Background: It is universally known that pregnancy is a vulnerable time for a woman's health. Women of all backgrounds endure significant physiological and anatomical changes during pregnancy and after childbirth. But the latest research studies have called attention to the unique experience of Black mothers. Compared to other racial and ethnic groups, Black women encounter health disparities at an all-time higher rate. According to research studies conducted in Haiti and the United States, Haitian women are amongst the community of Black women who are experiencing disproportionate maternal outcomes. Research Aims: The aim of this systematic review is to explore the prenatal and postpartum support lacking for Haitian women residing in the United States and Haiti, resulting in elevated pregnancy-related mortality and morbidity. Methods: To explore this study's research aims, a qualitative systematic review was conducted. Studies that met the inclusion criteria were found by inserting the following keywords in various research databases: Haitian women, maternal health, maternal disparities, Haitian-immigrant, maternal support, Haitian-American, Haitian pregnant women, Haitian descent, maternal mortality, and maternal morbidity. Key Findings: Prenatal and postpartum support was lacking in various forms for Haitian women. In Haiti, women noted that a lack of compassion from healthcare providers, personal finances, and hospital funds contributed to unpleasant maternal experiences. While Haitian women residing in the United States encountered an absence of support from their health professionals due to being culturally misunderstood.

No description available.

This dissertation is a collection of three separate essays on the health of women and children. In the first essay, I along with my co-authors, analyzed the impact of two large, national-level health policies (the Janani Suraksha Yojana (JSY) and the National Rural Health Mission (NRHM)) on maternal health outcomes (proportion of institutional deliveries) in India. We used data from the India Human Development Survey (IHDS) and found that the JSY and the NRHM had a greater impact on institutional deliveries in high-focus states. We also found that the conditions of the public health facilities, did not change after the implementation of the JSY and the NRHM. Finally, we found that adequacy of health facilities was not associated with the likelihood of mothers in high-focus states having an institutional delivery. In the second essay, I examined whether a key social determinant of health in South Asia- gender inequality, is associated with physical health outcomes among Indian women. I found that the gender inequality expressed as the gendered household practice of seclusion was negatively associated with body weight of Indian women. Further, I found that participation in all household decisions by women of the household was generally not associated with body weight outcomes. The association between gendered household practices and women’s body weight outcomes was generally similar among rural and urban Indian women. In the final essay, I examined whether perinatal food environments (FE), maternal gestational weight gain (GWG) and early childhood weight (ECW) outcomes are associated. I used data on mother-children dyads from the Early Childhood Longitudinal Study – Birth cohort (ECLS-B), Area Resource Files (ARF) and Current Business Practices (CBP). I found that maternal GWG was associated with ECW outcomes. I also found that measures of food environment were associated with ECW outcomes. Specifically, I found that having an additional full-service restaurant per one thousand population in the maternal perinatal county of residence was associated with lower Body Mass Index (BMI) among children at age two years. Finally, I found that GWG did not mediate the association between food environment and ECW outcomes.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18173号 / 医博第3893号 / 新制||医||1003(附属図書館) / 31031 / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 木原 正博, 教授 一山 智 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

Self-determination Theory postulates that there are innate psychological needs for autonomy, competence, and relatedness, and that satisfaction of these needs fosters the development of autonomous motivation. Research suggests that autonomous forms of motivation are important for behavior change and maintenance. With increasing research on Self-determination Theory and its possible applications, there is a demand for research that develops and tests behavioral interventions. This study seeks to apply Self-determination Theory to a prenatal care intervention for low-income pregnant women in the Los Angeles area. The Self-determination Theory based and the non-Self-determination Theory based prenatal care interventions will be compared. Perceived autonomy, competence, relatedness, and autonomous motivation will be measured as well as health care behaviors (healthy behavior habits, prenatal care return rates, and adherence to doctor’s regimen). Perceived autonomy competence, relatedness, autonomous motivation, and healthy behavior will be measured before and after the intervention. Return rate and adherence to doctor’s regimen will be measured post-intervention. The Self-determination Theory based intervention group is expected to report higher levels of autonomous motivation, perceived autonomy, competence, relatedness, and healthy behavior, higher return rates, and better adherence to doctor’s orders than the control group. The findings may help shape prenatal care interventions for low-income pregnant women resulting in healthier pregnancies and reduced risk factors for infant disease and mortality.

A violência por parceiro íntimo (VPI) é uma das formas mais frequentes de violência contra a mulher, e se constitui em um fenômeno complexo, que faz parte de uma construção histórica e possui íntima relação com as questões de gênero e suas relações de poder. Durante a gestação, a mulher utiliza com maior frequência os serviços de saúde, o que pode facilitar a construção de vínculo com a equipe de saúde e favorecer a identificação de casos de violência. Os objetivos deste estudo foram: identificar a prevalência de casos de VPI entre gestantes usuárias de um serviço público de saúde e classificar quanto ao tipo e frequência; identificar fatores sociais e demográficos das gestantes e seus parceiros que poderiam estar associados a episódios de violência; identificar os resultados obstétricos e neonatais e suas associações com a ocorrência da VPI na gestação atual. Trata-se de um estudo observacional, descritivo e analítico, desenvolvido no CRSM-MATER e no HCFMRP-USP, situados em Ribeirão Preto, SP. O projeto de pesquisa foi aprovado pelo CEP da EERP-USP, sob nº 1383/2011. Os dados foram coletados no período de maio a dezembro de 2012, por meio de entrevista estruturada por um questionário que contemplava as características sociodemográficas da mulher e de seu parceiro e características obstétricas, além das questões relacionadas à violência; também foram coletados dados dos prontuários das participantes com a utilização de um instrumento que contemplava as variáveis relacionadas aos resultados obstétricos e neonatais. Durante a coleta de dados, iniciada no ambulatório de pré-natal do CRSM-MATER, algumas participantes foram encaminhadas ao HC-FMRP e tiveram a coleta nos prontuários realizada nesta última instituição. Para análise dos dados, utilizou-se o programa estatístico SAS® 9.0. Esta análise foi fundamentada na estatística descritiva, além da utilização do Teste Exato de Fisher e Regressão Logística. Verificou-se que 15,5% das participantes sofreram algum tipo de VPI durante a gestação, sendo que 14,7% sofreram violência psicológica, 5,2%, violência física e 0,4% sofreu violência sexual. As mulheres que se autorreferiram como pretas ou pardas, que não moravam com o parceiro e que referiram consumir bebida alcoólica eventualmente, apresentaram maior chance de sofrer VPI na gestação. Além disso, as mulheres que não desejaram a gestação tinham 4,3 vezes a chance de sofrer VPI na gestação, quando comparadas com aquelas que desejaram a gestação (p<0,00; OR= 4,32 e IC 95% [1,77 - 10,54]). As participantes com parceiros na faixa etária de 15 a 18 anos apresentaram 5,5 vezes a chance de sofrer violência, quando comparadas com aquelas que tinham parceiros com 30 anos ou mais (OR= 5,5; IC 95% [1,02 - 30,2]). Com relação às repercussões obstétricas, não houve associação estatisticamente significativa entre as variáveis investigadas. Quanto às repercussões neonatais dos filhos das participantes, as análises também não apresentaram resultados estatisticamente significativos. Conclui-se que, para as participantes do estudo, não houve repercussões obstétricas e neonatais negativas relacionadas à VPI na gestação. No entanto, outras variáveis se mostraram associadas a este tipo de violência, o que indica, aos profissionais de saúde, a importância de se atentar a outras características das gestantes e de seus parceiros, favorecendo a identificação da violência e o oferecimento de suporte adequado a estas mulheres, quando necessário / The intimate partner violence (IPV) is one of the most frequent ways of violence against women, and it is constituted in a complex phenomenon, which is part of a historical construction and is intimately related to gender questions and its power relationships. During pregnancy, the woman attend health care more frequently, which can facilitate the bond building with the health staff and favours the identifications of violence cases. This study aims were: identify the prevalence of IPV cases between pregnant women who use public healthcare service and classify according to its type and frequency; identify the pregnant e their partners\' social and demographic factors which could be associated with violence episodes; identify the obstetric and neonatal results and their associations with the IPV occurrence in the current pregnancy. This is an observational, descriptive and analytic study, developed at CRSM-MATER and HCFMRP-USP, located in Ribeirão Preto, SP. The research project was approved by ethics committee from EERP-USP, under number 1383/2011. The data were collected between May and December 2012, via interview structured by a questionnaire which beheld the woman\'s and their partner\'s social- demographic characteristics and obstetric characteristics, beside the questions related to violence; there were also collected the participants\' records data using an instrument that contemplated the variables related to the obstetric and neonatal results. During the data collection, initiated at CRSM-MATER prenatal clinic, some participants were leaded to HC- FMRP and had the records collection done at this last institution. To analyze the data the statistic program SAS® 9.0 was used. This analysis was underlay on descriptive statistic, besides using the Fisher Exact Test and Logistic Regression. It was verified that 15,5% of the participants suffered some sort of IPV during pregnancy, knowing that 14,7% suffered psychological violence, 5,2% physical violence and 0,4% sexual violence. Women whom were considered themselves as black or brown-skinned, who haven\'t lived with their partners and who were referred as eventual liquor drinkers showed bigger chance of suffering IPV during pregnancy. Furthermore, women who didn\'t desire the pregnancy had 4,3 times chances of suffering IPV during pregnancy when compared to those ones who desired the pregnancy (p<0,00; OR= 4,32 e IC 95% [1,77 - 10,54]). The participants with partners between 15 and 18 years old showed 5,5 times chances of suffering violence when compared to those ones whose partners were 30 years old or older (OR= 5,5; IC 95% [1,02 - 30,2]). Relating to the obstetric repercussions, there was no association statistically meaningful between the variables investigated. As the participants\' children\'s neonatal repercussion, the analysis didn\'t present results statistically meaningful either. In conclusion, for the study participants, there were no negative obstetric and neonatal repercussions related to IPV in pregnancy. Nevertheless, other variables are shown associated to this type of violence, which indicates, to the health care professionals, the importance to be attentive to other pregnant women\'s and their partners\' characteristics, favoring the violence identification and offering appropriate support to these women, when necessary

O ganho de peso gestacional inadequado é considerado importante indicador para desfechos adversos na gravidez. O baixo peso pré-gestacional e/ou ganho de peso insuficiente durante a gestação resultam em maior risco de anemia e hemorragias. Por outro lado, o sobrepeso ou obesidade pré-gestacional e ganho de peso excessivo durante a gestação implicam em maior risco para desenvolvimento de diabetes gestacional, doença hipertensiva da gestação e maior retenção de peso pósparto. Objetivos: Avaliar a associação entre ganho de peso inadequado na gestação e ocorrência de anemia, insuficiência de vitamina A (IVA) e níveis pressóricos de gestantes atendidas no pré-natal na Estratégia de Saúde da Família de Cruzeiro do Sul, Acre. Métodos: Análise de dados aninhada a estudo de coorte de gestantes, atendidas no prénatal da atenção básica à saúde, na área urbana do município de Cruzeiro do Sul, Acre. Os dados socioeconômicos, demográficos, obstétricos, de assistência pré-natal, antropométricos e de estilo de vida foram coletados entre fevereiro de 2015 e janeiro de 2016. A exposição de interesse ganho de peso gestacional foi obtida pela diferença de peso avaliada entre o segundo e o terceiro trimestres gestacionais, dividida pelo número de semanas nesse intervalo e classificada em: insuficiente, adequado e excessivo segundo critérios do Institute of Medicine USA (IOM) 2009. O desfecho de interesse foi o estado nutricional no terceiro trimestre gestacional avaliado pela frequência de anemia (hemoglobina sanguínea <110 g/L), IVA (retinol sérico <1,5 mol/L) e valores de pressão arterial em mmHg. Medidas de tendência central, intervalos com 95 por cento de confiança (IC95 por cento ) e teste do qui-quadrado foram calculados com auxílio do pacote estatístico STATA 14.0, ao nível de significância de P < 0,05. Modelos de regressão de Poisson múltiplos com variância robusta foram testados para desfechos dicotômicos (anemia e insuficiência de vitamina A). A seleção inicial de variáveis independentes para ajuste múltiplo considerou critérios estatísticos (P < 0,20) e pressupostos teóricos. Resultados: No total, 458 gestantes completaram duas avaliações durante o seguimento. Destas, 72 por cento tinham menos de 30 anos e 19 por cento eram adolescentes. No início da gestação a prevalência de sobrepeso foi de 24 por cento , obesidade e baixo peso, foram semelhantes, na ordem de 7 por cento . No terceiro trimestre gestacional, 18,7 por cento das gestantes apresentaram ganho de peso insuficiente e 59,1 por cento ganho de peso excessivo. As frequências gerais de anemia, IVA e hipertensão (pressão arterial sistólica 140 mmHg e diastólica 90 mmHg) foram de 17,5 por cento , 13,4 por cento e 0,6 por cento , respectivamente. As gestantes com ganho de peso semanal insuficiente apresentaram menor frequência de anemia (8,2 por cento ) e maior ocorrência de IVA (33 por cento ) quando comparadas às gestantes com ganho de peso adequado (19,6 por cento e 11,8 por cento ) e excessivo (19,6 por cento e 19,0 por cento ), respectivamente (teste do qui-quadrado, P <0.05). As razões de prevalências (IC95 por cento ) para anemia entre gestantes com ganho de peso insuficiente e excessivo foram 0,41 (0,18-0,93) e 1,00 (0,63-1,59), respectivamente, quando comparadas às gestantes com ganho de peso adequado (após ajuste por idade, escolaridade e uso de suplementos de vitaminas e minerais). Já para IVA, a prevalência foi maior entre gestantes com ganho de peso insuficiente (2,85; IC95 por cento : 1,55-5,24) e excessivo (1,53; IC95 por cento : 0,84-2,74) quando comparadas às gestantes com ganho de peso adequado (após ajuste por idade, escolaridade e uso de suplementos de vitaminas e minerais). As gestantes com ganho de peso excessivo apresentaram valores médios de pressão arterial sistólica maiores (111,10; IC95 por cento : 109,9-112,2) quando comparadas às gestantes com ganho de peso insuficiente (107,50; IC95 por cento : 105,4-109,6) e adequado (106,20; IC95 por cento : 104,3-108,20). Conclusões: O ganho de peso semanal insuficiente ou excessivo entre segundo e terceiro trimestres gestacionais foram associados ao estado nutricional no terceiro trimestre de gestação. Estratégias visando monitoramento do ganho de peso gestacional com incentivo à alimentação saudável e prática regular de atividade física são necessárias durante toda a atenção e cuidado pré-natal / The gestational weight gain has been considered important indicator for adverse pregnancy outcomes. Low pre-gestational body weight and/or insufficient weight gain during pregnancy are associated with increased risk of anemia and bleeding. On the other hand, pre-gestational overweight or obesity and excessive weight gain during pregnancy imply a greater risk for the development of gestational diabetes, hypertensive gestational disease and greater postpartum weight retention. Objectives: To evaluate the relation between gestational weight gain and anemia, vitamina A insufficiency (VAI) and blood pressure in the third trimester of pregnancy. Methods: Data analysis nested in a cohort study of pregnant women attending prenatal care in the urban area of the city of Cruzeiro do Sul, Acre. Socioeconomic, demographic, obstetric, prenatal, anthropometric and lifestyle data were collected between February 2015 and January 2016. The main exposure \"weight gain\" was obtained by the body weight difference evaluated between the second and the third gestational trimesters, divided by the number of weeks in this interval and classified in relation to pre-gestational body weight in: insufficient, adequate and excessive according to the Institute of Medicine USA (IOM) 2009 criteria. The outcomes of interest were anemia (hemoglobin concentrations <110 g/L), VAI (serum retinol <1.5 mol/L) and blood pressure levels in mmHg. Descriptive statistical data, 95 per cent confidence intervals (95 per cent CI) and chi-square test were calculated using the software STATA 14.0, at P <0.05. Multiple Poisson regression models with robust variance were tested for dichotomous outcomes (anemia and VAI). The initial selection of independent variables for multiple fit considered statistical criteria (P <0.20) and theoretical assumptions. Results: Overall, 458 pregnant women completed two evaluations during follow-up. Of them, 72 per cent were under 30 years old and 19 per cent were teenagers. At the beginning of gestation, the prevalence of overweight was 24 per cent , obesity and low weight, were similar, around 7 per cent . In the third gestational trimester, 18.7 per cent of pregnant women presented insufficient and 59.1 per cent excessive weight gain. The general frequencies of anemia, VAI and hypertension (systolic blood pressure 140 mmHg and diastolic blood pressure 90 mmHg) were 17.5 per cent , 13.4 per cent and 0.6 per cent , respectively. Pregnant women with insufficient weekly weight gain presented a lower frequency of anemia (8.2 per cent ) and a higher occurrence of VAI (33 per cent ) when compared to pregnant women with adequate (19.6 per cent and 11.8 per cent ) and excessive weight gain (19.6 per cent and 19.0 per cent ), respectively (chi-square test, P <0.05). The prevalence ratios (95 per cent CI) for anemia among pregnant women with insufficient and excessive weight gain were 0.41 (0.18-0.93) and 1.00 (0.63-1.59), respectively, when compared to pregnant women with adequate weight gain (after adjusting for age, schooling and use of vitamin and mineral supplements). The risk for VAI was higher among pregnant women with insufficient (2.85; 95 per cent CI: 1.55-5.24) and excessive weight gain (1.53; 95 per cent CI: 0.84-2.74) when compared to pregnant women with adequate weight gain (after adjusting for age, schooling and use of vitamin and mineral supplements. Pregnant women with excessive weight gain had higher mean systolic blood pressure (111.10; 95 per cent CI: 109.9-112.2) when compared to pregnant women with insufficient (107.50; 95 per cent CI: 105.4-109.6) and appropriate weight gain (106.20; 95 per cent CI: 104.3-108.20). Conclusions: Insufficient or excessive weekly weight gain between the second and third gestational trimesters were associated with the nutritional status at the third trimester of gestation. Strategies aimed at monitoring gestational weight gain with encouragement of healthy eating and regular practice of physical activity are required throughout prenatal care

Literature provides evidence for disparities and inequities in health and birth outcomes based on geographical location, which highlight differential mother characteristics. These differences influence behaviors associated with adverse birth outcomes such as premature birth and low birth weight (LBW), the leading causes of infant morbidity and mortality. Consistent with the Healthy People 2020 and Millennium Development goal, to reduce infant morbidity and mortality rates, we sought to compare maternal characteristics and behaviors and the occurrence of adverse birth outcomes in Northeast (NETN) region, as defined by the Tennessee Department of Health, compared to the rest of Tennessee (TN). TN vital statistics birth record data for the years 2009 - 2014 were used in this analysis; n = 20,786 and 482,681 live births for NETN and TN respectively. Bivariate analyses were performed to deduce the demographic and birth characteristics and their proportions across the years. Logistic regression was used to calculate crude odds ratios for pre-pregnancy smokers, with the dependent variables of preterm birth and LBW. We followed with adjusted odds ratios, which controlled for mother’s demographic variables; age, education years and reported household income and mother’s behavioral characteristics; pre-pregnancy cigarette smoking, prenatal care by first trimester and previous preterm birth. From 2009 through 2014, the percentage of teenage mothers decreased for both TN groups, with a larger proportion in NETN (%:13.8,12.2,12.5, 11.9,9.6,9.4) compared to TN (%:12.8,11.8,10.8,10.0,9.0,8.4). A larger percentage of TN mothers did not have a high school degree or completed GED compared to NETN. A larger proportion of NETN mothers were married at the time of birth of the infant (%:60.3,60.5,59.3,58.6,57.6,57.8) compared to TN mothers (%:55.5,55.9,55.9,55.8,56.0,56.0). Over the period, 34% of NETN women smoked during the 3 months prior to pregnancy versus 21% for TN mothers. Through the third trimester 24% of NETN mothers reported cigarette smoking compared to 13% of TN mothers. Throughout, more adverse birth outcomes were observed in NETN. Compared to non-smokers, for six consecutive years and overall, the odds of a LBW among pre-pregnancy smoking mothers were higher in NETN (odds ratio (OR):2.16,1.73,2.56,2.03, 2.02,1.83,2.05) than in TN (OR:1.51,1.53,1.56,1.56,1.56,1.52,1.54), p-values

O ganho de peso gestacional inadequado é considerado importante indicador para desfechos adversos na gravidez. O baixo peso pré-gestacional e/ou ganho de peso insuficiente durante a gestação resultam em maior risco de anemia e hemorragias. Por outro lado, o sobrepeso ou obesidade pré-gestacional e ganho de peso excessivo durante a gestação implicam em maior risco para desenvolvimento de diabetes gestacional, doença hipertensiva da gestação e maior retenção de peso pósparto. Objetivos: Avaliar a associação entre ganho de peso inadequado na gestação e ocorrência de anemia, insuficiência de vitamina A (IVA) e níveis pressóricos de gestantes atendidas no pré-natal na Estratégia de Saúde da Família de Cruzeiro do Sul, Acre. Métodos: Análise de dados aninhada a estudo de coorte de gestantes, atendidas no prénatal da atenção básica à saúde, na área urbana do município de Cruzeiro do Sul, Acre. Os dados socioeconômicos, demográficos, obstétricos, de assistência pré-natal, antropométricos e de estilo de vida foram coletados entre fevereiro de 2015 e janeiro de 2016. A exposição de interesse ganho de peso gestacional foi obtida pela diferença de peso avaliada entre o segundo e o terceiro trimestres gestacionais, dividida pelo número de semanas nesse intervalo e classificada em: insuficiente, adequado e excessivo segundo critérios do Institute of Medicine USA (IOM) 2009. O desfecho de interesse foi o estado nutricional no terceiro trimestre gestacional avaliado pela frequência de anemia (hemoglobina sanguínea <110 g/L), IVA (retinol sérico <1,5 mol/L) e valores de pressão arterial em mmHg. Medidas de tendência central, intervalos com 95 por cento de confiança (IC95 por cento ) e teste do qui-quadrado foram calculados com auxílio do pacote estatístico STATA 14.0, ao nível de significância de P < 0,05. Modelos de regressão de Poisson múltiplos com variância robusta foram testados para desfechos dicotômicos (anemia e insuficiência de vitamina A). A seleção inicial de variáveis independentes para ajuste múltiplo considerou critérios estatísticos (P < 0,20) e pressupostos teóricos. Resultados: No total, 458 gestantes completaram duas avaliações durante o seguimento. Destas, 72 por cento tinham menos de 30 anos e 19 por cento eram adolescentes. No início da gestação a prevalência de sobrepeso foi de 24 por cento , obesidade e baixo peso, foram semelhantes, na ordem de 7 por cento . No terceiro trimestre gestacional, 18,7 por cento das gestantes apresentaram ganho de peso insuficiente e 59,1 por cento ganho de peso excessivo. As frequências gerais de anemia, IVA e hipertensão (pressão arterial sistólica 140 mmHg e diastólica 90 mmHg) foram de 17,5 por cento , 13,4 por cento e 0,6 por cento , respectivamente. As gestantes com ganho de peso semanal insuficiente apresentaram menor frequência de anemia (8,2 por cento ) e maior ocorrência de IVA (33 por cento ) quando comparadas às gestantes com ganho de peso adequado (19,6 por cento e 11,8 por cento ) e excessivo (19,6 por cento e 19,0 por cento ), respectivamente (teste do qui-quadrado, P <0.05). As razões de prevalências (IC95 por cento ) para anemia entre gestantes com ganho de peso insuficiente e excessivo foram 0,41 (0,18-0,93) e 1,00 (0,63-1,59), respectivamente, quando comparadas às gestantes com ganho de peso adequado (após ajuste por idade, escolaridade e uso de suplementos de vitaminas e minerais). Já para IVA, a prevalência foi maior entre gestantes com ganho de peso insuficiente (2,85; IC95 por cento : 1,55-5,24) e excessivo (1,53; IC95 por cento : 0,84-2,74) quando comparadas às gestantes com ganho de peso adequado (após ajuste por idade, escolaridade e uso de suplementos de vitaminas e minerais). As gestantes com ganho de peso excessivo apresentaram valores médios de pressão arterial sistólica maiores (111,10; IC95 por cento : 109,9-112,2) quando comparadas às gestantes com ganho de peso insuficiente (107,50; IC95 por cento : 105,4-109,6) e adequado (106,20; IC95 por cento : 104,3-108,20). Conclusões: O ganho de peso semanal insuficiente ou excessivo entre segundo e terceiro trimestres gestacionais foram associados ao estado nutricional no terceiro trimestre de gestação. Estratégias visando monitoramento do ganho de peso gestacional com incentivo à alimentação saudável e prática regular de atividade física são necessárias durante toda a atenção e cuidado pré-natal / The gestational weight gain has been considered important indicator for adverse pregnancy outcomes. Low pre-gestational body weight and/or insufficient weight gain during pregnancy are associated with increased risk of anemia and bleeding. On the other hand, pre-gestational overweight or obesity and excessive weight gain during pregnancy imply a greater risk for the development of gestational diabetes, hypertensive gestational disease and greater postpartum weight retention. Objectives: To evaluate the relation between gestational weight gain and anemia, vitamina A insufficiency (VAI) and blood pressure in the third trimester of pregnancy. Methods: Data analysis nested in a cohort study of pregnant women attending prenatal care in the urban area of the city of Cruzeiro do Sul, Acre. Socioeconomic, demographic, obstetric, prenatal, anthropometric and lifestyle data were collected between February 2015 and January 2016. The main exposure \"weight gain\" was obtained by the body weight difference evaluated between the second and the third gestational trimesters, divided by the number of weeks in this interval and classified in relation to pre-gestational body weight in: insufficient, adequate and excessive according to the Institute of Medicine USA (IOM) 2009 criteria. The outcomes of interest were anemia (hemoglobin concentrations <110 g/L), VAI (serum retinol <1.5 mol/L) and blood pressure levels in mmHg. Descriptive statistical data, 95 per cent confidence intervals (95 per cent CI) and chi-square test were calculated using the software STATA 14.0, at P <0.05. Multiple Poisson regression models with robust variance were tested for dichotomous outcomes (anemia and VAI). The initial selection of independent variables for multiple fit considered statistical criteria (P <0.20) and theoretical assumptions. Results: Overall, 458 pregnant women completed two evaluations during follow-up. Of them, 72 per cent were under 30 years old and 19 per cent were teenagers. At the beginning of gestation, the prevalence of overweight was 24 per cent , obesity and low weight, were similar, around 7 per cent . In the third gestational trimester, 18.7 per cent of pregnant women presented insufficient and 59.1 per cent excessive weight gain. The general frequencies of anemia, VAI and hypertension (systolic blood pressure 140 mmHg and diastolic blood pressure 90 mmHg) were 17.5 per cent , 13.4 per cent and 0.6 per cent , respectively. Pregnant women with insufficient weekly weight gain presented a lower frequency of anemia (8.2 per cent ) and a higher occurrence of VAI (33 per cent ) when compared to pregnant women with adequate (19.6 per cent and 11.8 per cent ) and excessive weight gain (19.6 per cent and 19.0 per cent ), respectively (chi-square test, P <0.05). The prevalence ratios (95 per cent CI) for anemia among pregnant women with insufficient and excessive weight gain were 0.41 (0.18-0.93) and 1.00 (0.63-1.59), respectively, when compared to pregnant women with adequate weight gain (after adjusting for age, schooling and use of vitamin and mineral supplements). The risk for VAI was higher among pregnant women with insufficient (2.85; 95 per cent CI: 1.55-5.24) and excessive weight gain (1.53; 95 per cent CI: 0.84-2.74) when compared to pregnant women with adequate weight gain (after adjusting for age, schooling and use of vitamin and mineral supplements. Pregnant women with excessive weight gain had higher mean systolic blood pressure (111.10; 95 per cent CI: 109.9-112.2) when compared to pregnant women with insufficient (107.50; 95 per cent CI: 105.4-109.6) and appropriate weight gain (106.20; 95 per cent CI: 104.3-108.20). Conclusions: Insufficient or excessive weekly weight gain between the second and third gestational trimesters were associated with the nutritional status at the third trimester of gestation. Strategies aimed at monitoring gestational weight gain with encouragement of healthy eating and regular practice of physical activity are required throughout prenatal care

BACKGROUND: Quality improvement (QI) efforts in which providers from various health facilities, with support from coaches, work together to implement innovations for improving health care are rapidly spreading from high-income settings to resource-poor settings. However, limited research exists regarding the factors which drive teams to succeed or fail, spread, and sustain best practices. The purpose of this study was to understand the factors facilitating or inhibiting the performance of QI teams of maternal and child health (MCH) service delivery in resource-poor settings. METHODS: A qualitative multi-site case study was conducted in northern Ghana to determine the views and beliefs of QI teams, coaches, and beneficiaries of Project Fives Alive (PFA) about the application of QI to MCH service delivery. Using key informant interviews, document review, and group interviews, the study elicited information about: 1) the factors that affect QI team success and failure when implementing QI methods designed to improve MCH service delivery; 2) the interplay of factors that facilitate or inhibit the spread of best practices among QI teams in northern Ghana; and 3) steps being taken by stakeholders to sustain these best practices. Grounded theory processes were used to identify themes from the data. RESULTS: Testing of changes using Plan-Do-Study-Act (PDSA) cycles and adoption of a client-centered model to the delivery of services has helped teams to identify the felt needs of clients, resulting in perceived increased uptake of MCH services. Key contributory factors to successes were: availability and accessibility of midwives, training of QI teams, incentive packages for providers and clients, community support groups, and PFA partners. Key challenges inhibiting success were: staff turnover, inadequate supervision, cultural practices, and inadequate infrastructure. Some of the key factors that shaped successes have dissipated, threatening sustainability of QI efforts two years after PFA ended. CONCLUSION: The presence of a midwife, providing leadership for organizing team members and implementing PDSA cycles, can facilitate success. Project staff support is important, but teams and coaches need space and time to drive the QI process independently and practice QI methods in ways that foster continuity beyond donor support.