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1.  Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off 
Revista de saude publica  2011;45(4):635-643.
OBJECTIVE
To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries.
METHODS
All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing – either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, χ2 tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used.
RESULTS
The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients.
CONCLUSIONS
C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor’s schedule. Drastic action is called for to change the current situation.
PMCID: PMC3794425  PMID: 21670862
Parturition; Cesarean Section, trends; Perinatal Care; Obstetrics; Socioeconomic Factors; Cohort Studies.
2.  Prevalence of sun exposure and its associated factors in southern Brazil: a population-based study* 
Anais Brasileiros de Dermatologia  2013;88(4):554-561.
BACKGROUND
Sunlight exposure is responsible for a large number of dermatological diseases.
OBJECTIVE
We estimated the prevalence of sunlight exposure and its associated factors in adults from southern Brazil in a cross-sectional, population-based study.
METHODS
We investigated a representative sample of individuals aged ≥ 20 years (n=3,136). Sunlight exposure and its associated factors were evaluated in two distinct situations: at leisure time and at work. The time period investigated ranged from December 2004 to March 2005, comprising 120 days of the highest ultraviolet index in the urban area of the city of Pelotas, in southern Brazil. The participants were asked about sunlight exposure for at least 20 minutes between 10 A.M. and 4 P.M. The analysis was stratified by sex, and sunlight exposure was grouped into five categories.
RESULTS
Among the 3,136 participants, prevalence of sunlight exposure at the beach was 32.8% (95% CI, 30.3 - 35.2) and 26.3% (95% CI, 24.2 28.3) among men and women, respectively. The prevalence at work was 39.8% (95% CI, 37.2 - 42.4) among men and 10.5% (95% CI, 9.1 - 12.0) among women. Age was inversely associated with sunlight exposure. Family income and achieved schooling were positively associated with sunlight exposure at leisure time and inversely associated with sunglight exposure at work. Self-reported skin color was not associated. Knowledge of any friend or relative who has been affected by skin cancer was positively associated with sunlight exposure among men at work.
CONCLUSION
Despite the media campaigns on the harmful effects of excessive sunlight exposure, we found a high prevalence of sunlight exposure during a period of high ultraviolet index.
doi:10.1590/abd1806-4841.20132122
PMCID: PMC3760930  PMID: 24068126
Environment and public health; Precancerous conditions; Public health practice; Skin neoplasms; Sunbathing
3.  Prognostic factors for low birthweight repetition in successive pregnancies: a cohort study 
Background
To identify prognostic factors associated with recurrence of low birthweight (LBW) in successive gestations, a study was carried out with a subsample of mothers enrolled in the 2004 Pelotas Birth Cohort.
Methods
Data were collected by hospital-based interviews. Newborns were weighed and measured. Gestational age was defined according to the date of last menstrual period, ultra-sound scan before the 20th week of pregnancy or the Dubowitz method. Mothers who reported at least one LBW newborn in the two previous gestations were included. Prevalence ratios (PR) and 95% confidence intervals were estimated from Poisson Regression. All estimates were adjusted for parity.
Results
A total of 4558 births were identified in 2004, and 565 met inclusion criteria, out of which 86 (15.2%) repeated LBW in 2004. Among mothers with two LBW babies before 2004, 47.9% presented LBW recurrence. Belonging to the highest socio-economic stratum (PR 0.89; 0.01-0.46) and gaining ≥ 10 kg during pregnancy (PR 0.09; 0.01-0.77) were protective against LBW recurrence. Higher risk of LBW recurrence was observed among mothers with higher parity (≥3 previous deliveries; PR=1.93; 95% CI 1.23-3.02); who had given birth to a previous preterm baby (PR=4.01; 2.27-7.10); who delivered a female newborn in current gestation (PR=2.61; 1.45-4.69); and that had not received adequate antenatal care (PR=2.57; 1-37-4.81).
Conclusion
Improved quality of antenatal care and adequate maternal weight gain during pregnancy may be feasible strategies to prevent LBW repetition in successive pregnancies.
doi:10.1186/1471-2393-13-20
PMCID: PMC3558483  PMID: 23342985
Prognostic factors; Low birthweight recurrence; Low birthweight; Preterm; Antenatal care
4.  Use of Medicines with Unknown Fetal Risk among Parturient Women from the 2004 Pelotas Birth Cohort (Brazil) 
Journal of Pregnancy  2012;2012:257597.
Background. To estimate the exposure to medicines with unknown fetal risk during pregnancy and to analyze the maternal characteristics associated with it. Methods. A questionnaire was administered to 4,189 mothers of children belonging to the 2004 Pelotas (Brazil) birth cohort study about use of any medicine during gestation. We evaluated the associations between use of medicines with unknown fetal risk and the independent variables through logistic regression models. Unknown fetal risk was defined as medicines in which studies in animals have revealed adverse effects on the fetus, and no controlled studies in women, or studies in women and animals, are available. Results. Out of the 4,189 women, 52.5% used at least one medicine from unknown fetal risk. Use of these medicines was associated with white skin color, high schooling, high income, six or more antenatal care consultations, hospital admission during pregnancy, and morbidity during gestation. Conclusion. The use of unknown fetal risk medicines is high, suggesting that their use must be addressed with caution with the aim of restricting their use to cases in which the benefits are greater than the potential risks.
doi:10.1155/2012/257597
PMCID: PMC3549362  PMID: 23346403
5.  Breastfeeding and feeding patterns in three birth cohorts in Southern Brazil: trends and differentials 
Breastfeeding is fundamental for child health. Changes in the duration of breastfeeding are compared for three population-based cohorts of children born in 1982, 1993 and 2004 in the city of Pelotas, Southern Brazil. Samples of the 1982 and 1993 children and all of the children from the 2004 cohort study were sought at home when they were aged around 12 months. Both the duration of breastfeeding and the stage at which different kind of foods were regularly introduced were investigated. The median duration of breastfeeding increased from 3.1 to 6.8 months in this period. Exclusive breastfeeding at three months was practically non-existent in 1982 and had reached one third of infants by 2004. The increase was faster after 1993, suggesting an important impact made by promotion activities. Up to about 6-9 months, breastfeeding was more prevalent in high-income families, but after this age it became more common among the poor. Low birth weight babies were breastfeed for shorter durations. The duration of breastfeeding is still far short of international recommendations, justifying further campaigns. Special attention should be given to low birth weight babies and those from low-income families.
PMCID: PMC3532951  PMID: 18797716
Breast Feeding; Child Welfare; Cohort Studies
7.  Gestational age at birth and morbidity, mortality, and growth in the first 4 years of life: findings from three birth cohorts in Southern Brazil 
BMC Pediatrics  2012;12:169.
Background
We assessed anthropometric status, breastfeeding duration, morbidity, and mortality outcomes during the first four years of life according to gestational age, in three population-based birth cohorts in the city of Pelotas, Southern Brazil.
Methods
Total breastfeeding duration, neonatal mortality, infant morbidity and mortality, and anthropometric measures taken at 12 and 48 months were evaluated in children of different gestational ages born in 1982, 1993 and 2004 in Southern Brazil.
Results
Babies born <34 weeks of gestation and those born between 34–36 weeks presented increased morbidity and mortality, were breastfed for shorter periods, and were more likely to be undernourished at 12 months of life, in comparison with the 39–41 weeks group. Children born with 37 weeks were more than twice as likely to die in the first year of life, and were also at increased risk of hospitalization and underweight at 12 months of life. Post-term infants presented an increased risk of neonatal mortality.
Conclusion
The increased risks of morbidity and mortality among preterm (<37 weeks of gestation) and post-term (>41 weeks) are well known. In our population babies born at 37 also present increased risk. As the proportion of preterm and early term babies has increased markedly in recent years, this is a cause for great concern.
doi:10.1186/1471-2431-12-169
PMCID: PMC3504558  PMID: 23114098
Gestational age; Preterm births; Early term births; Post-term births; Infant mortality; Neonatal mortality
8.  Effects of exercise on kidney function among non-diabetic patients with hypertension and renal disease: randomized controlled trial 
BMC Nephrology  2012;13:90.
Background
Chronic kidney disease is an important public health threat. Such patients present high morbidity and mortality due to cardiovascular disease, with low quality of life and survival, and also high expenditure resulting from the treatment. Arterial hypertension is both a cause and a complication of kidney disease; also, arterial hypertension is a risk factor for cardiovascular disease among patients with kidney diseases. There is some evidence that exercise interventions may be beneficial to chronic kidney disease patients, but previous studies included only end-stage patients, i.e. those undergoing dialysis. This study aims to evaluate the effect of exercise on kidney function, quality of life and other risk factors for cardiovascular disease among non-diabetic chronic hypertensive kidney disease patients who are not undergoing dialysis.
Methods
The participants will be located through screening hypertensive patients attended within the public healthcare network in Pelotas, a city in south of Brazil. Eligible individuals will be those with glomerular filtration rate between 15 and 59 ml/min x 1.73 m2. The randomization will be done in fixed-size blocks of six individuals such that 75 participants will be allocated to each group. At baseline, information on demographic, socioeconomic, behavioral, anthropometric, blood pressure and quality-of-life variables will be collected, and laboratory tests will be performed. The intervention will consist of three weekly physical exercise sessions lasting 60–75 minutes each, with a total duration of 16 weeks. The outcomes will be the kidney function progression rate, quality of life, blood pressure, lipid profile, hemoglobin level, ultrasensitive C-reactive protein level, and ankle-arm index. The patients in both groups (intervention and control) will be reassessed and compared partway through the study (8th week), at the end of the intervention (16th week) and in the 8th week after the end of the intervention.
Discussion
There is still a scarcity of data relating to the effect of physical exercise among the most numerous group of individuals with kidney disease, i.e. patients undergoing conservative treatment. In particular, there is a lack of randomized controlled studies. This study will help fill this gap.
doi:10.1186/1471-2369-13-90
PMCID: PMC3469357  PMID: 22928872
9.  Trends in socioeconomic inequalities in anthropometric status in a population undergoing the nutritional transition: data from 1982, 1993 and 2004 pelotas birth cohort studies 
BMC Public Health  2012;12:511.
Background
Socioeconomic inequalities in child nutrition may change rapidly over time, particularly in populations undergoing the nutrition transition. Yet, the few available studies are repeated cross-sectional surveys. By studying three prospective birth cohorts in the same city over a period of more than two decades, we describe secular trends in overweight and stunting at different ages, according to socioeconomic position.
Methods
Population-based birth cohort studies were launched in the city of Pelotas (Brazil) in 1982, 1993 and 2004, with follow-up visits at twelve, 24 and 48 months. Children were weighed and measured at every visit. Z-scores of length/height-for-age and body mass index-for-age were calculated using the WHO Child Growth Standards. The slope and relative indices of inequality, based on family income quintiles, were estimated for each follow-up visit.
Results
Between the 1982 and 2004 cohorts, stunting among four-year-olds declined (from 10.9% to 3.6%), while overweight increased (from 7.6% to 12.3%). In every visit, stunting prevalence was inversely related to income. Both absolute and relative inequalities declined over time; among four-year-olds stunting dropped from 26.0% in the 1982 cohort to 6.7% in the 2004 cohort in the poorest group, while in the richest group stunting prevalence dropped from 2.7% in 1982 to 1.1% in the 2004 cohort study. The secular trend towards increased overweight was evident for four-year-olds, in almost all socioeconomic groups, but not among one and two-year-olds. Among four-year old children, overweight prevalence increased in all income quintiles, by 130% in the middle-income group, 64% in the poorest and 41% in the richest group.
Conclusions
The decline in stunting is remarkable, but the increase in overweight among four-year olds – particularly among the poorest and the middle-income groups– requires concerted efforts to prevent the long term consequences of child overweight.
doi:10.1186/1471-2458-12-511
PMCID: PMC3490989  PMID: 22776157
Socioeconomic factors; Health status disparities; Cohort studies; Child nutrition; Overweight; Stunting
10.  Maternal Caffeine Consumption and Infant Nighttime Waking: Prospective Cohort Study 
Pediatrics  2012;129(5):860-868.
OBJECTIVE:
Coffee and other caffeinated beverages are commonly consumed in pregnancy. In adults, caffeine may interfere with sleep onset and have a dose-response effect similar to those seen during insomnia. In infancy, nighttime waking is a common event. With this study, we aimed to investigate if maternal caffeine consumption during pregnancy and lactation leads to frequent nocturnal awakening among infants at 3 months of age.
METHODS:
All children born in the city of Pelotas, Brazil, during 2004 were enrolled on a cohort study. Mothers were interviewed at delivery and after 3 months to obtain information on caffeine drinking consumption, sociodemographic, reproductive, and behavioral characteristics. Infant sleeping pattern in the previous 15 days was obtained from a subsample. Night waking was defined as an episode of infant arousal that woke the parents during nighttime. Multivariable analysis was performed by using Poisson regression.
RESULTS:
The subsample included 885 of the 4231 infants born in 2004. All but 1 mother consumed caffeine in pregnancy. Nearly 20% were heavy consumers (≥300 mg/day) during pregnancy and 14.3% at 3 months postpartum. Prevalence of frequent nighttime awakeners (>3 episodes per night) was 13.8% (95% confidence interval: 11.5%–16.0%). The highest prevalence ratio was observed among breastfed infants from mothers consuming ≥300 mg/day during the whole pregnancy and in the postpartum period (1.65; 95% confidence interval: 0.86–3.17) but at a nonsignificant level.
CONCLUSIONS:
Caffeine consumption during pregnancy and by nursing mothers seems not to have consequences on sleep of infants at the age of 3 months.
doi:10.1542/peds.2011-1773
PMCID: PMC3566755  PMID: 22473365
sleep; sleep duration; infant sleeping; night waking; infant; caffeine; coffee
11.  Food intake profiles of children aged 12, 24 and 48 months from the 2004 Pelotas (Brazil) birth cohort: an exploratory analysis using principal components 
Objectives
To identify food intake profiles of children during their first four years of life and assess its variations according to sociodemographic and behavioral characteristics.
Methods
The Pelotas Birth Cohort Study (Brazil) recruited 4,231 liveborns, who were followed-up at ages 3, 12, 24 and 48 months. Food consumption data of children aged 12, 24 and 48 months was collected using a list of foods consumed during a 24-hour period prior to the interview. The food profiles were identified with the use of principal component analysis (PCA) for each age studied.
Results
Five components were identified at each age, four of them similar in all time points, namely: beverages, milks, staple, and snacks. A meat & vegetables component was identified at 12 and 24 months and a treats component at 48 months. The greatest nutritional differences were found among children from different socioeconomic levels. With regard to the milks component, higher breast milk intake compared to cow's milk was seen among poorer children (12- and 24-month old) and higher milk and chocolate powdered milk drink consumption was seen among more affluent children aged 48 months. Poorer children of less educated mothers showed higher adherence to the treats component (48 months). Regarding to the snack component, poorer children consumed more coffee, bread/cookies while more affluent children consumed proportionately more fruits, yogurt and soft drinks. Child care outside of the home was also a factor influencing food profiles more aligned with a healthier diet.
Conclusions
The study results showed that very early in life children show food profiles that are strongly associated with social (maternal schooling, socioeconomic position and child care) and behavioral characteristics (breast-feeding duration, bottle-feeding and pacifier use).
doi:10.1186/1479-5868-9-43
PMCID: PMC3424118  PMID: 22510615
12.  Seasonality of infant feeding practices in three Brazilian birth cohorts 
Background We assessed the influence of season of birth on duration of breastfeeding and other feeding patterns in three population-based birth cohort studies in the city of Pelotas, Southern Brazil.
Methods In 1982, 1993 and 2004, all hospital-born children in the city were enrolled in three cohort studies (n = 5914, 5249 and 4287, respectively). Children and their mothers were periodically visited in the first 2 years of life, to collect information on the duration of breastfeeding and the ages at which different types of foods were introduced on a regular basis. Two independent variables were studied: month of birth and mean environmental temperature in the first month of life. Survival analyses and chi-squared tests were used to evaluate the associations. Temperature-based slope indices of inequality were also calculated.
Results Duration of breastfeeding was lower among children born from April to June (months preceding winter) and spending their first month of life in colder temperatures. The influence of season of birth on breastfeeding patterns and the introduction of cow's milk differed according to maternal education, with the strongest effects among children belonging to less educated mothers. Early introduction of fruits (1982 and 1993 cohorts) and vegetables (1982 cohort) were also associated with lower environmental temperature in the first month of life, but not with trimester of birth.
Conclusion Colder temperatures adversely affect duration of breastfeeding and feeding patterns in infancy, especially among the poorest. This finding should be considered in breastfeeding promotion programmes.
doi:10.1093/ije/dys002
PMCID: PMC3396312  PMID: 22354916
Breastfeeding; climate; cohort studies; temperature; supplementary feeding
13.  Cesarean section and risk of obesity in childhood, adolescence, and early adulthood: evidence from 3 Brazilian birth cohorts123 
Background: The number of cesarean sections (CSs) is increasing in many countries, and there are concerns about their short- and long-term effects. A recent Brazilian study showed a 58% higher prevalence of obesity in young adults born by CS than in young adults born vaginally. Because CS-born individuals do not make contact at birth with maternal vaginal and intestinal bacteria, the authors proposed that this could lead to long-term changes in the gut microbiota that could contribute to obesity.
Objective: We assessed whether CS births lead to increased obesity during childhood, adolescence, and early adulthood in 3 birth cohorts.
Design: We analyzed data from 3 birth-cohort studies started in 1982, 1993, and 2004 in Southern Brazil. Subjects were assessed at different ages until 23 y of age. Poisson regression was used to estimate prevalence ratios with adjustment for ≤15 socioeconomic, demographic, maternal, anthropometric, and behavioral covariates.
Results: In the crude analyses, subjects born by CS had ∼50% higher prevalence of obesity at 4, 11, and 15 y of age but not at 23 y of age. After adjustment for covariates, prevalence ratios were markedly reduced and no longer significant for men or women. The only exception was an association for 4-y-old boys in the 1993 cohort, which was not observed in the other 2 cohorts or for girls.
Conclusion: In these 3 birth cohorts, CSs do not seem to lead to an important increased risk of obesity during childhood, adolescence, or early adulthood.
doi:10.3945/ajcn.111.026401
PMCID: PMC3260073  PMID: 22237058
14.  Childbearing during adolescence and offspring mortality: findings from three population-based cohorts in southern Brazil 
BMC Public Health  2011;11:781.
Background
The role of young maternal age as a determinant of adverse child health outcomes is controversial, with existing studies providing conflicting results. This work assessed the association between adolescent childbearing and early offspring mortality in three birth cohort studies from the city of Pelotas in Southern Brazil.
Methods
All hospital births from 1982 (6,011), 1993 (5,304), and 2004 (4,287) were identified and these infants were followed up. Deaths were monitored through vital registration, visits to hospitals and cemeteries. The analyses were restricted to women younger than 30 years who delivered singletons (72%, 70% and 67% of the original cohorts, respectively). Maternal age was categorized into three groups (< 16, 16-19, and 20-29 years). Further analyses compared mothers aged 12-19 and 20-29 years. The outcome variables included fetal, perinatal, neonatal, postneonatal and infant mortality. Crude and adjusted odds ratios (ORs) were estimated with logistic regression models.
Results
There were no interactions between maternal age and cohort year. After adjustment for confounding, pooled ORs for mothers aged 12-19 years were 0.6 (95% CI = 0.4; 1.0) for fetal death, 0.9 (0.6; 1.3) for perinatal death, 1.0 (0.7; 1.6) for early neonatal death, 1.6 (0.7; 3.4) for late neonatal death, 1.8 (1.1; 2.9) for postneonatal death, and 1.6 (1.2; 2.1) for infant death, when compared to mothers aged 20-29 years. Further adjustment for mediating variables led to the disappearance of the excess of postneonatal mortality. The number of mothers younger than 16 years was not sufficient for most analyses.
Conclusion
The slightly increased odds of postneonatal mortality among children of adolescent mothers suggest that social and environmental factors may be more important than maternal biologic immaturity.
doi:10.1186/1471-2458-11-781
PMCID: PMC3207956  PMID: 21985467
pregnancy in adolescence; infant mortality; neonatal mortality; perinatal mortality; fetal mortality; cohort studies
15.  Menstrual bleeding patterns: A community-based cross-sectional study among women aged 18-45 years in Southern Brazil 
BMC Women's Health  2011;11:26.
Background
Population variation in the duration and amount of menstrual bleeding has received little attention in the literature. This study describes these characteristics and investigates the distribution of self-perceived amount of menstrual bleeding according to socio-demographic, behavioral, and reproductive characteristics.
Methods
A community-based cross-sectional study was conducted among 18-45 years old women users of the 31 primary health care (PHC) facilities in Pelotas city (Brazil). Interviews with structured questionnaire were carried out in the waiting rooms during two work shifts. Heaviness of menstrual bleeding was determined through the answer to the question: "Usually how much blood do you lose in every period?" Crude and adjusted analyses through Poisson regression took into account the aggregation per PHC facility.
Results
A total of 865 women were enrolled. Prevalence of heavy menstrual flow was 35.3% (95% CI 32.1-38.6%). In adjusted analyses, heavy menstrual bleeding was higher among the older, less educated and obese women, with higher number of pregnancies and who reported longer menstrual periods, extra-menstrual bleeding and clots in the flow. Use of hormonal contraceptive methods was protective against heavy menses.
Conclusion
Heavy menstrual bleeding is highly prevalent at the community level, and is associated with socio-demographic and anthropometric women's characteristics, as well as with duration of menstruation, extra-bleeding and presence of clots.
doi:10.1186/1472-6874-11-26
PMCID: PMC3118185  PMID: 21649903
16.  Maternal smoking during pregnancy and offspring growth in childhood: 1993 and 2004 Pelotas cohort studies 
Archives of Disease in Childhood  2011;96(6):519-525.
Objective
To explore the effects of maternal smoking during pregnancy on offspring growth using three approaches: (1) multiple adjustments for socioeconomic and parental factors, (2) maternal–paternal comparisons as a test of putative intrauterine effects and (3) comparisons between two birth cohort studies.
Methods
Population-based birth cohort studies were carried out in Pelotas, Brazil, in 1993 and 2004. Cohort members were followed up at 3, 12, 24 and 48 months. Multiple linear regression analysis was used to examine the relationships between maternal and paternal prenatal smoking and offspring anthropometric indices. In the 2004 cohort, the association of smoking with trunk length, leg length and leg-to-sitting-height ratio at 48 months was also explored.
Results
Maternal smoking during pregnancy was associated with reduced z scores of length/height-for-age at each follow-up in both cohorts and reduced leg length at 48 months in the 2004 cohort. Children older than 3 months born to smoking women showed a higher body mass index-for-age z score than children of non-smoking women.
Conclusions
The results of this study strongly support the hypothesis that maternal smoking during pregnancy impairs linear growth and promotes overweight in childhood.
doi:10.1136/adc.2010.191098
PMCID: PMC3093240  PMID: 21377989
17.  Child development in a birth cohort: effect of child stimulation is stronger in less educated mothers 
Background Child health has improved in many developing countries, bringing new challenges, including realization of the children's full physical and intellectual potential. This study explored child development within a birth cohort, its psychosocial determinants and interactions with maternal schooling and economic position.
Methods All children born in Pelotas, Brazil, in 2004, were recruited to a birth cohort study. These children were assessed at birth and at 3, 12 and 24 months of age. In this last assessment involving 3869 children, detailed information on socio-economic and health characteristics was collected. Child development was assessed using the screening version of Battelle's Development Inventory. Five markers of cognitive stimulation and social interaction were recorded and summed to form a score ranging from 0–5. The outcomes studied were mean development score and low performance (less than 10th percentile of the sample).
Results Child development was strongly associated with socio-economic position, maternal schooling and stimulation. Having been told a story and owning a book were the least frequent markers among children with score 1. These children were 8.3 times more likely to present low performance than those who scored 5. The effect of stimulation was much stronger among children from mothers with a low level of schooling—one additional point added 1.7 on the child's development for children of low-schooling mothers, whereas only 0.6 was added for children of high-schooling mothers.
Conclusions Our stimulation markers cannot be directly translated into intervention strategies, but strongly suggest that suitably designed cognitive stimulation can have an important effect on children, especially those from mothers with low schooling.
doi:10.1093/ije/dyp272
PMCID: PMC2817089  PMID: 19717543
Child development; cognitive stimulation; social determinants of health; social inequalities; birth cohort; child; Brazil
18.  Long-Lasting Maternal Depression and Child Growth at 4 Years of Age: A Cohort Study 
The Journal of Pediatrics  2010;157(3-3):401-406.
Objective
To investigate the association between sustained maternal depression at 12, 24, and 48 months post-partum and child anthropometry at age of 4 years.
Study design
A total of 99.2% of the 4287 children born in 2004 in Pelotas, Brazil, were enrolled in a cohort study. At 3, 12, 24, and 48 months, mothers were interviewed and provided information on several characteristics. Maternal depression was investigated through the Edinburgh Postnatal Depression Scale (EPDS). Weight-for-age, height-for-age, and weight-for-height z-scores at 48 months, according to World Health Organization growth curves, were the outcomes. Multivariate analyses were conducted through logistic regression.
Results
At the 48-month follow-up, of the 3792 children, prevalence of underweight was 1.7%; stunting, 3.6%; wasting, 0.6%; and overweight, 12.2%. Depression (EPDS ≥13) was observed in 17.9% of the 3748 mothers. Of the mothers, 4.7% were persistently depressed at the 12-, 24-, and 48-month visits. In crude analyses, maternal depression was positively associated with underweight and stunting. After adjustment, maternal depression was not associated with any of the anthropometric indices.
Conclusion
Long-lasting maternal depression at 12, 24, and 48 months post-partum is not a risk factor for impaired child growth or overweight at age of 4 years.
doi:10.1016/j.jpeds.2010.03.008
PMCID: PMC2937222  PMID: 20400093
BMI, Body mass index; EPDS, Edinburgh Postnatal Depression Scale; GA, Gestational age; H/A, Height-for-age; LBW, Low birth weight; LMP, Last menstrual period; W/A, Weight-for-age; W/H, Weight-for-height; WHO, World Health Organization
19.  Bed-Sharing at 3 Months and Breast-Feeding at 1 Year in Southern Brazil 
The Journal of Pediatrics  2009;155(4-4):505-509.
Objective
To investigate the association between bedsharing at age 3 months and breastfeeding (BF) at age 12 months.
Study design
Almost all children born in Pelotas, Brazil in 2004 (99.2%) were enrolled in a cohort study. At birth, age 3 months, and age 12 months, mothers were interviewed to gather information on sociodemographic, reproductive, BF, and bedsharing characteristics. Bedsharing was defined as habitual sharing of a bed between mother and child for the entire night or part of the night. The analysis was limited to children from single births who were breastfed at 3 months. Multivariate analyses were carried out using Poisson regression.
Results
Of 4231 live births, 2889 were breastfed at age 3 months. The prevalence of BF at age 12 months was 59.2% in the children who bedshared at 3 months and 44% in those who did not (adjusted prevalence ratio [PR] for weaning= 0.75; 95% confidence interval [CI] = 0.69-0.81; P < .001). Among children who were exclusively breastfed at 3 months, 75.1% of those who also bedshared were still breastfed at age 12 months, versus 52.3% of those who did not bedshare (adjusted PR = 0.63; 95% CI = 0.53- 0.75; P < .001). The adjusted PR was 0.74 (95% CI = 0.60-0.90; P = .003) in children who were predominantly breastfed and 0.83 (95% CI = 0.76-0.90; P < .001) in those who were partially breastfed.
Conclusions
Bedsharing at 3 months protected against weaning up to age 12 months.
doi:10.1016/j.jpeds.2009.04.037
PMCID: PMC3420018  PMID: 19595369
BF, Breast-feeding; CI, Confidence interval; DLP, Date of last period; IEN, National Economic Indicator (Brazil); LBW, Low birth weight; PR, Prevalence ratio; SIDS, Sudden infant death syndrome
20.  Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study 
BMC Public Health  2009;9:335.
Background
The postnatal period is the ideal time to deliver interventions to improve the health of both the newborn and the mother. However, postnatal care shows low-level coverage in a large number of countries. The objectives of this study were to: 1) investigate inequities in maternal postnatal visits, 2) examine differences in postnatal care coverage between public and private providers and 3) explore the relationship between the absence of maternal postnatal visits and exclusive breastfeeding, use of contraceptive methods and maternal smoking three months after birth.
Methods
In the calendar year of 2004 a birth cohort study was started in the city of Pelotas, Brazil. Mothers were interviewed soon after delivery and at three months after birth. The absence of postnatal visits was defined as having no consultations between the time of hospital discharge and the third month post-partum. Logistic regression analysis was used to estimate the association between absence of postnatal visits and type of insurance scheme adjusting for potential confounding factors.
Results
Poorer women, black/mixed, those with lower level of education, single mothers, adolescents, multiparae, smokers, women who delivered vaginally and those who were not assisted by a physician were less likely to attend postnatal care. Postnatal visits were also less frequent among women who relied in the public sector than among private patients (72.4% vs 96% among public and private patients, respectively, x2 p < 0.001) and this difference was not explained either by maternal characteristics or by health care utilization patterns. Women who attended postnatal visits were more likely to exclusively breastfeed their infants, to use contraceptive methods and to be non-smokers three months after birth.
Conclusion
Postpartum care is available for every woman free of charge in the Brazilian Publicly-funded health care system. However, low levels of postpartum care were seen in the study (77%). Efforts should be made to increase the percentage of women receiving postpartum care, particularly those in socially disadvantaged groups. This could include locally-adapted health education interventions that address women's beliefs and attitudes towards postpartum care. There is a need to monitor postpartum care and collected data should be used to guide policies for health care systems.
doi:10.1186/1471-2458-9-335
PMCID: PMC2749044  PMID: 19751521
21.  Differentials and income-related inequalities in maternal depression during the first two years after childbirth: birth cohort studies from Brazil and the UK 
Background
Depression is a prevalent health problem among women during the childbearing years. To obtain a more accurate global picture of maternal postnatal depression, studies that explore maternal depression with comparable measurements are needed. The aims of the study are: (1) to compare the prevalence of maternal depression in the first and second year postpartum between a UK and Brazilian birth cohort study; (2) to explore the extent to which variations in the rates were explained by maternal and infant characteristics, and (3) to investigate income-related inequalities in maternal depression after childbirth in both settings.
Methods
Population-based birth cohort studies were carried out in Avon, UK in 1991 (ALSPAC) and in the city of Pelotas, Brazil in 2004, where 13 798 and 4109 women were analysed, respectively. Self-completion questionnaires were used in the ALSPAC study while questionnaires completed by interviewers were used in the Pelotas cohort study. Three repeated measures of maternal depression were obtained using the Edinburgh Postnatal Depression Scale in the first and second year after delivery in each cohort. Unadjusted and adjusted analyses were carried out. The Relative index of Inequality was used for the analysis of income-relate inequalities so that results were comparable between cohorts.
Results
At both the second and third time assessments, the likelihood of being depressed was higher among women from the Pelotas cohort study. These differences were not completely explained by differences in maternal and infant characteristics. Income-related inequalities in maternal depression after childbirth were high and of similar magnitude in both cohort studies at the three time assessments.
Conclusion
The burden of maternal depression after childbirth varies between and within populations. Strategies to reduce income-related inequalities in maternal depression should be targeted to low-income women in both developed and developing countries.
doi:10.1186/1745-0179-5-12
PMCID: PMC2698823  PMID: 19500361
22.  Can mothers rely on the Brazilian health system for their deliveries? An assessment of use of the public system and out-of-pocket expenditure in the 2004 Pelotas Birth Cohort Study, Brazil 
Background
In a country where comprehensive free health care is provided via a public health system (SUS), an unexpected high frequency of catastrophic out-of-pocket expenditure has been described. We studied how deliveries were financed among mothers of a birth cohort and whether they were an important source of household out-of-pocket expenditure.
Methods
All deliveries occurring in the city of Pelotas, Brazil, during 2004, were recruited for a birth cohort study. All mothers were interviewed just after birth and three months later. Comprehensive data on the pregnancy, delivery, birth conditions and newborn health were collected, along with detailed information on expenses related to the delivery.
Results
The majority of the deliveries (81%) were financed by the public health system, a proportion that increased to more than 95% among the 40% poorest mothers. Less than 1% of these mothers reported some out-of-pocket expenditure. Even among those mothers covered by a private health plan, nearly 50% of births were financed by the SUS. Among the 20% richest, a third of the deliveries were paid by the SUS, 50% by private health plans and 17% by direct payment.
Conclusion
The public health system offered services in quantity and quality enough to attract even beneficiaries of private health plans and spared mothers from the poorest strata of the population of practically any expense.
doi:10.1186/1472-6963-8-57
PMCID: PMC2276487  PMID: 18366672
23.  Comparing validity of Edinburgh scale and SRQ20 in screening for post-partum depression 
The Edinburgh Postnatal Depression Scale (EPDS) is the instrument most used worldwide for screening of Post-Partum Depression (PPD). The SRQ20 questionnaire has been largely used for screening of minor psychiatric disorders. This study aimed to compare the accuracy of the two instruments in screening for PPD. At the third-month follow-up home visit to infants of the 2004 Pelotas Birth Cohort, Southern Brazil, a sub-sample of 378 mothers was selected. Among other questions, EPDS and SRQ20 were applied by trained fieldworkers. Up to 15 days later, a mental health professional re-interviewed the mother (the gold standard interview). Sensitivity and specificity of each cutoff point were calculated for EPDS and SRQ20 and the results were plotted at a ROC curve. The areas under both curves were compared. Highest sensitivity and specificity cutoff were observed for EPDS ≥ 10 (sensitivity 82.7%, 95%CI 74.0 – 89.4; specificity 65.3%, 95%CI 59.4 – 71.0) and for SRQ20 ≥ 6 (sensitivity 70.5%, 95%CI 60.8 – 79.0%; specificity 75.5%, 95%CI 70.0 – 80.5%). Shape of ROC curves and areas under both curves were virtually identical (respectively, 0.8401 ± 0.02 for EPDS and 0.8402 ± 0.02 for SRQ20; p = 0.9). In conclusion SRQ20 showed to be as valid as EPDS as a screening tool for PPD at third month after delivery.
doi:10.1186/1745-0179-3-18
PMCID: PMC2233608  PMID: 17903254
24.  Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study 
BMJ : British Medical Journal  1999;318(7194):1316-1320.
Objective
To determine whether breast feeding protects infants against pneumonia and whether the protection varies with age.
Design
Nested case-control study.
Setting
Pelotas, southern Brazil.
Subjects
Cases were 152 infants aged 28-364 days who had been admitted to hospital for pneumonia. Controls were 2391 cases in a population based case-control study.
Main outcome measure
Odds ratio of admission for pneumonia according to type of milk consumed (breast milk alone, breast and formula milk, or formula milk and other fluids only), use of fluid supplements apart from formula milk, and use of solid supplements.
Results
Infants who were not being breast fed were 17 times more likely than those being breast fed without formula milk to be admitted to hospital for pneumonia (95% confidence interval 7.7 to 36.0). This relative risk was 61 (19.0 to 195.5) for children under 3 months old, decreasing to 10 (2.8 to 36.2) thereafter. Supplementation with solids was associated with a relative risk of 13.4 (7.6 to 23.5) for all infants and 175 (21.8 to 1405.1) for those under 3 months old.
Conclusion
Breast feeding protects young children against pneumonia, especially in the first months of life. These results may be used for targeting intervention campaigns at the most vulnerable age groups.
Key messagesPneumonia is the leading cause of death in children under 5 years old across the worldIn Brazil infants who were not breast fed were 17 times more likely than those receiving breast milk alone to be admitted for pneumoniaThe relative risk of admission was 61 for children under 3 months of age, decreasing to 10 thereafterSupplementation with solids was associated with a relative risk of 13.4 for all infantsMothers must be encouraged to breast feed very young infants and be advised of the right time to introduce supplementary foods
PMCID: PMC27869  PMID: 10323815
25.  Maternal education inequalities in height growth rates in early childhood: 2004 Pelotas birth cohort study 
Summary
Matijasevich A, Howe LD, Tilling K, Santos IS, Barros AJD, Lawlor DA. Maternal education inequalities in height growth rates in early childhood: 2004 Pelotas birth cohort study. Paediatric and Perinatal Epidemiology 2012; 26: 236–249.
Socio-economic inequalities in attained height have been reported in many countries. The aim of this study was to explore the age at which maternal education inequalities in child height emerge among children from a middle-income country. Using data from the 2004 Pelotas cohort study from Brazil we modelled individual height growth trajectories in 2106 boys and 1947 girls from birth to 4 years using a linear spline mixed-effects model. We examined the associations of maternal education with birth length and trajectories of growth in length/height, and explored the effect of adjusting for a number of potential confounder or mediator factors.
We showed linear and positive associations of maternal education with birth length and length/height growth rates at 0–3 months and 12–29/32 months with very little association at 3–12 months, particularly in boys. By age 4 years the mean height of boys was 101.06 cm (SE = 0.28) in the lowest and 104.20 cm (SE = 0.15) in the highest education category (mean difference 3.14 cm, SE = 0.32, P < 0.001). Among girls the mean height was 100.02 cm (SE = 0.27) and 103.03 cm (SE = 0.15) in the lowest and highest education categories, respectively (mean difference 3.01 cm, SE = 0.31, P < 0.001). For both boys and girls there was on average a 3-cm difference between the extreme education categories. Adjusting for maternal height reduced the observed birth length differences across maternal education categories, but differences in postnatal growth rates persisted.
Our data demonstrate an increase in the absolute and relative inequality in height after birth; inequality increases from approximately 0.2 standard deviations of birth length to approximately 0.7 standard deviations of height at age 4, indicating that height inequality, which was already present at birth, widened through differential growth rates to age 2 years.
doi:10.1111/j.1365-3016.2011.01251.x
PMCID: PMC3491696  PMID: 22471683
childhood height; Pelotas birth cohort; maternal education; child growth

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