This study aimed to investigate the association between maternal psychological distress and impairment in mother-child relationship in a sample from a Northeast capital city in Brazil with a low Human Development Index, using directed acyclic graphs (DAG). A total of 3,215 women were evaluated for the presence of psychological distress through the Self Reporting Questionnaire instrument and for the mother-child relationship by the first factor of Postpartum Bonding Questionnaire, considered the most appropriate in the literature. Demographic and socioeconomic variables were used to construct a theoretical model and, after this, multivariate logistic regression was performed using variables suggested by Directed Acyclic Graphs (DAG). Psychological distress was present in 22.7% of the women and 12.6% of them presented impaired mother-child relationships. After adjustment, the variable ‘maternal mental distress' remained associated with impaired mother-child relationship (RR=3.03), and among the explanatory variables only ‘primary school level' (RR=1.48) was associated as a risk factor to this outcome. The results indicated that, in this population, women with psychological distress and lower schooling are more likely to present impaired mother-child relationships.

A prospective cohort study was conducted on a convenience sample of 1370 pregnant women with a gestational age of 20 to 25 weeks in the city of Ribeirão Preto. Data on obstetrical history, maternal age, parity, smoking habit, and a history of preterm delivery was collected with the application of a sociodemographic questionnaire. Cervical length was determined by endovaginal ultrasound, and urine and vaginal content samples were obtained to determine urinary tract infection (UTI) and bacterial vaginosis (BV), respectively. The aim of this study was to verify the association of cervical length and genitourinary infections with preterm birth (PTB). Ultrasound showed no association of UTI or BV with short cervical length. PTB rate was 9.63%. Among the women with PTB, 15 showed UTI (RR: 1.55, 95%CI: 0.93–2.58), 19 had BV (RR: 1.22, 95%CI: 0.77–1.94), and one had both UTI and BV (RR: 0.85, 95%CI: 0.13–5.62). Nineteen (14.4%) PTB occurred in women with a cervical length ≤2.5 cm (RR: 2.89, 95%CI: 1.89–4.43). Among the 75 patients with PTB stratified as spontaneous, 10 showed UTI (RR: 2.02, 95%CI: 1.05–3.86) and 14 had a diagnosis of BV (RR: 1.72, 95%CI: 0.97–3.04). A short cervical length between 20 and 25 weeks of pregnancy was associated with PTB, whereas UTI and BV determined at this age were not associated with short cervical length or with PTB, although UTI, even if asymptomatic, was related to spontaneous PTB.

Fetuses exposed to alcohol and/or tobacco are at risk for perinatal adversities. However, little is currently known about the association of the separate or concomitant use of alcohol and tobacco with infant motor and cognitive development. Thus, the objective of the present study was to investigate the association between maternal consumption of alcohol and/or tobacco during pregnancy and the motor and cognitive development of children starting from the second year of life. The study included 1006 children of a cohort started during the prenatal period (22-25 weeks of pregnancy), evaluated at birth and reevaluated during the second year of life in 2011/2013. The children were divided into four groups according to the alcohol and/or tobacco consumption reported by their mothers at childbirth: no consumption (NC), separate alcohol consumption (AC), separate tobacco consumption (TC), and concomitant use of both (ACTC). The Bayley Scale of Infant and Toddler Development Third Edition screening tool was used for the assessment of motor and cognitive development. Adjusted Poisson regression models were used to determine the association between groups and delayed development. The results indicated that only the ACTC group showed a higher risk of motor delay, specifically regarding fine motor skills, compared to the NC group (RR=2.81; 95%CI: 1.65; 4.77). Separate alcohol or tobacco consumption was not associated with delayed gross motor or cognitive development. However, the concomitant use of the two substances increased the risk of delayed acquisition of fine motor skills.

The present study was conducted to evaluate the validity of the Food Frequency Questionnaire (FFQ) used in the RPS Birth Cohort Consortium (Ribeirão Preto, Pelotas, and São Luís) to assess dietary intake of adolescents from São Luís, Maranhão. The research was developed with 152 adolescents aged 18 and 19 years. For the validation of the FFQ, the average of three 24-hour recalls (24HRs) was used as the reference method. The mean and standard deviation of energy and nutrient intake extracted from the surveys were estimated. The paired Student's t-test was used to verify the differences between the instruments. Pearson correlation coefficient, intraclass correlation coefficient (ICC), weighted Kappa, and the Bland-Altman plot were calculated in order to measure the agreement. The study adopted a level of significance <5%. Compared with the three 24HRs, the FFQ overestimated the consumption of most nutrients. Energy-adjusted and de-attenuated concordance Pearson correlation coefficients ranged from 0.06 to 0.43, and correlations were significant for iron, calcium, riboflavin, sodium, saturated fat, niacin, and vitamin C. The energy-adjusted and de-attenuated ICCs ranged from 0.01 to 0.31, and the weighted Kappa ranged from 0.01 to 0.46. The analyses of agreement were significant for vitamin C, fiber, calcium, riboflavin, niacin, sodium, lipids, and iron. In conclusion, the FFQ presented acceptable relative validity for lipids, saturated fatty acids, fiber, calcium, iron, riboflavin, niacin, vitamin C, and sodium. This instrument will be useful in studies about food consumption of adolescents in São Luís, Maranhão.

It is still unknown whether excessive consumption of sugar-sweetened beverages may be linked to gestational hypertensive disorders, other than preeclampsia. This study investigated the association between soft drink consumption and hypertension during pregnancy, analyzing the relationship from the perspective of counterfactual causal theory. Data from pregnant women of the BRISA cohort were analyzed (1,380 in São Luis and 1,370 in Ribeirão Preto, Brazil). The explanatory variable was the frequency of soft drink consumption during pregnancy obtained in a prenatal interview. The outcome was gestational hypertension based on medical diagnosis, at the time of delivery. A theoretical model of the association between soft drink consumption and gestational hypertension was constructed using a directed acyclic graph. Marginal structural models (MSM) weighted by the inverse of the probability of soft drink consumption were also employed. Using Poisson regression analysis, high soft drink consumption (≥7 times/week) was associated with gestational hypertension in São Luís (RR=1.48; 95%CI: 1.03-2.10), in Ribeirão Preto (RR=1.51; 95%CI: 1.13-2.01), and in the two cohorts combined (RR=1.45; 95%CI: 1.16-1.82) compared to lower exposure (<7 times/week). In the MSM, the association between high soft drink consumption and gestational hypertension was observed in Ribeirão Preto (RR=1.63; 95%CI: 1.21-2.19) and in the two cohorts combined (RR=1.51; 95%CI: 1.15-1.97), but not in São Luís (RR=1.26; 95%CI: 0.79-2.00). High soft drink consumption seems to be a risk factor for gestational hypertension, suggesting that it should be discouraged during pregnancy.

This study aimed to estimate and compare racial inequality in low birth weight (LBW), preterm birth (PTB), and intrauterine growth restriction (IUGR) in two Brazilian birth cohorts. This was a cross-sectional study nested within two birth cohorts in Ribeirão Preto (RP) and São Luís (SL), whose mothers were interviewed from January to December 2010. In all, 7430 (RP) and 4995 (SL) mothers were interviewed. The maternal skin color was the exposure variable. Associations were adjusted for socioeconomic and biological covariates: maternal education, per capita family income, family economic classification, household head occupation, maternal age, parity, marital status, prenatal care, type of delivery, maternal pre-pregnancy BMI, hypertension, hypertension during pregnancy, and smoking during pregnancy collected from questionnaires applied at birth. Statistical analysis was done with the chi-squared test and logistic regression. In RP, newborns from mothers with black skin color had a higher risk of LBW and IUGR, even after adjusting for socioeconomic and biological variables (P<0.001). In SL, skin color was not a risk factor for LBW (P=0.859), PTB (P=0.220), and IUGR (P=0.062), before or after adjustment for socioeconomic and biological variables. The detection of racial inequality in these perinatal outcomes only in the RP cohort after adjustment for socioeconomic and biological factors may be reflecting the existence of racial discrimination in the RP society. In contrast, the greater miscegenation present in São Luís may be reflecting less racial discrimination of black and brown women in this city.

The objective of this study was to describe the timing of the first dental visit and investigate the association of socioeconomic and behavioral factors with dental visit delay among 10/11-year-old children from two live-birth population cohorts with extremely contrasting socioeconomic profiles. Follow-up data (2004-2005) from cohorts of Ribeirão Preto (RP) (n=790) and São Luís (SL) (n=673) were evaluated. Delay in dental visit was defined as not visiting a dentist before the age of 7. Covariates included family socioeconomic characteristics, mother-related health behavior, and child-related characteristics. Prevalence ratios with robust standard errors were estimated. In both cohorts, less than 5% of children had visited a dentist before the age of two and about 35% of them had not visited a dentist before the age of seven. Lower mother’s schooling and lack of private health insurance were associated with the delay in first dental visit for both cohorts. A small number of mother's prenatal care visits and being from a single-father family or a family without parents were only associated in the RP cohort, while having ≥4 siblings and lifetime dental pain were associated in the SL cohort. The association with dental pain probably reveals a preventive care-seeking behavior. Therefore, the percentage of delayed first dental visit of children was very high even among those with the most educated mothers. Further studies are necessary to analyze recent changes and underlying factors related to access to first dental visit after the implementation of the National Oral Health Policy in 2006.

Gestational hypertension and pre-eclampsia are important causes of perinatal morbidity. The objective of the present study was to determine the increase in relative risk for developing hypertensive disorders of pregnancy based on the evaluation of pregnant women between 20 and 25 weeks of gestation, and to correlate the findings at this period with the outcome of pregnancy. We conducted a prospective cohort study, with a convenience sample of 1417 patients evaluated at this gestational age, of which 1306 were contacted at childbirth. We detected an increased relative risk of 2.69 (95%CI: 1.86 to 3.89) associated with pulsatility index of the uterine arteries, a 2.8 increase (95%CI: 1.58 to 5.03) in relative risk attributed to maternal age above 35 years, a 1.68 increase (95%CI: 1.17 to 2.40) attributed to parity greater than or equal to 3, and a 5.35 increase (95%CI: 4.18 to 6.85) attributed to chronic hypertension and obesity, with a progressive increase in relative risk according to the degree of overweight, i.e., grades 1, 2, 3, and morbid obesity (2.58, 3.06, 5.84, and 7.28, respectively).

Intrauterine growth restriction (IUGR) is related to a higher risk of neonatal mortality, minor cognitive deficit, metabolic syndrome, and cardiovascular disease in adulthood. In previous studies, genetic variants in the FTO (fat mass and obesity-associated) and PPARγ (peroxisome proliferator-activated receptor-gamma) genes have been associated with metabolic disease, body mass index, and obesity among other outcomes. We studied the association of selected FTO (rs1421085, rs55682395, rs17817449, rs8043757, rs9926289, and rs9939609) and PPARγ (rs10865710, rs17036263, rs35206526, rs1801282, rs28763894, rs41516544, rs62243567, rs3856806, and rs1805151) single-nucleotide polymorphisms (SNPs) with IUGR, through a case-control study in a cohort of live births that occurred from June 1978 to May 1979 in a Brazilian city. We selected 280 IUGR cases and 256 controls for analysis. Logistic regression was used to jointly analyze the SNPs as well as factors such as maternal smoking, age, and schooling. We found that the PPARγ rs41516544 increased the risk of IUGR for male offspring (OR 27.83, 95%CI 3.65-212.32) as well as for female offspring (OR=8.94, 95%CI: 1.96-40.88). The FTO rs9939609 TA genotype resulted in a reduced susceptibility to IUGR for male offspring only (OR=0.47, 95%CI: 0.26-0.86). In conclusion, we demonstrated that PPARγ SNP had a positive effect and FTO SNP had a negative effect on IUGR occurrence, and these effects were gender-specific.

We describe three birth cohort studies, respectively carried out in 1978/79 and 1994 in Ribeirão Preto, a city located in the most developed region of Brazil, and in 1997/98 in São Luís, a city located in a less developed region. The objective of the present report was to describe the methods used in these three studies, presenting their history, methodological design, objectives, developments, and difficulties faced along 28 years of research. The first Ribeirão Preto study, initially perinatal, later encompassed questions regarding the repercussions of intrauterine development on future growth and chronic adult diseases. The subjects were evaluated at birth (N = 6827), at school age (N = 2861), at the time of recruitment for military service (N = 2048), and at 23/25 years of age (N = 2063). The study of the second cohort, which started in 1994 (N = 2846), permitted comparison of aspects of perinatal health between the two groups in the same region, such as birth weight, mortality and health care use. In 1997/98, a new birth cohort study was started in São Luís (N = 2443), capital of the State of Maranhão. The 1994 Ribeirão Preto cohort and the São Luís cohort are in the second phase of joint follow-up. These studies permit comparative temporal analyses in the same place (Ribeirão Preto 1978/79 and 1994) and comparisons of two contrasting populations regarding cultural, economic and sociodemographic conditions (Ribeirão Preto and São Luís).

The objective of the present study was to investigate factors associated with cesarean sections in two cities located in different regions of Brazil and to determine factors that explain the higher cesarean section rate in the more developed city, Ribeirão Preto, compared to the less developed one, São Luís. Data from two cohort studies comprising 2846 women in Ribeirão Preto in 1994, and 2443 women in São Luís in 1997/1998 were used. Adjusted and non-adjusted risk estimates were calculated using a Poisson regression model. The cesarean section rate was 33.7% in São Luís and 50.8% in Ribeirão Preto. Adjusted analysis in a joint sequential model revealed a 51% higher risk of cesarean section in Ribeirão Preto compared to São Luís (prevalence rate ratio (PRR) = 1.51). Adjustment for category of hospital admission reduced the PRR to 1.09, i.e., this variable explained 82% of the difference in the cesarean section rate between the two cities. Adjustment for the variable "the same physician for prenatal care and delivery" reduced the PRR to 1.07, with the "physician" factor explaining 86% of the difference between rates. When simultaneously adjusted for the two variables, the PRR decreased to 1.05, with these two variables explaining 90% of the difference in the cesarean section rate between the two cities, and the difference was no longer significant. The difference in the cesarean section rate between the two Brazilian cities, one more and one less developed, was mainly explained by the physician factor and, to a lesser extent, by the category of hospital admission.

The association between early life factors and body mass index (BMI) in adulthood has been demonstrated in developed countries. The aim of the present study was to assess the influence of early life factors (birth weight, gestational age, maternal smoking, and social class) on BMI in young adulthood with adjustment for adult socioeconomic position. A cohort study was carried out in 1978/79 with 6827 mother-child pairs from Ribeirão Preto city, located in the most developed economic area of the country. Biological, economic and social variables and newborn anthropometric measurements were obtained shortly after delivery. In 1996, 1189 males from this cohort, 34.3% of the original male population, were submitted to anthropometric measurements and were asked about their current schooling on the occasion of army recruitment. A multiple linear regression model was applied to determine variables associated with BMI. Mean BMI was 22.7 (95%CI = 22.5-23.0). After adjustment, BMI was 1.22 kg/m² higher among infants born with high birth weight (³4000 g), 1.21 kg/m² higher among individuals of low social class at birth and 0.69 kg/m² higher among individuals whose mothers smoked during pregnancy (P < 0.05). The association between social class at birth and BMI remained statistically significant (P < 0.05) even after adjustment for adult schooling. These findings suggest that early life social influences on BMI were more important and were not reversed by late socioeconomic position. Therefore, prevention of overweight and obesity should focus not only on changes in adult life styles but also on factors such as high birth weight.

Few studies have described factors associated with infant and adolescent mortality since birth. We report here mortality during a 20-year period in a birth cohort from Ribeirão Preto in order to identify birth variables that influenced mortality among infants and children between 10 and 19 years of age, the main causes of death, and the influence of social inequality at birth on death. Mothers were interviewed shortly after delivery. Social, biological and demographic information was collected, and mortality up to 19 years of age was investigated in registry systems. Of the 6748 liveborn singletons born in the municipality from 1978 to 1979, 343 died before or when 19 years of age were completed. Most of the cohort mortality (74.9%) occurred during the first year of life and 19.6% occurred from 10 to 19 years. Mortality was higher among boys. Preterm birth (hazard ratio, HR = 7.94) and low birth weight (HR = 10.15) were strongly associated with infant mortality. Other risk factors for infant mortality were: maternal age ³35 years (HR = 1.74), unskilled manual occupation of family head (HR = 2.47), and for adolescent mortality: unskilled manual occupation of family head (HR = 9.98) and male sex (HR = 6.58). "Perinatal conditions" were the main causes of deaths among infants and "external causes" among adolescents, especially boys. Socioeconomic factors at birth, represented by occupation, influenced adolescent mortality due to external causes, which was higher among boys (7:1). The influence of social inequality at birth on death, measured by occupation, was greater in adolescence than in infancy.

Obesity is one of the rising public health problems characterized as a risk factor for many chronic diseases in adulthood. Early life events such as intrauterine growth restriction, as well as life style, are associated with an increased prevalence of this disease. The present study was performed to determine if intrauterine growth restriction interacts with overweight at primary school age to affect body mass index (BMI) in young adults. From June 1, 1978 to May 31, 1979, 6827 singleton liveborns from Ribeirão Preto, São Paulo State, Brazil, corresponding to 98% of all births at the 8 maternity hospitals, were examined and their mothers were interviewed. Samples from the initial cohort were examined again at primary school age (8 to 11 years of age) and at the time of military service (18 years of age). There were 519 male individuals with complete measurements taken in the three surveys. Intrauterine growth-restricted individuals had a BMI 0.68 kg/m² lower than that of individuals who were not restricted (95%CI = -1.34 to -0.03) and overweight at primary school age showed a positive and strong effect on BMI at 18 years of age (coefficient 5.03, 95%CI = 4.27 to 5.79). However, the increase in BMI was much higher - 6.90 kg/m² - when the conscript had been born with intrauterine growth restriction and presented overweight at primary school age (95%CI = 4.55 to 9.26). These findings indicate that the effect of intrauterine growth restrictionon BMI at 18 years of age is modified by later weight gain during school age.

In the late 1980's child malnutrition was still prevalent in Brazil, and child obesity was beginning to rise in the richest regions of the country. To assess the extent of the nutritional transition during the period and the influence of birth weight and maternal smoking on the nutritional condition of schoolchildren, we estimated the prevalence of excess weight and malnutrition in a cohort of Brazilian schoolchildren from 1987 to 1989. We calculated the body mass index (BMI) of 8- to 10-year-old schoolchildren born in Ribeirão Preto in 1978/79. We considered children with a BMI <5th percentile (P5) to be malnourished, children with P5³BMI<P85 to be thin and normal, and children with BMI ³P85 to be overweight. We evaluated the association of these nutritional disorders with birth factors (infant weight, sex, preterm delivery, number of pregnancies, maternal smoking during pregnancy, marital status, and schooling) and type of school using nominal logistic regression. A total of 2797 schoolchildren were evaluated. There was a significant prevalence of malnutrition (9.5%) and excess weight already tended to increase (15.7%), while 6.4% of the children were obese. Excess weight was more prevalent among children attending private schools (odds ratio, OR = 2.27) and firstborn children (OR = 1.69). Maternal smoking during pregnancy protected against malnutrition (OR = 0.56), while children with lower birth weight were at higher risk for malnutrition (OR = 4.23). We conclude that a nutritional transition was under way while malnutrition was still present, but excess weight and related factors were already emerging.