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Risk factors for perinatal deaths
CHILDREN'S HEALTH LAY C O U N S E L L O R S P R O M O T I N G BREASTFEEDING PRACTICES: A RANDOMIZED CONT R O L L E D TRIAL. A. Leite, R. Puccini, A. Atallah, A. Cunha, M. Machado, A. Capiberibe, R. Rodrigues. CEU, Universidade Federal Do Cear~; CEU, Escola Paulista de Medicina, S~o Paulo; CEU, Universidade Federal do Rio de Janeiro, Brazil. Objective: To estimate the effectiveness of lay counsellors visits program on breastfeeding practices. Design: Randomized controlled trial. Setting: Eight maternities and home visits in the community. Participants: Women and their babies were identified from interviews at 8 maternities linked to the public health system. Healthy babies with birth weight less than 3000g were included. Interventions: The intervention group was visited at home by lay counsellors on days 5, 15, 30, 60 and 120 after birth and compared to the con. trol group, which received usual care at health services (usual care). M a i n O u t c o m e M e a s u r e ( s ) : Breastfeeding practices at six months of life. An interview at household was performed on days 30 and 120 by a visitor who did not know the objectives of the study, to measure the outcolnes. Results: The intervention and control groups did not differ on maternal age, years of schooling, parity and birth weight. Of the 1003 mothers, 762 completed the sixth month visit (76%). In the intervention group (212 mothers and babies), 42.2% were totally breastfed (exclusive plus predominant plus partial breastfeeding) at the end ~f the sixth month compared to 181 (~6.2 %) of the control group. The intervention has improved the total breastfeeding practice in 15% (RR = 0.85; 95% CI 0.730-0.99); the absolute reduction of risk (RAR) was 7.8% and the number of mothers to be visited to avoid interruption in breastfeeding practice (NTN) was 1 in 12.8. C o n c l u s i o n s : A program of home visits after birth, penCormed by lay counsellors can improve breastfeeding practices in the sixth month of life. It is proposed that, if implemented in large scale, this policy could significantly reduce the infant mortality rate in areas such as the northeastern region of Brazil.
118 I N T E R . D I S T R I C T V A R I A T I O N S A N D DETERMIN A N T S OF C H I L D M O R T A L I T Y R A T E IN T H E S T A T E OF KERALA. Suneetha MaUa, R. S. Vasan, K. R. Thankappan, P. S. Sarma. Achutha Menon Centre for Health Science Studies, Trivandrum, India. O b j e c t i v e s : The child mortality rate (CMR) of Kerala approximates those of a developed country. However, the relative contributions of health services, social services and economic factors to low CMR have not been investigated systematically. We examined the inter-district variation in CMR and its relation to potential determinants in Kerala using data for the years 1981 and 1991. Design: Ecological study. M a i n O u t c o m e M e a s u r e ( s ) : The census estimates of CMR for the 12 districts for the years 1981 and 1991 constituted the outcome variables of interest. The predictor variables were classified into 4 categories: health services, social services (female literacy rate, urban population, percentage households with water-sealed toilets and tap water), economic factors (per capita income) and utility of health services (hospital beds-population ratio, doctor-population ratio, ratio of medical institutions to population, paramedical workers-population ratio, percentage institutional births). Multivariable linear regression and correlation analyses were used to evaluate the association of select variables with CMR in 198 l and 1991. Results: lnterdistrict differences in CMR narrowed between 198l and 1991. The regression analyses suggest that female literacy was the most significant correlate of CMR in 1981. However, data from 1991 suggest that doctor-population ratio was the most important correlate of ('.MR. The correlation coefficients for predictor variables with (;MR decreased in magnitude between 1981 and 1991. C o n c l u s i o n s : Female literacy rate and the doctor-population ratio were the most important correlates of CMR in 1981 and 1991, respectively, indicating that the determinants of health status in Kerala may have changed over time. Our study illustrates the importance of interdistrict and time variations that occur in factors related to health, and emphasizes that these considerations are necessary for effective district health planning.
PHYSICAL A B U S E IN CHILDREN: A PREDICTIVE MODEL. S. Muftoz, M. Aracena, P. Lorca, L. Bustos, F. Roman, D. Streiner. C E U , Universidad de La Frontera, T e m u c o , Chile; M c M a s t e r University, Canada. O b j e c t i v e : Develop a predictive model to detect potential physical abuse in children of low socio-economic status in Temuco, Chile. Design: Cross sectional study. Setting: Low socio-economic families with children under 15 years of age living in the city of Temuco, Chile. P a r t i c i p a n t s : A non-probabilistic sample of 522 parents, having at least one child 14 years of age or younger, was used to assess the validity of the instrument. The sample was restricted to those parents whose children had received attention in either a health care, an educational or justice public service of the city. The sample was stratified in three groups: physical abuse (128), at risk of maltreatment (184), and no maltreatment (210). M a i n O u t c o m e M e a s u r e ( s ) : Physical abuse determined by a group of experts (physicians, psychologists, social workers and statisticians). Statistical M e t h o d s : Model strategy: The sample was divided into a sample of 390 subjects for model building and into a second sample of 130 for model validation. Predictors include bio-socio-demographic variables, as well as other known risk factors and specially designed scales such as social support, child's expectations, conflict resolution, and interviewed past history. Results: The predictive model has an acceptable validity since its cross validation correlation is 0.31 and shrinkage on cross validation is 0.12. This indicates a relatively good stability of the estimated parameters of the model. Main predictors associated with physical abuse are: poor family support, low level of conflict resolution, the recognition parents have about having a child difficult to treat, children not attending either a care center or schools, the presence of economic and/or legal stress. Conclusions: The built predictive model of child abuse has a good validity and therefore can be used to determine different levels of child abuse in low socio-economic populations. The predictive model built here is based in the same population in which it will be applied (Chilean parents of low socio-economic status).
RISK F A C T O R S FOR P E R I N A T A L D E A T H S . H. Mej~_, S. Blanco. CEU, Universidad Mayor de San Andr6s, La Paz, Bolivia. O b j e c t i v e : To identify the risk factors related to perinatal deaths. Bolivia has the second highest perinatal mortality rate in Latin America. Design: Case control study. Setting: Women's Maternity Public Hospital, third level facility in La Paz, Bolivia. Participants: 114 stillborns or those who died in less than 7 days (cases) and 228 live borns (2 live borns after each death) as controls. Interventions: None. M a i n O u t c o m e M e a s u r e ( s ) : Assess on socioeconomic level, obstetric history, quality of delivery care and quality of care to the newborn. Results: 65% perinatal deaths at health facility. Main odds ratios are mother's schooling less than secondary OR 1.83 (95% CI 1.13-2.97); over five pregnancies OR 2.32 (95% CI 1.06-5.08); no prenatal controls OR 1.84 (95% Cl 1.1-3.0); previous stillbirths OR 3.82 (95% C1 1.14-13.48); hemorrhaging during pregnancy OR 3.05 (95% CI 1.7-5.48); the mother having received care from a general practitioner/nurse and then referred OR 2.58 (95% CI 1.48-4.51); dystocic delivery OR 2.9 (95% CI 1.754.81); less than 37 weeks of pregnancy OR 5.87 (95% CI 3.47-9.80); weight less than 1500 g OR 11.91 (95% CI 3.71-42.42); over 24 hours between hospital admission and delivery OR 3.71 (95% CI 1.31-10.79). Logistic regression shows the importance of socioeconomic factors and quality of care at delivery. C o n c l u s i o n s : There are problems of quality of care during pregnancy and delivery and lack of antenatal control attendance. Specific interventions should include training of general practitioners, and prompt and efficient early risk identification at the third level.
118 I N T E R . D I S T R I C T V A R I A T I O N S A N D DETERMIN A N T S OF C H I L D M O R T A L I T Y R A T E IN T H E S T A T E OF KERALA. Suneetha MaUa, R. S. Vasan, K. R. Thankappan, P. S. Sarma. Achutha Menon Centre for Health Science Studies, Trivandrum, India. O b j e c t i v e s : The child mortality rate (CMR) of Kerala approximates those of a developed country. However, the relative contributions of health services, social services and economic factors to low CMR have not been investigated systematically. We examined the inter-district variation in CMR and its relation to potential determinants in Kerala using data for the years 1981 and 1991. Design: Ecological study. M a i n O u t c o m e M e a s u r e ( s ) : The census estimates of CMR for the 12 districts for the years 1981 and 1991 constituted the outcome variables of interest. The predictor variables were classified into 4 categories: health services, social services (female literacy rate, urban population, percentage households with water-sealed toilets and tap water), economic factors (per capita income) and utility of health services (hospital beds-population ratio, doctor-population ratio, ratio of medical institutions to population, paramedical workers-population ratio, percentage institutional births). Multivariable linear regression and correlation analyses were used to evaluate the association of select variables with CMR in 198 l and 1991. Results: lnterdistrict differences in CMR narrowed between 198l and 1991. The regression analyses suggest that female literacy was the most significant correlate of CMR in 1981. However, data from 1991 suggest that doctor-population ratio was the most important correlate of ('.MR. The correlation coefficients for predictor variables with (;MR decreased in magnitude between 1981 and 1991. C o n c l u s i o n s : Female literacy rate and the doctor-population ratio were the most important correlates of CMR in 1981 and 1991, respectively, indicating that the determinants of health status in Kerala may have changed over time. Our study illustrates the importance of interdistrict and time variations that occur in factors related to health, and emphasizes that these considerations are necessary for effective district health planning.
PHYSICAL A B U S E IN CHILDREN: A PREDICTIVE MODEL. S. Muftoz, M. Aracena, P. Lorca, L. Bustos, F. Roman, D. Streiner. C E U , Universidad de La Frontera, T e m u c o , Chile; M c M a s t e r University, Canada. O b j e c t i v e : Develop a predictive model to detect potential physical abuse in children of low socio-economic status in Temuco, Chile. Design: Cross sectional study. Setting: Low socio-economic families with children under 15 years of age living in the city of Temuco, Chile. P a r t i c i p a n t s : A non-probabilistic sample of 522 parents, having at least one child 14 years of age or younger, was used to assess the validity of the instrument. The sample was restricted to those parents whose children had received attention in either a health care, an educational or justice public service of the city. The sample was stratified in three groups: physical abuse (128), at risk of maltreatment (184), and no maltreatment (210). M a i n O u t c o m e M e a s u r e ( s ) : Physical abuse determined by a group of experts (physicians, psychologists, social workers and statisticians). Statistical M e t h o d s : Model strategy: The sample was divided into a sample of 390 subjects for model building and into a second sample of 130 for model validation. Predictors include bio-socio-demographic variables, as well as other known risk factors and specially designed scales such as social support, child's expectations, conflict resolution, and interviewed past history. Results: The predictive model has an acceptable validity since its cross validation correlation is 0.31 and shrinkage on cross validation is 0.12. This indicates a relatively good stability of the estimated parameters of the model. Main predictors associated with physical abuse are: poor family support, low level of conflict resolution, the recognition parents have about having a child difficult to treat, children not attending either a care center or schools, the presence of economic and/or legal stress. Conclusions: The built predictive model of child abuse has a good validity and therefore can be used to determine different levels of child abuse in low socio-economic populations. The predictive model built here is based in the same population in which it will be applied (Chilean parents of low socio-economic status).
RISK F A C T O R S FOR P E R I N A T A L D E A T H S . H. Mej~_, S. Blanco. CEU, Universidad Mayor de San Andr6s, La Paz, Bolivia. O b j e c t i v e : To identify the risk factors related to perinatal deaths. Bolivia has the second highest perinatal mortality rate in Latin America. Design: Case control study. Setting: Women's Maternity Public Hospital, third level facility in La Paz, Bolivia. Participants: 114 stillborns or those who died in less than 7 days (cases) and 228 live borns (2 live borns after each death) as controls. Interventions: None. M a i n O u t c o m e M e a s u r e ( s ) : Assess on socioeconomic level, obstetric history, quality of delivery care and quality of care to the newborn. Results: 65% perinatal deaths at health facility. Main odds ratios are mother's schooling less than secondary OR 1.83 (95% CI 1.13-2.97); over five pregnancies OR 2.32 (95% CI 1.06-5.08); no prenatal controls OR 1.84 (95% Cl 1.1-3.0); previous stillbirths OR 3.82 (95% C1 1.14-13.48); hemorrhaging during pregnancy OR 3.05 (95% CI 1.7-5.48); the mother having received care from a general practitioner/nurse and then referred OR 2.58 (95% CI 1.48-4.51); dystocic delivery OR 2.9 (95% CI 1.754.81); less than 37 weeks of pregnancy OR 5.87 (95% CI 3.47-9.80); weight less than 1500 g OR 11.91 (95% CI 3.71-42.42); over 24 hours between hospital admission and delivery OR 3.71 (95% CI 1.31-10.79). Logistic regression shows the importance of socioeconomic factors and quality of care at delivery. C o n c l u s i o n s : There are problems of quality of care during pregnancy and delivery and lack of antenatal control attendance. Specific interventions should include training of general practitioners, and prompt and efficient early risk identification at the third level.