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Revista Brasileira de Saúde Materno Infantil

Print version ISSN 1519-3829On-line version ISSN 1806-9304

Rev. Bras. Saude Mater. Infant. vol.18 no.2 Recife Apr./June 2018

http://dx.doi.org/10.1590/1806-93042018000200005 

ORIGINAL ARTICLES

Prenatal follow-up of Haitian and Brazilian women in Mato Grosso

Delma Riane Rebouças Batista1 

Silvia Angela Gugelmin2 

Ana Paula Muraro3 

1,2Departamento de Saúde Coletiva. Instituto de Saúde Coletiva. Universidade Federal de Mato Grosso. Cuiaba, MT, Brasil.

3Programa de Pós-graduação em Nutrição, Alimentos e Metabolismo. Faculdade de Nutrição. Universidade Federal de Mato Grosso. Cuiaba, MT, Brasil. Av. Fernando Correa da Costa, 2367. Boa Esperança. Cuiabá, MT, Brasil. CEP: 78.060-900. E-mail: muraroap@gmail.com


Abstract

Objectives:

to analyze the prenatal follow-up performed by pregnant women in Haiti and Brazil in the state of Mato Grosso.

Methods:

a cross-sectional study of secondary database, with analysis of SINASC birth records in Mato Grosso between 2013 and 2015, of Brazilian children, born from both Brazilian and Haitian mothers. Variables related to the identification of the newborn and the woman, maternal data on gestational history, including information on prenatal follow-up of the last gestation were evaluated, besides the birth characteristics.

Results:

167,820 live births were registered in the state in the period, of which 139 (0.08%) were children of Haitian women. Haitian mothers were older, however with lower schooling when compared to Brazilian mothers. The proportion of mothers of Haitian nationality who had at least 6 prenatal consultations was lower, and the proportion of vaginal births was higher, when compared to Brazilian women. The prevalence of low birth weight among live births of Haitian mothers was also higher.

Conclusions:

the results of this study point to the need to understand these differences, since some indicators have distanced from those advocated by WHO. These findings may contribute to the public policies development aimed at this population.

Key words Emigration and immigration; Prenatal Care; Childbirth; Health policy; planning and management

Resumo

Objetivos:

analisar o acompanhamento pré-natal realizado pelas gestantes haitianas e brasileiras residentes no estado de Mato Grosso.

Métodos:

estudo transversal de base secundária, com análise de registros de nascimento do SINASC em Mato Grosso entre 2013 e 2015, de crianças brasileiras, filhos de mães brasileiras e de mães de nacionalidade haitiana. Foram avaliadas variáveis relativas à identificação do recém-nascido e da mulher, dados maternos sobre histórico gestacional, incluindo informações sobre o acompanhamento pré-natal da última gestação, além das características do parto.

Resultados:

foram registrados 167.820 nascidos vivos no estado no período avaliado, sendo 139 (0,08%) filhos de mulheres haitianas. As mães haitianas apresentaram faixa etária mais elevada, contudo, com menor escolaridade quando comparadas as mães brasileiras. Foi menor a proporção de mães de nacionalidade haitianas que tiveram pelo menos 6 consultas pré-natais e maior a proporção de partos vaginais, quando comparadas às brasileiras. Também foi maior a prevalência de baixo peso ao nascer entre os nascidos vivos de mães haitianas.

Conclusões:

os resultados deste estudo apontam para a necessidade de compreensão destas diferenças, pois alguns indicadores distanciaram-se do preconizado pela OMS. Esses achados podem contribuir para o desenvolvimento de políticas públicas voltadas para esta população.

Palavras-chave Emigração e Imigração; Cuidado pré-natal; Parto; Políticas; planejamento e administração em saúde

Introduction

Several social and economic factors in Haiti influence the migratory process of its population, which began at the end of the 19th century, with a large flow of Haitians leaving for the Dominican Republic and Cuba, in order to work on sugar production in these countries.1 Brazil began to be considered as one of the main destinations since 2010, when an increase was observed in the number of Haitian immigrants who sought in the country the means to a better life.2 This migratory movement has already involved thousands of Haitians, being this the main nationality among foreign workers currently registered in Brazil.3

The state of Mato Grosso has presented, since 2012, a progressive increase in the number of Haitian immigrants,3 among them, women of reproductive age which, in turn, may have caused the increase in the number of births of Haitian women’s children by the process of family reunification. This fact points to the need for closer attention to the living and health conditions of this segment of the population.

When dealing with maternal and child health, there are several particularities that can influence the gestational conditions, delivery and puerperium of each woman, from biological aspects to socioeconomic and psychic factors. In this sense, prenatal consultation is an important ally in maternal and neonatal health care, since several health problems, both of the pregnant woman and the child, can be prevented, identified and/or treated by professionals during the gestational period.4

The early initiation of prenatal care is very important for adequate care, and the first consultation is recommended until the third gestational month. The number of prenatal consultations to be performed, also recommended by the World Health Organization (WHO), should be equal to or higher than six, guaranteeing the quality of these consultations.4

Almeida et al.5 verified that foreign mothers started the prenatal follow-up later and had fewer consultations when compared to those of Portuguese nationality. In Brazil, a study on access to health care by Bolivian immigrant women and children reveals that this population positively faces access to health in the country where they live, when compared to their country of origin.6

In 2012, in Haiti, 67.3% of pregnant women performed at least four prenatal consultations,7 and in previous years (2005), there was a difference in coverage and number of consultations among pregnant women living in rural and urban areas, of 77.2% and 85.8%, respectively. The averages of prenatal consultations were 3.8 for rural residents and 5.1 for those residing in the urban area.8 These characteristics may be due to cultural issues as well as to the conditions offered by the Haitian health system.

Despite the growing trend in the number of births within Haitian women in Brazil, no studies were found to evaluate prenatal care offered to this population. In this sense, the present study aims to analyze the prenatal care performed by pregnant women living in the state of Mato Grosso, in order to encourage the planning of more specific actions to approach this population.

Methods

A cross-sectional study was performed, based on data available in the Live Birth Information System (Sinasc). The records of live births of Brazilian women and children of women of Haitian nationality in Mato Grosso in the years of 2013, 2014 and 2015 were considered. The data used were provided by the State Department of Health of Mato Grosso.

Sinasc was implemented by the Ministry of Health in 1990, which was based on the data obtained from the Live Births Declaration Registry (DN - Portuguese acronym), composed of eight blocks of information. The information collected is sent hierarchically to the Municipal and State Health Secretariat and, finally, provided to the Ministry of Health to feed the Information System of the Unified Health System (SUS).9

Data were collected from three of the eight information blocks of the DN, including: newborn identification, data on the mother, pregnancy and delivery. Haitian mothers’ data were compared with Brazilian mothers’ data, and this information was identified by the field "naturalness of the mother" in DN.

Regarding the information regarding the maternal data, the following were analyzed: mother’s age range (less than 25 years, between 25 and 29 years, and 30 years or more); mother’s marital status (single, married, common-law marriage or others); maternal schooling (5 to 11 years of study, and 12 years or more of study); number of previous pregnancies (none, one to two, three or more); number of children born alive (none, one to two, three or more); number of children born dead (none, one or more).

For the prenatal data analysis, the number of prenatal consultations was classified into two categories (6 or more and less than 6 visits), and the period of initiation of consultations was classified up to the third month of gestation or after the 3rd month. Both variables considered WHO’s recommendation.10

Concerning the child's birth data, gestational age was classified as preterm (up to 36 weeks), term (between 37 and 41 weeks) and post-term (42 weeks or more),4 being the latter two categories due to the low number of births recorded as post-term when referred to the children of Haitian mothers. The type of delivery (vaginal or cesarean section) and birth weight, classified according to WHO10 in adequate birth weight (≥ 2500 grams) and low birth weight (<2500 grams) were also evaluated. The Apgar index is related to the degree of anoxia that the newborn presents after birth and in the present study only the Apgar of the first minute of life was evaluated. Apgar between 8 and 10 is considered normal, 7 mild anoxia, 4 to 6 moderate anoxia and zero to 3 severe anoxia.11 In this study, the Apgar score was classified as up to 7 (some degree of anoxia) and between 8 and 10.

To test the differences among the proportions, the chi-square test was applied, and the analyses were performed using SPSS software, version 17.

This study is part of the research project approved by the Ethics Committee of Júlio Muller Hospital of the Federal University of Mato Grosso (No. 29120414.0.0000.5541). The research was funded by the Foundation for Research Support of the State of Mato Grosso (FAPEMAT - Process 155709/2014) and the National Council for Scientific and Technological Development (CNPq - Process 445842 / 2014-7).

Results

In Mato Grosso, 167,820 live births were registered between 2013 and 2015 (2013 = 53,573; 2014 = 57,083; 2015 = 57,164). The incompleteness of the mother's natural information (country, state or municipality) was only 1.32% (2,220 births). Thus, 165,600 birth records were selected initially, of which 765 were children of foreign mothers (0,50%). Among the records of mothers of other nationalities, the main countries of origin were Bolivia (n = 396, 0.2%), Paraguay (n = 139, 0.08%) and Haiti (n=139; 0.08%).

In the data analysis, the characteristics of the live births of Brazilian and Haitian mothers were compared, making a total of 164,974 evaluated births. Haitian mothers had a higher age group in the delivery period, however with lower schooling when compared to Brazilian mothers (Table 1). The Haitian women’s reproductive history (gestation number, number of live births and dead children) did not differ from Brazilian women (Table 1). Regarding prenatal and delivery, when compared to Brazilian mothers, there was a lower proportion of Haitian mothers with at least six prenatal consultations, a higher proportion of vaginal deliveries, and a higher prevalence of live births with low birth weight (Table 2). All deliveries of Haitian women evaluated occurred in a hospital environment (data not shown in the table).

Table 1 Maternal characteristics according to mother's nationality. Mato Grosso, 2013 to 2015. 

General Children of Haitian Children of Brazilian pa
n % n % n %
Age group of the mother (years) <0.001
< 25 79.303 48.1 29 20.9 79.274 48.1
25 to 29 41.862 25.4 61 43.9 41.801 25.4
≥30 43.809 26.6 49 35.3 43.760 26.5
Marital status of mother not applicable
Single 47.293 28.8 47 33.8 47.246 28.8
Married 46.637 28.4 26 18.7 46.611 28.4
Stable union 68.204 41.5 66 47.5 68.138 41.5
Others 2.289 1.4 - - 2.289 1.4
Mother's education (years)b
< 5 7.990 4.9 16 11.9 7.974 4.9 <0.001
5 to 11 86.179 52.6 75 56.0 86.104 52.6
≥ 12 69.608 42.5 43 32.1 69.565 42.5
Previous pregnanciesb 0.440
None 53319 34.5 41 32.5 53278 34.5
1 - 2 76879 49.8 60 47.6 76819 49.8
≥ 3 24251 15.7 25 19.8 24226 15.7
Number of children born aliveb 0.639
None 59.504 38.7 44 34.9 59.460 38.7
1 - 2 77.380 50.3 66 52.4 77.314 50.3
≥ 3 16.939 11.0 16 12.7 16.923 11.0
Number of children deadb 0.292
None 121.415 81.4 103 85.1 121.312 81.4
≥ 1 27.741 18.6 18 14.9 27.723 18.6

aChi-square test;

bVariable with incomplete information.

Table 2 Characteristics of prenatal care. Birth and conditions at birth, according to the mother's nationality. Mato Grosso. 2013 to 2015. 

General Children of Haitian Children of Brazilian pa
n % n % n %
Prenatal onsetb 0.112
Up to 3rd month of gestation 127.222 79.8 95 74.2 127.127 79.9
After the 3rd month 32.109 20.2 33 25.8 32.076 20.1
Number of prenatal visitsb 0.013
< 6 31.374 19.3 37 27.8 31.337 19.3
≥ 6 130.990 80.7 96 72.2 130.894 80.7
Gestacional ageb 0,569
Pre-term 17.513 10.9 17 12.4 17.496 10.9
Term or Post-term 143.262 89.1 120 87.6 143.142 89.1
Type of deliveryb <0.001
Vaginal 64.011 38.8 81 58.3 63.930 38.8
Caesarean 100.819 61.2 58 41.7 100.761 61.2
Sex of the childb 0.476
Male 84.473 51.2 67 48.2 84.406 51.2
Female 80.440 48.8 72 51.8 80.368 48.8
Weight at birth (grams)b <0.001
≥ 2500 152.387 92.4 115 82.7 152.272 92.4
< 2500 12.475 7.6 24 17.3 12.451 7.6
Apgar 1b 0.056
8 - 10 145.978 89.2 117 84.2 145.861 89.2
Up to 7 17.660 10.8 22 15.8 17.638 10.8

aChi-square test;

bVariable with incomplete information.

cNumber of post-term births of children of Haitian mothers less than 5.

When analyzing the distribution of low birth weight (Table 3), a higher prevalence was observed among mothers with a higher age group, lower education, first gestation, with less than 6 antenatal visits and Apgar in the first minute up to 7.

Table 3 Distribution of low birth weight (<2500g) by socio-demographic characteristics and related to prenatal and delivery, according to mother's nationality. Mato Grosso. 2013 to 2015. 

Stratified by nationality
General Children of Haitian Children of Brazilian
n % n % n %
Age group of the mother (years)
< 25 5816 7.3 4 13.8 5812 7.3
25 to 29 2939 7.0 8 13.1 2931 7.0
≥ 30 3726 8.5 12 24.5 3714 8.5
pa <0.01 - <0.01
Mother's education (years)b
< 5 658 8.3 3 18.8 655 8.3
5 to 11 6378 7.4 15 20.0 6363 7.4
≥ 12 5354 7.7 5 11.6 5349 7.7
pa <0.01 - <0.01
Previous pregnanciesb
None 4517 8.5 7 17.1 4510 8.5
1 - 2 4990 6.5 12 20.0 4978 6.5
≥ 3 1948 8.0 3 12.0 1945 8.0
pa <0.01 - <0.01
Prenatal onsetb
Up to 3rd month of gestation 9383 7.4 15 15.8 9368 7.4
After the 3rd month 2438 7.6 4 14.8 2434 7.6
pa 0.17 - 0.17
Number of prenatal visitsb
< 6 3918 12.5 10 27.0 3908 12.5
≥ 6 8222 6.3 11 11.5 8211 6.3
pa <0.01 0.03 <0.01
Gestacional ageb
Pre-term 4937 3.4 11 9.2 4926 3.4
Term or Post-termc 7216 41.2 13 76.5 7203 41.2
pa <0.01 <0.01 <0.01
Type of deliveryb
Vaginal 4893 7.6 11 13.6 4882 7.6
Caesarean 7578 7.5 13 22.4 7565 7.5
pa 0.35 0.17 0.24
Apgar 1b
8 - 10 8787 6.0 16 13.7 8771 6.0
Up to 7 3571 20.2 8 36.4 3653 20.2
pa <0.01 0.01 <0.01

aChi-square test;

bVariable with incomplete information;

cNumber of post-term births of children of Haitian mothers less than 5.

Discussion

The results of this study show that some important indicators have distanced themselves from those recommended by WHO among mothers of Haitian nationality, such as the number of prenatal consultations and the percentage of children with low birth weight. However, the proportion of vaginal deliveries among Haitians was higher when compared to Brazilian women, which may be related to both cultural characteristics and socioeconomic factors of this population group.

All the prenatal care provided during the gestational period can influence the type of delivery indicated and offered in each case. Currently, it is estimated that 40.5% of all births in Latin America and the Caribbean occurred through surgical birth, with South America being the subregion with the highest cesarean rates in the world, with 42.9%.12 As expected, therefore, data evaluated in this study present indices that exceed WHO’s recommendation,4 both in Brazilian and Haitian women, but show a statistically significant difference between the groups, with a lower proportion of cesarean sections among Haitian women. This fact may be related to the socioeconomic profile of immigrants, since in Brazil a positive association is observed between the level of maternal schooling and birth by the surgical route,13 with the majority of Haitian women residing in the country having low levels of schooling and having a socioeconomic status considered vulnerable.14,15 It is also worth mentioning the possible influence of skin color on the prenatal care offered and on the route of delivery. According to the Ministry of Health,16 the proportion of prenatal consultations performed by women who declared white skin color in 2013 was higher when compared to the black and brown categories and the agency also points out a trend in the increase of cesarean sections in the whole country, but especially in the South, Southeast and Midwest regions, and also among women aged between 20 and 39 years old, with a higher grade of schooling and white skin color.

The number of immigrant women spread throughout the world has increased, making it necessary to pay more attention to this population group, since they have cultural, psychosocial and biological specificities.17 According to Kobetz et al.,18 the greatest difficulties of access to health faced by immigrant Haitian women in Miami, regarding health services, were related to structural obstacles, such as financial problems related to treatment costs, problems (or irregularities) in immigrant status, communication difficulties (language) and lack of information on issues of health and rights.

Mascaro,19 on the other hand, described the difficulties of a health service in São Paulo on developing actions that facilitate the access of Bolivian women migrants. In addition to the language barrier and cultural differences, the following were listed as barriers on the establishment of links with these women: service hours, discrimination on the part of professionals, gender inequality and domestic violence. In this sense, the team sought overcoming and welcoming strategies in order to get through these barriers and offer quality care services. In Cuiabá, capital of the state of Mato Grosso, a study of the socioeconomic and health profile of Haitian immigrants showed a higher prevalence of health services utilization among women,20 which the authors evaluated as being associated, at least in part, to care related to gestation and delivery.

Essential care for immigrant women refers to prenatal care, as it is already recognized in the literature that several factors influence maternal and neonatal health care and conditions, including: maternal age, mother's education, number of previous pregnancies, number of children and type of childbirth.21 It should be remembered that among immigrants there are other factors involved in health care of women and children, such as language barriers, discrimination and irregularities in documentation,18,19 which indicate an inequality in the access to health service.

It is also necessary to point out possible deficiencies related to the Brazilian health system, such as areas that are not covered by basic health care teams, incomplete teams in basic health care, lack of preparation of staff to attend specific populations, management problems, and the application of funds directed towards health, among other factors that may have a direct influence on the indicators of prenatal care and childbirth, both for Brazilian women and immigrants.

It is essential that the pregnant woman initiates the prenatal follow-up in the first trimester in order to identify possible complications inherent to that period, as well as to receive relevant information that can minimize risks during pregnancy. Concomitant with the early initiation of this follow-up, WHO recommends that at least six prenatal consultations should be carried out, thus enabling adequate assistance and follow-up during this period.4 Based on the results presented, it can be observed that the number of Brazilian women (80.7%) who had six or more consultations was superior to the Haitian women (72.2%). This difference may be related to the poor understanding of the health network in Brazil, as well as to the Portuguese language, barriers considered common in the adaptation process to a new country.17 In addition, there are cases in which gestation started before migration process to Brazil, which should be considered in studies with this population.

A study with Bolivian immigrants in São Paulo showed that residence time in Brazil was associated with the use of different health services, especially primary health care, which was more used among those who lived in the country.6 Therefore, it is essential to promote actions that stimulate the search for prenatal care among Haitian pregnant women, in order to minimize possible impacts on the women’s and children’s health.

Regarding the age group, when the low birth weight with maternal age was evaluated in the studied population, a higher prevalence was observed among mothers aged 30 years or older, according to the literature.22 The results also showed a difference in the age of Haitian mothers when compared to the maternal age of Brazilian women, with the majority of Haitians (79.1%) at the time of delivery being 25 years or older, while 48.7% of the Brazilian women were of lower age to 25 years. The highest age group of Haitian women is possibly related to the profile of women who tend to migrate to Brazil, as verified by data from the Federal Police between 2010 and 2014, in which the majority of women were between 25 to 39 years.23 Likewise, it was estimated in Cuiabá that 78.2% of the women were between 26 and 45 years of age.14

The higher prevalence of low birth weight among the children of Haitian women may be related to two situations: inadequate follow-up during the gestational period (consultation number lower than that recommended), due to the difficulty accessing services; and the precarious living conditions of migrant women, who usually live in small households, with a greater density of people per room, unemployed. In a study with the Haitian population in Cuiabá, Leão et al.,15 verified that 45.6% of the women interviewed were unemployed and 41.6% reported having no income in the month prior to the interview.

Corroborating these hypotheses, in an additional analysis on the association of socio-demographic and prenatal characteristics with low birth weight, a higher prevalence of this outcome was found among mothers with lower educational level and less than six prenatal consultations. It is therefore opportune to understand the relation of these social and economic factors regarding access to health services, since LBW is one of the main risk factors for neonatal death and may influence the child’s health in the short and long term.24 Among the possible problems resulting from LBW is the delay in achieving adequate weight and length in the first year of life, intercurrences related to respiratory diseases and acute diarrhea, and the need for hospitalization for an average of 11 days in the first year of the child’s life.25

Another important risk factor for infant survival, as well as indicator of the socioeconomic familiar condition, refers to maternal schooling. Low maternal schooling has been related to fetal losses, risk of perinatal mortality, low birth weight and infant malnutrition. For this reason, the Ministry of Health preconizes higher children and maternal healthcare when the mother portrays low schooling. In Brazil, in the year 2010, approximately 35% of mothers had less than eight years of schooling.24

The present study highlights the socioeconomic profile of the population analyzed, in which the majority of Brazilian and Haitian women did not reach the conclusion of high school or equivalent schooling, tending to present inadequate socioeconomic conditions and greater social vulnerability. There is, however, a significant percentage difference in this sense, while 11.9% of the Haitian mothers evaluated in this study had schooling of up to five years of study, only 4.9% of Brazilians had this level of education, which seems to indicate inequality in the access to education among Haitian women. In Haiti, the educational system maintains, to a certain extent, the separation of elites and poor masses or popular classes, evidenced by the increase in the number of private schools, demonstrating a process of privatization of education. In 2008, approximately 83.0% of the schools in the country belonged to the private network, making it difficult for the less privileged population to access higher schooling levels.26

The woman’s obstetric history should also be considered, since the number of previous pregnancies, gestational and puerperal complications, type of delivery, among other factors, may directly influence later pregnancies,21 as well as the maternal perception about the need for care in this period. The present study presents, in an unprecedented way, that Haitians and Brazilians showed similarity in the number of previous pregnancies.

Finally, the Apgar score is another factor that can be influenced by prenatal care, since care during pregnancy can prevent, identify and/or treat possible problems that influence this variable. The necessary care at birth will vary according to the Apgar score of each child.11 In the present study, the first minute Apgar did not present a significant difference among the groups, with an index below 7, ranging from 10.8% (in the children of Brazilian mothers) to 15.8% (in the children of Haitian mothers). Although the statistical analysis does not indicate differences between the nationalities, it is important for the service to know this reality, since the index below 7 refers to children who need quick and effective monitoring and/or care in their first hours of life, in order to ensure their survival with health. Studies show the association of the low Apgar index with precarious socioeconomic conditions27,28 and inadequate prenatal care.29

Given the data and discussion, it is observed that, although higher among immigrant women, most of the problems identified in the study are commonly found and discussed among the national population, which may not only be due to immigrant status, but conditions offered by the Brazilian health system. These problems can be aggravated in the immigrant populations, as they commonly face difficulties in the host country, related to socioeconomic inequalities, leading to precarious access to the labor market, housing and education, as well as inadequate environmental conditions.30

Among the limitations of this study, the use of secondary source data should be considered, and the information quality related to adequate DN filling and Sinasc feeding should be considered. The Manual Instruction for completing the Birth Declaration9 emphasizes the importance of adequately completing all DN fields in order to ensure the reliability of the obtained data. However, there is still underreporting of Sinasc births, ranging from 75.8% to 99.5%, and inadequate completion of many variables, such as maternal education, parity and number of prenatal visits.27 The incompleteness of basic DN fields, such as gender of the newborn and type of delivery, was high among the findings of the present study, possibly indicating the lack of attention and importance given to DN by the professional responsible for filling it.

Despite the limitations and criticisms on secondary databases, the findings confirm the literature regarding the difference in prenatal care among Brazilian and Haitian women. It should be noted that the low incompleteness of maternal naturality information in Sinasc (1.32%) allowed the analysis of the maternal and infant characteristics of the births recorded in the state in the evalauted period However, this information is not available for analysis in other information systems, such as the SIH-SUS (Hospital Information System of SUS) and SIA (Ambulatory Information System), making it impossible to analyze the use of health services by international immigrants.

The present study reveals the importance of the development of studies on immigrants in Brazil, with a deepening of the discussion focused on health care for this population group and on the public policies evaluation, considering the vulnerabilities imposed by the migratory situation. Regarding women's and children's health, the socioeconomic characteristics of Haitian women can be highlighted, predominantly with low schooling, as a fact that may influence health care in a country with a health system different from its country of origin.

Acknowledgment

The State Secretary of Health, specifically to the Superintendency of Health Surveillance for the availability of data analyzed in this study. We also thank the suggestions and criticism of the first versions of this article, received in the discipline of Workshop of Production of Scientific Articles, by Professor Marina Tanaka, from the Graduate Program in Collective Health of the Federal University of Mato Grosso.

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Received: September 14, 2017; Accepted: April 02, 2018

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