.

Conclusion: Low coverage was found, both in the first and second year of life.
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http://dx.doi.org/10.1590/S1679-49742021000300010DOI Listing
July 2021

Rates and time trends in the consumption of breastmilk, formula, and animal milk by children younger than 2 years from 2000 to 2019: analysis of 113 countries.

Lancet Child Adolesc Health 2021 09 8;5(9):619-630. Epub 2021 Jul 8.

International Center for Equity in Health, Universidade Federal de Pelotas, Pelotas, Brazil.

Background: Previous analyses of trends in feeding indicators of children younger than 2 years have been limited to low-income and middle-income countries. We aimed to assess time trends in the consumption of different types of milk (breastmilk, formula, and animal milk) by children younger than 2 years from 2000 to 2019 at a global level.

Methods: In this time-series analysis, we combined cross-sectional data from 487 nationally representative surveys from low-income and middle-income countries and information from high-income countries to estimate seven infant and young child feeding indicators in up to 113 countries. Multilevel linear models were used in pooled analyses to estimate annual changes in feeding practices from 2000 to 2019 for country income groups and world regions.

Findings: For the absolute average annual changes, we found significant gains in any breastfeeding at age 6 months in high-income countries (1·29 percentage points [PPs] per year [95% CI 1·12 to 1·45]; p<0·0001) and at age 1 year in high-income countries (1·14 PPs per year [0·99 to 1·28]; p<0·0001) and upper-middle-income countries (0·53 PPs per year [0·23 to 0·82]; p<0·0001). We also found a small reduction in low-income countries for any breastfeeding at age 6 months (-0·07 PPs per year [-0·11 to -0·03]; p<0·0001) and age 1 year (-0·13 PPs per year [-0·18 to -0·09]; p<0·0001). Data on exclusive breastfeeding and consumption of formula and animal milk were only available for low-income and middle-income countries, where exclusive breastfeeding in the first 6 months of life increased by 0·70 PPs per year (0·51-0·88; p<0·0001) to reach 48·6% (41·9-55·2) in 2019. Exclusive breastfeeding increased in all world regions except for the Middle East and north Africa. Formula consumption in the first 6 months of life increased in upper-middle-income countries and in east Asia and the Pacific, Latin America and the Caribbean, the Middle East and north Africa, and eastern Europe and central Asia, whereas the rates remained below 8% in sub-Saharan Africa and south Asia. Animal milk consumption by children younger than 6 months decreased significantly (-0·41 PPs per year [-0·51 to -0·31]; p<0·0001) in low-income and middle-income countries.

Interpretation: We found some increases in exclusive and any breastfeeding at age 6 months in various regions and income groups, while formula consumption increased in upper-middle-income countries. To achieve the global target of 70% exclusive breastfeeding by 2030, however, rates of improvement will need to be accelerated.

Funding: Bill & Melinda Gates Foundation, through WHO.
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http://dx.doi.org/10.1016/S2352-4642(21)00163-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8376656PMC
September 2021

Finding Children with High Risk of Non-Vaccination in 92 Low- and Middle-Income Countries: A Decision Tree Approach.

Vaccines (Basel) 2021 Jun 13;9(6). Epub 2021 Jun 13.

International Center for Equity in Health, Federal University of Pelotas, Marechal Deodoro, 1160, Pelotas 96020-220, Brazil.

Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12-23 months at high risk of being zero dose (no doses of the four basic vaccines-BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.
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http://dx.doi.org/10.3390/vaccines9060646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231774PMC
June 2021

COVID-19 and social distancing among children and adolescents in Brazil.

Rev Saude Publica 2021 25;55:42. Epub 2021 Jun 25.

Universidade Federal de Pelotas. Faculdade de Medicina. Departamento de Medicina Social. Pelotas, RS, Brasil.

Objective: To estimate the prevalence of SARS-CoV-2 antibodies and the adherence to measures of social distancing in children and adolescents studied in three national surveys conducted in Brazil between May-June 2020.

Methods: Three national serological surveys were conducted in 133 sentinel cities located in all 27 Federative Units. Multistage probability sampling was used to select 250 individuals per city. The total sample size in age ranges 0-9 and 10-19 years old are of 4,263 and 8,024 individuals, respectively. Information on children or adolescents was gathered with a data collection app, and a rapid point-of-case test for SARS-CoV-2 was conducted on a finger prick blood sample.

Results: The adjusted prevalence of antibodies was 2.9% (2.2-3.6) among children 0-9 years, 2.2% (1.8-2.6) among adolescents 10-19 years, and 3.0% (2.7-3.3) among adults 20+years. Prevalence of antibodies was higher among poor children and adolescents compared to those of rich families. Adherence to social distancing measures was seen in 72.4% (71.9-73.8) of families with children, 60.8% (59.6-61.9) for adolescents, and 57.4% (56.9-57.8) for adults. For not leaving the house except for essential matters the proportions were 81.7% (80.5-82.9), 70.6% (69.6-61.9), and 65.1% (64.7-65.5), respectively. Among children and adolescents, social distancing was strongly associated with socioeconomic status, being much higher in the better-off families.

Conclusions: The prevalence of antibodies against SARS-CoV-2 showed comparable levels among children, adolescents, and adults. Adherence to social distancing measures was more prevalent in children, followed by adolescents. There were important socioeconomic differences in the adherence to social distancing among children and adolescents.
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http://dx.doi.org/10.11606/s1518-8787.2021055003832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8225319PMC
July 2021

Slow Spread of SARS-CoV-2 in Southern Brazil Over a 6-Month Period: Report on 8 Sequential Statewide Serological Surveys Including 35 611 Participants.

Am J Public Health 2021 08 29;111(8):1542-1550. Epub 2021 Jun 29.

Pedro C. Hallal, Mariângela F. Silveira, Ana M. B. Menezes, Bernardo L. Horta, Aluísio J. D. Barros, Nadege Jacques, Luís Paulo Vidaletti, Fernando P. Hartwig, Fernando C. Barros, and Cesar G. Victora are with the Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Brazil. Lúcia C. Pellanda and Helena Schirmer are with the Universidade Federal de Ciências de Saúde de Porto Alegre, Brazil. Gabriel D. Victora is with the Laboratory of Lymphocyte Dynamics, Rockefeller University, New York, NY. Odir A. Dellagostin is with the Postgraduate Program in Biotechnology, Universidade Federal de Pelotas. Claudio J. Struchiner is with the Fundação Getúlio Vargas, Rio de Janeiro, Brazil. Marcelo N. Burattini is with the Universidade Federal de São Paulo, Brazil. Marilia A. Mesenburg is with the Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, and the Universidade Federal de Ciências de Saúde de Porto Alegre. Emanuele L. Ambros is with the Secretaria Municipal de Saúde de Uruguaiana, Brazil. Evelise M. Berlezi is with the Universidade de Ijuí, Brazil. Jane D. P. Renner is with the Universidade de Santa Cruz do Sul, Brazil. Kaue Collares is with the Universidade de Passo Fundo, Brazil. Maria Letícia R. Ikeda is with the Universidade do Vale do Rio dos Sinos, Sao Leopoldo, Brazil. Thiago M. Ardenghi is with the Universidade Federal de Santa Maria, Brazil. Patricia de Gasperi is with the Universidade de Caxias do Sul, Brazil.

To evaluate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) over 6 months in the Brazilian State of Rio Grande do Sul (population 11.3 million), based on 8 serological surveys. In each survey, 4151 participants in round 1 and 4460 participants in round 2 were randomly sampled from all state regions. We assessed presence of antibodies against SARS-CoV-2 using a validated lateral flow point-of-care test; we adjusted figures for the time-dependent decay of antibodies. The SARS-CoV-2 antibody prevalence increased from 0.03% (95% confidence interval [CI] = 0.00%, 0.34%; 1 in every 3333 individuals) in mid-April to 1.89% (95% CI = 1.36%, 2.54%; 1 in every 53 individuals) in early September. Prevalence was similar across gender and skin color categories. Older adults were less likely to be infected than younger participants. The proportion of the population who reported leaving home daily increased from 21.4% (95% CI = 20.2%, 22.7%) to 33.2% (95% CI = 31.8%, 34.5%). SARS-CoV-2 infection increased slowly during the first 6 months in the state, differently from what was observed in other Brazilian regions. Future survey rounds will continue to document the spread of the pandemic.
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http://dx.doi.org/10.2105/AJPH.2021.306351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8489617PMC
August 2021

High prevalence of symptoms among Brazilian subjects with antibodies against SARS-CoV-2.

Sci Rep 2021 06 24;11(1):13279. Epub 2021 Jun 24.

Universidade Federal de Pelotas, Pelotas, Brazil.

Since the beginning of the pandemic of COVID-19, there has been a widespread assumption that most infected persons are asymptomatic. Using data from the recent wave of the EPICOVID19 study, a nationwide household-based survey including 133 cities from all states of Brazil, we estimated the proportion of people with and without antibodies for SARS-CoV-2 who were asymptomatic, which symptoms were most frequently reported, number of symptoms and the association with socio-demographic characteristics. We tested 33,205 subjects using a rapid antibody test previously validated. Information was collected before participants received the test result. Out of 849 (2.7%) participants positive for SARS-CoV-2 antibodies, only 12.1% (95% CI 10.1-14.5) reported no symptoms, compared to 42.2% (95% CI 41.7-42.8) among those negative. The largest difference between the two groups was observed for changes in smell/taste (56.5% versus 9.1%, a 6.2-fold difference). Changes in smell/taste, fever and body aches were most likely to predict positive tests as suggested by recursive partitioning tree analysis. Among individuals without any of these three symptoms, only 0.8% tested positive, compared to 18.3% of those with both fever and changes in smell or taste. Most subjects with antibodies against SARS-CoV-2 are symptomatic, even though most present only mild symptoms.
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http://dx.doi.org/10.1038/s41598-021-92775-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8225900PMC
June 2021

Social vulnerability as a risk factor for death due to severe paediatric COVID-19.

Lancet Child Adolesc Health 2021 08 11;5(8):533-535. Epub 2021 Jun 11.

Federal University of Pelotas, Pelotas, Brazil.

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http://dx.doi.org/10.1016/S2352-4642(21)00166-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192297PMC
August 2021

Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries.

Paediatr Perinat Epidemiol 2021 Sep 26;35(5):549-556. Epub 2021 May 26.

International Center for Equity in Health, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.

Background: Non-biological childhood mortality sex ratios may reflect community sex preferences and gender discrimination in health care.

Objective: We assessed the association between contextual factors and gender bias in under-five mortality rates (U5MR) in low- and middle-income countries.

Methods: Full birth histories available from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010-2018) in 80 countries were used to estimate U5MR male-to-female sex ratios. Expected sex ratios and their residuals (difference of observed and expected) were derived from a linear regression model, adjusted for overall mortality. Negative residuals indicate more likelihood of discrimination against girls, and we refer to this as a measure of potential gender bias. Associations between residuals and national development and gender inequality indices and with survey-derived child health care indicators were tested using Spearman's correlation.

Results: Mortality residuals for under-five mortality were not associated with national development, education, religion, or gender inequality indices. Negative residuals were more common in countries where boys were more likely to be taken to health services than girls (rho -0.24, 95% confidence interval -0.45, -0.01).

Conclusions: Countries where girls were more likely to die than boys, accounting for overall mortality levels, were also countries where boys were more likely to receive health care than girls. Further research is needed to understand which national characteristics explain the presence of gender bias, given that the analyses of development levels and gender equality did not discriminate between countries with or without excess mortality of girls. Reporting on child mortality separately by sex is required to enable such advances.
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http://dx.doi.org/10.1111/ppe.12763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453971PMC
September 2021

Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.

Lancet Glob Health 2021 08 26;9(8):e1101-e1109. Epub 2021 May 26.

International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil. Electronic address:

Background: Global reports have described inequalities in coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions, but little is known about how socioeconomic inequality in intervention coverage varies across multiple low-income and middle-income countries (LMICs). We aimed to assess the association between wealth-related inequalities in coverage of RMNCH interventions.

Methods: In this cross-sectional study, we identified publicly available Demographic Health Surveys and Multiple Indicator Cluster Surveys from LMICs containing information on household characteristics, reproductive health, women's and children's health, nutrition, and mortality. We identified the most recent survey from the period 2010-19 for 36 countries that contained data for our preselected set of 18 RMNCH interventions. 21 countries also had information on two common malaria interventions. We classified interventions into four groups according to their predominant delivery channels: health facility based, community based, environmental, and culturally driven (including breastfeeding practices). Within each country, we derived wealth quintiles from information on household asset indices. We studied two summary measures of within-country wealth-related inequality: absolute inequalities (akin to coverage differences among children from wealthy and poor households) using the slope index of inequality (SII), and relative inequalities (akin to the ratio of coverage levels for wealthy and poor children) using the concentration index (CIX). Pro-poor inequalities are present when intervention coverage decreased with increasing household wealth, and pro-rich inequalities are present when intervention coverage increased as household wealth increased.

Findings: Across the 36 LMICs included in our analyses, coverage of most interventions had pro-rich patterns in most countries, except for two breastfeeding indicators that mostly had higher coverage among poor women, children and households than wealthy women, children, and households. Environmental interventions were the most unequal, particularly use of clean fuels, which had median levels of SII of 48·8 (8·6-85·7) and CIX of 67·0 (45·0-85·8). Interventions primarily delivered in health facilities-namely institutional childbirth (median SII 46·7 [23·1-63·3] and CIX 11·4 [4·5-23·4]) and antenatal care (median SII 26·7 [17·0-47·2] and CIX 10·0 [4·2-17·1])-also usually had pro-rich patterns. By comparison, primarily community-based interventions, including those against malaria, were more equitably distributed-eg, oral rehydration therapy (median SII 9·4 [2·9-19·0] and CIX 3·4 [1·3-25·0]) and polio immunisation (SII 12·1 [2·3-25·0] and CIX 3·1 [0·5-7·1]). Differences across the four types of delivery channels in terms of both inequality indices were significant (SII p=0·0052; CIX p=0·0048).

Interpretation: Interventions that are often delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities or those that require changes in the home environment. Policy makers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions.

Funding: Bill & Melinda Gates Foundation and Wellcome Trust.

Translations: For the French, Portuguese and Spanish translations of the abstract see Supplementary Materials section.
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http://dx.doi.org/10.1016/S2214-109X(21)00204-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8295042PMC
August 2021

Patterns of Growth in Childhood in Relation to Adult Schooling Attainment and Intelligence Quotient in 6 Birth Cohorts in Low- and Middle-Income Countries: Evidence from the Consortium of Health-Oriented Research in Transitioning Societies (COHORTS).

J Nutr 2021 Aug;151(8):2342-2352

Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA.

Background: Growth faltering has been associated with poor intellectual performance. The relative strengths of associations between growth in early and in later childhood remain underexplored.

Objectives: We examined the association between growth in childhood and adult human capital in 5 low- and middle-income countries (LMICs).

Methods: We analyzed data from 9503 participants in 6 prospective birth cohorts from 5 LMICs (Brazil, Guatemala, India, the Philippines, and South Africa). We used linear and quasi-Poisson regression models to assess the associations between measures of height and relative weight at 4 age intervals [birth, age ∼2 y, midchildhood (MC), adulthood] and 2 dimensions of adult human capital [schooling attainment and Intelligence Quotient (IQ)].

Results: Meta-analysis of site- and sex-specific estimates showed statistically significant associations between size at birth and height at ∼2 y and the 2 outcomes (P < 0.001). Weight and length at birth and linear growth from birth to ∼2 y of age (1 z-score difference) were positively associated with schooling attainment (β: 0.13; 95% CI: 0.08, 0.19, β: 0.17; 95% CI: 0.07, 0.32, and β: 0.25, 95% CI: 0.10, 0.40, respectively) and adult IQ (β: 0.74, 95% CI: 0.35, 1.14, β: 0.73, 95% CI: 0.35, 1.10, and β: 1.52, 95% CI: 0.96, 2.08, respectively). Linear growth from age 2 y to MC and from MC to adulthood was not associated with higher school attainment or IQ. Change in relative weight in early childhood, MC, and adulthood was not associated with either outcome.

Conclusions: Linear growth in the first 1000 d is a predictor of schooling attainment and IQ in adulthood in LMICs. Linear growth in later periods was not associated with either of these outcomes. Changes in relative weight across the life course were not associated with schooling and IQ in adulthood.
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http://dx.doi.org/10.1093/jn/nxab096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436131PMC
August 2021

Overcoming Brazil's monumental COVID-19 failure: an urgent call to action.

Nat Med 2021 06;27(6):933

Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.

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http://dx.doi.org/10.1038/s41591-021-01353-2DOI Listing
June 2021

Missed childhood immunizations during the COVID-19 pandemic in Brazil: Analyses of routine statistics and of a national household survey.

Vaccine 2021 06 27;39(25):3404-3409. Epub 2021 Apr 27.

Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil.

Introduction: There is widespread concern that disruption to health services during the COVID-19 pandemic has led to declines in immunization coverage among young children, but there is limited information on the magnitude of such impact. High immunization coverage is essential for reducing the risk of vaccine preventable diseases.

Methods: We used data from two nationwide sources covering the whole of Brazil. Data from the Information System of the National Immunization Program (SIPNI) on the monthly number of vaccine doses administered to young children were analyzed. The second source was a survey in 133 large cities in the 27 states in the country, carried out from August 24-27. Respondents answered a question on whether children under the age of three years had missed any scheduled vaccinations during the pandemic, and available vaccination cards were photographed for later examination.

Results: SIPNI data showed that, relative to January and February 2020, there was a decline of about 20% in vaccines administered to children aged two months or older during March and April, when social distancing was at the highest level in the country. After May, vaccination levels returned to pre-pandemic values. Survey data, based on the interviews and on examination of the vaccine cards, showed that 19.0% (95% CI 17.0;21.1%) and 20.6% (95% CI 19.0;23.1%) of children, respectively, had missed immunizations. Missed doses were most common in the North (Amazon) region and least common in the South and Southeast, and also more common among children from poor than from wealthy families.

Interpretation: Our results show that the pandemic was associated with a reduction of about 20% in child vaccinations, but this was reverted in recent months. Children from poor families and from the least developed regions of the country were most affected. There is an urgent need to booster immunization activities in the country to compensate for missed doses, and to reduce geographic and socioeconomic inequalities.
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http://dx.doi.org/10.1016/j.vaccine.2021.04.046DOI Listing
June 2021

Inequalities in antenatal care coverage and quality: an analysis from 63 low and middle-income countries using the ANCq content-qualified coverage indicator.

Int J Equity Health 2021 04 17;20(1):102. Epub 2021 Apr 17.

International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas, RS, 96020-220, Brazil.

Background: Antenatal care (ANC) is an essential intervention associated with a reduction of maternal and new-born morbidity and mortality. However, evidence suggested substantial inequalities in maternal and child health, mainly in low- and middle-income countries (LMICs). We aimed to conduct a global analysis of socioeconomic inequalities in ANC using national surveys from LMICs.

Methods: ANC was measured using the ANCq, a novel content-qualified ANC coverage indicator, created and validated using national surveys, based upon contact with the health services and content of care received. We performed stratified analysis to explore the socioeconomic inequalities in ANCq. We also estimated the slope index of inequality, which measures the difference in coverage along the wealth spectrum.

Results: We analyzed 63 national surveys carried out from 2010 to 2017. There were large inequalities between and within countries. Higher ANCq scores were observed among women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment in nearly all countries. Countries with higher ANCq mean presented lower inequalities; while countries with average ANCq scores presented wide range of inequality, with some managing to achieve very low inequality.

Conclusions: Despite all efforts in ANC programs, important inequalities in coverage and quality of ANC services persist. If maternal and child mortality Sustainable Development Goals are to be achieved, those gaps we documented must be bridged.
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http://dx.doi.org/10.1186/s12939-021-01440-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052706PMC
April 2021

Complementary Feeding Practices in 80 Low- and Middle-Income Countries: Prevalence of and Socioeconomic Inequalities in Dietary Diversity, Meal Frequency, and Dietary Adequacy.

J Nutr 2021 Jul;151(7):1956-1964

International Center for Equity in Health, Post-graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil.

Background: Adequate complementary feeding practices in early childhood contribute to better food preferences and health outcomes throughout the life course.

Objectives: The aim of this study was to describe patterns and socioeconomic inequalities in complementary feeding practices among children aged 6-23 mo in 80 low- and middle-income countries.

Methods: We analyzed national surveys carried out since 2010. Complementary feeding indicators for children aged 6-23 mo included minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD). Between- and within-country inequalities were documented using relative (wealth deciles), gross domestic product (GDP) per capita, and absolute (estimated household income) socioeconomic indicators. Statistical analyses included calculation of the slope index of inequality, Pearson correlation and linear regression, and scatter diagrams.

Results: Only 21.3%, 56.2%, and 10.1% of the 80 countries showed prevalence levels >50% for MDD, MMF, and MAD, respectively. Western & Central Africa showed the lowest prevalence for all indicators, whereas the highest for MDD and MAD was Latin America & Caribbean, and for MMF it was East Asia & the Pacific. Log GDP per capita was positively associated with MDD (R2 = 48.5%), MMF (28.2%), and MAD (41.4%). Pro-rich within-country inequalities were observed in most countries for the 3 indicators; pro-poor inequalities were observed in 2 countries for MMF, and in none for the other 2 indicators. Breast milk was the only type of food with a pro-poor distribution, whereas animal-source foods (dairy products, flesh foods, and eggs) showed the most pronounced pro-rich inequality. Dietary diversity improved sharply when absolute annual household incomes exceeded ∼US$20,000. All 3 dietary indicators improved by age and no consistent differences were observed between boys and girls.

Conclusions: Monitoring complementary feeding indicators across the world and implementing policies and programs to reduce wealth-related inequalities are essential to achieve optimal child nutrition.
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http://dx.doi.org/10.1093/jn/nxab088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245881PMC
July 2021

Is women's empowerment associated with coverage of RMNCH interventions in low- and middle-income countries? An analysis using a survey-based empowerment indicator, the SWPER.

J Glob Health 2021 Mar 1;11:04015. Epub 2021 Mar 1.

International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.

Background: Women's empowerment has a strong potential to promote sustainable development. We evaluate the association between women's empowerment and the Composite Coverage Index (CCI), a weighted average of coverage of eight interventions in reproductive, maternal, newborn and child health (RMNCH). We also assess whether these effects are modified by wealth.

Methods: We used Demographic and Health Survey data from 62 low- and middle-income countries. Women's empowerment was measured using the three domains (attitude to violence, social independence and decision making) of the survey-based indicator of women's empowerment (SWPER). Analyses followed an ecological design. Meta-regression models were used to account for within-country uncertainty in the CCI. We also carried out meta-regression with wealth quintiles of households as the units of analyses and tested for interaction between wealth and each empowerment domain.

Results: We found positive associations between the three domains of SWPER and CCI at the country level. One standard deviation change in empowerment increased the CCI by 14.2 percentage points (attitude to violence), 15.3 percentage points (decision-making), and 16.3 percentage points (social independence). The association between social independence and CCI was modified by wealth: each additional standard deviation was associated with 21.8 (95% confidence interval (CI) = 14.0-29.6) and 8.7 (95% CI = 5.4-12.0) percentage points increase in the CCI among the poorest and the richest quintiles, respectively.

Conclusions: Our findings suggest that efforts toward the achievement of SDG5 (Achieve gender equality and empower all women and girls) may support improvements in RMNCH in low- and middle-income countries, especially among the poorest women and children.
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http://dx.doi.org/10.7189/jogh.11.04015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979155PMC
March 2021

Zero-dose children and the immunisation cascade: Understanding immunisation pathways in low and middle-income countries.

Vaccine 2021 07 18;39(32):4564-4570. Epub 2021 Mar 18.

1160 Marechal Deodoro, Pelotas, RS 96020-220, Brazil.

Introduction: Zero-dose prevalence refers to children who failed to receive any routine vaccination. Little is known about the "immunisation cascade" in low- and middle-income countries (LMICs), defined as how children move from zero dose to full immunisation.

Methods: Using data from national surveys carried out in 92 LMICs since 2010 and focusing on the four basic vaccines delivered in infancy (BCG, polio, DPT and MCV), we describe zero-dose prevalence and the immunisation cascade in children aged 12 to 23 months. We also describe the most frequent combinations of vaccines (or co-coverage) among children who are partially immunized. Analyses are stratified by country income groups, household wealth quintiles derived from asset indices, sex of the child and area of residence. Results were pooled across countries using child populations as weights.

Results: In the 92 countries, 7.7% were in the zero-dose group, and 3.3%, 3.4% and 14.6% received one, two or three vaccines, respectively; 70.9% received the four types and 59.9% of the total were fully immunised with all doses of the four vaccines. Three quarters (76.8%) of children who received the first vaccine received all four types. Among children with a single vaccine, polio was the most common in low- and lower-middle income countries, and BCG in upper-middle income countries. There were sharp inequalities according to household wealth, with zero-dose prevalence ranging from 12.5% in the poorest to 3.4% in the wealthiest quintile across all countries. The cascades were similar for boys and girls. In terms of dropout, 4% of children receiving BCG did not receive DPT1, 14% receiving DPT1 did not receive DPT3, and 9% receiving DPT3 did not progress to receive MCV.

Interpretation: Focusing on zero-dose children is particularly important because those who are reached with the first vaccine are highly likely to also receive remaining vaccines.
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http://dx.doi.org/10.1016/j.vaccine.2021.02.072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314014PMC
July 2021

Fetal cranial growth trajectories are associated with growth and neurodevelopment at 2 years of age: INTERBIO-21st Fetal Study.

Nat Med 2021 04 18;27(4):647-652. Epub 2021 Mar 18.

Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.

Many observational studies and some randomized trials demonstrate how fetal growth can be influenced by environmental insults (for example, maternal infections) and preventive interventions (for example, multiple-micronutrient supplementation) that can have a long-lasting effect on health, growth, neurodevelopment and even educational attainment and income in adulthood. In a cohort of pregnant women (n = 3,598), followed-up between 2012 and 2019 at six sites worldwide, we studied the associations between ultrasound-derived fetal cranial growth trajectories, measured longitudinally from <14 weeks' gestation, against international standards, and growth and neurodevelopment up to 2 years of age. We identified five trajectories associated with specific neurodevelopmental, behavioral, visual and growth outcomes, independent of fetal abdominal growth, postnatal morbidity and anthropometric measures at birth and age 2. The trajectories, which changed within a 20-25-week gestational age window, were associated with brain development at 2 years of age according to a mirror (positive/negative) pattern, mostly focused on maturation of cognitive, language and visual skills. Further research should explore the potential for preventive interventions in pregnancy to improve infant neurodevelopmental outcomes before the critical window of opportunity that precedes the divergence of growth at 20-25 weeks' gestation.
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http://dx.doi.org/10.1038/s41591-021-01280-2DOI Listing
April 2021

A new content-qualified antenatal care coverage indicator: Development and validation of a score using national health surveys in low- and middle-income countries.

J Glob Health 2021 Jan 30;11:04008. Epub 2021 Jan 30.

International Center for Equity in Health, Federal University of Pelotas, Pelotas, RS, Brazil.

Background: Good quality antenatal care (ANC) helps reduce adverse maternal and newborn outcomes, especially in low and middle-income countries (LMICs). Most of the currently used ANC indicators only measure contact with services. We aimed to create and validate a new indicator measured as a score, considering both contact and content, that can be used for monitoring.

Methods: We used data from national surveys conducted in LMICs. Information on ANC was used to build an adequacy score (ANCq) that would be applicable to all women in need of ANC. Cronbach's alpha and factor analysis were used to assess the proposed indicator. We also used a convergent validation approach, exploring the association of our proposed indicator with neonatal mortality.

Results: The ANCq score was derived from seven variables related to contact with services and content of care ranging from zero to ten. Surveys from 63 countries with all variables were used. The validity assessment showed satisfactory results based on Cronbach's alpha (0.82) and factor analysis. The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, the ANCq was inversely associated with neonatal mortality and the pooled for all surveys Odds Ratio was 0.90 (95% CI = 0.88-0.92).

Conclusions: ANCq allows the assessment of ANC in LMICs considering contact with services and content of care. It also presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.
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http://dx.doi.org/10.7189/jogh.11.04008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916319PMC
January 2021

Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda.

Lancet 2021 04 7;397(10282):1388-1399. Epub 2021 Mar 7.

Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.
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http://dx.doi.org/10.1016/S0140-6736(21)00394-9DOI Listing
April 2021

Association Between Preterm-Birth Phenotypes and Differential Morbidity, Growth, and Neurodevelopment at Age 2 Years: Results From the INTERBIO-21st Newborn Study.

JAMA Pediatr 2021 May;175(5):483-493

Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom.

Importance: The etiologic complexities of preterm birth remain inadequately understood, which may impede the development of better preventative and treatment measures.

Objective: To examine the association between specific preterm-birth phenotypes and clinical, growth, and neurodevelopmental differences among preterm newborns compared with term newborns up to age 2 years.

Design, Setting, And Participants: The INTERBIO-21st study included a cohort of preterm and term newborn singletons enrolled between March 2012 and June 2018 from maternity hospitals in 6 countries worldwide who were followed up from birth to age 2 years. All pregnancies were dated by ultrasonography. Data were analyzed from November 2019 to October 2020.

Exposures/interventions: Preterm-birth phenotypes.

Main Outcomes And Measures: Infant size, health, nutrition, and World Health Organization motor development milestones assessed at ages 1 and 2 years; neurodevelopment evaluated at age 2 years using the INTERGROWTH-21st Neurodevelopment Assessment (INTER-NDA) tool.

Results: A total of 6529 infants (3312 boys [50.7%]) were included in the analysis. Of those, 1381 were preterm births (mean [SD] gestational age at birth, 34.4 [0.1] weeks; 5148 were term births (mean [SD] gestational age at birth, 39.4 [0] weeks). Among 1381 preterm newborns, 8 phenotypes were identified: no main maternal, fetal, or placental condition detected (485 infants [35.1%]); infections (289 infants [20.9%]); preeclampsia (162 infants [11.7%]); fetal distress (131 infants [9.5%]); intrauterine growth restriction (110 infants [8.0%]); severe maternal disease (85 infants [6.2%]); bleeding (71 infants [5.1%]); and congenital anomaly (48 infants [3.5%]). For all phenotypes, a previous preterm birth was a risk factor for recurrence. Each phenotype displayed differences in neonatal morbidity and infant outcomes. For example, infants with the no main condition detected phenotype had low neonatal morbidity but increased morbidity and hospitalization incidence at age 1 year (odds ratio [OR], 2.2; 95% CI, 1.8-2.7). Compared with term newborns, the highest risk of scoring lower than the 10th centile of INTER-NDA normative values was observed in the fine motor development domain among newborns with the fetal distress (OR, 10.6; 95% CI, 5.1-22.2) phenotype.

Conclusions And Relevance: Results of this study suggest that phenotypic classification may provide a better understanding of the etiologic factors and mechanisms associated with preterm birth than continuing to consider it an exclusively time-based entity.
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http://dx.doi.org/10.1001/jamapediatrics.2020.6087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922239PMC
May 2021

A public health approach for deciding policy on infant feeding and mother-infant contact in the context of COVID-19.

Lancet Glob Health 2021 04 22;9(4):e552-e557. Epub 2021 Feb 22.

International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.

The COVID-19 pandemic has raised concern about the possibility and effects of mother-infant transmission of SARS-CoV-2 through breastfeeding and close contact. The insufficient available evidence has resulted in differing recommendations by health professional associations and national health authorities. We present an approach for deciding public health policy on infant feeding and mother-infant contact in the context of COVID-19, or for future emerging viruses, that balances the risks that are associated with viral infection against child survival, lifelong health, and development, and also maternal health. Using the Lives Saved Tool, we used available data to show how different public health approaches might affect infant mortality. Based on existing evidence, including population and survival estimates, the number of infant deaths in low-income and middle-income countries due to COVID-19 (2020-21) might range between 1800 and 2800. By contrast, if mothers with confirmed SARS-CoV-2 infection are recommended to separate from their newborn babies and avoid or stop breastfeeding, additional deaths among infants would range between 188 000 and 273 000.
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http://dx.doi.org/10.1016/S2214-109X(20)30538-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906661PMC
April 2021

A scoping review of methods for assessment of sex differentials in early childhood mortality.

BMC Pediatr 2021 01 26;21(1):55. Epub 2021 Jan 26.

International Center for Equity in Health, Postgraduate Program in Epidemiology, Federal University of Pelotas. Marechal Deodoro, 1160, 3rd floor, Pelotas, 96020-220, Brazil.

Background: While assessment of sex differentials in child mortality is straightforward, their interpretation must consider that, in the absence of gender bias, boys are more likely to die than girls. The expected differences are also influenced by levels and causes of death. However, there is no standard approach for determining expected sex differences.

Methods: We performed a scoping review of studies on sex differentials in under-five mortality, using PubMed, Web of Science, and Scopus databases. Publication characteristics were described, and studies were grouped according to their methodology.

Results: From the 17,693 references initially retrieved we included 154 studies published since 1929. Indian, Bangladeshi, and Chinese populations were the focus of 44% of the works, and most studies addressed infant mortality. Fourteen publications were classified as reference studies, as these aimed to estimate expected sex differentials based upon the demographic experience of selected populations, either considered as gender-neutral or not. These studies used a variety of methods - from simple averages to sophisticated modeling - to define values against which observed estimates could be compared. The 21 comparative studies mostly used life tables from European populations as standard for expected values, but also relied on groups without assuming those values as expected, otherwise, just as comparison parameters. The remaining 119 studies were categorized as narrative and did not use reference values, being limited to reporting observed sex-specific estimates or used a variety of statistical models, and in general, did not account for mortality levels.

Conclusion: Studies aimed at identifying sex differentials in child mortality should consider overall mortality levels, and report on more than one age group. The comparison of results with one or more reference values, and the use of statistical testing, are strongly recommended. Time trends analyses will help understand changes in population characteristics and interpret findings from a historical perspective.
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http://dx.doi.org/10.1186/s12887-021-02503-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836200PMC
January 2021

Post-partum depression: a cross-sectional study of women enrolled in a conditional cash transfer program in 30 Brazilian cities.

J Affect Disord 2021 02 19;281:510-516. Epub 2020 Dec 19.

Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas; Pelotas, RS, Brasil.

Objective: Investigate factors associated with symptoms of postpartum depression in mothers from families in social vulnerability.

Methods: Information was used from the baseline of a randomized trial to assess a child development program that enrolled 3,242 children < 12 months of age from beneficiary families of the Bolsa Família Program residing in 30 municipalities (counties) in six states of Brazil. The Edinburgh Postnatal Depression Scale (EPDS) was applied to the mothers, and depression was defined as score ≥10. Information on the mother (schooling, age, parity, marital status, skin color, smoking, number of prenatal appointments, and planning of the pregnancy), family (paternal schooling, household crowding, support from the child's father and the family during the pregnancy, and number of children under 7 years living in the household), and infant (sex, gestational age, birthweight, Apgar score, and child's age at the time of the interview) was collected. Prevalence rates for depressive symptoms were calculated with crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI), using hierarchical logistic regression, in a multilevel model.

Results: The analysis included 3,174 mothers with information on EPDS. The interviews were conducted on average 7.9 months (standard deviation= 2.9) after childbirth. Overall prevalence of depressive symptoms was 26.5% (25.0-28.1%). In the adjusted analysis, higher parity was associated with higher odds of postpartum depression (p <0.001). Women with ≥3 previous deliveries showed an odds 84% higher of presenting depressive symptoms (OR= 1.84; 1.43-2.35) than primiparae. Higher maternal and paternal schooling, presence of husband or partner, and having received support from the child's father and the family during the pregnancy were protective factors against postpartum depression.

Conclusion: The study showed high prevalence of postpartum depressive symptoms. Promotion of parental education, alongside with the promotion of support to the woman during pregnancy by the child's father and by the family, as well as family planning leading to birth spacing are measures that may help to prevent postpartum depressive symptoms.
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http://dx.doi.org/10.1016/j.jad.2020.12.042DOI Listing
February 2021

Sociedades justas: una nueva visión para la equidad en la salud en la Región de las Américas después de la COVID19.

Rev Panam Salud Publica 2020 15;44:e167. Epub 2020 Dec 15.

Universidad Federal de Pelotas Pelotas Brasil Universidad Federal de Pelotas, Pelotas, Brasil.

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http://dx.doi.org/10.26633/RPSP.2020.167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737846PMC
December 2020
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